Carroll Community College Division of STEM, Nursing and Allied Health Department of Nursing NURS 140/233 ‘Student Clinical Performance Evaluation - Summative Student: Ashley Jones Date (Term/Year) 2/2014 Location: Frederick Memorial Hospital. Faculty: Theresa Breitenbach ‘$= Satisfactory N=Needs Improvement U=Unsalisfactory _(") Denotes critical behaviors, ‘Students who meet any of the following criteria will be given a remediation plan 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 @ critical behavior = _ Two unsatisfactory grades in a non-critical behavior __- Four needs improvements in non-critical behaviors Integrating Concept: Context and Environment 7 Te ‘Outcome 1: Identifies policies, procedures, safety concems, patient characteristics, and | studore: | "Eval teamwork within the organizational structure, with assistance. (POIRNLG 2: Nursing Judgment, | selttval | student | POIRNLG 4: Spirit of Inquiry) SINU | SINIU “Maintains ethical accountability for nursing practice in accordance with the ANA Code of Ethics. | Ss js “Maintains legal accountability for nursing practice in accordance with the Maryland Nurse Practice Act. Ss s *Adheres to HIPAA guidelines regarding patient confidentiallty. Los s Demonstrates the role of the nurse as patient advocate. S20). 6. Integrating Concept: Knowledge and Science B AGERE Outcome 2: Identifies knowledge from nursing science and allied health disciplines to begin ‘seca | eoane designing and implementing patient centered care for fiduals, families, and communities, with | Self-eval | Student assistance. (PO/RNLG: 2 Nursing Judgment, POIRNLG: 4 Spirit of Inquiry) SINIU | SINIU Collects evidence related to lnical practice from appropriate resources. 3 Ss Integrates knowiedge of evidence based theory from nursing and other disciplines to plan care s s Demonstrates accurate and holistic pationt assessment skils ss Establishes appropriate nursing diagnoses based on patient assessment. Ss. s Determines patient specific etiology related to nursing diagnoses. s s Determines patient specific signs and symptoms related to nursing diagnoses. _ Ss s Determines patient specific outcomes for nursing diagnoses. 8. Ss Determines patient specific interventions for nursing diagnoses and outcome(s) _s Em Implements care according to established pian and desired outcomes. = s Ss Evaluates patient response to care and revises plan as needed. s s intograting Concept: Personal and Professional Developmont ‘sudan | BuSOr ‘Outcome 3: Identifies the need for the lifelong process of learning nursing skills, values, and ‘Self-Eval | Student: behaviors, with assistance. (PO/RNLG: 3 Professional identity, POIRNLG: 4 Spirit of Inquiry) | smvu_| “smu Discusses patient's plan of care with instructor. S$ s Completes assignments as required and submits on time ~ S $ Organizes time efficiently. e s s Demonstrates professional appearance and demeanor. : s s Engages in self-reflection and communicates learning needs to instructor. Ss. s 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 ‘ices members of the health care system through system effectiveness and individual practice, with ‘shine teas or assistance. (PO/RNLG: 1 Human Flourishing, POIRNLG 2: Nursing Judgment, POIRNLG 4: Spirit | seireval | sudent of Inquiry) SINU | SIN “Provides safe care according to established standards of nursing practice. Prioritizes patient care based on assessment. Readily incorporates technology into clinical practice: “Observes infection control precautions, Demonstrates accountabilly and responsiblity for own actions and altitudes, “Demonstrates knowledge of medications for assigned patients. : | “Administers medication safely using six rights of medication administration | co | co} cn|ca| N140_N233 Clinical Eval 1724/2014Carroll Community College Division of STEM; Nursing and Allied Health Department of Nursing : NURS 140/233 Integrating Concept: Relationship Centered Care = Outcome & Recognizes that nursing ls pat of a collaborative interdiccipiary team which provides holistic care.to individual, family, community, and:team relationships through the use of therapeutic communication, with assistance: (PO/RNLG: 1 Human Flourishing, POIRNLG: 3 Professional Identity) Demonstrates ably to develop and maintain therapeutic relalionships with diverse populations “Respects patients’ rights with regard to their dignity anc: human worth: Identifies patient/family health education needs and implements patient teaching. Documents patient care accurately and in.a timely manner using the written or electronic health record. ‘Applies therapeutic communications skis Antegrating Concept: Teamwork: Pee s ss leat Gutcome 6: Recognizes the Importance of affective. oniimunicauoet ane rautual feapoct Wile! Seisene | eee _ working with all members ofthe health care team: with assistance. (POIRNLG: $ Professional. | seeval | Stic Identity) ea INU: | SIN) Dertonstates inilative in assisting peers and healthcare team. members inthe cinical satin, s Ss ‘Seeks input from patient; instructor, peers, and-healthcaré team in the delivery of patient care: Ss s siructor and healthcare team regarding changes in the patient's condition ira'timely manner: | ~_S. s 3s professional communication skills using SBAR. s ctvely ir all aspects of the clinical experience. s ‘Student Reflection- Looking back on the rotatio How have you grown ag a nurse? Please explain and use specific examples, {really enjoyed this experience and the'amount of involvement | was able-to participate in. | also liked the knowledge I have gained and the amount of critical thinking the teacher put me through in order fo make me think like a nurse. Do you have any continuing concems about your performance? Please explain. | would just ike to be able to be more comfortable with engaging in-patient care in unknown/diferent environments. Faculty Comments/ Student Learni clarify student performance™) ‘Ashly had the-opportunity to care for pationts both on the in-pationt and ER sides of the unit. Because her patient was a fres, post-op, she prepared herseif to identify the possible risks and complications from his diagnosis/surgety. She'performed av detailed post-op assessment and frequent re-assessments to monitor her patient's progress:. Appropriate nursing diagnoses ‘were made aldng with a:plan of care’and teaching needs: ‘Stie had multiple opportunities to administer medications safely (F IM, 1V fluid maintenance). While in the ER, Ashley interacted! with’ many différent patient populations, adjusting-her approach to the developmental leve her patient and their family: She was quick to Identify abnormal values and report thein t6 the appropriate members of the pediatric staff She wa’ very eager to learn new skills and-offer help to the:nurses on the tinit.. When the patiert volume was low, Ashley was very engaged in conversations of different diagnoses, interpreting lab values and identifying the appropriate nursing care: ig Goals (“if an item was identified-as Nor U, narrative comments are necessary Student Signature:. Ashley Jones __ Date: 11/24/2014 Instructor Signature: Theresa Breitenbach; RNC, BSN Date: 11/22/14. N140,N239 Clnial Eyal 112472014