Carroll Community College Division of STEM, Nursing and Allied Health Department of Nursing NURS 133 Student Clinical Performance Evaluation - Weekly Student: Ashley Jones Date (Term/Year): May 9" (1/2014) CSE #:6 S = Satisfactory N= Needs Improverient _ U = Unsatisfactory () Denotes cilcal behaviors Students who meet any of the folowing criteria willbe given a remediation pian and may be placed on probation, Failure to progress in these areas may result in failure of the course. ~ One unsatisfactory grade in a critical behavior ~ Two needs improvements in a ertical behavior ~__Two unsatisfactory grades in a non-critical behavior_- Four needs improvements in non-critical behaviors Integrating Concept: Context and Environment ee Outcome 1: Identifies policies, procedures, safety concerns, patient charactetistics, and Instructor teamwork within the organizational structure, with coaching, (POIRNLG 2: Nursing Judgment, Sarva | Sweene POIRNLG 4: Spirit of Inquiry) SINU. | siNTU ‘Maintains ethical accountability for nursing practice in accordance with the ANA Code of Ethics Ss “Maintains legal accountability for nursing practice in accordance with the Maryland Nurse Practice Ack Ss Pa “Adheres to HIPAA quidelines regarding patient confidentiality s Identifies the role ofthe nurse as patient advocate s Integrating Concept: Knowledge and Science 7 Outcome 2: Identifies knowledge from nursing science and allied health disciplines to begin Student designing and implementing patient centered care for individuals, families, and communities, with | Swi, coaching. (POIRNLG: 2 Nursing Judgment, POIRNLG: 4 Spirit of Inquiry) ‘SINJU Collects evidence related to clinical practice from appropriate resources. Begins to integrate knowledge from nursing theory and other disciplines fo plan care. Demonstrates accurate and holistic patient assessment skills Establishes appropriate nursing diagnoses based on patient assessment Identifies patient specific etiology related to nursing diagnoses. ‘Identifies patient specific signs and symptoms related fo nursing diagnoses Identifies patient specific outcomes for nursing diagnoses. Identifies patient specific interventions for nursing diagnoses and outcome(@). Implements care according to established plan and desired outcomes, :2c2|00|c0| 9} 00 cn|en| eo Evaluates patient response to care and revises plan as needed. Integrating Concept: Personal and Professional Development. Student Outcome 3: Identifies the need for the lifelong process of learning nursing skills, values, and Soltval behaviors, with coaching. (POIRNLG: 3 Professional identity, POIRNLG: 4 Spirit of Inquiry) ‘SINIU instructor Evalof Studont SINU Discusses patient's plan of care with instructor. Completes assignments as required, ‘Organizes time efficiently. AN Demonstrates professional appearance and demeanor N Engages in self-reflection and communicates learning needs to instructor. jolojalo|en Integrating Concept: Quality and Safety Outcome 4: Identifies knowledge from nursing science and allied health disciplines to begin providing competent care based on current standards of practice to minimize risk of harm to all members of the health care system through system effectiveness and individual practice, with coaching. (POIRNLG: 1 Human Flourishing, POIRNLG 2: Nursing Judgment, POIRNLG 4: Spirit _of Inquiry) Provides safe care according to established standards of nursing practice Instructor Evalof Student Siu Prioriizes patient care based on assessment. Demonstrates beginning competency with technologies that contribute to safe “Observes infection control precautions. Identifies safety concems and notifies appropriate health team members. Demonstrates accountability and responsibilty for own actions and atlitudes. N13 Cincal Eval 6/12/2014 Reviewed 01/2013Carroll Community College Division of STEM, Nursing and Allied Health Department of Nursing NURS 133 i —- Integrating Concept: Relationship Centered Care Outcome &: Recognizes that nursing fs part of a collaborative nferdsciplinary team which 1 peccktoe provides holistic care to individual; family, community, and.team relationships through the use of |” student: | Eval of” therapeutic communication, with coaching: (PO/RNLG: 1 Human Flourishing, POIRNLG: 3 SeltEval | Student: Professional Identity) INU. |: SIN: Demonstrates abilty fo develop end maintain therapeutic relationships with diverse: populations s *Respects patients" fights with regard to their dignity and humanworth s Tdentifies patient/family health education needs and implements patient teaching = s ‘Documents patient care accurately and in-a timely mannerusing the written or electronic health recor S Demonstrates beginning therapeutic communications skis. ae § c Thtegrating Concept: Teamwork = f an Outgome 6: Recognizes the impottance of effective communication and mutual Le ‘when ‘Student: [eval ore working with all members ofthe health care team, with coaching. (PO/RNLG: 3 Professional Self-Eval: | Student Identity) [sin | siya Demonstrates infative in assisting peers and health care team members inthe dinicalsefing. ‘Seeks input from patient, instructor, peers, and healthcare team in the delivery of patient Gare. *Updates instructor and healthcare team reyarding changes'in the patients condition in a timely manfer: fi “Demonstrates professional communication skils using SBAR: in all aspects of the clinical experien: ‘Student Reflection: ; What did you loarn this week that has contributed to your growth as a nurse? Please explain: ‘This week I really only. feared: the importance of trying to'do the most leastinvasive measure anid exploring my options before doing the most cramati thing: Sometimes you have to just sit back and think before jumping fo an answer: When you have tied out all your other options then its okay to go after your last option, id you accomplish the objectives you and the instructor set for this. SE? Please explain. | feel like | successfully accomplished most of the objectives set, but not all: By using my. patient's report and background information | was able to better understand the scenario my patient was dealing with and gain a sense of what her current needs possibly were before | entered the room. | performed my safety chiecks as | walked in and explained why | was there, and asked for consent. When | entered the room my patient's O2sat was low so | administered 02 therapy. My patient's 02 was stil low so I taught incentive Soirometry and after taking a few breaths was-able to get her 02 level back up. | tried to encourage my patient to void but she was still unable to; at that time catheterization was needed and preformed: | did however, not compietely maintain sterile technique a few times during the:percedure, Do you have any concerns about your performance? Please.explain. Lethe a for once performed essentally wellin this performance minus breaking stele technique and tying to jump to the most dramatic measures. ‘Student Learning Goals (List desired learning goals for the next clinical simulation expetience. Goals should he based need to learn how to do-proper sterile technique during invasive measures and try to outweigh all my options wherr choosing my method of care. Faculty Comments/ Student Learning Goais (“If an item was identified as Noor U, narrative comments are necessary to, clarity student performance") F)shloy sig: dotny Well rity OGM \Z@y ha “Hire ond uxdoviod Opsestmok datas eth shots pew ia mokiny bow nye ns imlowartion (patos sport \lo} voy) tnonseyad in ‘cliniocl @ dimer Od dis ur bed Ob a Be Bee. ey Student Signature: Ashley Jones Date: May 9", 2014 aot ome aaeie A ke Sa pg N38 Clinical Eval 611212014 Reviewed: 01/2013,