STUDENT EVALUATION WORKSHEET DIAGNOSIS WEAK ORGANIZATIONAL SKILLS RT: Caring for more than two patients. GOALS STG: WEEK ONE: Orient to unit Develop an organized daily routine. Care for one NICU patient and finish on time with assistance. Take break/lunch during shift and finishes work on time. INTERVENTIONS Develop an organizational worksheet/schedule. Conduct time management exercise. Read articles on improving organizational skills. Orient self to unit. Become familiar with equipment and materials needed for patient care. Add one patient at a time to meet weekly goal until able to carry full patient load without assistance. Take report and organize patient care form report. Give an organized report on each patient to oncoming shift. Plan break/lunch according to patient care. ie: while patient is resting. Progressively assume more responsibility RT patient care. Organize materials needed hour by hour. EVALUATION 4/13/09 2100 ST goal orient to unit achieved. Familiarized self to unit via unit tour and cabinet/drawer investigation. Located items promptly when needed. Assisted staff to locate misc. items on the unit. Wrote down codes for utility room, supply room, and med cart. Plan for next week is to be familiar with computer charting and where to located documents in the computer and in the physical chart. ST goal organize daily routine is in progress. Tailors day according to patient’s needs. Accomplished all tasks within the allotted time. Plan for next week is to continue to develop daily routine. Include checking new MD orders, labs, and updating the kardex in daily routine. ST goal care for 1 NICU patient and take break/lunch was accomplished. Cared for 1 NICU patient with minimal assistance from preceptor. Demonstrated to preceptor proficiency in neonate assessment, OG feeding and residual check, critical thinking ability, and documentation ability. Took lunch/breaks on time with no impact on time management. All patient care and charting were completed within the allotted time. 4/18/09 2100 ST goal complete. Cared for 2 NICU patients c minimal assistance and finished on time. Reviewed schedule of events c RN in the AM. Stuck to planned schedule and finished on time. Takes AM report and organizes information to arrange a plan for the day. Continued on Back …. >
STG: WEEK TWO: Care for 1-2 NICU patients and finish on time with minimum assistance. Perfect daily routine. STG: WEEK THREE: Care for 1-2 non-stable NICU patients and finish on time with no assistance.
Daily routine is perfected for care of stable premature infants and will be adjusted according to patient’s needs and plan of care. NICU patient c minimal assistance. Gave end of shift report 2 days in a row to oncoming nurse. Utilized SBAR shift report. Plan for next week care for one non-stable NICU patient c minimal assistance. Continue giving end of shift report.
05/02/09 ST goal week 3 in progress. Took care of 1 unstable patient with minimal assistance from preceptor and finished on time. Planned and organized day based of patient’s needs and allotted time. Gathered all materials for the day and procedures ahead of time. Utilized time efficiently and charted accurately. Takes AM report accurately and organizes information from report to prioritize care. Daily routine is perfected and requires no direction in AM to begin care. Seeks guidance when appropriate and asks questions for further clarification.
DIAGNOSIS NON-INDEPENDENCE RT NICU inexperience and procedures.
STUDENT EVALUATION WORKSHEET GOALS INTERVENTIONS STG: WEEK ONE: Review any procedures specific to patient population Be familiar with common treatments and procedures that are unfamiliar. specific to patient population. Ask other staff nurses to Does not perform skills out allow me to perform of scope of practice or procedures on their patients training. with preceptor’s assistance. Perform all procedures with Review rationales and supervision of preceptor. reasons for treatments. Seeks appropriate support Review hospital protocol. when unsure of a procedure of Review quarter 3 treatment. information regarding NICU. Go over equipment and set STG: WEEK TWO: up for common Progressively perform all procedure/treatments. patient procedures with Prepare commonly used increasing independence. medication sheet specific to NICU. LTG: WEEK FOUR Perform all procedures independently with minimum or no assistance from preceptor.
