NORTH CENTRAL TEXAS COLLEGE RNSG2461 COURSE SYLLABUS

 

Course Title:	RNSG2461 Clinical Nursing III
Course Prefix & Number:		RNSG2461	Section Number:		Semester/Year:	Spring 2021
Semester Credit Hours:		4	Lecture Hours:		Lab Hours:	192
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.
Course Prerequisite(s): ENGL1302 Composition II (or may be taken concurrently.)  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. Concurrent with: RNSG2461     Corequisites: RNSG 2414; RNSG1163
Required or Recommended Course Materials: Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., &Camera, I. (2013). Medical-surgical Nursing: Assessment and management of clinical problems, (9thed.). St. Louis, Missouri: Elsevier. Harding, M., Snyder, J. (2016). Critical Thinking Cases in Nursing. (6th Ed). St. Louis, Missouri: Elsevier. Lowdermilk, Perry, Cashion, & Alden, (2016). Maternity and Women’s Health Care 11th ed. St. Louis, MO: Elsevier  EHR TUTOR and & All ATI Resources Textbooks used in previous semester.   Access: Texas Nursing Practice Act  www.bon.state.tx.us   Drug handbook or app of choice, Lab & Diagnostics handbook or app of choice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTOR INFORMATION

Name of Instructor:	Taryn Ogle
Campus/Office Location:	HSC Gainesville Campus 2428-N
Telephone Number:	940-668-7731 Ext. 4919
E-mail Address:	tlogle@nctc.edu

 

Name of Instructor:	Gabriella Udabor
Campus/Office Location:	HSC Gainesville Campus 2428-
Telephone Number:	940-668-7731 Ext.
E-mail Address:	gudabor@nctc.edu

 

Name of Instructor:	Kristina Scurlock
Campus/Office Location:	HSC Gainesville Campus 2428-
Telephone Number:	940-668-7731 Ext.
E-mail Address:	kscurlock@nctc.edu

 

Name of Instructor:	Mira Brown
Campus/Office Location:	HSC Gainesville Campus 2428-
Telephone Number:	940-668-7731 Ext.
E-mail Address:	mjbrown@nctc.edu

 

Name of Instructor:	Cynthia Andrews
Campus/Office Location:	HSC Gainesville Campus 2428-
Telephone Number:	940-668-7731 Ext.
E-mail Address:	candrews@nctc.edu

 

STUDENT LEARNING OUTCOMES

 

Texas Board of Nursing Differentiated Essential Competencies

Upon successful completion of this course, the student will be able to act as a: 

I. Member of the Profession: Provide nursing care within the parameters of professional nursing knowledge, scope of practice, education, experience, and ethical/legal standards of care.

II. Provider of Patient-Centered Care: Proactively manage priorities in patient care and follow-up on clinical problems that warrant investigation with consideration of anticipated risks.

III. Patient Safety Advocate: Safely administer medications and treatments. Recognize and report unsafe practices.

IV. Member of the Health Care Team: Assist patients and their families to communicate needs to their support systems and to other health care professionals.

 

 

 

 

 

GRADING CRITERIA

 

Clinical Performance: is based on evaluation of student performance.  See mid-term and final evaluation tools under Rubrics in Canvas.

 

***Clinical Points tool: Any infraction as listed on the clinical points tool will result in the assigned points taken from the mid-term or final evaluation grade. 

 

Patient Documentation

When at the hospital setting each student will fill out an ASSESSMENT AND PATIENT CARE RECORD and turn in complete with narrative documentation for 4 patients they have cared for during their clinical rotation.  These patients MUST be Medical, Surgical, ICU, HVU or PCU patients (NO ED, Women’s Services or patients in the OR or Outpatient Services).  Level III students will provide total patient care for three patients per day on the med-surg unit. The assessment and patient care data will be documented in EHR Tutor and submitted on four of the patients cared for this semester. Your clinical instructor will give you a course ID for your clinical EHR tutor course. EHR tutor assignments will be graded by the clinical instructor (see rubric in appendices). Failure to complete assigned ASSESSMENT AND PATIENT CARE RECORD and ATI: EHR tutor documentation by the due date as per the clinical instructor will result a zero on that assignment.

