II

Nursing 335 Pediatrics

CLINICAL SYLLABUS: KAISER PERMANENTE, DOWNEY CA.

Clinical Objectives Nrsg 335 Nursing process and Practice in the Care of Children

A. Assessment of Client

1. Interviews client/parents during day of care using the LAHC Nrsg

335 assessment form to include all physiological and psychosocial

modes.

B. Performs Physical Assessment

1. Completes a thorough assessment (head to toe) on all assigned

clients.

2. Organizes and completes an accurate assessment using the Nrsg 335

assessment form.

3. You must identify assigned patient by correct ID band and date of

birth prior to beginning physical assessment. If a student fails to

identify/check ID band, the student will automatically receive an

unsatisfactory for the day. Two offenses will equate to a CLINICAL

FAILURE (patient safety).

C. Analysis of Data

1. Identifies maladaptive behaviors.

2. Compares lab data to norms.

3. States a nursing diagnosis.

4. States reasons (maniputable stimuli) for medical diagnosis or nursing

diagnosis.

D. Planning of Client Care

1. Thoroughly researches for clinic prior to caring for client by

completing the Nrsg. 335 prep sheet.

2. Determines prioritized physiological and psychosocial problems for

each client using the Roy Adaptation Model.

3. Submits written Nursing Care plan as directed by instructor.

4. Identifies ineffective and effective interventions and revises Nursing

Care Plan.

E. Implementing Client Care

1. Safely and effectively preforms all skills learned in previous courses.

2. Prepares and administers medications safely and correctly.

3. Administers prescribed IV solutions and is able to work with IV tubing

and IV pumps.

4. Meets safety needs of clients- including restraints, proper ID of client,

properly functioning beds, etc.

5. Performs pediatric procedures as instructed-including restraints,

specimen collection, taking VS, O2 administration, gavage, etc.

6. Performs all care integrating the child’s growth and development

needs based on Piaget and Erikson.

7. Assess client’s/family knowledge deficit.

8. Develops and implements a teaching plan to meet knowledge deficit.

9. Bases all teaching on child’s developmental level.

10. Takes initiative in seeking out optimal learning experiences- including

selection of challenging patients.

11. Accurately reports and records (charting) findings and care given.

12. Records in writing, a nursing care plan to meet clients needs.

13. Organizes and prioritizes care and completes all cares in a timely

manner.

14. Completes individualized procedures in a safe and timely manner.

15. Works cooperatively and communicates effectively with the client,

family, and nursing/medical staff.

16. Arrives to clinic on time and ready to begin care.

17. Researches client care prior to clinical experience.

18. Adheres to LAHC grooming and uniform standards.

19. Correctly and completely evaluates own clinical performance and

quality of care given using the Nrsg. 335 evaluation form.

20. Correctly competes and submits required written work to the

instructor in a timely manner.

Nrsg. 335 Clinical Information

**If you are ill and will be absent, call your instructor at least one hour prior to

the start of clinical. Do not begin care until after you have received report from

the RN assigned to your patients.

1. Assignments are to be written in PENCIL.

2. When you arrive in A.M. locate your patient, remembering that rooms

and bed locations are frequently changed and patients are often

discharged home in the evening. Then change any information on the

assignment sheet, before the instructor or staff use the information.

3. Report starts at the client rooms. Take report on your sickest patient

first, then if necessary, find your other RN and get report on your other

patient.

4. Read all progress notes on your patient. Look for changes in orders

throughout the day, especially after the MDs make rounds.

5. MEDICATIONS

A. You must get instructor approval before giving any meds.

B. Instructor will be present during administration of all IVPB meds.

C. You may not give any IV push meds, this includes normal saline

flushes and heparin flushes.

D. All patients must have ID bands on before giving meds and prior to

having instructor at bedside. ID bands taped to bed or lying in the

bed no not meet this requirement.

E. There are routine times to give meds, but many meds are not given

on this schedule due to late restarts, stat meds, etc. Check your med

sheet/electronic MAR to see when last dose given.

6. CRIBS

A. All must have properly functioning latches.

B. Any child that is able to pull self/stand up must have “cage top”,

even if the child is in restraints.

