NORTH CENTRAL TEXAS COLLEGE COURSE SYLLABUS

 

Course Title:	Clinical Psychiatric Nursing (Post-Conference/Clinical)
Course Prefix & Number:		RNSG1163	Section Number:	100	Semester/Year:	Spring 2021
Semester Credit Hours:		1	Lecture Hours:		Lab Hours:	48
Course Description (NCTC Catalog): A health-related work-based learning experience that enables the student to apply specialized occupational theory, skills, and concepts.  Direct supervision is provided by the clinical professional.  Emphasis is on nursing skills essential for the care of clients along the mental health/mental illness continuum.
Course Prerequisite(s): All second semester Associate Degree Nursing courses are required to have been completed with a grade of “C” or better before a student may enroll in this course.
Required or Recommended Course Materials:  ATI:  RN Mental Health Nursing Review module                                                                                    All ATI resources Publication Manual of the American Psychological Association:  Optional

 

INSTRUCTOR INFORMATION

Name of Instructor:	Kristina Scurlock MSN, RN
Campus/Office Location:	HSC Gainesville Campus 2428-K
Telephone Number:	940-668-7731 ext. 4958
E-mail Address:	kscurlock@nctc.edu

 

OFFICE HOURS

Monday	Tuesday	Wednesday	Thursday	Friday
By appointment	Virtual Office Hours 0800-1600	Virtual Office Hours 0800-1600	By appointment	UBH Clinical 0700-1900

 

 

STUDENT LEARNING OUTCOMES (From Academic Course Guide Manual/Workforce Education Course Manual/NCTC Catalog

At the successful completion of this course the student will be able to:
	As outlined in the learning plan, apply the theory, concepts, and skills involving specialized materials, tools, equipment, procedures, regulations, laws, and interactions within and among political, economic, environmental, social, and legal systems associated with the occupation and the business/industry; and will demonstrate legal and ethical behavior, safety practices, interpersonal and teamwork skills, and appropriate written and verbal communication skills using the terminology of the occupation and the business/industry.
	Demonstrate legal and ethical behavior, safety practices, interpersonal and teamwork skills, and appropriate written and verbal communication skills using the terminology of the occupation and the business/industry.
	Apply the Nursing Practice Act in relation to patients and families experiencing mental illness

 

GRADING CRITERIA

Grading for the course will follow the nursing policy for grading and evaluation.  In order to pass this course, the student must achieve an average of 75 or higher.  There will be NO rounding up of grades.  Late work will result in a 0 for assignment, late work will not be accepted. 

The numerical course grade will be converted as follows:

 

Grade                                                  Numerical Letter Grade

 

90-100                                                 A

 

81-89                                                   B

 

75-80                                                   C

 

61-74                                                   D

 

60 and below                                      F

 

***Clinical Points tool: Any infraction as listed on the clinical points tool will result in the assigned points taken from the Journal assignment or final grade. 

Assignments: All assignments listed in the syllabus as well as any additional written assignments given by the clinical instructor must be satisfactorily completed and submitted on or before the assigned due date to the clinical instructor in order to receive a grade on the assignment. Failure to complete and submit assignments by the due dates will result in the student receiving a zero (0) for the assignment. All assignments must be completed and submitted in order to pass the course.  No-regrading of assignments.

Journals

During this course, the students will have two reflective journal assignments, the first one to be completed prior to attending clinical and the second completed following completion of both clinical days. 

• Reflective journals are utilized to promote self awareness and dialogue between students and instructors. 
• Expand knowledge base in psychiatric mental health nursing
• Process and “make sense of” the experience in the psychiatric mental health clinical by providing a forum to discuss feelings and thoughts in relationship to clinical experiences
• Acknowledge changes in clinical performance/personal growth during the clinical experience
• Develop critical thinking skills used to analyze and to integrate clinical concepts to practice
• Increase observational, assessment, and reading skills

Patient Documentation

While in the clinical setting, each student will complete a patient assessment and care plan on one patient for each assigned clinical day.  Documentation will be completed on nursing assessment form.

Suicide Case Study

Students will complete the suicide case study which will be included and counted towards clinical hours.  Failure to complete this assignment by the due date will result in a zero for the assignment.

 

 

 

 

 

 

 

Support Group Paper

Each student is required to attend one 12-step program meeting or one support group meeting. To locate groups you can look on the internet for “Support Groups” or check listings in the newspaper under upcoming events. Area hospitals hold meetings so check their websites or call their education department for schedules. Do not use a workshop/seminar for this assignment. Do not use any support groups attended during your two clinical days.  After attending the meeting you will submit a typed one page paper to include the following criteria:

Name of the group you attended, include location and date

Why did you choose this group?

