GUIDELINES FOR CLINICAL REQUIREMENTS TRINITAS SCHOOL OF NURSING NUR E 131 This packet contains the materials needed to guide you in completing your clinical requirements. Each guideline contains criteria and standards that have been determined by the course faculty. These standards are set in order to assist you in satisfactorily completing all practical and written requirements for the clinical and/or skill lab. Should you have any questions regarding completion of these assignments, please contact the course faculty.
Table of Contents 1. Guidelines for All Written Assignments………………………. 3 2. Bibliography Cards ……………………………………………. 4 Comprehensive Nursing Care Plans …………………………… 6 Weekly Assignments ……………………………………………. 10 a. History and Physical Assessment Tool…………………………. 13 5. Skills Performance Testing ……………………………………. 24 6. Community Health Presentation ………………………………. 27 7. Cultural Presentation …………………………………………. 29 8. Student Portfolio ………………………………………………. 30 -2- TRINITAS SCHOOL OF NURSING NUR E131 GUIDELINES FOR WRITTEN ASSIGNMENTS 1. All other assignments are to be handwritten in black ink. 2. Proper punctuation, spelling and grammar is to be expected. 3. Illegible papers/cards will not be accepted. 4. Papers with ragged edges and/or stains will not be accepted. 5. Papers and cards should be clearly labeled with the student’s name, course and division. Example: Jane Doe NURE 131 – Days 6. Papers and cards should be stapled or paper-clipped together. 7. Papers in which clients are referred to should only contain the client’s initials. (no names!) 8. Late papers/cards will not be accepted without prior approval from the instructor. 9. APA (American Psychological Association) Style is to be used for all references. See the guidelines for Bibliography Cards for an example of APA Style. The reference manual can be found on reserve in the library, and in the computer and skill laboratories. -3- TRINITAS SCHOOL OF NURSING NUR E131 BIBLIOGRAPHY CARDS Objectives: Upon completion of these assignments, the student will be able to: 1. identify professional nursing journals 2. locate articles in the current nursing literature to supplement course content from library and internet; and 3. learn to access existing literature to update clinical nursing information. Guidelines: 1. Select an article from a professional nursing journal. One article must be related to gerontological nursing, while the second article must be related to medical or surgical nursing. 2. Submit the article to your clinical instructor for approval. 3. The format should be on a 5” x 8” index card and include the following information using American Psychological Association (APA) format. For additional information refer to: http://apastyle.org a. Reference Citation Example:
Badger, J.M. (1994). Calming the anxious patient, American Journal of Nursing, 94(5), 46-50. 94 = volume number 5 = issue number 46 - 50 = page number b. Summary of Content Remember to paraphrase. Any quotes from the article must be properly referenced and documented. Failure to do so constitutes plagiarism and will be subject to disciplinary action. c. Reaction to Article Include your thoughts on the article and discuss how the article will affect your clinical practice. -4- BIBLIOGRAPHY CARDS (continued) 4. Include a copy of the article with your Bibliography Cards when you submit the assignment. 5. Due dates will be announced in class and also be found on the course calendar. -5- TRINITAS SCHOOL OF NURSING NUR E131 COMPREHENSIVE NURSING CARE PLAN Objectives: Upon completion of this assignment, the student will be able to: 1. identify client’s abilities and limitations. select appropriate nursing diagnoses for a chosen client. Formulate realistic short-term and long-term goals with time references. Choose and implement appropriate nursing interventions to achieve the stated goals. Evaluate nursing care based upon the stated goals. Guidelines: 1. Select one (1) of the clients you have been assigned to care for. The client must be from your gerontological experience. Identify three (3) nursing diagnoses for the selected client. Care plans should follow the format used in the attached sample and include the following areas: a. Abilities What are the client’s strengths? What factors enhance the client’s ability to perform self-care? b. Limitations What are the client’s weaknesses? What factors make it difficult for the client to perform self-care? c. Nursing Diagnosis Use only approved nursing diagnoses. Be sure to identify the causative factors (related to…) and the manifestations of the diagnoses. -6- TRINITAS SCHOOL OF NURSING NUR E131 COMPREHENSIVE NURSING CARE PLANS (continued)