C. If any child falls out of bed due to side rails left down or no cage top

when indicated, the student will automatically receive a FAIL for

clinic and will be dropped from the course due to endangerment of

patient.

7. Do not interrupt MD rounds. Notify RN and instructor of problems so

we can determine if MD is to be notified.

8. No child is to be left in a high chair or adult sized chair without

immediate supervision.

9. Review ISOLATION PROTOCOLS AND TECHNIQUES!!!!

10. Clothing

A. Arms and legs to be covered on older children. Diaper and

top/shirt on infants.

B. Patients to be covered with blanket or sheet when resting

or sleeping in bed.

C. Foot coverings are to be used when ambulating patients.

11. Nutrition

A. Young infant; formula as ordered or breastfeeding

B. Older infant; DFA (diet for age). You must know appropriate one.

Do not mix formula or milk and cereal and or fruit in bottle/cup. Do

not mix vegetable with fruit.

C. DO NOT ENLARGE NIPPLE HOLES. This is malpractice since infant

may choke. All infants on ward should be using regular nipples.

Preemie nipples should be used only under special circumstances;

always check with RN/Instructor and MD/OT order.

D. Child; diet as ordered.

12. General Care

A. All patients should receive shower/bath daily and oral care daily.

B. Utilize shower rather than giving a bed bath if applicable/safe.

C. Bathe infants/toddlers in large portable basins or with waterless

bathing sheets (check unit policy).

D. Daily linen changes.

13. Documentation

A. Vital signs must be taken and documented in EPIC computer system

at the bedside and in real time.

B. Document which extremity is used for blood pressure and what route

was used for obtaining temperature.

C. You must manually count respirations and Apical pulse per LAHC

policy. Do not document what is on the monitor.

D. Vital signs are taken every 4 hours (0800, 1200, 1600) and as

needed.

E. Report any abnormal vital signs to RN and Instructor immediately.

F. Head to toe assessments must be completed and documented in

EPIC system no later than 1100 am to allow instructor to review with

each student.

14. All toys at bedside must be cleared by child life specialist. Consider

safety precautions with infants/toddlers (no small parts, balloons,

ribbons, or cords).

15. Selecting Patients

A. Come to make/research assignments between 1200-1800. Do

not come on the unit prior to 5 am on clinic day.

B. You may come with another student and no one else. Wear

uniform, school ID, and Kaiser ID.

C. You may not interact with the patient or family when choosing

Patient assignments. Do not go to the immediate bedside. You may

access patient information from the electronic health record (EHR).

D. Do not select oncology patients undergoing active chemotherapy.

E. Do not select patients who are scheduled for surgical procedures

that will be off the unit for the most part of the day.

F. Do not select an assignment that is classified as a 3:1 for the first

two weeks of the rotation. Most of the patients classified as a 3:1

are oncology patients on chemotherapy or extremely ill patients.

Following the second week, verify with instructor if assignment is

appropriate.

G. When choosing assignments, select different age groups, patients

with IVPB medications, and patients to complete your projects/care

plans.

H. Do not select patients with a high likelihood of cross-

contamination. Example: isolation patient with an immune

compromised patient.

I. The instructor reserves the right to change assignments on students

who consistently take easy patients and under certain other

circumstances to ensure a positive learning experience.

J. Starting with week two, you will provide care for a two- patient

assignment (census allowing).

OVERALL OBJECTIVE: Students are to give total patient care, including

IV medication administration, document all care given on appropriate

hospital forms/EPIC system. This care does not include the reading of

EKG’s, blood gases, or giving IV push medications. Students are NOT

to administer any blood or blood products as this requires two

licensed personnel. Students are to do NO invasive procedures or any

care without an instructor present in the hospital. Instructor must

check drug dosages for all meds given by any route. Students are

responsible for all documentation in EPIC system. Instructor will

review charting throughout shift and provide feedback.

Clinical Hours:

Tuesday: 0630-1830

0630-0700: Preconference. Meet in cafeteria in basement of hospital. Be on

time.

0700-1200: Patient Care (take a 10- minute AM break)

1200-1230: 30 -minute lunch (will leave as an entire group)

1230-1800: Patient care (take a 10 -minute PM break), complete charting.