Brief history of program or group

What did you observe in the meeting?

In your opinion is the group effective in meeting the client’s needs? Was the group process (leadership style, established norms, etc.) effective?

*rubric located under appendices

Movie Presentation

Psych Video Presentation

The goal of this activity is to view a video of people with mental illness and the impact it has on their lives including relationships with other people.

In a group of 3-4 you will choose a movie to view and create a movie analysis and present to the class.  All movies should be emailed and approved by instructor.

Presentations will be virtual on Webex

The analysis and presentation should include the following items:

1. Description of the mental illness depicted in the movie
2. Description of main characters
3. Treatments prescribed in the movie
4. How does the illness affect the characters life? (Include family, personal relationships, work, etc.)
5. What are 2 priority nursing diagnoses for the character?
6. 2 short term goals- include 2 interventions for each goal. How would you evaluate?
7. 2 long term goals
8. What support groups would be available to the patient (if you were the nurse what groups would you refer patient to?)
9. If you were the nurse caring for this patient what would you do the same or differently? Include a reference other than the movie to depict best practice (use nursing/scholarly journal or reputable website)

*Rubric located under appendices

All group members will complete a peer evaluation, this tool will be considered when assigning grades for presentations

 

 

ATI Proctored Assessments

MENTAL HEALTH

This 70-item test offers an assessment of basic comprehension and mastery of mental health nursing principles including:

• Basic concepts in mental health nursing (assessment, legal and ethical principles, therapeutic communication, therapeutic nurse-client relationship, anxiety, and defense mechanisms, mental health nursing in diverse populations, therapeutic and safe environment)
• Nonpharmacological therapy of mental health disorders
• Pharmacological therapy of mental health disorders
• Nursing care of clients who have various mental health disorders

You have 70 minutes to complete the assessment

Level 1

Scores meeting the Proficiency Level 1 standard can be considered to meet the absolute minimum expectations for performance in this content area.  Scores at this level were judged by the content expert panel to indicate a student as likely to just meet NCLEX-RN standards in this content area.  ATI advises these students to develop and complete a rigorous plan of focused review in order to achieve a firmer grasp of this content.

Level 2

Scores meeting the Proficiency Level 2 standard can be considered to exceed minimum expectations for performance in this content area.  Scores at this level were judged by the content expert panel to indicate a student as fairly certain to meet NCLEX-RN standards in this content area.  ATI advises these students to engage in continuous focused review in order to improve their knowledge of this content.

Level 3

Scores meeting the Proficiency Level 3 standard can be considered to exceed most expectations for performance in this content area.  Scores at this level were judged by the content expert panel to indicate a student as likely to exceed NCLEX-RN standards in this content area.  ATI advises these students to engage in continuous focused review to maintain and improve their knowledge of this content.

**How to complete three critical points for remediation:

Take the practice assessment.  After completion print your Assessment Report.  Upload to the assignment in Canvas.  Find “Topics to Review” on your report.

Review each missed item, following the links given to your ATI Review Modules (books). You can also access the ATI books online by creating a Focused Review. This will open the book to the chapter where you’ll review the missed content. It’s a quick way to speed things up. View the short videos on the Focused Review to learn how this topic fits into the NCLEX test plan, nursing process, or QSEN competencies for expanded knowledge.

Reflect on what you’ve read about the missed topic. Use your textbook and class notes to look up missed items to gain more in-depth information about the topic. Decide upon the three most important things to know about that topic. Write these three important points to remember in a bulleted form, just like you’ll see in the ATI books. Keep it short, simple, and focused on just that missed item. Write your bullet points for each missed item in a composition notebook, noting the NCLEX Category of Client Need for each item missed. This is how you will be tested for NCLEX—according to the Test Blueprint detailing content in each Category. Start learning in that framework, as well connecting- the content to its NCLEX Category.

 

Remediation should be uploaded in Canvas to receive credit.

ATI Case Studies

You are assigned 4 ATI case studies located under the apply tab in ATI, Real Life Mental Health 3.0.  You may complete these case studies as many times as you would like on or prior to the due date to receive a satisfactory or better.  Please note:  a satisfactory or better must be achieved to receive credit for the assignment.

 

                                               

# of Graded Course Elements	Graded Course Elements	Percentage or Point Values
	Clinical Performance	60%
4	ATI case studies	25 pts.
2	Journals	100 pts.
	Suicide Case Study	100 pts.
2	Pt. Documentation	100 pts.
1	Support Group Assignment	10%
1	Movie presentation	20%
	ATI Proctored Exam	10%

 

COURSE SUBJECT OUTLINE (Major Assignments, Due Dates, and Grading Criteria)

Week 1	Review syllabus/assignments Unit 1-3	Chapt. 1-20
Week 2	Unit 4-6	Chapt. 21-33
Week 3	ATI Case Studies: Schitzophrenia Mood Disorder Anxiety Disorder Alcohol abuse   Suicide Case study	1/31/21 2359              1/31/21 2359
Week 4	ATI practice/proctor	Practice A &B/ remediation due 2/9/21 2359 Mental Health Proctor:  2/10/21 1000 on campus
Week 5
Week 6
Week 7
Week 8
Week 9	Spring Break
Week 10
Week 11	Clinical Journals Due Pt. assessments/care plans due Movie Presentations	03/28/21 2359 03/28/21 2359   03/31/21 1400-1700 Webex
Week 12
Week 13	Support Group paper due	4/11/21
Week 14
Week 15
Week 16	Final Grades

                                                               

**Please note these dates may be subject to change at the discretion of the clinical instructor.

NCTC Attendance Policy

http://nctc.smartcatalogiq.com/en/2016-2017/Catalog/Academic-Policies/Attendance-Regulations

Regular and punctual attendance is expected of all students in all classes for which they have registered.  All absences are considered to be unauthorized unless the student is absent due to illness or emergencies as determined by the instructor.  It is the student responsibility to provide documentation as to the emergency for approval and judgement by the faculty member.  Approved college sponsored activities are the only absences for which a student should not be held liable and only when provided by a college official ahead of the absence.  Valid reasons for absence, however, do not relieve the student of the responsibility for making up required work.  Students will not be allowed to make up an examination missed due to absence unless they have reasons acceptable to the instructor.  A student who is compelled to be absent when a test is given should petition the instructor, in advance if possible, for permission to postpone the exam.  Student will be dropped from a class by the Registrar upon recommendation of the instructor who feels the student has been justifiably absent or tardy a sufficient number of times to preclude meeting the course’s objectives.    Persistent, unjustified absences from classes or laboratories will be considered sufficient cause for College officials to drop a student from the rolls of the College. From Board Policy FC (LOCAL)

Students are expected to attend clinical and post conference on each assigned day.  Post conference will be held on Webex at 1900 .  There should be no clinical absences. If an untoward circumstance occurs and the student must miss a clinical day, points will be deducted on the Clinical Points Tool for each clinical day missed.  Any student missing more than 1 clinical day will have to schedule an appointment with the department chair and 1other faculty prior to the next clinical day.  The circumstances for the absences will be reviewed and the student may be dismissed from the program or be placed on a probationary contract stating that any further absences will result in dismissal from the program.   Tardiness of more than 30 minutes will be counted as an absence and points will be deducted. It is at the discretion of the clinical instructor for allowing the student to remain in clinical (even though points will be deducted) or be sent home.  All missed clinical time will be made up to successfully pass the course.

 

Last day to withdraw from a course with a “W” is  4/5/21.

 

 

  

The Office for Students with Disabilities (OSD) provides support services for students with disabilities, students enrolled in technical areas of study, and students who are classified as special populations (i.e. single parents).

Support services for students with disabilities might include appropriate and reasonable accommodations, or they may be in the form of personal counseling, academic counseling, career counseling, etc.  Furthermore, OSD Counselors work with students to encourage self-advocacy and promote empowerment. The Counselors also provides resource information, disability-related information, and adaptive technology for students who qualify.

