View
228
Download
3
Category
Preview:
Citation preview
N210 Control Lab/Clinical FolderTable of Contents
_____________________________________________________________________________Student preparation for Scenario Days 2SCP on VCE pt. 3Oral Medication Modules 4Patient Teaching Paper &Patient Teaching Paper Grading Rubric
5-6
Time Management Schedule 7-8Laboratory Learning Outcomes Environment/Safety/Asepsis/Infection Control
9
Vital Signs 10 Activity and Rest 11 Personal Hygiene Measures 12 Documentation and Reporting 13 Bandages/Binders/Restraints, Thermal Therapy, TED
14
Urinary & Bowel Elimination 15 Critical Thinking 16 NGT intubation 18 Nutrition lab 19 Foley catheterization 20 Wound Management (Wound Care) 21 Skills Video Demonstrations 22-23 Nursing Skills Peer Check Off Sheet 24-26Control Lab Sheets
Environment/Isolation/medical asepsis Control Lab Sheet (Infection Control, Fall Risk Assessment, )
27-29
Vital Signs Skills Check Off Stations 30-31 Bandages/Binders Restraints, antiembolism Stockings Thermal Therapy Critical Thinking Questions
32-33
Elimination practice check off sheet 34 PA Documentation Guide- general survey 35 PA Documentation Guide-skin,hair, nails 36 PA Documentation Guide-head and neck 37 PA Documentation Guide-chest and lungs 38 PA Documentation Guide-heart and peripheral vascular
39
PA Documentation Guide-abdomen 40 PA Documentation Guide- musculoskeletal 41 PA Documentation Guide-neurological 42-43 Physical Assessment Practicum grading Sheet
44-45
Nasogastric Tube Critical Thinking Questions
46
Nasogastric Tube Removal 47 Urinary Catheterization Critical Thinking Questions
48
Catheter Removal 49 Wound care practice check off sheet 50-51
N210 Clinical References
1
NPW & AG Guidelines 52-53 Roy Adaptation Model Reference Sheet for completing Assessment Guide
54-55
Assessment Guide Sample 56-57 N212 NPW/AG Blank Form 58-61 Medication Sheet for Non-Med Days (use in N210 Clinical) & Medication Sheet for Med Days (Use for Assignment)
62-63
Sample Med Sheet for Non-Med Days 64 N210 Clinical Course Evaluation 65-71 Guidelines for Clinical Performance Evaluation Tool
72-76
Approved abbreviations 77-79 Unapproved abbreviations 80 N210 Clinical Schedule Long TermCare 81-83 Clinical Absence Make-up guidelines 84 CPE Sheet 85-92
Student Preparation for Control Lab/Scenario Days in Skills Lab
Review all previously taught skills Bring Taylor’s Fundamentals of Nursing textbook Wear complete uniform and name tag References for documentation (class notes, abbreviation list, pen, etc.)
Personal Hygiene Measures Control Lab Day (Week 1 Wednesday) Bring:
o 2 towels, 1 washclotho 1 soap (bar or liquid)o 1 lotiono plastic bago sports bra and shorts (for females)o shorts (males)
Scenario Day #1 Bring:
o Shorts and tank top or sports brao Soap o Lotiono Toothbrusho Toothpasteo Stethoscopeo Washclotho Patient gown
Scenario Day #2 Bring:
o Shorts and tank top or sports brao Stethoscopeo Isolation gown and mask o Patient gown
2
Cerritos N210 Medical Surgical NursingLong Term/Acute Care Clinical Rotation
STANDARD CLINICAL PREPARATION: Nursing Process Worksheet Preparation
This activity will introduce you on how to navigate through the chart to gather patient information while filling out your Nursing Process Worksheet (NPW).
You will need the following materials: DVD on Standard Clinical Preparation (access online via N210 or
N212 TalonNet site OR obtain DVD from the library) Virtual Clinical Excursion (VCE) DVD-Rom. Complete the VCE patient
assigned to you by your instructor. TBA. A blank NPW form
Instructions:
1. Watch the video on Standard Clinical Preparation. (You may check out from the library or watch online via TalonNet).
2. Take notes for your reference.
3. Using the VCE DVD-Rom, Go through the Virtual Clinical Excursion (VCE) and practice looking through a patient’s chart. Choose the assigned patient from the VCE e.g. Harry George, Piya Jordan and fill out a blank NPW form with the patient information.
4. Fill out the blank NPW as you go through the VCE chart (follow the steps as shown in the Standard Clinical Preparation).
5. Pay attention to “Course of Events in the hospital”. FILL OUT AND COMPLETE THE PATIENT PREPARATION THINKING TOOL ON PAGES ______ ON THIS CONTROL LAB FOLDER to assist you with the course of events in the hospital. You will need to summarize this in your NPW as shown in the Standard Clinical Preparation video.
6. Turn in the completed NPW including lab data (significant normal lab results and all abnormal lab results (NO NEED TO complete “Reason for Abnormal Values” portion) of the NPW) of your VCE patient to your instructor by week 1 (THURSDAY) of N212.
7. Practice with as many patients as you’d like. You may do this in pairs. Each student is required to turn in 1 complete NPW for a VCE patient.
3
Name_________________Lab___________________
Cerritos College Nursing Department
N212: Medical Surgical Nursing Oral Medication Module
Instructions: Complete 2 “patient” medication preparation scenarios by the medication testing day. You may work individually or in groups of two. You may
complete as many scenarios as you wish, but only two are required.
PLEASE DO NOT OPEN THE MEDICATION PACKAGES!!!!!!!!!!
1. Choose one patient. 2. Gather the MAR, physician’s order sheet and pull the medication drawer from the
medication cart for the patient you have chosen. 3. Review the physician’s order sheet and the MAR and check for accuracy. Note any errors
found. 4. Using your Mosby drug book, look up all of the medications ordered in preparation for
administration (despite times ordered). 5. Note any errors found. 6. Note any information you would need to gather before administering the medication: why
is this medication given (look at diagnosis and history), dosage and range, nursing considerations (ex: antihypertensive medication, check BP before administration) and common side effects (try to group side effects if possible (Ex: nausea/vomiting/diarrhea should be GI distress). Complete dosage calculation if needed.
7. Remove the medications from the medication drawer in preparation for administration (5 “rights”). Note any errors or concerns.
8. Review the steps for administration that you would complete at the patient’s bedside (5 “rights”)
9. Complete the documentation below10. Review the errors/concerns found with the N47 faculty member or N47 student worker and
have him/her sign below verifying completion. 11. Repeat the above steps for a second patient.
Date Patient Name Faculty/Staff Signature
*Submit this form (completed with faculty/staff signatures) on medication testing day to your clinical instructor. Failure to do so will result in an advisement note.
4
Patient Teaching PaperEach student will complete a Patient Teaching on an actual client that the student has cared for in this clinical rotation. Patient Teaching Paper will be a written essay of your patient teaching experience. It should be submitted with a minimum of 1 page and a maximum of 2 pages (typed and double spaced).
You may include and submit brochures or handouts to enhance your teaching. Use different teaching strategies or tool to deliver effective patient teaching. Be creative!
Patient Teaching Paper Guidelines• Read the chapter readings on Patient Teaching (Taylor, Ch 22 Teacher and Counselor)• Patient Teaching Paper should be Nursing focused (i.e. teaching provided should be in the role of the
Nurse, not physician, radiologist, dietician, pharmacist, etc.)
Requirements: The Patient Teaching Paper should include the following:
1. A complete NPW on the client including med sheets and assessment guide (do not include concept maps).
2. Please read Chapter 22 of Taylor and write a paragraph describing the client you taught which includes the following:
a. A brief history of present illness (HPI) and a description of client characteristics including details about any client variables that may affect the teaching/learning experience.
b. Identify the client’s learning needs (see Taylor Ch 22- the content that the patient needs to learn; patient’s learning style; developmental level, literacy level, language barrier if applicable
c. Identify the client’s readiness to learn (discuss the patient’s physiologic and psychological readiness, willingness to make changes and participate, etc.)
d. Identify any unique socioeconomic, cultural, and ethnic aspects (look at your client’s ethnic background and consider any cultural factors that may affect the client’s learning and/or health care practices. If identified, identify how you will tailor your patient teaching.)
2. What specific content taught based on the patient’s learning need?
3. What specific teaching strategies (e.g. demonstration, video, verbal, written or a combination) did you use in patient teaching appropriate for your patient and situation and state the rationale for choosing the specific strategy/ies.
4. Include an evaluation of your patient teaching. How did you evaluate the effectiveness of your teaching? State specific client behaviors that demonstrates the effectiveness or ineffectiveness of your patient teaching. If the teaching was ineffective, state the rationale and how you would approach the client for a more effective teaching.
5. Attach your client’s completed NPW and Assessment Guide to your paper (Required). Attach the Grading rubric when you submit this paper.
6. Include at least 2 references in the back of your paper. – must have at least 2 sources (e.g., Taylor, Iggy, credible internet sites, etc.)
5
Patient Teaching Paper Grading Criteria
(Pass or Fail: 3/5 pts or greater= Pass)
Grading Rubric : Patient Teaching PaperStudent Name: ________________________________________
Clinical Instructor Name:
CATEGORY 1 0.75 0.5 0.25 Content - Accuracy
All content throughout the paper is accurate. There are no factual errors. Information is shortened to simple phrases.
Most of the content is accurate but there is one piece of information that might be inaccurate. Information is presented in long paragraphs.
The content is generally accurate, but one piece of information is clearly flawed or inaccurate.
Content is typically confusing or contains more than one factual error. There is little or no information.
Creativity Student used several teaching strategies and showed considerable work/creativity and which made the patient teaching very effective
Student used 1 teaching strategy that showed considerable work/creativity and which made the patient teaching effective.
Student used 1 teaching strategy which made the patient teaching somewhat effective.
Student used ineffective or inappropriate teaching strategy/ies that made the patient teaching ineffective.
Relevance Student assessed the patient’s learning needs. The content taught to patient was relevant to patient’s learning needs and condition/situation.
Student assessed patient’s learning needs. The content/s taught to patient was somewhat relevant to the patient’s learning needs. Some content/s included where unnecessary.
Student did not assess the patient’s learning needs and taught on content that was lacking relevance to patient’s learning needs and situation.
Student did not assess the patient’s learning needs. The content taught was not at all relevant to patient’s learning needs or situation.
Clarity Content of patient teaching presented clearly in relation to patient’s ability to understand information
Content of patient teaching presented somewhat clearly in relation to patient’s ability to understand information. Needs few clarifications.
Content of patient teaching not presented clearly in relation to patient’s ability to understand information. Needs several clarifications.
Content presented confusing and needs major clarifications.
Thoroughness And Completeness
Content is presented and explained completely. All areas of teaching paper #1,2,3, 4 &5 addressed thoroughly
Content is presented and explained somewhat completely (Missing some areas (subcontent i.e., #1 a, b, c, d) of the teaching paper).
Content presentation and explanation incomplete (Missing 1 major area (#1,2,3,4 &5) of the teaching paper).
Lacking in Content presentation and explanation (Missing more than 1 major area (#1,2,3,4 &5) of the teaching project).
*Final grade will be rounded to the nearest whole number.
6
Time Management Schedule
Time management will be a key issue for you if you are to successfully transition to nursing school. Complete the two assignments listed below as tools to assist you in planning for this new adventure. Think about the connection between time management and prioritizing tasks.
1. Time Management Schedule Fill in the prototype weekly calendar. This is what you “plan” to do every week. (Not what you did last week). Hints:
Begin by filling in all inflexible times (classes, work) Guide for study time: 2 hours of study per 1 hour of lecture and 1 hour of study
per 1 hour of laboratory/clinic) Write in your place of study (home, library, skills lab) Use color or design if this helps you organize Remember to add:
Sleep (particularly the night before clinical)Travel time (to and from school, work, childcare) Personal hygiene timeGrocery shopping, cooking, eatingFamily responsibilitiesFamily togetherness timeExercise “Don’t forget your spouse/significant other” timeRelaxing timeTelephone/internet
2. Mantra
Mantra have been used throughout time, beginning in India many centuries ago, as a method of focusing the mind. Mantras are considered to have powerful effects on those who use them. Literally the word mantra means “the thought that liberates or protects”. Repeating a mantra can help you overcome fear, increase your creativity, give you energy when you are tired, and inspire you to keep going when you want to quit.
Many of us are familiar with mantras but may not realize it. Our lives are filled with such mantras as “No pain, no gain”, or “The teacher is out to get me”, or “This is too hard, I might as well quit now” or “Practice, makes perfect”.
In some spiritual traditions, mantras are given to students by their teachers. However, it is possible to make up your own mantra and use it as an antidote to other negative mantras you may already be using.
Design a mantra for your personal use in nursing school. This mantra will be a simple phrase that you will recite over and over. Be creative and have some fun. Be inspired.
7
Time Management Schedule and Mantra
Student Name__________________Lab Group_______________________
Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday04050607
08
09
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12010203Add up Hours
Study: Work:Sleep:
Study:Work:Sleep:
Study:Work:Sleep:
Study:Work:Sleep:
Study:Work:Sleep:
Study:Work:Sleep:
Study:Work:Sleep:
Mantra: __________________________________________________
8
Laboratory Learning Outcomes: Environment/Safety/ Asepsis/Infection Control
After studying this content, you should be able to:
1. Outline strategies to provide a safe patient environment
2. Identify clients who are at high risk of falls
3. Identify nursing actions in the event of a fire
4. Describe and draw the six steps in the chain of infection
5. List and describe conditions that predispose clients to infection
6. Describe what is meant by the term nosocomial infection (now known as hospital acquired infection) and discuss one intervention that will help prevent it
7. List the major organisms responsible for nosocomial infections
8. Define the term surgical asepsis and medical asepsis
9. Describe how and when personal protective equipment should be used.
10. Demonstrate and outline the steps in donning and removing personal protective equipment according to the Centers for Disease Control
11. Describe the practice of standard precautions and transmission based precautions.
12. Discuss the purpose of neutropenic precautions/ isolation and the measures that should be followed with this type of isolation.
13. Discuss multidrug resistant organisms and nursing implications
14. List interventions that might be used to meet psychological needs of a patient in isolation.
15. Describe the contents and care of an isolation room.
Skill: Application and Removal of personal protective equipment
9
Laboratory Learning Outcomes: Vital Signs
After studying this content, you should be able to:
1. Define the terminology relating to vital signs
2. Explain physiologic processes involved in homeostatic regulation of temperature, pulse, respirations, and blood pressure.
3. Compare and contrast factors that increase or decrease body temperature, pulse, respirations, and blood pressure.
4. Identify sites for assessing temperature, pulse, and blood pressure.
5. Discuss the steps to accurately obtaining temperature, pulse, respirations, and blood pressure.
6. Discuss the normal ranges for body temperature, pulse, respirations, and blood pressure.
7. Demonstrate documentation of vital signs.
8. Discuss the steps to obtaining an orthostatic blood pressure and pulse as well as their indications.
Skills: blood pressure, orthostatic blood pressure, radial pulse, apical pulse, respirations and oral temperature, pulse oximetry
10
Laboratory Learning Outcomes: Activity and Rest
After studying this content, you should be able to: 1. State nursing guidelines and rationale for use of proper body mechanics.
2. Identify variables that influence body alignment.
3. Describe common patient positions.
4. Demonstrate supine, lateral and Fowler’s positions.
5. Discuss positioning and protective devices and indications for use.
6. List nursing guidelines and rationales for patient transfer and ambulation.
7. Demonstrate patient transfer using a gait belt: bed to wheelchair and wheelchair to bed.
8. Describe the effects of exercise and immobility on major body systems
9. Assess body alignment, mobility, and activity tolerance, using appropriate interview questions and physical assessment skills.
10. Relate nursing guidelines and rationales for performing range of motion exercises.
11. Demonstrate appropriate range of motion exercises to all body joints.
12. Document range of motion procedure.
13. Compare comfort, rest and sleep.
14. Relate spiritual needs to comfort.
15. Differentiate between NREM and REM sleep.
16. State the relationship of age to sleep requirements.
17. Examine sleep promoting and sleep suppressing factors.
18. Review drugs that affect sleep.
Skills: transfer patient from bed to wheelchair and from wheelchair to bed with and without a gait belt, perform passive range of motion on all joints, positioning of a patient in bed, moving a patient up in bed, ambulating a patient with and without a gait belt
11
Laboratory Learning Outcomes: Personal Hygiene Measures
After studying this content, you should be able to:
1. Describe and demonstrate correct hand washing techniques.
2. List all possible situations when hand washing should be performed.
3. Discuss the use of alcohol based antibacterial hand gels.
4. State the personal hygiene guidelines related to hair, fingernails and jewelry.
5. Discuss the characteristics of healthy skin, mucous membranes, nails, hair and teeth.
6. List nursing guidelines for bathing patients.
7. State the types of therapeutic baths and the purpose for each.
8. Describe interventions for care of patient’s teeth and mouth (including dentures and bridges), eyes, ears, nose, fingernails, feet, toenails and hair.
9. Describe how to shave male patients and list any nursing precautions.
10. Describe and give the rationale for making open and closed beds, beds with skeletal traction device and surgical beds.
11.List medical asepsis guidelines related to handling of linen and the disposition of contaminated articles.
Skills: hand hygiene, non-sterile gloving, bed bath, making occupied bed
12
Laboratory Learning Outcomes: Documentation and Reporting
After studying this content, you should be able to:
1. State at least 4 uses of documentation in a medical record and recognize when documentation is used inappropriately.
2. Define and apply the following types of nurse’s notes documentation (narrative, SOAPIE, Focus [DAR], PIE, and charting by exception)
3. Discuss the pros and cons of using flowsheets for documentation.
4. Name the components and use of a nursing care plan.
5. Discuss the pros/cons of computerized charting
6. Apply the “Golden Rules” of documentation
7. Recognize and utilize medical abbreviations, both approved and from the “Do Not Use” list.
8. Convert traditional time to military time
13
Laboratory Learning Outcomes: Bandages/Binders/ Restraints/ Thermal Therapy/ TED
After studying this content, you should be able to:
Bandages and Binders
1. State the purposes of bandages and binders.2. Discuss the general guidelines for application and removal of bandages and
binders. 3. Demonstrate application of the following:
A. An abdominal binderB. An ace bandage using the spiral turn, recurrent, and figure of eight turn
Restraints
1. Discuss the benefits and risks of using physical restraints2. Explain the basis for enacting restraint legislation and JCAHO accreditation
standards. 3. Demonstrate proper application of restraints4. Discuss nursing responsibilities related to use of restraints5. Differentiate between a restraint and a restraint alternative6. List 5 restraint alternatives
Thermal Therapy
1. Discuss concept of heat transfer and biophysical response to thermal therapy. 2. List the common uses for both heat and cold as therapeutic modalities. 3. Describe techniques and related nursing responsibilities for heat and cold
applications. 4. Discuss the risks of applying cold therapy for fever management
TED (Antiembolism stockings)
1. Describe the purpose of TED hose (antiembolism stockings) and the patient populations for which they are prescribed.
2. Describe the proper measurement and application of TED (antiembolism stockings).
3. Describe the neurovascular assessment performed on patients with TED hose (antiembolism stockings).
4. Discuss the purpose of sequential compression devices (venodyne, foot pumps, sequentials, SCDs).
Skills: Apply abdominal binder, vest and wrist restraint to patient in bed, antiembolism stockings; ace bandage using 2 techniques and application of vest to patient in wheelchair.
14
Laboratory Learning Outcomes: Urinary and Bowel Elimination
After studying this content, you should be able to:
Urinary Elimination
1. Describe the physiology of the urinary system.2. Identify variables that influence urination.3. Describe how the nurse would assist the patient with toileting, use of a
bedpan, a urinal, bedside commode and a condom catheter. 4. Describe the care and management of an indwelling catheter and external
urinary catheter. 5. State the rationale for measuring and recording the patient’s urinary
output.6. Discuss the use of a “hat” in a commode and graduated cylinder to
measure urine output. 7. Describe the process of emptying a foley catheter drainage bag.8. Describe how the collection of the following urine specimens are obtained
and give the reasons for why they are collected: A. MidstreamB. 24 hour D. Indwelling catheter.
Bowel Elimination
1. Review normal anatomy and physiology related to elimination.2. Describe the characteristics of normal bowel elimination and stool. 3. Identify nursing interventions for patients with diarrhea or constipation.4. Discuss the steps for the following procedures: removing fecal impaction;
rectal suppository, administering a large volume enema; administering a small volume enema.
5. Identify nursing interventions if signs and symptoms of vagal response occurs
6. Describe how stool specimens are collected and give the various reasons why they are collected.
Skills: Enema Administration, applying a condom catheter, emptying a Foley drainage bag, placing a patient on a bedpan/fracture pan, assisting a patient with use of a urinal, emptying a BSC, providing pericare and foley catheter care, obtaining a specimen from an indwelling foley catheter, changing a incontinence brief
15
Laboratory Learning Outcomes: Critical Thinking
After studying this content, you should be able to:
1. Define critical thinking.
2. Discuss the importance of critical thinking in nursing.
3. Describe the characteristics and attitudes of critical thinkers
4. Contrast 3 approaches to problem –solving.
5. Describe the 5 components of the nursing process.
6. Discuss the relationship of critical thinking to the nursing process.
7. Identify examples of critical thinking.
8. Apply critical thinking to a clinical situation.
Definition of Critical Thinking adopted by Cerritos College Department of Nursing
• Entails purposeful, outcome directed (results-oriented) thinking• Is driven by patient, family and community needs• Is based on principles of the nursing process and scientific method• Requires specific knowledge, skills and experience• Is required by professional standards and ethics codes • Requires strategies that maximize human potential (e.g. using individual
strengths) and compensate for problems caused by human nature (e.g. the powerful influence of personal perspectives, values and beliefs)
• Is constantly reevaluating, self-correcting and striving to improve
Alfaro-LeFevre, R. (1999) Critical Thinking in Nursing, 2nd Ed. Philadelphia: Saunders
16
Laboratory Learning Outcomes: Physical Assessment 3
After studying this content, you should be able to: Musculoskeletal System
1. Review the structure and function of the Musculoskeletal system2. Describe specific assessments performed during examination of the
Musculoskeletal system3. Identify the specific subjective data necessary to obtain a health history of
the Musculoskeletal System4. Define and describe the following common musculoskeletal conditions:
Rheumatoid arthritis, Osteoarthritis, Osteoporosis
Neurological System
5. Review the structure and function of the neurological system6. Describe specific assessments performed during examination of the
neurological system7. Describe the specific assessments included in the Glasgow Coma Scale8. Identify the specific subjective data necessary to obtain a health history of
the Neurological System9. Identify and describe sensory function tests and motor examination
17
Laboratory Learning Outcomes: Nasogastric Intubation
After studying this content, you should be able to:
1. Discuss reasons for nasogastric intubation
2. Describe the process of nasogastric tube insertion and removal including equipment needed.
3. Describe various methods to check placement of a nasogastric tube.
4. Discuss nursing interventions related to promoting patient comfort and maintaining a nasogastric tube.
5. Compare and contrast the Salem sump and Levin gastric tubes
6. Discuss nursing management of the NGT attached to suction
7. Identify the purpose of NGT to suction.
8. Discuss the steps to discontinuing an nasogastric tube
Skills: Insertion and removal of a nasogastric tube; attaching NGT to suction; discontinuing an NGT
18
Laboratory Learning Objectives : Nutrition Lab
After studying this content, you should be able to:
1. Discuss the assessment of a patient’s normal nutritional status.
2. Discuss cultural influences related to meeting nutritional needs.
3. Describe how to feed a patient with special needs.
4. Describe commonly ordered therapeutic diets.
5. Demonstrate meal percentage and oral fluid intake measurement and record.
6. List interventions to assist the patient who is on restricted fluids.
7. Discuss reasons for nasogastric and gastric intubation
8. Describe the process of administering a continuous and intermittent nasogastric and gastrostomy tube feeding.
9. Demonstrate the process of administering a water bolus via an NGT or gastrostomy feeding tube.
10.Discuss how nasogastric and gastrostomy feedings are measured and recorded.
11. Compare the risks and benefits of gastric feeding versus total parenteral nutrition.
Skill: Administering intermittent and continuous tube feeding; Administering a water flush of an NGT/G tube.; How to measure and document percentages of food tray consumed, and measuring fluid intake.
19
Laboratory Learning Outcomes: Foley Catheterization
After studying this content, you should be able to:
1. Demonstrate the insertion of a Foley catheter using sterile technique
2. Explain the procedure for removal of an indwelling catheter
3. Discuss patient teaching related to maintaining a foley catheter.
4. Discuss the patient teaching related to post foley catheter removal.
5. Identify unexpected outcomes that may occur during foley catheter insertion and recommended nursing interventions.
Skill: Insertion and removal of an indwelling urinary catheter
20
Laboratory Learning Outcomes: Wound Management
After studying this content, you should be able to:
1. Identify the three stages of wound healing
2. Discuss the difference between primary, secondary and tertiary intention wound healing.
3. List the factors that can affect wound healing to include nutrition, medications, and health status.
4. Identify the signs and symptoms of a wound infection.
5. Identify the solutions used for wound irrigation and rationale for use.
6. Describe various types of wound drainage.
7. Describe the different types of wound treatments: e.g. transparent, hydrocolloid, wound vac, hydrogel, calcium alginate and foams.
8. Discuss the indication for use of transparent and hydrocolloid wound dressings.
9. Discuss the wound closure devices: staples, sutures, retention sutures steristrips, dermabond and Montgomery straps, wound-vac.
10. Identify and discuss the mechanism of action of the following wound drainage devices: penrose, Jackson-Pratt and hemovac .
11.State the guidelines for maintaining a sterile field
12.Describe the steps (and rationale for each step) for performing a sterile wet to moist dressing.
13.Demonstrate a wet to moist sterile dressing change.
Skills: wet to moist sterile dressing change
21
TalonNet SKILLS VIDEO DEMONSTRATIONS
You are required to view the following skills demonstrations online (from any internet access computer or the skills lab computers in SL 121, 122, 123, 110) prior to assigned control lab days at http://talonnet.cerritos.edu/osp-portal (TalonNet)
These videos were developed as an instructional aide by your instructors for beginning nursing students.
Enter username (7 digit student ID number) and password (6 digit birthdate) Click on My Projects (top menu bar)
Click on My Video Links
Click on Nursing Skills Videos; click “I Agree” on the copyright;
Choose your video links according to assigned labs and view the videos (click on broadband if you have high speed internet; click on 56K if you have dial-up internet)
Content Name of Skills Video LinkMedical Asepsis Handwashing
Nonsterile Gloving
Sterile Gloving
HandHygiene
GlovingNSterile
GlovingSterile
Vital SignsSee Taylor Videos
Ch 24: Vital Signs, Watch and Learn: Measuring oral Temp, Radial pulse, resp rate and blood pressure
Ch 24: Vital Signs, Watch and Learn: Measuring an apical pulse (Use your scratch off access code on inside cover of textbook to access videos)
VitalSigns
ApicalPulse
PulseOximetry
RectalTemp
TymAxTemp
22
Activity and Rest Ambulating a patient
Bed Mechanics
Moving a Patient up in bed
ROM exercises
Positioning a Patient
Transferring a Patient
AmbPatient
BedMech
MovingPatient
PassiveRange
PositionPatient
TransPatient
Personal Hygiene Measures See TalonNet VideoORSee Taylor VideosCh: 31: Hygiene, Watch and Learn: Giving a Bedbath
Ch 31: Hygiene, Watch and Learn: Making an occupied bed
Bed_Bath
Physical Assessment No videos required prior to lab
B/B/Teds/Restraints/Thermal Therm
Bandages and Binders/Teds/Restraints/Thermal Therapy
Bandages
EliminationEnema
Collecting a Urine Specimen
Enema
UrineSpecimenPhysical Assessment No videos required prior to lab
Scenarios Review previously learned skills videos
Physical AssessmentNo videos required prior to lab
NGT Insertion TalonNet: Nasogastric tube Insertion
OR
See Taylor Video-Ch. 36: Nutrition, Watch and Learn: Inserting a Nasogastric tube
NGTube
VS Competency TestingReview Vital Signs videos
23
ScenariosReview all previously learned skills videos
Nutrition LabView Taylors Video Guide to Clinical Nursing Skills CD ROM
Administering a continuous tube feeding: Using a feeding pump and a prefilled closed tube feeding set-up
Foley Catheterization Foley Catheter Catheter
Wound Care Wound Care WoundCare
N210 Fundamentals of Nursing
Nursing Skills Peer Check Off
Following independent practice, demonstrate proper technique of the following nursing skills to your classmates three (3) separate times. Obtain peer signatures/dates indicating that you have demonstrated proper technique in performing the skills. If you need help, please refer to the videos online, your skills book, and/or see a skills lab instructor during open lab.