1800-1830: Post conference. All paperwork is due at the end of post-conference

and will be returned the following week. Only paperwork submitted in a clear

folder will be accepted. DO NOT STAPLE CLINIC PAPERWORK. WCET

EVALUATIONS MUST BE STAPLED.

Preparation for Clinic:

PARKING: All students and instructor must park off campus!!!!!!!

Address: 12200 Bellflower Blvd. Downey CA.

Park in back in the MARKED STALLS “HOSPITAL PARKING”

A shuttle will provide transportation to the medical facility.

***YOU MAY PARK ON CAMPUS WHEN YOU COME TO CHOOSE YOUR PATIENT

ASSIGNMENT IF YOU COME AFTER 5PM***

1. You may obtain information from the internet, but also write it briefly in

your own words on prep sheet.

2. Look up recommended dosages (safe dose) for ALL SCHEDULED

medications to be given during your shift and PRN meds. Be prepared to

show instructor medication order in EMAR, your calculation worksheet,

why medication is ordered, possible side effects, nursing responsibilities.

3. If you are to administer an IVPB medication, know what the initial volume

and flush will be and rate of administration; as well as max concentration.

Have information written out in a neat manner so instructor can review

with student.

4. Medications will be ordered on the chart and recorded on the EMAR.

Times of administration will be on the EMAR.

5. It is the student’s responsibility to verify administration time prior to

administering any medication (check EMAR previous doses).

6. On your prep sheet, write out your plan of care (what you are planning to

do that day). Show organizational plan. Include what your priority

assessments and interventions are. Show an estimated time line.

7. If you have not prepared a plan of care or calculated safe dosages on your

clients prior to clinic; you will be sent home with an UNSATISFACTORY

GRADE FOR BEING UNPREPARED FOR CLINIC.

8. Instructor must see the vial or bottle you have drawn your medication

from. No unlabeled syringes for medication administration will be

approved.

9. Under Nutrition on the prep sheet, record what a NORMAL child of that

age should be eating. Don’t write what the hospital diet is. Special diets

should be recorded elsewhere in the prep sheet ( a normal child is NOT on

Pediasure 30ml/hr).

10. Growth and development should be researched and recorded carefully

before you provide care for your patient. Record your text book and actual

assessment of your child on the NRSG. 335 Growth and Development form.

TEAM LEADERS & RESPONSIBILITIES:

For the most part we do not use team leaders but, in the rare occasion a team

leader is utilized the following are a list of responsibilities.

1. Write down medication administration times for all students. Make sure

students are ready to give meds when they are ordered (scheduled).

2. Know times of procedures such as tube feedings, suctioning and dressing

changes. Make sure students are ready.

3. Assign 10- minute breaks. Cover assignment while student is on break.

Make sure all students are ready to leave at the designated time for lunch

and at the end of shift. Make sure student has reported off to RN.

4. Assist students as needed with patient care.

5. Make sure all charting is complete and signed. Do not leave floor until all

students have finished charting, completed cares, and reported off to RN.

6. If a medication error is made because of lateness or omission, both the

team leader and the student assigned will receive an unsat for the day. If

charting is incomplete or care not completed, both the student and the

team leader will receive an unsat for the day.

7. Make rounds on assigned patients on a regular basis.

8. Alert instructor t any problems occurring with your student’s patients.

9. Follow instructor when not assisting students to listen and learn from the

experiences of others.

GUIDE FOR GIVING A REPORT:

TO THE INSTRUCTOR:

1. Name of patient and room number

2. Age of patient

3. Diagnosis

4. IV orders as written and necessary lab values

5. Diet

6. Special equipment patient is on. Ex: CAM, pulse oximetry, GT/NGT feeding

pump.

7. Significant procedures: dressing changes, Trach care, GT care etc.

8. Significant behaviors related to diagnosis

9. Other problems.

TO THE STAFF RN:

1. Give information on any significant changes in patient immediately and

throughout shift.

2. Let RN know if any specimens were collected, tests completed, last set of

vital signs, etc.

3. Inform RN when the last feeding was for infants.

4. If primary RN is unavailable, write a brief summary and give a verbal report

to the charge/covering nurse.

** It is the student’s responsibility to keep the instructor and staff RN updated

regarding any significant changes in the patient’s condition. FAILURE TO DO SO

WILL RESULT IN AN UNSATISFACTORY GRADE FOR THE DAY**

Preparation for PICU:

Patients in the PICU are more acutely ill than patients on the general ward. You

will only assist in cares on one patient. Your clinical prep will be more in depth.

Use the same forms as for patients on the ward but, pathophysiology of disease

processes must be fully researched. For example:

-A patient with a blunt head trauma on a ventilator: do not five a brief

explanation of head trauma only. Describe the consequence of blunt trauma (ie:

cerebral edema). Know why your patient is not breathing on his own, why is the

patient on a ventilator?, what nursing interventions are required for a client on a

ventilator?

Another example: gunshot wound to the chest. Why does your patient have a

chest tube? What happens when lungs are pierced? Describe care of a patient

with a chest tube.

1. Research and review all procedures you may witness in the PICU.

2. You will not be allowed to chart in EPIC (hospital policy), you may write

down vital signs and give to assigned RN.

3. You will not be allowed to give any medications in PICU but, you will be

responsible for listing all medications, safe dosage calculations, and

purpose for prescribing on Nrsg. 335 medication worksheet.

REQUIRED CLINICAL PAPERWORK:

1. Completed preparation forms for 2 patients (if you need to pick up a patient

due to a discharge or transfer, submit a modified prep page and look up

medications.

2. Weekly evaluation form (WCET).

**you must complete 2 projects/care plans to meet course requirements.

Projects consist of:

A. Prep sheets for the patient

B. Physiological nursing care plan

C. Psychosocial nursing care plan

D. H & A form

E. Growth & development

**You must submit a project every week until your instructor indicates that you

have successfully completed 2 acceptable projects**

NURSING 335 NURSING PROCESS & PRACTICE IN THE CARE OF THE CHILD

LOS ANGELES HARBOR COLLEGE NURSING HISTORY & ASSESSMENT

Student_____________________________ Instructor _______________________________________

DIRECTIONS: Circle or fill-in appropriate response. Highlight all ineffective behaviors.

HISTORY

Patient initials______ age______ sex______ date(s) of care __________________________________

Date of history_________ informant- parent, chart, other ______________________________________

All present medical diagnoses:

1. ___________________________________________________________________________________

2. ___________________________________________________________________________________

3. ___________________________________________________________________________________

Medications taken at home _______________________________________________________________

Surgical procedure(s) & date (s) ___________________________________________________________

_____________________________________________________________________________________

Past illnesses/conditions _________________________________________________________________

Hospitalizations ________________________________________________________________________

Allergies/reactions ______________________________________________________________________

Substance use by family/patient: tobacco, alcohol, drugs (by whom) ______________________________

Nutritional status:

Normal diet taken at home (describe typical diet for 24 hours) ___________________________________

_________________________________________________________________________________

Recent wt gain/loss__________ lbs. Type of formula______________ breast___________________

Fluid intake milk/formula for 24 hours____________ sucking behavior ___________________________

Drink from cup?___________ Vitamin/mineral supplements ____________________________________

Food likes___________________________dislikes_____________________________

Growth and development: At what age did your child?

roll over__________ sit alone_________ crawl_________ walk ____________________________

speak first word_________ speak first sentence_________ dress alone __________________________

toilet trained daytime______________ nighttime_____________

Immunization survey: list each immunization and how many of each was received. (No Up To Date)

_____________________________________________________________________________________

_____________________________________________________________________________________

Which immunizations are they missing for age? _______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

PHYSICAL ASSESSMENT

General assessment:

Appearance________________________ level of activity _____________________________________

State of consciousness: ability to communicate, orientation _____________________________________

_____________________________________________________________________________________

Vital Signs: T______ P______ R______ BP_______

ht________ %ile_________ (plot on graph from CDC.gov)

wt________ %ile_________ (plot on graph from CDC.gov)

Pertinent abnormal laboratory results (CBC, lytes, ABG’s. etc.) ___________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Head to toe assessment (Describe exact behaviors)

SKIN

color____________ temperature_____________ turgor ____________________________________

texture__________________________ hygiene _____________________________________________

rashes ________________________________________________________________________________

other________________________________________________________________________________

lesions/birthmarks/bruising/scars __________________________________________________________

