Bay College West

Student Name: Clausen,Leanne M

Associate Degree Nursing Program

Clinical Instructor: _Dr. Joyel

J.Brule Clinical Evaluation 1- NURS 134

Semester:Winter 2016
Clinical Site: VANC
Absence (s)_O

Tardy (s)

o.

Profile
Unsatisfactory

Threaded Concept
Human Needs

Performs a comprehensive nursing assessment

through analysis of assessment data, physical
assessment data, lab and other diagnostic data

Satisfactory

Needs Improvement/Specifics

'

Nursing Process

Evaluates for changes in health status and begins to

identify complex needs

Cultural
Competence

Integrates the impact of developmental,emotional,

cultural, religious, and spiritual influences on health
status

Nursing Process

Assesses for changes in health status and identifies

appropriate actions

Nursing Process

Analyzes patient's response to interventions

Nursing Process

Assess discharge needs and ability to access

community resources

X.

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Nursing Process

Evaluates patient's response to medications

Nursing Process

Recognizes trends in lab data and takes appropriate

nursing action

Communication

Assesses patient/support person(s) learning ability,

barriers, motivation to learn, and learning needs prior
to teaching-learning

Communication

Implements steps in the teaching process in

increasingly complex patients.

Communication

Participates in meeting goals toward discharge

Cultural
Competence

planning

Communication

Implements and evaluates teaching to patient's

identified at risk for complications

I:

Process
Caring Interventions

Integrates the steps of the nursing process, evidencebased 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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Informatics

Integrates evidence-based practice, collected through

technological resources and other modalities, in
decision-rna king.

Nursing Process

With assistance, utilizes nursing process and critical

thinking to prioritize and organize care for one or
more patients

Clinical Judgment

Follows existing care plan to provide for continuity of

care

Professional
Behavior

Seeks guidance in evaluation of care regimen

outcomes

Professional
Behavior

With supervision, provides safe, evidence-based care.

Profession
Communication

Integrates cultural sensitivity throughout the nursing

process

Communication

Utilizes appropriate communication channels to

report relevant assessment data

Communication

Communicates relevant and complex information in a

concise and clear manner to clients and healthcare
team members

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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

C ommunication

Utilizes verbal and nonverbal communication skills

while establishing caring relationships

Clinical Judgment

I
I

Informatics

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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Clinical Judgement

Evaluates for physiological & psychological safety of

patients

Clinical Judgement

Functions as a patient advocate

Nursing Process

Implements complex nursing interventions based

upon patient assessment

Profession
Professional

Accepts ethical/legal responsibility for own actions as

Behavior

expressed in ANA Code of Nursing

Professional

Demonstrates self-reflection by:

Behavior

Examining own ideas, feelings, and behaviors

Recognizing and accepting learning opportunity
Accepts responsibility for nursing care given by self

Professional

Maintains confidentiality of all healthcare

Behavior

information

Professional
Behavior

Professional

Functions, with minimal supervision, in the role of a

Behavior

professional nurse as a member of the healthcare

team.

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Professional
Behavior

Accurately documents nursing cares and procedures

Professional
Behavior

Utilizes self-reflection for continued growth in

nursing practice.

Professional
Behavior

Demonstrates personal responsibility by:

Arriving on time
Informing both school and agency of
absence/tardiness
Adhering to school and agency dress code
Following Student Handbook guidelines

Professional
Behavior

Demonstrates honesty in:

Documentation
Performance of skills (meds, treatments, etc.)
Interaction with others
Clinical paperwork

Collaboration

Identifies and recognizes roles and responsibilities of

members ofthe 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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Informatics

Utilizes appropriate technology in provision of care

Managing Care

Recognizes aspects of safe/unsafe environment

Managing Care

Provides patient-centered nursing care

Professional
Behavior

Demonstrates beginning level of patient

management, leadership, and organizational skills by:
appropriate delegation, accepting responsibility and
accountability for own actions, accepting
accountability and responsibility for delegated
nursing actions.

Professional
Behavior

With supervision, accepts legal/ethical responsibility

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

Managing Care

Maintains environment that supports patient

independence

Additional Comments:
Concept Map (Circle) #1Pass Fail

#2 Pass Fail #3 Pass Fail

Dosage calculation quiz (Circle) #1Pass Fail

#2 Pass Fail

Teaching and Discharge Plan (Circle) Pass Fail

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I have reviewed the contents of this evaluation and fully understand its implications.
(Circle) Pass Fail

Student Signatu

m L(/Qdl.ku.-

=ttach to E1 'jation)

All

c.P rJ

Date

2-Z-L{- /0

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Clinical Instructor Signature:

Additional Comm en ts:_

ft
L
}!_:_

{)z

/. Performs care safely with direct supervision

tJud,L

___

Date

l.-2J -20/(a

' !

Can state and is aware of some purposes, rationale and precautions R/T care of assigned patients
( R;quires no supervision to safely perf rm care after given instructio/ dem nstration)
(Approaches care in a systematic, organizeway)
( Performs care correctly according to policy/protocol;time required only slightly longer than experienced person

Can state and is aware of purpose, rationale and precautions R/T care of assigned patients Successfully performs care without formal
instruction/ demonstration
Adapts to unexpected occurrences without losing control of situation
Performs_care correctly according testablished policy/protocol in timely manner with accuracy and safety an evaluate the effectiveness of the
care and intery_entions

Acts as role model for others performing care

Proposes alternate methods/techniques to improve care/ performance-

Performs care correctly in a spontaneous way without hesitation Incorporates the whole picture in evaluating care/ outcome on patient