This sheet is to be completed prior to Skills CPE and submitted to clinical instructor on Skills CPE testing day (week 8). Any student who fails to turn in a completed sheet to the instructor will receive an advisement note and will not be allowed to test for CPE. Arrangements will be made with the instructor to test for CPE on a different day. If a student fails the CPE, a skills lab referral will be given for the failed skill and the student is to complete the Skills Lab referral within 1 week of the referral date.
24
Nursing Skills Peer Check Off
Student___________________________ Clinical Instructor_____________________
Skill Peer Name (PRINT) Signature DateBed Bath And Occupied Bed Making
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Handwashing 1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Sterile And Nonsterile Gloving
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Denture Care 1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Applying And Removing PPE
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Taking Full Set Of Vital Signs Temp (Oral, Ax, Tymp, Rectal); Pulse (Radial and AP), Resp, BP
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Patient Transfer From Bed To Chair
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Positioning A Patient In Bed 1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Ambulating A Patient 1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Applying Bandages, Binders, Restraints,Anti-Embolism Stockings, Thermal Therapy
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Enema Administration 1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Collecting Urine Specimen From A Urinary Catheter
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Sterile Wet-Moist Dressing Change
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
25
Urinary Catheterization (Male & Female)Requires 2 peer and 1 Skills Lab Personnel (instructor or student worker) signature
1. _______________2. _______________
3. _______________
1. _____________2. _____________
3. _____________
1. _______2. _______3. _______
Nasogastric Tube Insertion 1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Water Bolus Via Nasogastric Tube
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Moving A Patient Up In Bed
1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
Range of Motion Exercises 1. _______________2. _______________3. _______________
1. _____________2. _____________3. _____________
1. _______2. _______3. _______
REMINDER:
This sheet is to be completed prior to Skills CPE and submitted to clinical instructor on Skills CPE testing day (week 8). Any student who fails to turn in a completed sheet to the instructor will receive an advisement note and will not be allowed to test for CPE. Arrangements will be made with the instructor to test for CPE on a different day. If a student fails the CPE, a skills lab referral will be given for the failed skill and the student is to complete the Skills Lab referral within 1 week of the referral date.
26
Environment/Safety/ Asepsis/Infection ControlControl Lab Sheet
Chain of Infection1. Discuss the chains of infection (reservoir, portal of entry, mode of
transmission, etc.) then give examples that apply to each chain (e.g. mode of transmission = direct contact, droplet). See Chain of Infection Illustration.
2. ScenariosA. Scenario 1: The spread of InfectionAn elderly patient, hospitalized with a gastrointestinal disorder, was on bedrest and required assistance for activities of daily living. The patient had frequent uncontrolled diarrhea stools and the nurse provided excellent care to maintain cleanliness and comfort. While cleaning the patient, the soiled linens touched the nurse’s uniform. The nurse placed the soiled linens on a chair and left the room. Following 1 episode of cleaning the patient and changing the bed linen, the nurse immediately went to a second patient to provide am care and assist with the morning meal. The nurse’s hands were not washed prior to assisting the second patient. 2 days later, the second patient developed diarrhea. His stool cultures showed positive for Vancomycin Resistant Enteroccocus (VRE).
Let’s examine the chain of infection as it applies to this situation
Question#1What is the:
Answer
Susceptible hostInfectious agentPortal of entryMode of transmissionReservoirPortal of exit
Question #2 AnswerBreak the Chain of Infection…What should the nurse do to prevent the spread of infection? Which PPE should be worn?
27
B. Scenario 2: The Nurse Breaks the Chain
A patient assigned for morning care has an open wound on her left lower leg. The wound is draining and when last cultured, the microorganism MRSA was identified.
In preparation for bed making, the hands of the nurses were washed. Clean linen and a bag for soiled linen were gathered from the linen room and placed on the patient’s clean bedside stand.
To remove the soiled linen from the bed, the following procedure was followed:
Hands washedGloves wornEach side of the soiled linen ends folded towards the middle of bedSoiled linen held away from the nurses’ uniformSoiled linen placed in the linen bag for later discardProtective gloves removedHands washed
Let’s examine the chain of infection as it applies to this situation
Question#1What is the:
Answer
Infectious agentReservoirPortal of exit
Question #2 Answera. How did the nurse break
the chain of infection?b. Which chains where
broken?c. Which PPE should be
worn?
28
Environment/Safety/ Asepsis/Infection ControlControl Lab Sheet
Fall Risk Assessment
Mr. Jackson is a 73-year-old stroke patient with recent mental status changes, admitted for prostate surgery. He has right-sided weakness and has fallen once at home while trying to go to the bathroom. He has difficulty initiating a urinary stream, dribbling of urine, and nocturia. He has a history of hypertension, for which he takes hydrochlorothiazide (diuretic).
List specific interventions to ensure Mr. Jackson’s safety in the hospital.
29
N210 Fundamentals of Nursing
Vital SignsSkills Check Off Stations
Lab Groups Lab A & B Lab C & D Lab E & F
Room Assignment SL 105 SL 122 SL 123
ACTIVITY Faculty Initials
TemperaturePractice taking temperature on another student:
Oral axillary tympanic
Practice taking temperature on a manikin: rectal (using manikin)
Set of Vital SignsTake a full set of vital signs (temp., pulse & respirations, apical pulse, blood pressure) on 3 clients & document on the graphic sheet
Vital Signs ManikinApical PulseListen to apical pulse on manikin. Identify the rhythm and write on the back of this sheet.
Orthostatic Vital SignsPractice taking orthostatic vital signs on another student
Answer orthostatic vital signs questions on the poster. Use the back of this sheet.
VS Special Considerations (SL 121)Assess the client and answer Measuring Blood Pressure questions on the poster. Use the back of this sheet.
Complete this sheet by the end of week 2.
30
Vital Signs Questions
Apical PulseIdentify the rhythm on the VS manikin. ______________
Orthostatic Vital Signs1. How would you take orthostatic VS on a patient?
2. How would you take orthostatic VS on a patient who is dehydrated and is experiencing some dizziness upon rising from a lying position?
Measuring Blood Pressure (VS Special Considerations)1. You are caring for a post left-mastectomy patient. Where would you take
the patient’s blood pressure?
2. You received report from the previous shift’s nurse that your patient has an atrio-venous graft (AV dialysis graft) on her right arm. Where would you take the patient’s blood pressure?
31
N210: Fundamentals of NursingBandages/ Binders/ Restraints/ Antiembolism Stockings/ Thermal Therapy
Critical Thinking Questions
1. How often does the physician’s order need to be renewed for a client on restraints?
2. When initiating restraints without a physician’s order, what is the time frame in which the physician’s order needs to be signed?
3. How often do you release restraints on a client?
4. What are your nursing responsibilities when releasing a client from restraints?
5. What would you need to monitor on a client who is on restraints and how often would you do this?
6. How often should the need for continuation or termination of restraint use be determined?
7. What would you need to assess after applying an abdominal binder on a client?
8. What would you need to assess after applying anti-embolism stockings?
9. What are restraint alternatives? Give examples of these.
10.How would you prevent thermal injury on a client using a heating pad or hot compress?
32
N210: Fundamentals of NursingBandages/ Binders/ Restraints/ Antiembolism Stockings/ Thermal Therapy
Scenario:
As you enter your female client’s room, you find her with one leg over the side
rail, making attempts to get out of bed unassisted. Your client is an 82-year-
old female with a history of congestive heart failure (CHF). When you
question what she is doing, she tells you, “I need to go to the bathroom.” She
also tells you she is sure her dog needs to be let out because she hasn’t been
able to get out of bed all morning. This is your second day caring for your
client. Your initial assessment on admission 2 days ago included her being
oriented to person, place, time, and purpose. The night shift did report off
saying she was disoriented all night.
1. What is your first nursing action? Provide rationale for your response.
2. What additional priority nursing actions are justified for your client?
3. What additional information do you need to gather to determine the next step in her plan of care?
4. If it is determined that your client needs to be closely monitored for possible falls, what interventions, by priority, will you implement?
5. Identify the legal requirements that must be implemented when a client is placed on restraints. (Read the procedure, Managing a client of restraints)
6. What documentation must be provided when a client is placed on restraints?
33
N210: Fundamentals of Nursing
Elimination Practice Station Check-off
Station 1
Emptying Foley catheter bag______________________________Specimen from foley catheter______________________________
Station 2
Assisting with urinal _____________________________________Place a fellow student on a bedpan_________________________Changing a brief________________________________________
Station 3
Enema Administration___________________________________
Station 4
Pericare on female manikin_________________________________Emptying a BSC__________________________________________Foley catheter care________________________________________
Station 5 (self station)
Condom catheter________________________________________
34
Physical Assessment Documentation Guide
Student____________________________ Date ________________
Client/Patient Initials________Age ________Sex__________
General State of Health
Subjective Data: (Obtain all info under “General State of Health” from Review of Systems page 5 of Jarvis)
Objective Data:Appearance
Posture (relaxed, erect, tripod position, slumped, leaning to one side)Overall hygiene and grooming (clean, well groomed, unkempt)Any apparent signs of distress Dress (appropriately for situation)
BehaviorLevel of consciousness (awake, asleep, lethargic, comatose)Mood and affect/ Facial expressions (appropriate for situation)
CognitionOrientation (person, place, time, and purpose-X4)Speech (clear, garbled, slurred, incomprehensible)Responsiveness (follows directions and responds appropriately)
Documentations: (Include both Subjective and Objective Data in Narrative Form)
35
Physical Assessment Documentation Guide
Student____________________________ Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Skin, Hair, and Nails
Subjective Data: (Obtain all info under “Skin”, “Hair”, & “Nails” from Review of Systems page 5 Jarvis)
Objective Data:Inspection and palpation of the skin
Color(pink, cyanotic, jaundiced, erythematous),Pigmentation (even, hyper/hypopigmentation)Lesions (Describe 3)
Description – size & colorStructure - type of lesion (macule, papule, nodule etc.)Anatomical Distribution
Hydration – skin turgor (immediate recoil, tenting)Temperature & Moisture (warm/dry, cool/clammy)
Inspection and palpation of the hairColor & conditionQuantity, distribution, & texture (abundant; balding/receding vs. bald patches, smooth or course)
Inspection and palpation of the fingernailsColor of nail bedFirmness, texture, ridging, or irregularitiesClubbing:
Palpate for firm nail matrixEstimate nail angle (160 degrees or less; >160 degrees)
Documentation: (Include both Subjective and Objective Data in Narrative Form)
36
Physical Assessment Documentation Guide
Student____________________________ Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Head and Neck
Subjective Data: (Obtain all info under “Head, Eyes, Ears, Nose, Mouth and Neck” from Review of Systems page 5-6 Jarvis)
Objective Data:Inspection and palpation of the head and face
Skull for symmetry & tendernessFace (includes eyes, ears, nose, mouth, and neck)
SymmetryDiscolorationLesionsDrainageDistention of neck
Oral mucous membranes –color, hydration(dry/moist), lesions
Documentation: (Include both Subjective and Objective Data in Narrative Form)
37
Physical Assessment Documentation Guide
Student____________________________ Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Chest and Lungs
Subjective Data: (Obtain all info under Respiratory from Review of Systems in Jarvis page 6)
Objective DataInspect chest wall Color, Configuration (symmetry) and LesionsMovement
Respiratory rate, depth, and effort
Auscultate systematically for quality of lung soundsAssessment of lung sounds and location
(Clear, diminished, absent)Identify adventitious sounds if present:
Wheezes (sibilant or sonorous rhonchi)Crackles (fine or course)
Documentation: (Include both Subjective and Objective Data in Narrative Form)
38
Physical Assessment Documentation Guide
Student____________________________ Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Heart and Peripheral Vascular System
Subjective Data: (Obtain all info under Cardiovascular, Peripheral Vascular from Review of Systems page 6 Jarvis)
Objective DataHEARTInspection
Pulsations, lifts, heaveJVD with chest at 35-45 degree angle
AuscultationRhythm assessment of S1 and S2 (Regular/Irregular)
Assess all auscultatory sites: APETM Count Apical Heart Rate
PERIPHERAL VASCULAR SYSTEMPalpation of Peripheral Pulses
RadialFemoralPosterior TibialDorsalis Pedis
Skin color – extremities (upper and lower)Capillary refill after blanching (secs)
Fingers/toesPresence of Edema- depress for 5 seconds (grade if pitting)
Documentation: (Include both Subjective and Objective Data in Narrative Form)
39
Physical Assessment Documentation Guide
Student____________________________ Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Abdomen
Subjective Data: (Obtain all info under Gastronintestinal, Genitourinary from Review of Systems page 6-7 Jarvis)
Objective DataInspection
ContourLesionsScarsDistentionPulsationsHernia (while patient lifts head)
Auscultation (all quadrants)Bowel sounds
PalpationLight palpation
Tension of abdominal wall (soft, firm, hard)TendernessMasses
Deep palpationTendernessMassesEnlarged organs
PercussionCVA tenderness
Documentation: (Include both Subjective and Objective Data in Narrative Form)
40
Physical Assessment Documentation Guide
Student____________________________ Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Musculoskeletal System
Subjective Data: (Obtain info from Review of Systems under Musculoskeletal in Jarvis)
Objective DataMuscle strength
Check each muscle group against resistanceCompare right with left:
Upper extremitiesTricepsBicepsAdduction armsAbduction armsWrists – flexion, extension
Lower extremitiesQuadricepsHamstringsAbduction kneesAdduction kneesPlantar flexion feetDorsiflexion feet
Documentation: (Include both Subjective and Objective Data in Narrative Form)
41
Physical Assessment Documentation Guide
Student____________________________ Date ________________
Client/Patient Initials________Age ________Sex__________
Neurological Assessment
Subjective Data: (Obtain info from Review of Systems under Neurological in Jarvis)
Objective DataMental Status ExaminationAppearance (posture, body movement, dress appropriate
for setting, grooming/hygiene)Behavior (level of consciousness, facial expression,
mood and affect)Cognition (orientation x4, responsiveness, speech)Thought Processes (thought content for consistency and logic, perceptions
consistency with reality, any suicidal thought)
Pupillary Reaction (equality, size, shape, reaction to direct and consensual light)
Sensory system (assess for intactness of the following sensory functions)Light touchPain and temperature (only unable to feel light touch)VibrationKinesthesia/Proprioception (position sense)StereognosisGraphesthesiaTwo-point discrimination
Motor function (assess for strength)Hand grips (ask client which is dominant hand)Foot pushes( plantar flexion)
42
Deep tendon reflexes (Grade)Biceps Triceps Brachioradialis Quadriceps Achilles
Cerebellar FunctionsBalance
GaitGross motor coordination – heel to toe walkingRombergRapid Alternating Movements (RAM)
Documentation: (Include both Subjective and Objective Data in Narrative Form)
43
PHYSICAL ASSESSMENT PRACTICUM
Student____________________________ Date ________________
**Starred ** items are critical elements and must be passed by the student.
Technique Organization Clear Description (5) (5) Instructions(2) Accurate (4)
General Survey:Appearance (posture, grooming, hygiene,
apparent signs of distress, dress)Behavior (attitude, mood and affect, facial expressions)Cognition (mental status, speech, level of orientation)
SkinColor (pink, cyanotic, jaundice, dusky, pale/appropriate for race)Hydration – skin turgorTemp. and Moisture (warm/cool, dry/clammy)Lesions (describes morphology, size, color, pattern of
arrangement, and distribution) (Describe two lesions)Neurological
Pupils - equal, round, reactive to direct and consensual lightHead and Neck
Visual Inspection of skull, face (eyes, ears, nose, mouth, and neck)Include oral mucous membranes (color, moist/dry, lesions)Assess for drainage, lesions, distention, discoloration, and symmetry
LungsPerforms inspection before auscultationAssess respiratory effort and rateAssess for symmetry of chest wall movement Auscultate for breath sounds (anterior or posterior chest)
in a systematic orderHeart
Identify auscultatory sites:Aortic – 2nd right ICSPulmonic – 2nd left ICSTricuspic – Left 5th ICS sternal border or midsternal lineMitral – left 5th ICS midclavicular line
**Auscultate S1 and S2 - assess rhythm (S1 S2 Reg./irreg.)assess for extra heart sounds & murmurs
Identify PMI (left 5th ICS midclavicular line)Count Apical heart rate (BPM) for 1 full minute
44
Technique Organization Clear Description(5) (5) Instruction (2) Accurate (4)
Peripheral VascularPalpates for pulses together:Radial, Pedal
Capillary refill (secs) (hands) **Assess for edema (depresses medial malleolus & pretibial area for 5 seconds)
Abdomen ** Auscultation before PalpationInspect for contour,lesions,distentionAusculate all 4 quadrants for bowel sounds Count in each quadrant for 1 full minuteLight palpation all quadrants (bend knees before palpation) (begins at RLQ and proceeds clockwise)
Motor - Assess hand grips and foot pushes bilaterally
_______________________________________________________________________________________________________________ Musculoskeletal
ROM and Motor strength against resistance:If unable to assess patient’s ability to move in the bed during the assessment, then test specific muscle sets:
Upper extremities (arms only – biceps, triceps)Lower extremities (legs only – quadriceps, hamstrings)
PerformanceHIPIE
Worked from head to toe X X X Professional behavior (verbal and nonverbal communication,
draping of patient)
TOTAL SCORE: _____/149 /50 /45 /18 /36COMMENTS:__________SATISFACTORY (95% or better= 141/149 points)__________NEEDS INPROVEMENT (90-94% = 133-140/149- Skills Lab Referral for head to toe physical assessment)__________UNSATISFACTORY (<90% or 132/149: Advisement note and retest with instructor).*** Failure to pass retest will result in requirement to complete N251 course prior to Fall semester N220 course or concurrent with Spring semester N220 course.
45
Nasogastric Tube InsertionCritical Thinking Questions
Act out the most appropriate nursing actions for the following patient situations while you practice with the manikins.
1. Name nursing interventions/actions appropriate for a nasogastric tube that is difficult to advance
2. What nursing action is appropriate if the client coughs, is unable to speak, and becomes cyanotic during NGT insertion?
3. During advancement of the NGT, passed the nasopharynx, the client gags and coughs, but remains pink and is able to speak. What is the nurse’s next appropriate action?
4. Your client has a history of dysphagia from a previous stroke. The physician has ordered the client to remain NPO (nothing by mouth) and to insert a nasogastric tube. How would you proceed to instruct the patient to assist in advancing the NG tube once you have passed the nasopharynx.
5. If a Salem Sump pigtail leaks gastric contents, what should the nurse do?
6. Your client who has an NG tube connected to suction suddenly vomits around the tube. What is the appropriate action the nurse should take next?
7. Your client who is receiving a bolus NG-tube feeding is due for his morning medications. As you proceed to assess placement (by flushing with air and aspirating for gastric contents), you feel resistance and are unable to push the plunger. What may be the cause of the resistance and what is your most next appropriate action?
8. Your 72 year old male client has had a left sided stroke and is receiving a continuous G-tube feeding at 60 mL/hr.
a. In considering the client’s diagnosis and treatment, what is he most at risk for?b. What is the most appropriate nursing intervention to prevent this risk?c. You are checking the client’s residual and you obtain no residual. What does this mean and
what actions will you take?d. You are checking the client’s residual and you obtain 12 mL of residual volume. What does
this mean and what action will you take?
9. Practice connecting the tubing for the Kangaroo pump and priming the tubing prior to connecting to the end of the NG tube or G-tube.
46
Nasogastric Tube Removal (AIR-WATER-AIR)
1. Check physician’s order for NG tube removal
2. Gather equipment: Towel, paper towel, stethoscope, container of sterile normal saline (or
tap water), 60 mL syringe with catheter tip, tissues, clean gloves, tube plug
3. Assess client to determine presence of bowel sounds. Signs more indicative of GI function
include passage of flatus, bowel movement, absence of nausea and vomiting, and
presence of hunger.
4. Perform IPIE. Explain to client that removal may cause some nasal discomfort, coughing,
sneezing, or gagging.
5. Place towel over client’s chest
6. Disconnect NG tube from suction tubing of feeding machine if indicated
7. AIR : Flush tube with a 15-20 mL bolus of air (to displace the tube from the gastric mucosa)
then aspirate gastric contents to check for placement8. WATER : Flush NG tube with 20 mL of NS or tap water (To clear tube so that GI contents
do not inadvertently drain into the esophagus during tube removal)
9. AIR : Follow saline or water flush with a 20 mL bolus of air (to clear saline or water from tube and to free tube from stomach or intestinal lining)
10.Unpin tube from client’s gown and loosen tape that secures tube to client’s nose.
11.Plug tube or clamp it by folding it over in your gloved hand
12.Pinch tube to client’s nares, have client take a deep breath and hold it while you withdraw
the tube (Holding breath closes glottis and helps prevent aspiration)
13.Wrap tube in paper towel and remove from client’s view
14.Offer oral and nasal hygiene
15.Empty and record amount and character or drainage if applicable
16.Discard equipment and clean up
17.Remove gloves and perform hand hygiene
47
Urinary CatheterizationCritical Thinking Questions
1. Catheter is inserted into the female client’s vagina. What is the next most appropriate action by the nurse? (Role play this during practice and discuss your options with your fellow classmates).
2. Difficulty inserting catheter into a male client.a. Name two or three reasons a catheter would be difficult to insert in a male client.
b. Identify appropriate nursing actions if experiencing this difficulty.
3. As you are inserting an indwelling catheter into your male client, he begins to have an erection. What is the most appropriate nursing action at this time?
4. As you insert an indwelling catheter into your male patient, there is no urine return. What are possible causes and what are appropriate actions by the nurse in this case?
5. Demonstrate and practice the steps to removing a catheter. See back page (Catheter Removal).
6. What appropriate nursing assessments and client teachings would you perform for a client who has had his/her catheter remove/discontinued?
7. Continuous Bladder Irrigation (CBI) – see CBI station and do the following as a group.a. Discuss the purpose of a CBIb. Discuss the procedure of initiating a CBI on your patientc. What color and consistency of urine output would you expect to see on the urine drainage
bag immediately after a TURP-Transurethral Resection of the Prostate; and just before discontinuing the continuous bladder irrigation?
ACCEPTABLE Alternative method during catheter insertion : Once the unine flows, you may choose to keep the sterile dominant hand holding the catheter and use your nonsterile /nondominant hand to inflate
the balloon.
48
N210 Fundamentals of Nursing
CATHETER REMOVALSKILLS CHECKLIST
Recommended TechniqueS
N.I.U
Comments
CHECK physician’s orders (and when last changed if requiring changing)WASH handsASSEMBLE equipment: syringe, unsterile glovesIdentify (armband)ExplainPrivacyPOSITION: -Male: none required -Female: legs slightly apartREMOVAL: -empty FC drainage bag and discard urine. -empty catheter baloon by withdrawing fluid with syringe until resistance felt (balloon empty); note location of meatus in female if F/C being changed -Gently pull on F/C near meatus while pinching tube; inspect F/C for intactness (tip sent for C&S in some agencies)CLEAN perineum; provide patient comfortMEASURE urine; record I&ODISCARD equipmentDOCUMENT procedure -Time -Patient’s responseTEACHING: -2500 cc fluid/day, possibly acidifying liquids (cranberry juice) -Dribbling can occur for several hours -Need to void within 6-8 hrs; report if unable urge/fullnessASSESSMENT: -First void after d/c (If no void, include in shift report) -Frequency -Burning -Hesitation -Dribbling -Cloudiness or any other color or change in characteristicsRev. Fall’07
49
Wound Care Practice Station Check OffN210: Fundamentals of Nursing
Station 1
Identify the wound pictures. Identify the wound as red/yellow/black. Stage the pressure ulcer.
Picture 1_____________________________Picture 2_____________________________Picture 3_____________________________Picture 4_____________________________
Station 2
Identify the name of each treatment and what type of wounds each treatment is used for. (use pg 924 and 925 as a reference)
Transparent dressing_______________________________________________Hydrocolloid dressing_______________________________________________Wound vac_______________________________________________________Hydrogel_________________________________________________________Alginate__________________________________________________________Foams___________________________________________________________
Station 3
Identify which wound is healing by primary intention and which wound is healing by secondary intention. Pay special attention to statement on tertiary healing in page 1189 -1190 of Taylor’s textbook.
Primary _________________________Secondary_______________________Tertiary _________________________
Station 4
Identify each drainage device. The JP and Hemovac work by negative pressure- when compressed the drainage is PULLED into the collection area.
Penrose__________________________________________________Jackson-Pratt______________________________________________Hemovac__________________________________________________
Station 5
Identify each of wound closure device
50
Staples_____________________________________________________Retention sutures_____________________________________________Sutures_____________________________________________________Dermabond__________________________________________________Steristrips____________________________________________________Montgomery straps____________________________________________
Station 6
Identify each of the following types of wound drainage
Serous__________________________________________________________Sanguineous_____________________________________________________Serosanguineous__________________________________________________Purulent_________________________________________________________
Station 7
Check your answers on the study guide
Station 8 (optional) Remove sutures
Station 9
Practice a sterile wet to moist dressing change.
51
NPW and Assessment Guide Guidelines
General Instructions: All work must be neat and legible NPW to be completed on EVERY patient cared for in the clinical setting BEFORE you
provide nursing care to the patient Complete an assessment guide for ONE patient and submit each week Staple any additional papers Highlight any abnormal findings on the Assessment Guide Make extra blank copies and keep them in your clinical folder If no order can be found, write “no order”.
NPW Page 1Student: write your full nameDate: date(s) caring for patientCo-Assigned Nurse/NA: Nurse and nursing assistant assigned to the patientPatient Initials: Remember HIPPA regulations and only put the patient’s initialsRoom #: The room number of the patientAge: Age of the patientAdmit date: The date the patient was admitted to the facilitySurgery date: If applicable, state the date the patient had surgery relevant for the current admissionCode Status: The resuscitation status for the patient. Ex: DNR, No Code, Full Code, No CPRAllergies: State all allergies to medications, food, environmentAdmitting diagnosis: State the diagnosis given as reason for admission. Ex: Pneumonia. May not have admitting diagnosis in long term care. May only have chronic diagnoses. Ask your instructor for assistance as necessary.History of present illness: Describe the events that occurred from time of onset of illness to time of admission. May not have in long term care.Course of events in hospital: What major events occurred from the time of admission to the time you assume care. Ex: Admitted with R/O Myocardial Infarction. That diagnosis was ruled out. Patient was found to have a hiatal hernia causing him chest pain and is schedule for surgery (fundoplication) to repair the hiatal hernia. Will not complete in long term care.Hx: State the patient’s significant past medical and surgical history. Ex: History of COPD, osteoarthritis, cataracts in the right eye
MD Orders*ONLY MD ORDERS FROM THE ORDER SECTION OF THE CHART ARE ENTERED IN THIS SECTIONVital Signs: Frequency ordered Ex: every 4 hours. Diet/Feedings: Diet ordered and/or tube feedings (name of solution, volume to be administered, continuous vs. intermittent)Activity: The activity level ordered IVF: Intravenous fluids ordered for continuous infusion only. Ex: D5.45NS @ 100 ml/hr. Any piggyback solutions are written under medicationsBlood glucose monitoring: Frequency ordered Ex: QAC and HS (before meals and before bedtime). Treatments/Nursing Orders: This section should include any additional orders for the patient. Ex: strict I/O, wet to dry dressing change every 8 hours, Foley catheter, O2 at 2L NC.
Diagnostic Results Should be the most recent lab results
Record the normal range for each lab result-Urine: specify which urine test you are referring to. Ex: culture normal (-), patient result is + for E.Coli
52
-X-ray: specify which X-ray is done. Ex: CXR normal is (-) and patient result is right lower lobe infiltrate
Record the reason for patient values. -If normal: state WNL. If this normal is unexpected, also state this and whyEx: WBC is normal for a patient admitted with pneumonia is an abnormal finding, but could be explained in a patient that is immunocompromised-If abnormal: state the reason the value is abnormal. Ex: Elevated WBC in a patient with pneumonia occurs because of response to inflammation and infection.
NPW Page 2Create two concept maps to represent the following information: pathophysiology, signs and symptoms, medical treatment and nursing interventions.
