Nsg 125 Clinical Guides and Assignments F10 by keralaguest

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									Nursing 125 Clinical
    Guides and
   Assignments




                (08/16/10)
                          Nursing 125 Clinical Assignments Summary

The following assignments are due to satisfactorily complete Nursing 125. Unless otherwise noted,
all assignments are due at the beginning of the first clinical day of each week.

Medical-Surgical: Mini-care plans and drug cards are due the morning of clinical on each
assigned patient. The 60 Second Situational Assessment will be completed at the start of each day
on each assigned patient. A care plan and physical assessment is due the following week on a
selected patient.

Pediatrics: Mini-care plans and drug cards are due the morning of clinical on each assigned
patient. The 60 Second Situational Assessment will be completed at the start of each day on each
assigned patient. A care plan and physical assessment is due the following week on a selected
patient. Complete and turn in the Orientation to Pediatrics check off.

Cardiopulmonary: A 1-2 page paper is due summarizing the experience and addressing the
specific clinical objectives listed in the guide.

Physical Therapy: A 1-2 page paper is due summarizing the experience and addressing the
specific clinical objectives listed in the guide.

Surgical Rotation: A major case study is due 2 weeks following the clinical rotation-see clinical
guide for details.

Obstetrics Weeks: A journal will be kept weekly and turned in for review by the instructor. The
journal guide is included in this packet. Assigned questions for the journal may be added. The 60
Second Situational Assessment will be completed at the start of each day on each assigned
patient. A quiz on pharmaceutical agents commonly used in obstetrics will be administered late in
the semester.

Evidence-Based Poster Presentation: An obstetric health care problem will be identified and the
research related to the problem will be developed into a poster and presented in post-conference.
This is a group collaborative assignment worth 50 points. See guideline for specifics.

Postpartum: Drug cards are due the morning of clinical. Complete the postpartum assessment
form “normals” before clinical. The 60 Second Situational Assessment will be completed at the start
of each day on each assigned patient. Care plan and completed assessment form and physical
assessment forms are due one week after the first and second rotations. For all other postpartum
rotations, turn in the postpartum assessment and physical assessment forms on a client.

Nursery: Drug cards are due the morning of clinical. Complete the nursery assessment form
“normals” before clinical. The completed assessment form is due one week after the first nursery
rotation.

Labor and Delivery/Antepartum: Drug cards are due the morning of clinical. Complete the labor
and delivery pre-assignment before clinical. The 60 Second Situational Assessment will be
completed at the start of each day on each assigned patient. Turn in completed form with
information on the client you assessed the following week along with a care plan related to the
labor client.

Women’s Health Clinic (if attended): A 2-3 page paper is due addressing the specific clinical
objectives listed in the guide. Attach the women’s health student evaluation form (signed by staff
member) and turn this in.
                                         Clinical Orientation

Clinical Times
    1. Clinical times are posted for each area. Clinical starts at the scheduled time and students
       are expected to be there on time.
    2. If you are going to be absent or late, call the hospital and speak directly to your instructor.
       Hospital staff members are not required to take messages from students.
    3. If you are going to be absent or late from an outpatient rotation, call your clinical instructor
       and the outpatient site to inform them of this.
    4. Tardiness to a post-conference without instructor’s okay is considered a tardy.
    5. Failing to contact the clinical instructor when late or absent is a clinical unsatisfactory and
       will reflect in your clinical grade.
    6. Clinical hours may vary depending on assignment.

Clinical Assignments
    1. For obstetrics, clinical assignments are made the day of your rotation.
    2. For med/surg and pediatrics, clinical assignments are made the afternoon prior to clinical.
       Check with your instructor for estimated time assignments are posted.
    3. If your assigned patient has been discharged, pick another patient and note it on the
       assignment sheet. Try to avoid overlapping with another student’s assignment.
    4. The student is responsible for researching the assigned patients prior to clinical.
    5. Completed assignments must be neat and computer generated. Do not submit assignments
       online unless instructed to by the individual instructor.

Mini-care plans and Pre-assignments
   1. Pre-assignments and mini-care plans will be turned in upon arrival to clinical each day.
   2. Mini-care plans shall have a minimum of 2 nursing diagnoses.
   3. Mini-care plans and pre-assignments may be handwritten legibly or computer generated.

Clinical Forms
    1. All clinical forms are available on the website of the 2nd semester instructors.
    2. For drug cards, make sure to include IV information as noted in the drug card sample on
       the web.

Uniforms
   1. The uniform is a professional symbol of your status as a RN student and should be worn
      whenever you are at the hospital in a student role. This includes picking up assignments,
      clinical hours, and any follow-up work needed to complete assignments.
   2. Part of the “uniform” is the policy on hygiene, nails, jewelry, tattoos, hairstyle, and
      identification.
   3. Please review and abide by the uniform guidelines in the Student Handbook.
   4. If a student does not meet the guidelines, the instructor has the authority to send the
      student home to change. This will be reflected in hours of absence and in the clinical
      evaluation.
   5. Please do not use scented aftershave, perfume, body lotions during clinical.
   6. The IVC RN Student name tag must be displayed above the waist at all times in clinical.
   7. Leave items of value and cash at home or locked in your car. There is limited space for
      personal belongings at both hospitals.
                                         Clinical Guide
                                    Medical-Surgical Nursing

Focus:        Nursing care of the patient with surgical or medical problems.

Behavioral Objectives:
      1.      Utilize the nursing process in caring for patients with surgical or medical problems.
      2.      Know the pathophysiology, medications, and nursing intervention needs of assigned
              patients with surgical, respiratory, reproductive, and integumentary problems.
      3.      Identify preoperative and postoperative needs of assigned patients.
      4.      Demonstrate the ability to communicate therapeutically with assigned patients.
      5.      Recognize the emotional significance of surgical, respiratory, reproductive, and
              integumentary problems.
      6.      State the nurse’s role in the prevention and control of assigned patient’s health
              problems.
      7.      Identify specific problems that the nurse may encounter in caring for patients with
              respiratory, reproductive, integumentary, and surgical problems.
      8.      Gain additional skills in procedures used with patients who have surgical,
              respiratory, reproductive, and integumentary problems.
      9.      Gain skill in providing appropriate nursing care and physical assessment.
      10.     Gain beginning experience in clinical practice as a team member.
      11.     Provide appropriate care related to medication administration, including IV therapy
              and blood adminstration.

Learning Activities Guide:
       1.      Prepare for clinical practice
               a.      Make an assessment of assigned patients.
               b.      List client goals in the order or priority.
               c.      Develop your preliminary plan of care with rationale for action.
               d.      Make drug cards for medications to be administered.
       2.      Keep your care plans updated. Select one of your patients and write a
               comprehensive care plan including evaluation of patient goal achievement.
       3.      Review nursing care needs related to your assigned patients.
       4.      Closely observe and accurately document physical and behavioral change noted in
               your assigned patients.
       5.      Perform procedures necessary in the care of your patients, with instructor
               permission and guidance.
       6.      Report abnormal findings and/or behavioral change immediately to the assigned RN
               and to the instructor.
       7.      Using the SBAR format, give the staff RN a report on assigned clients prior to
               leaving clinical area.
       8.      All documentation is to be completed prior to leaving clinical area.

Postconference:
      1.     Discussion of objectives achieved and not achieved.
      2.     Evaluation of self activities for the day.
                                         Clinical Guide
                                  Cardiopulmonary Department

Focus:         Respiratory therapy in an inpatient and outpatient setting.
               The cardiopulmonary technician will direct your learning experience.

Behavioral Objectives:

         Through the observation become acquainted with the equipment and procedures used in
         respiratory therapy.

Learning Activities Guide:

         1.    Identify the role of the cardiopulmonary technician on the client care management
               team.
         2.    Observe the technician while respiratory therapy is admitted to patients.
         3.    Practice assessment skills as follows: chest sounds, 02 needs, hypoxia, maintaining
               patent airway, suctioning.
         4.    Identify procedures used in chest therapy such as: Byrd treatments, incentive
               spirometry, PPT, nebulizer, postural drainage, care of ventilators, and 02 therapy.
         5.    Identify medications and solutions used in respiratory treatments. Review possible
               complications, side effects, and dosage.
         6.    Acquaint yourself with the information documented on the patient’s chart by the
               cardiopulmonary technician.
         7.    Aid in eliminating possible factors in the environment that reduce the patient’s ability
               to rest.
         8.    Assist the infection control measures for protection of client, self, and others.
         9.    Observe EKG and EEG procedures.
         10.   Identify nursing implications for clients on respiratory therapy.
         11.   Identify equipment used and what is required in the care of the equipment used in
               cardiopulmonary.
         12.   Be prepared to discuss the purpose of respiratory therapy procedures.
         13.   Write a 1-2 page report defining the purpose of respiratory therapy, nursing
               interventions which may augment this therapy, and the importance of a collaborative
               relationship between cardiopulmonary and nursing departments.
                                          Clinical Guide
                                   Physical Therapy Department

Focus:          Physical therapy in an inpatient and outpatient setting.
                The physical therapist will direct your learning experience.

Behavioral Objectives:

         1. Through observation become acquainted with the equipment and procedures used in
            physical therapy for promoting, maintaining or restoring the musculoskeletal system on
            the adult, geriatric, and pediatric clients with disorders of the musculoskeletal system.

Learning Activities Guide:

         1.     Identify the role of the physical therapist and physical therapy team in caring for the
                patient with rehabilitative needs.
         2.     Observe the physical therapist while performing physical therapy to clients with
                rehabilitative needs.
         3.     Practice physical assessment skills on the musculoskeletal system.
         4.     Identify medications used to promote physical therapy treatments. Review possible
                complications, side effects, and dosage.
         5.     Acquaint yourself with the information documented on the patient’s chart by the
                physical therapist.
         6.     Aid in eliminating possible factors in the environment that reduces patient injury,
                such as falls, alteration in skin integrity related to physical therapy equipment,
                hazards of immobility.
         7.     Assist the infection control measures for protection of patient, self, and others.
         8.     Observe and assist in the application of Buck’s tractions, skeletal traction, casts,
                splints and sling procedures.
         9.     Identify equipment used and what is required in the care of the equipment used in
                physical therapy.
         10.    Be prepared to discuss the purpose of physical therapy procedures.
         11.    Write a 1-2 page report defining the purpose of physical therapy and nursing
                interventions which may augment this therapy, and the importance of a collaborative
                relationship between physical therapy and nursing departments.
                                           Clinical Guide
                                 Pediatric Department in Hospital

Focus:         Nursing care of the hospitalized child.

Behavioral Objectives:
      1.      Utilize the nursing process in caring for the hospitalized child.
      2.      Establish rapport with co-workers, the child, and the family.
      3.      Assess the child’s reaction to his or her illness and compare behavioral
              manifestation to the norms for the child’s age.
      4.      Identify the impact of the child’s illness on the family members.
      5.      Gain skills in communicating with the ill child and the family members.
      6.      Gain skills in pediatric procedures and in administering pediatric medications.
      7.      Identify clinical conditions specifically related to children, and compare the
              manifestations of the conditions to your theory text.
      8.      Promote the safety and security of the hospitalized child, self, and others.
      9.      Demonstrate skill in providing appropriate nursing care which meets psychosocial,
              psychological, cultural, and developmental needs of child.

Learning Objectives:
       1.     Prepare for clinical practice.
              a.      Make an assessment of assigned client (s).
              b.      List the patient problems in the order of priority.
              c.      Write beginning plan of care.
              d.      Make drug cards for medications to be administered.
       2.     Keep care plans updated as you care for assigned patients. Select one patient and
              write a complete care plan, including evaluation of patient goal achievement.
       3.     Practice making observation of ill child’s behavioral manifestations and compare
              with norms for that age group.
       4.     Practice communication skills with ill child, family, and co-workers.
       5.     Research the clinical diagnosis of assigned clients and compare findings/treatment
              with textbook.
       6.     Assist the sick child to meet his or her need for play and love during hospitalization.
       7.     Practice basic pediatric procedures and calculation of pediatric medication.
       8.     Report vital signs and behavioral manifestations (both normal and abnormal)
              immediately to the assigned RN. Give report using SBAR format before leaving for
              the day.

Postconference

         1.    Discussion of objectives achieved and not achieved.
         2.    Evaluation of self activities for the day.
                                          Clinical Guide
                                          Surgical Unit

Focus:        The scope of peri-operative nursing care.
              The nursing supervisor will direct your learning experiences.

Behavioral Objectives:
      1.      To demonstrate the student’s ability to prepare the patient both pre- and
               post-operatively.
      2.      To demonstrate skills in surgical asepsis and sterile techniques.
      3.      To improve student abilities to provide nursing intervention for the surgical patient.
      4.      To observe and assist the unit manager or designated staff member, in organizing
              and managing daily O.R. activities.
      5.      To provide physiologic and psychosocial support to each patient before surgery and
              during the recovery phase.
      6.      To identify safety issues, collaborative practice issues, and nursing care designed to
              decrease risk to the surgical client and staff.

Guides for Observation:
      1.      Define the role and duties of the members of the surgical team as follows and how
              they collaborate to achieve a positive outcome:
              a.       Chief surgeon
              b.     Assistant surgeon
              c.     Anesthesiologist
              d.     Supervisor nurse
              e.     Circulating nurse
              f.     Scrub tech
      2.      Observe positioning of patients as well as:
              a.     Comfort measures
              b.     Patient transfer
              c.     Patient privacy
              d.     Patient safety
      3.      Observe safety measures taken throughout the procedure and if they are in
              agreement with recommended practice.
      4.      Observe surgical procedures including:
              a.     Skin opening and closure
              b.     Hemostasis
              c.     Sponge, needle, and instrument count
              d.     Fluid deficit measurement
              e.     Placement of cautery pads, ECG leads
              f.     Drains and suctions
      5.      Observe psychological support.
      6.      Observe and assist with provision of perioperative care
              a.     Medication administration
              b.     Safety measures
              c.     Assessment and interventions
              d.     Family involvement
              e.     Education and support

Learning Activity Guide:
       1.      Assist in preoperative patient preparation.
       2.      Do surgical scrub, glove, and gowning as directed.
       3.      Open sterile supplies and prepare for surgical procedures when directed.
       4.      Assist the scrub nurse or circulating nurse as directed
       5.      Assist in postoperative patient care.
       6.     Assist in clean-up duties.


Postconference:
      1.     Share how objectives were or were not achieved.
      2.     Share incidental learning experiences.
      3.     Share actual and potential complications of surgical procedure observed.
      4.     Share pre- and post-operative education and nursing interventions required in
             relation to actual and potential complications.


Assignment:
      Completion of a comprehensive surgical case study.
                                 Surgical Case Study Guidelines

The Surgical Case Study is a professional research-based paper. The paper must be computer
generated and conform to the APA format. All references including research information, patient’s
chart, interviews and web-based sources must be appropriately cited throughout the paper and in
the reference list. In addition to the assigned textbooks, a minimum of 3 professional references
must be utilized. These references must be from recent professional nursing journals and/or
professional nursing and health care websites. Popular magazines and consumer-focused
websites are not acceptable.

Grading:
The grade for the written case study will be valued at 70 points. The following point system will be
used. Please include this point system with your case study. Late papers will be discounted 5
points/day. See attached guideline for what must be specifically included in each section. Paper
is due 2 weeks after first surgical assignment day.

Content                   Assigned Points           Points Earned             Comments
Biographical Data         P/F

Chief Complaint           5
Why did patient come
to hospital, Hx of
Present Illness
Personal and
Psychosocial hx
Family Hx

Review of Systems         5

Pre-op Physical Asst      5

Pre-op Labs and Dx        5
Testing

Analysis of Data          10
Collected, Strengths,
Weaknesses,
Nursing Diagnoses,
goals, actions,
rationales, evaluation

Pre-op Fears,             5
Teachings, Consents

Pre-op Preparations,      5
Pre-op Meds

Anesthesia, Nursing       5
Care Intraoperatively,
Surgical Procedure,
Safety

Post-operative            5
Complications-Actual
and Potential; Post-op
Medications; EBL

Analysis of Intra- and    10
Post-Operative Case,
Nursing Dx, Goals,
Interventions,
Rationales, Evaluation
Techniques,

Conclusion: Pt-           5
centered view,
collaborative issues,
opinion on
improvement

Research evidence:        5
Appropriate use of
professional
references, APA
format utilized, proper
spelling and grammar,
no plagiarism

                                                                              Points Earned


       Surgical Follow-Through Case Study

History and Physical Assessment:

I.     Biographical Data
       A.    Patient's Initials only:
             (Note: It is a violation of patient confidentiality to print names in a study of this type).
       B.    Age:
       C.    Sex:
       D.    Marital Status:
       E.    Race:
       F.    Education:
       G.    Occupation:
       H.    Religion:
       I.    Number of Children:
       J.    Insurance:
       K.    Primary Diagnosis: (Usually the reason for surgery)
       L.    Secondary Diagnosis:
       M.    Other Diagnosis:
       N.    Operative Procedure: (Correct wording as on Surgical Consent)
       O.    Reliability of Historian or Other:
              (Patient's ability to accurately relate facts about medical history)

II.    Client's Current Health Status
       A.     Chief Complaint: Stated in patient's own words

       B.      Why did client come to the hospital: Stated in patient's own words

       C.      History of present Illness: Investigate symptoms and make a concise chronological
               story
     Guide for each symptom relevant to Primary Diagnosis using OLDCARTS
     1. Onset – When and how did it begin? What were you doing? Does anyone else
                     have same symptoms?
     2.Location – Where are the symptoms? Is it localized or general? Any radiation of
       pain and if so, to where?
     3.Duration – How long do the symptoms last? Worsening? Improving? Constant or
       intermittent? How often?
     4.Characteristics – What does symptom look or feel like? Describe the sensation or
       appearance. Is it changing?
     5.Aggravating and alleviating factors – What makes the symptoms better or worse?
       Any change with movement, activity? Anything in the environment that improves
       or makes it worse?
     6. Related symptoms – What other symptoms are present?
     7.Treatment – What self-treatment has the patient tried? How has it helped or not
       helped? If self-treatment was done, when, what, and for how long?
     8.Severity – Describe the severity of the symptom, i.e., size, extent, number,
       amount, scale of 0-10. Does symptom interrupt activities?

D.   Past Medical History: Include treatments, outcomes, timeframe for any positive
     findings:
             1.    Chronic illnesses
             2.    Other major illnesses, acute or chronic
             3.    Hospitalizations
             4.    Surgeries
             5.    Injuries
             6.    Allergies
             7.    Medications taken regularly, reason, when last taken
             8.    Previous blood transfusions
             9.    Habits: Use of (how much)
                   a.       Tobacco
                   b.       Alcohol
                   c.       Drugs
                   d.       Coffee, tea

E.   Family History: (Biological parents, grandparents, siblings, children) Ages and
     present state of health. Include common diseases: diabetes, cancer, hypertension,
     coronary artery disease, hypertension, seizure disorder, mental illness, Alzheimer’s,
     alcohol/substance addiction, endocrine disease, kidney disease, genetic disorders)

F.   Personal and Psychosocial:

     Functional ability: Ability to perform self-care activities, ability to perform skills
     needed for independent living

     Socioeconomic: Work history, insurance, housing

     Cultural and spiritual: Race, ethnicity, religion. Any specific alterations in care
     required of this patient

     Developmental stage: Compare patient with Erickson’s developmental stage
     Health promotion behaviors: What activities are performed regularly to maintain
     health? I.e., exercise level, seat belts, routine exams, environmental protections

     Lifestyle practices: Relationships, support system, sleep/rest patterns, what is
     important to the patient to maintain a satisfying life, coping mechanisms, domestic
                 violence risk.

                 Diet and nutrition: Typical diet, BMI (based on ht/wt), is patient in a healthy range,
                 average 24-hour food/liquid intake.

                 Patient's impression of his general state of health: What is patient’s personal
                 perception of his health? (Often a patient may feel his health is good when another
                 person may not agree. This relates to how a patient copes with chronic or acute
                 illness)

       H. Review of Systems: Inquire about past and present health of each of the patient’s body
          systems. If you have covered a specific area in the symptom analysis, you may note
          this.

              General symptoms: Pain, fatigue, weakness, fever, sleep disturbances, weight
              changes

              Integumentary: Changes in skin color, temperature, texture, rashes, pruritis, bruising;
              Changes in hair color, texture, character, loss, pruritis; Changes in nail color, shape,
              texture; Any measures to protect from skin cancer

              Head and neck: Headaches, trauma, vertigo, syncope; Eyes: discharge, redness,
              excessive tearing, vision changes, use of corrective devices; Ears: hearing, pain,
              excessive cerumen, discharge, tinnitus, use of hearing aids, changes in balance;
              Nose: discharge, epistaxis, sneezing, change in ability to smell; Mouth: Sores,
              dentures or bridges, lesions, difficulty chewing, altered taste, dysphagia; Neck: lymph
              node enlargement, limited movement, masses

              Respiratory/Chest: Cough, hemoptysis, dyspnea, wheezing, abnormal breathing
              patterns, changes in respiratory status, smoker, allergies

              Cardiovascular: Palpitations, chest pain, dyspnea, orthopnea, coldness to
              extremities, numbness, edema, varicosities, pain with exercise, color change in
              extremities

              Gastrointestinal: Pain, N/V, hematemesis, jaundice, bowel habits, blood in stool,
              hemorrhoids, use of digestive aids, typical diet, weight issues

              Urinary: Frequency, burning, changes in urinary function, incontinence, flank pain,
              hematuria, polyuria, oliguria

              Reproductive: Male: lesions, penis or testicular pain or masses, discharge, hernia;
              Female: lesions, pain, discharge, odor, LMP if applicable, birth control method or
              hormone replacement if applicable, menses history, pregnancy history.

              Musculoskeletal: Muscle pain, twitching, weakness, joint swelling or pain, redness,
              stiffness, deformity, crepitus, limitations in movement or ability to do ADLs. Back
              pain, pain radiating down leg

              Neurological: Syncope, LOC, seizures, cognitive changes, disorientation, changes in
              gait, dizziness, balance problems, paralysis, tremor, spasms, pain

III.    Pre-operative Physical Assessment: See physical assessment form for details on
             examination techniques for each system. Give detailed responses for each section of
             the physical examination in this section of your paper. Write in complete sentences.
          A.   General Survey: VS, initial observations, gait, posture, ease of movement
          B.   Head and Neck
          C.   Integumentary
          D.   Respiratory
          E.   Cardiovascular
          F.   Gastrointestinal
          G.   Urinary
          H.   Reproductive
          I.   Musculoskeletal
          J.   Neurological

IV.    Pre-operative Labs and Diagnostic Tests
          List the preoperative lab work and diagnostic testing done. Include rationale for each.
          Discuss abnormal values and relate significance to patient's health care problem.

V.     Analysis of patient’s history, physical assessment, labs/diagnostic tests: On
       review of the information obtained on this patient, describe the strengths of this patient,
       the weaknesses of this patient, and how you think this may affect both the surgical
       outcome and the patient’s general health status.

       A. Identify patient strengths.

       B. Identify patient weaknesses.

       C. Analyze data collected and identify two nursing diagnoses and measurable goals
       appropriate for the pre-operative stage for this patient. Explain the justification for these
       two diagnoses based on the data you have collected.

       D. Identify four nursing interventions appropriate for each of the diagnoses chosen.
       Explain the rationale for each intervention and how you would measure if the patient’s
       goals were met.

Surgical Intervention

 I.    Discuss specific preoperative fears of your patient and compare with expected
       preoperative fears related to the surgical intervention. Discuss recommended and actual
       nursing interventions used to help allay preoperative fears. Use research findings to
       justify your answers.

       Discuss specific preoperative teaching the nurse would contribute related to the surgical
       and nursing interventions. Compare recommended preoperative teaching with what
       happened in this case. What preoperative education did you provide? Use research
       findings to justify your answers.

II.    Discuss the legal factors and importance of the "informed surgical consent."
       Was this done? What other consents were signed? Why?

III.   Discuss the physical preoperative preparation done for your patient and the rationale for
       each (i.e., skin prep, NPO, enema, positioning, safety, etc.).

 IV.   Describe the purpose and effects of the preoperative medications ordered for your
       patient. If your patient did not have any, discuss types of pre-operative medications and
       rationales for usage. What safety precautions are utilized?

V.     Identify the anesthetics and drugs used during anesthesia, their purpose and effects.
                                                                                                   14
         Discuss nursing responsibilities related to these and include safety measures
         undertaken to prevent errors.

VI.      Discuss nursing responsibilities and actions during the surgical procedure, pre- and
         during anesthesia (i.e., respiratory status, state of consciousness, VS, safety
         precautions). Identify safety procedures used to prevent errors in the surgical suite.
         Briefly describe the surgical procedure performed on your patient in surgery. What did
         the nurse do during the surgery? Compare with expected duties of the RN in the
         operative suite.

VII.     Identify possible and actual postoperative complications related to the specific surgery
         and include their signs, symptoms, and recommended and actual nursing interventions.
         Note estimated blood loss during surgery, surgical dressings and/or drains utilized.

VIII.    Discuss postoperative medications given and include nursing responsibilities related to
         their administration and actual outcomes from usage.

IX.      Analysis: Analyze data collected and identify two nursing diagnoses and goals
         appropriate for the post-operative stage for this patient. Explain the justification for these
         two diagnoses based on the data you have collected. Identify four nursing interventions
         appropriate for each of the diagnoses chosen. Explain the rationale for each intervention
         and how you would measure if the patient’s goals were met.

XI.      Conclusion: Relate the patient's view and your view of whether this surgery was
         successful. Describe any positive or negative examples of team work and collaboration
         you saw throughout the perioperative procedure. Make suggestions for improvement
         pre-, intra-, and postoperatively that you feel could have helped the patient through this
         experience and/or enhanced the safety of the surgical unit.




(8/10)




                                                                                                    15
                                    60 Second Situational Assessment

This exercise is designed to assist you in the development of situational awareness. In the patient care
area, situational awareness focuses on the art of patient observation. This includes routine use of a
general survey (observation) of the patient, family, and environment during every incidental encounter
and periodically at planned intervals throughout the day. Situational awareness promotes a safer patient
care environment and helps the nurse develop care priorities and attention to clinical detail.

Directions: Enter the patient’s room and observe the patient, family, and environment for up to 60
seconds while reviewing the following questions in your mind.

ABC without touching the patient:
    What data leads you to believe there is a
       problem with airway-breathing-circulation?
    Is the problem urgent/non-urgent?
    What clinical data would indicate that the
       situation needs immediate action and why?
    Who needs to be contacted and do you have
       any suggestions/recommendations?
Tubes and Lines:
    What tubes and/or IVs does the patient have?
    Is the IV solution the correct one at the correct
       rate?
    Does the patient need these tubes, and if so,
       why?
    Do you note any complications?
    What further assessment needs to be done?

Respiratory Equipment:
      If the patient is utilizing oxygen, what do you
          need to continue to monitor?
      What rate is the O2 at and is this correct?
Patient Safety Survey:
      What are your safety concerns with this
          patient?
      Is there a problem and if so, to whom must you
          report this?
Environment Survey:
      What about the environment could lead to a
          problem for this patient?
      How would you manage this problem?
Sensory: What are your senses telling you:
      Do you hear, smell, see, or feel something that
          needs to be explored?
      Does the patient’s situation seem “right”? How
          or how not?
What additional information would be helpful for further
clarification of the patient’s situation?

What questions are unanswered and what answers are
unquestioned?

Author: Deborah Struth, MSN, RN at UPMC Shadyside School of Nursing (struthdl@upmc.edu)
http:www.qsen.org/search.php?id=89&text=60 second situational assessment

(8/10)



                                                                                                       16
                                            Clinical Guide
                                    Labor and Delivery Unit

Focus:         Nursing care of the patient in the intrapartum setting.

Behavioral Objectives:
      1.      Utilize the nursing process in caring for patients in the intrapartum setting.
      2.      Know the pathophysiology, medications, and nursing intervention needs of
              assigned patients.
      3.      Identify preoperative and postoperative needs of assigned patients as
              appropriate.
      4.      Demonstrate the ability to communicate therapeutically with assigned patients.
      5.      Recognize the emotional significance of pregnancy and birth.
      6.      State the nurse’s role in the prevention and control of assigned patient’s health
              problems.
      7.      Identify specific problems that the nurse may encounter in caring for patients in
              the intrapartum unit.
      8.      Gain additional skills in procedures used with patients in the intrapartum setting.
      9.      Gain skill in providing appropriate nursing care and physical assessment.
      10.     Gain beginning experience in clinical practice as a team member.
      11.     Provide appropriate care related to medication administration.