 

Virtual Clinical via Swift River

Students may be asked to complete clinical assignments via Swift River for completion of their clinical hours on clinical days specified by the clinical instructor. Swift River clinical modules will be set according to clinical instructors, and students are expected to complete the assigned weekly module as per the clinical instructor. Failure to complete the assigned Swift River modules with the assigned time and assessment scores will result in an absence for that clinical day and a 10 point deduction as per the clinical points tool

 

Performance Evaluation is an assessment of both cognitive and psychomotor skills. Students will report to the simulation lab at their scheduled time.  At that time, they will be assigned a role in the simulation (charge nurse, primary nurse or unsilenced assistive personnel).  Each student must know their role and ability to act within that role.  Delegation and prioritization will be evaluated as well as ability to communicate and perform skills. See performance evaluation tool under rubrics on canvas.

 

Assignments: All assignments listed in the syllabus as well as any additional 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. LATE ASSIGNMENT = 0

All assignments must be completed and submitted in order to pass the course.

 

Discharge Teaching Assignment: Students will work together in instructor-assigned groups of 2 to develop discharge instructions for a hypothetical patient with a predetermined assigned clinical diagnosis. Diagnoses will follow according to current material and content in didactic Complex Care Needs course. Follow the rubric to prepare your project. Present discharge teaching according to assigned diagnosis to your clinical instructor. Presentation of discharge plan will be done in post-conference at clinical to peers. Students may utilize any teaching-learning modality as appropriate, to include, but not limited to: role play, poster-board presentation, powerpoint, or other audio/visual modality. Discharge planning and presentation should reflect level 3 knowledge as described in the RNSG 2461 syllabus.

 

Math Competency:  Dosage calculation modules are assigned and can be accessed through your ATI account.  Clinical Nursing III students are required to take one dosage and calculation test.   The student will have three opportunities to pass the test with a minimum score of 100%.  The math exam will consist of 10 questions and the student will be allowed one 50 minutes to complete the exam. If the student is not successful on the first or second attempt, he/she will be required to seek remedial math instruction with their clinical instructor or the NCTC math lab and retake the math test within two weeks after the first math exam. Failure to pass the third math test with a minimum score of 100% will result in a clinical failure. If a student misses the math exam that missed exam will be considered a failed attempt.

 

Student Portfolios:  The student must have a portfolio consisting of all remediation, documentation, evaluation forms and clinical points tool that they will need to bring to clinical each day.  The contents of this portfolio will be submitted with the final evaluation and will be part of the student file.  Failure to have this portfolio at the clinical site will result in deduction from clinical points tool. 

 

The numerical course grade, after points are deducted for absences and other infractions (see Clinical Points Tool), will be converted as follows:

                                                     Numerical Grade                           Letter Grade

                                                90 – 100                                           A

                                                81  -  89                                            B

                                                75  -  80                                            C

                                                66  -  74                                            D

                                                            65 and Below                                   F

 

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

 

# of Graded Course Elements	Graded Course Elements	Percentage or Point Values
	Clinical Performance	50%
		Point value per evaluation
1	Mid-term Evaluation	100 (25% of grade)
1	Final Evaluation	100 (25% of grade)
Total # of Assignments	Assignments	25%
5	EHR Tutor Clinical Documentation 3 for Clinical 2 for Simulation	100 (15% of grade) Each submission is 3% of grade
1	Patient Discharge Teaching Project	100 (5% of grade)
1	End of Clinical Reflection Journal	100 (5% of grade)
	Performance Evaluation	25%
1	Performance Evaluation	100

 

 

 

 

 

 

 

 

 

 

 

 

 

Course Dates and Scheduled Assignments:

Week 1: January 19-22	Clinical Orientation- Course expectations, grading and schedules Hospital Orientation TBA:   Review Dosage Calculations from Level I & II, and Complete the Following Modules in ATI: ATI Math – Pediatric Medications ATI Math – Critical Care Medications ATI Math – Dosages by Weight ATI Math – Parenteral (IV) Medications Take the Practice Math Exam Available in ATI
Week 2: January 25-29	Clinical III Math Exam Attempt 1: Wed. Jan. 27th 8 a.m. ON CAMPUS in computer labs
Week 3: February 1-5
Week 4: February 8-12	Respiratory Discharge Teaching Project Presentation
Week 5: February 15-19	Clinical III Math Exam Attempt 2: Feb. 17th 8 a.m. on CAMPUS in computer labs   EHR TUTOR Clinical Documentation 1 DUE
Week 6: February 22-26	Cardiac Discharge Teaching Project Presentation
Week 7: March 1-5	Clinical III Math Exam Attempt 3: March 3 8 a.m. on CAMPUS in computer labs
Week 8: March 8-12	MidTerm Evaluations Due   GI Discharge Teaching Project Presentation   EHR TUTOR Clinical Documentation 2 DUE
Week 9: March 15-19	SPRING BREAK
Week 10: March 22-26
Week 11: March 29 – April 2	Neuro Discharge Teaching Project Presentation
Week 12: April 5-9	Last Day to drop with W – April 5th   EHR TUTOR Clinical Documentation 3 DUE
Week 13: April 12-16	Performance Evaluations
Week 14: April 19-23	Immune/Cancer Discharge Teaching Project Presentation
Week 15: April 26-30	Final Evaluations   EHR TUTOR Clinical Documentation 4 DUE
Week 16: May 3-7	Reflection Journal Finals Week

 

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

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)

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

Students are expected to attend clinical on each assigned clinical day.  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 2 clinical days or clinical labs 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.  Two days of being tardy up to 30 minutes will be counted as 1 absence.  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.

 

Last day to withdraw from a course with a “W” is April 5th. 

 

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

 

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

 

Syllabus Addendum – Spring 2021

NCTC Student Services and Resources

 

• Frequently Asked Questions-all you need to know as a new or continuing student
• Student Services page-all the offices and contact information you need!

• Advising FAQ's-all majors and programs!

• Meet Your Advisor/Coach
• Degree Plans and Online Registration
• Career Services and Completion Center
• Course Combination/Credit Hour Maximization Matrix
• Lion365 Year-Round Registration!
• Post-Registration Checklist
• Navigating Your First Year at NCTC

• Affinity Groups and Student Life & Organizations 
• Awareness, Community Resources, and Wellness
• CARES Team and Counseling Services

• Financial Aid and Scholarships 
• Equity, Diversity, and Inclusion
• Student Success/Tutoring, TRIO, and OSD (Disability Services)
• Testing Services
• QLess and Signing into Virtual Lines  
• Keep track of NCTC campus and COVID-related updates 

 

Affinity Groups

Staff and faculty representing the Employee Resource Groups (ERG’s), along with academic advisors, counselors and success coaches, serve as mentors for NCTC’s student-centered ​Affinity Groups​.

An ​Affinity Group​ is a population of students who have specific needs, barriers or systems they are needing to navigate not only within college, but within life. Providing mentorship, support and resources for identified Affinity Groups such as Black/African American students, veterans and active military, single parents, students with disabilities, adult learners, Latinx, LGBTQ+ and students who have experienced foster care and/or homelessness, enables us to make more impactful, meaningful connections with students who are in dire need of equity and understanding.

 

Career Services Center

In need of employment? NCTC Career Coaches meet one-on-one to provide training in writing resumes, job searches, interviewing, and more. The Skills to Succeed Academy is also a free interactive, online employability training program focused on building the skills and confidence you need to find the best career.

 

Completion Center

The Completion Center provides a variety of services for first-time in college students. These include academic success coaching, goal setting, course planning, student resources, career development, and job placement services for all new college students. Free online Success Seminars are also available through Student Lingo and new students will also enroll in a First Year Experience (NCTC 1001) course to get started on the right track!

 

Counseling and Advising

Academic Advisors and Counselors help students explore majors and programs offered, how to take the best combination of classes to meet your goals, assist with questions related to university transfer, and guide students towards academic and personal success, and more. At NCTC, you are assigned to a specific advisor or success coach based on your major or career interests. You can locate our advisors and their majors, along with contact information on the Meet Your Advisor page-and even schedule an appointment with them through their online calendar!

 

Early Alert and CARES

The NCTC Early Alert program assists students who are at risk of failing or withdrawing from a course. Faculty and staff may refer students through the Early Alert process at any point in the semester in an effort to provide appropriate intervention and access to support services. Examples of behaviors that could prompt an Early Alert referral could be missing assignments, failing tests, excessive absences, or personal circumstances impacting academic performance. A student submitted as an Early Alert will be contacted by an academic advisor or success coach through text, phone, and/or via their NCTC e-mail address to discuss any current challenges as well as helpful resources and success strategies-we want our students to finish strong and know that education is a partnership!

 

The NCTC CARES Team is concerned not only about our students' academic success, but also their emotional and physical well-being. As a student, you have the ability to report concerning behavior which could impact your own safety or the safety of another NCTC student, such as stalking, harassment, physical or emotional abuse, violent or threatening behavior, or self-harm. Visit the NCTC CARES site to also locate campus and community resources, or email counseling@nctc.edu.  As always, if you feel there is an immediate threat to your own safety or welfare (or to another student), please call 911 immediately.

 

Equity, Diversity and Inclusion (EDI)

EDI partners with the entire campus community to create, maintain and demonstrate NCTC’s commitment to an equitable, diverse and inclusive learning environment where NCTC students succeed. NCTC defines equity as encompassing the practice of acknowledging individual differences and systemic disparities when developing new programs and resources for our campus community, which may sometimes challenge our own beliefs and assumptions, in order to ensure balanced educational opportunities toward completion. Everyone Included. Everyone Belongs. Everyone Valued. Everyone Inspired. 

 

Financial Aid

The Office of Financial Aid provides students with information and guidance with applying for eligible types of financial assistance, such as the FAFSA (Free Application for Federal Student Aid). Students who have any types of exemptions or tuition waivers will also work with the Financial Aid Office to have these funds applied to their accounts. Additionally, the Scholarship Office provides local scholarship opportunities through an online application process, and tips on how to secure other types of scholarship awards which can help finance educational goals.

 

Student Success Center

The Student Success Center is designed to help all students at NCTC develop tools to achieve their academic goals. The center links students to FREE tutoring, including a Writing Center, a Math Lab, and free online tutoring.  Student Success offers academic coaching, tutoring, including a Writing Center, and a Math Lab to 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 services.

 

Testing Services

The mission of NCTC Testing Services is to provide high-quality testing services that adhere to the professional standards and guidelines to meet the needs of students, faculty, and community members.

 

 

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.

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 Statements Spring 2021 - COVID-19 Specific

 

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 as conditions change.

 

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 the spring 2021 semester, 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendices

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Therapeutic Nursing Interventions

Therapeutic Nursing Interventions are acts carried out by nurses to foster and enhance the well-being of patients based on relevant scientific findings that guide a holistic approach to health care.  At the Clinical I and Clinical II Level of clinical performance, students are expected to demonstrate competency of selected psychomotor skills.  By the end of Clinical III mastery of these basic skills is expected.  Additionally, at the Clinical III and IV Levels of clinical performance, students are expected to demonstrate cognitive knowledge of the theory for skills performance that requires critical decision making even though they may not be able to demonstrate clinical mastery.

