N421 Clinical Evaluation Tool

N421 Clinical Evaluation Tool
The instructor and preceptor will complete the evaluation tool. It is the student's responsibility to provide the instructor and preceptor with information that indicates satisfactory performance. S = Satisfactory U = Unsatisfactory NO = Not observed
Objective 1: Applies theories and concepts to the nursing care of clients with complex acute needs.
Sample behaviors		S/U	NO
1.1	Applies School of Nursing Framework to initiate care for the client. Able to describe framework. Able to identify internal and external environmental factors that affect client's progression towards wellness. Able to identify if nursing interventions are independent or collaborative; preventive, maintenance, promotional or restorative.
1.2	Uses coping and grief concepts when working with clients with complex acute illness and their significant others. Able to identify coping mechanisms used by client and significant others. Able to differentiate between beneficial and detrimental coping mechanisms. Able to assist client and significant others to improve coping ability.
1.3	Uses family crisis theory in dealing with the client and significant others. Able to describe crisis theory. Able to apply family crisis theory when communicating with client and significant others. Describes how client's illness affects significant others. Identifies alternative mechanisms for client and significant others.
1.4	Applies basic sciences to support rationale for care of assigned clients. Uses basic biology, physiology, anatomy, and psychology to support rationale for care of assigned client. Able to use math correctly on a consistent basis.
1.5	Applies theories of development to assess the developmental status of the client when appropriate.
1.6	Articulates thorough descriptive pathophysiology of all the client's medical diagnoses. Able to verbalize predisposing factors, signs and symptoms, diagnostics, usual medical/surgical treatment, and potential complications of all the client's diagnoses.

Comments:

Objective 2: Applies the nursing process using professional standards in care of clients with complex acute needs.
Objective 2a. Assesses clients with multiple complex acute alterations in physiological functioning using data from their internal and external environments obtained by physical and psychological assessments and from technical devices and laboratory reports.
Sample behaviors		S/U	NO
2.a.1	Collects accurate subjective and objective data from relevant sources.
2.a.2	Describes psychological status of client to determine needs.
2.a.3	Describes developmental status of client.
2.a.4	Describes client's nutritional status based upon caloric and nutrient needs, laboratory data, and disease process.
2.a.5	Interprets significant lab values and trends.
2.a.6	Relates data obtained from bioinstrumentation to client status.
2.a.7	Accurately interprets physical assessment data and relates to client situation.
2.a.8	Analyzes ECG rhythm strip at beginning of shift and whenever there is a change in rhythm. Analyzes rhythm strip for rate, regularity of R-R complexes, PR interval, QRS duration, rhythm and artifacts.
2.a.9	Performs appropriate assessment for pre- and post-procedures and diagnostic tests
2.a.10	Integrates information from various assessments to determine client needs.

Comments:

Objective 2b: Develops nursing diagnoses based on assessment data from client's internal and external environments.
Sample behaviors		S/U	NO
2.b.1	Consistently selects appropriate physiological and psychological diagnoses using current NANDA nomenclature.
2.b.2	Correctly uses a 3-part (P/E/S) diagnostic statement for actual problems and a 2-part (P/E) statement for potential problems.
2.b.3	Identifies appropriate etiologies and defining characteristics to support each problem.
2.b.4	Accurately prioritizes nursing diagnoses and demonstrates evidence of reprioritizing diagnoses as needed. Prioritizes life-threatening diagnoses over non-life-threatening problems. Able to provide rationale for prioritization.
2.b.5	States realistic goals in client-oriented behaviors, using broad terms which reflect resolution or improvement of the problem.
2.b.6	Writes realistic outcome criteria in specific measurable terms: who, what, where, when. Outcome criteria consistently specific, measurable and realistic. Outcome criteria based upon the nursing diagnosis.
2.b.7	Develops nursing interventions which are individualized, specific, realistic, and relate to nursing diagnosis, goals and outcome criteria. Interventions are written considering individual needs and not taken directly from book. Nursing interventions identify nursing's unique contribution to client care. Includes interventions to monitor client, show collaboration and to meet client and significant other's learning needs.
2.b.8	Updates care plan as needed to correlate with changes in client situation.

Comments:

Objective 2c: Implements nursing care plan based on prioritized nursing diagnoses.
Sample behaviors		S/U	NO
2.c.1	Performs procedures proficiently and safely according to standard nursing practice with minimal assistance from preceptor. Able to provide rationale for procedures. Transfers skills learned in Clinical Learning lab to equipment/supplies available on unit. Actions are safe for client, self and others. Uses equipment correctly. Reports changes in client status immediately. Consistently monitors for safety: restraints, siderails, etc.
2.c.2	Uses aseptic technique appropriately.
2.c.3	Follows through on proposed plan of care. Includes all important treatments.
2.c.4	Initiates client and/or significant other teaching. Aware of learning needs of client and significant others.
2.c.5	Prioritizes procedures during clinical appropriately.
2.c.6	Organizes time during specific clinical hours to complete assigned client care responsibilities. Consistently able to leave unit on time. Consistently administers medications and treatments within 30 minute window. Completes responsibilities in time to allow for documentation.
2.c.7	Effectively manages level of stress/anxiety to perform responsibilities. Manages level of anxiety to allow verbalization of knowledge to faculty/preceptor.
2.c.8	Uses appropriate precautions when handling blood and body secretions.
2.c.9	Attends to personal care needs of client without prompting (oral care, perineal care, catheter care, bathing, repositioning, etc)
2.c.10	Uses appropriate interventions based upon pre- and post-procedure/diagnostic test assessments.
2.c.11	Implements appropriate comfort measures for clients. Uses nonpharmaceutical measures to promote comfort.
2.c.12	Uses skill learned in previous and current courses.
2.c.13	Documents in medical record accurately and appropriately. Documentation reflects plan of care, procedures, changes in condition, and progress toward desired outcome. Documents at bedside when appropriate.
2.c.14 2.c.14.a	Administers medications based upon standards of care. Verbalizes/writes knowledge of client's medications: classification, generic & trade name, major side effects, nursing implications and expected outcomes. Able to explain specifically why client is receiving medication.
2.c.14.b	Establishes appropriate baseline data before administering medications (VS, urine output, lab data, allergies, absence of rash, etc.)
2.c.14.c	Correctly prepares and administers medications. Administers all IV medications in correct amount of proper diluent (if required) over time period recommended in IV handbook. Flushes feeding tube or IV line prior to and after medication administration. Flushes central lines with appropriate solution (according to unit policy) after medication administration. Follows the 5 rights of medication administration. Consistently uses appropriate techniques to prepare and administer medications. Identifies medications which are not compatible.
2.c.14.d	Documents medication administration accurately and in a timely manner. Signs off medications immediately after administration. Documents site and amount of PRN medications given. Writes small enough to allow for more than one PRN medication to be signed off in appropriate space. Consistently signs medication record.

Comments:

Objective 2d: Evaluates effectiveness of care and revises plan accordingly.
Sample behaviors		S/U	NO
2.d.1	Evaluates client's response to medications and treatments. Verbalizes assessments necessary to evaluate response to medication. Aware of adverse medication reactions.
2.d.2	Evaluates whether outcome criteria were met using appropriate subjective/objective data. Relates data to outcome criteria.
2.d.3	Evaluates effectiveness and appropriateness of nursing interventions. Identifies nursing interventions which are not effective based upon client's response.
2.d.4	Revises plan of care whenever problem is resolved, patient is not moving toward expected outcome, or interventions are not effective or appropriate.

Comments:

Objective 3: Communicates appropriately with client system in crisis and stressful situations.
Sample behaviors		S/U	NO
3.1	Aware of own nonverbal communication. Accurately interprets nonverbal cues of client and/or significant others.
3.2	Attempts to communicate or anticipate needs of clients with impaired communication. Considers alternative methods of communication. Maintains eye contact and checks to see if client needs anything before leaving room. Talks to unresponsive clients.
3.3	Demonstrates caring behaviors towards clients and significant others. Uses a soothing tone of voice. Uses affective touch. Listens to client and significant others. Refrains from talking to others in room as though client was not present.

Comments:

Objective 4: Uses advanced technology in a safe and effective manner.
Sample behaviors		S/U	NO
4.1	Responds to alarms while on the clinical unit. Identifies actual or potential problems when an alarm sounds. Attempts to resolve problem when an equipment alarm sounds.
4.2	Demonstrates safe practice when using equipment. Uses equipment according to unit policy and manufacture recommendations. Asks for assistance when using unfamiliar equipment. Checks that monitor alarms are on and set appropriately. Checks that equipment is plugged into appropriate outlet.
4.3	Performs appropriate checks on equipment to ensure accuracy. Checks equipment before obtaining data.
4.4	Performs appropriate checks on ECG monitor (lead placement, parameter alarms) and makes changes as needed. Monitors in an appropriate lead. Changes monitor patches to reduced artifact.
4.5	Performs appropriate checks on pressure lines: alarm parameters, level of transducers, zero reference point, pressure bag inflated to 300 mm Hg. Recognizes dampened waveform, wedged waveform and catheter fling. Levels and zero traducers prior to recording data. Checks arterial BP against cuff BP at least once each shift.
4.6	Explains client ventilator modes, peak inspiratory pressure, FiO₂, rate and alarms. Manually bags client if problem arises that cannot be immediately resolved. Aware when client's ventilator is alarming. Checks client condition first when a ventilator alarm sounds

Comments:

Objective 5: Uses knowledge of legal, ethical, cultural, and economic issues in providing outcomes based care.
Sample behaviors		S/U	NO
5.1	Strictly maintains confidentiality of all client data. Removes identifying information from laboratory reports. Only uses client initials on papers.
5.2	Reports errors immediately when discovered. Aware that an error occurred. Institutes corrective actions after an error has occurred. Aware of actions to take after an error.
5.3	Seeks guidance from instructor and other appropriate resources. Admits when not adequately prepared.
5.4	Identifies advance directives of clients. Aware of what advance directive means to care of client.
5.5	Identifies legal and ethical issues that occur in the clinical setting.
5.6	Writes legibly in medical record.
5.7	Assumes responsibility for own actions. Assignments are given to instructor in complete form and at time specified. On time for clinical practicum and/or conferences. Informs instructor, preceptor and clinical unit if late or absent. Arranges with preceptor and instructor make up time, if necessary. Consistently prepared for clinical assignment. Participates actively in clinical conferences. Changes behaviors (corrects deficiencies) when needed in response to feedback from instructor. Keeps preceptor informed regarding client status and clinical activities.
5.8	Follows policies established by the School of Nursing, the University and the clinical agency. (See School of Nursing Handbook). Uses professional standards of care for the client with complex acute illness.
5.9	Maintains BLS affirmation during the entire course.
5.10	Aware of the cost of care. Returns unnecessary equipment to proper source for credit. Charges for supplies used.
5.11	Aware of cultural, ethic, and religious influences when caring for clients with complex acute illnesses.
5.12	Identifies instances where advocacy was used or could have been used.

Comments:

Objective 6: Collaborates with the interdisciplinary team to provide care to clients with complex needs.
Sample behaviors		S/U	NO
6.1	Coordinates care of client with primary nurse in charge of client. Recognizes significant changes in client status and immediately reports these to primary nurse.
6.2	Consistently reports pertinent information to charge personnel prior to leaving unit. Does not leave clinical unit without informing primary nurse.
6.3	Consults with other health team members in a respectful manner (MD, RT, RD, unit secretary, nursing assistant, social worker, pharmacist, case manager, chaplain, etc).
6.4	Begins to function as an interdisciplinary team. Stays in client's room when other team members are discussing plan of care. Recognizes role of other team members. Able to recognize nursing's contribution to interdisciplinary care.
6.5	Recognizes client system as part of the interdisciplinary team.

Comments:

Objective 7: Relates current nursing research findings to the care of clients with complex needs.
Sample behaviors		S/U	NO
7.1	Uses current nursing research in appropriate clinical situations.
7.2	Differentiates between research and informative materials.
7.3	Follows guidelines established by clinical instructor regarding application of research.

Comments: