N210 Control Lab/Clilnical Folder - Cerritos Collegeweb.cerritos.edu/rsantiago/SitePages/My...

N210 Control Lab/Clinical FolderTable of Contents

_____________________________________________________________________________Student preparation for Scenario Days 2Clinical Folder Contents 3Clinical Absence Make-up guidelines 4Weekly Journal Assignment 5Journal Questions 6Time Management Schedule 7-8

Laboratory 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 Physical Assessment 3 17 NGT intubation 18 Nutrition lab 19 Foley catheterization 20 Wound Management (Wound Care) 21

Control Lab Sheets Skills Video Demonstrations 22-25 Nursing Skills Peer Check Off Sheet 26-28 Environment/Isolation/medical asepsis Control Lab Sheet (Infection Control, Fall Risk Assessment, )

29-32

Vital Signs Skills Check Off Stations 33-34 Bandages/Binders Restraints, antiembolism Stockings Thermal Therapy Critical Thinking Questions

35-36

Elimination practice check off sheet 37 PA Documentation Guide- general survey 38 PA Documentation Guide-skin,hair, nails 39 PA Documentation Guide-head and neck 40 PA Documentation Guide-chest and lungs 41 PA Documentation Guide-heart and peripheral vascular

42

PA Documentation Guide-abdomen 43 PA Documentation Guide- musculoskeletal 44 PA Documentation Guide-neurological 45-46 Physical Assessment Practicum grading sheet

47-48

Nasogastric Tube Critical Thinking Questions

49

Nasogastric Tube Removal 50 Urinary Catheterization Critical Thinking Questions

51

Catheter Removal 52 Wound care practice check off sheet 53-54

N210 Clinical References

1

NPW Assessment guide Guidelines 55-56 RAM reference for Assessment guide 57 NPW/ AG Blank form 58-63 NPW/ AG Example 64-69 Concept Mapping/Nursing CareMap guidelines

70-72

How to Use Your Nursing Caremap 73 N210 Clinical Course Evaluation 74-81 Guidelines for Clinical Performance Evaluation Tool

82-86

Approved abbreviations 87-89 Unapproved abbreviations 90 N210 Clinical Schedule Long TermCare 91-93 CPE Sheet 94-101

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

Clinical Folder Contents

The clinical folder is a record of your accomplishments throughout N210 and will continue to be used in N212. You are creating a quick reference resource for use at the clinical site. Insert any documents you think may be useful.

It should consist of the following elements:

1. Facility information and handouts2. Skills checklists (optional) or notes to assist in skill performance in clinical3. Clinical Evaluations4. Nursing Process Worksheet (NPW): guidelines, blank copies, examples,

completed NPW assignments5. Clinical Absence Make-Up Guidelines6. References: Charting examples, abbreviations (approved and unapproved);

Resident’s bill of rights. 7. N210 Clinical Schedule – Long Term Care

Please place in a 1” 3 ring binder.

3

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.

4

Weekly Journal Assignment

Definition: A reflective paper used to assist the student in identifying strengths and weaknesses.

Purpose: 1. Assist the student to identify and analyze his/her behaviors that may advance

or interfere with student learning. 2. Assist the student with evaluating problem solving skills. 3. Provide a one to one communication between student and instructor. 4. Allow the student the opportunity to have questions answered or concerns

addressed. 5. Find meaning in the activities experienced in lab and clinical.

Procedure: 1. Structure

Each entry must be dated. You may handwrite or use computer. If handwritten, it must be legible

and you must use a pen and a full sheet of lined paper. Minimum length is one page. Staple all pages together

2. Content Journal questions are provided on the next page. Your journal entry should address only the question asked. Your response

should show reflection and insight into the clinical experience.

3. Grading Turn in your journal on Tuesday. Your instructor will return it to you

during the week. Journals will not be graded based on content, but are an indicator of

your growth. Journals are a requirement of this course and a component of your

grade. All five journals must be turned in and must follow guidelines in order to receive full credit (Pass). If you fail to submit 1 journal, a verbal warning will be given to you by your clinical instructor. If you fail to submit 2 or more journals, you will be given an advisement note and you will fail the Journal Submission portion of the clinical component.

5

Journal Questions

The student should respond to all aspects of the question and turn in his/her journal entry on the following Tuesday to his/her clinical instructor.

Question

Journal 1 You have learned several nursing skills (vital signs, PHM, activity and rest) and were able to practice these skills. Discuss how it felt to practice these skills with your peers as well as your challenges in applying critical thinking skills with learned nursing skills. Discuss how you overcame these challenges?

Journal 2 Communication is a crucial aspect of the nurse-client relationship. Discuss your communication style. What are your strengths and what could you improve regarding communication. Describe what challenges you may face when communicating with a person who is ill, angry due to a terminal illness, or depressed due to a chronic disease.

Journal 3 You have now completed several weeks of nursing school. Based on your experience thus far, what do you think is the most challenging part of being a nurse and/or nursing as a profession?

Journal 4 Part of the role of a nurse is to provide end of life care. Discuss how you feel about this aspect of nursing, the challenges you might encounter and how you will overcome those challenges.

Journal 5 What was your first impression of long term care? Discuss both the positive and negative impressions of the facility, environment, staff and patients. Now that you have spent some more time in LTC, how has your first impressions changed? Discuss how your impression of nursing may have changed.

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


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


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


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


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


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


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


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


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


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


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

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 SignsVital Signs (T,P,R,BP)

Apical Pulse

Pulse Oximetry

Rectal Temperature

Tympanic & Axillary Temperature

VitalSigns

ApicalPulse

PulseOximetry

RectalTemp

TymAxTemp

22

http://talonnet.cerritos.edu/osp-portal

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 MeasuresBed Bath and Occupied BedMaking Bed_Bath

Physical AssessmentNo 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

UrineSpecimen

Physical Assessment No videos required prior to lab

Scenarios Review previously learned skills videos

Physical Assessment No videos required prior to lab

NGT Insertion Nasogastric tube InsertionNGTube

VS Competency TestingReview Vital Signs videos

ScenariosReview all previously learned skills videos

Nutrition LabView Taylors Video Guide to Clinical Nursing Skills CD ROM

23

Administering a continuous tube feeding: Using a feeding pump and a prefilled closed tube feeding set-up

Administering an intermittent tube feeding: Using a gravity set-up and an open feeding bag system

Unexpected situations

Foley Catheterization Foley Catheter Catheter

Wound Care Wound Care WoundCare

SKILLS VIDEO DEMONSTRATIONS- Continued

The Taylor’s Video Guide to Clinical Nursing Skills CD ROM is used as a supplement to the instructional videos provided on TalonNet. If there are no skills video on a particular skill on TalonNet, YOU ARE REQUIRED TO view the skills

video from the Taylors CD ROM prior to assigned control lab days. Insert CD ROM Click Chapter Select Watch the videos stated below r/t control lab activity

Title of CD ROM Skills VideoModule 2 Asepsis

Module 1 Vital Signs

Performing Hand Hygiene Putting on Sterile Gloves Removing soiled gloves

Measuring oral temperature, radial pulse, resp rate, and blood pressure

Measuring blood pressure with an automatic electronic device

Measuring tympanic temperature Measuring rectal temperature Measuring axillary temperature Measuring an apical pulse Unexpected situations

Module 9 Activity Turning a patient ROM exercises Assisting a patient up in bed one nurse working alone Assisting a patient up in bed two nurses working together Assisting a patient into a wheelchair Unexpected situations

24

Module 7 Hygiene Making an unoccupied bed Giving a bedbath and changing an occupied bed Assisting a patient with oral care Unexpected situations

CT ATI

PA 1

No videos to preview

B/B/Restraints/Therm

Module 11Urinary Elimination

Module 13Bowel Elimination

See Video from TalonNet

Assisting with a urinal Assisting with a bedpan Applying a condom catheter

Administering a large volume cleansing enema Administering a small volume cleansing enema Unexpected situations

Doc and Reporting

PA 2

No videos to preview

Scenarios Review previously learned skillsPA 3 No videos to preview

NGT insertion Administering a nasogastric tube Irrigating a nasogastric tube Removing a nasogastric tube Unexpected situations

Scenarios Review previously learned skills

Nutrition Lab Administering a continuous tube feeding: Using a feeding pump and a prefilled closed tube feeding set-up

Administering an intermittent tube feeding: Using a gravity set-up and an open feeding bag system

Unexpected situationsUrinary

Catheterization Catheterizing the female urinary bladder:

intermittent catheter Catheterizing the female urinary bladder:

indwelling catheter Catheterizing the male urinary bladder: indwelling

catheter Catheterizing the male urinary bladder:

intermittent catheter Irrigating the urinary catheter using a closed

system Unexpected situations

25

Wound Care See TalonNet video of wound care (wet-to moist dressing)

Obtaining a wound culture Irrigating a wound using sterile technique Unexpected situations

26

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.

27

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. _______

28

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.

29

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?

30

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?