d. Nursing System Identify whether the client is wholly compensatory, partly compensatory, or supportive-educative. It is possible for a client’s care plan to encompass all three (3) systems depending upon your client’s condition and the diagnosis you have selected. e. Client Goals What will the client be able to do as a result of your nursing intervention? Remember goals must be measurable with time frames. Be sure to include at least two (2) short-term goals and one (1) long-term goal for each diagnosis. f. Nursing Actions List all assessments and interventions needed to accomplish each client goal. g. Scientific Rationale For each nursing action identified, give the reason why you included the action. Be sure to cite the source of your information. h. Implementation These are more specific nursing actions. For example, if the nursing action is to perform range-of-motion exercises 3 times a day, the implementation would be performed range-of-motion exercises with morning care, at 2:00 p.m., and with evening care daily. Do not rewrite the exact same nursing action. Be specific about what was actually done. i. Evaluation Were the goals met? This should simply address the attainment of goals not the implementation of nursing actions. Submit the completed Care Plan along with the History & Physical Assessment Tool you completed for the client. 5. Due date will be announced in class and can also be found in the course calendar. -7- TRINITAS SCHOOL OF NURSING WEEKLY ASSIGNMENTS Objectives:
Upon completion of these assignments, the student will be able to: 1. perform a basic head-to-toe physical assessment. 2. discuss common diagnostic tests and procedures including the purpose of the test 3. describe commonly used medications including their purpose, major side- effects, and appropriate nursing care. 4. identify abilities and limitations for each assigned client. 5. develop a plan of care for each assigned client. 6. discuss the basic pathophysiology of common health deviations and the related nursing care. Guidelines: 1. For each assigned client, completed the following: a. History & Physical Assessment Form b. Nursing Care Plan c. Client Data Card – Due at beginning of or prior to caring for client 2. Complete the History & Physical Assessment Form as follows: a. Avoid vague terms such as “good”, “poor” and “normal”. Describe your findings b. Your clinical instructor will discuss each area and determine which areas are to be completed. NOTE: Certain areas, while not required in the beginning of the semester may be required later. 3. Weekly assignments are to be submitted to your clinical instructor at the conclusion of -10- TRINITAS SCHOOL OF NURSING GUIDELINES FOR THE USE OF CLIENT DATA CARDS The Client Data Card shall contain the following information:
a. Client’s initials, age, sex b. Room number c. Medical diagnosis; Surgery; Date of Surgery d. Food and drug allergies e. Medication – date ordered, name of drug, dosage, route and frequency of administration
f. Use of medication for this patient g. Diet h. Activity i. Treatments ( To be written at the back of card) j. Anticipatory times for activities such as medication administration, V/S assessment, dressing changes, and OOB transfers-11- TRINITAS SCHOOL OF NURSING
TITLE: GUIDELINES FOR THE USE OF CLIENT DATA
EXAMPLE (FRONT OF PATIENT DATA CARD) M.J. 49 y.o. Male Your Name Appendicitis; Diabetes Mellitus No Known Allergies Surgery: Appendectomy Diet: Clear Liquid Date of Surgery: 9/4/96 Activity: OOB as tolerated Standing Orders 9/4 ciprofloxacin hydrochloride 500 mg. Po q 12 hrs. (Cipro) – antinfective Treatment of Urinary Tract Infection caused by E. Coli 9/4 glyburide micronized 1.5 mg. po OD (Glynase) – antidiabetic To control diabetes mellitus 9/4 sertraline 100mg po BID (Zoloft) – antidepressant To decrease suicidal ideation and improve depressed mood and withdrawn behavior. 9/4 lorazepam 1 mg. po q 4 hrs. prn (Ativan) - antianxiety To decrease agitated behavior
BACK OF PATIENT DATA CARD TREATMENT OR PLAN OF CARE - Blood Accucheck q 12 hours 6 am & 6 pm - Incentive Spirometer Q2 Hr. - Dressing Change PRN - Restrain PRN - Intake and Output - Suicidal Precaution - Daily weight - Fall Precautions -12- TRINITAS SCHOOL OF NURSING Understanding Pathophysiology: Based on the information on your completed pathophysiology cards for all disease processes that apply to this client, answer the following questions.
How do current disease processes and other chronic disease processes, major surgeries, or injuries affect each other? (If there is no history of other disease processes, state “Not Applicable”.)
Explain how chronic disease processes, major surgeries, or injuries will affect client’s recovery. (If there will be no effect, state “None”.)
-16- TRINITAS SCHOOL OF NURSING Perception of Health Status: Do not leave any blanks. Write “not applicable” if nothing is found.
___________________________________ Client’s perception (Subjective Statement) of health status and expected recovery. Significant other’s (Subjective Statement) understanding of health status. What teaching is required for the client to return to optimum level of functioning?
-17- TRINITAS SCHOOL OF NURSING Diagnostic Testing: List the diagnostic tests that were done of this patient. If none, state “None”.
Diagnostic Test Results Purpose Pre & Post Cause for Client (Normal (Why were these Test Care Abnormal Values Range) done on your client) -18- TRINITAS SCHOOL OF NURSING Medication Record: Complete the following. Add additional sheet as necessary.
