The document provides an evaluation tool for a pediatric clinical course taken by Emily Tarrell. It outlines the course description and evaluation standards. The evaluation covers six essential competencies for nursing: patient-centered care, systems-based practice, evidence-based practice, informatics, quality improvement, and teamwork/collaboration. For each competency, the evaluator provides comments and examples of how Emily demonstrated the competencies in her clinical work from June 3rd to June 12th. Overall, the evaluation indicates Emily met course expectations and showed improvement over the rotation.
Health
THREE ASPECTS OF HEALTH
Nursing Assessment
Objectives of health assessment
Reasons for doing assessment:-
Reasons for doing assessment:-
Importance of health assessment
Conti…
Types of Assessment
Initial assessment
Problem focused assessment
Emergency assessment
Time lapsed assessment
Initial assessment
Problem Focused Assessment
Emergency assessment
Time – lapsed reassessment
Setting and environment
Data collection
Data collection is the process of gathering information about a client’s health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
Types of data collection
Two types:
subjective data and
objective data.
1. Subjective data, also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data.
Conti….
2. Objective data, also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data
Sources of data collection
Sources of data are primary or secondary.
Primary : It is the direct source of information. The client is the primary source of data.
Secondary: It is the indirect source of information. All sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources.
Methods of data collection
Conti….
Observation includes looking, watching, examining. Observation begins the moment the nurse meets the client. It is a conscious, deliberate skill that is developed through efforts and with an organized approach.
Observation has two aspects:
Noticing the data and
Selecting, organizing, and interpreting the data.
2- Interviewing
STAGES OF AN INTERVIEW
An interview has three major stages:
The opening or introduction
The body or development
The closing
3- Examination
Inspection
Auscultation
Palpation
Types of palpation
Light palpation
Deep palpation
Bimanual palpation
Percussion
4- Intuition
Data Validation
3- Organization of data
4- Documenting Data
this is the detailed contents of various steps in nursing process, make use of my content.regards.R.BABU.
PROF & HOD,THE OXFORD COLLEGE OF NURSING -BANGALORE
The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps.
Tags: nursing process, purpose of nursing process, characteristics of nursing process, nursing process framework, importance of nursing process, components of nursing process
NURSING PROCESS
The Cornerstone of The Nursing Profession
The nursing process generally is defined as a systematic problem- solving approach toward giving individualized nursing care.
Nursing process is a critical thinking process that professional nurses use to apply the best available evidence to care giving and promoting human functions and responses to health and illness (American Nurses Association, 2010).
Nursing process is a systematic method of providing care to clients.
The nursing process is a systematic method of planning and providing individualized nursing care.
The nursing process is a systematic method that directs the nurse and patient as together they accomplish the following:
Assess the patient to determine the need for nursing care;
Determine nursing diagnoses for actual and potential health problems;
Identify expected outcomes and plan care;
Implement the care; and
Evaluate the results.
Components of nursing process
Assessment (data collection),
Nursing diagnosis
Planning
Implementation and
Evaluation.
Nursing
diagnosis
Purposes of nursing process
To identify a client’s health status and actual or potential health care problems or needs.
To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs.
Characteristics of Nursing Process
Cyclic
Dynamic nature,
Client centeredness
Focus on problem solving and decision making
Interpersonal and collaborative style
Universal applicability
Use of critical thinking and clinical reasoning.
Steps in nursing process, Specific to the nursing profession
A framework for critical thinking
It’s purpose is to:
“Diagnose and treat human responses to actual or potential health problems”
Health
THREE ASPECTS OF HEALTH
Nursing Assessment
Objectives of health assessment
Reasons for doing assessment:-
Reasons for doing assessment:-
Importance of health assessment
Conti…
Types of Assessment
Initial assessment
Problem focused assessment
Emergency assessment
Time lapsed assessment
Initial assessment
Problem Focused Assessment
Emergency assessment
Time – lapsed reassessment
Setting and environment
Data collection
Data collection is the process of gathering information about a client’s health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
Types of data collection
Two types:
subjective data and
objective data.
1. Subjective data, also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data.
Conti….
2. Objective data, also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data
Sources of data collection
Sources of data are primary or secondary.
Primary : It is the direct source of information. The client is the primary source of data.
Secondary: It is the indirect source of information. All sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources.
Methods of data collection
Conti….
Observation includes looking, watching, examining. Observation begins the moment the nurse meets the client. It is a conscious, deliberate skill that is developed through efforts and with an organized approach.
Observation has two aspects:
Noticing the data and
Selecting, organizing, and interpreting the data.
2- Interviewing
STAGES OF AN INTERVIEW
An interview has three major stages:
The opening or introduction
The body or development
The closing
3- Examination
Inspection
Auscultation
Palpation
Types of palpation
Light palpation
Deep palpation
Bimanual palpation
Percussion
4- Intuition
Data Validation
3- Organization of data
4- Documenting Data
this is the detailed contents of various steps in nursing process, make use of my content.regards.R.BABU.
PROF & HOD,THE OXFORD COLLEGE OF NURSING -BANGALORE
The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps.