In long term care, you may create concept maps for chronic medical problems. Ideally ones that have signs and symptoms you can observe and that have nursing interventions you can implement.
In N212, you will need a concept map for every admitting medical/surgical diagnosis and additional concept maps if the patient has diabetes, hypertension, COPD and/or chronic renal failure (ESRD, CRD, is on dialysis).
Medications Page 3Drug Names: State the trade (one) and the generic name of the medicationClass: State both the functional and chemical class for each drug. Dosage and range: State the normal dosage range for this person (ex: elderly) and the dosage ordered for the patientRoute: State the route ordered for the patient. Ex: oral, intramuscular, subcutaneous, etc.Indication for use for this patient and nursing implications: Why is this medication ordered for this patient? State any nursing implications for the administration of this medication. Ex: Check BP before administering an antihypertensive. Time and frequency: State when the drug is ordered to be administered and the frequency of administration. Ex: Ordered twice a day and the administration times are 0900 and 2100
Attach additional paper if needed
Assessment Guide (AG) Page 4The Assessment Guide is based on the diagnostic divisions based on the Roy Adaptation Model. The RAM diagnostic divisions page should be used as a guide to assist you in figuring out what information should be included in each section. This page is arranged in a stepwise approach, addressing each piece of information as you complete the Assessment Guide chart. Eventually this will become second nature and you will not have to refer to the diagnostic divisions page for reference.
Once the data collection is completed, you will be directed from your clinical instructor on how many complete diagnostic divisions should be thoroughly completed, starting with one, adding more sections as you become more proficient.
AG Psychosocial & Documentation Page 5Use this area for documentation as directed by your clinical instructor. You may be instructed to document a narrative, DAR, SOAPIE note or any variation that may be used by your facility.
53
Roy Adaptation Model Reference Sheet for Completing the Assessment GuideNeurological
Neurological Function-Subjective DataObj: LOC, GCS (eye opening, verbal response, motor response), seizures (describe, timing), altered mental status, aphasia, intellectual functioning-Lab results: radiology (EEG, MRI, etc)-Interventions: seizure precautions, etc.Include Sensation-Subjective Data-Pain (location, intensity, character, onset and duration), vision, hearing, response to sensory overload-Interventions: PCA pump, special devices (glasses, hearing aid)
ProtectionProtection-Subjective Data, immunization status-Obj: Temperature, Shivering, Diaphoresis, Skin/Hair/Nails (describe), Lesions (describe, location), Incisions (describe, location), IV site (describe, location), AV shunt (describe)-Lab results: WBC, C&S (specify source: wound, sputum)-Interventions: Wound dressing (location, describe), drainage tubes (type, site, describe), Isolation, Siderails, Bed position, Restraints (Type, reason)
F&EFluid and Electrolytes-Subjective Data-Obj: Changes in weight, LOC, thirst, 24 hour intake/output, abnormal loss (edema, drainage, diuresis, diaphoresis, tachypnea, diarrhea, emesis), tissue turgor, mucous membranes)-Lab results: Na; Cl; K; ABG: HCO3, pH; Urine specific gravity -Interventions: IVF (solution, tonicity of solution, flow rate), NG drainage (amount, describe)
Oxygenation-gas exchange
Oxygenation : Gas Exchange-Subjective Data -Obj: Respiratory Rate, Depth, Effort, Breath Sounds (describe, location), Cough (describe), Sputum production (describe)-Lab results: Sputum C&S, radiology results, ABG -Interventions: positioning, turning, DB&C, oxygen (flow rate and method), pulse oximetery (% on how much oxygen), incentive spirometer (volume, frequency of use), suctioning (type, frequency, response)
Focused Assessment Plan
Oxygenation-gas transportOxygenation: Gas Transportation-Subjective Data-Obj: Blood pressure, apical pulse, peripheral pulses (location, rhythm and strength), edema (degree, location), capillary refill (location), skin/mucous membranes, Homan’s sign (if appropriate)-Lab results: Hgb, Hct, RBC, platelets, PT/PTT, INR
Nutrition
Nutrition-Subjective Data-Obj: Height, Weight, Ideal body weight, Nutrition intake, NPO status and reason, food intolerances , nausea, emesis (describe), swallowing ability, gag reflex, oral cavity (inspect and describe), cultural preferences-Lab results: Cholesterol (HDL, LDL), blood sugar, Ca, K, Na, Albumin -Interventions: Diet; Enteral feedings (tube type, formula and flow rate), TPN/Lipids
Bowel/Urinary Elim
Bowel/Urinary Elimination -Subjective Data-Obj: Abdomen (inspection, auscultation, palpation), urine (describe), Flatus, Stool (describe), last bowel movement-Lab results: Urinalysis/Culture, Serum: BUN, creatinine, RBCs, WBCs, stool specimen results, radiological studies-Interventions: catheter, colostomy/ileostomy, bladder irrigation
Act & Rest
Activity and Rest-Subjective Data-Obj: Activity level and tolerance-Muscle and joints (description, movement, strength, coordination), posture/gait (describe), circulation/sensation/movement (describe), rest and sleep patterns
(describe)-Lab results: Ca, Phos, Mg, radiological results-Interventions (assistive equipment-cast, trapeze, traction, CPM, etc), special beds (type)
Endocrine
Endocrine Function-Subjective Data-Diabetes Mellitus, Thyroid, Parathyroid, Reproductive function (last menstrual period, menopause, infertility, changes in sexual function)-Lab results: Thyroid (TSH, T3, T4), blood sugar, estrogen, other
54
Assessment Guide-PsychosocialInterdependence:
-Interdependence: Significant others and support systems: Does patient have families/significant others/friends who can assist them? Assess for safety concerns regarding their behaviors and ability to care for self both in the hospital and when they go home. Assess the patient’s ability to accept assistance and care from their healthcare team. Assess and document if the patient is exhibiting inappropriate dependent or independent behaviors affecting patient safety.
Role Function
-Role Function: Focus on assessment of patient chronic diseases and their acceptance, knowledge and home management. Focus on how the patient is adapting to their acute illness and hospitalization. Are they participating in their care, or refusing care? Assess for body image concerns in patients who have removal of organs, incisions or tubes, disfiguring procedures and surgeries such as amputations or removal of a breast or prostrate?
Cultural Considerations
Cultural: Health care beliefs (pain, nutrition, disease, health, family and gender roles). Language (barriers) and Communication considerations; cultural considerations re: eye contact, touch, & space.
Self Concept
-Self Concept: Focus on how the patient views themselves. Do they have
positive or negative self-esteem? Do they feel good about themselves? Are they out going or withdrawn? Are they experiencing any fear, anxiety, anger or
grief regarding their life situation? How are they coping? What spiritual
concerns might they have and are spiritual needs being met? Any
problems with sexuality?
Date/Time Focus Documentation
55
Assessment GuidePatient Initial: _______ Room#: ______ Date: __________
NeurologicalSubj: “My hands ache, it must be raining outside”Obj: AAOX4, GCS 15Pain 5/10 Bil. hands, aching, onset-upon waking, Motrin ↓’d pain to 1/10
Labs: NA
ProtectionSubj: Flu shot in the fall, Pneumovax 1 year ago
Obj: Temp 100.5 F, No chillsSkin: intact, ,pink, warm and dryLesion: R heel stage III. 1cmX 1cm, red, serous discharge. IV site: R AC. No s/s infection or infiltration.
Labs: WBC: 18
Fluid and ElectrolytesSubj:Obj: 2 lb wt loss since admission2/5/05 I: 1500 ml/ O: 2200mlTissue turgor: goodMM: dryLabs: Na: 144, K: 4.0; Cl: 102
Oxygenation: Gas ExchangeSubj: “I can’t breathe”Obj: RR 24, even and labored. O2@ 2L NC with O2 Sat. of 95%. Breath sounds: crackles BLL. Cough productive of mod. amt of thick green/yellow sputum. Labs: CXR: BLL infiltrate
Focused Assessment PlanOxygenation: Gas TransportObj: BP 142/85 lying; Apical: 105 S1S2 irregular;Radial/pedal 2+ Bil., irregularEdema: none; Cap refill BUE/BLE 2 secSkin color: pink; Skin temp: warm ; MM: pink/dryLabs: H/H: 16/48; RBC: 5.2; platelet: 200,000; PT: 12; PTT: 62; INR: 2.3
NutritionSubj: “I’m not hungry”Obj: Ht: 5’11” Wt. 176 lbsIBW: 166 lbsIntake: Breakfast 30%, Lunch 40%Oral cavity: full dentition, Tongue: pink/dry, no lesions; Gums: pink/dryLabs: 205; Ca: 8.5; K: 4.0; Na 144: Albumin: 3.8
Bowel/UrinarySubj:Obj: Abdomen non-distended, soft, nontender, BS X4-hypoactive. LBM 2/1/05. States “I usually have a bowel movement every day after I eat my bran cereal. I feel constipated”Urine: clear, yellow
Labs: UA: negative 2/4/05BUN: 11, Creat: 0.6
Activity/RestSubj: “I feel weak”Obj: BRP,Muscle/Joints: no contractures, morning stiffness in B hands. Movement limited in hands. Strength: strong BUE, BLECoordination: smoothPosture/gait: kyphotic/ steady CSM: Feet cool, sensation intact, movement intactSleeps 6 hours a night with one wakening for bathroom
Labs: Ca: 8.5
EndocrineSubj: “I’ve been a type II diabetic for 5 years”Obj:
Labs: Serum glucose: 205Fingerstick BS (0730) 198, (1130) 213
56
Assessment Guide-PsychosocialInterdependence
Significant OthersSubj: Wife and childrenObj: Rec: Accepts calls and visits from family. Giving: Returns affection of wife, calls wife
Psychosocial: Role FunctionPrimary Role:Sex M Age 68Ego integrity vs. DespairSecondary Role:Role: DiabeticInstr: Check BS 4X/day at home. Asks about glucose reading. Tries to follow dietExpr: “I know I have to keep my BS under control, I don’t want to loose a limb.”Role: HusbandInstr: Calls wife every dayExp: “I have to get home and be with my wife, she misses me”Tertiary Role:Role: Pneumonia patientInstr: Takes breathing treatments and oral meds, Performs TCDS exercisesExp: “I want to get my breathing back to normal”Role: Masonic memberInstr: Attends monthly meetings. Chairperson of fundraisingExp: “It feels good to be a member of a group.”
Cultural Considerations Self Concept
Psychosocial Self ConceptPhysical Self: Body sensation Subj: “My hands ache”“I don’t like to wear this oxygen, it makes me feel old”“Am I going to have to wear this oxygen forever?” “I just want to go back to my normal self” “I believe that God will help me through this. “Obj: wearing O2 al 2L per NCRubbing hands together.Tears in eyesPerforms TCDB exercises, verbalizes desire to learn about medications and treatments to improve.Prays in room. Asks for chaplain to visit
Date/Time Focus Documentation
02/02/12 Resp S: “I can’t breathe”----------------------------------------------------------------------------
1400 O: Resp shallow, labored, 30/min. Intercostal retractions present. BS c coarse crackles BLL and sibilant wheezes BUL. O2 @ 2L NC c pulse ox 90%.-A: Impaired gas exchange--------------------------------------------------------------------
P: Administer prn bronchodilator----------------------------------------------------------
I: Administered Albuterol unit dose via face mask @ 1340 ----------------------
E: States “My breathing is better now” Resp regular, unlabored, 22/min. No intercostals retractions. Remains on O2@2L NC c pulse ox 95%. BS c coarse crackles BLL. No wheezing noted. . No apparent distress noted. ________________________________________________N.Nurse SNCC
57
Student:____________________________ Date(s):____________ Co-Assigned Nurse/Nursing assistant:_____________________Patient Initials:_________ Room #_________Age/Sex_______ Admit Date:___________ Surgery Date:__________________Code Status:___________ Allergies:_______________________________________________________________________________Admitting Dx:
History of present illness:
PMH:
Course of events in hospital:
MD Orders from Physician Order Section of ChartVital Signs (Frequency) Treatments/ Nursing Orders: (Restraints, Fluid Restriction, PT etc)
Diet/Feedings: O2 I & OActivity: Foley NGT
JPGlucose Testing Times: IV & Rate:Tests & Procedures: Wound Care & Dressing Change
Result and (↓ ↑)
Admit
NormalRange
Result (↓↑)Day 1 of
Care
Result (↓↑)Day 2 of Care
Lab Result Summary: Discuss abnormal lab values and diagnostics and relate them to the admitting diagnosis or chronic/concurrent diseases
Comments(Monitoring , Actions, Notified MD)
Na+ 136-145K+ 3.5-5.0Cl- 98-106Ca+ 9.0-10.5Albumin 3.5-5.0Creatinine (M) 0.6-1.2
(F)0.5-1.1BUN 10-20Glucose 70-150WBC 5000-10000RBC (M)4.7-6.1
(F)4.2-5.4Hgb (M)14-18
(F)12-16Hct (M)42-52
(F)37-47
Platelets 150000-400000PT 11-12.5PTTaPTT
60-7030-40
INR 0.9-1.2Urine NEG
N212 Nursing Process Worksheet-NPW Lab Group _____
58
X-ray NEG
Assessment Guide
Patient Initial: _______ Room#: ______ Date: __________Neurological
Subj:
Obj:
Labs:
NIC:
ProtectionSubj:
Obj:
Labs:
NIC:
F&ESubj:
Obj:
Labs:
NIC:
Oxygenation-gas exchangeSubj:
Obj:
Labs:
NIC:
Focused Assessment PlanOxygenation-gas transport
Subj:
Obj:
Labs:
NIC:
Nutrition
Subj:
Obj:
Labs:
NIC:
Bowel/Urinary Elim
Subj:
Obj:
Labs:
NIC:
59
Act & Rest
Subj:
Obj:
Labs:
NIC:
Endocrine
Subj:
Obj:
Labs:
NIC:
Assessment Guide-PsychosocialInterdependence:
Subj:
Obj:
Role Function
Subj:
Obj:
Cultural Considerations Self Concept
Subj:
Obj:
Date/Time Focus Documentation
60
Nursing CareMaps
Identify the MAIN medical/ surgical diagnosis and all chronic medical diagnosis. Construct a Caremap (See CareMap Guidelines) that includes the following:
1. Define and explain the pathophysiology of the Medical diagnosis. 2. Identify all signs and symptoms pertinent for the medical diagnosis.3. List nursing interventions appropriate for the medical diagnosis. 4. List all treatments including pharmacological and non-pharmacological modalities for the medical diagnosis5. List all the diagnostic tests and laboratory tests pertinent to this medical diagnosis.6. In N212, all of the following chronic conditions should be completed: diabetes, hypertension, COPD, ESRD.
