Lourdes University Health and Professional Requirements MSN Nurse Anesthesia Program for Years 2 & 3 Table of Contents 1. Health and Professional Requirements NAP Student Checklist 2. Pre-Clinical Physical Examination 3. Healthcare Provider Immunization Verification 4. Technical Standards for Nursing Students (Healthcare Provider Information Sheet) 5. Agencies Offering Immunizations, TB Testing and/or Physicals 6. CPR/BLS Information 7. Nurse Anesthesia Program Drug and Alcohol Policy P:\CRNA\Health and Professional Requirements\For Continuing Students\3_Table of Contents Revised 10.2016.doc
Health & Professional Requirements NAP Student Checklist This list should be used as a checklist for your H&P requirements. All students enrolled in a clinical nursing course must meet all College of Nursing Health and Professional Requirements as described the Handbook for the MSN Graduate Student. All documentation must be turned in by the specified deadline (see letter from Program Administrator). The student should retain the original documentation and submit copies to the MSN Administrative Assistant. Healthcare Provider Form: Healthcare Provider Immunization Verification Pre-Clinical Physical Exam Technical Standards Verification by Healthcare Provider Student Form: Completion of Core Competencies: Please go to www.lourdes.edu > Academics > College of Nursing > Current Students > Health Forms and Uniforms > MSN. You may submit an e-mail attachment or a hard copy with your other documents. Student Information Sheet: Current BLS (CPR), ACLS, PALS: You must successfully complete an American Heart Association Health Care Provider Courses and submit a copies of your cards (front and back) OR proof of completion. BLS/CPR EXPIRATION DATE: ACLS EXPIRATION DATE: PALS EXPIRATION DATE: Nurse Anestheisa Program Drug and Alcohol Policy
PRE-CLINICAL PHYSICAL EXAMINATION Healthcare Provider Form The individual whose name appears on this form is a student in the Master of Science in Nursing Nurse Anesthesia Program at Lourdes University. To meet admission criteria to the clinical agencies, the following examination is required. Name: Last Name First Name MI Maiden/Other Address: Street City State Zip Date of Birth: Month Date Year Yearly PPD: Date Results: Positive Negative Date circle one Yes, Free of evidence of communicable disease No, not free of evidence of communicable disease If no, Comments/Recommendations: TECHNICAL STANDARDS VERIFICATION BY HEALTHCARE PROVIDER* Check only one of the boxes below and sign where indicated: I certify that I have examined the above named student and that the student has no physical or mental conditions that in my professional judgment would prevent him/her from meeting the Technical Standards for Nursing Students* outlined in the accompanying table (see page 4). I certify that I have examined the above-named student and that I have found a condition(s) that would prevent him/her from meeting, without disability-related accommodations, the Technical Standards for Nursing Students* outlined in the accompanying table. I recommend that the student contact the Lourdes University Office of Accessibility Services to discuss disability-related accommodation options. I certify that I have examined the above named student and that I have found a condition(s) that would prevent him/her from meeting, the Technical Standards for Nursing Students* with or without disabilityrelated accommodations outlined in the accompanying table. List condition(s) (use back of form if additional space is required): * Please review Technical Standards for Nursing Students form attached. Date of Physical Examination: Name of Health Care Provider (Print or Type): Address of Health Care Provider: Signature of Health Care Provider: P:\CRNA\Health and Professional Requirements\For Continuing Students\5_Physical form - Rev. 10.2016.doc
Healthcare Provider Form Healthcare Provider Immunization Verification Health and Professional Requirements - Graduate Student Name: (Please PRINT) ID #: DOCUMENTATION NEEDS TO BE PROVIDED FOR ALL REQUIREMENTS A Physician waiver will not be accepted by clinical agencies as meeting the requirements Tetanus/Diphtheria Immunization (within last ten years) date: Negative yearly PPD Date #1 Result OR Yearly physician statement of absence of disease for positive reactors. Date: OR T-Spot Date #1: Result: Most Recent Seasonal Influenza Vaccination it is suggestes you get your yearly flu shot between Halloween and Thanksgiving (date) Healthcare Provider Signature: Date: Healthcare Provider Name: (PRINT or TYPE)
Technical Standards for Nursing Students Table Healthcare Provider Information Sheet The Lourdes University College of Nursing is committed to equal access for all qualified program applicants and students. The College of Nursing faculty has identified specific technical standards essential to the delivery of safe, effective nursing care during clinical education activities. These standards determine the students ability to acquire knowledge and develop the clinical skills required by the curriculum. Clinical education is a major focus throughout the program involving considerations, such as patient safety, that are not present for classroom activities. Therefore, the student must meet these standards and maintain satisfactory demonstration of them for successful program progression and graduation. Nursing students, with or without reasonable accommodation, must satisfy the performance standards described below. Technical Standard