Tags: nursing process, purpose of nursing process, characteristics of nursing process, nursing process framework, importance of nursing process, components of nursing process
NURSING PROCESS
The Cornerstone of The Nursing Profession
The nursing process generally is defined as a systematic problem- solving approach toward giving individualized nursing care.
Nursing process is a critical thinking process that professional nurses use to apply the best available evidence to care giving and promoting human functions and responses to health and illness (American Nurses Association, 2010).
Nursing process is a systematic method of providing care to clients.
The nursing process is a systematic method of planning and providing individualized nursing care.
The nursing process is a systematic method that directs the nurse and patient as together they accomplish the following:
Assess the patient to determine the need for nursing care;
Determine nursing diagnoses for actual and potential health problems;
Identify expected outcomes and plan care;
Implement the care; and
Evaluate the results.
Components of nursing process
Assessment (data collection),
Nursing diagnosis
Planning
Implementation and
Evaluation.
Nursing
diagnosis
Purposes of nursing process
To identify a client’s health status and actual or potential health care problems or needs.
To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs.
Characteristics of Nursing Process
Cyclic
Dynamic nature,
Client centeredness
Focus on problem solving and decision making
Interpersonal and collaborative style
Universal applicability
Use of critical thinking and clinical reasoning.
Steps in nursing process, Specific to the nursing profession
A framework for critical thinking
It’s purpose is to:
“Diagnose and treat human responses to actual or potential health problems”
Each student is required to complete and turn in the evolution oAlyciaGold776
Each student is required to complete and turn in the evolution of the course prior to sitting for the final exam. This is a portfolio requirement that must be completed at the end of each course. You will not be allowed to sit for the final without having completed the evolution for this course.
Rubric
NURS_307 - Nursing Evolution Rubric
NURS_307 - Nursing Evolution Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeReflects on current theory and clinical class with concepts and theories using the Program Learning Outcomes and BSN Essentials listed in the syllabus
3.3 pts
Meets Expectations
1. Reflects on current theory class and clinical and how courses support each other (transfer of knowledge to apply to clinical)- Focused to Current Term. 2. Synthesizes theories and concepts from liberal education to build an understanding of the human experience. 3. Uses skills of inquiry and analysis to address practice issues 4. Applies knowledge of social and cultural factors in the care of populations encountered in this course.
2.51 pts
Approaches Expectations
1. Limited reflection on current theory class and clinical and how courses support each other (transfer of knowledge to apply to clinical)- Focused to Current Term. 2. Limited synthesis of theories and concepts from liberal education to build an understanding of the human experience 3. Use limited skills of inquiry and analysis to address practice issues 4. Applies limited knowledge of social and cultural factors in the care of populations encountered in this course.
1.65 pts
Does Not Meet Expectations
1.No reflection on current theory class and clinical and how courses support each other 2. Does not synthesize theories and concepts from liberal education to build an understanding of the human experience 3. Does not use skills of inquiry and analysis to address practice issues 4. Does not apply knowledge of social and cultural factors in the care of populations encountered in this course.
3.3 pts
This criterion is linked to a Learning OutcomeDevelops an effective communication style for interacting with current patients, families, and the interdisciplinary health team when providing holistic, patient centered nursing care to populations encountered in this course.
3.4 pts
Meets Expectations
1. Reflects on providing holistic patient care to populations encountered in this course. 2. Describes inter-collaborative involvement (i.e. Interprofessional rounds; consultations and interaction with PT/OT; Respiratory Therapy, Pharmacist consultation---describe their role/ contribution.)
2.58 pts
Approaches Expectations
1. A limited reflection on providing holistic patient care to populations encountered in this course. 2. Describes limited inter-collaborative involvement
1.7 pts
Does Not Meet Expectations
1. No reflection on providing holistic patient care to populations encountered in this course. 2. Does not describes inter-collaborative involvement
3.4 pts
This criterion is ...
Connecting the dot with the Nursing Process and Critical thinki.docxdonnajames55
Connecting the dot with the Nursing Process and Critical thinking
Manda McIntyre
Debra Hunt
1
Overview
Develop a educational program on the nursing process to first semester students.
Utilize advance nursing knowledge to assist students in understanding the nursing process, critical thinking skills, and implementation needed to deliver best nursing practice.
This practicum experience will involve teaching novice-nursing students beginning their first semester of the nursing program. It is at this time that students are introduced to the nursing process and critical thinking skills. Nurse educator teaches the students that the American Nurses Association Standards hold the nursing process as the framework for critical thinking. The writer chose the nursing as an educational curriculum to provide a thorough understanding of the nursing process for the nursing students to gain knowledge of critical thinking, problem soloing, and passing of the NCLEX-RN examination. The nursing process is used by nurses worldwide to explore the delivery of care.
2
The nursing process was developed in the 1950’s as an educational tool to promote patient centered nursing.
It provides a solid framework for the nursing practice.
It is integrated throughout in the nursing curricular in most of the nursing colleges and the National Council Licensure Examination-Registered Nurse (NCLEX-RN).
It provides the student the ability to use critical thinking skills and response on the basic of the scientific method.