 

	Clinical I	Clinical II and Transition	Clinical III	Clinical IV
Respiratory	Oxygen Therapy Nasal cannula Oxygen Mask Incentive spirometry	Pulse oximeter Oropharyngeal Suctioning Nasopharyngeal Suctioning	Suctioning: Artificial airway Tracheotomy care IPPB Chest Physiotherapy Chest Tubes	Mechanical Ventilation ET/tracheotomy
Medications	Oral/Topical/Buccal Injections SQ/IM Injections  Z  track/Intradermal	IV Piggyback	IV bolus Titrate dosage IVP	Emergency drugs
IV	Assess IV Site only	Start IV , DC IVs, DC Saline Locks Regulate IV flow rate Change IV & Central Line dressing Change IV tubing/solutions	IVPB TPN Pumps/ PCA Venous access devices	Blood/blood products transfusions
Wounds	Dressing change Hot/cold therapy Remove staples/sutures	Care of acute and chronic wounds		Emergency care/burns/trauma
Elimination	Enemas Douches Foley catheter	Ostomy care/irrigation NG tube (Insertion/Irrigation) Tube feedings/ Gastrostomy tube	Hemodialysis/peritoneal dialysis
V S	Temperature/ Pulse/ Respiration Blood Pressure	Pediatric Neonate	Neuro exam
Physical Assessment	Adult and Geriatric Patient	Pediatric and neonate Patient OB patient	5-lead EKG Interpretation	Emergency Assessment Intro to 12-lead EKG
Lab	I&O Specimen collection Finger stick blood sugar	CBC, Electrolytes, Platelets, BUN, Creatinine, PT, INR, PTT Urinalysis, Oxygen Saturation	ABGs Interpretation F & E
Mobility	ROM Transfer/ Positioning/ Ambulation TED hose/compression pump	Traction/Cast care		Rehabilitation
Competency   Basic Care	Bathing/Oral Care/Hair care/Shave Bed making/Feeding/Weight

 

Mastery

Theory

 

DAILY PHYSICAL ASSESSMENT RECORD

Date (s) of Care _______________Room #_____________

Pt. Info:  Age__________ Gender____________ Ethnicity____________Allergies: ______________________

Medical Diagnoses: _____________________________________________________________________________

Pertinent Medical History________________________________________________________________________

Height: _______Weight: ______________ Code Status:_______Fall Risk:______

Time	Temp	Pulse	Resp.	BP	Pain Rating (0-10)	IV Location & Intact?	IV Fluid & Rate	O2 Device & √Setting	O2 Sat

 

Time	Intake				Output
	Oral	IV	IVPB	Blood	Urine	BM	Emesis	Drains
Totals

 

Labs/DX tests	Pt’s Value	Medication	Category	Nsg Considerations
Hgb Hct RBC HbA1C WBC Platelets Na++ K+ Phos. Glucose BUN Creatinine BNP TROPONIN Liver enzymes PT/INR PTT Albumin UA   Doppler CXR XRay CT EF% Other__________

Instructions: Complete the following assessment of your pt. using your observation, interviewing and physical assessment skills. Include documentation of each criteria item.

 

