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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: