INDIVIDUALIZED CLIENT TEACHING RUBRIC NAME: DATE: TOPIC: COURSE: START TIME: END TIME: Criteria 4-5 2-3 0-1 Points Comprehensive Assessment Clear and concise discussion of client’s admission diagnosis, demographic data, and anticipated learning needs. Clear and comprehensive client assessment data to support a deficient knowledge nursing diagnosis. V Vague and incomplete discussion of client’s admission diagnosis, demographic data, and anticipated learning needs. V Vague and incomplete client assessment data to support deficient knowledge nursing diagnosis. N No discussion of client’s admission diagnosis, demographic data and anticipated learning needs. N No comprehensive client assessment data to support deficient knowledge nursing diagnosis Client Learning Assessment Clear and complete assessment of learner (client /family), teaching needs, and special learning needs, if present. Clear identification of client’s strengths and weaknesses relevant to learning needs. I Incomplete assessment of learner (client and/or family), teaching needs, and special learning needs, if present. Incomplete identification of client’s strengths and weaknesses relevant to learning needs. No assessment of learner (client and/or family), teaching needs, and special learning needs, if present. No discussion of client’s strengths and weaknesses relevant to learning needs. Teaching / Learning Principles Clear and correct identification of relevant teaching principles used. discussion of data to support teaching/learning principles chosen. Incomplete identification of relevant teaching/learning principles used. Vague/inaccurate data to support teaching/learning principles chosen. No relevant teaching/learning principles identified and discussed. No data included to support teaching/learning principles chosen. Mechanics 4-5 2-3 0-1 Points -
Organization/ Evidence-based Information Open and closing remarks that capture client’s attention. Clear and correct statement of 2 teaching objectives. and organized presentation of evidence-based client teaching. Open or closing remarks displayed. Vague/incorrect teaching objectives. Vague/disorganized presentation of evidence-based client teaching. No open or closing remarks displayed. No teaching objective stated. Poor or disorganized presentation of teaching from inappropriate sources. Body Language Direct eye contact and appropriate gestures/movements during teaching. Relax, self-confident nature and no mistake during teaching. Minimal eye contact and little movement or descriptive gesture during teaching. Mild tension, lack of self-confidence and difficulty recovering from mistakes. No eye contact, and inappropriate gestures during teaching. Tension and nervousness obvious, trouble recovering from mistakes. Voice Use of clear speech and inflection, maintains the interest of the learner. Some level of inflection during delivery. Monotone voice consistently. Teaching/ Learning Evaluation Clear/appropriate evaluation of client’s response and of teaching. Reflective analysis of teaching including discussion of strengths and weaknesses. Vague/inappropriate evaluation of client’s response and of teaching. Vague reflective analysis of teaching including discussion of strengths and weaknesses. No evaluation of client’s response and effectiveness/ ineffectiveness of teaching. Absent reflective analysis of teaching. Total COMMENTS: _______________________________________________________________________________ STUDENT SIGNATURE: DATE: INSTRUCTOR SIGNATURE: DATE:
Nursing Care Plan Student Course Date Instructor Patient IN DOB Age DOA Ht Wt Unit Room# Allergies Admission Diagnosis (2pts) Diagnostic Procedures/Surgeries (include (2pts) Include dates Date not please state so Discharge Referrals (2pts) Erickson’s Developmental Stage with Rationale (2pts) (APA citation) Socioeconomic/Cultural Orientation (2pts) Psychosocial Considerations (2pts) History of Present Illness (presenting signs & symptoms/diagnostic reports) (2pts) Past Medical History Past Surgical History (Concurrent, onset, dates) (2pts) Date not please state so Pertinent lab test (normal ranges in parentheses) & diagnostic reports (with dates) (2pts) Rationale for Abnormal Labs Pathophysiology of admitting and/or related medical diagnosis Describe How this diagnosis relates to your patient (with APA citations) (5pts) Collaborative Problems Current Prescriber’s Order (include diet, test, and treatments) (2pts) Rationale for Orders (with APA citations) (2pts) Identify Potential Health Deviations (“At Risk for…” nursing dx) (5pts) Related Factors (of “at risk” condition, signs and symptoms should they manifest) (5pts) Interventions (at least two each) (Independent Nursing Functions) (10pts)
Functional Health Pattern (5pts) Nursing Diagnosis (AT LEAST 2) (5pts) Planning (outcome/goal) Measureable Goal during your shift 7A-7P (5pts) Implementations (Independent and collaborative nursing intervention include further assessment, intervention and teaching (10pts) Rationale (use APA citations) (5pts) Evaluation Goal Met Goal not Met (5pts) Temp C/F Site (1pt) Pulse Site (1pt) Respiration (1pt) Blood PressureCuff/Machine Site (1pt) Pain Scale 1-10 (1pt) Current Medications (10pts) Medications (with APA citations Time Dose (& Mechanism of action Onset of action Common side effects Nursing considerations
BEHAVIORAL OBJECTIVES 4TH Week 7TH Week STRENGTHS FOR IMPROVEMENT GRADE RATING SCALE (CIRCLE ONE) 3. Uses research methods, such as evidenced-base practice to obtain data for determining the best nursing care available Uses various sources to obtain nursing clinical data 1 2 3 4 5 Incorporates evidenced based information in the plan of nursing care 1 2 3 4 5 Presents data that can be utilized in designing nursing care plans 1 2 3 4 5 Uses format in presenting written sources of clinical data 1 2 3 4 5 4. Demonstrates skills in using the nursing process as a framework for development of a nursing plan of care for an older adult client A. Demonstrates comprehensive nursing assessmentskills. 1 2 3 4 5 B. Develops a multidisciplinary plan of care based on assessment data 1 2 3 4 5 Implements plans as appropriate to client situation 1 2 3 4 5 D. Evaluates goal achievement and nursing interventions 1 2 3 4 5 5. Identifies areas of instruction needed by the older adult client that will aid in development of health promotion and health maintenance of self-care activities Is able to assess and provide for the educational needs of the older adult client 1 2 3 4 5 Collaborates with the family to design, provide and evaluate an educational plan for the client and family 1 2 3 4 5 Designs educational sessions appropriate to the learning abilities of the client and family 1 2 3 4 5 Demonstrates the effectiveness of knowledge acquisition of the client, family or community 1 2 3 4 5 6. Uses effective written, verbal and nonverbal therapeutic communication skills. Demonstrates written communication skills. 1 2 3 4 5 Demonstrates verbal communications skills. 1 2 3 4 5 Demonstrate non-verbal communication skills. 1 2 3 4 5 Speaks and writes in a professional manner 1 2 3 4 5 7. Demonstrates beginning management and leadership roles. Demonstrates an accountability to agency and college protocols 1 2 3 4 5 Demonstrates an accountability for client/ family well being 1 2 3 4 5 Demonstrates and understanding of accountable for ones own professional and self development 1 2 3 4 5 Shows proper leadership styles depending on the nursing care or professional situation 1 2 3 4 5 TOTAL RATING SCALE:
COMMUNITY EXPERIENCE RUBRIC NAME: ____________________________________ DATE: ______ COMMUNITY SITE: __________________________________________COURSE: ________ CRITERIA 10 8 6 4 0 POINTS Name and purpose of organization Gives name, address of the organization; clearly describes the purpose of the organization. Provides the name of the organization with a brief purpose of the organization Gives the name of organization and no more than two sentences describing the purpose of the organization. Inappropriately brief discussion of organization name and purpose Did not identify the name and purpose of the organization Population served a. Type of clients served b. Type of health care concerns an excellent understanding of the population served at this organization. Presents a satisfactory understanding of the population served at this organization Shows a minimal understanding of the population served at this organization. Inappropriately brief discussion of population served. Did not discuss the population served. Professional services available in this setting Identifies all the professional services available in this setting Identifies some of the professional services available at this setting. Identifies a minimal number of professional services available at this setting. Inappropriately brief list of professional services available. Did not identify any professional services. CRITERIA 15 12 9 6 3 POINTS Geographical/ environmental issues a. Describe the facility b. Describe the physical layout c. Address accessibility for clients d. Address transportation issues Insightful, mature analysis and understanding of the geographical and environmental issues of the organization. All four issues are thoroughly discussed. All four geographical and environmental issues of the organization are adequately discussed. Marginal explanation of the four issues included in the geographical and environmental issues. Simplistic, inappropriate or incoherent description of the geographical and environmental issues Lacks appropriate structure and development; did not address the geographical and environmental issues