62
MEDICATION:Generic / Trade Classification (Functional/Chemical)
DOSE /ROUTE/ FREQUENCY:
Reason why THIS Patient is receiving
MEDICATION SHEET (for Non-Med Days)
MEDICATION:Generic / Trade Classification (Functional/Chemical)
ROUTE/DOSE / FREQUENCY:
Safe Dose Range
ACTION &
Reason why my pt is receiving this
SIDE EFFECTS:Most common and life threatening
NURSING CONSIDERATIONS:ASSESSMENTS / LABS
PT TEACHING NEEDED:
Medication Sheet for Med Days
MEDICATION CHARTDrug Names (trade/generic)Class (functional/chemical)
Dose Route Time Frequency
Why is my patient receiving this
Apo-Pen VK/ penicillin V potassiumF: Broad spectrum antiinfectiveC: natural penicillin
400mgIV
QID1200,0600,1800,2400
- Bacterial pneumonia (gram + cocci)
Cleocin/ clindamycin HCLF: antiinfective-miscC: Lincomycin derivative
600 mgIV
BID0900, 2100
- Bacterial pneumonia
Proventil/albuterolF: BronchodilatorC: Adrenergic B2-agonist, sympathomimetic, bronchodilator
2.5mg/ml unit doseInhaled
QIDPRN
- Bronchodilation to assist breathing difficulty from pneumonia
OxycodoneF: Opiate analgesicC: Semisynthetic derivative
5mgPO
Q 4 hoursPRN
- Reduce pain caused by osteoarthritis and pleuritic chest pain
Tylenol/ acetaminophenF: Nonopiod analgesicC: nonsalicylate, paraminophenol derivative
325mg POQ 4 hours
PRN
- Fever and could be used for pain management for the osteoarthritis and pleurtic chest pain
Cardura/ doxazosinF: Alpha Blocker, antihypertensiveC: Quinazoline
2mg POOnce a
Day
0900
- To lower blood pressure (hx of HTN)
Coumadin/ warfarinF: Anticoagulant
2.5mg POOnce a Day
1600
- Prevent embolus formation from atrial fibrillation
Humulin R/ regular insulin RISS/SC - Lower blood sugar (Hx of diabetes )
Perc
ocet
Student _______________________________Fall____Spring _____Year
Cerritos College Health Occupations Division
Associate Degree Nursing ProgramClinical Performance Evaluation
Nursing 210
This evaluation tool will be used for measurement of the clinical course objectives. Evaluation of the clinical performance will be based on behaviors identified in the evaluation key and the accompanying guidelines. Professional nursing requires competency in both theoretical knowledge and application to clinical practice. Clinical Competency must be demonstrated by meeting all Critical Clinical Competencies, as well as a “satisfactory” or “needs improvement” marking at the end of the clinical tool to pass the clinical component of this nursing course.
CRITICAL CLINICAL COMPETENCIES:MASTERY MUST BE DEMONSTRATED IN ALL OF THE FOLLOWING CRITICAL CLINICAL COMPETENCIES AT ALL TIMES. A CRITICAL BEHAVIOR IN ONE OF THE FOLLOWING AREAS WILL CONSTITUTE AN IMMEDIATE CLINICAL FAILURE.
Demonstrates safe practice of designated nursing skills. Provides for physical safety of patient. Protects patients from emotional harm. Communicates clearly both verbally and in writing Seeks assistance from instructor or other healthcare members for care which
is beyond the student’s level of knowledge or experience. Calls attentions to own errors and reports situations accurately. Maintains confidentiality. Complies with college and agency policies and procedures. Submits required graded papers. Passes Medication Calculation ExamOther behaviors that will result in clinical failure include:
Dishonesty including but not limited to cheating, plagiarism, fabrication, and misrepresentation.
Violent or aggressive behavior Disrespectful and/or abusive language or behavior Use of drugs or alcohol (legal or otherwise) in clinical setting Stealing Conviction of felony
0 OUTSTANDING: Consistently above-average performance and self-directed.
Requires minimum guidance.S SATISFACTORY: Overall satisfactory, occasionally requires some guidanceNI NEEDS IMPROVEMENT: Inconsistent performance requires repeated
guidance and supervision.
Nursing 210 Clinical Evaluation Tool
Overall Clinical Performance Evaluation:
There are (8) Major Areas of clinical performance for evaluation: Professional Behaviors, Communication, Critical Thinking and Clinical Decision Making, Nursing Process, Caring, Teaching and Learning, Clinical Skills, and Managing Care.
I. Three or more needs improvement “NI” in one major area will result in an “overall needs improvement” for that major area. (ex: 3 “NI”s out of the 8 criteria in the area of Professional Behaviors will result in an overall NI for Professional Behaviors). A student may progress to the next clinical with an overall “NI” in only one major area. In this case, the student will receive an overall “Needs Improvement” in clinical and an Advisement Notice for the major area of Needs Improvement.
II. A student who receives an “overall needs improvement” in more than one major area will fail clinically. (ex: overall “NI” in Communication and overall “NI” in Nursing Process).
III. A student who has a “needs improvement” marking in eight or more single, isolated boxes throughout the entire tool will fail clinically.
IV. For less than eight single “needs improvements” throughout the entire tool, the student can progress to the next clinical with an overall “Satisfactory” or “Needs Improvement” (with an Advisement Notice attached) based upon instructor evaluation and anecdotal.
Core Clinical Competencies
PROFESSIONAL BEHAVIORS: Practices safe professional behaviors consistent with ethical, legal and regulatory standards of professional nursing practice when providing client care.
O S NI1. Complies with college, nursing department, and facility regulations and policies. 2. Arrives at clinical prepared for patient care. Submits all assignments within designated time frame, including referrals and make-up assignments. 3. Notifies instructor when unable to attend clinical or will be late.4. Demonstrates responsibility and accountability for one’s actions. a. Calls attention to errors and reports situations to clinical instructor. b. Reports unsafe practices. c. Maintains professional boundaries in the nurse-client relationship.5. Practices within guidelines of N210; individual knowledge and expertise; and seeks assistance for care beyond level of knowledge.6. Abides by HIPPA standards 7. Follows universal precautions.8. Demonstrates professional behavior such as a positive attitude, punctuality, self-direction, and an appropriate appearance (follows dress code – ref. student handbook).OVERALL EVALUATION ON PROFESSIONAL BEHAVIORS:
COMMUNICATION: Communicates effectively with nursing staff, various members of the healthcare team, patients and family members.
O S NI1. Communicates verbally in a clear and concise manner in English.2. Writes in a clear and concise manner in English.3. Begins to utilize therapeutic communication when interacting with patients, family and significant others.4. Verbalizes assessment, interventions and evaluations using appropriate medical terminology at a beginning level. 5. Begins to communicate with the healthcare team: providing patient updates in a timely manner to staff
nurse and instructor. OVERALL EVALUATION ON COMMUNICATION:
CRITICAL THINKING AND CLINICAL DECISION MAKING: Uses critical thinking when performing all steps of the nursing process with patients in the clinical setting.
O S NI1. Begins to make clinical judgment decisions to ensure safe and effective care when providing patient care with instructor support. 2. Begins to organize plan of care and prioritize total patient care for one patient.3. Demonstrates, at a beginning level, the ability to apply theory to clinical situations, stating scientific rationale, incorporating best practices. OVERALL EVALUATION ON CRITICAL THINKING / DECISION MAKING: NURSING PROCESS: Applies the Nursing Process in implementing care.
O S NI1. Begins to utilize appropriate sources to elicit data about the patient. 2. Performs and documents a physical assessment, demonstrating appropriate use of medical terminology and approved abbreviations, at a beginning level.3. Initiates an environmental assessment. 4. Begins to identify appropriate nursing problems / nursing diagnosis. 5. Begins to develop patient-specific interventions. 6. Begins to evaluate patient response to care and revises patient care as needed.
OVERALL EVALUATION ON NURSING PROCESS:
CARING INTERVENTIONS: Demonstrates caring behaviors towards the patient and significant others.
O S NI1. Assists the patient to obtain optimum comfort and functioning.2. Provides a safe physical and psychological environment protecting the patient from undue harm, maintaining
dignity and respect. 3. Identifies and adapts care to honor the patient’s values and customs, and the emotional, cultural, and spiritual needs.4. Advocates for the patient.5. Demonstrates empathy when providing nursing care.OVERALL EVALUATION ON CARING BEHAVIORS:
TEACHING AND LEARNING: Demonstrates application of teaching-learning principles.
O S NI1. Provides simple explanations and instruction to patients prior to interventions and / or procedures. OVERALL EVALUATION ON TEACHING AND LEARNING:
CLINICAL SKILLS: Competently performs technical skills with patients in the health care setting.
O S NI1. Demonstrates safe practice of designated nursing skills for N210 in clinical and/or skills lab. 2. Seeks out patients that provide varied learning and skills opportunities. OVERALL EVALUATION ON CLINICAL SKILLS:
MANAGING CARE AND COLLABORATION: Effectively manages patient care in collaboration with other members of the healthcare team, patient and significant others.
O S NI1. Begins to work cooperatively with health care team members, peers, faculty, patients and their significant others toward common patient-centered outcomes. 2. Manages the patient assignment in an organized and efficient manner completing care within allotted time frame.OVERALL EVALUATION ON MANAGING CARE:
N210 Nursing Skills CompetencyCheck box for each skill: S= Satisfactory, NI= Needs Improvement, LP= lab Performance only, LO= Lack of opportunity to evaluate
S NI LP LOPerforms skills necessary to meet activity and rest needs including: Utilizing body mechanics, positioning, ambulation, and transfer activities Utilizing active and passive range of motion and isometric exercises Making unoccupied and occupied bedsPerforms skills necessary to meet nutritional needs including: Feeding patients orally Feeding patients via nasogastric and/or gastrostomy tubes (H20 flush/placement check) Inserting nasogastric tube Assessing nutritional status (% of meal consumed and recording oral intake)Performs skills necessary to meet elimination needs including: Assisting with toileting Inserting and maintaining catheters Assessing and recording fluid output Administering an enema or Harris flush Inserting rectal tube and/or suppository Collecting specimensPerforms skills necessary to meet oxygenation needs including: Performing, assessing and recording vital signs (temperature, pulse [apical and radial], respirations, pulse oximetry and blood pressure)Performs skills necessary to meet protection needs including: Hand hygiene Provide personal hygiene measures (bath, oral care) Gowning and gloving Applying isolation techniques Applying bandages, binders, restraints and anti-embolism stockings Maintaining a sterile field Providing wound care Assessing level of pain
Performs physical assessment practicum (Pass/Fail)Pass random skill testing within 2 tries. Failure to pass within 2 attempts will be reflected in your overall clinical evaluation.List all skills the student performed in this clinical rotation:
N 210 Overall Clinical Competency
0 OUTSTANDING: Meets all Critical Clinical Competencies. Consistently above-average performance and self-directed. Requires minimum guidance.
S SATISFACTORY: Meets all Critical Clinical Competencies. Overall satisfactory, occasionally requires some guidance
NI NEEDS IMPROVEMENT: Meets all Critical Clinical Competencies. Inconsistent performance requires repeated guidance and supervision.
1) Overall “NI” in only one major area OR2) Fewer than eight single needs improvement throughout the clinical tool
*Advisement Notice Required for students with an overall “Needs Improvement”U UNSATISFACTORY: Unsatisfactory performance.
1) Fails to meet one or more critical clinical competency OR2) Receives more than one “overall needs improvement” in a major area OR3) Receives a single “needs improvement” in eight or more single boxes throughout the entire tool.
*Results in clinical failure.
Midterm Evaluation (as needed): _________ Needs Improvement ___________ Unsatisfactory
Comments:
Instructor Signature:___________________________ Date:_____________Student Signature:_____________________________ Date:_____________
Final Overall Evaluation: ____Outstanding _____Satisfactory _____Needs Improvement _____Unsatisfactory Comments:
Instructor Signature:___________________________ Date:_____________
Student Signature:_____________________________ Date:_____________
Cerritos CollegeHealth Occupations
Department of NursingGuidelines for Clinical Performance Evaluation Tool
Professional BehaviorStudents will practice safe professional behaviors consistent with ethical, legal and regulatory standards of professional nursing practice when providing client care.
Students are held accountable to standards of practice for nursing care. Policies and procedures should be used to guide practice and be upheld.
Students must notify instructor of any clinical absence or tardiness. Failure to do so will result in a clinical failure.
Tardiness is not an accepted clinical behavior. The first tardy will result in a verbal warning, the second will result in an advisement note and the third tardy will result in a clinical failure.
Two or more absences may result in a clinical failure. All clinical hours will be made up according to individual course policy.
Students are to arrive at the clinical site in a timely manner with written assignments completed and equipped with the knowledge necessary to give safe competent care. Failure to do so will result in adjustment of the patient care assignment, up to and including being sent home.
Students are expected to demonstrate consistency in growth in both written assignments and clinical performance.
The ability to follow directions and guidelines is imperative in the practice of professional nursing. Students are expected to adhere to all directions and guidelines, both in the care of the patient and in preparation of written assignments. It is the responsibility of the student to seek clarification, if unclear about expectations. Assessment of the ability to follow guidelines and directives extends to the policies and procedures of the clinical facility to which the student is assigned.
Practices within guidelines of N210 and individual knowledge and expertise and seeks assistance for care beyond level of knowledge. Clinical instructors recognize that students are learning. Students are to acknowledge the limitations of their knowledge and seek to correct areas of knowledge deficit. Assistance should be sought as needed; failure to do so may jeopardize the patient, the student or others.
Students are expected to verify dependent nursing interventions in the physician’s orders prior to implementation. This includes all treatments and medications. In addition the student is responsible to check the
physicians’ orders regularly to determine if existing orders have been altered or new orders have been written.
Students represent not only themselves and their families, but Cerritos College, the clinical facility to which they are assigned and the profession of nursing as a whole. Physicians, patients, families and other health care team members judge nursing care by the behavior and appearance of the nurse. The expectation is that students will role model the highest standards of professionalism, including adherence to the Student Dress Code policy. A professional demeanor is to be maintained at all times.
A component of action and behavior on the part of the professional is the ability to be self-directed, and example of which is to use clinical time wisely by seeking learning experiences. Students are expected to participate in shared learning experiences, including group conferences. Development of awareness and understanding of how personal/professional behavior influences patient care is expected of each student.
Students are to demonstrate knowledge of and competency in infection control measures appropriate to the clinical site and the needs of each patient. These include but are not limited to: hand hygiene, wiping down equipment, and proper use of personal protective equipment.
Students are expected to maintain the confidentiality of all personal health information in accordance with HIPPA. Identifying data must be removed from all documents leaving the clinical site.
Communication Students will communicates effectively with nursing staff, various members of the healthcare team, patients and family members.
Students are expected to communicate clearly in English at all times and use appropriate medical terminology. Bilingual students may communicate with their patients in the patient’s preferred language.
The student should be able to communicate a clear and concise verbal report of their patients. Students are expected to communicate with their patients while providing care.
Written assignments should be legible and grammatically correct. Students are expected to show improvement in their documentation
and verbal skills as they progress in clinical. Ability to communicate following proper lines of authority will be
included in the evaluation. Students are expected to clarify their role responsibilities with the RN and CNA prior to assuming care.
Verbal Report First Semester Students
Students should begin to formulate a verbal report that includes patient condition, pertinent assessment findings and priority care needs.
Second semester studentsStudents are expected to provide an organized verbal and written report.
Second Year Level Students
Students are expected to provide an organized verbal report reflecting patient condition, pertinent assessment findings and priority care needs.
Critical Thinking and Clinical Decision Making Student will use critical thinking when performing all steps of the nursing process with patients in the clinical setting.
Nursing Process Worksheets (NPWs) are to be completed on all patients prior to clinical. Arriving to clinical unprepared will result in adjustment of the patient care assignment, up to and including being sent home. Being sent home warrants an advisement note and the student is required to complete a clinical make-up assignment. .
Students are expected to show progression in critical thinking and problem solving skills.
Students are expected to function within the scope of practice within their respective course.
Unsafe clinical behaviors/judgment will result in a clinical failure. Students are expected to transfer and apply knowledge from previous and
current courses. Students must show progression in the application of scientific rationale. Students are expected to show a progression in the ability to synthesis
data and develop an understanding of the patient’s clinical situation. Students should show a progression in being able to recognize the relationship between assessment data (physical assessment findings, diagnostic tests, and medications).
Problem Solving First Year Level Students will begin to apply problem solving with support from the clinical instructor. Students should present problem issues to the clinical instructor armed with possible solutions to the problem at hand that demonstrate critical thinking. Second Year Level
Students will apply problem solving while providing care for more complex and increased number of patients with increased confidence. Students should begin to anticipate possible outcomes prior to deciding nursing actions. They will validate decisions with the instructor and require less direction and dependency throughout the clinical rotation. Their level of independence remains within the student role but allows for a safe and smooth transition to the next course.
NURSING PROCESSStudent will apply the Nursing Process in implementing patient care.
Students will utilize the nursing process when assessing, implementing and evaluating care.
The Roy Adaptation Model will be used to collect and organize assessment data.
Assessment data should include subjective and objective data. Objective data may include but not limited to diagnostic tests, lab values, past
medical history, physical assessment, medications, physician orders and interdisciplinary treatments.
Students are expected to use NANDA approved nursing diagnoses provided in the course packet. (N/A at N210)
The ability to formulate a nursing care plan that reflects the priority nursing problems for a patient is critical to the function of a nurse. Failure to achieve 75% on the Nursing Care Plan/Concept Map will result in an advisement note. Failure of a Nursing Care Plan/Concept Map in a subsequent course will result in a clinical failure in that course. (N/A at N210)
Students are encouraged to seek instructor assistance and/or guidance prior to submission of the Nursing Care Plan/Concept Map. (N/A at N210)
Caring InterventionsStudent will demonstrate caring behaviors towards the patient, significant others, peers and members of the healthcare team. Students are expected to:
Protect and promote the patient dignity. Identify psychosocial needs. Provide for the privacy of patients at all times. Protect the patient from physical harm by identifying potential or actual
threats and act to correct them. Examples of unacceptable behaviors include: leaving side-rails down when patient is at risk for falling, leaving syringes with needles in the room, not recognizing breaks in sterile technique, picking up items off the floor and using in patient care, not discriminating clean versus unclean, not using gloves when needed when protecting self or others, not utilizing hand hygiene, not recognizing when contamination occurs and taking appropriate corrective actions or not adhering to isolation policies.
Protect the patient from emotional harm by identifying potential or actual threats and act to correct them. Examples of unacceptable behaviors include: ignoring patient concerns; failure to psychologically prepare patients before procedures; making statements that instill fear or anxiety; using inappropriate “slang” language or inappropriate terms of endearment such as “honey” or “sweetie”; sexual innuendos; not promoting an environment that allows the patient to express their feelings; not demonstrating empathy while caring for patients and performing procedures; not seeking guidance if unsure of course of action; failure to report abnormal findings or change in condition.
Teaching and LearningStudents will demonstrate application of teaching-learning principles. Students are expected to:
Document patient teaching on NPW and patient record as indicated.
Include teaching in the care of their patients and families from the first clinical course and throughout the program.
Demonstrate the ability to prepare and present educational needs of the patient as well as evaluate the effectiveness of the teaching.
Utilize patient teaching opportunities with medication administration. (N/A at N210)
Assess the patient’s understanding of clinical situation or disease process. Assess patient’s management of chronic conditions. Respond to patient questions appropriate to their level.
Managing Care/CollaborationStudents will effectively manage patient care in collaboration with other members of the healthcare team.
Students are expected to interact in a professional and collegial manner with all members of the healthcare team.
The student team coordinator obtains pertinent data from team members on all patients assigned to the team. (N/A at N210)
The team coordinator gives a complete report to the clinical instructor on the status of patients assigned to the team. (N/A at N210)
All students are to utilize appropriate channels of communication (assigned staff nurse, student team coordinator, and instructor) when providing patient care.
Students are expected to report to appropriate staff and instructor pertinent abnormal patient information or when patient situations change. Examples: abnormal VS, respiratory distress, unrelieved pain, low urine output, abnormal labs, signs of bleeding, changes in level of consciousness and inappropriate behavior.
Students are to assist fellow students and staff as needed. Students are expected to answer all patient call lights and requests for assistance even if the student is not assigned to the patient. Students should relay requests to appropriate staff nurse.
Students will delegate aspects of nursing care to the appropriate members of the student team according to Team Role Guidelines. (N/A in N210)
Students are expected to begin developing leadership and assertiveness skills and show initiative in solving problems and meeting patient needs. Examples: Following up on missing food trays, medications, checking orders, providing education, asking MD questions, volunteering to assist MDs, seeking out learning opportunities, and developing communication skills.
Approved Abbreviations
i oneii two∆ change° degrees or hoursā beforeAAOx4 awake, alert, and
oriented X4abd abdomenABG arterial blood gasAC antecubitala.c. before mealsADA American Diabetes
AssociationADL activities of daily livingad lib as desiredAFA appropriate for ageaka also known asAKA above knee amputationalb albuminALOC altered level of
consciousnessAMA against medical adviceamb ambulateamt amountant anterioras tol as toleratedASA aspirinASHD arteriosclerotic heart
diseaseAx axillarybid twice a dayBKA below knee amputationBLE bilateral lower
extremitiesBM bowel movementBMP basic metabolic panelB/P or BP blood pressureBPH benign prostatic
hypertrophyBR bedrest
BRBPR bright red blood per rectum
BRP bathroom privilegesBS bedsideBS bowel soundsBSC bedside commodeBUN blood urea nitrogenBX biopsy℅ complains of,
complaints ofc with Ca calcium CA cancerCABG coronary artery bypass
graftCAD coronary artery diseasecap capsulecath catheterCBC complete blood countCDB cough and deep breathC/D/ I clean, dry, intactCHF congestive heart failurecm centimetersCMP complete metabolic
panelCMS circulation, movement,
sensationCNS central nervous systemCOPD chronic obstructive
pulmonary diseaseCP chest painCPM continuous passive
motionC&S culture and sensitivityCT computerized
tomographyCTA clear to auscultationCVA cerebrovascular
accidentCVD cardiovascular diseaseCXR chest X-ray
DAT diet as toleratedDJD degenerative joint
diseaseDKA diabetic ketoacidosisDM diabetes mellitusDOB date of birthDOE dyspnea on exertionDP dorsalis pedisdrsg dressingDSD dry sterile dressingDVT deep vein thrombosisDX diagnosisECF extended care facilityECG/EKG electrocardiogramED emergency departmentEGDesophagogastroduodenoscopyESRD end stage renal
diseaseFA forearmFBS fasting blood sugarFC foley catheterFFP fresh frozen plasmaF/U follow up FUO fever of undetermined
originFWB full weight bearingfx fractureGCS Glasgow coma scaleGI gastrointestinalG-tube gastrostomy tubeGU genitourinaryHA headacheHct hematocritHD hemodialysisHgb hemoglobinH & H hemoglobin and
hematocritHOB head of bedHOH hard of hearingH&P history and physicalHR heart ratehs at bedtime HTN hypertensionI&D incision and drainageIDDM insulin dependent
diabetes mellitusinc incontinent
IM intramuscularI&O intake and outputIS incentive spirometerIV intravenousJ-tube jejunostomy tubeJVD jugular vein distentionK potassiumKCL potassium chlorideKVO keep vein openKUB kidneys, ureters, and
bladder x-rayL leftLE lower extremitylg largeLLL left lower lobe (lung)LLQ left lower quadrantLMP last menstrual periodLUL left upper lobe (lung)LVN licensed vocational
nurseMAE moves all extremitiesmg milligramsMOM milk of magnesiaMRI magnetic resonance
imagingMRSA methicillin-resistant
Staphylococcus aureusMAR medication
administration recordsml milliliterMM mucous membranesMVA motor vehicle accidentNa sodiumNAD no apparent distressNCP nursing care planNGT nasogastric tubeNIDDM non-insulin dependent
diabetes mellitusNKA no known allergiesNS normal salineNsg nursingNPO nothing by mouthN/V/D nausea, vomiting,
diarrheaNWB non-weight bearingO2 oxygenOA osteoarthritis
OBS organic brain syndromeOOB out of bedORIF open reduction and
internal fixationp afterpc after mealsper by, or throughPCN PenicillinPCXR portable chest X-rayPEG percutaneous
endoscopic gastrostomy
PERL pupils equal and reactive to light
PERLA pupils equal and reactive to light and accommodation
PERRLA pupils equal, round, reactive to light and accommodation
PICC peripherally inserted central catheter
PMH past medical historypo by mouthPOD postoperative daypost afterpre beforePR per rectumPRN as neededPt patientPT physical therapyPVD peripheral vascular
diseasePWB partial weight bearingq2h every 2 hoursR rightR/O rule outRR regular rhythmRUL right upper lobe (lung)RUQ right upper quadrantRx prescriptions withoutsat saturationSL sublingualSNF skilled nursing facilitySOB shortness of breathS/P status post
spec specimenS/S signs and symptomsSSE soap suds enemaSSRI selective serotonin
reuptake inhibitorSTAT at onceSW social workersx symptomTCDB turn, cough, deep
breatheTDWB touch down weight
bearingTHA total hip arthroplastyTHR total hip replacementTIA transient ischemic
attackT.O telephone ordertol toleratedTWE tap water enemaTPN total parentral nutritionTSH thyroid stimulating
hormoneTURP transurethral resection
of the prostateTx treatmentUA urinalysisUE upper extremityUGI upper gastrointestinalUO urine outputURI upper respiratory
infectionUS ultrasoundUTI urinary tract infectionVO verbal orderVRE vancomycin-resistant
enterococcusWBAT weight bearing as
toleratedWBC white blood cell W/C wheelchairW&D warm and dryWNL within normal limitsVS vital signs
Unapproved Abbreviations
DO NOT USE
AU each earcc cubic centimeterD/C, DC discharge, discontinueIU international unitsMgSO4 Magnesium SulfateMS Morphine Sulfate, Multiple Sclerosis, Mitral StenosisMR Mitral Regurgitation, may repeat, medial recordHCTZ Hydrochlorothiazideq everyqhs, qd, qod every hour sleep, every day, every other daySQ or SC subcutaneousU or u unitµg microgramOD right eyeOS left eyeOU both eyesper os orallyss sliding scale
Do not use slash marks to separate doses (/) (ex: 25 units/100ml). Use “per”
Do not use “greater than” (>) or “less than” (<) marks. Spell out greater than or less than.
When writing dosages, do not use zeros after the decimal point for doses in whole numbers (ex. 1mg). Always use a zero before the decimal point when the dose is less than a whole number (0.5mg)
**For a complete list of Error –Prone abbreviations, visit the Institute of Safe Medication Practices website http://www.ismp.org/Tools/errorproneabbreviations.pdf
CERRITOS COLLEGE NURSING PROGRAMN210 CLINICAL SCHEDULE
LONG TERM CARE
WK DATE ASSIGNMENT EXPERIENCES POST-CONFERENCE
What is due?
60800-1100
LTC Orientation
1200-1500 PA Practicum
Tour, Scavenger HuntFacility information, Fire/disaster codes, clinical expectations, Clinical evaluation toolNPW/ Assessment Guide; Clinical Schedule and Student Assignments
Nothing
60650-1150
Caremaps and Meds for COPD Due
Buddy with C.N.A.
By the end of the day, choose 1 patient (1 diagnosis) for next week’s assignment and complete front and back page of NPW (include concept map); No Lab data
1330-1530PA Practicum
Skills: baths, beds, feeding, assist with transfers, ROM, VS, NGT/GT feedings, positioning, hot/cold applications, bandages/binders, TED hose, restraints, enemas, isolation, Physical Assessment Foley Cath, Wound Care, NGT
Charting: VS, I&O
1100-1150
NPW / Assessment Guide: sample/blankClinical Experiences
NPW: page 1 and page 2 including concept map due next Tuesday in pre-conference.
7 0650-1250 Skills: baths, beds, feeding, assist 1100-1150 Nothing
Care of 1 patient NPW due in pre-conference
with transfers, ROM, VS, NGT/GT feedings, positioning, hot/cold applications, bandages/binders, TED hose, restraints, enemas, isolation, Physical Assessment Foley Cath, Wound Care, NGT
Charting: VS, I&O
NPW/ Assessment GuidePhysical Assessment techniquesClinical Experiences
and observations
710/3
0650-1250SCP/NPW on VCE patient Due
By the end of the day, choose 1 patient (2 Diagnoses) for next week’s assignment and complete front and back pages of NPW (include concept map) + medications; No Lab data
Skills: Same as above 1100-1150
NPW / Assessment Guide: sample/blankClinical Experiences
NPW: page 1, & 2 including concept map, and page 4 (documentation) for the patient cared for this week due on Wed post-conference
8 0650-1250 Skills: Same as above 1100-1150 NPW: page 1-5
Care of 1 patient NPW due in pre-conference By the end of the day, choose 1
patient (2 diagnoses) for next week’s assignment and complete front and back pages of NPW (include concept map) + medications and Lab data
NPW/ Assessment GuidePhysical Assessment techniques
for patient cared for this weekANDAssessment guide: all sections for physical mode for patient cared for this week due on Tues post-conference
8 SL 121 0700-1600CPE: All skillsFull Uniform
9 0650-1250
Show this week’s completed NPW/AG to clinical instructor by end of day for feedback
CPE RetestingArrange Hours with Instructor
Skills: Same as above 1100-1150NPW/ Assessment GuidePhysical Assessment techniquesClinical Experiencesand observations
Nothing
9 No Clinical
All NPWs due in pre-conference to your clinical instructors which will be returned to you during clinical
Clinical Absence Make-Up Guidelines
Make-up for any clinical absence in N210:
1. The student will be assigned by the instructor to write a paper on one of the diagnoses of the patient(s) that the student would have cared for on the missed day.
2. The student is to research the diagnosis using the library or internet to find a recent nursing journal (within last 5 years) about the diagnosis.
3. The article should include the following information related to:
An explanation of the diagnosis Signs and Symptoms Risk factors/causes Diagnostic tests/measures Medical and Nursing treatment Evaluation of Outcomes
4. The student is to summarize the article, including in the summary all of the data stated in #3 (if possible).
5. The paper is to be typed. The paper and a copy of the article are to be turned in to the clinical instructor.
If the absence is due to illness, the paper is to be turned in on the Monday after the illness.
If the absence is due to being sent home for not being prepared, the paper is to be turned in the next day (ie: for a Tuesday absence, the paper is due on Wednesday)
6. The student may be asked to present the paper in post conference.
Cerritos CollegeDepartment of Nursing
NURS 210: Competency Performance Examination (CPE)
Official Record of Student Performance
Name of Student______________________________________
Vital Signs CompetencyDate________Name of Clinical Examiner_______________________________Pass___________ Fail_____________Comments_____________________________________________Retest Date___________Pass ___________Fail ______________Comments _____________________________________________
Comprehensive Skill CompetencyDate___________Name of Clinical Examiner_________________________________Pass__________ Fail_______________
Check ALL competencies examined in this CPE:
___Universal competencies ___Bed bath___Occupied bed making ___Range of Motion___Positioning of Patient ___Transfer of Patient from bed to chair ___Ambulating a patient ___Moving a Patient up in bed___Applying Bandages ___Applying restraints___Applying Binders ___Applying and removing PPE___Applying antiembolism stockings ___Irrigation (flush) of NGT/Gtube ___Administering an enema ___Administering intermittent/continuous___NGT insertion +/- suction tube feeding___Sterile wet to moist dressing change ___ Foley catheter insertion
Legal Validation of Failure to Meet Critical Elements:In the case of failure of the comprehensive skill CPE, the examiner must cite the specific critical element(s) that the student did not pass and write the objective description of the reason for failure, using the space below (use additional lines as needed). ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Retest date_________________________ Pass_______ Fail________Outcome of performance___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Cerritos CollegeDepartment of Nursing
The Universal Competencies and related clinical elements are supplied in all aspects of client care. The Universal Competencies which will be evaluated in N210 include: safety and security, standard precautions (asepsis), comfort and documentation.
At the end of the clinical rotation, the student will be able to perform the following competencies and related critical elements:
Universals:
Safety and Security1. Physical safety and security: Any action or inaction on the part of the
student that threatens the patient’s well being or is in violation of the patient’s physical security.
2. Emotional security: Any action or inaction which threatens the emotional well being of the patient or significant others or is a violation of the patient’s emotional security.
It is important to realize that all potential failures to protect the patient from harm can not be described here.
Met Not Met Critical Elements___ _______ 1. Identify assigned patient by reading ID bracelet before initiating care___ ________ 2. Protect the patient from physical harm at all times, such as
the following: a. Side rails are raised when indicatedb. Bed is left in low positionc. Patient’s ability to ambulate safely is assessed before beginning
ambulationd. Restraints are secure, when required, without injuring patient
___ _____ 3. Protect the patient and significant other from psychological harm by the following actions:
a. Refer to the patient by designated or preferred nameb. Communicate verbally and non-verbally in professional mannerc. Communicate verbally and non-verbally in a manner that does
NOT express anger, distrust, abuse, familiarity or demeaning behaviors to the patient and/or significant others.
d. Provide accurate information to patient and/or significant otherse. Keep all patient-related information professionally confidentialf. Maintain patient’s personal privacy at all timesg. Explain procedure to patient prior to initiating skill
Standard Precautions: The prevention of the introduction or transfer of organisms
Met Not Met Critical Elements___ _______ 1. Wash hands before initiating direct contact with patient and whenever hands are contaminated by patient’s body secretions or substances. (During an examination wash hands in presence of examiner before beginning care.)___ ________ 2. Wear gloves whenever coming in contact with human secretions___ ________ 3. Protect patient from contamination. ___ ________ 4. Protect self and others from contamination___ _______ 5. Confine contaminated material to contaminated areas.___ ________ 6. Dispose of contaminated materials in designated containers,___ ________ 7. Implement any designated special precautions as required
Comfort: The assessment of and interventions related to the patient’s tolerance of the procedure.
Met Not Met Critical Elements___ _______ 1. Assess the patient’s comfort level before, during and after a potentially uncomfortable procedure. ___ _______ 2. Provide interventions to increase the patient’s comfort level
Documentation: The recording of data required by, or pertinent to, the designated situation.
Met Not Met Critical Elements___ _______ 1. Document patient care using the following methods, as
designated: a. assessment forms, flow graphs, or other standard clinical formsb. narrative process recording
___ ________ 2. Document patient changes and responses to care in designated records.___ ________ 3. Use language, terms, and abbreviations that are consistent
with professional standards, agency protocols, and other specific guidelines
___ _______ 4. Record data so that entries are: a. clearb. accuratec. precised. pertinent/relevant
Competencies Specific to N210: Fundamentals of Nursing
1. Vital Signs: to measure the blood pressure, pulse, respirations, temperature and pulse oximetry of a patient
Met Not Met Critical Elements:
___ _______ 1. Measure vital signs accurately a. within +/- 4 mmHg of systolic and diastolic blood pressureb. within +/- 4 bpm of pulsec. within +/- 2 of respirations per minute
___ ______ 2. Prepare and place thermometer correctly___ ______ 3. Count irregular and apical pulse for one minute___ ______ 4. Count irregular respiration for one minute___ ______ 5. Use correct size blood pressure cuff___ ______ 6. Correctly identify location of apical pulse
2. Handwashing: reducing microbial load on hands with the use of water and soap.
Met Not Met Critical Elements:
___ _______ 1. Regulate water temperature and flow___ _______ 2. Lather with soap covering all aspects of hands and wrists for appropriate length of time___ _______ 3. Dry hands___ _______ 4. Maintain medical asepsis and do not contaminate self
3. Occupied bedmaking: to change the soiled sheets on a bed occupied by a patient
Met Not Met Critical Elements:
___ _______ 1. Maintain medical asepsis of linen___ _______ 2. Place bed at working level for height___ _______ 3. Keep patient covered at all times___ _______ 4. Maintain proper positioning of patient and body mechanics of nurse. ___ _______ 5. Create mitered corner and foot tent___ _______ 6. Center top sheet and bedspread to hang equally on both
sides___ _______ 7. Place clean pillowcase on pillow
4. Range of Motion: to move patient’s joints actively or passively through set movements
Met Not Met Critical Elements:
___ _______ 1. Proceed systematically from head to toe___ _______ 2. Support joint being exercised___ _______ 3. Perform exercise 3-5 times
5. Transfer of patient from bed to chair: assisting a patient to change locations
Met Not Met Critical Elements:
___ _______ 1. Assess patient’s ability to assist; presence of weaknesses or paralysis; cognitive function___ _______ 2. Maintain use of good body mechanics by the nurse ___ _______ 3. Maintain proper body alignment of the patient during Changes in position by supporting weak limbs___ _______ 4. Position bed at working level for height___ _______ 5. Demonstrate appropriate use of gait belt___ _______ 6. Position wheelchair at appropriate angle and locked
6. Moving a patient up in bed: assisting a patient to a higher position in a hospital bed, so that the patient bends at the appropriate place
Met Not Met Critical Elements:
___ _______ 1. Assess the patient’s ability to assist___ _______ 2. Position a draw sheet under the patient appropriately___ _______ 3. Use proper body mechanics___ _______ 4. Properly instruct the patient how to assist
7. Applying restraints : Apply a device that limits movements of an extremity or body part
Met Not Met Critical Elements:
___ _______ 1. Assess CSM or any contraindications to use___ ________ 2. Explain rationale to patient and/or family___ ________ 3. Apply restraint properly___ ________ 4. Secure restraint to proper location on bed or wheelchair as appropriate___ ________ 5. Assess at frequency dictated by agency policies
8. Applying and removing personal protective equipment: use of materials that are worn to decrease the transmission of microbes
Met Not Met Critical Elements:
___ _______ 1. Identify needed equipment___ _______ 2. Apply appropriate equipment in proper order___ _______ 3. After use, remove protective equipment in proper order to Prevent contamination
9. Administering an Enema: instilling a solution per rectum
Met Not Met Critical Elements: ___ _______ 1. Use warm water___ _______ 2. Position patient to facilitate flow___ _______ 3. Regulate flow of water to appropriate rate___ _______ 4. Offer and place patient on bedpan after instillation
10. Nasogastric tube insertion +/- suction to insert a catheter through the nose into the stomach and attach to suction if ordered
Met Not Met Critical Elements:
___ _______ 1. Measure tube for appropriate positioning___ _______ 2. Lubricate the tube___ _______ 3. Instruct the patient regarding procedure and patient participation___ _______ 4. Facilitate chin tuck when appropriate___ _______ 5. Insert the tube to the appropriate place___ _______ 6. Check placement___ _______ 7. Secure the tube___ _______ 8. Attach tube to suction appropriately
11. Sterile Wet to moist dressing change:
Met Not Met Critical Elements:
___ _______ 1. Remove and assess old dressing___ _______ 2. Assess wound and drainage___ _______ 3. Establish sterile field___ _______ 4. Properly apply sterile gloves___ _______ 5. Cleanse wound using sterile technique___ ______ 6. Apply dressing using sterile technique___ _______ 7. Secure dressing
12. Bed bath: to clean the body of a patient that remains in bed
Met Not Met Critical Elements:
___ _______ 1. Prepare supplies using medical asepsis___ _______ 2. Maintain proper body positioning of the patient and good body mechanics of the nurse; minimizing movements of the patient and nurse___ _______ 3. Keep patient covered to maintain modesty and prevent chilling___ _______ 4. Clean from head to toe; perineal area last___ _______ 5. Change water when appropriate
13. Positioning a Patient: assisting a patient into positions used therapeutically in nursing practice
Met Not Met Critical Elements:
___ _______ 1. Maintain use of good body mechanics for the nurse and patient
___ _______ 2. Use pillows appropriately for support___ _______ 3. Support body during position changes as appropriate
14. Ambulating a patient: providing a one person assistance to walkMet Not Met Critical Elements:
___ _______ 1. Assess patient’s ability to ambulate___ _______ 2. Correctly position self and arms to provide for assistance and safety___ _______ 3. Evaluate patient’s gait, distance and tolerance of exercise
15. Applying bandages : Apply a device that provides support to a designated area/joint
Met Not Met Critical Elements:
___ _______ 1. Assess CSM___ _______ 2. Position body part in neutral, elevated position if possible___ _______ 3. Apply bandage using equal distance and equal pressure___ ______ 4. Use the proper wrapping technique for the body part ___ _______ 5. Wrap the extremity distal to proximal ___ _______ 6. Secure appropriately___ ______ 7. Reassess CSM
16. Applying binders : Apply a device that provides support to the abdomen and/or torso
Met Not Met Critical Elements:
___ _______ 1. Choose proper sized binder for the patient___ _______ 2. Position the binder appropriately___ _______ 3. Assess for potential breathing or skin impairment
17. Applying antiembolism stockings : Apply a device that promotes the return of blood to the heart
Met Not Met Critical Elements:
___ _______ 1. Measure patient for proper fit___ _______ 2. Apply the stocking appropriately ___ _______ 3. Assess CSM and presence of wrinkles in stockings
18. Intermittent and continuous tube feeding administration: administering a set amount of tube feeding solution via a NGT, G-tube, or J-tube.
Met Not Met Critical Elements:
___ _______ 1. Position HOB at least 30º unless contraindicated___ _______ 2. Check placement and patency of tube___ _______ 3. Perform residual check; hold if residual >100 mL___ _______ 4. Administer correct type and amount at prescribed rate___ ______ 5. Keep HOB at least 30° for at least 1 hour after feeding for
intermittent feedings and maintain HOB always at least 30°for continuous feedings
19. Foley catheter insertion: to insert a catheter into bladder utilizing sterile technique
Met Not Met Critical Elements:
___ ______ 1. Establish sterile field___ _______ 2. Properly apply sterile gloves___ _______ 2. Check foley balloon___ _______ 3. Cleanse perineum correctly___ _______ 4. Insert catheter maintaining sterile technique___ _______ 5. Inflate foley bulb at appropriate location & holds on to catheter during inflation
20. Irrigation (flush) of NGT/Gtube to instill water or saline into NGT/Gtube
Met Not Met Critical Elements: ___ ______ 1. Stop current feeding or suction (as applicable)___ _______ 2. Check tube placement ___ _______ 3. Aspirate for residual ___ _______ 4. Instill prescribed solution and amount using appropriate method___ _______ 5. Resume feeding or suction (as applicable)
Recommended