IV site___________________ solution__________________ rate _____________________________

HEAD

measure head circumference & plot for child < 13 mo: cm____ %ile _____________

fontanel: patent, closed, flat, bulging, soft

appearance of scalp:____________ lice_______ dandruff_________ cradle cap________

appearance of hair: dry/ brittle/ shiny/ dull,

hair distribution__________ date hair last washed ___________________________________________

other_________________________________________________________________________________

EYES

pupils______________________________ drainage _________________________________________

tearing____________ conjunctiva______________ sclera ___________________________________

strabismus__________________ swelling/inflammation_______________________________________

other________________________________________________________________________________

EARS

pinnae: shape___________________ placement ____________________________________________

discharge_______________________ pain ______________________________________________

NOSE

lesions _______________________________________________________________________________

exudate ______________________________________________________________________________

MOUTH

lesions: __________ tongue________________________ lips___________________________________

dentition : caries______________ number of teeth____________________________________________

mucous membranes: dry, moist, cracked, other________________________________________________

appearance of pharynx_ ______________________ ___________________________________________

NECK

masses________________________________ nodes ________________________________________

tenderness____________________ mobility _______________________________________________

bruits/venous distention _________________________________________________________________

CHEST/LUNGS

symmetry of respiratory effort___________ rhythm/pattern __________________________________

breath sounds: ________________________________________________________________________

chest tubes: type__________ location___ _______________________________________________ ___

retracting ____________________ cough ________________________________________________

O2: mode__________ flow %___________ pulse oximeter reading ____________%

HEART

pulse: regular/irregular/bounding/weak/thready

symmetry of peripheral pulses_________________________

capillary refill_____________seconds BP: ________________Extremity taken? __________

extra heart sounds heard_________________________________________________________________

heaves/lifts/thrills_______________________________________________________________________

clubbing__________________ activity tolerance _____________________________________________

ABDOMEN

bowel sounds_______________ firmness___________________

masses___________ tenderness___________________ hernias ______________________________

incisions___________________ dressings________________ drains ___________________________

NG tubes/abd tubes_________ feeding solution_____________ amount __________________________

date of last BM_____________ amt_________ frequency of stools ______________________________

character of stool (color,odor,consistency) ___________________________________________________

other________________________________________________________________________________

GENITOURINARY

males: hernia, hydrocele what side/sides? ______

penis: circumcised/noncircumcised/ discharge/ redness ________________________________________

testes : descended/undescended/masses ____________________________________________________

females: vaginal lesions/discharge/redness __________________________________________________

intake: last 24 hour_________________ urine output: last 24 hrs(chart)________

fluid balance positive by ___________mL or negative by _____________________mL

urine color_____________ odor___________________ clarity _________________________________

urine specific gravity_______________ foley catheter ________________________________________

other_________________________________________________________________________________

MUSCULOSKELETAL

curvature of spine? _____________________________________________________________________

muscle tone ___________________________________________________________________________

range of motion: all joints/extremities ______________________________________________________

swelling/inflammation of extremities_______________________________________________________

hips: symmetrical/asymmetrical__________________ Gait ____________________________________

paralysis________________________contractures_____________________________________________

other_________________________________________________________________________________

Traction/casts/splints____________________________________________________________________

IV MEDICATION EVALUATION CHECKLIST

Medication Order: _______________________________________________________________________________

Usual pediatric dose in mg/kg: ____________________________My patient’s weight:________________Kilos

Specific instructions, time limits, side effects etc.: ______________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Compatible with IV solution?________ Safe dose for your patient? __________________

Remember the 8 rights!

CONTINUOUS IV ORDERS

Rate of ordered IV infusion & solution: ______

Can the drug be given using this rate? If not, recalculate rate. _____________________________________________

Consider special precautions such as pt age and diagnosis.

Initial solution in buretrol: _______mL

Amount of medication: mL

Total sol. ____________mL

Rate: __________mL/hr

Time to check for flush:__________

Remember, if you changed the IV rate, you use the same rate until the flush is finished. Then return the IV to the

ordered rate.

ADMINISTRATION OF MEDICATION IN VOLUME CONTROL SET

1. ID your patient using 2 identifiers.

2. Check IV for infiltration and patency.

3. Adjust the amount of solution in buretrol if needed.

4. Make a "closed" system of IV buretrol.

5. Clean injection port on buretrol. ·

6. Inject medication.

7. Adjust flow rate if needed.

N335 GRADING YOUR PERFORMANCE 1. There are 38 behavior areas to be considered. The minimum passing rating (75%) is criteria for clinical

performance that you have been given.” Needs to improve” will be evaluated as passing if the student’s

performance improves to a satisfactory level after considerable practice and/or instructor counseling. The

first few weeks you will probably have “needs improvement” in some areas. These are the areas you need to

work on. Don’t panic! No one knows everything when you start a new course. That is an unrealistic

expectation. Please rate yourself appropriately and reflectively. Clinical evaluation tools with everything

marked satisfactory the first few weeks will be returned to be redone.

2. Critical performance areas are identified with an *. If the student earns an unsatisfactory in any of these critical elements, he/she will receive an overall weekly UNSAT for clinic. 3. If a student accumulates 2 Needs Improvement (N.I.) for the same behavior area, the 3rd

N.I. in that same behavior area will result in an UNSAT. 4. A student having more than 3 behavior areas (non-critical elements) of UNSAT/NI in any one week will receive an overall weekly UNSAT for clinic.

5. A student may not accumulate more than 1 UNSAT week over the duration of clinical in Nursing 335.

6. If a student receives 2 UNSAT clinical weeks in N335, they will have earned an overall UNSATISFACTORY for clinic and will not meet course minimal standards for passing (a score of “Satisfactory” on or above for 75% of the clinical rotation). To successfully pass N335 the student must pass both theory and clinical.

Los Angeles Harbor College Associate Degree Registered Nurse Program Nsg 335 Pathophysiology Preparation Sheet*

Medical Diagnosis: How would you define this diagnosis to your patient and parent (brief): Etiology: Pathophysiology: Laboratory & Diagnostic tests – What abnormal would you expect and why?

Anticipated Ineffective Behaviors (clinical manifestations): Collaborative Interventions : Medical: 1. 2. Nursing: 1. 2.

Top 3 (Actual or High Risk For) Nursing Diagnoses and what related to: 1. 2. 3.

*Site Sources for Diagnoses:

Student:

Clinical

Instructor:

Agency: Semester:

Evaluation Criteria Satisfactory: Clinical performance demonstrates continued growth towards course competencies. Behaviors are consistent, safe, and

performed at expected learner level described in the student competency behavior descriptors for satisfactory performance.

Needs Improvement: Behaviors manifested have potential for causing harm. Student requires excessive prompting and directing to

perform safely and at expected learner level.

Unsatisfactory: Behaviors performed or omitted are unsafe. Student’s behavior(s) lack knowledge base and skill competencies expected

(see unsatisfactory behavior descriptors.

* Represents critical competency behaviors. Competency behaviors must be met in order to pass the clinical component of this course.

“Unsatisfactory” rating will be given for the following behaviors: an unsatisfactory rating in any critical behavior or 3 or more “needs

improvement” ratings in one week of clinical or 1 “unsatisfactory” rating in a non critical behavior and “needs improvement” in one clinical

week. The student must demonstrate a satisfactory level of performance for 75% of the clinical rotation in order to pass. Two

unsatisfactory clinical weeks will result in a clinic failure. The student must pass theory and clinical in order to pass the course.

COMPETENCY & PERFORMANCE CRITERIA

I. INTEGRATE THE NURSING PROCESS USING THE ROY ADAPTAION MODEL TO PROMOTE ADAPTATION OF INDIVIDUALS, FAMILIES, AND THE COMMUNITY. 1. Collects comprehensive assessment data that includes the child’s/family’s values, preferences, expressed

needs, and developmental, emotional, cultural, religious, and spiritual influences.

2. Creates a nursing history and assessment on child-family that categorize ineffective behaviors that affect

adaptation in the four modes: Physiological, self-concept, role function, and interdependence.*

3. Analyze assessment data to determine actual and potential problems.

4. Proposes actual and potential nursing diagnoses and formulates expected outcomes based on

child/family values, preferences, and expressed needs.

5. Coordinate with child/family and inter-professional team to develop a plan that prescribes strategies and

alternatives to achieve expected outcomes.

6. Implement identified plan for both child and family.*

7. Evaluate progress toward attainment of outcomes and modify plan of care as needed.*

Week/Date 1 2 3 4 5 6

Satisfactory Orientation

Needs Improvement

Unsatisfactory

II. INTERNALIZE PROFESSIONAL BEHAVIORS OF NURSING PRACTICE.

1. Constructs one’s role as a nurse in ways that reflect integrity, responsibility, ethical practices, and an

evolving identity as a nurse committed to evidence based practice, caring, advocacy, and safe, quality

care for diverse patients within a family and community context. *

2. Integrates the Code of Ethics, Standards of Practice, and policies and procedures of Los Angeles Harbor

College, nursing program, and clinical agencies into practice.*

3. Codifies appropriate behaviors, e.g. prompt and timely arrival to class and clinic; adherence to uniform

standards; attendance, honesty; and attitude.

4. Accepts accountability and responsibility for own actions.

5. Advocates for patients and families in ways that promote their self-determination , integrity, and ongoing

growth as human beings.

6. Evaluates own performance correctly and thoughtfully on WCET form.

Week/Date 1 2 3 4 5 6

Satisfactory Orientation

Needs Improvement

Unsatisfactory

III. FORMULATE CLINICAL JUDGMENTS IN PRACTICE THAT PROMOTE THE

HEALTH OF PATIENTS.

1. Analyze and demonstrate critical thinking in making clinical decisions, e.g. information regarding medical

history, assessment, diagnostic tests, laboratory values, and medications to develop an individualized plan of

care for child-family.

2. Differentiate stimuli of effective and ineffective behaviors.

3. Categorize and document all relevant information and use developmentally appropriate resources, and

reasoning for clinical decision-making.

Week/Date 1 2 3 4 5 6

Satisfactory Orientation

Needs Improvement

Unsatisfactory

IV. PROVIDE SAFE, PATIENT-CENTERED CARE.

1. Analyze the pathophysiology and pharmacotherapy for patients.

2. Examine learning needs, develop teaching plans, implement teaching and evaluate effectiveness.

3. Respect and encourage individual expression of patient values, preferences, and expressed needs.

4. Provide patient-centered care with sensitivity and respect for developmental stage, values, customs,

religion, ethnicity, and culture.

5. Analyze pain and implement interventions for treatment in light of patient values, preferences, and

expressed needs.

6. Performs nursing skills competently and safely according to college or agency policy, e.g. follow 8 rights of

medication administration. *

7. Adheres to current National Patient Safety Guidelines.

8. Demonstrates strategies to prevent and reduce harm. *

Week/Date 1 2 3 4 5 6

Satisfactory Orientation

Needs Improvement

Unsatisfactory

V. ASSIMILATE EFFECTIVELY WITHIN NURSING AND INTER-PROFESSIONAL TEAMS FOSTERING EFFECTIVE COMMUNICATION TO ACHIEVE QUALITY PATIENT CARE.

1. Function competently within scope of practice as a member of the health care team.

2. Utilize therapeutic communication techniques with interdisciplinary team members to assist patient,

family, and significant others to cope with alterations of health and achieve goals.

3. Follow communication practices that minimize risks associated with handoffs among providers across

transitions of care (SBAR).

4. Reports ineffective behaviors, accurate, pertinent information, and patient concerns in a timely manner

to staff and/or instructor. *

Week/Date 1 2 3 4 5 6

Satisfactory Orientation

Needs Improvement

Unsatisfactory

VI. INTEGRATE BEST CURRENT EVIDENCE WITH CLINICAL EXPERTISE FOR OPTIMAL HEALTH CARE.

1. Analyze evidence-based practice to include the components of research evidence, clinical expertise, and

patient/family values.

2. Compare and contrast efficient and effective search strategies to locate reliable sources of evidence that

will provide the ability to make judgments in practice, substantiated with evidence, that integrate nursing

science in the provision of safe, quality care and promote health of patients within a family and

community context.

3. Systematize the evidence that underlies clinical nursing practice to challenge the status quo, question

underlying assumptions, and other new insights to improve the quality of care for patients, families, and

communities.