Learning Activities Guide:
       a.      Prepare for clinical practice
               a.      Make an assessment of assigned patients.
               b.      List patient goals in the order or priority.
               c.      Develop your preliminary plan of care with rationale for action.
               d.      Make drug cards for medications to be administered during your clinical
                       hours.
       a. Assess assigned patient for risk factors, EDD, stage of labor, coping mechanisms,
          and family support.
       b. Participate in admission of a patient to the labor unit.
       c. Teach a patient breathing and relaxation techniques to assist with labor.
       d. Provide appropriate medications as ordered and describe rationale for each.
       e. Place patient on electronic fetal monitor and identify normal fetal heart tones and
          signs of fetal distress.
       f. Determine onset, duration, strength, and frequency of contractions by palpation and
          by fetal monitoring.
       g. Assist staff nurse with set up for delivery and assist with delivery if possible.
       h. Observe and assist staff nurse with both a vaginal and Cesarean birth.
       i. Palpate and massage the uterine fundus and bladder during the fourth stage of
          labor.
       j. Provide nursing care to a laboring patient through delivery.
       k. Identify factors increasing a patient’s risk in the intrapartum period.
       l. Identify common instruments used in the delivery room and their usage.
       m. Assist and observe immediate neonatal care in the delivery room.
       n. Observe the placenta and umbilical cord and identify characteristics related to the
          birth.
       o. Provide patient with medications as ordered using appropriate technique and be able
          to give rationale for usage.
Postconference:
       1.      Discussion of objectives achieved and not achieved.
       2.      Evaluation of self activities for the day.

                                                                                                17
                                         Clinical Guide
                                        Postpartum Unit

Focus:         Nursing care of the patient in the postpartum setting.

Behavioral Objectives:
      1.      Utilize the nursing process in caring for patients in the postpartum setting.
      2.      Know the pathophysiology, medications, and nursing intervention needs of
              assigned patients.
      3.      Identify preoperative and postoperative needs of assigned patients as
              appropriate.
      4.      Demonstrate the ability to communicate therapeutically with assigned patients.
      5.      Recognize the emotional significance of birth and adaptation to the postpartum
              state.
      6.      State the nurse’s role in the prevention and control of assigned patient’s health
              problems.
      7.      Identify specific problems that the nurse may encounter in caring for patients in
              the postpartum unit.
      8.      Gain additional skills in procedures used with patients in the postpartum setting.
      9.      Gain skill in providing appropriate nursing care and physical assessment.
      10.     Gain beginning experience in clinical practice as a team member.
      11.     Provide appropriate care related to medication administration.

Learning Activities Guide:
               Prepare for clinical practice
               a.     Make an assessment of assigned patients.
               b.     List patient goals in the order or priority.
               c.     Develop your preliminary plan of care with rationale for action.
               d.     Make drug cards for medications to be administered during your clinical
                      hours.
       a. Assess, plan, and implement care on a postpartum patient.
       b. Assess the dietary needs of a breastfeeding mother and contrast with the needs of
          the formula feeding mother.
       c. Contrast similarities and dissimilarities of primiparous and multiparous patients in
          terms of nursing care and educational needs.
       d. Develop a care plan for a postpartum patient.
       e. Develop a teaching plan for a postpartum patient.
       f. Use critical thinking skills in the assessment, planning, and implementation of care
          for a patient with a postpartum complication.
       g. Discuss nursing actions appropriate to a variety of postpartum complications and
          give rationale for each during postconference.
       h. Adapt the routine postpartum teaching goals to meet the needs of a patient with a
          complication.
       i. Using the SBAR format, give the staff RN a report on assigned patients prior to
          leaving clinical area.

Postconference:
      1.     Discussion of objectives achieved and not achieved.
      2.     Evaluation of self activities for the day.



                                                                                                 18
                                         Clinical Guide
                                         Nursery Unit

Focus:         Nursing care of the patient in the nursery.

Behavioral Objectives:
      1.      Utilize the nursing process in caring for patients in the nursery setting.
      2.      Know the pathophysiology, medications, and nursing intervention needs of
              assigned patients.
      3.      Identify preoperative and postoperative needs of assigned patients as
              appropriate.
      4.      Demonstrate the ability to communicate therapeutically with assigned patients.
      5.      Recognize the emotional significance of becoming a parent.
      6.      State the nurse’s role in the prevention and control of assigned patient’s health
              problems.
      7.      Identify specific problems that the nurse may encounter in caring for patients in
              the nursery.
      8.      Gain additional skills in procedures used with patients in the nursery.
      9.      Gain skill in providing appropriate nursing care and physical assessment.
      10.     Gain beginning experience in clinical practice as a team member.
      11.     Provide appropriate care related to medication administration.

Learning Activities Guide:
       Prepare for clinical practice
               a.      Make an assessment of assigned patients.
               b.      List patient goals in the order or priority.
               c.      Develop your preliminary plan of care with rationale for action.
               d.      Make drug cards for medications to be administered during your clinical
                       hours.
               e.      Complete newborn assessment normals on assigned sheet.
         a. Observe delivery of infant and immediate delivery room care of the newborn.
         b. Assist staff nurse with the immediate newborn care
         c. Admit or assist with admission of the newborn to the nursery unit.
         d. Administer routine medications to the newborn.
         e. Perform a physical assessment and gestational age assessment on a newborn and
            document findings on assigned sheet.
         f. Provide discharge education on newborn care to the parents.
         g. Provide daily care to a newborn including bathing, dressing, swaddling, changing
            diaper, and feeding.
         h. Assist a new mother with breastfeeding her newborn.
         i. Assist the staff nurse with care of an at risk newborn
         j. When possible, provide daily care to an at risk newborn
         k. Observe the equipment used in the NICU and explain rationale for its use
         l. Research common newborn complications and nursing management.

Postconference:
      1.     Discussion of objectives achieved and not achieved.
      2.     Evaluation of self activities for the day.
      3.     Discuss in postconference the needs of the staff nurse caring for newborns in the
             NICU
      4.     Discuss in postconference the emotional support needed by the family of an at
             risk newborn.
      5.     Discuss your chosen neonatal complication research topic.


                                                                                                  19
                                           Clinical Guide
                                        Women’s Health Clinic

Focus: Nursing Care of the Pregnant, Postpartum, or Reproductive Health Client in an
outpatient setting

Behavioral Objectives:

          1. Explain the roles of the nurse and nurse practitioner in caring for women and families
          of childbearing age.
          2. Explain educational, nutritional, psychosocial, and clinical needs of the women and
          her family.
          3. Verbalize and demonstrate routine education for gynecologic, prenatal and
          postpartum patients.
          4. Verbalize and demonstrate elements of the prenatal assessment and examination.
          5. Identify educational materials appropriate for specific patients being seen at the
office.
          6. List services available at the site along with financial guidelines used by the office
          staff to determine eligibility.

Learning Activities Guide:

          1. Prepare for your clinical day by reviewing prenatal and postnatal assessment and
          educational recommendations in your textbook.
          2. Identify roles of the nurse, nurse practitioner, and physician (if available) at the site.
          3. Observe and assist the nurse practitioner and/or physician in examination of patients.
          4. Participate in checking FHTs, EFM, Leopolds Maneuvers, and fundus measurement.
          5. Assist with processing of patients through the office visit, i.e., vital signs, fingersticks,
          setting up sterile fields, injections, patient education as appropriate.
          6. Identify common discomforts and health care problems of pregnant or gynecologic
          patients and measures explained by the staff to relieve these discomforts
          7. Identify educational materials used at the site to assist in patient education.
          8. Take or participate in the history-taking of a gynecological or prenatal patient.
          9. Perform physical assessment techniques as appropriate and within the RN scope of
          practice.
          10. Write a 2-3 page paper describing your experience and addressing the above
          learning activities. Identify one health care problem seen during your visit and
          include information on the recommended treatment(s), and ways that the RN can
          improve outcomes related to the problem. Reference this using appropriate
          professional journals and/or websites. This is due one week after your day at the
          clinic site.
          11. Have clinic staff sign off on your evaluation form and attach this to your paper.