31

RISK FACTOR LEVEL RISK SCORERECENT FALLS none in last 12 months……………………………………… 2(To score this, complete history of falls, overleaf)

one or more between 3 and 12 months ago………………. 4one or more in last 3 months………………………………. 6one or more in last 3 months whilst inpatient / resident…. 8

MEDICATIONS not taking any of these……………………………………… 1(Sedatives, Anti-Depressants taking one …………………………………………….……… 2Anti-Parkinson’s, Diuretics taking two ……………………………………………………. 3Anti-hypertensives, hypnotics) taking more than two……………………………………….. 4PSYCHOLOGICAL does not appear to have any of these…………………….. 1(Anxiety, Depression appears mildly affected by one or more…………………... 2Cooperation, Insight or appears moderately affected by one or more……………. 3Judgement esp. re mobility ) appears severely affected by one or more……………….. 4COGNITIVE STATUS intact…………………….….… 1

mildly impaired……….…….… 2mod impaired…………..….… 3severely impaired ……..….… 4

(Low Risk: 5-11 Medium: Risk: 12-15 High Risk: 16-20) RISK SCORE /20Automatic High Risk Status: (if ticked then circle HIGH risk below) Recent change in functional status and / or medications affecting safe mobility (or anticipated) Dizziness / postural hypotension

Fall Risk Assessment Tool (FRAT)

FALL RISK STATUS: ( Circle ): LOW / MEDIUM / HIGH

Modified and Adopted from http://www.health.vic.gov.au/agedcare.

In 2005 the Department of Human Services funded the National Ageing Research Institute to review and recommend a set of falls prevention resources for general use. The materials used as the basis for this generic resource were developed by Peninsula Health Falls Prevention Service under a Service Agreement with the Department of Human Services. This and other falls prevention resources are available from the department’s Aged Care website at: http://www.health.vic.gov.au/agedcare.

32

http://www.health.vic.gov.au/agedcare

http://www.health.vic.gov.au/agedcare

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.

33


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.

34

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 atriovenous graft (AV dialysis graft) on her right arm. Where would you take the patient’s blood pressure?

35

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?

36

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?

37

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________________________________________

38

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)

39


Student____________________________ Date ________________


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)

40


Student____________________________ Date ________________


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


41


Student____________________________ Date ________________


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)


42


Student____________________________ Date ________________


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)


43


Student____________________________ Date ________________


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


44


Student____________________________ Date ________________


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


45


Student____________________________ Date ________________


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)

46

Deep tendon reflexes (Grade)Biceps Triceps Brachioradialis Quadriceps Achilles

Cerebellar FunctionsBalance

GaitGross motor coordination – heel to toe walkingRombergRapid Alternating Movements (RAM)


47

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

48

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.

49

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.

50

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

51

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.

52


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

53

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__________________________________________________

54

Station 5

Identify each of wound closure device

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.

55

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-X-ray: specify which X-ray is done. Ex: CXR normal is (-) and patient result is right lower lobe infiltrate

56

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, create 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

Documentation Page 4Use 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.

Assessment Guide The 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.

57

Neurological Function-Subjective DataLOC, GCS (eye opening, verbal response, motor response), seizures (describe, timing), altered mental status, aphasia, intellectual functioning; PERRLA; special devices like hearing aids or glasses-Lab results: radiology (EEG, MRI, etc) Include Sensation-Subjective Data-Pain (location, intensity, character, onset and duration), vision, hearing, response to sensory overload

Oxygenation : Gas Exchange-Subjective Data -Respiratory Rate, Depth, Effort, Breath Sounds (describe, location), Cough (describe), Sputum production (describe)-Lab results: Sputum C&S, radiology results, ABG -Interventions: oxygen (flow rate and method), pulse oximetery (% on how much oxygen), incentive spirometer (volume, frequency of use), suctioning (type, frequency, response)

Oxygenation: Gas Transportation-Subjective Data-Blood pressure, apical pulse, peripheral pulses (location, rhythm and strength), edema (degree, location), capillary refill (location), skin/mucous membranes, Homan’s sign (if appropriate); Heart sounds (S1,S2, extra heart sounds or murmurs)-Lab results: Hgb, Hct, RBC, platelets, PT/PTT, INR

Fluid and Electrolytes-Subjective Data-Changes in daily weights, thirst, 24 hour intake/output, abnormal loss (edema, drainage, diuresis, diaphoresis, tachypnea, diarrhea, emesis), tissue turgor, mucous membranes); IVF (solution, tonicity of solution, flow rate), NG drainage (amount, describe)-Lab results: Na; Cl; K; ABG: HCO3, pH; Urine specific gravity

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

Nutrition-Subjective Data-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 -Diet; Enteral feedings (tube type, formula and flow rate), TPN/Lipids

Elimination -Subjective Data-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-Presence of catheter vs. voiding , colostomy/ileostomy, bladder irrigation

Activity and Rest-Subjective Data-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 -assistive equipment-cast, trapeze, traction, CPM, etc, special beds (type)

Protection-Subjective Data-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)Wound dressing (location, describe), drainage tubes (type, site, describe), Isolation, Restraints (Type, reason)

Psychosocial Modes-Include Subjective and Objective Data for each section-Self Concept: Physical Self: body sensation (subjective/objective), body image (subjective/objective)

Personal Self: self consistency (subjective/objective), self ideal (subjective/objective), moral/ethical/spiritual (subjective/objective)

-Role Function: Primary role: sex and age, developmental stage; Secondary roles: Instrumental behaviors, expressive behaviors Tertiary roles: Instrumental behaviors, expressive behaviors

-Interdependence: significant others (receiving behaviors, giving behaviors), support systems (receiving behaviors, giving behaviors)

58

Roy Adaptation Model Diagnostic Divisions reference sheet for completing the assessment guide

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:

Hx:

Course of events in hospital:

MD Orders from Physician Order Section of ChartVital Signs (Frequency)___________________________________________

______________________________________________________________Diet/Feedings:__________________________________________________Activity:_______________________________________________________IVF___________________________________________________________Blood glucose monitoring (frequency)________________________________

Result and (↓ ↑)

NormalRange

Reason for patient values

Na+136-145

K+3.5-5.0

Cl-98-106

Ca+9.0-10.5

Albumin3.5-5.0

Creatinine (M) .6-1.2(F) .5-11

BUN10-20

Glucose70-105

WBC 5,000-10,000

RBC (M) 4.7-6.1(F) 4.2-5.4

Hgb (M) 14-18(F) 12-16

Hct (M) 42-52(F) 37-47

Platelets 150,000-400,000

PT11-12.5

PTT or aPTT

60-7030-40

INR depends on indication

UrineNegative

X-rayNegative

C& SSputum Negative

Nursing Process Worksheet

59

Treatments/ Nursing Orders (I/O, Dressing, Drains, Foley, Oxygen, Restraints, Fluid Restriction, Specimens):

Laboratory and Diagnostic Results

Identify the MAIN medical/ surgical diagnosis and one chronic medical diagnosis: Nursing CareMap1. Define and explain the pathophysiology of each diagnosis. 2. Identify the Nursing Diagnoses associated with this medical diagnosis3. State the expected signs and symptoms for each nursing diagnosis identified.3. List treatment appropriate for the medical diagnosis. 4. In N212, all of the following chronic conditions should be completed: diabetes, hypertension, COPD, renal failure

Lab Group ___________

60

N210 MEDICATION SHEET

MEDICATION:Generic / Trade Classification

Dosage &Range ROUTE/ TIME &FREQUENCY:

Reason why THIS Patient is receiving

DOCUMENTATION

Client’s Initial: ____ Room #: ____ Date: _____ Assessment Guide

NeurologicalSubj:

Obj:

Labs:

NIC:

NutritionSubj:

Obj:

Labs:

NIC:

Bowel/UrinarySubj:

Obj:

Labs:

NIC:

Gas TransportSubj:

Obj:

Labs:

NIC:

Gas ExchangeSubj:

Obj:

Labs:

NIC:

ProtectionSubj:

Obj:

Labs:

NIC:

Fluid and ElectrolytesSubj:

Obj:

Labs:

NIC

Activity/RestSubj:

Obj:

Labs:

NIC:

EndocrineSubj:

Obj:

Labs:

NIC:

Focused Assessment Plan

Assessment Guide: Psychosocial

Psychosocial: Role Function

Primary Role:

Secondary Role:

Tertiary Role:

Psychosocial Self ConceptPhysical Self: Body sensation Subj:

Obj:

Body image Subj:

Obj:

Personal Self: Self consistency Subj:

Obj:

Self ideal Subj:

Obj:

Moral/ethical/spiritualSubj:

Obj:

InterdependenceSignificant OthersSubj:

Obj:

Support SystemsSubj:

Obj:

Subj:

NURSING PROCESS WORKSHEET

Student: Nancy Nurse Date(s): 2/4-2/5Co-Assigned Nurse/NA: Barbara RN, Joan CNAPatient Initials: DS Room # 118B Age/Sex 78 MAdmit Date: 2/3/05 Surgery Date: N/ACode Status: DNR Allergies: NKA

Admitting Dx: Chest Pain

History of present illness: CP started at 10pm 2/2. Pain rated 8/10 substernal. Also with c/o SOB and weakness. Pain did not resolve with rest. Drove self to ER

Course of Events in Hospital: 2/3/05 CXR showed BLL pneumonia; chest pain now thought to be pleuritic not cardiac in nature

Hx: HTN, Diabetes, Atrial fibrillation, Osteoarthritis

MD Orders:Vital Signs (Frequency ) Q8 hoursDiet/Feedings: 2gm Na ADA Activity: BRPIVF D5.45 NS @ 100 ml/hrBlood glucose monitoring (frequency) Q AC, HS

Treatments/ Nursing Orders (I/O, Dressing, Drains, Foley, Oxygen, Restraints, Fluid Restriction, Specimens):

O2 @ 2L NC Right heel stage III wet to moist drsg ∆ Q8 hours I/O

Result and (↓ ↑)

NormalRange

Reason for patient values

Na+144 136-145 WNL

K+4.0 3.5-5.0 WNL

Cl-102 98-106 WNL

Ca+8.5 9.0-10.5 WNL

Albumin3.8 3.5-5.0 WNL

Creatinine0.6

(M) .6-1.2(F) .5-11 WNL

BUN11 10-20 WNL

Glucose205 ↑ 70-105 Hx of diabetes and has active infection

WBC18 ↑

5,000-10,000 Active infection: pneumonia

RBC5.2

(M) 4.7-6.1(F) 4.2-5.4 WNL *normal range for male

Hgb16.0

(M) 14-18(F) 12-16 WNL *normal range for male

Hct48

(M) 42-52(F) 37-47 WNL * normal range for male

Platelets200,000

150,000-400,000 WNL

PT12.5 11-12.5 WNL

PTT oraPTT

62 60-7030-40 WNL

INR2.3

depends on indication WNL for patient with Atrial fibrillation

UrineUrinalysis Negative Negative No UTI

X-rayCXR

BLLInfiltrate Negative Pneumonia

C& SSputum

Gram +Cocci Negative Bacterial Pneumonia

Lab Group_____G____________

Laboratory & Diagnostic Results

MEDICATION CHARTDrug Names (trade/generic)Class (functional/chemical)

Dosage and Range

Route Time +Frequency

Indication for use for this Patient and Nursing Implications

Apo-Pen VK/ penicillin V potassiumF: Broad spectrum antiinfectiveC: natural penicillin

400mg

250-500 mg Q6hours

IV QID

1200,0600,1800,2400

- Bacterial pneumonia (gram + cocci)- Check for PCN allergy- Monitor for overgrowth infections

Cleocin/ clindamycin HCLF: antiinfective-miscC: Lincomycin derivative

600 mg

1.2-1.8g/day in 2-4 divided

doses

IV BID

0900, 2100

- Bacterial pneumonia - Watch for GI symptoms (N/V/D/Abd pain)- Watch for allergic reaction (may occur several days after starting therapy)- Assess for overgrowth infections

Proventil/albuterolF: BronchodilatorC: Adrenergic B2-agonist, sympathomimetic, bronchodilator

2.5mg/ml unit dose

2.5mg TID-QID

InhaledQIDPRN

- Bronchodilation to assist breathing difficulty from pneumonia- Assess respiratory function and need for breathing treatment

(RR, pulse oximeter, respiratory effort, dyspnea)- Monitor for side effects: tachycardia, palpitations, tremors,

anxiety, restlessness, nausea/vomiting

OxycodoneF: Opiate analgesicC: Semisynthetic derivative

5mg

10-30mg Q4

POQ 4 hours

PRN

- Reduce pain caused by osteoarthritis and pleuritic chest pain - Monitor CNS changes before and after dose- Check pain level, last dose adm time and resp rate before

admin.- Assess for side effects: CNS depression, nausea/anorexia, rash,

constipation Perc

ocet

Tylenol/ acetaminophenF: Nonopiod analgesicC: nonsalicylate, paraminophenol derivative

325mg 325-650mg Q4

hours. Max 4g/day

POQ 4 hours

PRN

- Fever and could be used for pain management for the osteoarthritis and pleurtic chest pain

- Monitor for hepatotoxicity (overdose, given with other hepatotoxic drug, alcoholics)

Cardura/ doxazosinF: Alpha Blocker, antihypertensiveC: Quinazoline

2mg

4-16 mg/day

POOnce a

Day

0900

- To lower blood pressure (hx of HTN)- Monitor for side effects (dizziness, orthostatic hypotension)- Check blood pressure before administration- Teach patient to rise slowly from sitting to standing position- First dose given at HS

Coumadin/ warfarinF: Anticoagulant

2.5mg/dayTitrated to PT

or INR

POOnce a Day

1600

- Prevent embolus formation from atrial fibrillation- Check latest PT or INR and ensure values within desired range

before administration- Monitor for s/s of bleeding (bruising, gums, stool, urine)

Humulin R/ regular insulinF: pancreatic hormoneC: exogenous unmodified insulin

based on BS result and given according to sliding scale

SC QAC, HS

0730,1130,1700,2100

- Lower blood sugar (Hx of diabetes )- Check fingerstick blood sugar ; Monitor hemoglobin A1C

results- Monitor for s/s of hyperglycemia (acetone breath, polyuria,

fatigue, polydipsia, flushed, dry skin, lethargy)

DOCUMENTATION

2/5/05 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___________________________________

DOCUMENTATION OF PATIENT TEACHING

2/5/05 D: Takes off oxygen via nc. Upset about wearing oxygen. States “I don’t like to wear the oxygen tube, I look funny 1500 with it on.” O2 sat 90%. Unable to verbalize the importance of oxygen administration. Knowledge deficit re:

oxygen A: Instructed re: purpose of oxygen, proper use and application of oxygen via nasal cannula , how to care for skin

and mucous membranes and how to prevent skin breakdown due to prolonged use of oxygen via nc.R: Patient verbalized understanding of all instructions. Demonstrated proper care of skin and mucous membranes.

O2 at 2L via nc in use and appropriately in place. O2 Sat 96% on O2 at 2L nc.

Client Initials: DS Room #: 118B Date(s): 2/4-2/5 Assessment Guide

NeurologicalSubj: AAOX4, GCS 15“My hands ache, it must be raining outside”Obj: Pain 5/10 Bil. hands, aching, onset-upon waking, Motrin ↓’d pain to 1/10

Labs: NA

NIC: Admiistered Motrin 600mg PO at 0800

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: 3.8NIC:

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

NIC:

Oxygenation: 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

NIC:

Osygenation: 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

NIC: Maintained O2 at 2L per NC

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

NIC: back care, wound care to stage III ulcer, covered with comfeel drsg.

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: 102NIC

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

NIC: BRP assist; PROM bil hands at 0730

EndocrineSubj: “I’ve been a type II diabetic for 5 years”Obj:

Labs: Serum glucose: 205Fingerstick BS (0730) 198, (1130) 213

NIC: accucheck achs; SSRI coverage ac Breakfast (4 units); ac Lunch (4 units)

Focused Assessment Plan

Client’s Initial____Room # _____ Date___ Assessment Guide: Psychosocial

Psychosocial: Role Function

Primary Role:Sex M Age 68Ego integrity vs. Despair

Secondary 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.”

Psychosocial Self ConceptPhysical Self: Body sensation Subj: “My hands ache”Obj: Rubbing hands together

Body image Subj: “I don’t like to wear this oxygen, it makes me feel old”Obj: wearing O2 al 2L per NC

Personal Self: Self consistency Subj: “Am I going to have to wear this oxygen forever?”Obj: Tears in eyes

Self ideal Subj: “I just want to go back to my normal self”Obj: Performs TCDB exercises, verbalizes desire to learn about medications and treatments to improve.

Moral/ethical/spiritualSubj: “I believe that God will help me through this. “Obj: Prays in room. Asks for chaplain to visit

InterdependenceSignificant OthersSubj: Wife and childrenObj: Rec: Accepts calls and visits from family. Giving: Returns affection, calls wifeSupport SystemsSubj: NeighborsObj: Rec: Accepts calls and visitsGiving: Participates in informal neighborhood gatherings. Organizes block party every year..

Concept Mapping Guidelines“The Art of Nursing”

I. What is it? Concept mapping is a visual representation of key concepts and relationships that deal with a

specific subject matter. Also known as Mind Maps, Cognitive Maps, Flow Charts, and Graphic Organizers. Can be used to represent the nursing process, medical diagnosis, or a nursing concept (e.g.

immobility, skin integrity) Concept Maps shows relationships between concepts using shapes and links. Shapes (boxes

or circles) represent concepts; links (solid or dotted lines) represent relationships.

II. Why use it?

Learners learn not by memorizing but by organizing and relating concepts into their cognitive structures.

Facilitates critical thinking. Utilizes an active process of thinking and drawing relationships. Promotes meaningful learning and allows the student to see the whole picture.

III. How do you do it?

Required Materials: blank paper, colored pencils/pens/markers, and your imagination

General Guidelines

Use just key words, or wherever possible images Make the primary concept the strongest visual image

Put keywords on lines (medimap)

Print rather than write in script. Do not write in all CAPS

Use color to depict themes, relationships, and to make ideas stand out.

Think three dimensionally.

Use arrows, icons, or other visual aids to show links between different elements

Don’t get stuck in one area, if you dry up in one area, do another branch.

Put ideas down as they occur, don’t judge or hold back.

Break boundaries. If you run out of space, don’t start a new sheet, paste more paper onto the map ( Break the 8x11 mentality)

Be creative. Creativity aids memory.

Get involved. Have fun.

(Retrieved from http://www.peterussell.com/MindMaps/Howto.html on 7/6/2004)

http://www.peterussell.com/MindMaps/Howto.html%20on%207/6/2004

Draw 2 different types of maps: one representing the Medical/Surgical Diagnoses (two diagnoses can be represented on two separate

To draw the Medical/Surgical Map (Nursing CareMap) : 1. Begin with Medical/Surgical Diagnosis1. Identify the general categories (See Nursing CareMap Guidelines below).2. Draw the concept maps using shapes for concepts, and links to show relationships.3. Use different colors to differentiate the various concepts4. Create a key identifying the symbols, links, and colors and what they represent if

the map is complex

IV. Evaluation CriteriaNursing CareMap:

Are all the major concepts and general categories presented? Is your information accurate, inclusive, and thorough? Is a key included? (if needed) How were the connecting lines drawn? Are they logical? Did the student show an

understanding of the whole picture? Is your concept map neat, legible, logical, visually appealing, easy to follow?

Be Creative!!!

N210: Fundamentals of Nursing

Nursing Caremap GuidelinesObtain and print out the Talonet Caremaps from the N210 TalonNet site

The following are guidelines for constructing your own CareMap:

1. The XMind template will provide the format. Include 4 nursing diagnoses. You may have less than 4 for less complex diagnoses.

2. Maps will be labeled as Care Maps. EX: Cancer Care Map, Pneumonia Care Map

3. Please include the following in your CareMapsa. Obtain the following info from Medical Surgical Nursing Textbook

(IGGY): Pathophysiology Signs and symptoms for the medical diagnosis (IGGY) Treatment

b. Obtain the following info from “Nursing diagnosis Handbook:Nursing diagnoses, signs and symptoms related to the nursing diagnoses (Underlying characteristics) & nursing interventions related to the nursing diagnosis.

4. Nursing diagnosis do not need a R/T (related to)

5. Signs & Symptoms will be labeled S/SX. Nursing Interventions will be labeled NIC

6. Risk for diagnoses: Do not list the risk factors; list the S/SX of the diagnosis in which the patient is “At Risk for”

7. No psychosocial nursing diagnosis unless they are a significant factor in the medical diagnosis.

8. If you have interventions that are listed in IGGY or other program texts as “Best Practices” you go to textbook for interventions. See Pneumothorax Care Map for example.

9. Nursing interventions should be from our textbooks such as NCP, Taylor’s, IV Therapy or Iggy. They should be reliable, validated nursing interventions. Interventions need to reflect current best practices, standards of care and evidenced-based practice and guidelines.

10. Specify the treatments portion of the Caremap by including all medications of each drug classification (for example, Ace inhibitors,: Lisinopril, Captopril, diuretics:furosemide, hydrochlorothiazide, etc)

Rev10/11

How to Use Your Nursing Caremaps

Your Nursing Caremaps is a guide to understand your patient’s diseases. It includes information such as pathophysiology, signs and symptoms, possible problems/nursing diagnoses, interventions and treatments generic for a patient admitted with a certain disease. When used correctly, Caremaps can help you develop individualized plan of care (and Nursemaps) for your patient.

To maximize the use of your Nursing Caremaps, you must highlight and write on your caremaps all information that applies to your patient during clinical.

The following are steps to help you make most of your Nursing Caremaps:

Prior to Clinical:1. Review your Nursing Caremap/s prior to clinical.2. Prepare a written focused assessment concept map (using a diagram of a body

or stick figure) using Nursing Caremaps.

During Clinical:1. Highlight on your Caremaps the signs and symptoms that your patient is

experiencing.2. Highlight and add specific medications that your patient is receiving that relates

to the “Treatment” portion of your Caremaps.3. Write your patient’s findings next to assessment and monitoring interventions

(NICs). For ex: next to “monitor VS “ in the NIC portion, enter your patient’s vital signs.

4. Highlight the nursing interventions that you performed during your care for your patient.

5. Add and write in any additional interventions or teachings that you did for your patient on your Caremaps.

6. Write in your patient’s response to the interventions that you did next to the highlighted or written interventions under “NIC”. For ex: You highlighted the intervention “Teach use of I/S”- next to it, write in “Patient demonstrated proper use of I/s, volume 1500 mL; used 10 x q 1h.

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. Begins to collects and organizes data in all 4 modes of the Roy Adaptation Model recognizing the psychosocial nature of the patient. (N/A at N210)3. Performs and documents a physical assessment, demonstrating appropriate use of medical terminology and approved abbreviations, at a beginning level.4. Initiates an environmental assessment. 5. Begins to identify appropriate nursing problems / nursing diagnosis. 6. Begins to develop patient-specific outcomes. (N/A at N210)7. Begins to develop patient-specific interventions. 8. Begins to evaluate patient response to care and revises patient care as needed. 9. Completes the Nursing Care Plan/Concept Map with a 75% or higher. (N/A at N210 )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 NI

1. Provides simple explanations and instruction to patients prior to interventions and / or procedures. 2. Begins to identify patient’s knowledge level and readiness to learn. (N/A at N210)3. Provides teaching according to patient needs. (N/A at N210)4. Begins to document and report patient’s response to instruction on the NPW. (N/A at N210)OVERALL EVALUATION ON TEACHING AND LEARNING:

CLINICAL SKILLS: Competently performs technical skills with patients in the health care setting.

O S NI1. Administers medications safely according to N212 guidelines and program policies. (N/A at N210)2. Passes Medication Calculation Exam with 80% or greater. (N/A at N210) 3. Demonstrates safe practice of designated nursing skills for N210

in clinical and/or skills lab. 4. 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.

O S NI1. Works cooperatively with health care team members, peers, and faculty toward common patient-centered outcomes. 2. Functions in the role of team coordinator/ leader as identified in the course guidelines. (N/A at N210)3. 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 specimens

Performs 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 painPerforms 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:

N210 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 StudentsStudents 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 bedrestBRBPR bright red blood per

rectum BRP bathroom privilegesBS bedside

BS 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-rayDAT diet as toleratedDJD degenerative joint

diseaseDKA diabetic ketoacidosisDM diabetes mellitusDOB date of birthDOE dyspnea on exertion

DP 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 incontinentIM intramuscularI&O intake and outputIS incentive spirometerIV intravenousJ-tube jejunostomy tubeJVD jugular vein distention

K 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 osteoarthritisOBS organic brain syndromeOOB out of bedORIF open reduction and

internal fixationp after

pc 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 postspec specimenS/S signs and symptomsSSE soap suds enema

SSRI selective serotonin reuptake inhibitor

STAT 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

http://www.ismp.org/Tools/errorproneabbreviations.pdf

CERRITOS COLLEGE NURSING PROGRAMN210 CLINICAL SCHEDULE

Fall 2012 – LONG TERM CARE

WK DATE ASSIGNMENT EXPERIENCES POST-CONFERENCE

What is due?

6 9/250800-1100

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

6 9/260650-1150

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.

710/2

0650-1250

Care of 1 patient NPW due in pre-conference

Skills: baths, beds, feeding, assist with transfers, ROM, VS, NGT/GT feedings, positioning, hot/cold applications, bandages/binders,

1100-1150

NPW/ Assessment Guide

Nothing

TED hose, restraints, enemas, isolation, Physical Assessment Foley Cath, Wound Care, NGT

Charting: VS, I&O

Physical Assessment techniquesClinical Experiences

and observations

710/3

0650-1250

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 Thursday lecture

810/9

0650-1250

Care of 1 patient NPW due in pre-conference

Skills: Same as above 1100-1150

NPW/ Assessment Guide

NPW: page 1, 2, 3, 4. for patient cared for this weekAND

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

Physical Assessment techniques

Assessment guide: all sections for physical mode for patient cared for this week due on Thursday Lecture

810/10

SL 121 0800-1600CPE: All skillsFull Uniform

910/16

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

910/17

No Clinical

All NPWs due in pre-conference to your clinical instructors which will be returned to you during clinical

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.


___ _______ 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


___ _______ 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


___ _______ 1. Proceed systematically from head to toe___ _______ 2. Support joint being exercised___ _______ 3. Perform exercise 3-5 times5. Transfer of patient from bed to chair: assisting a patient to change locations


___ _______ 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


___ _______ 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


___ _______ 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


___ _______ 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 instillation10. Nasogastric tube insertion +/- suction to insert a catheter through the nose into the stomach and attach to suction if ordered


___ _______ 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:


___ _______ 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


___ _______ 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


___ _______ 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


___ _______ 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


___ _______ 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


___ _______ 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.


___ _______ 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


___ ______ 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

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)

N210 Control Lab/Clilnical Folder - Cerritos Collegeweb.cerritos.edu/rsantiago/SitePages/My...

Documents

Transcript of N210 Control Lab/Clilnical Folder - Cerritos Collegeweb.cerritos.edu/rsantiago/SitePages/My...