EVALUATION 4/14/09 2100 ST goal be familiar with common treatments and procedures specific to patient population in progress. Researched and typed up a list of common procedures and rationales for procedures R/T patient population. Asks appropriate questions about unfamiliar procedures. Reviewed quarter 3 information. Set up for treatments after proper instruction and prepared a common medication sheet specific to the NICU. Plan for next week includes performing all tasks/procedures independently and expose myself to at least 1 unfamiliar procedure per week. ST goal does not perform skills out of scope of practice or training, perform all procedures with supervision of preceptor, and seeks support, have been accomplished. Did not perform any skills out of my scope of practice or training. All tasks and procedures were done under the direct supervision of the preceptor until proficiency was proven.* Sought appropriate support when needed. Plan for next week is to gain comfort and confidence in difficult or intimidating procedures, such as neonatal IV and resuscitation guidelines. 04/18/09 2100 Weeks 1 & 2 ST goals achieved. Preformed all NICU procedures on own for 2 NICU patients. Inserted an OG tube on own with preceptor observing the procedure. Read chapters of the book Core Curriculum for Neonatal Intensive Care Nursing, by Awohnn & Nann. Asked other RN’s to perform any procedures they have. Continued on Back…… >
04/20/09 2100 ST goals achieved continued. Attempted an IV start. Bottle fed stable infant. Prepped area for infant prior to c-section birth, on own. Did 3 newborn admission assessments, medications, 2 baths and charted with minimal assistance. Plan for next week increase independence in all procedures and procedures of other RN’s patients. Become confident and comfortable caring for and doing procedures to an unstable neonate. 05/02/09 LT goal in progress. Inserted an OG tube, closely monitored, administered medications via OG tube, titrated and monitored CPAP to maintain spO2 of 86-98% c minimal assistance from preceptor. Bottle fed a stable infant on own. Did lots of parent education on breast feeding, skin to skin, and NICU environment on own. Did newborn admissions and medications c preceptor supervising. Gave shift report on own 6 out of 8 shifts c preceptor supervising. Gathered supplies and set up procedures for myself and other RN’s. * With in accordance to DeAnza IV Policy, Preceptorship Agreement, and the hospital’s Faculty Policy.
DIAGNOSIS POTENTIAL FOR IMPROVED LAB FINDING INTERPRETATIONS AND CORRECT ACTION.
STUDENT EVALUATION WORKSHEET GOALS INTERVENTIONS nd STG: by the end of the 2 week: Make a sheet with common normal lab values and causes Will know the normal values for the most common NICU lab of abnormal findings specific tests. to patient population. Study sheet every day. LTG: by the fourth week: At the beginning of each Will be able to examine lab shift, look up each patient’s results and identify lab values in the computer. potential/actual decline or Discuss each patient’s lab improvement in patient values with preceptor. condition. Have preceptor ask me what I would do in real or hypothetical situations RT lab findings. If allotted the time, ask other staff RNs to view their labs. Compare/contrast labs of patients with similar and different conditions to reinforce leaning.
EVALUATION 04/13/09 2100ST goal will know the normal values for the most common NICU lab tests, is in progress. Neonate Lab sheet was developed and is review daily. Labs within patient’s chart are reviewed at the beginning of the shift and unfamiliar labs are looked up for review. Lab importance and critical values are discussed when applicable with preceptor. Plan for next week continue to review lab sheet and ask preceptor to provide hypothetical situations. Implement new intervention noted. 04/21/09 2100 ST goal complete. Knows and recognizes labs out of normal limits such as Bilirubin >12, Hgb <14 & > 23, Hct <34 & >75, and glucose <40 & > 90. Understands importance of labs drawn in relation to patient’s condition. Plan for next week is to recognize s/s to indicate need/cause for lab. Review 2 patient’s lab values once every shift to compare and contrast labs to patient’s condition. 05/02/09 LT goal complete. Recognized patient in respiratory acidosis without compensation based on s/s and ABG lab values. Recognized H & H extremely low levels on patient and the need for packed red blood cells to be administered. Recognized the importance of Vancomycin Lab level order for patient receiving Vancomycin medication.