Definition Examples Senses Have functional use of the senses of vision, touch, hearing, and smell so that data received by the senses may be quickly integrated, analyzed, and synthesized in an accurate manner. Hear, observe and speak to patients; detect skin color changes, anatomical abnormalities such as edema, sounds related to bodily functions using a stethoscope, and odor associated with a wound infection. Physical Abilities Cognitive Communication Perform gross and fine motor movements with reasonable endurance, strength, flexibility, balance, mobility, and precision as required to provide holistic nursing care. Collect, analyze, and integrate information and knowledge to make clinical judgments and decisions that promote positive patient outcomes. Communicate effectively and sensitively with patients and families, other professionals, and groups to elicit information and transmit that information to others. Possess sufficient interpersonal skills to interact positively with people from all levels of society, all ethnic backgrounds, and all belief systems. Perform CPR, safely transfer and control fall of a patient, and manipulate equipment such as syringes and medication packages. Measure, calculate, reason, and understand information and graphs; identify priorities; problem-solve in a timely manner; select, implement and evaluate interventions; and teach patients and families. Speak, read, write, and comprehend English at a level that meets the need for accurate, clear, and effective communication; perceive patients nonverbal communication; maintain accurate patient records; obtain accurate health history; establish rapport with patients, faculty, peers, and agency staff; and accept constructive feedback on performance. Mental/Emotional Have sufficient emotional health to fully Function under stress, problem solves, adapt to Stability use intellectual ability, exercise good judgment, and complete all changing situations, and follow through on assigned patient care responsibilities. responsibilities necessary to the care of patients. Professional Engage in activities consistent with safe Does not demonstrate behaviors of addiction Behavior nursing practice and display responsibility and accountability for actions as a student and as a developing nurse. to, abuse of, or dependence on alcohol or other drugs that may impair judgment; displays compassion, nonjudgmental attitude, consciousness of social values, honesty, integrity and confidentiality; displays appropriate dress and appearance in clinicalrelated activities; and demonstrates motivation, appropriate attitude, and professional behavior.
Student Information Sheet AGENCIES OFFERING IMMUNIZATIONS TB Testing and/or Physicals ALLEN COUNTY Allen County Combined Health District 219 E. Market St., Lima, Ohio 45802 (419) 228-4457 allecohd@odh.ohio.gov DEFIANCE COUNTY Defiance County General Health District 1300 E. Second St., Defiance, Ohio 43512 (419) 784-3818 deficohd@odh.ohio.gov ERIE COUNTY Erie County General Health District 420 Superior St., Sandusky, Ohio 44870 (419) 626-5623 eriecohd@odh.ohio.gov FULTON COUNTY Fulton County Health Department 606 S. Shoop Ave., Wauseon, Ohio 43567 (419) 337-0915 fultcohd@odh.ohio.gov FINDLAY CITY HEALTH DEPARTMENT 1644 Tiffin Ave., Suite A, Findlay, Ohio 45840 (419) 424-7105 health@ci.findlay.oh.us HENRY COUNTY Henry County General Health District 1843 Oakwood Ave., Napoleon, Ohio 43545 (419) 599-5545 henrcohd@odh.ohio.gov HURON COUNTY Huron County General Health District 180 Milan Ave., Norwalk, Ohio 44857 (419) 668-1652 hurocohd@odh.ohio.gov LUCAS COUNTY Toledo-Lucas County Health Department 635 N. Erie Street, Toledo, Ohio 43604 (419) 213-4100 lucacohd@odh.ohio.gov Adult/Travel Immunization Clinic (419) 213-4163 By appointment only Western Lucas County Clinic 330 Oak Terrace, Holland, Ohio 43528 (419) 213-6255 THE TOLEDO HOSPITAL Occu Health Center 2150 W. Central Ave., Toledo, Ohio 43506 (419) 291-5517 REYNOLDS CLINIC 2450 N. Reynolds Rd., Toledo, Ohio 43615 (419) 535-3214 NW OHIO URGENT CARE CENTER (formerly Industrial Medical Center) 5911 Benore Rd. Toledo, OH 43612 (419) 726-6500 OTTAWA COUNTY Ottawa County Health Department 1856 E. Perry St., Port Clinton, Ohio 43524 (419) 734-6800 ottacohd@odh.ohio.gov PUTNAM COUNTY Putnam County Health Department 256 Williamstown Rd., Ottawa, Ohio 45875 (419) 523-5608 putncohd@odh.ohio.gov SANDUSKY COUNTY Sandusky County Combined General Health District 2000 Countryside Dr., Fremont, Ohio 43420 (419) 334-6377 sandcohd@odh.ohio.gov SENECA COUNTY Seneca County General Health District 71 S. Washington St., Tiffin, Ohio 44883 (419) 447-3691 senecohd@odh.ohio.gov WILLIAMS COUNTY Williams County Combined Health District 310 Lincoln Ave., Montpelier, Ohio 43543 (419) 485-3141 willcohd@odh.ohio.gov WOOD COUNTY Wood County Combined General Health District 1840 E. Gypsy Lane Rd., Bowling Green, Ohio 43402 (419) 352-8402 woodcohd@odh.ohio.gov
Lourdes University College of Nursing Policy and Procedure Subject: Nurse Anesthesia Program (NAP) Drug and Alcohol Policy APPROVAL DATE/INITIALS: 5/2011, 5/2014, 09/2016 RENEWAL DATES/INITIALS POLICY: The Lourdes University College of Nursing requires that all nurse anesthesia students must be free of illicit or illegal drugs and alcohol in the classroom setting, when providing patient care or on call to provide patient care. Further, students may not use illegal drugs, abuse prescription drugs, or engage in excessive alcohol use while enrolled in the Program. PROCEDURE 1. All applicants will be asked if they are currently using illegal drugs, abusing prescription drugs, or engaging in excessive alcohol use at the time of application. An affirmative answer is grounds for denial of admission. 2. Initial Screening: After acceptance into the MSN Nurse Anesthesia Program, but prior to enrollment, all students will be asked about prior illegal drug use, abuse of prescription drugs, and/or prior excessive alcohol use. Past users will be monitored, including but not limited to drug testing. As a condition of matriculation, all students will be required to submit to a 10 Panel drug test which tests for marijuana, cocaine, amphetamines, opiates, phencyclidine, Benzodiazepines, Barbiturates, Methadone, Propoxyphene, and Methaqualone. All students must provide the Program with proof of drug screening from an approved clinical laboratory conducted under approved procedures for securing evidence. A list of approved laboratories will be provided to all students. The report of the initial screening must be forwarded from the laboratory directly to: Nurse Anesthesia Program Administrator Lourdes University 6832 Convent Blvd Sylvania, Ohio 43560 Failure to comply with this policy or failure of a drug test will result in dismissal from the program. Fees associated with testing will be the responsibility of the student. 3. Random Screening: All students may be required to submit to random or scheduled drug testing at any point in the Program based on the decision of the Nurse Anesthesia Program Administrator or as a requirement of the assigned clinical agency. Reports of random or scheduled results must be forwarded directly to the Nurse Anesthesia Program Administrator at the address listed in #2 above. Failure to comply with this policy or failure of a drug test will result in dismissal from the Program. Fees associated with random drug screening or scheduled drug testing under this policy will be paid by the P:\CRNA\Health and Professional Requirements\For Continuing Students\17_Nurse Anesthesia Program (NAP) Drug and Alcohol Policy 10.2016.doc
University. 4. Reasonable Suspicion: Any didactic or clinical affiliate faculty member or student who has reasonable suspicion that a student may be impaired as a result of misuse of drugs or alcohol will notify the Nurse Anesthesia Program Administrator in writing. If the behavior is suspected in the clinical area, the clinical coordinator or designee will be notified of the situation. Reasonable suspicion exists when any student demonstrates unusual or unexplained behaviors. These behaviors may include, but are not limited to: Slurred speech Odor of alcohol on breath or person Unsteady gait Confused or disoriented behavior Significant change in work habits Unexplained injury or accident Excessive sick days Excessive tardiness to clinical practicum or class Change in alertness, sleepy, confused Change in personality, physically assaultive, violent, indifferent Change in physical appearance, inappropriate clothing/sloppy Any student suspected of substance abuse during a clinical practicum assignment will be asked to leave the patient care area immediately and go with a faculty member and/or clinical affiliate faculty and/or witnesses to discuss the situation in a private location ensuring confidentiality. The NAP Administrator will be informed, the discussion will be documented, and drug or alcohol testing may be required. If the decision is made to test for drugs or alcohol, the student will be escorted to an approved laboratory by Nurse Anesthesia faculty and/or witness. Drug and alcohol testing must be performed according to proper procedures for securing evidence and the student will be suspended from the clinical practicum area, Lourdes University program events and professional activities until the results of the test have been reviewed by NAP Administration. The student must remain available to meet with NAP Program Administration while awaiting the results of the drug test. The student needs to be available to meet in person with NAP Administration once results are available. The Nurse Anesthesia Program Director will notify the student of the results once they are available, both in writing and via email. The NAP Program Director will inform the Dean of the College of Nursing and University Provost prior to notification of the Ohio Board of Nursing. Failure to comply or refusal of a requested drug or alcohol test will result in dismissal from the Program and the student will be referred for appropriate alcohol/drug counseling services and rehabilitation. Fees associated with testing, counseling, and or rehabilitation will be the responsibility of the student. Should the test results be negative, P:\CRNA\Health and Professional Requirements\For Continuing Students\17_Nurse Anesthesia Program (NAP) Drug and Alcohol Policy 10.2016.doc
the student will be released to the clinical practicum area without penalty. Any missed clinical time will be made up at the discretion of the NAP Administrator. 5. Following successful completion of a rehabilitation program, documentation of the criteria set by the NAP Program Administration and documentation supporting this evidence, the student may be considered for re-entry into the Program. Re-entry into the NAP program will be considered on an individual case basis and final decisions made by the NAP Program Administration. P:\CRNA\Health and Professional Requirements\For Continuing Students\17_Nurse Anesthesia Program (NAP) Drug and Alcohol Policy 10.2016.doc