If you feel you have needs for services that the institution provides, please reach out to either Wayne Smith (940) 498-6207 or Yvonne Sandman (940) 668-4321.  Alternative students may stop by Room 170 in Corinth or Room 110 in Gainesville.

http://www.nctc.edu/StudentServices/Disabilityservices.aspx

 

Course Type: WECM Course

COUNSELING AND TESTING CENTER

Counseling and Testing staff offer a variety of services to current and prospective students, such as College 101, placement testing, academic advising and course registration, transfer assistance, and College Success seminars (Time Management, Study Skills, Test Anxiety, Choosing a Major, Learning Style Strategies, Career Exploration), and much more. 

http://www.nctc.edu/StudentServices/CounselingTesting.aspx

 

SUPPORT SERVICES

Student Success offers academic coaching, tutoring, including a Writing Center, a Math Lab, free 24/7 online tutoring through Grade Results and assist new students acclimate to college by providing computer lab services for prospective students.   First generation students can also participate in TRIO which offers specialized support services.

http://www.nctc.edu/StudentServices/SupportServices.aspx

 

Financial Aid offers financial resources for students that qualify, visit the financial aid offices for more information.  http://www.nctc.edu/FInancialAidHome.aspx

 STUDENT HANDBOOK

Students are expected to follow all rules and regulations found in the student handbook and published online.

http://nctc.smartcatalogiq.com/en/2016-2017/Catalog/North-Central-Texas-College-Student-Handbook

 

 

Scholastic dishonesty shall include, but is not limited to cheating, plagiarism, academic falsification, intellectual property dishonesty, academic dishonesty facilitation and collusion.  Faculty members may document and bring charges against a student who is engaged in or is suspected to be engaged in academic dishonesty.  See Student Handbook, “Student Rights & Responsibilities: Student Conduct ([FLB(LOCAL)]”.

 http://nctc.smartcatalogiq.com/en/2016-2017/Catalog/North-Central-Texas-College-Student-Handbook/Section-II/Student-Rights-and-Responsibilities-Student-Conduct/Specific-Conduct-RegulationsRestrictions

 

See the ADN Student Handbook regarding specific policies regarding academic dishonesty.

 

Please note: For students in this course who may have a criminal background, please be advised that the background could keep you from being licensed by the State of Texas.  If you have a question about your background and licensure, please speak with your faculty member or the department chair. You also have the right to request a criminal history evaluation letter from the applicable licensing agency.

COVID-19 Addendum  

“Covid -19 statement: please be advised that NCTC may have to go fully online should the COVID situation worsen.”

 

Due to the COVID-19 pandemic, changes may occur at any time that would restrict or limit access to campus which would result in changes in the grading system or any use of the Health Science Building for testing. The NCTC nursing faculty reserves the right to make any changes necessary to the syllabus to ensure the clinical student receives the highest quality clinical experience. It is a mandatory requirement that any time a student must come to the campus or enter a clinical site, that the student shall do the required health check in canvas and submit to having a temperature check before entering the facility(s)

 

Due to the COVID-19 pandemic, changes may occur at any time that would restrict or limit access to campus which would result in changes in the grading system related to the in-lab practice and check offs. The NCTC nursing faculty reserves the right to make any changes necessary to the syllabus to ensure the students receives the highest quality lab experience. It is a mandatory requirement that any time a student must come to the campus, hospital sites or other approved facilities, that the student shall do the required health check in canvas and submit to having a temperature check before entering the facility, along with following the appropriate safety measures (social distancing, smaller numbers of students allowed in the classroom or lab space, masks, sanitized work space, etc.) set forth by NCTC.

 

 

Syllabi statement regarding potential Conversion of Onsite Classes to Online/Remote Format: North Central Texas College students should be aware that in the event of a college closure due to COVID-19, onsite classes will be converted to an online/remote format. Students should plan ahead to ensure they have access to the computer equipment (either PC, MAC, or tablet), webcam, and internet connectivity to continue their classes in an online/remote format. Please read all your official North Central Texas College student emails as the transition from onsite to online/remote might require a reorganization in your personal situation. Students will be granted a 72-hour transition and grace period. Online classes will continue as scheduled without disruption. Wear a mask, stay safe, and contact your Instructor as the situation arises. These policies and procedures were updated on July 30, 2020 and are subject to change.

 

Syllabi Statement Regarding Face Coverings: Per the North Central Texas College guidance on face coverings on campus, in the instructional setting, faculty and students must wear face coverings, such as masks or face shields. Students without coverings, or those who do not comply with the rules relating to face coverings, will not be able to participate in on-campus classroom activities. To request an exception to this requirement, students should contact the NCTC HR Office of Enrollment Management (ccove@nctc.edu). Failure to comply with the face coverings requirement may result in the Instructor directing the student to leave the classroom. Any student asked to leave the classroom may be referred to the student conduct officer. These policies and procedures were updated on July 30, 2020 and are subject to change.

 

Temporary COVID-19 Attendance Policy for Face-to-Face Meetings: We are facing an unprecedented situation in which all of us must be flexible and make prudent decisions in the best interest of our families, our campus, and our community. In light of this, North Central Texas College is temporarily establishing the requirement that faculty keep records of student attendance for face-to-face course meetings as well as a documented seating chart. In addition, students who are sick or need to quarantine should not attend classes. Students will not be required to provide formal documentation from a health care provider and will not be penalized for COVID-19 related absences when proper notification to campus health officials is made in accordance with the guidelines stated below.

 

Faculty will:

 

• Notify students about important course information and delivery changes through Canvas and campus email.

 

Students should:

• Provide notification to campus officials (via NCTC Daily Health Check protocol through Canvas) if they have tested positive for COVID-19 or have to quarantine so we can confirm reported absence with instructors, monitor, and assist the campus community.
• Notify instructors in advance of the absence.
• Connect with that class through Webex if the class session is being transmitted in a hybrid fashion.
• Keep up with and/or make up missed classwork or assignments.
• Submit assignments digitally through Canvas or other means as announced by your instructor.
• Work with their instructors to reschedule exams, labs, and other critical academic activities described in the course syllabus.
• Check Canvas and campus email daily to receive important announcements pertaining to the course.

During this period, faculty with face-to-face meetings will establish assigned seating/work stations to facilitate roll-taking, and, if necessary, contact tracing. Additionally, we ask all members of the College community to be attentive to their health, and safeguard others, by following the CDC’s guideline to “stay home when you are sick.” You should stay home if you have symptoms. More information on what to do if you are sick is available at the CDC’s website.

Additional NCTC information is available at http://www.nctc.edu/coronavirus/index.html

 

 

 

 

 

 

 

QUESTIONS, CONCERNS, or COMPLAINTS

Name of Chair/Coordinator:	Diane Neu MSN, RN
Office Location:	2428-A
Telephone Number:	940-668-7731 ext. 4381
E-mail Address:	dneu@nctc.edu
Name of Instructional Dean:	Brandon Hernandez
Office Location:	2420-A
Telephone Number:	940-668-7731 ext. 4322
E-mail Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendices

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATI Proctored Assessments Rubric
Practice Assessment 4 points
Complete Practice Assessment A ·     Minimum 1-hour Focused Review on initial attempt. ·     For each topic missed, complete an active learning template and/or identify three critical points to remember**.		Complete Practice Assessment B ·     Minimum 1-hour Focused Review on initial attempt. ·     For each topic missed, complete an active learning template and/or identify three critical points to remember.
Proctored Assessments
Mental Health Nursing
Level 3 Suggested Remediation ·     Minimum 1-hour focused review ·     For each topic missed, complete an active learning template and/or identify three critical points to remember.	Level 2 Suggested Remediation ·     Minimum 2-hour focused review ·     For each topic missed, complete an active learning template and/or identify three critical points to remember.	Level 1 Suggested Remediation   ·     Minimum 3-hour focused review ·     For each topic missed, complete an active learning template and/or identify three critical points to remember.	Below level 1 Suggested Remediation Minimum 4-hour focused review ·     For each topic missed, complete an active learning template and/or identify three critical points to remember.
10/10 points	9/10 points	7/10 points	6/10 points

 

 

 

 

 

 

 

 

 

 

Clinical Points Tool

Infraction	Date	Point Deduction or Consequence	Student/Faculty Initials
HIPAA Violations		Clinical Failure
Unsafe Patient Care: Anything that places the patient at risk of harm/injury		Clinical Warning
Medication Error (Any of the 6 Rights)		-10
Any additional medication errors (Any of the 6 rights)		Clinical Warning
Failure to complete sim-chart assignment.		-10
Failure to complete sim-chart documentation for simulation.		-10
Failure to complete and correct daily physical assessment record		-10
Failure to use isolation / Universal precautions		-10
Violating tobacco policy		Clinical Warning
Unprofessional appearance / behavior		-10
Failure to properly perform previously checked off skills		-10
Clinical Absence		-15
Tardy (up to 30 mins late) >30 min is absent		-10
Failure to follow instructions of Clinical Instructor or primary nurse		-10

 

These points will be deducted from the Pt. documentation assignment and or final grade

**If a Clinical Warning is issued, the final clinical grade will be reduced by one letter grade. 

 

 

 

 

 

 

 

 

 

Mental Status Exam and Psychiatric Nursing Care Plan

                                           

Student Name: 

Patient’s initials:      

Date of Admission:      

Date of Assessment:         

 

Click on the gray box to type.  Put an “x” in all that apply.  Tab between boxes.                                                 

