course materials

1. Discussion:Clinical Performance Assessment
Discussion:Clinical Performance Assessment ON Discussion:Clinical Performance
AssessmentHello. This is a nursing course. I need a detail care plan write up for my virtual
patient as notified in the case study document. I need you to be creative in doing your
assessment. My professor will not mind you creating assessment information to use in the
care plan as long as the information makes sense and is chronological. You will have to
assess the mom and the new born and write out 3 priority nursing diagnoses each for mom
and baby. Making a total of 6 priority nursing diagnoses (including R/T and AEB). Now, as
you feel the Care plan template, you will chose one nursing diagnosis for mom and write
long term and short term goals, write 5 intervention and 5 rationales. Do the same thing for
the baby. make sure you do in-text citations and references. Do well to answer every
question that in the care plan. When you’re done send me back the filled template with the
responses. Discussion:Clinical Performance AssessmentCLINICAL
PERFORMANCEASSESSMENT WORKSHEET Student Name: Rating Scale Date: ________________
Subscales Week ________ Comments Grade 1. ASSESSMENT- Gathered data on the
pathophysiology of the illness/disease, medications, culture/spiritual factors, and
nutritional status. Incorporated and interpreted new data correctly. Also, gathered
information regarding epidemiology & stratification as it applies to client. 2.
ANALYSIS/NURSING DIAGNOSIS – Formulated nursing diagnoses for actual & potential
health problems relating to health promotion behaviors, growth and development,
medications, nutrition, and cultural and spiritual awareness; prioritizes problems according
to clients’ needs. 3. Discussion:Clinical Performance AssessmentPLAN/GOAL – Developed
client and family goals that promoted progression toward health. Goals are individualized
and SMART (Specific, Measurable, Attainable, Realistic, Time Frame) 4. INTERVENTIONS –
Nursing interventions are individualized for the client. Each intervention implements care
which reflects planning, organization & flexibility to meet client’s needs that promotes
standards of care and practice. 5. RATIONALE – Identified rationale for nursing actions that
the plan of care with current professional literature and research findings. Has significant
and complete information regarding health promotion, growth and development,
pathophysiology of the illness/disease, medications, nutrition, and treatments; calculates
dosage, knows appropriate sites for drug administration, and calculates IV drip rates
correctly (if applicable).6. EVALUATION – Facilitated alteration of care plan to reflect
evaluation of client’s progress toward goals; evaluates effectiveness of specific
interventions; evaluates ways to maintain standards of care & practice; evaluates criteria

2. that are congruent with clients’ health goals. Applies concepts of health promotion &
dimensions of health when evaluating care & client outcomes. Reflections of own
performance demonstrates self awareness and identifies areas for growth as well as reflects
systematic movement to meet course learning objectives . 7. NURSING SKILLS – Performed
skills safely & correctly at reasonable speed; adapts to changes from learned sequence;
organizes equipment & supplies involved in client care; recognizes obvious breaks in
technique. Efficient in use of technology for client care. Demonstrates use of Presence to
promote health and healing. 8. COMMUNICATION – Reported & documented medications,
procedures, treatments & changes in client’s condition & client responses to care &
interventions. Effectively communicated with clients, staff, & faculty.Maintained
confidentiality & adherence to information management policies. 9. PROFESSIONALISM –
Prepared to give safe care; adhered to policies & reported own errors; assumed
responsibility for maintaining safety; took extra precautions to maintain client’s
confidentiality; used appropriate channels to promote a high level of care for the client;
selected learning experiences which require additional preparation; demonstrated prudent
judgment in unfamiliar situations; was punctual; maintained a professional appearance;
promoted the client’s welfare & upheld dignity & professional boundaries; reflected
consideration of cultural and spiritual differences when interacting with clients & members
of the interdisciplinary team. 10.INTERPERSONAL RELATIONSHIPS – Used communication
skills in therapeutic relations; adapted communication to client’s developmental level;
promoted positive group & learning activities & staff relations; was able to accurately assess
own abilities & began to plan for growth in self.. Reflected consideration of cultural and
spiritual differences when interacting with clients & members of the interdisciplinary team.
KEY: F= Failing (1); MI = Must Improve (2); A=Acceptable (3); C=Commendable (4); and
E=Excellent (5) Houston Baptist University NURS 4434 Care of Childbearing Family
Postpartum Care Worksheet Student Name Date of Care Pt Initials Rm# Age GTPAL after
delivery Allergies Diet Marital Status Current Wt. Birth Wt Gender M/F Delivery Date &
Time Vaginal/CS Test and result/date Blood type Rh factor Antibody screen Hgb Hct WBCs
Platelets EDC Wks. Gestation Pre-pregnant Wt. Breast/Bottle Baby’s Blood type Test and
result/date Rubella HIV RPR/VDRL HbSAg Gonorrhea Chlamydia GBS Interpretation of
abnormal lab results: Rhogam Needed? Given? Brief Pregnancy history. Feelings about
pregnancy. Family configuration. (prior obstetric history. Brief Labor History (if C-Section,
why?).Present Postpartum history, including level of Activity. Vital Signs Date Time Temp
Treatment for pain & time: Pulse Respirations BP Pain 0/10 Site Reassessment of pain
(Time and Results) Physical Assessment (BUBBLE – HEE) Breasts Nipples (condition,
secretion) Abdominal Incision (color, discharge, approximation) Fundus (consistency,
height, position) Bowel (sounds, flatus, stool) Hemorrhoids Urinary Elimination Signs of UTI
Costovertebral Angle Tenderness Lochia (type, amount) Perineum/Episiotomy (REEDA)
Signs of Thrombophlebitis (redness, swelling, warmth, or pain) Edema (site, extent)
Emotions (explain evidence of (+) or (-) bonding) Teaching Needs: What is your patient’s
culture and what information did you learn about the patient’s culture to assist you in
delivering culturally competent care? Infant Intake and Output: Time: Type of Feeding
Amount or # of Minutes Voids Stools Newborn Assessment: Male/Female Apgar’s: 1 min

3. _______ 5 min _______ Put an X by the ones that apply ACTIVITY: Quiet Alert/Active Sleeping
Lethargic TONE: Normal Jittery Hypo/Hyper Reflexes (+) CRY: Strong Weak High-pitched
COLOR: Pink Pale Acrocyanosis Jaundiced Meconium stained Mottled SKIN: Warm
Additional Notes when needed: Bruising Cool Petechiae Newborn Rash HEAD: Fontanel
Soft/Flat Other Skull molded Caput/Cephalohematoma Forcep marks/Abrasions EYES:
Clear Other CHEST: Breath Sounds Clear/Equal Decreased R/L Rales/Rhonchi Grunting
Nasal Flaring Retractions Mild/Moderate Heart Sounds Regular/Irregular Murmur (-)
absent / (+) present Vital Signs: T______ P______ R______ ABDOMEN Soft Distended Bowel
Sounds (-) absent / (+) present GENITOURINARY (Circle the one that applies) Male testes
descended/undescended Female normal/discharge Prioritized Problem List/Nursing
Diagnoses, R/T and AEB: (two for Mom and one for baby): This section is for any additional
evaluation of yourself that you may want to share with the instructor Nursing Skills:
Strengths: Opportunities for Improvement: Comments: Initial Assessment Data r/t Priority
Nursing Dx: For the MOM Rationale for Nursing Dx #1: 1. 2. Highest Priority Nursing Dx: 3.
4. Plan: Short Term/ Long Term Goal: 5.Interventions: Evaluation: 1. 2. 3. 4. Skills Used for
this Nursing Dx: 5. Explore potential Legal/Ethical Issues r/t caring for patient: Safety
Concerns when caring for this patient: Rationale for Nursing Dx #1: Initial Assessment Data
r/t Priority Nursing Dx: for the BABY 1. 2. 3. Highest Priority Nursing Dx: 4. Plan: Short
Term/ Long Term Goal: 5. Interventions: Evaluation: 1. 2. 3. Skills Used for this Nursing Dx:
4. 5. Explore potential Legal/Ethical Issues r/t caring for patient: Safety Concerns when
caring for this patient: Houston Baptist University NURS 4434 SCHEDULED MEDICATION
WORKSHEET Student __________________________________ Date______________________________ Unit &
Room ______________________________ Drug Name Class/Action (Generic & Trade Name) Side
Effects Dose/ Route Recmd dose Rationale for your Patient Frequency & Times Military
Time You Will Give Lab values/ Nursing implications Week 3 Pospartum Case Study V/S (q6
hr)136/77, 88 131/66, 84 Weight = 220 pounds Mother gave birth a few hours ago by
cesarean section. Mother and baby did well during her stay. Baby breastfeed well,
appropriate wet and dirty dippers. Mother had some pain due to her c/s. What
interventions would you do for laceration? Baby is LGA needs 3 glucose checks >45. Baby
also got circumcision. Mother and baby went home in 42 hours. Care plan for mother and
baby. Prioritize Nursing diagnosis (including R/T and AEB) 3 for both mother and baby. Cite
where you got this information. NB – Professor needs 3 priority nursing diagnoses for Mom
(including R/T and AEB) And 3 priority nursing diagnoses for baby (including R/T and
AEB) Then, use one care plan with 2 of the 6 nursing diagnoses above and do interventions
for mom and baby …Purchase answer to see full attachment