Head, Face, Neck   Head, Face (head round and symmetrical normocephalic, microcephalic, macrocephalic, headache, symmetrical facial features, asymmetrical facial features   Neck (full range of motion, limited range of motion, without swelling, trachea midline trachea shifted right, cervical lymph nodes palpable, thyroid visible, jugular vein distension)   Comments:		Integumentary   Skin Color (Appropriate for ethnicity, even distribution, pallor flushed, cyanosis, jaundice Skin Temperature/Condition (Intact, not intact- See skin comments, warm, hot, cold, cool, dry, diaphoretic, swelling) Skin Turgor (Recoils immediately, recoils slowly, tenting       Comments:             Braden Scale Sensory perception            Moisture              Activity Mobility Nutrition              Friction and shear              Total score
Eyes, Ears, Nose, Throat   Eyes (Symmetrical, no drainage, denies pain, asymmetrical, exophthalmia, glasses, contacts, blind)   Ears (Symmetrical  placement, no drainage, hearing intact, no pain, difficulty hearing, deaf, hearing aid)   Nose, Throat (Oral mucosa moist and intact, oral mucosa dry, oral lesions, teeth missing, dentures, bad breath, deviated septum, nasal discharge, sinus pain, nose bleed, sore throat, throat red, tonsils red and swollen     Comments:		Musculoskeletal   RUE      LUE       RLE       LLE       (Full range of mobility, limited range of mobility, weakness, paralysis, contracted, amputation     Comments:     Morse Fall Scale History of falling Secondary diagnosis          Ambulatory aid   IV/Saline Lock    Gait/Transferring Mental Status      Total       Select Risk level based on total score
Neurological   Level of Consciousness    Orientation (Oriented X4, oriented to person, place, time, situations/event; disoriented, unable to assess)   Cognitive (WDL, no short-term memory loss, short-term memory loss, appropriate for developmental age, inappropriate for developmental age, appropriate attention/concentration, poor attention/concentration, unable to assess   Speech (WDL, Clear, Comprehensible, Slurred, Aphasic)   Pupil Response (Bilateral pupils reactive, bilateral pupils fixed (nonreactive), R pupil nonreactive, L pupil nonreactive, R pupil reacts sluggishly, L pupil reacts sluggishly, unable to assess Pupil size (mm)   left: right:   Glasgow Coma Scale Best Eye Response            Best Verbal Response        Best Motor Response        Glasgow Total       Comments:		Respiratory   Resp. (Effort/Pattern, WDL, regular rhythm, bilaterally even and unlabored, irregular rhythm, labored, retractions, dyspnea with exertion, dyspnea, nasal flaring, tachypneic, bradypneic, kussmaul, apnea, Cheynes-Stokes Breath Sound,                  Cough    Sputum      Resp. Interventions (Suction, chest physiotherapy, turn, cough and deep breathe, incentive spirometry) Intervention, Comments    Respiratory Airways/Drain (Endotracheal tube, tracheostomy tube nasal tube, oral tube, chest tube Airway/Drain, Comments Oxygen Source    (Oxygen rate and comments)       Comments:
Cardiac   (Cardiac Rhythm/Sounds  WDL, regular rhythm, normal rate S1 and S2 present, irregular rhythm, murmur, adventitious heart sounds Pacemaker/ICD? Cardiac symptoms: peripheral edema-pitting, peripheral edema-nonpitting, palpitations, dizziness, syncope, chest pain   Monitors/Telemetry?               Comments:		Genitourinary   Urinary Symptoms (WDL, continent, voiding without discomfort, incontinent, bladder distention, burning, dysuria, oliguria, retention, polyuria, anuria   Urine Color          Urine Characteristics (No odor, foul odor, clear, cloudy, mucous, purulent, sediment, blood clots, stones, unable to assess       Comments:
Gastrointestinal   Abdomen (WDL, Soft, nondistended, nontender, rigid, tender, distended, flat, rounded, ascites   Bowel Sounds (Present in four quadrants, active, hypoactive, hyperactive, absent) Passing Flatus     Last Bowel Movement            Comments:		Pain Assessment (Pain location, numeric pain rating, pain rating-faces     Pain Relieved by (Medication, position, meds, cold, heat, rest, activity)     Comments:
Peripheral Vascular   RUE LUE RLE LLE    (WDLCapillary refill less than 3 secs, pulse is palpable and strong, no edema or pain, capillary refill greater than 3 secs, doppler used+1-weak pulse+2-moderate pulse+3-strong pulse+4-bounding pulse, no pulse, edema=+1 (mild pitting, slight indentation) edema=+2 (moderate pitting, indentation subsides rapidly) edema=+3 (deep pitting, indentation remains for short time) edema=+4 (very deep pitting, persistent) Pain (Describe in comments)     Comments:

 

 

 

Nursing Diagnosis: ______________________________________________________________________________

 

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Nursing Documentation - Narrative

Suggested focus for documentation- Focused assessment (based on the patient’s problem(s);  Nutrition; Safety issues; Education given to patient; etc. 