                                                                                                       20
                               Postpartum Assessment

When completing your physical assessment, use standard form and attach this
information to it. This will complete the postpartum physical assessment. Before each
postpartum rotation, complete the normals. Document your patient’s assessment
findings in the appropriate column. This will be due the first day of the following week
after each postpartum clinical rotation.

Day postpartum:             Type of delivery:           G:    P:
   Assessment Area              Normal Findings              Patient Assessment
                                                                  Findings
Breasts/Nipples


Abdomen and Fundus


Lochia


Perineum


Lower Extremeties


Bladder


Bowel Elimination


Incision (if applicable)


Psychologic Adaptation


Attachment


Rest and Sleep


Infant Feeding




                                                                                           21
                               Labor and Delivery Assessment
Before the L&D rotation, complete the “normals”. Document your patient’s assessment findings
in the appropriate column. This will be due the first clinical day of the following week after each
L&D clinical rotation.

 Assessment           Normal Findings           Patient Assessment              Patient
    Area                                       Findings (beginning of         Assessment
                                                        shift)              Findings (end of
                                                                                  shift)
Weeks
gestation

Risk status
(check history
and present
findings)
Patient’s Plan    N/A


Vital Signs


Fundal Asst
and fetal
position
Cervical
dilation

Cervical
effacement

Fetal station


Membrane
status

FHR and
status

Anesthesia
Analgesia

Coping
mechanisms

Delivery type




                                                                                                 22
                              NEWBORN ASSESSMENT SKILL

During the first clinical nursery rotation observe a newborn, and with the assistance of an R.N.,
complete the following form, writing your observations in the column at the right. Prior to your
clinical observation, complete the textbook descriptions given in the maternal-newborn textbook
and compare these observations. Completed Newborn Maturity Rating (Ballard or
Dubowitz) form and Newborn Assessment are to be returned to the instructor the
following week.

Newborn’s Age in days: _______ Type of delivery: ______________
Weeks gestation of pregnancy: _______
Prenatal/Intrapartum/Postnatal Complications:_______________________________________

           Points To Be Noted                Textbook Description          Infant Observed

Respiratory Rate
Pulse Rate: (apical)
Temperature:
Length: (range: in. & cm.)

Weight: (range: lb. & gm.)

Color:

Posture:

Skin Characteristics:

Shape of the head:

Head Circumference:(in. & cm.)

Fontanel, anterior:

Fontanel, posterior:

Face:

Eyes:

Ears:

Mouth and Palate:

Chest Circumference

Respiratory Assessment

Cardiac Assessment

Abdomen:

                                                                                               23
Umbilical Cord: (number of vessels)
and appearance
Extremities

Genitals
Buttocks and Anus
 Urine: (color)
Bowel movement:
Baby's "Apgar" at birth:
          (1 min., 5 min.)


 Nutritional Intake: (Breast or type and
quantity of formula, feeding method,
ability)
Reflexes:                                  Describe:
    Rooting:
    Sucking/Swallowing:

    Tonic neck reflex:

    Grasping

    Startle (Moro):

    Babinski

   Stepping:



Reference:




                                                       24
                                        Orientation to Hospital Pediatrics

       While on rotation in the Pediatrics Department at PMHD or ECRMC, students will be expected
       to use the following guidelines:

       1.      Routine V.S.'s: BP & TPR taken q2-8h and (PRN).
       2.      Patients with a respiratory related diagnosis are to have 02 saturations checked on room
               air and on 02 q2h (and PRN).
       3.      IV sites are checked q1h (and PRN).
       4.      Keep accurate I & O on flow sheet. Include description of stools, especially on patients
               with a diagnosis of gastroenteritis.
       5.      Complete physical assessment on assigned patient.
       6.      Provide report to nursing staff when leaving the unit; use SBAR format.

       Keep nursing staff informed of all information especially abnormal assessments related
       to the patient.

Students will be expected to know how to do the following:
                           Skill                                  Nurse initials when
                                                                 student demonstrates
                                                                    skill satisfactorily

 Pulse oximeter reading.
 Use of the automatic blood pressure machine
  Describe how to determine urine output from a
 diapered infant.

  Demonstrate/describe how to obtain urine specimen
 from an infant.


  Appropriate medication administration, may include po,
 IM, IV, rectal as ordered
 Weigh a baby.
 Bathe a baby.
 Physical assessment of assigned patient



After completion of pediatric rotation, the student will return this list, completed and signed by nursing staff, to
clinical instructor.




                                                                                                           25
Student Name: __________________________

                                             Clinical Guide
                                Women’s Health Experience Evaluation Form

Thank you for your assistance in training students in the women’s health field. Your input is appreciated.
Students are in their 2nd semester of the ADN Nursing Program at IVC. Part of this rotation focuses on the
obstetric patient/family and reproductive health issues. As part of their experience, students will spend time in a
clinic site specializing in the care of pregnant women or women of childbearing age. Please complete the
bottom part of this form to verify the student’s attendance at your site and feel free to contact the
instructor if there are any questions or problems (Donna Davis, NP-C, 355-6345). Thank you again for
your help.

Learning activities for this rotation include:
       1. Identify roles of the nurse, nurse practitioner, and physician (if available) at the site.
       2. Observe and assist the nurse practitioner and/or physician in examination of patients.
       3. Participate in checking FHTs, EFM, Leopolds Maneuvers, and fundus measurement.
       4. Assist with processing of patients through the office visit, i.e., vital signs, fingersticks, setting up
       sterile fields, injections, patient education as appropriate.
       5. Observe an initial prenatal assessment including educational, nutritional, and psychosocial aspects
       and counseling along with follow-up assessments.
       6. Identify common discomforts and health care problems of pregnant or gynecologic patients and
       measures explained by the staff torelieve these discomforts
       7. Identify educational materials used at the site to assist in patient education.
       8. Take or participate in the history-taking of a gynecological or prenatal patient.
       9. Perform physical assessment techniques as appropriate and within the RN scope of practice.
       10. Write a 2-3 page paper describing your experience and addressing the above learning
       activities. Identify one health care problem seen during your visit and include information on the,
       recommended treatment(s) and ways that the RN can improve outcomes related to the problem. This is
       due the first day of clinical in the week following your day at the clinic site.
       11. Have clinic staff sign off on your evaluation form and attach this to your paper.


        Staff: Please check acceptable or not acceptable and sign bottom of page.
                                     Acceptable                        Not Acceptable
Attitude (enthusiasm, willingness to
participate, caring behaviors)
Professional demeanor
(appearance, respect for staff and
patients, communication)
Competence (ability to provide
education, basic assessment,
medication administration if done)
Additional comments




     Staff signature __________________________                      Date ______________




                                                                                                                26
                                         Clinical Journal Guide

Purpose:
The purposes of the journal writing exercise are to: (1) contemplate the clinical experience and (2)
address critical, ethical, or problematic situations occurring in the maternal/newborn health field.

Grading Criteria:
Journals will be completed at the end of each clinical week and turned in to your clinical instructor at the
beginning of the next clinical day. Journals must be legible and in a notebook. The journals will be
checked by the instructor and returned to the student on the next clinical day. Journals are a
requirement of Clinical. Failure to complete the journal assignments will result in an
unsatisfactory in clinical for the day. Journals are a personal reflection of a clinical experience, and
will be viewed as such. Journals are not a summation of what was done on the clinical rotation, but
instead allow for the free thinking and expression of reactions, learning, and critiquing of personal and
clinical experiences.

Suggestions for Journal Writing:
•     Discuss the most significant event of the rotation, why it was significant, how did the nurse
      react, patient reaction and finally how did you react. What did you learn from this event?
•     Discuss a nurse with whom you worked. Did this person promote the profession of nursing and
      if so, how, and if not, why not. Would you want to be viewed by a student this way? Why or why
      not?
•     Occasionally in maternity nursing, a great tragedy will occur, i.e., a stillbirth, neonatal death,
      maternal death, or an infant born with a disability. If this occurs during your clinical experience,
      write about that experience. As a nursing student it is very important to identify your feelings,
      emotions, regarding these events. Discuss the case, the staff, and the patient.
•     Discuss a new concept you learned today. Was there a new skill, or concept that you learned?
      How will this enhance your experience as a nursing student?
•     Discuss an event that has you concerned. It can be with a patient or a staff member (nursing,
      physician, allied health, etc.). What was the issue, your part in this, and your recommendation
      for improvement or a solution.
•     Write a letter or poem to a patient, an infant or about nursing.
•     Write about a new skill you learned, or a way to do skills or nursing care better. What nursing
      care that you have seen impressed you and why?
•     From your time on this unit, what have you learned and how can you apply this to your own
      practice (even if not in this field of nursing)?
•     What leadership roles have you seen and how were they implemented in this department? How
      do you see yourself fulfilling the role as leader in a nursing department?
•     Discuss any examples of evidence based practice you might see, or identify areas where this
      should be enhanced.
•     Identify examples of collaboration between the patient and health care team and how this
      enhanced care.




                                                                                                         27
              Evidence-based Practice (EBP) Group Assignment/Poster Presentation

Purpose: To demonstrate understanding of evidence based practice and initiating change on a nursing
unit

Assignment Guidelines: The student nurse will identify a clinically-oriented obstetrics health care
issue at the hospital or in the community. This may relate to a disease, clinical practice, medication,
safety, administrative or supervisory issue. Complete a literature review to identify the problem and a
nursing response that may alleviate the issue or improve the situation. The topic may be specific, i.e.,
nursing care of a particular type of patient, or general, i.e., maintaining a safe environment in the labor
and delivery room. It may be hospital related, i.e., nursing care of the infant with cleft palate, community
related, i.e., decreasing adolescent pregnancy rates in California, or global related, i.e., HIV prevention
in women worldwide. Based on a minimum of 3 related professional journal articles, identify a possible
solution and implementation process that could be utilized to change practice.

Groups of 3 students will be selected. On the 2nd week of the OB rotation, discuss your group’s topic
with the clinical instructor. Presentations will begin after the 3rd week of OB clinical. At least one week
prior to the presentation, email to your instructor the links to the selected journal articles.

A poster will be developed by each group to enhance understanding of the EBP presentation and
should clearly identify the practice problem, literature review findings, analysis of the results,
improvement plan, and goal if implemented. Literature utilized must be cited using APA format.

The presentations should include the following information:

1. Identify the practice problem you have chosen to research and why it was chosen. Include statistical
data if appropriate.
2. Clearly describe the findings from your literature review and how they relate to the selected problem.
3. Evaluate the studies to see if there were enough subjects to feel comfortable with the results and
how each study’s subject selection or clinical site affect the results. Explain how this information affects
how their findings would work within the population you identified for your research.
4. Analyze how these results could be implemented in a local clinical site. Identify factors that would
improve the likelihood of success or would hinder the ability to implement change.
5. Identify the key personnel who would be needed to implement change and how to involve them. Note
any collaboration between professions that would be required.
6. Explain how the change in practice could be evaluated.
6. Answer questions of students and encourage further discussion of the chosen topic.

It is expected that all members of each group shall participate in the research, preparation,
presentation, and poster development.

The presentation is expected to meet intellectual standards of clarity, accuracy, precision, relevance,
depth, breadth, and logic. Presenters display professional language and can comfortably discuss the
research findings and implementation along with answering questions from those in attendance.
Presentations should be last no more than 20 minutes.

Maximum point scoring for this assignment is 50.



(8/10)


                                                                                                              28
                              Guidelines for Writing Nursing Care Plans

These guidelines will be used in instructor’s review of nursing care plans and for student to check for
completeness. Care plans will receive a grade of satisfactory or unsatisfactory. Refer to student
handbook re: nursing care plans.

       I.      Physical Assessment
               a.     Include with each nursing care plan.
                      Use form given by your clinical instructor.
                      During the OB rotation, include postpartum and/or intrapartum forms along with
                      the general physical assessment form.

       II.     Developmental Stage Assessment
               a.    State and define client’s developmental stage for age (Erickson).
               b.    Commentary/comparison of your client to the development stage.

       III.    Cultural/Religious Considerations:
               a.     State and define client’s culture and religion and relate this to the client’s concept
                      of health and present condition.

       IV.     Medication
               a.    Include all medications (I.V. meds, H.S. meds, O2, p.r.n.’s etc.)
               b.    Individualize medication information to your client’s diagnosis, medication order,
                     health status, and labs.
                     Are lab values appropriate for administering medication?
                     1.      Remember: oxygen is a medicinal gas.
                     2.      Reference and relate to the client’s diagnosis.

       V.      Lab Work/Diagnostic Tests
               a.    Each lab value should be researched separately as to the information it provides.
                     (i.e., WBC, RBC, Hgb, Hct)
               b.    Circle or highlight all abnormal values. Relate values to client’s condition by
                     using lab book, M/S, OB, and pediatric textbooks.
               c.    Use Pediatric Lab Values for infants and children.
                     Reference: Pediatric textbook - Appendix.
               d.    For postpartum and labor, lab values must include blood type and rh, rubella
                     immunity status, and group b strep results.

       VI.     Data Collection
               a.    Subjective and objective data must be included which support the nursing
                     diagnosis.
               b.    Individualize data to the specific client and to the specific nursing diagnosis.
               c.    Include data in mini-care plans and final care plan.


       VII.    Nursing Diagnosis
               a.     Actual nursing diagnosis is a three-part statement:
                      Problem + Etiology + Signs and Symptoms present (as evidenced by)
               b.     Potential and possible nursing diagnosis is a two-part statement:
                      Problem + Etiology.


                                                                                                          29
          c.     Should be from most current NANDA approved list.
          d.     Must be prioritized.
          e.     Must have a minimum of 4 nursing diagnoses/care plan

VIII.     Client Goals (Outcome statements)
          a.      Should be written in client behavioral terms or as a client statement and be
                  measurable.
          b.      Should have a time element for evaluation purposes (when the goal will be
                  evaluated for attainment).
          c.      Should be realistic.
          d.      Should relate to the assessment data/problems of your client.

 IX.      Nursing Actions/Interventions
          a.     Identify those that would reduce or remove the contributing factors (etiology) of
                 the nursing diagnosis.
          b.     Assessment and monitoring of status should be one or less interventions.
          c.     Use pediatric textbook as major reference for pediatric clients and obstetrics
                 textbook for obstetric clients.
          d.     Must be individualized for your client.
          e.     Must have a minimum of 5 interventions per diagnosis

     X.   Rationales
          a.     Number each rationale to correspond with each nursing action.
          b.     Each rationale should be referenced with page number and referenced author’s
                 initials. The reference should be written at bottom of page, giving title and author.
          c.     Rationale must come from textbooks or professional journals, not care
                 plan books.

     XI. Evaluation
         a.     Should relate to the client goal and indicate whether goal was met partially,
                completely, or not met. Should also include the client’s responses to nursing
                interventions. If goals partially or not met, determine reason.

 XII.     Reassessment
          a.    Assess which interventions should be continued, discontinued, or any changes.

Each care plan to include:

1.        Physical assessment (see supplementary handouts)
2.        Front information/history sheet
3.        Lab values and diagnostic tests
4.        Medications
5.        4 nursing diagnoses, even if client was cared for only one day. Each diagnosis will have
          a minimum of 5 interventions with rationales.

Note: 1)          When student is assigned a Med/Surg or Pediatric client and cardiopulmonary or
                  physical therapy in the same week, a report on the special area and a care plan
                  with 4 nursing diagnoses will be submitted the following week.
          2) If student is assigned the OR case study one day and another client the other day of
             clinical that week, the care plan must be done on the OR client, including 4 nursing
             diagnoses on either pre or post considerations.


                                                                                                     30
               3) For postpartum and labor, a care plan is due after each rotation. Use the
                same forms as for your other care plans. For the physical assessment, use the
               routine form and the addendum related to postpartum or labor clients.

Note: Correct spelling, neatness, and grammar are important in all written projects. Use a dictionary,
      textbook, and reference book as needed. Spell check and grammar check computer programs
      are available in NLC. Complete references are required in all areas of the care plan.


                             Suggestions for Nursing Diagnosis - Postpartum

Breastfeeding
      Ineffective Breastfeeding                    r/t: knowledge deficit, mother unable to position at
                                                   breast to promote a successful latch-on response,
                                                   previous history of breastfeeding failure, interrupted
                                                   breastfeeding.

       Interrupted breastfeeding                   r/t: infant illness

       High risk for impaired skin integrity       r/t: breastfeeding

Cesarean Delivery
      Pain                                         r/t: cesarean delivery

       High risk for infection                     r/t: interrupted skin integrity, surgical intervention.

       Altered Urinary Elimination                 r/t: tissue trauma, anesthesia

       Constipation                                r/t: decreased mobility, abdominal surgery

       Knowledge deficit                           r/t: post-op care at home

Vaginal delivery
      High risk for injury                         r/t: childbirth, altered involution, altered eliminating

       Altered Urinary Elimination                 r/t: perineal edema, anesthesia, trauma

       Pain                                        r/t: episiotomy, laceration, hemorrhoids, swelling,
                                                   bruising or hematoma, uterine cramping, involution,
                                                   fatigued muscles.

       High risk for fluid volume deficit          r/t: hemorrhage secondary to uterine atony, retained
                                                   placental fragments, cervical lacerations

       Knowledge deficit                           r/t: continuing needs of self, family, and infant during
                                                   postpartum period, lack of experience
       High risk alteration in parenting           r/t: failure to take on role of mother

Grief, Perinatal Loss
        Dysfunctional grieving                     r/t: perinatal loss, secondary to spontaneous


                                                                                                             31
                                            abortion, ectopic pregnancy, gestational
                                            trophoblastic disease, pre-term delivery, intrauterine
                                            fetal death, or neonatal death

       Altered Family Processes             r/t: crisis associated with perinatal loss

       Knowledge deficit                    r/t: options in perinatal loss, lack of familiarity with
                                            situation

       Self-Esteem disturbance              r/t: perceived inadequacy in “normal” reproductive
                                            role

Postpartum Hemorrhage
      Fluid volume deficit                  r/t: hemorrhage

       High risk for activity intolerance   r/t: deconditioned status, circulatory problems

Thrombophlebitis
     High risk for injury (internal)        r/t: obstructed venous return, embolus

       Pain                                 r/t: inflammation, edema, venous stasis, and tissue
                                            hypoxia

       Altered Role performance             r/t: inability to perform role (new mother/parent) as
                                            anticipated, decreased maternal/infant interaction

       Knowledge deficit                    r/t: disease process, treatment and diagnostic
                                            procedure




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                           OB/Neonatal/Gyn Medications
Knowledge of these medications is required prior to your clinical rotation in these
specific areas. Drug cards or PDA access are required to be with you for all
medications listed, regardless of your assigned area. You are responsible to review
prescribed medications prior to clinical. Be prepared to answer questions prior to
administration of all medications.

      POST-PARTUM
      Ampicillin
      Ancef
      Anzemet
      Benadryl
      Ceftriaxone
      Clindamycin
      Compazine
      Darvocet N-100
      Demerol
      Dulcolax
      Gentamycin
      Hemabate
      Inapsine
      Methergine
      Metronidazole
      Morphine
      Narcan
      Nupercainal Ointment (Dibucaine)
      Percocet
      Pericolace
      Reglan
      RhoGAM
      Rubella Vaccine (Meruvax II)
      Senekot-S
      Simethecone
      Toradol
      Vancomycin
      Vicodin
      Vistaril
      Zofran

      INTRAPARTUM (Labor & Delivery-CS)
      Ampicillin
      Apresoline
      Astromorph
      Brethine (terbutaline)
      Calcium Gluconate
      Cefotan



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Clindamycin
Cytotec
Fentanyl
Magnesium Sulfate
Penicillin
Pitocin
Nifedipine
Nubain
Stadol
Sublimaze

NURSERY
Ampicillin
Aquamephyton
Erythromycin Ophthalmic Ointment
Hepatitis B Vaccine
Narcan




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                                  Contents of a Shift Report
Include the four Ps:
Purpose- Why is the client here? What are the priorities?
Picture- What are the expected results, both short-term and long-term? What is the picture of
the current condition?
Plan- What did or didn’t work?
Part- What part can you play during the next shift?

(Hansten, R, 2003 Nursing Management Vol 34(8) pp58-59)


                               Shift Report Checklist using SBAR

S:     Admitting Diagnosis:
       Secondary Diagnosis:
       Date of Admission:
       Current Issues:

B:     Pertinent Medical History
       Physician and Ancillary Staff Consults: Prior and Planned
       Previous Tests and Treatments
       Psychosocial Issues
       Allergies, Current Code Status

A:     Physical Assessment Findings
       VS
       IVs, Drips, Line Sites
       O2, Vent Settings
       Pain Status
       Drains, Tubes
       Wound Assessment and Care
       ADLs, Diet, Activity
       Restrictions: Fall, Bleeding, Fluid, Isolation, etc.
       Labs, Diagnostic Tests
       Response to Treatments
       Care Partner, Family Updates

R:     Plan of Care
       Needs to be Addressed
       Orders Pending Completion
       Pending Treatments and Tests
       Discharge Planning, Issues, Barriers




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