A scientific method that us a step-by-step process to identify and problem solve.
Critical thinking is a vital process for the students to connect the dot in the nursing process.
Introduction
The nursing process was introduced in the 1955 by Hall and Johnson (1959). Nursing process is the essential core of practice for the nurse to provide holistic, patient-centered care. It is provide critical thinking competency that should be taught through out the nursing curriculum. The nursing process is a systematic approach to identifying patient’s actual problem or potential problems and establish a plan to meet the identified needs. It is a process that can be implemented in all areas of nursing. The nursing process is a framework that nursing students and nurses should use consistently and methodically use throughout their career to enable them to organize data and deliver evidenced based practice-nursing care.
3
Nursing students will:
Define and explain the importance of the nursing process.
Discuss the components of nursing process.
Analyze critical thinking in nursing practice's
Implement the nursing process to a patient
care assignment.
Demonstrate the use of critical thinking to prior-
itize for a client assignment.
Program Objectives
The nursing process and critical thinking is the essential core of practice for nursing students to deliver holistic, patient, patient-centered care. It is important t.
Dr. Ameri and class,After reflecting over the course of Advanced.docxmadlynplamondon
Dr. Ameri and class,
After reflecting over the course of Advanced Clinical Diagnosis and Practice Across the Lifespan, the student identified achievements of the course outcomes. This course had a few specific areas that the student reflected on that assisted her in preparing for the Master of Science program outcome #4, the Master of Science in Nursing (MSN) Essential IV, and the Nurse Practitioner Core Competency #7.
The professional outcome #4 is to “Integrate professional values through scholarship and service in health care.” This outcome was achieved by taking the week 4 APEA predictor exam. As the student studied for the exam, she identified several areas of improvement. By reviewing a wide knowledge base of concepts seen in the primary care setting the student was to identify her areas of strengths and weaknesses. The test was broken down into categories and assisted the student to find her professional identity. Another way the student found her professional identity was through clinicals. The preceptor pushed autonomy and let the student formulate the treatment plan while she would offer suggestions and advice. The student realized that in a few short months that she would be in practice with varying levels of guidance depending on job location. The student identified her professional identity in the clinic which will aide her in her next rotation and future practice.
The MSN Essential IV is “Translating and integrating scholarship into practice recognize that the master’s prepared nurse applies research outcomes within the practice setting, resolves practice problems, works as a change agent, and disseminates results.” Over the course, the student achieved the MSN Essential IV by discussion in week 6 mental health presentation and in the clinical setting. The student is accustomed to seeing a lot of mental health patients but sometimes has difficulty categorizing the present illness. The week 6 presentation allowed each student to formulate a patient scenario with a diagnosis provided by the instructor. The student saw how mental illness was related, but also how it differed form patient to patient. This assignment assisted the student in identifying patient’s chief complaints, differentiate from different ailments, educate and act as a change agent, and evaluate results over time. In the clinical setting, the student was able to educate teens about IUDs. The NP she followed at the FQHC would insert IUDs that lasted for 5 years for $20. Many teenage girls would come to the clinic and admit to being sexually active without the use of protection or teenagers that already had a few kids would come in asking for birth control options. The student felt as if she was able to minimize teenage pregnancy or unwanted pregnancies by providing patients with the appropriate knowledge and offer an affordable pregnancy prevention method.
The Nurse Practitioner Core Competency #7 is geared towards Health Delivery System Competen ...
Dr. Ameri and class,After reflecting over the course of Advanced.docx
Evaluation-Peds
1. NRS 411 Peds Clinical & Seminar Evaluation Tool
Student: Emily Tarrell Instructor: Erika Bourdeaux Advisor: Taylor Garcia/Katie Selle
Semester: Summer I
Course Description: (Revised 12/13) Clinical course focused on nursing care of pediatric clients in an acute care setting. The course is designed to further develop the necessary
skills for baccalaureate generalist nursing practice including an introduction to patient safety, quality improvement, and information management. Continued development and
application of professional practice standards are addressed.
Student Signature: ______________________________________________
I am willing to have subsequent clinical instructors review this evaluation for the purpose of promoting my learning in future clinical experiences.
Course assignments are designed to allow students to demonstrate the knowledge and behaviors essential to meet each clinical objective and succeed in the course. The
interdependent nature of the objectives precludes having any one assignment sufficiently correlate with or measure student progress. Instructor ratings and comments on the
various assignments, do however serve to document the student’s growth and areas for development. Ratings of – or + should be supported with comments.
Each critical behavior is considered essential and must be satisfactorily demonstrated to pass the course. Passing the course includes satisfactory completion of all the
assignments.
Evaluation Standards
Meets the standard Fails to meet the standard
• Demonstrates expected behavior consistently.
• Initiates expected behaviors constantly.
• Requests assistance as needed and appropriate.
• Rarely requires reminders to demonstrate
expected behavior.
• Demonstrates competence in expected behavior.
• Performance improves with practice and
experience.
• Consistently solves routine problems.
• Demonstrates expected behavior only occasionally or inconsistently.
• Requires promoting or reminders from others to initiate executed behaviors.
• Requires assistance from others to demonstrate the behavior.
• Seldom initiates expected behavior.
• Performs expected behavior inaccurately or incompletely.
• Makes errors in performance and/or judgment, or would make errors without the intervention of others.
• Does not recognize need for assistance and/or does not request assistance when needed.
• Performance is not significantly improved with practice and experience.
• Often fails to solve simple problems or make routine clinical decisions.
2. • Makes accurate clinical decisions in routine
situations.
Essential II. Apply skills in
leadership, quality
improvement, and patient
safety to provide high
quality health care in a
systems environment.
Competencies:
1) Apply leadership concepts, skills, and decision making in the provision of high quality nursing care, healthcare team coordination, and the
oversight and accountability for care delivery in a variety of settings.
2) Participate in quality and patient safety initiatives, recognize that these are complex system issues, which involve individuals, families,
groups, communities, populations, and other members of the healthcare team
Evaluated by: Date Comments
Competency 1
1) As demonstrated by advocating for
patient.
6-6-2015 As the SN, I spend the greatest amount of time with my patient. I communicate throughout the day with my nurse
as I begin to notice slight changes in her affect. As the condition worsens, I call for extra help and the
neurosurgeon comes to assess the patient.
(+) This student used critical thinking, recognized a change in patient behavior and demonstrated patient
advocacy during a specific emergent situation. She took control of the situation and acted appropriately by
calling for her primary nurse and staying with the patient and family until the situation was stabilized. The
student was open to discussion when finalizing decisions and updated staff on patient progress.
2) As demonstrated by taking initiative
of patient’s care and approaching
instructor/nurse for direct nursing care
actions (ex. giving meds).
6-3-2015 I approach Professor B, as well as Tracy (RN), to discuss the POC. I collaborate with my nurse and verbalize which
medications prepare to administer. I use the SBAR process to communicate with my nurse my assessment for the
day, as well as my recommendation for the evening shift. For example, “SG’s temperature has been rising steadily
throughout the shift, I recommend frequent temperature checks throughout the evening shift.”
(+) This student demonstrated taking initiative in patient care on several occasions by consulting her
instructor/nurse regarding direct nursing care actions and followed through with the action independently.
3) As demonstrated by approaching
instructor or nursing staff with question
regarding patient. Student should have
6-3-2015 I prep my medications for the day regarding patient, SG. I know the proper dosage, safe dosage, and reason for
administration. I take the initiative to approach Professor B, as well as my RN, to discuss the reason for
administering Wellbutrin. I am prepared to discuss its effects as an antidepressant, as well as alternate uses, such
3. some knowledge base about topic prior
to asking question.
as ADHD. However, the medical history does not show either diagnoses. We discuss how this may be a home
medication in order to treat his anxiety.
(+) This student approached the instructor throughout the clinical to clarify patient information,
documentation, medications, and procedures.
Competency 2
1) As demonstrated by initiating or
upholding patient safety precautions.
6-3-2015 My patient is a high-fall risk due to his history of Ewing’s sarcoma and present infection in his left lower extremity.
Activity orders only allow touchdown movement, no weight-bearing activities. I take extra precautions while
adjusting and repositioning my patient, helping him stand, and assisting with the urinal. We use appropriate
devices, like the walker, to get SG standing steadily to void properly.
2) Safe medication administration.
Including passing the pediatric
medication quiz.
3-31-2015 Peds Med Quiz. Pass - I completed the pediatric medication quiz during the theory course prior to the clinical
experience.
3) Uses optimal judgment in safety for
pediatric patients.
6-6-2015 My patient is very unsteady throughout the shift. I make the decision to always transfer with two medical
personnel instead of with her mother due to safety concerns regarding her care.
4) Discuss potential and actual impact of
national patient safety resources,
initiatives and regulations. Discuss
current patient safety initiatives that
the unit is working on.
6-6-2015 In our post-conference discussion, I relay the impact of safety resources to my classmates regarding AFCH’s QI
about pain control in pediatrics. I find a presentation from the nursing staff that presents current standards, new
discussions, and future goals for the unit.
5) Seek information about outcomes of
care for populations served in care
setting
6-10-2015 I am interested in the two cases I observe in the sedation clinic. I try to ask as many questions as possible, and I
learn about the preparation for an MRI as it is performed on a six month old. I am able to watch a VCUG for an
eleven year old.
6) Communicate observations or
concerns related to hazards and errors
to patients, families and the health care
team.
6-6-2015 As mentioned in Competency 1, I use the SBAR method of communication to describe the concerns I have
regarding my patient’s differing behavior throughout the shift. At first, the nurse and I are concerned that the child
is having a bad reaction to her pain medication, Morphine. We try a different method of pain management in
order to see if this helps with her CNS changes.
7) Describe factors that create a culture 6-3-2015 I am aware of the policies on the unit, which allow parents to administer the medication to their children. After
4. of safety (such as, open communication
strategies and organizational error
reporting systems)
scanning in an order of Lactulose, my patient’s mother decides to wait for administration. I relay the information
to Professor B, as well as my assigned nurse in order to maintain appropriate medication administration. I strive to
promote safety for my patient by communicating with my nurse all of the medications I have administered as the
shift progresses.
5. Essential III: Translate
current evidence into the
practice of nursing.
Competency:
Participate in the process of retrieval, appraisal, and synthesis of evidence in collaboration with other members of the healthcare team
to improve patient outcomes
Evaluated by: Date Comments
1) Address in weekly assignment,
weekly clinical preps, 3 clinical
assignments, and care plans.
6-11-2015 Physical Assessment Assignment (in APA format) submitted 6-11-2015
(+) Completed on time with a passing grade
Development Assignment (in APA format) submitted 6-11-2015
(+) Completed on time with a passing grade
2) Participate effectively in
appropriate data collection and other
research activities and share in pre
and post conference discussions.
6-3-2015
through
6-12-2015
Each day I arrive on the unit prepared to work. I gather information pertinent to my patient for the day. I
communicate effectively with my classmates throughout the day, and I share information regarding new procedures
and treatments in post-conference.
(+) This student was prepared to contribute to post conference discussions including high/low of the day
SBAR patient hand off and any off site experiences.
3) Base individualized care plan on
patient values, clinical expertise and
evidence
6-3-2015
through
6-12-2015
Care plan 1 : 7(revised) 6-3-2015
Care plan 2: 8 (revised) 6-5-2015
Care plan 3: 9 (revised) 6-6-2015
(+) This student utilized instructor feedback to improve her assignments. She demonstrated increased
analytical skills and an upward progression in her scores over the over clinical rotation.
4) Weekly writing assignments/off
unit assignments that demonstrate
increasing analytical skills and
increasing depth of inquiry.
6-11-2015 Weekly assignments/off unit write-ups completed __X__
(+) Completed all submissions on time with a passing grade
I submitted my written assignment from my experience at the sedation clinic 6-10-2015
5) Describe how the strength and
relevance of available evidence
6-6-2015 I research the current practices of pain control in pediatrics on the unit and relay the message to my classmates
during post conference. This QI reveal a current council project in an effort to reduce the number of “pokes” per
6. influences the choice of interventions
in provision of patient-centered care
child per hospital stay. Trying to reduce pain in this population includes a new discussion for the unit. New methods
include ice packs, increased documentation, RNs’ ability to order emla cream, and PCAs for patients.
(+) This student was prepared to contribute to the quality initiative discussion in post conference presenting
relevant research and data on their chosen initiative at AFCH.
6) Participates in first simulation
session at the CHES to demonstrate
assessment skills and translation of
simulation into practice.
5-19-2015 The CHES experience was successfully completed prior to the clinical at AFCH.
7) Participates in the second
simulation session to demonstrate
increased pediatric knowledge in
clinical judgment planning &
implementing during a scenario and
evaluating outcomes of care during
debriefing sessions.
6-2-2015 The second simulation at the Edgewood College Monroe Street campus was successfully completed prior to the
clinical at AFCH.
Essential IV: Demonstrate
knowledge and skills in
information management
and patient care technology
Competencies:
1) Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients’ right to privacy
2) Use standardized terminology in a care environment that reflects nursing’s unique contribution to patient outcomes
Evaluated by: Date Comments
Competency 1
1) Uphold HIPPA policies regarding use
of a patient’s electronic medical
record.
6-3-2015
through
6-12-2015
I log off of the computers when I am done reviewing the EMR at AFCH. I refer to my patients by initials as I write
down information regarding their diagnosis and POC. I do not discuss patients using any identifiers, and I control
conversations to appropriate locations within the hospital.
2) Does not discuss patient information
in inappropriate settings. Including
6-3-2015
through
As aforementioned, I limit what is said about patients. This includes discussing them in inappropriate settings. I do
not use identifiers if the report needs to be discussed in the hallway. Additionally, I only reveal patient information
7. information that may appear through
the use of social media.
6-12-2015 with family members, after reviewing who is legally able to receive private information on the EMR.
3) Complete clinical organization Epic
Charting course/training.
May 2015 This Epic training was completed by my cohort during the second Spring session. It was verified before the summer
clinical began.
Competency 2
1) Comprehension of the unique health
care needs of pediatric patients and
national safety concerns regarding
appropriate care of the pediatric
patient within a technological health
care setting.
6-3-2015 I am aware that my patient is in an immunosuppressed state due to his history of cancer, as well as any residual
effects of his ten months of chemotherapy treatment. Due to the infection in his leg, his mobility is very limited. In
order to prevent pneumonia, or any other hospital acquired illness, I encourage SG to use the incentive spirometer
every hour when I check in. Also, I maintain clean and clear pathways in his room for he is a high fall risk patient.
Additionally, I keep his belonging close to him on the side table, and I ensure that his call light is within reach at all
times.
2) Competent use and appropriate
application of all bedside technology
systems (blood glucose meter, pulse
oximetry, bladder scan, volumetric IV
pumps, secured drug dispensation
system) and interpretation/use of data
in pediatric reference ranges.
6-3-2015 Professor B and I review the location of all the beside technology systems in order to take vital signs and make an
assessment as soon as possible when I come onto the floor. Prior to vital signs, I review the appropriate ranges for
the pediatric population, and anything that may be suitable for his height and weight.
(+) This student took the initiative to familiarize herself with bedside technology at this institution by asking the
instructor to personally review the equipment with her on the first day.
3) Appropriately documents in
computerized information system.
6-3-2015 I appropriate chart the necessary information regarding my first patient-VS and pediatric assessment q 4 hours,
Respiratory assessment and Sedation level q 2 hours, I/O q 8 hours.
4) Uses appropriate strategies to
reduce reliance on memory (such as
checklists)
6-3-2015 Regarding above assessments, I mark the times I need to complete each assessment and have my documentation
into Epic as soon as possible thereafter.
5) Able to delineate the benefits &
limitations of selected safety-
enhancing technologies (such as
barcodes, computer provider order
6-3-2015 I make sure to scan his wrist band prior to any administration of medications, and I go through the 6 R’s as I obtain
each medication from the med room. I am able to see the pharmacists during rounds, and I observe the
entry/confirmation of a new medication as it is ordered for SG.
9. Essential VI. Perform
communication and
collaboration skills consistent
with professional standards
when working in
interprofessional settings to
improve health services
Competencies:
1) Demonstrate appropriate teambuilding and collaborative strategies when working with interprofessional teams
Evaluated by: Date Comments
1) Initiates relationship building with
client, unit staff and other healthcare
professionals
6-3-2015 I quickly build rapport with my 16 yo male client, by sitting with him for an hour after his mother leaves for work.
We discuss his interests and hobbies, education, family his reaction to the hospital stay, and all of the emotional
responses to these factors.
2) As demonstrated by attending
multidisciplinary rounds on patient.
6-3-2015 I stay near my patient’s room and try to be involved in every meeting with all personnel within my patient’s IDT. I
hear from orthopedics, his pediatrician, the medical attending, pharmacy, as well as his primary nurse.
3) Participates in interprofessional
collaboration through shift-shift report.
(Using and documenting with the SBAR
processes)
6-3-2015 I write my first SBAR note as my daily shift summary report, and I communicate this to my nurse before signing off
for the day.
(+) This student reviewed her SBAR nursing shift summary note with the instructor each clinical day before singing it
and reporting off the floor using the SBAR process.
4) Arrives at resolutions to conflict
through brainstorming, questioning,
active listening or negotiation.
6-6-2015 I am able to provide care for a patient on P4 two days in a row. Therefore, I was able to see the changes in her
behavior as she travelled from the unit, to OR, PACU, PICU, and back to P4. As I start to question changes in affect, I
brainstorm that the patient may be experiencing absence seizures and relay the message to my nurse who agrees to
bring in neurosurgery.
5) Involves the client in decision-making. 6-3-2015 My client is in a lot of pain, and I allow him to guide the transition process in order to get him up to void. I ask him to
rate his pain in bed, as well as in the standing position. I allow him to guide the time it takes to move through each
position.
10. 6) Uses developmentally appropriate
communication strategies with patients
and families. Communicates effectively
using verbal and nonverbal techniques
6-3-2015 My patient is able to communicate well for his age. At 16, I treat him like an adult, rather than a child, like he sees a
lot on this unit. As a teenager, individuality is very important. Therefore, I try to incorporate this aspect into his care
throughout the day.
7)Participates in SBAR exercise to
practice communication strategies
6-2-2015 At the Edgewood Monroe Street campus, my cohort goes through three simulations. My last unit was the SBAR
practice. I successfully communicate various examples to my classmates in preparation for this clinical.
Essential VIII:
1)Integrate professional
standards of moral, ethical
and legal conduct in nursing
practice.
2)Formulate a personal
professional practice model
that addresses
accountability, continuous
professional engagement &
lifelong learning.
Competencies:
1) Demonstrate the professional standards of moral, ethical, and legal conduct
2) Assume accountability for personal and professional behaviors
3) Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession
4) Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional
boundaries with patients and families as well as among caregivers
5) Recognize the impact of attitudes, values, and expectations on the care of the very young, frail older adults, and other vulnerable
populations
6) Protect patient privacy and confidentiality of patient records and other privileged communication
7) Incorporate professional attitudes, values, & expectations on the care of the very young, frail older adults & other vulnerable populations.
Evaluated by: Date Comments
Competency 1
1) Will follow the Edgewood College
SON Code of Professional Conduct, as
it applies to the clinical unit.
6-3-2015
through
6-12-2015
My educational background at Edgewood College has allowed me to utilize the Dominican values throughout my
career as a nursing student. I strive to tie in each of the values to my relationships with my classmates, professors,
professional staff at clinical sites, and especially my patients.
Competency 2
1) Engage in self-evaluation on a
regular basis
6-3-2015
through
6-12-2015
Each day at post-conference I take the time to reflect upon my day in order to debrief and evaluate my performance
throughout the shift. My written assignments also reflect self-evaluation.
11. 2) Seeks constructive feedback
regarding one’s own practice
6-6-2015 I engage in discussion with my nurse after a situation with our shared patient. I am happy to hear that my nurse is
pleased with my critical thinking skills.
3) Takes action to achieve goals
identified during the evaluation
process
6-10-2015 I seek constructive criticism and feedback from Professor B on previous assignments, and I strive to make progress on
future assignments.
Competency 3
1) Will arrive at clinical with all pre-
clinical work completed.
6-3-2015
through
6-12-2015
I work ahead in order to prepare as much as possible. I worked diligently during the theory course in order to apply
that knowledge to the clinical experience. I am not afraid to admit my limitations, and I strive to research the
problems that I do not yet know.
2) Demonstrates energy, excitement
and a passion for quality work.
6-3-2015
through
6-12-2015
I come to AFCH each day eager to participate; I am an avid learner. I use my positivity to see each experience as an
opportunity to grow as a student, and as a nurse.
3) Willingly accepts mistakes by self
and others, thereby creating a culture
in which risk-taking is not only safe,
but expected.
6-3-2015
through
6-12-2015
Throughout the clinical experience, I have been open and honest about my work. I strive to provide the most
beneficial patient-centered care daily. Still, I am humbled by the idea that I am still a learner in this process. I try to
learn something new from every patient, each nurse I follow, and all experiences incorporated into this clinical.
Competency 4
1) Will arrive on time and
professionally dressed.
6-3-2015
through
6-12-2015
I follow the guidelines as presented in the Edgewood Code of Conduct, as well as the specifications listed on the course
syllabus. My scrub uniform is clean and pressed each day. My hair is pulled back, and I am ready to go each day when I
arrive at the hospital.
(+) This student consistently arrived on time wearing appropriate dress each clinical day.
2) Analyze differences in
communication style preferences
among patients and families, nurses
and other members of the health team
6-6-2015 I am disturbed by the attitude presented by my patient’s family. I notice that they use jokes and degradation in order
to communicate with my patient. I try to be a role model for positive reinforcement by playing games with the girl,
spending time with her, and giving compliments and encouragement throughout the shift.
3) Describe impact of own
communication style on others
6-3-2015 In post-conference, I reveal that I was nervous for my first patient interaction. I did not know if a 16 yo male would be
opposed to a young student nurse. I was so pleased to see that I quickly built rapport with him by making sure I saw
him as a person, not just another patient. I found ways to communicate with him in a way to make him feel like he
was in charge of the care I provided. By connecting with him, I was able to make him feel empowered in such a
12. difficult time.
4) Value the perspectives and
expertise of all health team members
6-3-2015
through
6-12-2015
I try to participate in each of the meetings, rounds, and discussions regarding each of my patients throughout the
clinical experience. I listen intently to each member of the healthcare team and I strive to provide appropriate nursing
care based on their recommendations.
5) Respect the centrality of the
patient/family as core members of any
health care team
6-3-2015 As aforementioned, I worked hard to build a professional relationship with my patient. I also tried to make his mother
feel as comfortable as possible. I knew that I had succeeded when she thanked Professor B for allowing me to work
with their family and all of the positivity I was able to bring into their day.
6) Recognizes the impact and values of
dealing with vulnerable populations by
demonstrating respect and completing
evaluations for guest presenters
speaking on pediatric topics.
5-28-2015 At the Monroe Street campus, I listen to all four guest presenters. I sit in the front row and actively engage in each
presenter. I complete evaluations for the presenters to utilize for future presentations. Additionally, I complete two
reviews and submit them prior to the due date.
Competency 5
1) Able to identify at risk populations
6-3-2015 I was able to adjust my POC due to my patient’s high fall risk. Additionally, I encouraged the incentive spirometer
several times throughout the day in order to keep his lungs open due to his lack of mobility.
(+)This student recognized their patient was at risk for various complications during the hospital stay and
implemented appropriate nursing actions on their shift to help decrease these risks.
2) Recognizes the pediatric population
as a highly influential group.
6-10-2015 I participate in the post-conference large group discussion regarding the influences of pediatrics, especially concerning
vulnerable populations like the hem/onc unit.
3) Completes 2 reviews of guest
speakers & topic based on
presentation and assigned article
5-28-2015 I wrote two guest speaker reviews prior to the clinical at AFCH, responding to the topics presented to our cohort at the
Edgewood College Monroe Street campus. Both of these papers were graded by Professor Patrick with passing rates.
For the pediatric topic, I chose to review the Bereavement Parents Panel.
(+) Completed on time with a passing grade
Competency 6
1) Follow HIPPA policies
6-3-2015 I log off of the computers when I am done reviewing the EMR at AFCH. I refer to my patients by initials as I write down
information regarding their diagnosis and POC. I do not discuss patients using any identifiers, and I control
conversations to appropriate locations within the hospital.
2) Will not take protected patient 6-3-2015 Like Essential IV, Competency 1 and 2, I only discuss patient information in pertinent situations while the location is
13. information off the unit appropriate. I do not discuss this information in any situation where the patient’s privacy could be at risk.
3) Maintain patient confidentiality
within legal and regulatory
parameters.
6-3-2015 In writing assignments, I refer to my patient by his initials. I discuss information with his mother and family friend after
confirming that these two individuals are granted release of information.
Competency 7
1) Use developmentally appropriate
and up to date patient education
when educating vulnerable
populations
6-10-2015 In the sedation clinic, I read an article regarding the art of distraction while providing mild, moderate, or deep
sedation. I put these tactics into practice as I follow my nurse for the day. Without a Child Life employee, I am able to
fulfill this role by distracting our patient during PIV placement.
Essential IX. Demonstrate knowledge
& skills in the care of patients,
including individuals, families, groups,
communities, and populations across
the lifespan and across the continuum
of healthcare environments.
Competencies:
1) Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship
2) Demonstrate the application of psychomotor skills for the efficient, safe, and compassionate delivery of patient care
3) Provide nursing care based on evidence that contributes to safe and high quality patient outcomes within healthcare
microsystems
4) Create a safe care environment that results in high quality patient outcomes
5) Revise the plan of care based on an ongoing evaluation of patient outcomes
6) Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the
healthcare team
7) Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health
literacy considerations to foster patient engagement in their care
8) Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and
promoting health across the lifespan
9) Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences
10) Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology,
pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all
healthcare settings
11) Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network
14. Evaluated by: Date Comments
Competency 1
1) As demonstrated in weekly post-conference
discussions and observations of clinical instructor
6-3-2015
through
6-12-2015
My goal during post-conference is to always create an open atmosphere for my classmates to share. I
talk honestly about my experiences, and I show support and encouragement for them as well.
Competency 2
1) As demonstrated in developmental assignment.
6-11-2015 My completed developmental assignment on Thursday, 6-11-2015, with its assigned rubric attached.
Competency 3
1) As demonstrated by proper documentation in
institutions EMR.
6-3-2015 I have minimal corrections to make on my first experience documenting on this unit. I have all of the
necessary information concluded prior to 1000. Throughout the rest of the shift, I require no reminders
for appropriate documentation.
Competency 4
1) As demonstrated by using proper protective
equipment and following proper patient isolation.
6-3-2015 As my patient receives a PICC line, I explain to him and his family what is meant by a sterile field. I
maintain aseptic technique as I provide comfort and reassurance throughout the placement.
Competency 5
1) Able to interpret physical exam and change care
accordingly
6-3-2015
through
6-12-2015
Each day, I make every effort to plan care around my patient’s circumstances. When I care for SG, I
focus on pain management. With JS, I aim to reduce her fall risk.
2) Able to interpret laboratory data and change care
accordingly.
6-6-2015 I carefully observe the lab results for nine month old, JV. We are looking for indicators of LL pneumonia.
A decrease in WBCs demonstrates less chance of infection. Therefore, we are able to begin pulling
together all of his discharge instructions.
Competency 6
1) As demonstrated by hand-off reporting for lunch
and end of shift
6-3-2015
through
6-12-2015
Each time I leave the floor, I utilize the SBAR technique to effectively communicate with Professor B and
other members of the nursing staff.
Competency 7
1) As demonstrated in post-conference discussions
and observation of clinical instructor
6-3-2015
through
6-12-2015
In post-conference, I successfully communicate the techniques I have used for patient teaching. I have
care for developmentally appropriate and developmentally delayed patients. I share how I adjusted my
care in each circumstance.
Competency 8 6-3-2015 I wrote and revised three passing care plans, completed 6-3-2015, 6-5-2015, 6-6-2015
15. 1) As evidenced by Care Plan assignments through
6-12-2015
Competency 9
1) Respects family/patient preferences
6-6-2015 I have two different patients due to low census, a discharge, and an admission back to the unit. I
recognize the differences between family preferences and I discuss them in post-conference.
2) Integrate understanding of multiple dimensions of
patient centered care:
· patient/family/community preferences, values
· coordination and integration of care
· information, communication, and education
· physical comfort and emotional support
· involvement of family and friends
· transition and continuity
6-10-2015 In large group, I talk about the different behaviors I have observed over the past week. I share my
experiences, and I support my friends as they discuss their observations. I understand the severity of
the stress placed on these families living with children suffering chronic illness. I strive to provide care
for my patients, as well as their families, and I admit when I have difficulty with withdrawn families as I
see its effect on the children.
3) Describe how diverse cultural, ethnic and social
backgrounds function as sources of patient, family,
and community values
6-3-2015
through
6-12-2015
It is apparent to me which families cope with stress in healthy ways, and which let it consume them.
The culture of family has been such an interesting topic as we discuss the relationships between our
patients and their loved ones.
Competency 10
1) Provides holistic patient care
6-3-2015
through
6-12-2015
My goal throughout this entire process has been to provide the best care possible to the patients I have
had the privilege to serve. In that, I try to look at the entire care process, including multiple aspects of
the patient’s life in order to offer the most holistic care possible.
Competency 11
1) Includes all team members in patient’s care
6-3-2015
through
6-12-2015
I have enjoyed learning about the dynamics incorporated at AFCH. I love working as a cohesive
member of the interdisciplinary team, and I work to include all members, opinions, and beliefs into my
care in a respectfully and care way.
Competencies that began prior to NRS 411 and continue throughout the entire program will be indicated by an *