Identifying Data:	Gender:  Male   Female  Age:              Unit:         Legal Status:           Allergies
Reason for Admission:
General Appearance:	Unkempt Unclean Well-groomed  Posture:      Ht.:     Wt.:     Pulse :       Blood Pressure:      Respirations:       Temp:       Pain/Other:
Motor Activity:	Tremors      Tics     Hyperactivity    Restlessness Aggressiveness     Rigidity      Psychomotor Retardation Agitation     Other:
Speech Patterns:	Slow     Rapid     Pressure of Speech     Volume:       Stuttering   Other:
General Attitude:	Cooperative  Uncooperative  Friendly    Hostile    Defensive Disinterested   Apathetic   Attentive    Guarded    Other:
Mood:	Sad   Depressed    Despairing   Irritable      Anxious   Elated    Euphoric    Fearful      Guilty    Labile   Other:
Affect:	Congruent with mood    Blunted   Constricted     Flat   Appropriate   Fearful   Other:
Thought Processes:	Flight of ideas    Associative Looseness   Circumstantiality Tangentiality    Neologisms   Concrete Thinking    Clang Word Salad  Perseveration   Mutism   Poverty of Speech    Other:
Form:	Ability to concentrate   Attention span – How Long?
Content:	Delusions/type         Obsessions  Paranoia  Magical Thinking Religiosity Phobias    Poverty of Content   Other:
	Suicidal:  if positive for ideation, state plan:        Homicide: if positive for ideation, state plan:
	What does the patient’s topic of speech tell you about what he or she is thinking?
Perceptual Disturbances:           Judgment     and Insight: (impaired or intact)	Hallucinations/Type         Illusions          Depersonalization          Derealization   Were hallucinations present prior to admission? No  Yes   per chart?  per patient?   Ability to solve problems:      as evidenced by:        Ability to make decisions:      as evidenced by:        Knowledge about self:      as evidenced by:
Memory:	Recent Memory: Impaired   Intact Disoriented    Confused   Orientation:
Sociocultural Factors:   Work? School? Family? Legal? Spiritual? Hobbies? Friends?
What medical concerns does your patient have?  Sleep concerns?

Psychiatric Disorder(s)________________________________________________________   ___________________________________________________________________________       Identify clinical behaviors that support the psychiatric diagnoses:

 

 

Medication:

Brand Name:       Generic Name:          Dose and Time:      Date Ordered:          Purpose (for this patient):          Side Effects/Adverse Effects:          Nursing Considerations:          Medication Effectiveness:  Is this medication effective for your patient? Explain how it is or how it is not.           What are the specific adverse effects your patient is experiencing? What significant ones are they not experiencing?          Patient Teaching Needs:

 

 

 

Medication:

Brand Name:        Generic Name:          Dose and Time:          Date Ordered:          Purpose (for this patient):          Side Effects/Adverse Effects:          Nursing Considerations:          Medication Effectiveness:  Is this medication effective for your patient? Explain how it is or how it is not.           What are the specific adverse effects your patient is experiencing? What significant ones are they not experiencing?            Patient Teaching Needs:

 

Medication:

Brand Name:       Generic Name:          Dose and Time:       Date Ordered:          Purpose (for this patient):          Side Effects/Adverse Effects:          Nursing Considerations:          Medication Effectiveness:  Is this medication effective for your patient? Explain how it is or how it is not.           What are the specific adverse effects your patient is experiencing? What significant ones are they not experiencing?          Patient Teaching Needs:

Abnormal Lab Values/Diagnostic Tests:

Test:                           Value:        Nursing Interventions:                Test:                  Value:        Nursing Interventions:

Use the following format:  nursing diagnosis related to **** as evidenced by (or manifested by)****.  (For example:  ineffective airway clearance related to pain, position, and possible complication on affected side as manifested by shortness of breath, shallow respirations, use of accessory muscles.)

 

Use physical nursing assessment, measurable clinical findings, and values to formulate nursing diagnoses, patient goals, nursing interventions based on evidence-based practice, and applicable evaluations. Evaluation – if they met goals, explain how you know this; If not, why not.

 

 

Assessment	Nursing Diagnosis	Goals	Interventions	Evaluations
Subjective:               Objective:
Assessment	Nursing Diagnosis	Goals	Interventions	Evaluations
Subjective:               Objective:

 

 

 

Assessment	Nursing Diagnosis	Goals	Interventions	Evaluations
Subjective:                 Objective: