Clinical 3 Midterm Evaluation PDF

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Practical Nursing Diploma Program-Clinical SEM II-NRSG 199 Midterm and Final Evaluation Student Name: Jennah Farnell

Student ID: 10213665

Clinical Faculty: Charlee Grove

Agency and Unit: ROSS 3 Medical

Hours Absent: *20 points will be deducted for each day (6-hours) Clinical Dates: feb 2, feb 16, feb 23, mar 2, mar 23, mar 30, apr 13, apr 20

Level Sem 3 Definition

Outstanding performance: Consistently, skillfully, and with early and progressive independence is able to meet all objectives (90-100% of the time)

Good performance:

Minimal performance:

With limited guidance is able to meet all clinical objectives (8089% of the time)

With ongoing guidance is able to meet all clinical objectives (50-79%) of the time- -Meets minimal standards for safe practice

Points Grade

228-205 4

182-204 3

160-181 2

Unsatisfactory performance: Inconsistent in meeting clinical objectives (2649%) of the time— inconsistent in meeting any/all minimal standards for safe practice), 59-159 1

Unsafe performance: (0.0%- 25%--failure in meeting any/all minimal standards for safe practice)

58-0 0

1 PN SEMESTER -II, Clinical Evaluation

Minimum Level – Designated Standards in order to pass clinical 2 Criterion Grouping

Requirement

4.0 Professional Accountability – Implementation: Medication Administration

A minimum performance level “Good Performance – 3” in the final evaluation

6.0 Professional Accountability – Safety in the Practice Setting

A minimum performance level of “Good Performance -3” in all elements in the final evaluation

7.0 Ethical Practice

A minimum performance level of “Good Performance – 3” in all elements in the final evaluation

Unit/specialty specific outcomes (ie. Surgical, medical, mental health, community, maternal/child)

A minimum performance level of “Minimal Performance – 2” in all elements in the final evaluation

Care Plans

A “minimum of a 4” on the final (second) care plan

If at any time during the clinical rotation the student is at risk for a fail status, the instructor or student can implement a Student Success Contract.

PASS: The student demonstrated acquisition of a total score of >160 and met the minimum required level in designated standards. FAIL: The student did not demonstrate acquisition of a minimum score of >160, and/or did not meet the minimum required level in designated standards This document represents a formal and legal representation of the performance of the student during their clinical rotation and must be fully completed and electronically submitted in a manner that reflects professionalism. The student must continue to abide by the Fleming Confidentiality Form and any Agency Confidentially Forms

Mid-term Status:

Pass

Fail

Student Success Alert Implemented:

Yes

No

Final Status:

Pass

Fail

2 PN SEMESTER -II, Clinical Evaluation

1.0 PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY – ASSESSMENT Midterm Criteria ASSESSMENT Accurately describes pathophysiology/psychopathology specific to alterations in physical and mental health assessment

Final

Student Comment Met/Not Met

Met/Not Met

4 3 2 1 0 4 3 2 1 0 X

Identifies and describes the effect of stressors on the health status of specific clients

X

Accurately gathers data using appropriate techniques/instruments and utilizes an assessment tool to record and organize data collected; assessment data is documented in a timely manner and abnormal finding are communicated to the clinical instructor/MRN immediately

X

Describes the significance of normal/abnormal assessments and lab results for specific clients

X

Identifies the growth and development status of clients across the lifespan specific to alterations in physical and mental health; incorporates knowledge of age-related changes when developing plan of care

X

Identifies deficits that affect, or may affect the client’s ability to explain self, ask questions, understands information.

X

Analyses past medical history, and history of present illness including lab data to accurately formulate a plan of care that includes goals, measurable outcomes and interventions.

X

***************ASSESSMENT: COMMENT REQUIRED- STUDENTS TO MARK/COMMENT ON EACH SECTION First thing in the morning I find my nurse and ensure to get report on my patient(s) for the day. I make sure to learn my patients name and also be sure that they know mine. I gather as much data about my given patient by looking in their chart to see past and present medical history, stressors and health concerns. I am collectively gathering data throughout the day based on each thing I do with the patient. I can identify abnormalities during my assessment and inform nurse + instructor is there are any concerns. I identify who my patient is and what obstacles I will occur when caring for them. For example a patient I was with, had a developmental delay, so to ensure she was happy throughout the day I provided YouTube video’s off their own iPad along with colouring and toys brought from home.

3 PN SEMESTER -II, Clinical Evaluation

2.0 PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY – PLANNING Midterm

Final

Student Comments Met

PLANNING Accurately describes pathophysiology/psychopathology specific to alterations in physical and mental health assessment;

4

3

2 1 0 4 X

3

Not/Met

Met

Not/Met

2 1

X Provides evidence-based/informed rationale for all decisions based on pathophysiology/psychopathology, nursing theory and skills lab content. X Identifies nursing diagnosis presented in NANDA format using assessment data X Develops a nursing plan of care based on accurate nursing diagnosis and SMART goals Collaboratively develops a client centred plan of care through effective X communication with all appropriate parties (patient/client, family, health care providers, clinical instructor) Analyses client’s needs and establishes priorities, with the ability to X prioritize multiple or competing care needs X Correctly selects a high priority nursing diagnosis and discusses at least two interventions that are supported by evidence-based practice X Develops interventions that are individualized to the patient/client. X Incorporates culturally appropriate, and age/developmental care needs X Describes provisions for the continuity of care Accurately documents in a timely manner, assessment findings and X care according to practice standards and program expectations **********************Comments: ASSESSMENT: COMMENT REQUIRED- STUDENTS TO MARK/COMMENT ON EACH SECTION Before meeting my patient, I collect as much information about them from report from night nurse and the documents in their chart. I try to do this in the mornings before I see my patient so that I can have a good understanding of their needs, diagnosis, past history and reason for admission. I carry a notebook with me so that I can document any or all, important information or changes about my patient so that I can tell the nurse and also to write efficient progress notes. I develop a basic nursing care plan in my head based off the information about my patient so that I know what interventions I will be implementing during the day. One patient I had their method of coping was their stuffed animals. I always made sure these stuffed toys were on the bed with their owner at all times. This kept 4 PN SEMESTER -II, Clinical Evaluation

the patient happy and calm so I could perform skills like vitals. At the start of my assessment, I always look for what the patient needs, and priorities of the day will be. I try to document when I have free time and during slower parts of the day.

PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY – INTERVENTIONS/ IMPLEMENTATION Midterm

Final Met

Nursing Interventions/Implementation Develops and utilizing a plan of care that includes expected outcomes and is implemented in a safe, timely, and appropriate manner

4

3

2 X

Analyses plan of care to ensure nursing interventions are supported by evidence-based practice, CNO standards and agency/unit policy

X

Consistently demonstrates competence in nursing skills appropriate to practice setting and specialty area* See agency/unit specific evaluation criteria

X

Considers patient’s cultural, developmental and psychosocial status; re-evaluates and modifies care plan accordingly in consultation with the instructor

X

Demonstrates sensitivity and inclusion of client diversity and right to choose in plan of care

X

Demonstrates critical thinking and independent judgment in clinical decision making through the following activities:  Pre and post conferences

X



Nursing care plans.



Instructor interactions

Establishes a therapeutic relationship with the client and

1

0

4

3 2

1

Not Met

Met

Not Met

0

X

5 PN SEMESTER -II, Clinical Evaluation

family by demonstrating principles of relational practice including active listening, sensitivity to emotional context, questioning, self-observation, and reflection

Demonstrates the use of empathy in interactions with client/family

X

Accurately describes nursing interventions, patient’s pathophysiology and related symptoms in his/her own words when interacting with the client/patient

X

Identifies and reports changes in client health status to the clinical instructor or most responsible nurse (MRN) in a timely manner.

X

Adheres to the established client care plan or, in conjunction with the clinical instructor, modifies the client care plan to reflect changes in condition

X

Documents all assessment, care and evaluation accurately, in a timely manner, and according to CNO standards, practice setting and specialty area.

X

Maintains asepsis and standard precautions; recognizes and responds appropriately to breaches in sterility or precautions

X

*******************ASSESSMENT: COMMENT REQUIRED- STUDENTS TO MARK/COMMENT ON EACH SECTION When entering a patient’s room, I observe the surroundings for any indications or religious background or any items that may help me to start an open conversation with a patient. While I take vitals and during my assessments, I try to talk to the patient to get an understanding of their cognitive level and a feel for their personality. During a past clinical day I had a pt tell me all about her kids, family, and where she came from. I always take part in pre and post conference and interact frequently throughout the day with my instructor.

4.0 PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY –IMPLEMENTATION - COMMUNICATION WITH THE HEALTH CARE TEAM MIDTERM Final 6 PN SEMESTER -II, Clinical Evaluation

Mid Term COMMUNICATION-HEALTH TEAM Introduces self and explains status to health team members

4

3 X

2

Establishes and maintains an effective, respectful and professional working relationship with the health care team including other students and clinical instructors

X

Demonstrates a working knowledge of, and respects the roles of health team members

X

Collaborates with health care team members under the guidance of the clinical instructor to develop, modify or reevaluate plan of care

X

Accurately reports pertinent information, verbally and in writing, to the clinical instructor and other health care team members in a timely manner

X

Develops leadership skills at a beginning level through adoption of the student team leader role

X

Shares information and actively participates in pre-postconference to enhance group learning

X

Identifies care activities that could be delegated to appropriate personnel in consultation with the clinical instructor

X

1

Final 0

4

Met/Not Met 3

2

1

0

****************Comments: ASSESSMENT: COMMENT REQUIRED- STUDENTS TO MARK/COMMENT ON EACH SECTION I introduce myself to staff/ patients and explain my status as a student nurse. I maintain an effective, respectful and professional working relationship with all Members of the health care team and the patients. During a clinical day I like to chat with my assigned nurse frequently so that she/he is updated and can give me tips and advice. After I see my patient I like to report to the primary nurse if care was provided. I collaborate with my classmates discussing our patients and situations so that so we can assist one another. I will ask my classmates to help me in performing patient care when needed or for everyone’s learning purposes.

5.0 PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY - SAFETY IN THE PRACTICE SETTING 7 PN SEMESTER -II, Clinical Evaluation

** A MINIMUM PERFORMANCE LEVEL OF A “3” AT MID-TERM AND AT FINAL EVALUATION IN ALL ELEMENTS IN THE FINAL TO ATTAIN AN OVERALL GRADE OF PASS IN THE COURSE ** SAFETY Seeks clinical instructor assistance in a timely and appropriate manner.

4

3 2 1 0 4 3 2 X

Seeks clinical instructor supervision as directed with the performance of nursing skills

X

Prepares for clinical assignments in advance of clinical shift each day

X

Verbalizes using own words an accurate patient update to clinical instructor or MRN at any point during the clinical shift

X

Promptly reports to the instructor and facility any situation that is unsafe for clients.

X

Follows all college/CNO/unit/agency policies related to safety and professionalism including but not limited to, infection prevention and control, confidentiality, social media, clientnurse relationship, harassment, bullying and discrimination

X

MIDTERM

1

Met/Not Met

Met/Not Met

FINAL

****************Comments: ASSESSMENT: COMMENT REQUIRED- STUDENTS TO MARK/COMMENT ON EACH SECTION I seek the clinical instructor for assistance/ supervision when performing skills or care. If I know I am going to need the instructor for a skill or task I will let her know ahead of time or try to find her before beginning. Before preforming any skills on patient’s, I make sure the instructor knows what I’m doing, when and what it is beforehand. I like to update my instructor frequently throughout the day, so she knows and feels confident in my skills and builds trust. Report to the primary nurse with vitals and assessments, urgently will state if the client is unsafe. Also, I always follow the CNO and unit/agency’s policies by enforcing the 3 med checks and 10 rights. I maintain a professional relationship with patient following CNO standards.

6.0 ETHICAL PRACTICE/PROFESSIONALISM

8 PN SEMESTER -II, Clinical Evaluation

** A MINIMUM PERFORMANCE LEVEL OF “3” IN ALL ELEMENTS IN THE FINAL EVALUATION IS REQUIRED FOR THIS STANDARD TO ATTAIN AN OVERALL GRADE OF PASS IN THE COURSE ** MIDTERM FINAL

9 PN SEMESTER -II, Clinical Evaluation

ETHICAL PRACTICE Demonstrates honesty and integrity. Reports to the instructor or clinical coordinator any observed breaches of CNO standards, agency or college policy, including violation of social media and confidentiality policies

4

3 2 1 0 4 3 2 1 0 X

Demonstrates a thorough understanding of confidentiality by respecting and maintaining client privacy legislation, CNO standards and agency/unit policy

X

Promotes client well-being by respecting the client’s right to safety, dignity, privacy and independence.

X

Identifies personal values in the context of professional practice and in accordance with CNO standards.

X

Ensures that the client is the focus of the client-student relationship

X

Demonstrates respect for and functions within the boundaries of the professional therapeutic relationship

X

Consistently models professionalism demonstrated by being punctual for all scheduled clinical activities (e.g., pre and post conferences, report, etc.); appropriate dress, language, and behavior; proper identification of one’s self and role

X

Met/Not Met

Met/Not Met

X Recognizes her/his knowledge, skills and abilities, limits of responsibilities, legislative authority and supervision requirements Reports to the instructor ethical concerns that arise during practice whether it be client focused or impacts on self, peers or the program Identifies areas of strengths and limitations and areas that need improvement. Seeks out constructive feedback regarding own practice Takes action to achieve goals identified by instructor during a performance appraisal

X

X PN SEMES R -II, Clinical Evaluation X

10

**************Comments: ASSESSMENT: COMMENT REQUIRED- STUDENTS TO MARK/COMMENT ON EACH SECTION In this section I know that I demonstrate honesty and integrity. I have a well understanding of Confidentiality and client privacy legislation. I rightfully respect all patient’s well-being by understanding who they are and how they function day-to-day. I maintain a client-student relationship with patients by never crossing any boundaries. I know that I model professionalism by coming into clinical on time, dressed in uniform, all supplies on hand, and with a bright attitude ready to start the day. I understand and recognize what my abilities and limits are of my skills practice. I would never perform a skill I have not learned or do not feel I could provide safe care. I see areas where I am strong. I enjoy giving injections whether it be IM or SUBCUT and have received good patient feedback. I would say I am weak in the aspect of head-to-toe assessments. I feel that each time I miss a few steps for example I frequently forget to check pedal pulses. I seek assistance and feedback from clinical instructor by addressing my concerns so that I can continue to grow and learn to be better. Professional Accountability – Implementation: Medication Administration ** A MINIMUM PERFORMANCE LEVEL OF “Met” IN ALL ELEMENTS IN THE FINAL EVALUATION IS REQUIRED FOR THIS STANDARD TO ATTAIN AN OVERALL GRADE OF PASS IN THE COURSE ** Nursing students must:     

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Criteria

Met X

No...