THE NURSING PROCESS EVALUATION

Transcription

1 N4612 Senior Practicum (jm/2007) 1 University of Texas at El Paso College of Health Sciences School of Nursing THE NURSING PROCESS EVALUATION Student: Term: Preceptor: Faculty: Site: Date: INSTRUCTIONS: A. The Nursing Process Evaluation will occur between weeks 3 and 5 of your clinical rotation. Refer to the syllabus for further explanation of grading. B. Students must pass the Nursing Process with an average score of 75 or greater in order to pass the course. C. SCORING: 1) Scoring for each objective within the Nursing Process Evaluation will be as follows: A = , B = 80-89, C = 75-79, D = 65-74, F = < 65 2) Faculty will score each objective. 3) Total the score of each section and divide that total by the number of objectives in each section. 4) Enter the averaged total score in the appropriate box on the last page of this evaluation. 5) For each Evaluation completed, total the column and divide by four to get final score/grade. D. Faculty and student comments will be noted as required. Patient Report

2 N4612 Senior Practicum (jm/2007) 2 ASSESSMENT Student performs systematic and continuous nursing assessment of patient s health status. Data Collection: Completes required client profile and collects sufficient data to support nursing diagnoses, including subjective and objective data. Collects data from multiple sources, and recognizes reason for client s continued hospitalization. Data Analysis/Nursing Diagnoses: Interprets data and formulates minimum of 6 appropriate nursing diagnoses, correctly justified, stated, and prioritized. Includes diagnostic data and applies it to client s plan of care. Determines client s development level using Erikson s stages of development and how this effects the plan of care. Analyzes client physiologic and psychosocial needs and responses based on objective and subjective data, assessment, and evaluation of interventions. Validates data by obtaining cultural, spiritual, psychosocial, and socioeconomic data on the client and family, indicates the effects on the client s plan of care. Relates data to the medical diagnosis. Identifies and anticipates potential client and family needs at discharge. Identifies responses that indicate change in physiologic or psychosocial status leading to new nursing diagnoses. Anticipates complications and identifies appropriate assessments to identify complications. Priority Setting: Establishes priorities with assistance. Prioritizes patients by acuity/medical diagnosis, nursing diagnosis, and clinical needs. Independently identifies and sets priorities according to client needs and nursing actions. Prioritizes according to actions that are immediate (within 1 hour), can be done within shift, and should be done within shift. Independently and correctly establishes priorities and validates six nursing diagnoses based on appropriate rationale. TOTAL (ASSESSMENT)

3 N4612 Senior Practicum (jm/2007) 3 PLANNING Student formulates nursing goals to provide a framework to address and resolve client s health care needs, care using evidence-based clinical guidelines to achieve goals. Goal Setting Outcome Criteria: Develops client centered, realistic, achievable, goals based on nursing diagnosis. Identifies evidence needed that indicates goals are met, not met, ongoing, or need revision. Teaching: Identifies client/significant other education needs, and develops goals to address those needs. Correctly assesses the client s and family s readiness to learn. Planning: Identifies appropriate, specific nursing interventions to meet established goals. Bases plan of care on nursing theory and research. Maintains confidentiality of client and family at all times. Develops goals that are consistent with and supportive of collaborative plan of care. Sets realistic time lines for goal accomplishment. Includes the client and significant others in setting and achieving goals. Identifies specific content and teaching strategies based on client s and/or family s stages of development and readiness to learn. Supports teachings with evidence based clinical guidelines. Describes expected outcomes of nursing and medical plan of care. Demonstrates the ability to revise the plan of care based on patient response to interventions. Includes client and family educational needs in the plan. Develops goals with measurable client outcomes and in the proper format. Establishes goals mutually with the client, family and other health care providers for continuity of care after discharge. Identifies client/significant other educational needs throughout hospitalization, including discharge. Formulates strategies to facilitate teaching effectiveness. Collaborates with other health disciplines to develop a comprehensive, holistic plan of care. Interventional plan includes activities that demonstrate collaborative planning effort, based on evidence based clinical findings. TOTAL (PLANNING)

4 N4612 Senior Practicum (jm/2007) 4 IMPLEMENTATION Student implements the plan of care per local nursing care standards and attention to the client s physiological, psychological, cultural, spiritual, and educational needs. Interventions: States the purpose, process, and rationale for planned interventions. Describes how the chosen nursing intervention will meet the established goals. Client Communication: Introduces self to clients and significant others. Addresses patients, significant others by their appropriate names and titles. Interacts with patients and staff in a professional manner. Recognizes personal and client characteristics that may interfere with maintaining professional demeanor. Professional Communication: Recognizes and reports client s condition to appropriate personnel. Maintains confidentiality in all verbal and written communication. Demonstrates sensitivity toward subordinates and fellow students when describing interactions. Identifies what can and cannot be delegated. Includes client and family in the implementation of the plan of care. Implements plan of care in a manner consistent with unit policies and procedures. Describes the importance and methods of documentation of interventions. Identifies potential complications and the ability to prioritize and revise interventions. States techniques to assist clients and significant others to express their feelings. Demonstrates empathy and nonjudgmental acceptance of patient and family point of view. Recognizes barriers that may interfere with client/significant other communication. Identifies other health care disciplines involved in the care of the client, what information is communicated between disciplines, and the impact of communication on patient outcomes. Demonstrates documentation of client assessment, teaching, and responses. Recognizes behaviors that enhance or impede communication and team building in the clinical setting. Understands rationale for interventions to resolve adverse client responses. Explains nurse s role and responsibilities in delegation of assigned client s care and its impact on interventions. Understands the role of other health disciplines in resolving adverse client responses. Recognizes client s concerns and identifies methods of verbal and non-verbal support in times of stress. Recognizes actions to be taken in response to personal & client characteristics that interfere with maintaining professional demeanor. Demonstrates principles of therapeutic communication when relating to client and significant others. Reports anticipated nursing care needs of the client to appropriate personnel Recognizes Unit s political influences on communication. Describes appropriate communication techniques for delegation and assignment of duties. Identifies personal strengths and weaknesses related to documentation and how to improve documentation technique. SUB-TOTAL (IMPLEMENTATION)

5 N4612 Senior Practicum (jm/2007) 5 IMPLEMENTATION (continued) Medication administration: Is knowledgeable of all client medications, purpose, SE, AR, and dosages. States the 6 rights of medication administration and rationale. Describes organizational and unit policies that affect the medication administration process. Calculates dosages (identifies appropriate site/route) with minimal assistance. Organization: Organizes equipment needed for care of client. Explains how to perform a procedure and necessary equipment. Organizes and sets priorities based on client needs. Teaching: States why content taught to client is appropriate and evidence based. Uses appropriate language and educational resources to meet learning needs of the client and significant others. Initiative: Demonstrates self-motivation in delivery of patient care and takes initiative in caring for assigned clients. Seeks clarification and asks questions related to client assignment. Independently relates medications to client condition, and calculates IV drip rates based on client s condition. States anticipated patient responses to medication, and appropriate nursing interventions in the event of SE or ARs. Identifies legal ramifications and organizational policies that impact medication administration. States time management principles and how they apply to nursing care of individuals, groups, and unit responsibilities. Demonstrates how the client and client s significant others were incorporated into the education plan. Discusses educational techniques used to enhance patient learning. Identifies additional activities and personnel needed to maximize care for assigned clients, and the processes implemented to include those activities or personnel in the care of the client. Independently calculates drug dosages and selects appropriate site and route. Evaluates patient responses to medications and intervenes/reports as appropriate. Documents medications and patient responses according to unit/organizational policy. Demonstrates effective time management in the care of multiple clients and families. Develops or uses tools in the clinical setting that improve time management. Discusses rationale for why client is taught specific information. States how teaching methods and teaching plan were altered based on client s responses. Demonstrates participation in unit specific functions or activities that contribute to nursing support and professional development. Volunteers for additional learning experiences beyond client care, and assists other staff when appropriate. (use back of eval tool as needed) SUB-TOTAL (IMPLEMENTATION) TOTAL SCORE (IMPLEMENTATION)

6 N4612 Senior Practicum (jm/2007) 6 EVALUATION AND MODIFICATION Student evaluates client progress toward goal achievement and effectiveness of nursing interventions. Evaluation: Evaluates client outcomes to nursing interventions including status of goal and rationale for continuing or revising a goal. Recognizes effects (intended and unintended) of nursing actions and interventions. Incorporates client/significant others responses in determining level of goal achievement. Indicates client responses that support the conclusion of goals met or not met. Explains how quality of a client s care is effected by the evaluation process. Modification: Recognizes the need for modification of goals, interventions, and care plan. Modifies, with assistance, the plan of care based on client needs and responses. Independently modifies the plan of care based on client needs and responses, by developing alternative interventions. Identifies new nursing problems, and develops goals and interventions based on the problem. Recognizes when and why goals need to be modified. Able to format new goals as needed. Able to state at least one modification even if goal met. TOTAL (EVAL & MODIFICATION)

7 N4612 Senior Practicum (jm/2007) 7 University of Texas at El Paso College of Health Sciences School of Nursing THE NURSING PROCESS EVALUATION SCORE SHEET ASSESSMENT Score PLANNING IMPLEMENTATION EVALUATION/MODIFICATION TOTAL (add above scores and divide by 4): Faculty Signature: Student Signature: COMMENTS (please date and sign all comments):