Section B:Course Outline Week/ Date Course Objectives Content Outline Specific Course Activity Student Assignments 1 To have an overview of the course requirements, clinical expectations, and assignments. To have an overview of the hospitals set-up, policy and procedures, physical set-up, and student requirements. To describe perinatal care nursing roles. To identify and discuss specific issues and safety issues in the perinatal practice. To describe the care of mother and newborn during labor, and after delivery. Introduction Required day orientation topics Clinical objectives and syllabus. Watch Stages of Labor video breastfeeding video Watch Newborn assessment videos Simulation lab: fundal height measurements, Leopold’s maneuver fundal massage, vaginal examination Simulation lab: newborn assessment newborn gestational age assessment newborn care Client/family education on breastfeeding, pericare and circumcision care. Review references for Competency Pearson Hall Real Nursing Skills Maternal-Newborn & Women’s Health Nursing Skills: -Prenatal Care Videos -Intrapartum Videos -Postpartum Videos -Newborn Videos (review the video for the assigned area for each week) Moore, D. S., Kennett, J. R. (2007). Nursing Skills Checklist. Boston, MA: Pearson Custom Publishing. Davidson, M.R., London, M.L., Ladewig, P.A. (2008). Maternal-Newborn Nursing Women’s Health across the Lifespan. Upper Saddle River, NJ: Pearson Prentice Hall. The Newborn: Chapters 28, 29, 30, 31 (p. 983-988, 1002-1011)Postpartum Care: Chapter 34 2 To observe and provide nursing care to hospitalized antepartum patients. To assess antepartum clients and identify deviations from normal. To examine the role of nursing in providing physical, psychosocial and spiritual support to with compromised pregnancies. Antepartum testing clinic Prenatal visits and OB Triage/observation. Hospitalized antepartum clients for PTL, Preeclampsia, Eclampsia, PROM, etc. systems and needs. Provide teachings to clients experiencing complications of pregnancy. MED CARD for ** meds due in clinical Pick patient for Care Plan &collect data/ interview patient. Recommended References: Davidson, London & Ladewig 8th Ed Content Masters Series Maternal-Newborn Nursing
2 (cont) To observe and provide nursing care to pregnant women during prenatal visits in a variety of settings. Recognize common complications in pregnancy. Document relevant information and pathophysiology related to client’s condition. Pearson Hall Real Nursing Skills Maternal-Newborn & Women’s Health Nursing Skills: -Prenatal Care Videos -Intrapartum Videos -Postpartum Videos -Newborn Videos (review the video for the assigned area for each week) EVOLVE website for study skills, case studies in maternity/obstetrical care, sample tests and remediation. Pearson Hall Real Nursing Skills Maternal-Newborn & Women’s Health Nursing SkillsPrenatal Videos Other Student Resources Include: ATI Videos/DVD 3 To observe and provide nursing care for a client during and/or delivery. To observe, through various monitoring techniques, response to labor. To observe and/or provide nursing care for the newborn in the immediate postnatal period. To analyze the nursing role in providing care for a client during and delivery. To examine interrelationships between behavioral and physical responses to labor. Care of client after admission, and follow patient through L&D experience, recovery room and transfer to postpartum. Utilize the Labor & Delivery assessment sheet. Base-line data entries on data sheet at every hour (depending upon hospital protocol) and as often as necessary as labor progresses Behavioral responses and descriptions: facial, verbal. Physiological responses: signs, cervical dilatation, fetal heart tones and uterine contractions. Nursing Care Plan due Recommended References: Davidson, London & Ladewig 8th Ed Ch 13-21 ATI Content Masters Series Maternal-Newborn Nursing Other Student Resources Include: HESI Textbook ATI Videos Case Studies on line at EVOLVE.com
4 (cont) To recognize and symptoms of deviations from normal. To assess psychosocial needs of women in postpartum period. To learn how to provide physical care to the normal newborn infant experiencing transitioning to extrauterine life. To observe and recognize normal variations in the newborn. To perform a physical assessment on a newborn. To recognize and utilize teaching opportunities for the parents of infants in the assigned nursery. To recognize signs and symptoms of deviations from normal. (If applicable). Students in selected sites will visit the neonatal intensive care nursery and assist with the care of a compromised neonate. Newborn care after delivery Physical assessments on newborn infants in the nursery or post-partum area. Calculate dosage and give newborn medications. Assisting procedures such as circumcision, newborn screening test, hearing test, and septic Glucose monitoring for hypoglycemic and LGA newborns. Care of newborn on Bili light therapy. Teaching Project due in Post-conference Maternal-Newborn Nursing Ch 3,4,5,6 Student Resources Include: HESI Textbook ATI Videos Case Studies on line at EVOLVE.com 5 Changes in physiology that occurs when a baby is born Assessment of the newborn to determine the extent of resuscitation needs Identify risk factors that can help predict which babies will require resuscitation Equipment and personnel needed to resuscitate a newborn Patient Teaching & Community Experience Due
Evaluate resources in the community that will enhance maintenance of health and prevention of illness for infants, children, and adolescents and their families. Importance of proper hydration and electrolyte balance in the pediatric patient Nutritional therapies to meet pediatric patient Application of family centered care concepts Case presentation Post Conference discussions Self-evaluation Units 3 & 4 of Virtual Clinical Excursions Book. 8 Participate with faculty, peers, and the nursing team in the evaluation of nursing care. Analyze therapeutic, nutrition, and drug regimens for appropriateness and effectiveness in infants, children, and adolescents/ Identify important aspects of community support for the nursing care of well and ill infants, children, and adolescents and their families. Evaluate resources in the community that will enhance maintenance of health and prevention of illness for infants, children, and adolescents and their families. Nursing care of acute and chronic pediatric patients Common problems of pediatric inpatients Pharmacotherapeutics for pediatric patients related to age and weight or BSA Intravenous therapy and IV medications administration Importance of proper hydration and electrolyte balance in the pediatric patient Nutritional therapies to meet pediatric patient needs Application of family centered care concepts DUE: Community Experience Report Paper Clinical Experience to include but not limited to: Pre-conference planning Direct patient care Bedside tutorials Case presentation Post Conference discussions Self-evaluation Community Experience Paper (CEP) is due this week Observed head to toe assessment with instructor (individual and graded) View Pearson’s Real Nursing Skills Videos on Pediatric Nursing Skills Units 5 & 6 of Virtual Clinical Excursions Book. 9 To prioritorize the emergency assessment--the A-B-C’s--of a pediatric patient. To introduce concepts of fluid resuscitation for the dehydrated, hypovolemic pediatric patient To introduce the concepts of securing and maintaining an airway Nursing care of acute and chronic pediatric patients Common problems of pediatric inpatients Pharmacotherapeutics for pediatric patients related to age and weight or BSA DUE: Patient Clinical Experience to include but not limited to: Pre-conference planning Observed head to toe assessment with instructor (individual and graded) Course Evaluation is due this week.
using oral/nasal airways and ventilation. To identify the special situations that may complicate emergency pediatric care To discuss ethical issues pediatric end of life. Intravenous therapy and IV medications administration Importance of proper hydration and electrolyte balance in the pediatric patient Nutritional therapies to meet pediatric patient needs Application of family centered care concepts Direct patient care Bedside tutorials Case presentation Post Conference discussions Self-evaluation Patient Teaching Demonstration due this week.