 

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	Mid-term Rating	Comments	Final Rating
Member of the Profession Use nursing judgment to anticipate and prevent patient harm.
Patient-Centered Care Use knowledge of societal and health care trends and evidence-based outcomes to identify and communicate patient physical and mental health care problems.
Patient Safety Advocate Document and report reactions and untoward effects to medications, treatments, and procedures and clearly and accurately communicate the same to other health care professionals.
Health Care Team Advocate on behalf of patients and their families with other members of the interdisciplinary health care team
Clinical Points Tool Deduction		Clinical Points Tool Deduction
Mid-Term Grade		Final Grade

(Rating Code: 15=marginal, 18=fair, 20=satisfactory, 22=good, 25=excellent)

                   

 

 

 

RNSG 2461 Clinical Skills/Competencies
Outcomes	Date:	Discuss Rationale	Identifies Impact on the Client	Explains Procedure to Client	Selects Equipment	Completes Procedure	Uses Appropriate Aseptic Technique	Interprets Client Response	Reports and Documents Results	Provides Appropriate Follow-up	Instructors/RN Initials
Suctioning Artificial airway Tracheotomy care Airway Clearance Techniques Chest Physiotherapy Chest Tubes
IV Bolus Titrate dosage IVPB
TPN Pumps/PCA Venous Access Devices
Hemodialysis/peritoneal dialysis
Neuro Exam
ABG’s Interpretation Fluids and Electrolytes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student Signature/Date_______________________________                                          Instructor Signature/Date_________________________________

 

 

**Skills completed must be initialed by RN or clinical instructor the day they are performed.

 

Performance Evaluation: Creighton Competency Evaluation Instrument (CCEI) 

 

Student Name:           Staff Nurse Instructor Name:	0= Does not demonstrate competency 1= Demonstrates competency NA= Not applicable				Date:          /                   /                   MM / DD / YYYY
ASSESSMENT	Circle Appropriate Score for all Applicable Criteria - If not applicable, circle NA			COMMENTS:
1. Obtains Pertinent Data	0	1	NA
2. Performs Follow-Up Assessments as Needed	0	1	NA
3. Assesses the Environment in an Orderly Manner	0	1	NA
COMMUNICATION 4. Communicates Effectively with Intra/Interprofessional Team (TeamSTEPPS, SBAR, Written Read Back Order)	0	1	NA
5. Communicates Effectively with Patient and Significant Other (verbal, nonverbal, teaching)	0	1	NA
6. Documents Clearly, Concisely, & Accurately	0	1	NA
7. Responds to Abnormal Findings Appropriately	0	1	NA
8. Promotes Professionalism	0	1	NA
CLINICAL JUDGMENT
9. Interprets Vital Signs (T, P, R, BP, Pain)	0	1	NA
10. Interprets Lab Results	0	1	NA
11. Interprets Subjective/Objective Data (recognizes relevant from irrelevant data)	0	1	NA
12. Prioritizes Appropriately	0	1	NA
13. Performs Evidence Based Interventions	0	1	NA
14. Provides Evidence Based Rationale for Interventions	0	1	NA
15. Evaluates Evidence Based Interventions and Outcomes	0	1	NA
16. Reflects on Clinical Experience	0	1	NA
17. Delegates Appropriately	0	1	NA
PATIENT SAFETY 18. Uses Patient Identifiers	0	1	NA
19. Utilizes Standardized Practices and Precautions Including Hand Washing	0	1	NA
20. Administers Medications Safely	0	1	NA
21. Manages Technology and Equipment	0	1	NA
22. Performs Procedures Correctly	0	1	NA
23. Reflects on Potential Hazards and Errors	0	1	NA