Bay College West Associate Degree Nursing Program Clinical Evaluation |~ NURS 134 Student Name: Smith, Brenda Mae Clinical Instructor: _Dr. Joyel J. Brule Semester: Winter 2016 Clinical site: VANC Absence (s)_0, Tardy (s)_0. Profile i Threaded Concept Unsatisfactory | Satisfactory | Needs Improvement/Specifics Human Needs | Performs a comprehensive nursing assessment x | through analysis of assessment data, physical assessment data, lab and other diagnostic data Nursing Process | Evaluates for changes in health status and begins to x identify complex needs Cultural Integrates the impact of developmental, emotional, x Competence cultural, religious, and spiritual influences on health status ‘Nursing Process | Assesses for changes in health status and identifies, x appropriate actions ‘Nursing Process _| Analyzes patient’s response to interventions x ‘Nursing Process | Assess discharge needs and ability to access % community resources 2016-02-22 UB 1|PageNursing Process Evaluates patient's response to medications ‘Nursing Process | Recognizes trends ia lab data and takes appropriate nursing action Commu ‘Assesses patient/support person(s) earning ability, barriers, motivation to learn, and learning needs prior Cultural to teaching-learning Competence Communication Implements steps in the teaching process increasingly complex patients. Communication Participates in meeting goals toward discharge planning ‘Communication ‘Caring Interventions Implements and evaluates teaching to patient’s identified at risk for complications Integrates the steps of the nursing process, evidence: based practice, and critical thinking in patient care ‘Nursing Process Identifies pathophysiology of the medical surgical patient and relates to patient situation. 2016-02-22 JB 2|Pageconcise and clear manner to clients and healthcare team members Informatics Integrates evidence-based practice, collected through x technological resources and other modalities, in decision-making ‘Nursing Process With assistance, utilizes nursing process and critical x thinking to prioritize and organize care for one or | more patients Clinical Judgment | Follows existing care plan to provide for continuity of x care | Professional ‘Seeks guidance in evaluation of care regimen x Behavior outcomes Professional With supervision, provides safe, evidence-based care. x Behavior Profession ‘Communication | Integrates cultural sensitivity throughout the nursing x process | ‘Communication | Utilizes appropriate communication channels to x report relevant assessment data ‘Communication | Communicates relevant and complex information in a x 2016-02-22 4B. 3|Page| Clinical Judgment Reports medication side effects or medication inaccuracies to appropriate member of the health care team and instructor in a timely manner Communication Establishes therapeutic communication with patients ‘Communication Utilizes verbal and nonverbal communication skills while establishing caring relationships Informatics L Demonstrates intermediate computer literacy related to patient care. Nursing Process Demonstrates with minimal supervision the ability to perform procedures/skills based on facility guidelines Professional Behavior Establishes and maintains caring relationships with patient’s/support person(s). Clinical Judgement Safely administers medication with minimal supervision Nursing Process Evaluates patient response to medications Professional Behavior Maintains human dignity Clinical Judgement Provides developmentally appropriate nursing care 2016-02-22 IB 4|PageClinical Judgement | Evaluates for physiological & psychological safety of x patients Glinical Judgement | Functions as a patient advocate x Nursing Process | Implements complex nursing interventions based x | upon patient assessment Profession Professional ‘Accepts ethical/legal responsibility for own actions as x Behavior expressed in ANA Code of Nursing Professional Demonstrates self-reflection by: x | Behavior Examining own ideas, feelings, and behaviors Recognizing and accepting learning opportunity Professional ‘Accepts responsibility for nursing care given by self 1x Behavior Professional Maintains confidentiality of all healthcare x Behavior information Professional Functions, with minimal supervision, in the role of a x | - Behavior professional nurse as a member of the healthcare team. 2016-02-22 UB 5|PageProfessional Behavior ‘Accurately documents nursing cares and procedures Professional Utilizes self-reflection for continued growth in Behavior nursing practice, Professional Demonstrates personal responsibility by: | Behavior Arriving on time Informing both school and agency of absence/tardiness ‘Adhering to school and agency dress code Following Student Handbook guidelines Professional Demonstrates honesty inz Behavior Documentation Performance of skills (meds, treatments, etc) Interaction with others Clinical paperwork Collaboration Identifies and recognizes roles and responsibilities of members of the health care team and collaborates with the team effectively Professional Behavior Collaborates with patient/family in setting goals and evaluation ‘Managing Care Provides evidence-based, cost effective patient care 2016-02-22 JB 6|PageInformatics Utilizes appropriate technology in provision of care x Managing Care Recognizes aspects of safe/unsafe environment x Managing Care | Provides patient-centered nursing care x Professional Demonstrates beginning level of patient, x Behavior management, leadership, and organizational skills by: appropriate delegation, accepting responsibility and accountability for own actions, accepting. | accountability and responsibility for delegated nursing actions. Professional With supervision, accepts legal/ethical responsibility x Behavior for nursing care. Follows agency policy and procedures, functions within legal scope of a nursing student, shares pertinent information with agency staff and instructor Managing Care _| Promotes the rehabilitation potential of the patient x Managing Care | Maintains environment that supports patient x independence Additional Comments: Concept Map (Circle) #1 Pass Fail #2 Pass Fail #3 Pass Fail Dosage calculation quiz (Circle) #1 Pa Fail #2 PSB ral ‘Teaching and Discharge Plan (Circle) Pass Fail 2016-02-22 UB 7|PageIhave reviewed the contents of this evaluation and fully understand its implications. Fall Clinjeg Contract (tach t Evaluation) Dring dith vate A/44/ A/G Clinical Instructor Signature: Wt Dek Muh vate_2-23-20/6 Additional Comments? Performs care safely with direct supervision Can state an is aware of some purposes, rationale and precautions R/T care of assigned patients Requires no supervision to safely perform care after given instruction/ demonstration Approaches care in a systematic, organized way S| Performs care correctly according to poi rotoco time required ony stl longer thangaperenced peso) ‘Can state and is aware ot purpose, rationale and precautions R/T care of assigned patients Successfully performs care without formal instruction/ demonstration ces without losing control of situation \ Adapts to unexpected occurrences —_— —__ a Performs care correctly according to established policy/protocol in timely manner with accuracy and safety Can evaluate the effectiveness of the not ote prongems SX Proposes alternate methods/techniques to improve care/ performance F Performs care correctiy in a spontaneous way without hesitation Incorporates the whole picture in evaluating care/ outcome on patient 2016-02-22 1B 8|Page