Monash Nursing & Midwifery BACHELOR OF NURSING (BN ...€¦ · with a tool to develop a holistic approach to assessing and managing patients. The patient assessment profile not only

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Monash Nursing & Midwifery

BACHELOR OF NURSING (BN) - CLINICAL PRACTICE PORTFOLIO

TABLE OF CONTENTS

SECTION 1: GENERAL INFORMATION ........................................................................................................................ 4

INTRODUCTION ......................................................................................................................................................... 4

HOW TO USE THE PORTFOLIO .................................................................................................................................... 4

NURSING CLINICAL PRACTICE .................................................................................................................................... 5

CLINICAL PLACEMENT ............................................................................................................................................... 5

Pre-placement mandatory requirements ........................................................................................................... 5

Attendance at Clinical Placement ...................................................................................................................... 6

POLICIES AND RESOURCES ....................................................................................................................................... 6

REFLECTIONS OF SELF AND PRACTICE ....................................................................................................................... 7

SECTION 2: PATIENT ASSESSMENT PROFILES ...................................................................................................... 10

ACUTE CARE PATIENT ASSESSMENT PROFILE .......................................................................................................... 11

PRIMARY CARE PATIENT ASSESSMENT PROFILE ....................................................................................................... 13

MENTAL HEALTH PATIENT ASSESSMENT PROFILE ..................................................................................................... 15

SECTION 3: PHARMACOLOGY LOG .......................................................................................................................... 18

SECTION 4: CLINICAL ACTIVITY LOG ....................................................................................................................... 24

SECTION 5: REFLECTIONS OF SELF AND PRACTICE ............................................................................................ 29

SECTION 6: CORE CLINICAL COMPETENCIES ........................................................................................................ 32

YEAR 1: MANDATORY ASSESSMENTS .............................................................................................................................. 37

PHYSICAL ASSESSMENT ........................................................................................................................................................ 37

ESSENTIAL NURSING CARE .................................................................................................................................................... 39

NUR1114 FORMATIVE CLINICAL PERFORMANCE REPORT ................................................................................................... 41

NUR1114 SUMMATIVE CLINICAL PERFORMANCE REPORT ................................................................................................... 45

YEAR 2: MANDATORY ASSESSMENTS .............................................................................................................................. 51

ASEPTIC TECHNIQUE ............................................................................................................................................................. 51

ORAL MEDICATION ADMINISTRATION ...................................................................................................................................... 53

PARENTERAL MEDICATION ADMINISTRATION ........................................................................................................................... 55

CARE OF A SINGLE PATIENT ................................................................................................................................................... 57

NUR2225 MENTAL HEALTH NURSING AND MIDWIFERY PRACTICE (INPATIENT) ......................................................................... 59

NUR2225 MENTAL HEALTH NURSING AND MIDWIFERY PRACTICE (NON-INPATIENT) ................................................................. 70




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YEAR 3: MANDATORY ASSESSMENTS ............................................................................................................................ 105

ADMINISTRATION OF INTRAVENOUS THERAPY ........................................................................................................................ 105

CLINICAL HANDOVER ........................................................................................................................................................... 107

RISK ASSESSMENT .............................................................................................................................................................. 109

CLINICAL DOCUMENTATION .................................................................................................................................................. 111

RESPONDING TO THE DETERIORATING PATIENT .................................................................................................................... 113

CARE OF A GROUP OF PATIENTS .......................................................................................................................................... 115

NUR3310 FORMATIVE CLINICAL PERFORMANCE REPORT ................................................................................................. 117

NUR3310 SUMMATIVE CLINICAL PERFORMANCE REPORT ................................................................................................. 121

NUR3312 FORMATIVE CLINICAL PERFORMANCE REPORT ................................................................................................. 125

NUR3312 SUMMATIVE CLINICAL PERFORMANCE REPORT ................................................................................................. 129

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SECTION 1: GENERAL INFORMATION

Bachelor of Nursing

Clinical Practice Portfolio

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SECTION 1: GENERAL INFORMATION

Introduction

Clinical placement provides you with an opportunity to translate the theoretical content and

procedural management that you have learned at university into the clinical practice

environment.

This clinical portfolio is a record of clinical activity undertaken across the three year Bachelor

of Nursing program or the four year Bachelor of Nursing/Bachelor of Midwifery program

(N.B. a separate portfolio will also need to be completed for the midwifery component of this

program). The portfolio is a repository of evidence to meet the requirements of the nursing

programs. The portfolio will allow you to record and monitor your experiences whilst on

clinical practice. Reflection will allow you to further develop your clinical experiences and link

theory to practice.

How to Use the Portfolio

The nursing Clinical Portfolio has two overall purposes:

Provide the student, lecturer, preceptor, educator or facilitator with general

information and documentation required relating to nursing practice;

Provide the student with a cumulative repository of nursing practice and experience;

and reflections over the entire period of their course.

The clinical portfolio is divided into six (6) sections

Section One: General Information

Section Two: Patient assessment profiles

Section Three: Pharmacology log

Section Four: Clinical activity log

Section Five: Reflections of self and practice

Section Six: Core clinical competencies

Students are responsible for the maintaining and safe keeping of their portfolio. Students

need to ensure that the portfolio is kept up to date and made available upon request by

educators or lecturers. Additional pages and material can be added to portfolio.

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Nursing Clinical Practice

Nursing clinical practice occurs in both simulated and healthcare environments. Simulation

will provide clinical experience through all year levels of the programs. Clinical practice in the

health care environment will commence year 1 semester 2.

You are encouraged to make the most of all learning opportunities offered in both the

simulated and clinical environment.