Week/Date 1 2 3 4 5 6

Satisfactory Orientation

Needs Improvement

Unsatisfactory

VII. DESCRIBE STRATEGIES FOR IMPROVING OUTCOMES OF CARE IN CLINICAL

PRACTICE. 1. Analyze a variety of sources of information to review outcomes of care and identify potential areas for

improvement.

2. Differentiate nursing and other health professions as parts of systems of care that affect outcomes for

patients, families, and communities.

3. Complete care safely, cost effectively, organized and timely to improve the quality of care.

4. Integrates measurable outcomes on care plans to evaluate care.

Week/Date 1 2 3 4 5 6

Satisfactory Orientation

Needs Improvement

Unsatisfactory

VIII. INCORPORATE INFORMATION AND TECHNOLOGY TO COMMUNICATE, MANAGE KNOWLEDGE, MITIGATE ERROR, AND SUPPORT DECISION MAKING.

1. Demonstrate successful navigation and documentation within the electronic health record in the clinical

setting.

2. Examine appropriate resources, collected electronically or other means to communicate with the

interprofessional teams and solve patient problems.

3. Maintains patient confidentiality and security of all health records.

Week/Date 1 2 3 4 5 6

Satisfactory Orientation

Needs Improvement

Unsatisfactory

STUDENT REFLECTIONS: Write about feelings, opinions and concerns regarding patient care activities that

went well or not so well, transfer of theoretical knowledge and nursing interventions that promoted

effective adaptation of your patient. Write comments related to resolution of performance, lessons

learned, procedures performed. Writing should be analytical and not merely observational.

Reflection Comments Use Back of Page as Needed

List Week’s Nursing Diagnoses

List Procedures Performed

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

INSTRUCTOR’S WEEKLY FEEDBACK REGARDING STUDENT CLINICAL PERFORMANCE. State positive

performance and suggestions for improvement.

Week 1 Welcome to Pediatrics! Congratulations on passing the math exam. Health packet complete. Actively participated in orientation.

Week 2

Week 3

Week 4

Week 5

Week 6

Please initial the evaluation every week after reading it. Your initials indicate only that you have read and

understand the evaluation.

Week/Dates Satisfactory Unsatisfactory Student’s

Initials

Student Comments

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

FINAL INSTURCTOR EVALUATION

SATISFACTORY ______ UNSATISFACTORY ______ TOTAL POINTS: ________ FINAL GRADE:

__________

PROJECT 1: AGE _____ DX.__________________ PHYSIO ____/15 PSYC/SOCIAL ____/15

PROJECT 2: AGE _____ DX.__________________ PHYSIO ____/15 PSYC/SOCIAL ____/15

COMMENTS:

FINAL STUDENT COMMENTS:

STUDENT’S SIGNATURE: ____________________________________________________________ DATE:

____________

INSTRUCTOR’S SIGNATURE:

__________________________________________________________DATE:____________

Student: Date(s) of Care: Admit Date: Initials

Age: Room# Allergies:

CC: Admit Diagnosis:

Surgery/Procedures:

History:

Activity:

Lines: AL PICC PIV TLC CVP SL

Tubes: FC Other: NG/GT CT JP

Resp Interventions:

IV Fluids:

IV Drips: Diet/Tube Feeding:

FSBS:

Diagnostic Tests: CXR EKG ECHO Other:

ABGs: pH PaCO2 HCO3 PaO2

O2 sat% BE

Labs: Na CL BUN Glucose K+ CO2 Cr HgB WBC Platelets HcT

Medications 08 09 10 11 12 13 14 15 16 17 18 19 Treatments: Follow-Up: Plan of Care:

STUDENT NAME: NURSING COURSE: 335 Room Number:

Patient Initials:

NURSING PROCESS Nursing Care Plan

Medical diagnosis:

Date: Facility:

Instructor: Developmental Stage:

Assessment First Level Behaviors

Assessment Second Level

Stimuli

Nursing Diagnosis

GOALS/Expected Outcomes

THERAPEUTIC NURSING INTERVENTIONS (Nursing activities to achieve outcomes

and Rationales for interventions)

Evaluation Check Outcomes:

Yes? No?

Subjective Data:

As manifested by:

Goal(s):

Objective Data:

Expected outcomes As evidence by: