Bay College West
Associate Degree Nursing Program
Clinical Evaluation |~ NURS 134
Student Name: Smith, Brenda Mae
Clinical Instructor: _Dr. Joyel J. Brule
Semester: Winter 2016
Clinical site: VANC
Absence (s)_0, Tardy (s)_0.
Profile i
Threaded Concept Unsatisfactory | Satisfactory | Needs Improvement/Specifics
Human Needs | Performs a comprehensive nursing assessment x
| through analysis of assessment data, physical
assessment data, lab and other diagnostic data
Nursing Process | Evaluates for changes in health status and begins to x
identify complex needs
Cultural Integrates the impact of developmental, emotional, x
Competence cultural, religious, and spiritual influences on health
status
‘Nursing Process | Assesses for changes in health status and identifies, x
appropriate actions
‘Nursing Process _| Analyzes patient’s response to interventions x
‘Nursing Process | Assess discharge needs and ability to access %
community resources
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1|PageNursing Process
Evaluates patient's response to medications
‘Nursing Process | Recognizes trends ia lab data and takes appropriate
nursing action
Commu ‘Assesses patient/support person(s) earning ability,
barriers, motivation to learn, and learning needs prior
Cultural to teaching-learning
Competence
Communication
Implements steps in the teaching process
increasingly complex patients.
Communication
Participates in meeting goals toward discharge
planning
‘Communication
‘Caring Interventions
Implements and evaluates teaching to patient’s
identified at risk for complications
Integrates the steps of the nursing process, evidence:
based practice, and critical thinking in patient care
‘Nursing Process
Identifies pathophysiology of the medical surgical
patient and relates to patient situation.
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2|Pageconcise and clear manner to clients and healthcare
team members
Informatics Integrates evidence-based practice, collected through x
technological resources and other modalities, in
decision-making
‘Nursing Process With assistance, utilizes nursing process and critical x
thinking to prioritize and organize care for one or
| more patients
Clinical Judgment | Follows existing care plan to provide for continuity of x
care
| Professional ‘Seeks guidance in evaluation of care regimen x
Behavior outcomes
Professional With supervision, provides safe, evidence-based care. x
Behavior
Profession
‘Communication | Integrates cultural sensitivity throughout the nursing x
process
|
‘Communication | Utilizes appropriate communication channels to x
report relevant assessment data
‘Communication | Communicates relevant and complex information in a x
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3|Page| Clinical Judgment
Reports medication side effects or medication
inaccuracies to appropriate member of the health
care team and instructor in a timely manner
Communication
Establishes therapeutic communication with patients
‘Communication
Utilizes verbal and nonverbal communication skills
while establishing caring relationships
Informatics
L
Demonstrates intermediate computer literacy related
to patient care.
Nursing Process
Demonstrates with minimal supervision the ability to
perform procedures/skills based on facility guidelines
Professional
Behavior
Establishes and maintains caring relationships with
patient’s/support person(s).
Clinical Judgement
Safely administers medication with minimal
supervision
Nursing Process
Evaluates patient response to medications
Professional
Behavior
Maintains human dignity
Clinical Judgement
Provides developmentally appropriate nursing care
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4|PageClinical Judgement | Evaluates for physiological & psychological safety of x
patients
Glinical Judgement | Functions as a patient advocate x
Nursing Process | Implements complex nursing interventions based x |
upon patient assessment
Profession
Professional ‘Accepts ethical/legal responsibility for own actions as x
Behavior expressed in ANA Code of Nursing
Professional Demonstrates self-reflection by: x |
Behavior
Examining own ideas, feelings, and behaviors
Recognizing and accepting learning opportunity
Professional ‘Accepts responsibility for nursing care given by self 1x
Behavior
Professional Maintains confidentiality of all healthcare x
Behavior information
Professional Functions, with minimal supervision, in the role of a x | -
Behavior professional nurse as a member of the healthcare
team.
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5|PageProfessional
Behavior
‘Accurately documents nursing cares and procedures
Professional
Utilizes self-reflection for continued growth in
Behavior nursing practice,
Professional Demonstrates personal responsibility by:
| Behavior Arriving on time
Informing both school and agency of
absence/tardiness
‘Adhering to school and agency dress code
Following Student Handbook guidelines
Professional Demonstrates honesty inz
Behavior Documentation
Performance of skills (meds, treatments, etc)
Interaction with others
Clinical paperwork
Collaboration Identifies and recognizes roles and responsibilities of
members of the health care team and collaborates
with the team effectively
Professional
Behavior
Collaborates with patient/family in setting goals and
evaluation
‘Managing Care
Provides evidence-based, cost effective patient care
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6|PageInformatics Utilizes appropriate technology in provision of care x
Managing Care Recognizes aspects of safe/unsafe environment x
Managing Care | Provides patient-centered nursing care x
Professional Demonstrates beginning level of patient, x
Behavior management, leadership, and organizational skills by:
appropriate delegation, accepting responsibility and
accountability for own actions, accepting.
| accountability and responsibility for delegated
nursing actions.
Professional With supervision, accepts legal/ethical responsibility x
Behavior for nursing care. Follows agency policy and
procedures, functions within legal scope of a nursing
student, shares pertinent information with agency
staff and instructor
Managing Care _| Promotes the rehabilitation potential of the patient x
Managing Care | Maintains environment that supports patient x
independence
Additional Comments:
Concept Map (Circle) #1 Pass Fail #2 Pass Fail #3 Pass Fail
Dosage calculation quiz (Circle) #1 Pa Fail #2 PSB ral
‘Teaching and Discharge Plan (Circle) Pass Fail
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7|PageIhave reviewed the contents of this evaluation and fully understand its implications.
Fall Clinjeg Contract (tach t Evaluation)
Dring dith vate A/44/ A/G
Clinical Instructor Signature: Wt Dek Muh vate_2-23-20/6
Additional Comments?
Performs care safely with direct supervision
Can state an
is aware of some purposes, rationale and precautions R/T care of assigned patients
Requires no supervision to safely perform care after given instruction/ demonstration
Approaches care in a systematic, organized way S|
Performs care correctly according to poi rotoco time required ony stl longer thangaperenced peso)
‘Can state and is aware ot purpose, rationale and precautions R/T care of assigned patients Successfully performs care without formal
instruction/ demonstration
ces without losing control of situation
\ Adapts to unexpected occurrences
—_—
—__ a
Performs care correctly according to established policy/protocol in timely manner with accuracy and safety Can evaluate the effectiveness of the
not ote prongems SX
Proposes alternate methods/techniques to improve care/ performance
F Performs care correctiy in a spontaneous way without hesitation Incorporates the whole picture in evaluating care/ outcome on patient
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