Clinical Placement

Pre-placement mandatory requirements

Prior to commencing clinical placement you MUST meet the pre-placement mandatory

requirements. The pre-placement mandatory requirements are immunisations, Working with

Children Check and police check.

Immunisation Compliance as per Faculty of Medicine, Nursing and Health Sciences

policy

o You must comply with procedures to minimise the risk of cross-infection of

communicable diseases during your BN.

o The link to the policy and forms is:

http://www.med.monash.edu.au/current/immunisation/

Working with Children Check

o Working with Children Checks are completed online.

o The link is: https://online.justice.vic.gov.au/wwccu/onlineapplication.doj

Police Check (Fit2work)

o You will need a complete a police check for every year you are enrolled in the

BN.

o You will receive an email in your student email account inviting you to

complete an online application for Fit2Work.

Detailed information on the mandatory clinical requirements can be found on the Clinical

Placement Moodle site and in the Clinical Placement Information Pack available on the

School of Nursing and Midwifery website (http://www.med.monash.edu.au/nursing/).

http://www.med.monash.edu.au/current/immunisation/

https://online.justice.vic.gov.au/wwccu/onlineapplication.doj

http://www.med.monash.edu.au/nursing/

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Attendance at Clinical Placement

Clinical placements take considerable negotiation and co-ordination. The clinical venues

concerned offer a great deal of good will in accepting and providing clinical teaching for

students’ supervised practice. It is expected that students will highly value the opportunity

afforded to them.

At all times it is expected that students attend all (100%) of allocated practice for which they

are rostered. If unavoidable absence from practice occurs the student is responsible for

notifying both the ward/agency and clinical office as soon as the absence occurs. A medical

certificate needs to be provided to the Monash University clinical office as soon as possible

after the event.

Any time absent from your allocated clinical placement will need to need made up. Failure to

complete the hours will result in a delay to you completing your program and therefore

registration.

Policies and Resources

Clinical/fieldwork placement policies, procedures and behavioural requirements

o http://www.med.monash.edu.au/policies/docs/clinical-fieldwork-placement-

guidelines.pdf

Clinical placement information pack

o http://www.med.monash.edu.au/nursing/info-4-students/clinical-enrolment-

pack/2016-clinical-enrolment-pack-v4.pdf

Student upload of mandatory requirements

o http://www.med.monash.edu.au/nursing/info-4-students/clinical-enrolment-

pack/inplace-guidelines-student.pdf

http://www.med.monash.edu.au/policies/docs/clinical-fieldwork-placement-guidelines.pdf

http://www.med.monash.edu.au/policies/docs/clinical-fieldwork-placement-guidelines.pdf

http://www.med.monash.edu.au/nursing/info-4-students/clinical-enrolment-pack/2016-clinical-enrolment-pack-v4.pdf

http://www.med.monash.edu.au/nursing/info-4-students/clinical-enrolment-pack/2016-clinical-enrolment-pack-v4.pdf

http://www.med.monash.edu.au/nursing/info-4-students/clinical-enrolment-pack/inplace-guidelines-student.pdf

http://www.med.monash.edu.au/nursing/info-4-students/clinical-enrolment-pack/inplace-guidelines-student.pdf

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Reflections of Self and Practice

A theme of the courses is for graduates to become reflective registered nurses. You may

have heard about reflective practice but have not encountered the ‘doing’ or application of

this concept. As a beginning practitioner you need to consider the why, when and how to

reflect to assist you in your development and in working with patients, clients, family and

carers.

Reflective practice is related to the individual perceptions and thinking you have in different

practice situations. From your experiences in clinical placement you are encouraged to

critically analyse and reflect upon practice. This creates the potential for you to learn about

how you behave in particular scenarios and gain knowledge of what happens. Therefore

reflection not only presents the opportunity to further explore your practice on different

levels, but by using critical thinking and analysis they can think of different ways to improve

your practice in the future.

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SECTION 2: PATIENT ASSESSMENT PROFILES

Bachelor of Nursing


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SECTION 2: PATIENT ASSESSMENT PROFILES

Clinical placement creates an ongoing opportunity to assess your patients, evaluate the

effectiveness of implemented interventions and reassess. Patient assessment is a

fundamental practice that will inform your clinical decision making. It enables you to critically

think about the underlying pathophysiological processes and responses to develop a person-

centred care plan that directly links to the patients’ presenting condition and needs.

To support your formative assessment (used for feedback and interim evaluation, does not

count towards your final grade) and summative assessment (count towards your final grade),

as well as your own reflective practice, the following patient assessment profile provides you

with a tool to develop a holistic approach to assessing and managing patients. The patient

assessment profile not only demonstrates your assessment and critical thinking skills, but

forms a useful reflective tool for study.

Whilst on clinical placement it is expected that you will complete one patient assessment

profile and present/discuss this with your educator/facilitator each week. The expectation is

that there is increasing complexity with the patient profile as the student progresses through

their program.

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Acute Care Patient Assessment Profile

Clinical Placement Venue: Assessment Number

Handover:

Assessment (using a systematic approach)

Problems/Issues Identified

Planned Care / Nursing Interventions

Pathophysiology and Pharmacology

Outcomes/Evaluation (including Discharge Planning)

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Primary Care Patient Assessment Profile

Clinical Placement Venue: Assessment Number:

Handover:

Primary Care Assessment - Ensure your assessment is inclusive of the following domains: -

biological, psychological, social (including family), environmental and spiritual.


Planned interventions/strategies/services

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Mental Health Patient Assessment Profile

Clinical Placement Venue: Assessment Number

Handover:

Client Assessment


Planned interventions/strategies/services

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SECTION 3: PHARMACOLOGY LOG

Bachelor of Nursing


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SECTION 3: PHARMACOLOGY LOG

Registered nurses’ must have a safe level of pharmacological knowledge to:

Safely administer medications;

Develop an understanding of the effects of the drugs on the body; and

Monitor the body’s response to the drug.

You will have numerous opportunities to administer medications in a variety of settings. To

support your formative assessment (used for feedback and interim evaluation, does not

count towards your final grade) and summative assessment (counts towards your final

grade), as well as your own reflective practice, the following pharmacology log provides you

with a tool to record medications administered to patients.

Whilst on clinical placement it is expected that you will complete at least one pharmacology

log and present/discuss this with your educator/facilitator each week.

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Pharmacology Log

1. Client information

Gender: F / M Age: years

Presenting diagnosis:

Relevant past history:

2. Description of chosen medication:

Generic name:

_________________________________________________________________________________

Trade name:

_________________________________________________________________________________

Drug category (ies):

Date medication commenced (if known):

_________________________________________________________________________________

Route of administration for patient/client:

_________________________________________________________________________________

List the possible routes of administration:

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Prescribed dosage regime for patient:

________________________________________________________________________________

How does the dosage compare to the recommended dosage?

3. In your own words, describe the action/s of the medication.

4. Discuss why the medication has been ordered for this particular patient/client. What is the desired

effect?

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5. What are the reported side effects of this medication? Indicate which of these side effects (if any)

the patient/client has experienced and the subsequent management (medical & nursing) of these

effects?

6. List other medications (over the counter [OTC] & prescribed) the patient/client is currently taking,

Are there any particular interactions that need to be observed for? Are there any contraindications

in their concurrent use?

7. Are there any dietary or lifestyle considerations relating to the use of this drug? If so, outline

below.

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8. Describe the nursing considerations for administration of this drug. Include the various routes of

administration.

9. Describe in detail, the education that you would provide the client with about this medication.

Include administration, storage, monitoring and handling considerations. Use language that the

client will understand.

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SECTION 4: CLINICAL ACTIVITY LOG

Bachelor of Nursing


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SECTION 4: CLINICAL ACTIVITY LOG

You will have numerous opportunities to deliver care to patients that involve the application

of technical skills e.g. attending to hygiene, IDC insertion, IV medication administration. To

support your formative assessment (used for feedback and interim evaluation, does not

count towards your final grade) and summative assessment (counts towards your final

grade), as well as your own reflective practice, the following clinical activity log provides you

with a tool to record learning and development opportunities.

For every technical skill that you perform, a rationale must be provided as to why the patient

required the intervention, alongside a self-assessment of the level you are performing at.

This activity log will be used during your summative evaluation to provide evidence of your

progression; it is a requirement that you keep an ongoing activity log throughout placements.

You are able to undertake any clinical skills at any point in the BN as long as you are

supervised, working in accordance with hospital policy, and have permission from your

preceptor/educator.

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Date &

Year

level

Skill performed Rationale for intervention: Self-Assessed

Performance

(Use Grading Scale

on page 33)

I P A S D

EXAMPLE ONLY

11/05/15

Year 1

Personal Hygiene Patient required assistance to shower. Encouraged with self-care but assistance given as needed.

Pressure area assessment completed.

EXAMPLE ONLY

11/05/15

Year 2

Venepuncture Pathology requested prior to theatre to establish baseline electrolyte and cross match

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SECTION 5: REFLECTIONS OF SELF AND

PRACTICE

Bachelor of Nursing


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SECTION 5: REFLECTIONS OF SELF AND PRACTICE

Students are required to use the following template to document their engagement in

reflective practice. It is expected that a minimum of three reflective exercises will be

undertaken during each clinical placement as evidence of reflection on self and practice; a

component of competency assessment.

Description of Incident Date ___________

Reflection on incident Date ____________

Research/discussion with critical friend Date ____________

Further reflection/competency attained Date ____________

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SECTION 6: CORE CLINICAL COMPETENCIES

Bachelor of Nursing


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SECTION 6: CORE CLINICAL COMPETENCIES

The clinical competencies within Monash University Nursing and Midwifery clinical portfolio

must be successfully passed to complete the Bachelor of Nursing or Bachelor of Nursing /

Bachelor of Midwifery. It is important to remember that these clinical competencies are not to

be viewed in isolation, but as an intervention that is required for the patient, based on your

clinical assessment.

You will be required to complete the clinical competencies by the end of each year level as

indicated. You are encouraged to practice the skills at every opportunity in the clinical and

simulated setting, including after you have completed the competency assessment. Use the

Clinical Activity Log and Pharmacology Log (above) to demonstrate practice and mastery of

skills and knowledge.

The core clinical competencies are based on the National competency standards for the

registered nurse. The link to the competency standards is:

http://www.nursingmidwiferyboard.gov.au/Search.aspx?q=national+competency+standards+

for+the+registered+nurse

In regards to the formative and summative assessments. A formative assessment is to be

completed approximately half way through your clinical placement. A summative is to be

completed at the end of the placement. Please select the assessment that suits the clinical

placement that you are in e.g. GP practice primary health care; hospital setting acute.

All year level mandatory requirements must be completed before the final summative report

for the year can be completed (NUR2228 and NUR3312).

EXPECTATIONS

By the end of year 2 (NUR2228 summative) you are expected to be caring for 50% of

a normal patient load e.g. 2-3 patients at an assisted level

By the end of year 3 (NUR3312 summative) you are to be caring for the equivalent of

a full patient load e.g. 4 patients at a proficient level.

http://www.nursingmidwiferyboard.gov.au/Search.aspx?q=national+competency+standards+for+the+registered+nurse

http://www.nursingmidwiferyboard.gov.au/Search.aspx?q=national+competency+standards+for+the+registered+nurse

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Minimum expected performance for Clinical Placement (Bachelor of Nursing M2006)

(Adapted from Bondy; 1984)

SCALE

PERFORMANCE STANDARD

QUALITY OF PERFORMANCE

SUPPORT REQUIRED

I

(Independent)

Safe and accurate

Effective each time

Appropriate behaviour and demeanour each time

Proactive, coordinated, confident delivery of care

Occasional expenditure of excess energy

Within an expedient time frame

Minimal prompts required

Year 3 Minimum expected level of practice

P

(Proficient)

Safe and accurate

Effective each time

Appropriate behaviour and demeanour each time

Coordinated, confident delivery of care

Some expenditure of excess energy

Within a reasonable time frame

Occasional supportive cues

Year 2 Minimum expected level of practice A

(Assisted)

Safe and accurate

Effective most of the time

Appropriate behaviour and demeanour most of the time

Skilful in parts of procedure / behaviour

Inefficiency and lacking coordination

Expends excess energy

Within a delayed timeframe

Frequently requires directive verbal and occasional physical prompts

Year 1, Minimum expected level of practice S

(Supported)

Safe but not alone

Performs at risk

Accurate not always

Effective occasionally

Appropriate behaviour and demeanour occasionally

Unskilled, inefficient

Considerable expenditure of excess energy

Prolonged time period

Requires continuous verbal and frequent physical prompts

D

(Dependent)

Unsafe

Unable to demonstrate behaviour

Unable to demonstrate procedure/behaviour

Lacks confidence, coordination, efficiency

Requires continuous verbal and physical prompts

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YEAR 1: MANDATORY ASSESSMENTS

Bachelor of Nursing


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Physical Assessment

Student Name: ___________________________ Student Number: __________________

PHYSICAL ASSESSMENT Demonstrates ability to effectively assess a patient's physical status

NSQHS Standard:

CRITERIA I = Independent P = Proficient A = Assisted S = Supervised D = Dependent N/A = Not applicable

PERFORMANCE CRITERIA (Professional Standard) I P A S D N/A

Identifies indication for physical assessment (1)

Gathers appropriate equipment and prepares environment (4)

Evidence of therapeutic interaction with the patient, e.g. gives clear explanation of procedure (2)

Performs hand hygiene (1, 6)

Undertakes a primary assessment (4, 6)

Conducts a systematic physical assessment of the patient (4, 6)

- obtains vital signs, height and weight (as appropriate)

- inspects the patient throughout the physical assessment

- assesses the neurological functioning (as appropriate)

- assesses the cardiac functioning(as appropriate)

- assesses the respiratory functioning (as appropriate)

- assesses the gastrointestinal functioning (as appropriate)

- assesses the genitourinary functioning (as appropriate)

- assesses the musculoskeletal functioning (as appropriate)

Obtains a focused health history (4, 6)

Gathers information for a mental status assessment during the physical assessment (4, 6)

Cleans, replaces and disposes of equipment appropriately (1)

Documents relevant information in a timely manner (1, 6)

Demonstrates ability to link theory to practice (1, 6)

Assessor’s Name: _________________________________________________

Assessor’s Signature: ______________________________________________

Assessor’s Designation: ____________________________________________

Date: ___________________________________________________________

Student Signature: _________________________________________________

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Essential Nursing Care


ESSENTIAL NURSING CARE Demonstrates the student’s ability to effectively maintain a dependent patient’s personal hygiene

NSQHS Standard:



Identifies indication for hygiene activity (1)

Assesses patient for ability to self-care (5, 6)

Evidence of therapeutic interaction with the patient, e.g. gives patient a clear explanation of procedure, incorporates patient’s preferences (2, 6)

Gathers equipment (4)


Dons personal protective equipment as required (1, 6)

Demonstrates problem-solving abilities, e.g. provides privacy, adjust bed height, attends to environmental temperature, positions patient (1, 3, 5, 6)

Carries out the hygiene measure/s required (bed bath, assisted shower, shave, hair care, mouth care, nail care) (1, 5, 6)


Documents relevant information in a timely manner (1)


Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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Monash University Nursing and Midwifery

NUR1114 FORMATIVE Clinical Performance Report

Date: _____/_____/_____ to _____/_____/_____ Hospital & Ward: _______________________________________________________________

Student Name: _____________________________________ Student ID: ______________________ Campus: Clayton Peninsula

Clinical Experience: Acute Aged Care Community Mental Health Rehabilitation Specialty (Specify) ____________________________

Appraisal Key to be utilised: I = Independent P = Proficient A = Assisted S = Supported D = Dependant NA = Not Applicable

Final Placement Appraisal

Student Facilitator

I P A S D

Standards

Standard 1: Thinks critically and analyses nursing practice

Access, analyses and uses the best available evidence, that includes research findings, for safe quality practice Develops practice through reflection on experiences, knowledge, actions, feelings and beliefs to identify how these shape practice

Respects all cultures and experiences, which includes responding to the role of family and community that underpin the health of Aboriginal and Torres Strait Islander peoples and people of other cultures

Complies with legislation, regulations, policies, guidelines and other standards or requirements relevant to the context of practice when making decisions

Uses ethical frameworks when making decisions Maintains accurate, comprehensive and timely documentation of assessments, planning, decision making, actions and evaluations

Contributes to quality improvement and relevant research Standard 2: Engages in therapeutic and professional relationships

Establishes, sustains and concludes relationships in a way that differentiate the boundaries between professional and personal relationships

Communicates effectively, and is respectful of a person’s dignity, culture, values, beliefs and rights Recognises that people are the experts in the experience of their life Provides support and directs people to resources to optimise health-related decisions Advocate on behalf of people in a manner that respects the person’s autonomy and legal capacity Uses delegation, supervision, coordination, consultation and referrals in professional relationships to achieve improved health outcomes

Actively fosters a culture of safety and learning that includes engaging with health professionals and others, to share knowledge and practice that supports person-centred care

Participates in and/or leads collaborative practice Reports notifiable conduct of health professionals, health workers and others

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Standard 3: Maintains the capability for practice Considers and responds in a timely manner to the health and wellbeing of self and others in relation to the capability for practice

Provides the information and education required to enhance people’s control over health Uses a lifelong learning approach for continuing professional development of others and self Accepts accountability for decisions, actions, behaviours and responsibilities inherent in their role, and for the actions of others to whom they have delegated responsibilities

Seeks and responds to practice review and feedback Actively engages with the profession Identifies and promotes the integral role of nursing practice and the profession in influencing better health outcomes for people

Standard 4: Comprehensively conducts assessments Conducts assessments that are holistic as well as culturally appropriate Uses a range of assessment techniques to systematically collect relevant and accurate information and data to inform practice

Works in partnership to determine factors that affect, or potentially affect, the health and wellbeing of people and populations to determine priorities for action and / or for referral

Assess the resources available to inform planning Standard 5: Develops a plan for nursing practice Uses assessment data and best available evidence to develop a plan Collaboratively constructs nursing practice plans until contingencies, options priorities, goals, actions, outcomes and timeframes are agreed with the relevant persons

Documents, evaluates and modifies plans accordingly to facilitate the agreed outcomes Plans and negotiates how practice will be evaluated and the time frame of engagement Coordinates resources effectively and efficiently for planned actions Standard 6: Provides safe, appropriate and responsive quality nursing practice Provides comprehensive safe, quality practice to achieve agreed goals and outcomes that are responsive to the nursing needs of people

Practises within their scope of practice Appropriately delegates aspects of practice to enrolled nurses and others, according to enrolled nurse’s scope of practice or others’ clinical or non-clinical roles

Provides effective timely direction and supervision to ensure that delegated practice is safe and correct Practises in accordance with relevant policies, guidelines, standards, regulations and legislation Uses the appropriate processes to identify and report potential and actual risk related system issues and where practice may be below the expected standards

Standard 7: Evaluates outcomes to inform nursing practice Evaluates and monitors progress towards the expected goals and outcomes Revises the plan based on the evaluation Determines, documents and communicates further priorities, goals and outcomes with the relevant persons

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Student Number: _________________________

Clinical Facilitator General Comments:

Areas of Practice Requiring Development:

Student Comments:

Status: Incomplete Satisfactory Unsatisfactory (please circle)

Total Number of additional Hours / Days Absent: _______________

Clinical Facilitator’s Name: ___________________________________ Clinical Facilitator’s Signature: ____________________________

Designation __________________ Date: ______________ Student’s Signature: ______________________________________________

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45


NUR1114 SUMMATIVE Clinical Performance Report






Student Facilitator

I P A S D

Standards











46











47

Student Number: _________________________



Student Comments:





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Bachelor of Nursing


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Aseptic Technique


ASEPTIC TECHNIQUE Demonstrates ability to effectively and safely establish and maintain a sterile field

NSQHS Standard:



Identifies indication for aseptic technique (1)

Evidence of therapeutic interaction with patient, e.g. gives explanation (2)

Demonstrates problem-solving abilities, e.g. positions patient comfortably (1, 3, 5, 6)


Prepares equipment for procedure (4)

Performs required procedure (1, 6)


Documents relevant information (1, 6)


Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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Oral Medication Administration


Oral medication administration

Demonstrates ability to effectively and safely administer oral medications.

NSQHS Standard:

CRITERIA I = Independent P = Proficient A = Assisted S = Supported D = Dependent N/A = Not applicable


Identifies indications for administration (1)

Verifies validity of medication order (1, 6)


Adheres to general concepts of working with therapeutic substances (1, 6)

Accurately calculates the dose required (1, 6)

Gathers required equipment (1)

Evidence of therapeutic interaction with patient, clear explanation given, discusses effects and any adverse reactions with patient (2)

Displays problem-solving ability eg. positions patient, assessment of patient as required (1, 6)

Uses the “rights” to administer medication (1, 6)

Prepares the medication (1, 6)

Assists the patient to take the medication (1, 6)


Accurately documents relevant information (1, 6)


Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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Parenteral Medication Administration


Parenteral Medication Administration

Demonstrates the student’s ability to effectively and safely administer an injection (subcutaneous or intramuscular)

NSQHS Standard:



Identifies indications for administration of intramuscular or subcutaneous medications (1)

Verifies validity of order (1)



Evidence of therapeutic interaction with the client and preparation of client (2)

Adheres to general concepts of working with therapeutic substances (1, 6)

Accurately calculates the dose required (1)

Safely assembles the syringe and needle, and draws up medication, using aseptic principles (1, 6)

Uses the “rights” of medication administration (1, 6)

Displays problem-solving abilities e.g. provides privacy, positions patient, assessment of patient (1 ,6)

Selects and assesses appropriate injection site and correctly identifies landmarks. (1, 6)

Safely administers medication to maximize effects and minimise discomfort (1, 6)

Tends to puncture site appropriately (1, 6)




Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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Care of a Single Patient


CARE OF A SINGLE PATIENT

Demonstrates the student’s ability to effectively and safely coordinate the care of a single patient for a period of care

NSQHS Standard:



Reviews and verifies available information on the patient (handover, history, medication chart, documentation etc.) (1, 6)


Dons Personal Protective Equipment as needed (1)


Maintains patient dignity, privacy and comfort (1, 2)

Demonstrates problem solving abilities e.g. positions patient comfortably (1, 6)

Completes a systematic patient assessment

primary assessment

secondary assessment

focused assessment (4)

Develops a plan of care in consultation with the patient/family and multidisciplinary team (1, 2, 3, 5, 6, 7)

Prioritizes workload and responds promptly and appropriately to patient’s needs (6, 7).

Carries out interventions according to devised plan of care (1, 2, 3, 5, 6)

Evaluates the outcomes of planned interventions and revises plan of care as needed (7)



Communicates relevant information with the patient and staff in a timely manner (2)


Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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NUR2225 Mental Health Nursing and Midwifery Practice (Inpatient)

Mental Health Assessment: For students in an in-patient unit

The Mental Health Assessment needs to be completed during your mental health clinical

placement. Summative report cannot be completed until the assessment is undertaken.

If you are on a placement in an in-patient unit you MUST complete the following mental health

assessment.

Mental health assessment form

Client Pseudonym

Client Age

Client Gender

Reason for referral/presentation

History of present problem

Chronological summary of: current symptoms, treatment and response, precipitating events.

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Medical History

Record current and relevant past medical illnesses, hospitalisations, injuries, treatments, surgery,

sensory deficits (e.g. diabetes, cardiovascular problems, asthma, hypotension).

Developmental history and psychosocial development

Note any relevant or noteworthy problems in early development (e.g. schooling, upbringing,

relationships, response to life transitions, history of abuse and major events. Also consider sexual

development/orientation).

Social History

Current living arrangements, important relationships. Available support (including health service

providers). Functioning in current roles (e.g. marriage, parenting, daughter or son). Financial

problems/issues.

61

Substance use/abuse history

Past and present use of substances, including: alcohol, nicotine (tobacco), caffeine, marijuana

(cannabis), cocaine, opiates, sedative-hypnotic agents, solvents and hallucinogens.

Alcohol Nicotine Cannabis Amphetamines Inhalants Other

(specify)

Age first used

Age of 1st

regular use

Route of

administration

Average daily

use

Number of days

used in past

week

Number of days

used in past

month

Date/time of

last use

Periods of

abstinence

Apparent stage

of change*

Additional

information

62

Legal/Forensic History

Any previous or current involvement with the juvenile justice or legal systems including pending

proceedings.

Occupational History

Sequence of jobs held, reason for job changes, current or most recent employment. Military

service.

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Family history

Construct a genogram, recording names, ages and sex of siblings, parents and children for 2

generations. Record in order of birth. Give age and cause of death. Note familial disease e.g.

alcoholism, intellectual disability, mental illness including suicide.

Male Female Death Identified Client

Marriage Divorce Unmarried Relationship

A & W

Alive & well

Over-close Relationship

Conflictual Relationship

Twins

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Physical examination

Vital signs: T P R BP

(lying & standing)

Weight:

Any obvious trauma, marks/scars. Note prominent physical characteristics (e.g. tattoos or

birthmarks).

Current prescribed medications, complementary and OTC medicines

Medication Dose Frequency Route

Note any adverse effects currently experienced by client

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Known allergies Signs and symptoms of allergy

Adherence to prescribed medications and ability to manage own medications

Activities of daily living (ADL’s)

Sleep: current patterns, including diurnal variation. Distinguish type of insomnia – early, middle or

terminal.

Usual diet and fluid intake and current appetite: N.B. cultural/religious considerations.

Elimination pattern.

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Current exercise pattern: active exercise hours per week or sedentary.

Self-care: current abilities relating to dressing, bathing, feeding, toileting etc.

Independent living skills: driving, using public transport, shopping, keeping house,

communicating by mail, telephone and managing own money.

Mental status examination

Describe general appearance and behaviour.

67

Motor Activity

Describe posture, movement and gait. Record, describe and give examples of abnormalities

including: medication induced disorders, posturing, decreased or increased movements. N.B. if

movements are under voluntary control.

Mood and affect

Describe mood and affect including appropriateness, intensity, mobility, range and reactivity.

Speech

Assess fluency, rate, rhythm, melodic intonation articulation. Record, describe and give examples

of abnormalities including aphasias, pressure and poverty of speech, mutism, dysarthria, profanity,

perseveration, echolalia, monotonous tone, increased latency.

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Thought process/form

Record, describe and give examples of abnormalities including circumstantiality, tangentially,

racing thoughts, flight of ideas, loosening of associations, word salad, clang associations,

neologisms and thought blocking.

Thought content

Record, describe and give examples of abnormalities including delusions, obsessions/overvalued

ideas, harm to self or others.

Perception

Record, describe and give examples of abnormalities including hallucinations, illusions.

Judgement

Contemplative or reflective versus impulsive.

Direct questions about current impending decisions or record examples of recent decision made by

the client.

Hypothetical questions. “What would you do with a stamped addressed letter found on the street?”

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Insight

Direct questions regarding understanding of illness and need for treatment.

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NUR2225 Mental Health Nursing and Midwifery Practice (Non-Inpatient)

Mental Health Assessment: For students in a NON in-patient unit.

The Mental Health Assessment needs to be completed during your three weeks mental health

clinical placement. Summative report cannot be completed until this assessment is undertaken.

If you are on a placement other than an in-patient unit (for example, crisis assessment team, or

any other areas of the community mental health team) you MUST complete the following Mental

Health Assessment.

Mental health assessment form

Client Pseudonym

Client Age

Client Gender

Client Diagnosis

Reason for Follow up

Discharged from: (date)

Present Medical Conditions

Record current medical illnesses, hospitalisations, injuries, treatments, surgery, sensory deficits

(e.g. diabetes, cardiovascular problems, asthma, hypertension).

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Present Social History/Living arrangements

Current living arrangements. Any present available support (family support including health service

providers). Functioning in current roles (e.g. married, divorced, parenting, living alone). This is an

important aspect of the recovery process.

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Any present substance use/abuse? Yes / No

If yes. Any present use of substances, including: alcohol, nicotine (tobacco), caffeine, marijuana

(cannabis), cocaine, opiates, sedative-hypnotic agents, solvents and hallucinogens.

Alcohol Nicotine Cannabis Amphetamines Inhalants Other

(specify)

Route of

administration

Average daily

use

Number of days

used in past

week

Number of days

used in past

month

Date/time of

last use

Periods of

abstinence

Apparent stage

of change*

Any relevant

additional

information

Any present Legal/Forensic History

Any current involvement with the juvenile justice or legal systems including pending court

proceedings. If yes give brief reasons for this.

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Present Occupational History

Current or most recent employment, including if patient is on any Centrelink assistance.

Is there a need to presently involve a Social Worker? Yes / No

If yes, give a brief reason for referral.

Current prescribed medications, complementary and OTC medicines

Medication Dose Frequency Route

Note any side effects/adverse effects currently experienced by client.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________

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Does the client need a medication review? Yes / No

If Yes reasons for review:

Who will organise the review?

Is the client able to manage and adhere to the present prescribed medications?

Yes / No

If No give a brief reason for non-adherence and/or elaborate who is presently managing their

prescribed medication.

Self-care and activities of daily living (ADL’s)

Sleep Pattern: Good/Poor

If Poor give a brief reason for this:

______________________________________________________________________________

______________________________________________________________________________

_______________________________________________________________

Appetite: Good/Poor

Has the client lost any recent unexplained weight loss?

______________________________________________________________________________

______________________________________________________________________________

_______________________________________________________________

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Self-care: e.g. current abilities relating to dressing, bathing, feeding, toileting.

Independent living skills: driving, using public transport, shopping, keeping house,

communicating by mail, telephone and managing own money.

Present mental status examination.

Describe general appearance and behaviour.

Motor Activity

Describe posture, movement and gait. Record, describe and give examples of abnormalities

including: medication induced disorders, posturing, decreased or increased movements. N.B. if

movements are under voluntary control.

76

Mood and affect

Describe mood and affect including appropriateness, intensity, mobility, range and reactivity.

Speech

Assess fluency, rate, rhythm, melodic intonation articulation. Record, describe and give examples

of abnormalities including aphasias, pressure and poverty of speech, mutism, dysarthria, profanity,

perseveration, echolalia, monotonous tone, increased latency.

Thought process/form

Record, describe and give examples of abnormalities including circumstantiality, tangentially,

racing thoughts, flight of ideas, loosening of associations, word salad, clang associations,

neologisms and thought blocking.

Thought content

Record, describe and give examples of abnormalities including delusions, obsessions/overvalued

ideas, harm to self or others.

77

Perception

Record, describe and give examples of abnormalities including hallucinations, illusions.

Judgement

Contemplative or reflective versus impulsive.

Direct questions about current impending decisions or record examples of recent decision made by

the client.

Hypothetical questions. “What would you do with a stamped addressed letter found on the street?”

Insight

Direct questions regarding understanding of illness and need for treatment.

Any present presenting RISKS? Yes/No

If yes please indicate clearly the presenting risk and any immediate actions to be taken.

78

Further actions to be taken and by whom?

79





Clinical Experience: Acute mental health Community mental health



Student Facilitator

I P A S D

Standards




Complies with legislation, regulations, policies, guidelines and other standards or requirements relevant to the context of practice when making decisions including Victorian Mental Health Act (2014)




Communicates effectively, is non-judgemental, respectful of a person’s dignity, culture, values, beliefs and rights Recognises that people are the experts in the experience of their life Provides support and directs people to resources to optimise health-related decisions Advocate on behalf of people in a manner that respects the person’s autonomy and legal capacity Uses delegation, supervision, coordination, consultation and referrals in professional relationships to achieve improved health outcomes



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Standard 4: Comprehensively conducts assessments Conducts assessments that are holistic as well as culturally appropriate Uses a range of assessment techniques to systematically collect relevant and accurate information and data to inform practice including ability to identify ques and illicit further information from clients contemplating suicide



Discusses links between thoughts, feelings and behaviours to gain an understanding of the “disturbed” behaviours in the client

Documents, evaluates and modifies plans accordingly to facilitate the agreed outcomes Plans and negotiates how practice will be evaluated and the time frame of engagement Coordinates resources effectively and efficiently for planned actions Identify processes by which a client can be admitted as involuntary Standard 6: Provides safe, appropriate and responsive quality nursing practice Provides comprehensive safe, quality practice to achieve agreed goals and outcomes that are responsive to the nursing needs of people




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Student Number: _________________________



Student Comments:




Designation __________________ Date: ______________ Student’s Signature: ____________________________________________

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Clinical Experience: Acute mental health Community mental health



Student Facilitator

I P A S D

Standards




Complies with legislation, regulations, policies, guidelines and other standards or requirements relevant to the context of practice when making decisions including Victorian Mental Health Act (2014)




Communicates effectively, is non-judgemental, respectful of a person’s dignity, culture, values, beliefs and rights Recognises that people are the experts in the experience of their life Provides support and directs people to resources to optimise health-related decisions Advocate on behalf of people in a manner that respects the person’s autonomy and legal capacity Uses delegation, supervision, coordination, consultation and referrals in professional relationships to achieve improved health outcomes



84




Standard 4: Comprehensively conducts assessments Conducts assessments that are holistic as well as culturally appropriate Uses a range of assessment techniques to systematically collect relevant and accurate information and data to inform practice including ability to identify ques and illicit further information from clients contemplating suicide



Discusses links between thoughts, feelings and behaviours to gain an understanding of the “disturbed” behaviours in the client

Documents, evaluates and modifies plans accordingly to facilitate the agreed outcomes Plans and negotiates how practice will be evaluated and the time frame of engagement Coordinates resources effectively and efficiently for planned actions Identify processes by which a client can be admitted as involuntary Standard 6: Provides safe, appropriate and responsive quality nursing practice Provides comprehensive safe, quality practice to achieve agreed goals and outcomes that are responsive to the nursing needs of people




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Student Number: _________________________



Student Comments:




Designation __________________ Date: ______________ Student’s Signature: ____________________________________________

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Student Number: _________________________



Student Comments:





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Student Number: _________________________



Student Comments:





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Student Number: _________________________



Student Comments:




Designation __________________ Date: ______________ Student’s Signature: _____________________________________________

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Student Number: _________________________



Student Comments:




Designation __________________ Date: ______________ Student’s Signature: ___________________________________________

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103


Bachelor of Nursing


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105


Administration of Intravenous Therapy


Administration of Intravenous Therapy

Demonstrates the student’s ability to effectively and safely manage intravenous therapy

NSQHS Standard:



Verifies validity of medication order (1)

Identifies indications for administration of intravenous therapy (1)

Identifies indications for administration of intravenous therapy via an infusion pump (1)

Evidence of therapeutic interaction with patient, clear explanation given, discusses effects and any adverse reactions with patient (2)

Assess the IV site and/or assist with establishment of IV access (2)



Uses aseptic principles to safely assemble and prime the IV line (1, 6)

Uses “rights” of medication administration (1, 6)

Connects IV line to the patient and establishes correct flow rate (1, 6)

Displays problem-solving ability e.g. management of IV line and patient clothing (1, 6)


Monitors patient throughout shift (e.g. infusion of correct volume of fluids/medications, adverse reactions) (1, 5, 6)



Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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107

Clinical Handover


CLINICAL HANDOVER Demonstrates ability to clearly and concisely report the condition of a patient or group of patients to another health care professional

NSQHS Standard:



Identifies indications for handover (1)

Considers patient privacy (1, 6)

Delivers handover using a structured / systematic format e.g. ISBAR (1, 6)

Information is accurate, concise and complete (1)

Medical terminology is appropriately used (1)

Delivery of information is timely (1, 6)


Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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Risk Assessment


RISK ASSESSMENT Demonstrates the ability to select and apply a risk assessment tool relevant to patient condition

NSQHS Standard:



Identifies indications for risk assessment (1, 5, 6)

Uses appropriate assessment tools and strategies to assist the collection of data (1, 5, 6)

Acts upon risk assessment findings (1, 5, 6)


Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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111

Clinical Documentation


CLINICAL DOCUMENTATION Demonstrates the ability to accurately record information about a patient in a timely manner

NSQHS Standard:



Identifies indications for documentation in patients chart/record (1, 5, 6, 7)

Uses appropriate medical terminology and approved abbreviations and acronyms (1, 5)

Content is relevant and accurate (1, 5)

Adheres to legal requirements (1, 5, 7)

Demonstrates ability to effectively use the facilities’ documentation processes (1, 5, 6, 7)

Documents information in timely manner (1, 5, 6, 7)


Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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113

Responding to the Deteriorating Patient


RESPONDING TO THE DETERIORATING PATIENT Demonstrates the ability to effectively and safely monitor and respond to a deteriorating patient within their care

NSQHS Standard:

CRITERIA I = Independent P = Proficient A = Assisted S = Supported D = Dependent N/A = Not Applicable




Maintains patient dignity, privacy and comfort (1)

Demonstrates problem solving abilities (1, 6)

Completes a comprehensive and systematic patient assessment of the deteriorating patient

primary assessment



Correctly interprets assessment findings and acts with appropriate urgency (e.g. DRSABC, activating emergency assist buzzer, +/- activating a MET call according to the clinical facility MET call criteria) (1, 4, 5, 6, 7)

Plans and prioritises care in consultation with the patient/family and the multidisciplinary team (1, 2, 5, 6)

Delivers interventions according to plan of care (1, 5, 6)

Evaluates the outcomes of planned interventions and revises plan of care as needed (7)

Communicates the relevant information with patient/family and staff in a timely manner (2)

Documents relevant information in timely manner (1, 5, 6, 7)

Delegates care of other patients as required (6)



Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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Care of a Group of Patients


CARE OF A GROUP OF PATIENTS

Demonstrates the student’s ability to effectively and safely coordinate the care of a group of patients for a span of duty/period of care.

NSQHS Standard:


Performance Criteria (Professional Standard) I P A S D N/A

Reviews and verifies information on the group of patients (handover, history, medication charts, documentation etc.) (1, 5)


Dons Personal Protective Equipment as required (1, 6)


Maintains patient dignity, privacy and comfort (1)

Demonstrates problem solving abilities (1, 6)

Completes a systematic patient assessment of the group of patients

primary assessment



Plans and prioritises care according to the needs of the group of patients (5, 6)

Delivers interventions in a timely manner, in accordance with plan of care (5, 6)

Evaluates the outcomes of planned interventions and revises plans of care as needed (7)


Communicates relevant information with patients and staff in a timely manner (2)

Documents relevant information in timely manner (1, 5, 6, 7)


Assessor’s Name: _________________________________________________



Date: ___________________________________________________________


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Student Number: _________________________



Student Comments:




Designation __________________ Date: ______________ Student’s Signature: __________________________________________

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Student Number: _________________________



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Clinical Experience: Acute Specialty (Specify) ____________________________



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Student Number: _________________________



Student Comments:





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Clinical Experience: Acute Specialty (Specify) ____________________________



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Student Number: _________________________



Student Comments:



