x Carroll Community College Division of STEM, Nursing and Allied Health Department of Nursing NURS 140 - Nursing Concepts 2 ‘Student Clinical Performance Evaluation - SUMMATIVE ‘Student _Alex Mace Date 4/5/16 Location UMH Faculty _Chris Henyon 'S = Satisfactory _[ N= Needs Improvement | U = Unsatisfactory | N/A = Not applicable | (*) Critical behavior Failure to progress in these areas may result in failure of the course. -One unsatisfactory grade in a critical behavior -Two needs improvements -Two unsatisfactory grades in a non-critical behavior __-Four needs improvements. a critical behavior Students who meet any of the following criteria will be given a remediation pian and may be placed on probation. ‘Student | Instructor Outcome 1 Solf- | Eval of Apply the nursing process when creating a plan of care. (SLO 1, GE 3) Eval | Student smu | siNu Collects evidence related to assigned patienl(s) from appropriate resources. This rotation was on an orthopedic floor, most of the patients admitted were healthy adults undergoing elective surgery. There was not a lot of information in the chart or EMAR to gather. However you were s 3 able to find PMH, labs, and diagnostic studies if available, We had many discussion about your patients and | always had you summarize the plan of care ~ so | think you have a good beginning {grasp of collecting evidence. ‘Demonstrates accurate patient assessment skils, Aiways attempled to perform a good head to toe assessment on your patients, your paperwork contained all the pertinent assessment data. s 8 Very few abnormal findings in this population other than pain, musculoskeletal. & skin integrity Establishes appropriate nursing diagnoses based on collected evidence and patient assessment._| 5. s Prioriizes patient care based on assessment. You got better with this as the rotation progressed, Understanding the priorities according to whether the surgery was hip, knee, or back. Back s s surgeries especially confused you at first but | think you got it — Identifies measurable patient outcome based on nursing diagnosis. 5 5 Implements care interventions according to established plan and desired outcomes. _s Ss Uses therapeutic communication techniques during nurse/patient interactions to facilitate the nursing process. sl s Identify appropriate interventions based on assessment. Assessed soiled TED stockings and changed immediately. My patient's Spo2 sat dropped below 92% so | encouraged the use of the incentive spirometer and deep breathing. Throughout my clinical experience I nave taken ‘measures to promote comfort and reduce pain when my patient shows or vocalizes signs of distress. This includes using ice therapy, elevating extremities, administering pain medications. decreasing external stimuli, and providing pilows The good thing about orthopedic patients is that they have the same post-operative nursing interventions — you became very competent with following these orders: VS. 1&0, IS, cold therapy, neurovascular checks, weight bearing status wi assistive dovice, DVT prophylaxis, ect s s Demonstrates knowledge of medications for assigned patients. Ve altempted to pass medications weekly, the task of passing meds became very smooth by the end of the rotation. Keep working on why you are giving the medication and nursing considerations. This will come with experience and exposure s s *Administers medication safely using six rights of medication administration. Don't let your nerves get in the way of following the six rights ~ even with scanning you need to ask the patient their name and date of birth - s s “implements appropriate infection control precautions, Ss = Follows through with all patient care. I have given head to toe assessments on all of my patients during the clinical experience and reported any abnormalities such as hypotension. | took and recorded vital signs and 1&0. | administered medications and provided patient education. | have followed through on orders for Foley care, PT, and pain management, s s Evaluates patient response to care and revises plan as needed. Completed concept map =Keep | 5 s this as an example you will have to do another one for N233 ‘Student | instructor Outcome 2 _ ‘Sait | Evolot ‘Seek opportunities that promote personal and professional growth and a commitment tolifelong | Eva | Student learning. (SLO 2, GE 5) enu | SU Participates actively n al aspects of the dinical experience. The morning on this unit was very busy with medical rounds, and PT/OT. You consistently observed ancillary staff assessments and | _S s ‘Approved 12/4/14; Revised 48/2016Carroll Community College Division of STEM, Nursing and Allied Health Department of Nursing NURS 140 — Nursing Concepts 2 Student Clinical Performance Evaluation ~ SUMMATIVE therapy. At imes you are timid - don't be afraid to ask questions this will only enhance your learning. Discusses patient's plan of care with instructor. Every week we talked about your patients, expected outcomes, complications, clarifying knowledge about medical diagnoses and care. | ‘had to pull information out of you....but you were definitely getting the jest of it. Ss S ‘Demonstrates professional behavior and appearance. s s | Engages in self-reflection and communicates learning needs to instructor. s s ‘Completes assignments as required and submits on time. s s Organizes time efficiently. s Ss Student | Instructor Outcome 3 Self | Eval of Plan holistic, culturally competent care for patients and families. (SLO 3, GE 6) Eva | Student smu | SINU Demonstrates caring behaviors with the abilly to develop and maintain therapeutic relationships with people from diverse backgrounds. Ss S Considers patient values, cultural characteristics and religous differences when planning care. s s ‘Student | instructor Outcome 4 Self | Eval of Contribute to healthcare teams to provide patient-centered care. (SLO 4, GE 1) Eva | Student ciate oI smu | SINU Identifies patientfamiy health education needs. oe c s s Implements patient and family education. Teel that with more practice and preparation Iwill better be able to apply what I learned in the class room, such as the anatorry and physiology of certain patients’ conditions, to patient and family education. | am sti! learning how to make the connections between my assessment information and my patients’ conditions. | would like to become more efficient in this area; however | stil feel that | have improved. Teach more - every time you're in a patient room take that as an opportunity to teach about medication, nursing interventions, discharge needs, ect. it N S. ‘Seeks input from patient, instructor, peers, and healtheare team in the delivery of palent care | _S s “Updates instructor and healthcare team regarding changes in the patient's condition. s s “identifies safety concerns and notifies instructor and appropriate heaitlicare team members. There were a lot of safety concerns on this floor with hip precautions. spinal precautions, you were very good about seeking assistance if you were unsure how to move a patient. s s Demonstrates initiative in assisting peers and healthcare team members in the clinical setting. s Ss Demonstrates communication skills using SBAR. | modeled how to ive effective nursing shift report, you had a lot of practice both verbelly and with written documentation. I think you have it ~ now build on it. _ s s ‘Acts as an advocate for patients and families. reported patient concerns to their nurse promptly ‘and notified my instructor of my patients’ condition. My patients had concerns regarding constipation, abnormal blood pressures, pain, Foley discontinuation, and medications. All of these | address to the best of my ability while staying within my scope of practice. [os s ‘Student | instructor ‘Outcome 5 Self | Eval of Provide nursing care based on scientific evidence. (SLO 4, GE 1) Eva | Student sinu_| SIN. identifies evidenced-based rationale thal supports the patient plan of care, My concept map and care plan helped me to improve my thinking process while caring for my patients. s s Integrates knowledge from nursing and other disciplines to plan care. Ss s aeons = ae Plan nursing care based on legal and ethical principles and standards of practice. (SLO6,GE | Ey | student sinu_| SIN ‘Adheres to attendance policy. Ss Ss “Demonstrates safe clinical practice Ss Ss Approved 1214/14; Revised 4/8/2018Carroll Community College Division of STEM, Nursing and Allied Health Department of Nursing NURS 140 — Nursing Concepts 2 ‘Student Clinical Performance Evaluation ~ SUMMATIVE Provides nursing care based on the policies and procedures of the facility. “Maintains legal accountability for nursing practice in accordance with the Maryland Nurse Practice Act. “Adheres to HIPAA guidelines regarding patient confidentially. “Provides care according to the ANA Nursing Scope and Standards of Practice. ofea|ea}en eal la|ca|colen lea} “Demonstrates accountability and responsibilty for own actions and attitudes. Student | Instructor Outcome 7 Self. | Eval of Develop informatics skils using technology and electronic sources of health care information to | Bol | Eva Of ‘Support clinical decisions, promote communication, and monitor care outcomes. (SLO7,GE4) | gray | Sonny ‘Gathers data from the electronic medical record to provide patient care. Ss Ss Uses electronic medical record to document patient care accurately and in a timely manner. Ss s ‘Student Reflection - Looking back on the rotation: How have you grown as a nurse? Please explain and use specific examples. ‘Compared to the first day on the floor at Union Memorial | have become much more confident in my abilities. I have Practiced crucial skils such as Foley care, wound care, and medication administration. | have also grown in my ability to communicate with my patient and peers. For example, | can now give a comprehensive SBAR report for my patient ‘and identify significant findings. This type of critical thinking has helped me prioritize my assessments and care. | have become much more comfortable talking to my patients as well Do you have any continuing concerns about your performance? Please explain. | would lke to improve my patient and client teaching. sill have trouble with connecting certain pathophysiology ‘quickly to my clients concems and condition, an¢ then explaining things in the most effective way. item was identified as N or U, narrative comments are Faculty Comments! Student Learning Goals (“If necessary to clarify student performance") ‘You started out the rotation very unsure of yourself and nervous in the clinical setting — | saw so much growth and improvement in your nursing role. You really grew in your confidence. So your task in the future is “fake it til you make it’. You want to instil the impression in your patients that you are competent to take care of them. Also have confidence in you knowledge, when | would ask a question about pathophysiology or pharmacology you were the student that often knew the answer...say it loud and proud! ‘Alex you were taught the basics this rotation: organizing information (although you are a pretty good organizer without my help), prioritizing care, performing physical assessments, & passing medications - now you need to build on it It was a pleasure working with you at Union! Student Signature: ( Liv MW lovez Alexandra Mace Date: _4/5/16 Instructor Signature: Chris Henyon RN, MSN_ Date: _4/8/16 Aoproved 1214/14; Revised 4/8/2016