Concept Map Template Nurse - DOC

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					A Student Resource




  MacMurray College

   Division of Nursing

   447 E. College Ave.

  Jacksonville, IL 62650

      July 26, 2007

   Revised: August 1, 2008
            June 2, 2009
            July 15, 2009
            June 7, 2010




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                                                                             MacMurray College
                                                                     Clinical Education Manual

Table of Contents

Page4:         Clinical Education Introduction

Page 5:        Clinical Policies
               Clinical Preparedness Expectations

Page 6:        Student Health and Safety Information

Page 7:        Preparation for Providing Clinical Care

Page 8:        Daily Routine Example

Page 9:        Essential Nursing Actions Common to All Procedures

Page 10:       The ABCs of Patient Safety

Page 11:       2009 National Patient Safety Goals

Page 12:       The Chaplain’s Corner: “Help… They want me to Pray!

Page 14:       Nursing Student Folders
               Electronically Submitted Work
Page 15:       Clinical Evaluation Tool Documentation
               Technical Skills Checklist
               Electronic Submission of Written Work
Page 16:       Clinical Forms

Page 17:       Collaborative Problems

Page 19:       Concept Care Mapping Guide

Page 23:       Concept Map Example (Steps 1-3)

Page 24:       Concept Map Template

Page 26:       Written Care Plan Instructions/Guidelines

Page 27:       Care Plan Form

Page 28:       Clinical Data Tool

Page 32:       Clinical Evaluation Tool

Page 38:       Clinical Competencies for Evaluation

Page 53:       Clinical Data Tool Grading Rubric

Page 55:       Complete Database and Care Plan Grading Rubric
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Table of Contents (continued)

Page 56:       Clinical Absence Documentation Form

Page 57:       Medication Administration Policy

Page 58:       ClinDoc Implementation Quick Reference Guide

Page 59:       Evidence-Based Care Sheets

Page 60:       Example Evidence-Based Care Sheet: Pain Assessment in Special Populations

Page 62:       Evidence-Based Practice Tutorial

Page 66:       Additional On-line Evidence-Based Practice Resources




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                                                                                                       Clinical Education Manual

CLINICAL EDUCATION INTRODUCTION

O’Connor (2001) states:

         The ultimate goal of nursing education is to prepare the student to think critically,

         communicate accurately, and perform indicated therapeutic nursing interventions in

         patient care situations; exhibit the caring behaviors inherent in nursing actions; apply

         ethical perspective in clinical decision making; and function as a team member within

         the organizational structures surrounding the delivery of patient care. (p. 1)

The information included within this manual has been developed to facilitate the clinical nursing education

process. It is the intent of the author to provide each student with the tools necessary to successfully integrate

theory into clinical nursing practice. O’Connor has also identified the following goals of clinical nursing

education:


              1.   Apply theoretical learning to patient care situations through the use of

                   critical thinking skills to recognize and resolve patient care problems and

                   the use of the nursing process to design therapeutic nursing interventions

                   and evaluate their effectiveness.

              2.   Develop communication skills in working with patients, their families, and

                   other health care providers.

              3.   Demonstrate skill in the safe use of therapeutic nursing interventions in

                   providing care to patients.

              4.   Evidence caring behaviors in nursing actions.

              5.   Consider the ethical implications of clinical decisions and nursing actions.

              6.   Gain a perspective on the contextual environment of health care delivery.

              7.   Experience the various roles of the professional nurse within the health care

                   delivery system. (pp. 1-2)


O’Connor, A.B. (2001). Clinical instruction and evaluation: A teaching resource. Massachusetts: Jones and Bartlett Publishing


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                                                  Clinical Polices

MacMurray College Division of Nursing policies regarding clinical attendance, behavior, and dress code can be
found in the Nursing Student Handbook.




                                       Clinical Preparedness Expectations

    1. *Arrival of the student will be prompt and on-time.
    2. *Student will be properly attired.
            a. Inappropriate attire will be cause for dismissal from the clinical area (Review clinical dress code
                in Student Handbook).
    3. *Student will arrive with the necessary equipment:
            a. Watch with second hand
            b. Pen
            c. Stethoscope
            d. Pen light
            e. Scissors
    4. Student will safeguard computer log-in and password and be able to access agency computer system.
            a. Student should never allow another individual to enter information using his/her login and
                password, nor should the student document using another individual’s login and password.
            b. If a student forgets his/her login or password information notify instructor for further
                instructions.
    5. Clinical Data Tool will be completed to the extent possible pre-care.
    6. Student will be able to verbalize plan of care, including verbalization of rationales for care activities.



*Items 1-3 are also expectations for Clinical Simulation Lab




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STUDENT HEALTH AND SAFETY

Hospitalization Insurance:

Students are responsible for having their own illness/accident insurance policies. Neither the Division of Nursing
nor the College is responsible for medical expenses incurred by a student while in the classroom or in clinical
agencies. Student health insurance is available through a third party insurer. Brochures are available in Student
Life.

Procedure for Exposure to Blood/Body Fluids

Due to the nature of our work, health care providers are at risk for exposure to various infectious diseases.
Primary prevention of disease transmission depends on appropriate immunizations and scrupulous, consistent
use of standard and transmission- based precautions. Students receive education about standard and
transmission-based precautions throughout the nursing curriculum and must adhere to these standards anytime
they are in contact with patients.



       In case of accidental exposure to blood or body fluids, students are to immediately:
             o Wash needlesticks and cuts with soap and water.
             o Flush splashes to the nose, mouth, or skin with water.
             o Irrigate eyes with clean water, saline, or sterile irrigants.
       Immediately report the exposure to your clinical instructor and workplace supervisor. The clinical
        instructor will report the incident to the nursing program director.
       Go to the hospital emergency room or to the nearest emergency room if you are in a community setting
        and describe your injury. The student is responsible for the costs associated with any diagnostic testing,
        counseling, and treatment. Therefore, it is essential that you have health insurance.
       Complete all incident forms required by the facility and/or college.




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PREPARATION FOR PROVIDING CLINICAL CARE

It is essential that students are prepared to practice in the clinical area. An important element of
preparation is to know what to expect or anticipate. In order to provide safe and efficient care in the
clinical area you must prepare by seeking answers to the following questions.

   1. What problems do I know or suspect my patient has?
   2. What are the signs and symptoms of these problems?
   3. What will I need to assess to determine the status of these signs and symptoms?
   4. What are the usual causes of these problems?
   5. What will I assess to determine the status of the causes of the problems?
   6. How do these problems usually progress, and how are they managed?
   7. How can these problems be prevented?
   8. What could cause these problems to change and in what way?
   9. What are the signs and symptoms of potential complications of these problems, and how will I
       monitor for these signs and symptoms?
   10. What other processes are likely to be seen along with these problems?
   11. What medications and treatments are likely to be used, and why?
   12. What medication-related or treatment-related problems might I encounter, how will I monitor
       or detect them, and how are they usually managed?
   13. What cultural factors, values, or beliefs might have bearing on health practices in relation to
       these health problems?
   14. What are the key things people need to know to manage these problems independently, and
       what will I do to ensure that this knowledge is gained?



Taken from work by Rosaline Alfaro-LeFevre




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Daily Routine (This is an example; develop a routine that works for you.)

Organization and time management are critical skills necessary for safe, efficient, and effective care. One way to
develop these skills is to establish a daily routine. Following is an example of a daily routine for providing care in
an acute care setting.

Obtain Assignment

Review chart, action list (or kardex), and MAR (medication administration record)

Develop Plan of Care (POC)—use concept map care plan tool--- This needs to be more than just a task list.

Obtain Report

Introduce self to patient—brief general assessment/spot check (how does patient look/respond to you, how did
they do during night, anything special needed today; questions/concerns, etc.; check equipment/orders (IV, O2,
I&O, etc.); what patient can expect of you and what you would like patient to do (call before getting out of bed,
measuring urine, etc.)

Discuss POC with instructor

Provide care (include hourly rounds):
     Obtain morning vital signs
     Review a.m. labs
     Review medications with instructor and pass at appropriate times (must obtain information needed to
        safely pass meds—BP, etc.)
     Chart
     Complete assessment (ideally this should be done as early in shift as possible (i.e., if no 0800 meds, do
        assessment before 0900 meds).
     Chart
     Complete a.m. care (bathing, ambulation/activity, dressing change, incentive spirometer, teaching, etc.)
     Chart
     Round with MD, completing new orders, additional meds, etc.
     Chart
     Repeat vital signs

Lunch (~1130)

Provide care (including hourly rounds)
     Review medications with instructor and pass at appropriate times (must obtain information needed to
        safely pass meds—BP, etc.)
     Chart
     Total I&O by 1400 (including IV totals), enter information into computer.
     Document E-note
     Report off to RN by 1430
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                              Essential Nursing Actions Common to All Procedures


The following nursing actions are an integral part of every nursing procedure and should be referred to before
reading or practicing any procedure describes in the text.




1. Check the need for the procedure.
2. Make sure that there is a valid order for the procedure if an order is needed.
3. When appropriate, take into consideration the patient’s preferences and the way the procedure has been
    done before.
4. Assemble the equipment needed, paying attention to efficiency and economy.
5. Maintain medical asepsis at all times, with special emphasis on proper handwashing and standard
    precautions.
6. Identify the patient.
7. Explain the purpose and nature of the procedure to the patient and/or family. Explain the patient’s role and
    how he can help.
8. Protect the privacy of the patient.
9. Use protective body mechanics at all times.
10. Assess the status of the patient before starting the procedure to obtain a baseline for determining the
    effectiveness of the procedure.
11. Communicate appropriately with the patient throughout the procedure. (Seek feedback about the effect of
    the procedure, give psychological support, continue an ongoing nursing history or teach.)
12. Leave the patient comfortable and his unit tidy at the end of the procedure.
13. Take care of equipment in accordance with the nature of the procedure.
14. Report and/or record the outcomes of the procedure legibly, promptly, completely and accurately.




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                                                                                            MacMurray College
                                                                                    Clinical Education Manual

                                          Nursing Student Folders

Each student will have a folder that is accessible on the MacMurray College computer network. The
folder can only be accessed by the individual student and the nursing department faculty.

This folder is intended to be the place to store important documents, papers, projects, etc., which will
be used to identify academic, technical, clinical, and professional growth as you progress through the
nursing program. Many of the documents will be used in the development of your academic portfolio.
To help organize files within each individual folder there will be subfolders labeled Professional
Growth, Technical Skills, Clinical Evaluations, Clinical Written Work, Papers and Projects, and
miscellaneous. The miscellaneous folder will be a good place to store work you are completing or
work that will be submitted electronically for feedback or grading.

You can access this file from any computer on campus. Click on the start button. Choose “Log-Off”.
A dialog box will come up asking you “Are you sure you want to log off?” Select yes. A “Welcome to
Windows” dialog box will appear. Press Ctrl-Alt-Delete to begin. A Log on to Windows dialog box
appears. From this point follow the instructions below:

   1. Log-in: lastname.firstname@mac.edu

   2. Leave password box empty and hit enter.

   3. A dialog box will appear that says: “You are required to change your password at first login” Select “OK”

   4. A “Change Password” box appears.

   5. Leave the box that asks for the current password blank.

   6. Type a password of your choice into next box and then re-type in the next box for confirmation.

   7. You will receive the message that your password has been changed.

   8. The desktop will open.

   9. Select “My Computer” either from an icon on the desktop or by selecting the start button and choosing
      “My Computer”

   10. You will see that you are connected to the (N:) network. Double click on this icon and it will open your
       folder.


Electronically Submitted Work
All electronically submitted work will be reviewed by instructors and placed in the appropriate
subfolder when feedback and/or grading is complete. It will be the responsibility of the student to
confirm that graded work has been placed within the folder. Graded clinical work will be returned via
e-mail as well to ensure timely feedback. Reviewing feedback is essential to growth.

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                                                                                 Clinical Education Manual

Clinical Evaluation Tool Documentation
During clinical courses students will document comments supporting outcome achievement on the
clinical evaluation form on a weekly basis. The evaluation forms will be submitted electronically to the
clinical instructor on designated dates to coincide with midterm and the end of the semester.
Instructors will add comments and share feedback with students. At the end of the course the
completed evaluation form will be placed in the student network folder and a signed hard copy will be
placed in the student’s permanent clinical folder.

Technical Skills Checklist
During the sophomore year the Technical Skills and Technology Checklist will be jointly completed by
the Nursing 211 lab and clinical instructor. It is the responsibility of the student to ensure the checklist
is updated (must bring checklist to every clinical and laboratory session). A copy of the technical skills
list will be attached to each clinical evaluation and placed in the student’s clinical file. The original
technical skills checklist will be returned to the student at the beginning of the junior year. As the
student progresses through other courses and learns new skills, it will be the responsibility of the
student to document new skills as they are acquired.

Electronic Submission of Written Work

   1. All students must create written work using MSWORD.
           a. To open a MSWORD 2007 document in an earlier version you will need to install Microsoft
              Office Compatibility Pack for 2007 Office Word, Excel and PowerPoint file formats.
                    i. Go to http://www.microsoft.com/downloads/
                   ii. Under “Popular Downloads” select: “MS Office Compatibility Pack for Word, Excel, and
                       PowerPoint 2007 file formats”.

   2. Creating and Saving Documents
          a. Using the appropriate Microsoft Office program create your document.
          b. Save the document to your hard drive or flash drive.
          c. Label your document as follows so your instructor can easily identify the author and specific
              document.
                   i. Clinical written work files should be labeled with student’s last name, course and date
                      of clinical. (e.g., lastname N330 clinical 7.26.07)
                  ii. Written work for the course should be labeled with the student’s last name, course,
                      assignment, semester, and year. (e.g., lastname N330 Teaching Plan Fall 2007)

   3. Written work needs to be submitted using your MacMurray e-mail.
         a. If you have difficulty or questions contact the IT Department.




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                                                                              Clinical Education Manual

                                                 Clinical Forms

In the Nursing Division Computer Lab forms can be accessed by:
     1. Selecting “My Computer”
     2. Selecting the “Student Data” drive


Outside of the Nursing Division the forms can be accessed by:
   1. Accessing Professor Staake’s website: www.mac.edu/faculty/christinestaake
   2. Selecting “Clinical Forms” from the home page



                                                Forms Available:

      Care Plan Document 2010

      Clinical Data Tool Grading Rubric 2010

      Clinical Data Tool Revised 6-2010

      Combined Clinical Data Tool and Grading Rubric 2010

      Concept Map Template 2010

      Medication Sheet 2010

      Combined Complete Database and Grading Rubric 2010

      Technical Skills and Technology Checklist Revised 4-2010

      Weekly Clinical Evaluation of Critical Behaviors Template

      Clinical Paperwork Free Pass 6-2010

      Clinical Absence Documentation Form 2010




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COLLABORATIVE PROBLEMS

Ignatavicius and Workman

“Collaborative problems are potential health problems for which the nurse monitors and helps to prevent. They
often require interdisciplinary interventions” Nurses assess and identify health problems as early as possible and
notify the health care provider. “Then, in collaboration with interdisciplinary care team members, carry out
interventions to resolve the problem” (p. 13)

Example: Potential for hypoglycemia for a client with diabetes.

          Potential for post-op complications in a post-surgical client.

When determining whether a Collaborative Problem exists, think about:

        “What do we want to prevent?”

        “What could occur?”



Brunner and Suddarth

“In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain
situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to
potential problems or complications that are medical in origin and require collaborative interventions with the
physician and other members of the health care team. The term collaborative problem is used to identify these
situations.

Collaborative problems are certain physiologic complications that nurses monitor to detect changes in status or
onset of complications. Nurses manage collaborative problems using physician-prescribed and nursing-
prescribed interventions to minimize complications (Carpenito-Moyet, 2004). When treating collaborative
problems, a primary nursing focus is monitoring patients for the onset of complications or changes in the status
of existing complications. The complications are usually related to the disease process, treatments, medications,
or diagnostic studies. The nurse recommends nursing interventions that are appropriate for managing the
complications and implements the treatments prescribed by the physician.” (pp. 37, 39).




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                                           Concept Care Mapping Guide

Schuster (2008) provides guidelines for quickly organizing and analyzing patient data in the book Concept
Mapping: A Critical-Thinking Approach to Care Planning. Excerpts from Chapter 1: “ ‘Twas the Night Before
Clinical. . .” are included in this reference guide.

Concept = idea

Schuster states: Concept maps (in general)
    Show hierarchical organization of concepts
    Demonstrate relationships among concepts (important ideas are linked together)
    Assist in assimilating knowledge
    Build/integrate new knowledge into what is already known
    Identify and integrate what is already known
    Reveal what is not understood (Schuster, 2008, p. 2)

Schuster identifies that concept map care plans:
    Enhance critical thinking skills and clinical reasoning
    Allow clear and succinct visualization of priorities and identification of relationships
    Assist students to organize patient data, analyze relationships in data, establish priorities, build on
       previous knowledge, identify what is not understood
    Enable holistic view of patient situation

Concept mapping requires critical thinking to analyze relationships in clinical data. This in turn builds clinical
reasoning skills.

What should be linked together? According to Schuster, you should link:
   Medical and nursing diagnoses
   Pertinent clinical data

Foundational framework for concept map care plan development = Nursing Process

Concept map care planning process must start with gathering clinical data.
Review of patient record will determine:
        Current health problem
        Medical history
        Physical assessment data
        Medications
        Treatments



                                                          19
According to Schuster, steps in developing a concept map care plan include the following steps:
   1) Develop a Basic Skeleton Diagram (based upon clinical impressions)
       The student will need to determine “Why does the patient need health care?”
       Write the reason for seeking care (usually the medical diagnosis) in the middle of a blank page of paper.
       Next the student will need to determine “What is the patient’s response to this need?”
       Around the central diagnosis arrange general problems that represent patient responses to the reason
       for seeking health care.

        The student should initially identify what he/she thinks are the patient’s problems with whatever words
        come to mind. Nursing Diagnosis statements can be developed or refined later.

    2) Analyze and Categorize Data
       Use data gathered from medical record review and brief encounter with patient to provide evidence to
       support the medical and nursing diagnoses (or identified problems).

        Identify and group the most important assessment data related to the reason for seeking care. Also,
        identify and group clinical assessment data, treatments, medications and medical history data related to
        problem/nursing diagnosis.

        List the current information on diagnostic test data, treatments, medications, and medication history
        data under appropriate problem/nursing diagnosis.

        If you don’t know where the data should go, but you know it is important, list it out to the side and ask
        your clinical instructor for guidance or clarification.

        You can place symptoms or data in more than one category (list with more than one problem or nursing
        diagnosis) if relevant.

        It is essential to determine priority assessments that must be performed regarding the primary reason
        for seeking care. Write these assessments in the central box of the concept map care plan. These
        assessments must be completed on first contact with the patient and carefully monitored throughout
        the remainder of the clinical day.

    3) Analyze Nursing Diagnosis Relationships
       Analyze relationships among nursing diagnoses. Draw solid lines for direct relationships and broken
       lines for indirect relationships between problems or nursing diagnoses. Be prepared to verbally explain
       to your clinical faculty why you have made these linkages.

    4) Identify Goals, Outcomes, and Interventions
       On a separate sheet of paper write patient outcomes and then list interventions to attain outcome for
       each diagnosis on concept map.



                                                        20
        List nursing care you intend to provide during your scheduled clinical interactions. You can either check
        off interventions as completed or make revisions in the concept map diagram and interventions as you
        interact with the patient.

        Interventions will include key areas of assessment and monitoring procedures, as well as therapeutic
        interventions such as patient teaching or therapeutic communication.

        Goals and rationales for interventions do not have to be written down, but the student will need to be
        prepared to verbally explain goals and rationales for intended nursing actions.

        If the patient requires an intervention that the student has not yet learned, the intervention should be
        included on the concept map with the notation that the primary nurse or other team member will be
        completing.

        Students will need to be prepared to discuss the basic purpose for all interventions (the ones he/she
        completes as well as those completed by staff).

    5) Evaluate Patient’s Response
       This step involves the written evaluation of the patient’s physical and psychosocial responses. As the
       student performs a nursing activity, the patient’s response should be written down.

        It is not realistic for all expected outcomes to be fully met. It is important to assess and document the
        degree to which the expected outcome is met or unmet. In addition to the information about meeting
        expected outcomes you should include discussion regarding reassessment and necessary changes to the
        plan of care to progress toward achievement of the expected outcome(s).

        This step also involves writing clinical impressions and inferences regarding the patient’s progress
        toward expected outcomes and discussion of the effectiveness of interventions.
        This summary statement should be written for each nursing diagnosis.


During the clinical day the student and clinical instructor will have an on-going discussion regarding changes in
patient assessment data, effectiveness of interventions, and patient responses to interventions.