Drug/Dose/Frequency (include Purpose & Action Side Effect Nursing Actions generic & trade names) (include functional & Ex: digoxin (Lanoxin) chemical classifications) Func. Class: inotropic, dysrhythmic, cardiac glycosides Chem Class: digitalis preparation. -19- TRINITAS SCHOOL OF NURSING Intravenous Solutions: Indicate the IV solutions the client received.
IV Solution flow rate Physiological Action Rationale for Use Nursing Responsibilities in cc/hr and gtts/min. Identifying Nursing Care Problems: Client’s Assets: (Abilities) Client’s Deficits: (Limitations) Identify the nursing problem areas that relate to your client. Star(*) priority problems. Develop nursing diagnosis based on the starred problems.
-20- TRINITAS SCHOOL OF NURSING Will include: A. The first nursing diagnosis will incorporate all aspect of the nursing process, i.e., goals, interventions, rationale, implementations and evaluations. The remaining two (2) nursing diagnoses may or may not require all aspect of the nursing process as stipulated by the student’s clinical instructor. Nursing Dx Goals Nursing Intervention/Scientific Rationales -21- TRINITAS SCHOOL OF NURSING Nursing Dx Goals Nursing Intervention/Scientific Rationales -22- TRINITAS SCHOOL OF NURSING Based on your nursing care plan and the care you actually gave, evaluate your plan of care. Indicate why one of your nursing interventions was not done, why it might not be appropriate for this client and how you would later the plan to help meet your stated client goals. If your nursing diagnosis was not correct, state why. If your goals (client) were unachievable, why do you think this is so? If you think you did a great job and your care plan was working, tell me why. Implementation Evaluation -23- TRINITAS SCHOOL OF NURSING SKILLS PERFORMANCE TESTING Objectives: Upon completion of performance testing, the student will be able to demonstrate the following skills: 1. Applying a gown, gloves and mask. 2. Cleaning a wound and applying a sterile dressing. 3. Assisting a client out of bed to a chair. 4. Dosage Calculation Competency.*
5. Medication Administration Proficiency.* 6. Administering and maintaining enteral feedings. 7. Inserting a straight or indwelling catheter. Guidelines:
1. Vital signs and administering medications, and urinary catheterization will be tested by the course faculty on the days designed on the course calendar. 2. For the remaining skills, students will follow the procedure outlined below: a. After the skill has been demonstrated in class, the student will make an appointment to practice the skill in the skills lab. b. When the student feels comfortable with his/her performance of the skill, he/she will make an appointment for testing in the skill lab. c. When the student successfully demonstrates the skill, the skill lab instructor will sign and date the skills checklist (see attached) d. Due dates for the successful completion of all skills will be announced in class and can be * Medication proficiency testing requires passage of the Dosage Calculation test prior to testing.
-24- TRINITAS SCHOOL OF NURSING GUIDELINES FOR CLINICAL SKILLS 1. Skills will be tested according to the procedures outlined in Perry & Potter (2003) Clinical Nursing Skills and Techniques. (5th edition) 2. The skills can be found on the following pages: A. Applying a gown, gloves and mask …………………………Chapter 31 B. Cleaning a wound and applying a sterile dressing ……… Chapter 32, 35, 36 C. Assisting a client out of bed to a Chair……………………. Chapter 27 D. Measuring Vital Signs ………………………………………. Chapter 9 E. Administering Medications ………………………………… Chapter 16, 17, 18 F. Administering & Maintaining Enteral Feedings …………Chapter 22 G. Managing a client with urinary catheter …………………. Chapter 24 -25- _______________________ Semester _______________________ Name NURE 131 SKILLS PERFORMANCE TESTING (Comments) Instructor Date Skill Signature 1. Isolation precautions:
washing hands applying mask wearing gown wearing gloves 2. Cleaning a wound and applying a sterile dressing. 3. Assisting a Client Out of Bed 4. Measuring Vital Signs
temperature pulse respiration blood pressure 5. Administering Medications.
oral subcutaneous intramuscular 6. Enteral nutrition:
verifying tube placement administering feeding dressing of skin around feeding tube 7. Managing a client with indwelling urinary catheter:
insertion care removal of catheter -26- TRINITAS SCHOOL OF NURSING NURE 131 COMMUNITY HEALTH PRESENTATION Objectives: Upon completion of this assignment, the student will be able to: 1. identify health problems within a community utilizing many sources including the internet. 2. locate resources to deal with the health problems of a community. 3. develop a proposal to meet the health needs of a community for which there aren’t any 4. learn to present or sell an idea to a group of people. Guidelines: 1. Prepare a 10 minute presentation for the class utilizing aids such as poster board with graphs 2. Survey your community gathering information on the following areas: a. population: number, ethnic-cultural composition, age and gender. b. economic trends: socio-economic grouping, employment patterns, local industries. c. environmental conditions: pollution, airport, highways, garbage, industrial waste, high d. housing: multiple vs. single dwelling occupancies, availability of government subsidized e. major health problems in your community. f. resources to meet these health problems. g. what health needs are not being met by existing health resources? 3. Professional attire required. Notify faculty if in need of equipment (eg. Laptop, overhead 4. Failure to complete the community presentation will result in a clinical failure.
-27- TRINITAS SCHOOL OF NURSING NURE 131 COMMUNITY HEALTH PRESENTATION (continued) 5. Your presentation should include a brief description of your community and a discussion of the major health problems in your community along with the resources to meet those problems. 6. Focus your presentation on one unmet health need and your proposal to solve this problem. Include how you would staff, finance, and market this proposal. Be sure to include cultural considerations in this proposal. 7. Your classmates will represent your local town council. Your job is to sell the town council on 8. You may work together with the other classmates if they live in the same town as you. Groups, however, may not have more than four (4) members. -28- TRINITAS SCHOOL OF NURSING CULTURAL PRESENTATION Objectives: Upon completion of this assignment, the student will be able to: 1. discuss the effects of cultural beliefs upon his/her personal health care practices. 2. describe the effects of cultural beliefs upon the health care practices of others. Guidelines: 1. Prepare a five (5) minute presentation for the class. 2. Discuss the following:
a. your cultural beliefs as they pertain to health care. b. use of nontraditional health practices (i.e. foods, prayer). c. attitudes towards traditional health care (i.e. last resort, provider must be of same culture in order to form therapeutic relationship). 3. Due date will be announced in class and can also be found on the course calendar. -29- TRINITAS SCHOOL OF NURSING Students should submit samples of care plans and papers as requested by faculty for portfolio. -30- Client Behavioral Goals Nursing Actions and Scientific Rationale Implementation Evaluation 1. Assess present level of 1. To establish baseline data and capability ability (lecture notes by ….) 2. Consult with M.D. to 2. To increase level of activity to provide trapeze prevent prolonged pressure to 3. Instruct in the use of the one area, Ulrich, p. 74 4. Encourage the use of the 4. (Same as above) trapeze q 1 hr: NOTE: For each additional action you must document a scientific rationale with text and pages identified, i.e. Burrell, Ulrich, etc. GOAL 1. Participate in measures 1. Assess entire body area 1. To identify areas of concern Goal 2. List all nursing measures 2. To prevent skin breakdown 1. Assess and measure open 1. To establish baseline data 2. List all nursing actions, 2. To facilitate healing 1. Assess V/S especially 1. To establish baseline data 2. Assess present level of 2. To establish baseline data fluid intake 3. To correct poor skin 3. Provide at bedside turgor and prevent dehy- a. pitcher of water dration (Perry & Potter) b. ginger ale
ABBREVIATIONS: Wholly Compensatory (WC) Partly Compensatory (PC) Support-Educative (SE) NOTE: DO NOT MOVE ON TO THE NEXT GOAL UNTIL THE FIRST GOAL IS COMPLELTELY CARRIED THROUGH
Sample Care Plan Dx: 75 year old female with a fracture of the right hip ABILITIES LIMITATIONS NURSING DIAGNOSIS NURSING SYSTEM: Identify Which System is Appropriate For Your Client Alert Immobile ALTERATION IN SKIN INTEGRITY 1. WHOLLY COMPENSATORY: Eager to Learn Able To Turn Self With Related to Client is unable to do anything for Caring Neighbor Assistance PROLONGED PRESSURE ON him/herself and is wholly dependent Church Open Area On Sacrum TISSUE (Immobility) on the nurse. You would start by Family (5 cm dia.) saying: Client will show evidence Physician Reddened Area on Both Manifested by: of…meaning that the resolution was Nurse Elbows achieved by the nurse. Student Nurse Poor Skin Turgor 1. Immobile (only able to turn with Able to Use Upper Temp. 99.4 F assistance) 2. PARTLY COMPENSATORY Extremities Hard of Hearing 2. Open Area On Sacrum (5 cm. dia.) Client can make contributions or Able to Turn With Wears Glasses 3. Reddened Area on Elbow assist in their own care by following Assist Has No Teeth 4. Poor Skin Turgor instructions. (See handout on client Is Without Dentures 5. Temp. 99.4o F goals.) Lives Alone Has No Children Above mentioned manifestation will tell 3. SUPPORT-EDUCATIVE you the number of client behavioral Client will independently carry out NOTE: goals, i.e., 4-5 short term goals. nursing measures taught by nurse. (see handout on client goals.) All limitations should be analyzed and clustered NOTE: Your Care Plan may according to universal encompass all 3 nursing systems self-care requisites, i.e. depending on your client’s condition, air, water, etc. i.e., immediate post-op, etc.
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