To facilitate this discussion the student should keep the concept map care plan readily available (in his/her
pocket) and review at intervals to ensure that everything is done and evaluated. Take notes, make changes to
the concept map care plan, add or delete interventions, and record patient responses as appropriate.

The concept map, interventions, and patient responses will be the basis for the student’s documentation. It will
serve as a guide for adequate documentation of patient problems, interventions, and evaluation of patient
responses.




                                                        21
Using Concept Map Care Plan to Facilitate Medication Administration

List ordered medications under the appropriate problem or nursing diagnosis. Also include time medication is to
be administered to help remind you of importance of administration times. By organizing the medications
under the correct problem or nursing diagnosis it shows your understanding of relationships of the drug to the
problem. This will also make it easier to integrate medications with lab values and pathology associated with
problems.

Nursing Standards of Care and Concept Care Maps

Using the nursing process as a framework, Concept Care Maps are individualized to the assigned patient and
ensure safe and effective nursing care. The process is contingent upon the student knowing accepted standards
of care and following those standards. When planning care the student must ask “What are the standards of
care pertinent to the assigned patient and the patient’s medical and nursing diagnoses?”

ANA Standards of Nursing Practice

    1. The collection of data about the health status of the client/patient is systematic and continuous.
       The data are accessible, communicated, and recorded.

    2. Nursing diagnoses are derived from health status data.

    3. The plan of care includes goals derived from the nursing diagnoses.

    4. The plan of nursing care includes the priorities and the prescribed nursing approaches or
       measures to achieve the goals derived from the diagnoses.

    5. Nursing actions provide for client/patient participation and health promotions, maintenance,
       and restoration.

    6. Nursing actions assist the client/patient to maximize his health capabilities.

    7. The client’s/patient’s progress or lack of progress toward goal achievement is determined by the
       client/patient and the nurse.

    8. The client’s/patient’s progress or lack of progress toward goal achievement directs
       reassessment, reordering of priorities, new goal setting, and revision of the plan of nursing care.

Nursing Social Policy Statement, ed. 2. American Nurses Association, Washington, D.C., 2003.



The Joint Commission

The Joint Commission provides health care agencies with specific standards that must be followed in the
nursing care of patients. Infractions of these standards could result in the health care agency losing its
accreditation and ability to provide care for clients/patients. The written policies and procedures of the health
care agency guide client/patient care and meet the mandated requirements of JCAHO.

Resources: Schuster, P.M. (2008). Concept mapping: A critical-thinking approach to care planning 2nd Ed.
Philadelphia, PA: F.A. Davis Company.

                                                        22
23
                                              Now fits with the
                               I don’t know how thisis the time
  Key Problem #                                                        Key Problem #
                               problems.

                                                    Njnjnjnjnv
  Supporting Data:                                                     Supporting Data:
                                                        V

                                                        V




Key Problem #                                          V
                       Key Demographic Data:                                      Key Problem #
                       Reason for Needing Health Care: V
                       Medical Diagnosis/Surgical Procedure:
Supporting Data:                                       V                          Supporting Data:
                                                        V
                       Key Assessments:
                                                        V




                                 Key Problem #          V

    Key Problem #                                       V         Key Problem #

                                 Supporting Data:       V

    Supporting Data:                                              Supporting Data




                                                       24
Identified Nursing Diagnoses        Expected Outcomes                         Plan/Interrventions           Patient Responses to
     (in order of priority) :   (What do you expect patient will        (what do you intend to do to help       Interventions
                                           achieve)                      patient/client achieve expected
                                                                                     outcome):




                                                                   25
                                Written Care Plan Instructions/Guidelines



Sophomore:

      Use 5 column form

      Rationales for all interventions must come from course text(s) and be cited appropriately.

      Rationales from care planning books are not allowed.



Junior/Senior:

      Use 5 column form with Complete Data Base

      Draw from knowledge base to articulate rationales for all interventions.

      If you do not know or can’t recall the rationale for a selected intervention, look it up in course
       text(s) and cite source appropriately.

      When developing comprehensive plans of care for specialty areas (Psych, OB, Peds,
       Geriatrics), utilize course text(s) for rationales and cite source appropriately.




                                                     26
                                           PATIENT CARE PLAN

     DIAGNOSES        PATIENT OUTCOMES   INTERVENTIONS         RATIONALE   PATIENT EVALUATION

   (Circle Primary)                                                         /SELF ASSESSMENT

MEDICAL:




NURSING (NANDA):




                                                   27
                                       CLINICAL DATA TOOL (Revised 6/2010)

Student:                                                Date:

Medical Diagnosis:                                                          Physician:

Comorbidities:

Chief Complaint as stated by patient/client:



Client Demographics:       Initials:      Age:             History of current illness:
Room:        Gender:           Race:
                                                           Past Health History:
Allergies:
                                                           Contributing or Risk Factors:
Admission Date:          LOS:

Admitted from:

3 Generation Family history:



Brief Discussion of Major Medical Diagnosis in your own words: (Must Cite Source, Do not cut & paste)

Pathophysiology:

Major symptoms:

Major medical treatment:

Pertinent Assessment Findings: (Focused assessment R/T priority problem(s); include subjective and objective)

General:

Skin/Hair/Nails:

Head/Neck:

Eyes/Ears:

Nose/Mouth/Throat:

Breast/Axilla:

Thorax/Lung:

Heart/Great Vessels:

Abdomen:

Peripheral Vascular:

Musculoskeletal:


                                                         28
Neurological:

Genitourinary:

Anus/Rectum:

Plan of Care:

 Identified Nursing        Expected Outcomes             Plan/Interventions (what      Patient Responses to
 Diagnoses (in order       (what do you expect           do you intend to do to help   Interventions
 of priority):             patient will achieve):        patient/client achieve EO):




Diagnostic Interpretation (List diagnostic results and include discussion of how they correlate to the clinical
picture. Include relevant normal values:

WBC:

RBC:

Platelets:

H&H:

K+:

CL-:

Na+:

Glucose:

Additional labs:

CXR:

ECG:

Additional diagnostics:




Patient Education: (Identify learning needs and describe education provided to assigned client. Identify and
discuss application of teaching/learning principles.)



                                                         29
Collaboration:

Collaborative Problems:

Collaborative Partners:

Communication:

Communication techniques utilized:

Barriers encountered:

Analysis:



Ethics:

Ethical principles:

Ethical issues:

Response and Implications for care:

Self-Reflection:




Evidence-Based Practice: (Clinical guidelines, research studies, journal articles. Please include link to
any on-line articles.)




                                                     30
MEDICATION—SUMMARY

*Name at least one important side effect for which to monitor

**Identify important nursing implications for this drug (What do you need to know about administering or monitoring this drug?).

Include pertinent lab tests that should be monitored




   MEDICATION              CATEGORY             INDICATIONS           DOSE     ROUTE      FREQUENCY        MAJOR           SIDE MAJOR NURSING
                                                                                                           EFFECTS *            IMPLICATIONS **
   (Include generic and    Therapeutic &        For this Client
   trade name)             Pharmacologic
                           class




                                                                                                                                   More medications can be
                                                                                                                                   added by pressing the
                                                                                                                                   <Tab> key while the
                                                                                                                                   cursor is in this cell


                                                                                                                                                         31
                                                        MACMURRAY COLLEGE CLINICAL EVALUATION TOOL

Student’s Name__________________________________________________________               Date__________________       Pass / Fail

Demonstration of the eight following Core Competencies requires integration of concepts from the behavioral, biological and natural sciences. Competency
reflects an understanding of the human condition.

                     COMPETENCY                                                    Supporting Evidence                                     Met    Unmet
1.   ASSESSMENT AND INTERVENTION SKILLS
     a.   Utilizes the nursing process as a decision
          making model.
          i)     Differentiates between normal
                 assessment findings and those that
                 require additional assessment and
                 monitoring.


          ii)    Formulates plan of care and safely
                 carries out therapeutic nursing
                 interventions and procedures based
                 upon assessment data


          iii)   Integrates pertinent data from
                 multiple sources to plan, administer
                 and evaluate care.



     b.   Integrates safety and protection principles
          and precautions into practice.



2.   COMMUNICATION SKILLS
     a.   Demonstrates effective oral
          communication.

                                                                                                                                                           32
          i)    Integrated therapeutic
                communication techniques into client
                interactions.


          ii)   Implements effective communication
                techniques when communicating
                with team members.

     b.   Demonstrates effective written
          communication.



     c.   Demonstrates effective computing skills.




     d.   Provides empathetic care.




3.   CRITICAL THINKING SKILLS
     a.   Demonstrates self-awareness



     b.   Demonstrates self-discipline



     c.   Demonstrates autonomy and
          responsibility




                                                       33
     d.   Demonstrates caution and prudence with
          unfamiliar situations



     e.   Demonstrates honesty



     f.   Demonstrates analysis and insight.




     g.   Demonstrates open and fair mindedness.



4.   HUMAN CARING AND RELATIONSHIP SKILLS
     a.   Demonstrates understanding of ethical
          implications for care.



     b.   Demonstrates client advocacy




     c.   Recognizes client’s rights.
          i)  Protects client privacy



          ii)   Preserves confidentiality




                                                   34
     d.   Verbalizes legal implications of specific
          interventions or client care situations.



     e.   Demonstrates moral, ethical and legal
          behaviors.



     f.   Identifies resources in health care system
          and community that contribute to health
          promotion.


5.   MANAGEMENT SKILLS
     a.   Utilizes material resources effectively.



     b.   Organizes time effectively.



     c.   Prioritizes care



     d.   Demonstrates effective planning,
          delegation and supervision of others as
          appropriate.
     e.   Collaborates with resource persons as
          appropriate.


6.   LEADERSHIP SKILLS
     a.   Demonstrates creativity.



                                                       35
     b.   Demonstrates flexibility.




     c.   Demonstrates sensitivity.




7.   TEACHING SKILLS
     a.   Utilizes knowledge of teaching/learning
          principles to plan and deliver care




8.   Knowledge Integration Skills
     a.   Integrates information technology into the
          practice of nursing.




     b.   Integrated pharmacologic/medication
          administration principles into care delivery.




     c.   Identifies the interrelationships that
          comprise the whole client (General
          Systems Theory).



                                                          36
    d.   Interprets and uses quantitative data.




    e.   Integrated knowledge from liberal arts,
         natural and social sciences into care
         planning and delivery.


Instructor Summary/Comments:



Student Comments/Goals:



Instructor_______________________________________________________
*Student________________________________________________________
Date___________________________________________________________
*My signature indicates an instructor has discussed this evaluation with me.




                                                                               37
                                MACMURRAY COLLEGE DEPARTMENT OF NURSING: CLINICAL COMPETENCIES FOR EVALUATION*
*This document is based on the eight core competencies identified by Carrie B. Lenburg, EdD, RN, FAAN. Many of the indicators were taken from a collection of her published works.

1) Assessment and Intervention Skills
   a) Utilizes the nursing process as a decision making model.
      i) Differentiates between normal assessment findings and those that require additional assessment and monitoring.
Indicators:                                   Sophomore Level                               Junior Level                               Senior Level
Demonstrates accurate physical                Progressive competence in assessing           Competent in comprehensive                 Competent in comprehensive
assessment and history taking skills          body systems and obtaining patient            subjective and objective body system       subjective and objective body system
                                              history.                                      assessment of ill adults. Thoroughly       assessments of special populations
                                                                                            explores patient history.                  (Psych, Maternal-Child, Geriatric)
                                                                                                                                       Thoroughly explores patient history.
Verbalizes normal vs. abnormal                Focus on identification of normal             Identifies abnormal assessment findings Identifies abnormal assessment findings
assessment findings.                          findings. Can note variations from            and verbalizes the pathophysiology of      within the special population and
                                              normal but limited knowledge base             the abnormality and how the                verbalizes the pathophysiology of the
                                              prevents ability to comprehensively           abnormality impacts the plan of care.      abnormality and how the abnormality
                                              address abnormalities.                                                                   impacts the plan of care.
Selects follow-up measures based on           Not expected at this level based on           Identifies measures to minimize,           Identifies measures specific to the
knowledge of theory and review of             knowledge base limitations.                   resolve, or further monitor abnormal       special population to minimize, resolve,
relevant research.                                                                          assessment findings and verbalizes         or further monitor abnormal
                                                                                            rationales.                                assessment findings and verbalizes
                                                                                                                                       rationales.
Appropriately interprets VS, diagnostic       Expected to know normal VS                    Expected to report any VS variation. Expected to identify changing trends in VS
tests, lab values                             parameters and report variations.             and intervene before problem occurs. Identify abnormal lab and diagnostic
                                                                                            findings and take appropriate action.
Explains the relationship between             Patient response focus: Identifies            Disease specific focus: identifies nursing Disease specific focus (Psych, Peds,
specific nursing problems,                    nursing diagnoses and interventions           diagnoses, interventions, medications,     Geriatric): identifies nursing diagnoses,
pathophysiology, pharmacology, lab            related to immobility, skin integrity,        diagnostic tests and lab values and        interventions, medications, diagnostic
values, and interventions.                    oxygenation, elimination, fluid balance,      verbalizes the interrelationships.         tests and lab values and verbalizes the
                                              and pain.                                                                                interrelationships. Population specific
                                                                                                                                       (Antenatal, Labor and Delivery) will
                                                                                                                                       focus on identification of variations
                                                                                                                                       from the normal or expected
                                                                                                                                       progression and discuss
                                                                                                                                       interrelationships of pathophysiology,
                                                                                                                                       pharmacology, diagnostics and
                                                                                                                                       interventions.


                                                                                                                                                                                     38
Uses interventions based on                Expected to seek guidance from              Expected to research factors which may    Incorporates families in care planning
understanding of family theory,            instructor or staff related to care of      impact care of culturally diverse clients.and delivery. Completes family or
community and cultural factors.            culturally diverse clients.                 Expected to discuss interventions with    community assessments to identify
                                                                                       instructor or staff.                      priorities and appropriate
                                                                                                                                 interventions.
Identifies spiritual needs.                Progressive competence with spiritual       Expected to comprehensively assess spiritual needs and incorporate interventions
                                           assessment and identification of needs.     into plan of care.

         ii) Formulates plan of care and safely carries out therapeutic nursing interventions and procedures based upon assessment data.

Indicators:                                Sophomore Level                             Junior Level                               Senior Level
Completes pre-planning                                                                     As outlined by course instructor
Verbalizes priorities for care based       Progressively expected to identify          Expected to prioritize nursing diagnoses/care based upon preplanning data and
upon client needs.                         priority nursing problem.                   verbalize any changes determined by actual patient assessment data.
Confers with client about plan of care.    Progressively expected to include client    Expected to share preliminary plan of care with client, family, or population and
                                           in planning process.                        make adjustments based upon client needs and preferences.
Collaborates with client to determine      Progressively expected to collaborate       Expected to rely on client input to determine goals and client response to evaluate
goals and evaluate outcomes.               with client to set goals. Include client    outcomes.
                                           response in evaluation of outcomes.
Identifies steps for procedures            With instructor guidance will be            Will be able to independently verbalize standard steps for basic procedures and
                                           expected to progressively verbalize the     identify when adaptations to the standard protocol is necessary. Expected to seek
                                           standard steps for basic procedures:        instructor guidance for unfamiliar procedures.
                                           VS, Hygiene, Positioning, Activities,
                                           Wound care, Dressing changes, Suture
                                           and Staple removal
Reassesses before carrying out             With instructor guidance and                Expected to independently reassess prior to procedures and seek guidance from
measures.                                  supervision.                                instructor and staff as appropriate.
Modifies plan of care to reflect changes   Follows direction of instructor or staff    Expected to monitor for trends which would indicate an impending condition
in client condition.                       when patient condition change is            change. Expected to verbalize necessary adaptations to plan of care based upon
                                           identified.                                 change and seek guidance of instructor as needed.
Assesses client response to intervention   Progressively expected to identify client   Expected to monitor/assess client response to interventions within appropriate
                                           response to basic nursing interventions.    time frame and report findings as indicated.
Uses outcomes to evaluate                  Expected to identify expected outcome       Expected to identify specific and measurable expected outcomes. Evaluation is
effectiveness of care.                     for identified priority nursing problem     expected to be clearly based on outcome and include discussion of effectiveness
                                           and seek assistance of instructor to        and need for adaptation to plan of care as needed.
                                           evaluate.




                                                                                                                                                                             39
         iii) Integrated pertinent data from multiple sources to plan, administer and evaluate care.
Indicators:                                 Sophomore Level                            Junior Level                                 Senior Level
Receives report on client.                                                            Consistently expected throughout all levels.
Reviews current labs.                       With instructor guidance will review       Independently review labs and verbalizes clinical significance related to the
                                            pertinent labs.                            population.
Obtains pending labs.                       With guidance of instructor.               Independently seeks pending lab results.
Review chart of changes.                    With guidance of instructor.               Independently reviews chart for changes, with particular focus on changes in
                                                                                       physician orders.
Notes changes in assessment data.           Progressively demonstrates ability to      With minimal guidance will identify          Independently identifies changes in
                                            recognize changes.                         changes in assessment data and report        assessment data and reports or
                                                                                       appropriately.                               intervenes appropriately.
Integrates data from support systems        Progressively demonstrates ability to      Consistently demonstrates                    Consistently demonstrates
into care.                                  incorporate family/significant others in   incorporation of family and significant      incorporation of family and significant
                                            data collection process.                   others in data collection process when       others in data collection process when
                                                                                       designing and coordinating care.             managing care for individuals, families
                                                                                                                                    or populations.
Integrates Standards of Care (Policies      With direction of instructor will utilize  Takes initiative to utilize policy and procedure manuals to plan care interventions.
and Procedures) of specific agencies.       policy and procedure manuals.              Reviews findings with instructor or staff prior to implementation.

    b) Integrates safety and protection principles into practice.
Indicators:                                 Sophomore Level                           Junior Level                              Senior Level
Identifies client according to agency                                        Consistent demonstration is expected throughout all levels .
protocol.
Maintains a safe practice environment.                                       Consistent demonstration is expected throughout all levels .
Bed at appropriate height for care.                                          Consistent demonstration is expected throughout all levels .
Bed in lowest position with side rails up                                    Consistent demonstration is expected throughout all levels .
when student not at bedside.
Incorporates interventions to minimize                                       Consistent demonstration is expected throughout all levels .
risk of injury to client and self during
care delivery.
Demonstrates Standard Precautions                                            Consistent demonstration is expected throughout all levels .
Demonstrates appropriate use of PPEs                                         Consistent demonstration is expected throughout all levels .
Demonstrates appropriate Isolation                                           Consistent demonstration is expected throughout all levels .
Precaution techniques.
Is in compliance with all Health and                                         Consistent demonstration is expected throughout all levels .
Safety Requirements.
Completes agency specific training prior                                     Consistent demonstration is expected throughout all levels .
to entering clinical setting.

                                                                                                                                                                              40
2) Communication Skills
   a) Demonstrates effective oral communication.
      i) Integrates therapeutic communication techniques into client interactions.
Indicators:                               Sophomore Level                            Junior Level                              Senior Level
Introduces self to client                                                   Consistent demonstration is expected throughout all levels .
Knocks before entering room                                                 Consistent demonstration is expected throughout all levels .
Uses effective communication skills in    Progressively grows in use of              Demonstrates a variety of therapeutic
obtaining patient assessment data.        therapeutic communication skills.          communication techniques.
Recognizes the effects of own             With instructor guidance will recognize    With minimal instructor guidance will     Independently identifies impact of own
behaviors and communication style on      own communication style and                recognize impact of own                   communication style and formulates
others                                    implications. Responds positively to       communication style. Will formulate       strategies to overcome any
                                          feedback.                                  strategies to facilitate communication.   deficiencies. Recognizes adaptations to
                                                                                     Responds positively to feedback.          communication strategies when
                                                                                                                               interacting with groups.
Uses self reflection as a tool for        Progressively grows in use of reflection. Becomes increasingly comfortable with Independently relies upon self-
personal growth                                                                      use of reflection and utilizes insight to reflection as a tool to measure
                                                                                     adapt approach to care design and         adequacy of clinical performance and
                                                                                     coordination.                             develop strategies for improvement if
                                                                                                                               appropriate.
Establishes a therapeutic relationship.                                     Consistent demonstration is expected throughout all levels .
Demonstrates therapeutic use of self to   Progressively becomes comfortable in       Demonstrates caring behaviors and         Demonstrates caring behaviors and
establish a caring relationship.          role of care provider.                     actively engages with client on an        actively engages with individuals or
                                                                                     interpersonal level.                      groups on an interpersonal level.

         ii) Implements effective communication techniques when communicating with team members.

Indicators:                               Sophomore Level                             Junior Level                             Senior Level
Actively participates as a member of       Identifies pertinent information to give   Organizes and gives report based on      Gives and receives delegation report
the interdisciplinary team be receiving   in report and reports off before leaving.   relevant data and priorities of care.    appropriately.
report and reporting off at the end of
care.
Reports relevant information to staff                                      Consistent demonstration is expected throughout all levels .
and instructor in a timely manner.
Actively contributes to clinical                                           Consistent demonstration is expected throughout all levels .
conferences.
Demonstrates assertiveness.               Progressively improves in assertive       Consistently demonstrates assertive communication with team members.
                                          communication with team members.
Demonstrates common courtesy                                               Consistent demonstration is expected throughout all levels .

                                                                                                                                                                         41
    b) Demonstrate effective written communication.
Indicators:                              Sophomore Level                             Junior Level                                Senior Level
Demonstrates documentation in            With instructor guidance formulates         With minimal guidance will formulate        Independently formulates
accordance with agency policy.           documentation based upon client             documentation based upon client             documentation based on assessment of
                                         assessment findings and effective           assessment findings and effective           individuals or groups and effective
                                         communication principles.                   communication principles.                   communication principles.
Identifies pertinent data and            With instructor guidance documents          With minimal guidance documents             Independently documents pertinent
documents appropriately.                 pertinent information in client record      pertinent information in client record in   information in client record in clear,
                                         in a clear, concise manner                  clear, concise manner.                      concise manner.

    c) Demonstrate effective computing skills.
Indicators:                              Sophomore Level                            Junior Level                              Senior Level
Attends orientation to agency specific                                      Consistent demonstration expected throughout all levels.
computer documentation system.
Implements computer documentation                                           Consistent demonstration expected throughout all levels.
as required by agency policy.

    d) Provides empathetic care.

Indicators:                              Sophomore Level                             Junior Level                                Senior Level
Demonstrates a caring presence.          Progressively demonstrates use of           Independently utilizes active listening     Independently utilizes active listening
                                         active listening and other therapeutic      and therapeutic communication.              and therapeutic communication.
                                         communication techniques.                   Demonstrates comfort with silence and       Demonstrates acceptance of individual
                                                                                     remaining engaged with client during        or group. Remains engaged and
                                                                                     difficult situations.                       accessible during difficult situations.

Demonstrates ability to understand the   With the assistance of instructor will      With minimal instructor guidance will       Independently explores feelings of
feelings of others.                      explore client feelings and verbalize the   explore client feelings and incorporate     individuals and groups and incorporates
                                         implications for care provision.            into care design and coordination.          into the management of care.

3) Critical Thinking Skills
   a) Demonstrates self-awareness.
Indicators:                              Sophomore Level                             Junior Level                                Senior Level
Identifies own strengths and             With assistance of instructor can           Independently can identify strengths        Independently identifies strengths and
weaknesses.                              identify strengths and weaknesses.          and weaknesses. Collaborates with           weaknesses. Develops strategy for
                                         Receptive to instructor feedback.           instructor to choose strategies for         improvement with minimal assistance
                                                                                     improvement.                                of instructor.

                                                                                                                                                                           42
Identifies stereotypical biases.         With assistance of instructor will          Can independently identify                Can independently identify
                                         acknowledge stereotypical biases.           stereotypical biases that apply to        stereotypical biases that apply to
                                         Receptive to instructor guidance to         individual clients. Can formulate         populations +/or families. Incorporates
                                         overcome biases.                            strategies to prevent biases from         strategies into care planning and
                                                                                     affecting client care.                    management which prevent biases
                                                                                                                               from affecting care delivery.
Identifies when thinking is influenced   Will identify with assistance of            Will independently identify emotion based thinking and formulate strategies to
by emotions.                             instructor and be receptive to feedback.    overcome.


    b) Demonstrates self-discipline.

Indicators:                              Sophomore Level                             Junior Level                               Senior Level
Demonstrates ability to stay on task     With guidance of instructor will identify   Independently will identify and            Organizes and completes care for more
                                         and accomplish care delivery                accomplish care delivery expectations.     than one patient.
                                         expectations. Does not waste time on        Maintains focus on meeting client
                                         extraneous activities.                      needs. Does not waste time on
                                                                                     extraneous activities.
Demonstrates ability to manage time      Able to complete basic care procedures      With minimal assistance of instructor      Independently will identify and
and address selected priorities.         in allotted time. Focuses on assigned       will identify and prioritize client care   prioritize client care needs and manage
                                         aspects of care delivery.                   needs and remain focused on                the care of individuals, families, or
                                                                                     completing established plan of care.       populations.


    c) Demonstrates autonomy and responsibility

Indicators:                              Sophomore Level                             Junior Level                               Senior Level
Completes assignments without            Progressively becomes more                  Independently initiates care and           Independently initiates care and
prodding.                                independent in initiating care delivery.    completes assignments with minimal         completes assignments.
                                                                                     guidance of instructor.
Expresses own responsibility for         Verbalizes understanding of personal        Verbalizes understanding of personal       Verbalizes understanding of personal
outcomes.                                responsibility. Identifies own role in      responsibility. Identifies own role in     responsibility. Identifies own role in
                                         providing care.                             designing and coordinating care.           managing care of individuals or groups.


    d) Demonstrates caution and prudence with unfamiliar situations.

Indicators:                              Sophomore Level                             Junior Level                                Senior Level
Seeks help as needed                         Assertively asks for help in unfamiliar situations, when over-whelmed or when client safety dictates additional help.
Seeks additional information as              Asks questions of instructor or other resources when unsure. Does not attempt aspects of care without knowing the
needed.                                                                           rationale and nursing implications of actions.

                                                                                                                                                                          43
    e) Demonstrates honesty

Indicators:                                   Sophomore Level                             Junior Level                             Senior Level
Seeks the truth in all situations and          Student is honest and trustworthy at all times. Any evidence of dishonesty is grounds for clinical failure and dismissal from
admits mistakes.                                                                                   the nursing program.


    f) Demonstrates analysis and insight.

Indicators:                                   Sophomore Level                            Junior Level                                Senior Level
Sorts and organizes data while                Reviews chart and computer data to         Reviews chart and computer data             Organizes data from chart, computer,
recognizing connections between               identify and prioritize nursing            coupled with data from patient and          client, family, and staff to manage care
pieces of data                                problems. With assistance of               staff to design and organize care.          of individuals and groups.
                                              instructor will correlate client           Makes connections between clinical          Demonstrates problem solving,
                                              information to theory.                     data and theory with minimal                decision making, clinical reasoning and
                                                                                         assistance of instructor.                   ability to prioritize within groups.
Provides rationales for clinical activities   Based on limited knowledge base will       Drawing upon knowledge base the student will verbalize rationales in his/her own
                                              use text resource for rationales.          words.
Reflects upon and analyzes clinical           Will identify clinical decisions and       As care designer and coordinator will       As manager of care will independently
decisions                                     reflect upon and analyze with the          incorporate clinical decision making        incorporate clinical decision making.
                                              guidance of the instructor.                with minimal assistance of instructor.      Will independently reflect and analyze.
                                                                                         Will independently reflect and analyze.
Identifies alternatives as appropriate.       With assistance of instructor will         With minimal instructor assistance          Student will independently utilize
                                              identify any alternatives to care          student will utilize scientific inquiry and scientific inquiry, evidence-based
                                              provision.                                 evidence-based practice to design and       practice and the research process to
                                                                                         coordinate the care of individuals.         manage the care of individuals and
                                                                                                                                     groups.


    g) Demonstrates open and fair mindedness.

Indicators:                                   Sophomore Level                            Junior Level                               Senior Level
Questions and clarifies own viewpoints.       Demonstrated with guidance from            Independently recognizes when own          Independently recognizes when own
                                              instructor.                                viewpoint differs from client’s and does   viewpoint differs from that of
                                                                                         not let own viewpoint influence care       individuals or groups and prevents own
                                                                                         design or coordination.                    viewpoint from influencing
                                                                                                                                    management of care.
Supports fairness and non-                    Respects viewpoints of others. Does        Respects viewpoints of others. Does        Respects viewpoints of others. Does
discrimination through tolerance of           not discriminate in care provision.        not discriminate in care design or         not discriminate in care management of
other viewpoints.                                                                        coordination.                              individuals or groups.

                                                                                                                                                                                44
Clarifies how one’s own values, beliefs,   Demonstrates values clarification with       Independently demonstrates values           Independently demonstrates values
needs, and preferences may differ from     assistance of instructor. Verbalizes         clarification and verbalizes implications   clarification and verbalizes implications
those of others.                           implications for providing care.             for care design and coordination.           for care management of individuals and
                                                                                                                                    groups.


4) Human Caring and Relationship Skills
   a) Demonstrates understanding of ethical implications for care.

Indicators:                                Sophomore Level                              Junior Level                                Senior Level
Identifies ethical issues and takes        Will identify ethical principles relevant    Independently identifies ethical            Independently identifies ethical
appropriate action.                        to client care provision.                    principles relevant to care design and      principles relevant to management of
                                                                                        coordination.                               care for individuals, families, or
                                                                                                                                    populations.
Analyzes ethical issues and identifies     With instructor guidance will identify       Analyzes ethical problems/dilemmas          Analyzes ethical problems/dilemma and
alternatives.                              ethical issues and possible solutions.       and incorporates strategies to resolve.     incorporates strategies to resolve.


    b) Demonstrates client advocacy.

Indicators:                                Sophomore Level                              Junior Level                                Senior Level
Puts the needs of the client before own    Develops plan of care based on client’s      Collaborates with client to                 Collaborates with individual, family, or
needs.                                     needs. Physical care of client is focus of   comprehensively assess, identify and        group to comprehensively assess,
                                           care provision. Does not take break or       prioritize client needs. Designs and        identify and prioritize needs. Manages
                                           focus on additional data collection until    coordinates care based upon identified      care based upon identified needs.
                                           physical needs of the client are met.        needs. Client remains at center of all      Individual or group remains the center
                                                                                        activities. Does not take break or focus    of all activities. Ensures that all physical
                                                                                        on paperwork until physical needs of        needs of the individual or group are
                                                                                        the client are met.                         either directly or indirectly met before
                                                                                                                                    taking breaks or focusing on
                                                                                                                                    paperwork.
Develops cooperative interpersonal         Establishes rapport with client. With        Establishes rapport with client.            Establishes rapport with individual or
relationship with client                   guidance of instructor will identify         Independently identifies advocacy           family. Independently identifies
                                           advocacy needs. Will intervene with          needs of client and will advocate for       advocacy needs and intervenes as
                                           guidance of instructor or report need to     client or report need to appropriate        appropriate. Reports needs to
                                           appropriate staff.                           staff.                                      appropriate staff when beyond the
                                                                                                                                    scope of the student.




                                                                                                                                                                                   45
    c) Recognizes client’s rights.
       i) Protects client’s rights.

Indicators:                                Sophomore Level                            Junior Level                             Senior Level
Places bathing sign on door.                                                  Consistent demonstration expected throughout all levels.
Pulls curtains during care.                                                   Consistent demonstration expected throughout all levels.
Provides appropriate information           With guidance of instructor.               Independently provides appropriate       Independently provides appropriate
before procedures.                                                                    information for familiar procedures.     information to individuals or groups.
                                                                                      With minimal guidance of instructor for
                                                                                      newly acquired skills.


         ii) Preserves confidentiality.

Indicators:                                Sophomore Level                                Junior Level                              Senior Level
Appropriately gathers patient data.        Gathers only data relevant to providing        Gathers only data relevant to designing Gathers only data relevant to managing
                                           care to assigned client. Does not              and coordinating care of assigned         care of individuals, families or
                                           review other charts/data without               client. Does not review other             populations. Does not review other
                                           instructor permission.                         charts/data without instructor            data without instructor permission.
                                                                                          permission.
Does not discuss client in inappropriate   Utilizes a “need to know” approach when discussing client with other individuals. Does not discuss client(s) outside of the
manner.                                    clinical area. Can discuss client situations in post-conferences under the direction of the instruction.
Does not take client identifying data      Clients are only identified by initials in written work. No identifying client data may be photo-copied and removed from the
from clinical area.                        clinical area. Any printed material with patient identifiers must remain in the possession of the student during clinical and be
                                           protected from viewing by others. Any printed materials with client identifiers must be properly disposed of prior to leaving
                                           the clinical setting


    d) Verbalizes legal implications of specific interventions or client care situations.

Indicators:                                Sophomore Level                             Junior Level                               Senior Level
Demonstrates awareness of legalities of    With guidance of instructor can             Independently identifies the legal         Independently identifies the legal
nursing practice.                          verbalize the legal implications of care.   implications of care. Utilizes knowledge   implications of care. Utilizes knowledge
                                           Recognizes client care is guides by NPA     of NPA and Standards of Care to design     of NPA and Standards of Care to
                                           and Standards of Care.                      and coordinate care of individuals.        manage care of individuals and groups.




                                                                                                                                                                              46
    e) Demonstrates moral, ethical, and legal behaviors.

Indicators:                               Sophomore Level                             Junior Level                             Senior Level
Demonstrates professional behavior in                                         Consistent demonstration expected throughout all levels.
action and appearance when in clinical.
Practice is guided by moral and ethical                                      Consistent demonstration expected throughout all levels.
principles
Practices within legal boundaries.        Consistent demonstration expected throughout all levels. Infractions may be grounds for clinical failure and dismissal from
                                                                                               the program.


    f) Identifies resources in health care system and community that contribute to health promotion.

Indicators:                               Sophomore Level                             Junior Level                               Senior Level
Provides appropriate referrals            Will collaborate with staff to identify     Will demonstrate identification of         Will demonstrate identification of
                                          appropriate referrals.                      referral needs based upon client           referral needs based upon individual,
                                                                                      assessment findings. Will collaborate      family, or population assessment and
                                                                                      with staff to provide referral.            will independently initiate referrals as
                                                                                                                                 appropriate.


5) Management Skills
   a) Utilizes material resources effectively.

Indicators:                               Sophomore Level                             Junior Level                               Senior Level
Assesses environment to determine         Not indications of waste                    No indications of waste                    No indications of waste
supply needs.


    b) Organizes time effectively.

Indicators:                               Sophomore Level                             Junior Level                              Senior Level
Completes care within allotted time.      Progressively needs less assistance to      Independently provides care and prioritizes to accomplish all aspects of care
                                          complete care. Takes initiative to          within allotted time.
                                          provide care individually but seeks
                                          assistance when needed.




                                                                                                                                                                            47
    c) Prioritizes care.

Indicators:                             Sophomore Level                             Junior Level                                 Senior Level
Priorities of care are congruent with   Focuses on identifying priority client      Assesses for and prioritizes all client      Assesses for and prioritizes all
patient needs.                          nursing problem.                            nursing problems. Able to verbalize          individual, family, or population
                                                                                    rationale for priority ranking.              nursing problems. Able to verbalize
                                                                                                                                 rationale for priority ranking.


    d) Demonstrates effective planning, delegation and supervision of others as appropriate.

Indicators:                             Sophomore Level                             Junior Level                                 Senior Level
Planning                                Plans for individual care provision only.   Plans for designing and coordinating         Plans for managing care with includes
                                                                                    care which may include collaboration         collaboration with all team members.
                                                                                    with other staff.
Delegation                              Not expected at this level.                 In coordinating care of individual may       In managing care of individuals or
                                                                                    delegate to assistive personnel.             groups will delegate to licensed and
                                                                                                                                 assistive personnel.
Supervision                             Not expected at this level.                 Minimal supervision expected at this         In managing care of individuals or
                                                                                    level.                                       groups will supervise licensed and
                                                                                                                                 assistive personnel.


    e) Collaborates with resource persons as appropriate.

Indicators:                             Sophomore Level                             Junior Level                                 Senior Level
Seeks answers to questions              Utilizes instructor as primary resource.    Utilizes instructor and staff as resource.   Utilizes staff as primary resource.
Seeks support for plan of care          Progressively formulates plan of care       Will formulate plan of care as part of       Demonstrates proficiency in
                                        and discusses with instructor prior to      process of designing and coordinating        formulating plan of care as part of care
                                        providing care. With assistance of          care. Will seek guidance from                management process. Seeks guidance
                                        instructor will reflect on clinical         instructor or staff if questions related     and support of instructor or staff when
                                        performance and identify strengths and      to plan of care arise. Post-care, with       situation beyond scope of student.
                                        areas needing improvement.                  minimal instructor guidance, will reflect    Post-care will independently reflect
                                                                                    upon clinical performance and identify       upon clinical performance and identify
                                                                                    strengths and weaknesses. Will seek          strengths and weaknesses. Will
                                                                                    collaborative assistance in formulating      demonstrate self-correction. Will seek
                                                                                    strategies for improvement.                  collaborative assistance when
                                                                                                                                 necessary.



                                                                                                                                                                            48
6) Leadership Skills
   a) Demonstrates creativity.
Indicators:                                Sophomore Level                             Junior Level                               Senior Level
Formulates alternatives as appropriate     With guidance of instructor will identify   Identifies each client care situation as   Utilizes data gathered during
                                           situations in which the standard            unique and incorporates alternative        assessment of individual, family, or
                                           approach may need to be adapted.            approaches into the design and             population to incorporate alternative
                                                                                       coordination of care.                      approaches into the management of
                                                                                                                                  care.
Demonstrates risk taking                   Not expected at this level.                 Analyzes client care situation to          Draws from knowledge base and past
                                                                                       determine when risks can be safely         clinical experience to determine when
                                                                                       incorporated into care design and          risks can be safely incorporated into the
                                                                                       coordination.                              management of care.
    b) Demonstrates flexibility.
Indicators:                                Sophomore Level                             Junior Level                               Senior Level
Changes approaches as needed to            With instructor assistance identifies       With minimal guidance of instructor or     Independently identifies need to adapt
achieve favorable outcomes.                need to change plan +/or approach to        staff indentifies need to adapt or         or change approach to management of
                                           care provision. Responds positively to      change approach to care design or          care of individuals, families or
                                           instructor feedback.                        coordination. Responds positively to       populations.
                                                                                       feedback.
Demonstrates professional                  Responds to changes in patient              Responds to changes in patient             Demonstrates professional behavior
accountability                             assignments with professional               assignment with professional behavior.     when clinical situations require change
                                           behavior.                                                                              in approach +/or plan.
Adapts plan as needed                      Progressively expected with guidance        Expected to identify need to adapt plan Expected to independently identify
                                           of instructor.                              with minimal guidance of instructor.       need to adapt plan.
Anticipates needs and collaborative        Progressively expected with guidance        Expected to demonstrate ability to         Expected to independently
problems                                   of instructor.                              anticipate needs and adapt plan            demonstrate ability to anticipate needs
                                                                                       accordingly with minimal guidance of       and adapt plan accordingly. Expected
                                                                                       instructor. Expected to incorporate        to incorporate knowledge of
                                                                                       knowledge of collaborative problems        collaborative problems in managing
                                                                                       into care design and coordination.         care of individuals, families, or
                                                                                                                                  populations.
Uses evidence to support actions           Progressively expected as knowledge         Expected to verbalize rationale for adapting plan of care.
                                           base increases.
Engaged in learning and willing to adopt   Demonstrates desire to learn and            Independently seeks out learning opportunities. Takes advantage of all learning
new behaviors.                             transfer classroom knowledge to             opportunities. Receptive to suggestions to adapt care delivery practices.
                                           clinical setting. Demonstrates skills as
                                           learned.

                                                                                                                                                                              49
    c) Demonstrates sensitivity.

Indicators:                               Sophomore Level                            Junior Level                             Senior Level
Expresses appreciation of human           With assistance of instructor will show    Independently shows respect for          Independently shows respect for
differences.                              respect for diverse client values and      diverse client values and preferences.   diverse values and preferences of
                                          preferences. With assistance of            With minimal instructor guidance will    individuals, families, or populations.
                                          instructor takes action to learn about     take action to learn about cultural      Independently takes action to learn
                                          cultural variations.                       variation.                               about cultural variations and
                                                                                                                              implications for care management.
                                                                                                                              Takes action to change negative and
                                                                                                                              prejudicial behavior in self and others.
Adapts care to meet individual            Incorporates client preferences into       Incorporates client preferences into     Incorporates client, family, or
preferences as feasible.                  provision of care.                         design and coordination of care.         population preferences into
                                                                                                                              management of care.
7) Teaching Skills
   a) Utilizes knowledge of teaching/learning principles to plan and deliver care.

Indicators:                               Sophomore Level                            Junior Level                             Senior Level
Provides health education                 With instructor assistance will provide    With minimal instructor guidance will    Independently provides health
                                          basic heath education to client.           provide health education relevant to     education to individuals, families, and
                                                                                     client situation.                        populations.
Integrates teaching/learning activities   With instructor guidance actively          With minimal guidance will engage        Will independently engage individuals,
into client interactions.                 engages client in learning.                client in relevant learning activity.    families, or populations in learning
                                                                                                                              activities.
Incorporates health promotion +/or        With instructor assistance will identify   Assesses client education needs.         Assesses learning needs of individuals,
teaching into plan of care.               basic teaching/learning needs and          Incorporates teaching/learning           families, or populations. Incorporates
                                          incorporate interventions into plan of     interventions when designing and         teaching/learning interventions when
                                          care.                                      coordinating care.                       managing care.
8) Knowledge Integration Skills
   a) Integrates information technology into the practice of nursing

Indicators:                               Sophomore Level                            Junior Level                              Senior Level
Utilizes computer generated data to       Reviews computer documentation             Reviews computer documentation when collecting pre-planning data. Utilizes on-
process information about clients, to     when collecting pre-planning data.         line resources to find evidence-based support for interventions .
research client problems, and to          Utilizes on-line resources to enhance
enhance understanding of client           understanding of client condition.
condition.


                                                                                                                                                                         50
Utilizes computer databases to find        With guidance of instructor will locate   Will take initiate to access networked      Independently accesses networked
educational resources and review           networked policy and procedure            policy and procedure manuals and on-        policy and procedure manuals and on-
pertinent policies and procedures.         manuals.                                  line resources such as Micromedex to        line resources to facilitate care
                                                                                     facilitate care design and coordination.    management for individuals or groups.
                                                                                     Will discuss findings with instructor
                                                                                     prior to implementation.

    b) Integrates pharmacologic/medication administration principles into care delivery.

Indicators:                                Sophomore Level                           Junior Level                              Senior Level
Verbally demonstrates knowledge of all                                      Consistent demonstration is expected throughout all levels .
routes of medication administration.
Verbally demonstrates knowledge of         Independently verbalizes 6 rights and     Independently verbalizes 6 rights and       Consistently applies application of the 6
responsibilities of medication             patient identification procedure.         patient identification procedure.           rights and patient identification
administration, including expected         Utilizes medication summary to            Progressively decreasing reliance on        procedure. Responsible for knowledge
outcome, rationale, adverse reaction,      verbalize other responsibilities.         medication summary to verbalize other of other responsibilities prior to
teaching and nursing implications.                                                   responsibilities.                           medication administration.
Utilizing standards of practice,           With guidance of Instructor               Demonstrates ability to calculate fractional medication dosages. Always has
accurately calculates fractional                                                     calculations checked by instructor or preceptor.
medication dose.
Administers prescribed medication to       With guidance of instructor               Consistently demonstrates accurate medication delivery.
designated patient per agency protocol.
Accurately documents medication            With guidance of instructor               Completes any required training for medication documentation (e.g., e-MAR).
administration per agency policy.                                                    Consistently demonstrates accurate documentation in accordance with policies.
Monitors patient response to               With guidance of instructor               Consistently incorporates monitoring and follow-up into plan of care.
administered medication within
appropriate time frame.

    c) Identifies the interrelationships that comprise the whole client (General Systems Theory).
Indicators:                                Sophomore Level                           Junior Level                                Senior Level
Utilizes assessments which support         Progressively demonstrates inclusion of   Identifies client as center of system and   Independently assesses individual,
holistic view of client when formulating   assessment of the whole person in data    completes assessment of the whole           family and population systems.
plan of care.                              collection.                               person. Identifies relevant sub-            Identifies how changes will affect all
                                                                                     systems. Incorporates assessment            subsystems. incorporates knowledge of
                                                                                     findings into designing and coordinating    systems theory into managing care.
                                                                                     care. Verbalizes impact of changes          Demonstrates ability to perform family
                                                                                     within client system to overall system.     assessments.


                                                                                                                                                                             51
    d) Interprets and uses quantitative data.
Indicators:                              Sophomore Level                             Junior Level                            Senior Level
Incorporates quantitative data (VS,      Progressively demonstrates                  Consistently demonstrates understanding of clinical significance of quantitative
Anthropometic data, Lab values,          understanding of clinical significance of   data.
diagnostic) results into plan of care.   quantitative data.

    e) Integrates knowledge from liberal arts, natural and social sciences into care planning and delivery.
Indicators:                              Sophomore Level                             Junior Level                            Senior Level
Demonstrates effective speaking and      Actively participates in pre- and post-conferences. Written work demonstrates clear organization of thought.
writing skills.
Integrates knowledge of A&P, Micro,      With guidance of instructor will            With minimal guidance of instructor        Will independently demonstrate
and Chemistry to facilitate              demonstrate application of knowledge        will demonstrate application of            application of knowledge from support
understanding of client conditions.      from support courses into formulating       knowledge from support courses in the      courses when managing care of
                                         plan of care and provision of care.         design and coordination of client care.    individuals or groups.




                                                                                                                                                                        52
                     MacMurray College Division of Nursing Clinical Data Tool Grading Rubric

    1.   All- all required elements of area are clearly identified within database
    2.   Most- no pertinent data elements required of an area missing
    3.   Median- required data elements of an area are included but vague or incompletely identified
    4.   Marginal- required data elements are not complete; gaps are present
    5.   Absent- required data elements are missing



   Data Area                                                                                                      Comments
Medical            Identifies medical diagnosis/diagnoses.                         3    2.25 1.5       .75    0
Diagnosis          Identifies co-morbidities                                       5    3.75 2.5       1.25   0
                   Identifies chief complaint                                      2    .75    .5      .25    0
                                                                                   Area Subtotal:
Client             Information Complete                                            2    1.5    1       0.5    0
Demographics       Includes 3 generation family history (genogram or narrative)    2    1.5    1       0.5    0
                   Lists allergies and reactions.                                  2    1.5    1       0.5    0
                   Identifies where client was admitted from.                      2    1.5    1       0.5    0
                   Identifies admission date and length of stay                    2    1.5    1       0.5    0
                                                                                   Area Subtotal:
Health History     Concise description of current illness.                         5    3.75 2.5       1.25   0
and Physical       Summary of past health history                                  5    3.75 2.5       1.25   0
Assessment         Identification of contributing or risk factors                  5    3.75 2.5       1.25   0
                   Identifies pertinent objective and subjective assessment data   5    3.75 2.5       1.25   0
                                                                                   Area Subtotal:
Major Medical      Concise description major medical diagnosis- Cites source       2    1.5    1       0.5    0
Diagnosis          Identifies major symptoms of medical diagnosis                  1    .75    0.5     .25    0
                   Describes usual medical treatment for diagnosis                 2    1.5    1       0.5    0
                                                                                   Area Subtotal:
Plan of Care       Identifies Nursing Diagnoses and lists in order of priority     3    2.25 1.5       .75    0
                   Identifies measurable Expected Outcomes                         4    3      2       1      0
                   Identifies key interventions planned to meet E.O.               3    2.25 1.5       .75    0
                                                                                   Area Subtotal:
Diagnostic         All pertinent diagnostics are interpreted                       5    3.75 2.5       1.25   0
Interpretations    Abnormal findings are correlated with client condition          5    3.75 2.5       1.25   0
                                                                                   Area Subtotal
Patient            Identified learning needs                                       2    1.5    1       0.5    0
Education          Described education provided                                    1    .75    0.5     .25    0
                   Discussed application of teaching/learning principles           2    1.5    1       0.5    0
                                                                                   Area Subtotal:
Collaboration      Identifies collaborative problems                               3    2.25 1.5       .75    0
                   Identifies collaborative partners                               2    1.5    1       0.5    0
                                                                                   Area Subtotal:
Communication      Identifies communication techniques used                        2    1.5    1       0.5    0
                   Identifies barriers to communication                            1    .75    0.5     .25    0
                   Analyzes communication and reflects on strategies to            2    1.5    1       0.5    0
                   improve future communication
                                                                                   Area Subtotal:
Ethics             Identifies ethical principles incorporated into care            2    1.5    1       0.5    0
                   Identifies actual or potential ethical issues (dilemmas)        1    .75    0.5     .25    0
                   Analyzes ethical issues and discusses future implications       2    1.5    1       0.5    0
                                                                                   Area Subtotal:
Self-Reflection    Insightful analysis of performance, thoughts, feelings          5    3.75 2.5       1.25   0
                                                                                   Area Subtotal:
                                                                                                                   53
Evidence-based    Provides evidence (clinical guidelines, research study, journal   5    3.75 2.5    1.25   0
Practice          article) to support plan of care                                  Area Subtotal:
Medication        Includes all pertinent medication data.                           5    3.75 2.5    1.25   0
Summary                                                                             Area Subtotal:
Overall Comments:                                                                   Overall grade:




                                                                                                                54
        MacMurray College Division of Nursing Complete Database and Care Plan Grading Rubric (6/10)
      1. All- all required elements of area are clearly identified within database
      2. Most- no pertinent data elements required of an area missing
      3. Median- required data elements of an area are included but vague or incompletely identified
      4. Marginal- required data elements are not complete; gaps are present
      5. Absent- required data elements are missing
      Data Area                                                                  A    B      C   D     E   Comments
Demographic             Information Complete                                     2    1.5    1   0.5   0
Data                    Includes 3 generation family history (genogram or        2    1.5    1   0.5   0
                        narrative)
                        Medication Summary Sheet complete                        4    3      2   1     0
                        Current orders/treatments listed (action list or kardex 2     1.5    1   0.5   0
                        data)
                        Most recent vital signs and pain assessment included     2    1.5    1   0.5   0
                                                                                 Area Subtotal:
Health History          Subjective data thorough and pertinent                   8    6      4   2     0
and Physical            Objective data thorough and pertinent                    8    6      4   2     0
Assessment              Uses appropriate descriptive terms                       2    1.5    1   0.5   0
                                                                                 Area Subtotal:
Assessment of the Psychosocial development (defines theoretical stage)           2    1.5    1   .5    0
Whole Person            Mental Health Assessment                                 4    3      2   1     0
 All assessment         Nutritional Assessment (must include BMI, pertinent      4    3      2   1     0
areas must              labs)
include evidence        Sociocultural Assessment                                 4    3      2   1     0
to support              Functional Assessment                                    3    2.25 1.5 .75     0
                        Risk Assessment                                          3    2.25 1.5 .75
                                                                                 Area Subtotal:
Diagnostic Data         Diagnostics are interpreted for significance (must       6    4.5    3   1.5   0
                        include abnormal labs; include discussion of normal
Diagnostics             values as appropriate)
include all testing     Correlates abnormal results of diagnostics with client   4    3      2   1     0
(labs, xrays, scans, condition.
etc)
                                                                                 Area Subtotal:
Major Medical           Thoroughly describes major medical diagnosis             3    2.25 1.5 .75     0
Diagnosis               Identifies major symptoms of medical diagnosis           3    2.25 1.5 .75     0
                        Describes usual treatment for diagnosis                  3    2.25 1.5 .75     0
                        Cites sources used                                       1    .75    0.5 .25   0
                                                                                 Area Subtotal:
Analysis of Care        Chooses appropriate nursing diagnoses/client             5    4      3   2     0
Plan                    problems which are clearly identified in third column
                        of database
                        Lists measurable expected outcomes                       4    3      2   1     0
                        Lists appropriate nursing interventions that apply to    7    5      3   1     0
                        nursing diagnoses identified for this client
                        Included a teaching intervention for all nursing         1    .75    0.5 .25   0
                        diagnoses.
                        Lists appropriate rationale for interventions. If        5    4      3   2     0
                        reference is used it is appropriately cited.
                        Evaluates expected client outcomes                       5    4      3   2     0
                        Includes self-reflection in evaluation column            5    4      3   2     0
                                                                                 Area Subtotal:
Overall Comments:                                                                Overall grade:



                                                                                                                  55
                                            Clinical Absence Documentation Form


The Student is      Date of Clinical Absence:
responsible for
                    Clinical Course:
completing this
section.            Instructor:

Within 24 hours     Clinical Site:
of the absence      Date and time clinical area notified of absence:
the student will
submit this form    Method of notification:
by e-mail to the    Date and time instructor notified of absence:
clinical and
course              Method of notification:
instructor.         Reason for clinical absence:
                    Signature of student:

Within 48 hours
of receipt the      Student notified instructor and clinical site per policy: ____
clinical
                    Clinical absences this rotation:
instructor is to
complete the        Clinical experience missed:
first three items
of this section     Signature of clinical instructor:
and submit to       Alternate assignment:
course
instructor.         Alternate assignment due:
                    Alternate assignment received:
Within 24 hours
of receipt from     Signature of course instructor:
clinical
instructor,
course
instructor will
submit
assignment to
student.

This section is     After faculty review it is determined that the absence is:   Excused      Unexcused
to be completed
by the course       An excused absence is granted when faculty determine that the alternate assignment meets
instructor after    conditions for giving credit for the missed clinical day.
review by full      An unexcused absence will be give no credit for the missed clinical day and will be considered
faculty.            when determining successful completion of the clinical portion of the course.

                    Clinical absences to date (this course):
                    Cumulative clinical absences:
                    Faculty recommendations:
                    Signature of Course Instructor:




                                                                                                                     56
                                    MacMurray College Department of Nursing

                                     MEDICATION ADMINISTRATION POLICY



After completion of didactic instruction and psychomotor demonstration of skills related to medication
administration students will be able to administer medications in clinical areas. The student and instructor are
equally accountable and responsible for actions related to medication administration and must adhere to the
following.

General Medication Administration Policy Statements:

  Strict adherence to Infection Control principles is essential (e.g., handwashing).
  Medications will be administered in accordance with established standards (6 Rights).
   o Right Medication
   o Right Dose
   o Right Client/Patient
   o Right Route
   o Right Time
   o Right Documentation
  Student must demonstrate knowledge of medication action, indications for use in assigned patient, major
   side effects and nursing implications.
  All medications must be checked three times before administration.
  No medication will be documented prior to administration.
  Medications must be documented immediately after administration.
  Client/Patient will be identified in accordance with established clinical agency policy.
  Any irregularities or errors will be immediately brought to the attention of the nursing instructor and
   appropriate agency personnel.


Level Specific Policy Statements:

   Clinical faculty must check and accompany sophomore level students to the bedside for administration of all
     medications.
   Clinical faculty may check oral medications with junior and senior level students and allow them to
     administer independently when competence related to the 6 Rights has been determined.
   No direct IV push medications may be administered by a student without being checked and directly
     observed by the clinical instructor.
Clinical instructor must check and directly observe IV Piggyback administration until the time the instructor
determines competence with IVPB administration skills.




                                                                                                               57
58
                                          Evidence Based Care Sheets

Henry Pfeiffer Library provides access to Evidence Based Care Sheets through CINAHL Plus with Full Text. This
can be a valuable resource when searching for evidence to support the care provided to patients. The following
steps can be used to access the resource.

   1. Go to the MacMurray home page: www.mac.edu

   2. Select Library from selection ribbon beneath picture of MacMurray campus

   3. On the left hand side of the page locate the heading “Electronic Resources”

   4. Select “Journal and Newspaper Articles”

   5. Select “EBSCO Host”

           a. If you are on the campus network skip to 6

           b. If you are accessing the resource from home

                    i. Log in to EBSCO host with the username: S8457775

                    ii. Enter the password provided to you by your instructor

   6. Select CINAL Plus with Full Text

   7. From the blue ribbon at the top of the page, select “Evidence Based Care Sheets”

   8. Select topic for search by going through alphabetical list or typing in a key work or phrase




                                                                                                            59
60
61
        The following information was retrieved from:
    http://www.ihs.gov/medicalprograms/pacona/documents/ebp_tutorial.doc

                            EVIDENCE BASED PRACTICE TUTORIAL
           (EXCERPTS FROM THE NIH RESOURCE TRAINING MANUAL by Judith Welsh, RN, MLS and
           MAKING THE CASE: WHY EVIDENCE BASED PRACTICE? by Gwenyth R. Wallen,, PhD, RN)




WHAT IS EVIDENCE BASED PRACTICE (EBP)?

Evidence based practice is the conscientious use of current best evidence in making decisions about patient care
(Sackett, Straus, Richardson, Rosenberg, & Hayes, 2000). It is a problem solving approach to clinical practice that
integrates:

       A systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical
        question
       One’s own in clinical experience
       Patient preference and values


WHY PRACTICE EBP?

Unfortunately, a great deal of research reported in journal articles is poorly done, poorly analyzed or both, and
thus is not valid. A great deal of research is also irrelevant to our patients and practices. Making decisions is a
fact of life for nurses. It’s what the nursing process is all about. But we need to know that the decisions we make
are sound and based on best evidence. In fact, the ANA has put forth a statement to that effect: “Nurses have a
mandate to measure the end results of their care and to improve the results over time.”


                                                                                                                62
FIVE STEPS OF EVIDENCE BASED PRACTICE

   1. Ask the burning clinical question
              Sample burning clinical question:

               In nurses, how effective is magnet status versus non-magnet status in improving job satisfaction,
                       recruitment, and retention?

   2. Collect the most relevant and best evidence
              The search for best evidence should first begin with systematic reviews or meta-analyses and
               evidence-based clinical practice guidelines
                      What is a systematic review? It is a summary of evidence on a particular topic, typically
                      by an expert or expert panel that uses a rigorous process for identifying, appraising, and
                      synthesizing studies to answer a specific clinical question. Conclusions are then drawn
                      about the data gathered through this process. Using a rigorous process of well-defined,
                      preset criteria select studies for inclusion in the review, bias is overcome, and results
                      are more credible.

              If systematic reviews or evidence-based guidelines are not available, proceed to randomized
               controlled trials
              If randomized controlled trials are not available, continue to other types of studies that generate
               evidence to guide decision making
   3. Critically appraise the evidence
   4. Integrate all evidence with one’s clinical expertise, patient preferences, and values in making a practice
       decision or change.
   5. Evaluate the practice decision or change


INTEGRATING EBP INTO YOUR PRACTICE

   •   Try questioning the norm
   •   Challenge the “way we have always done it”
   •   Speak DATA
   •   See one—Do one—Teach One


IGNITING THE SPIRIT OF INQUIRY

   •   EBP rounds
   •   Burning clinical question box
   •   Develop EBP Teams




                                                                                                               63
WHERE TO SEARCH FOR THE BEST EVIDENCE
Cochrane Library

PubMed

CINAHL (Cumulative Index to Nursing and Allied Health Information)

           To access all these above sites, go to the Health Services Research (HSR) Library @

           http://hsrl.nihlibrary.nih.gov/

           To access the Cochrane Library or CINAHL, click on the above link, click on “Research Tools”
           select “Databases” then choose your database. Enter your search criteria.

           To access PubMed, go to the above link and click on “PubMed” under “Quick Links” on the left-
           hand side. Enter your search criteria.

           Summary of these sites:

           The Cochrane Library:

                  Contains high-quality, independent evidence to inform health care decision-making
                  Includes reliable evidence from Cochrane and other systematic reviews, clinical trials,
                   and more
                  Reviews bring you the combined results of the world’s best medical research studies
               Recognized as the gold standard in evidence-based health care
           PubMed:

                  Covers the fields of medicine, nursing, dentistry, veterinary medicine, the health care
                   system, and the preclinical sciences
                  Contains bibliographic citations and author abstracts from more than 5,000 biomedical
                   journals published in the United States and 80 other countries
               Contains over 15 million citations dating back to the mid-1950’s
           CINAHL:

                  Premier database of journal articles covering nursing and allied health
                  Includes publications from the American Nurses Association and National League for
                   Nursing
                  Also provides access to healthcare books, nursing dissertations, selected conference
                   proceedings, standards of professional practice, educational software and audiovisual
                   materials in nursing
                  Indexes articles from over 1600 journals from 1982 to the present




                                                                                                          64
OTHER GREAT RESOURCES:

Sigma Theta Tau International Honor Society of Nursing Research Library:

      Uses Evidence-based nursing to improve world health care
      Provides resources to bridge research and clinical practice
       http://www.nursingsociety.org/Research/pages/default.aspx



Evidence Based Public Health Nursing (EBPHN):

      Disseminates the evidence in public health nursing
       http://www.uic.edu/depts/lib/projects/ebphn/index.html




                                      REMEMBER!




                                                                           65
                              Additional On-line Evidence Based Practice Resources

Evidence-Based Practice: An Interprofessional Tutorial
http://www.biomed.lib.umn.edu/learn/ebp

Evidence Based Nursing
http://hsl.osu.edu/8426.cfm

Evidence Based Practice
http://www.ahrq.gov/clinic/epcix.htm

Evidence Based Practice
http://healthlinks.washington.edu/ebp

Basic Introduction to Evidence Based Practice Resources
http://healthlinks.washington.edu/hsl/classes/evidence




                                                                                     66

				
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