College of San Mateo s1

COLLEGE OF SAN MATEO NURSING DEPARTMENT CLINICAL EVALUATION NURSING 222

STUDENT______CLINICAL AREA______

DATE______CLINICAL GRADE: PASS_____ NO PASS_____

ABSENCES______

CODE: P = Pass; NP = No Pass; NI = Needs Improvement ** = 100% Required To Pass; * = 96% Of Starred Criteria Required To Pass (39/41) All “Competencies of Care” from previous courses are to be met.

COMMENTS - NI AND NP ALL NURSING PROGRAM CORE COMPETENCIES MUST BE MET P NP REQUIRES EXPLANATION NI **A. Asepsis **B. Emotional Well-being **C. Interpersonal Relations **D. Physical Well-being **E. Professional Behaviors

COMMENTS - NI AND NP CLINICAL OBJECTIVES P NP REQUIRES EXPLANATION NI I. OPERATIONALIZES THE NURSING PROCESS TO PROMOTE HOMEOSTASIS Uses the nursing process, with guidance, to provide safe nursing care for pregnant women/families with common well-defined health needs. A. Collects and organizes data from a variety of sources including data on developmental levels to identify basic patient needs. *1. Collects data from a variety of sources to identify the woman’s newborn’s and family’s needs including grandparents...... ______**2. Is prepared for patient assignment in each perinatal area...... ______*3. Gathers data pertinent to patient, from patient, family, Kardex, report, and chart and utilizes critical thinking skills to differentiate normal from ______abnormal......

D:\Docs\2018-04-01\085f23e0c394402fa9d4ced563a3fd3e.doc Nurs 222 Clinical Evaluation 2 COMMENTS - NI AND NP CLINICAL OBJECTIVES P NP REQUIRES EXPLANATION NI *4. Correlates patient data with nursing theory to prepare for patient assignment...... ______B. Assess patient status **1. Assesses the woman’s recovery from the birth process with a thorough postpartum assessment………………………………… ______*2. Evaluates maternal/infant bonding behaviors...... ______**3. Assesses/describes the adaptation of the newborn to extra-uterine life and identifies real/potential threats to homeostasis (e.g., vital signs, skin color, reflexes, elimination, etc.)...... ______*4. Determines the woman’s ability to meet the biopsychosocial needs following birth and identifies potential problems...... ______*5. Identifies nursing diagnoses, and states related outcome criteria.. ______*6. Applies theoretical data to nursing practice...... ______C. Plans with guidance, individualized nursing interventions designed to assist women/family to meet their basic needs and to promote their homeostatic adaptive mechanisms. *1. Identifies nursing interventions that will assist in meeting stated outcome criteria...... ______*2. Involves the woman/family including grandparents in the plan of care. ______*3. Presents plan to instructor/resource person prior to care...... ______*4. Applies critical thinking principles to a variety of clinical situation...... ______D. Consistently performs, with guidance, appropriate nursing interventions safely and competently. **1. Applies previously learned knowledge as well as perinatal concepts to provide safe nursing ______care...... **2. Demonstrates knowledge of medications...... ______*3. Adjusts nursing care to meet the needs of the maternity patient and extended family members...... ______**4. Correctly performs treatments and administration of ______medications.. **5. Utilizes principles of asepsis and universal precautions...... ______*6. Expands comfort measures to include those pertinent to the perinatal patient...... ______**7. Follows accepted protocols for safe newborn care...... ______*8. Identifies priorities when organizing care, utilizing principles of Nurs 222 Clinical Evaluation 3 time management...... ______COMMENTS - NI AND NP CLINICAL OBJECTIVES P NP REQUIRES EXPLANATION NI E. Recognizes, with guidance, whether nursing intervention(s) met identifies needs. *1. Explains appropriate rationales for nursing intervention(s) with references, keeping in mind the specific needs of the perinatal patient... ______*2. Assists in revising nursing care by evaluating whether objectives were met on the daily care worksheet...... ______*3. Modifies the nursing care as needed keeping in mind the specific needs of the perinatal patient...... ______**F. Demonstrates competent performance of designated skill...... ______

II. ASSUME ROLE AS A COMMUNICATOR

A. Utilizes a variety of basic communication skills to support the woman/family, and to interact with other members of the health ______team. *1. Assesses maternal verbal and non-verbal behaviors...... ______**2. Communicates data and questions, regarding the woman/family to appropriate health care ______professionals...... *3. Communicates results of care during report and ______conferences...... *4. Evaluates effectiveness and identifies barriers to ______communication... *5. Identifies own limitations when giving information...... ______**6. Utilizes HIPAA guidelines for all verbal and written ______communications…… B. Reports and records accurately, with guidance, patient assessments, nursing interventions and their effectiveness, and other significant occurrences affecting patient status. *1. Charts accurately in a legible, pertinent, organized manner using acceptable abbreviations, grammar and format for postpartum and neonate ______patients……………………………………………………... *2. Uses Nursing Care Plan as a guide for charting...... ______**3. Reports status of patient during clinical time and prior to leaving unit..... ______Nurs 222 Clinical Evaluation 4 *4. Contributes in conferences...... ______III. ASSUME ROLE AS A TEACHER A. Recognize the woman’s/family’s obvious need for health teaching and either conveys information or takes other appropriate ______action...... COMMENTS - NI AND NP CLINICAL OBJECTIVES P NP REQUIRES EXPLANATION NI III. ASSUME ROLE AS A TEACHER *1. Considers obvious factor(s) that may interfere with ability to ______learn.. **2. Initiates teaching as well as supports the teaching plan of ______others..... **3. Gives instruction in health promotion that assists in meeting the needs of the perinatal patient, extended family members and the ______newborn..... *4. Uses teaching materials provided by the clinical facility...... ______*5. Documents patient/family teaching...... ______**6. Completes graded teaching presentation...... ______IV. ASSUME ROLE AS A LEADER/MANAGER A. Recognizes the patient’s/family need for the services of other team members and/or agencies and discusses the need for appropriate referrals. *1. Assumes responsibility for managing care for assigned ______patient(s).... *2. Identifies sociocultural differences and seeks help when necessary (e.g., interpreter, dietitian, etc.)...... ______**3. Completes post conference cultural presentation………………. ______….. *4. Consults with health team members to meet needs that cannot be met by the student...... ______B. Identifies priorities and provides care for two to three patients within the assigned clinical time. *1. Implements care in stressful situations...... ______*2. Describe RN role in perinatal care...... ______V. ASSUME ROLE AS MEMBER WITHIN THE PROFESSION Practices within the ethical standards and legal framework with guidance. Nurs 222 Clinical Evaluation 5 *1. Researches agency policies and procedures as needed...... ______*2. Identifies ethical issues in the clinical area and discusses such with instructor and at conference...... ______*3. Describes the interventions used by a nurse functioning as a patient or family ______advocate...... B. Identifies own learning needs and demonstrates initiative in obtaining specific experiences. Nurs 222 Clinical Evaluation 6

COMMENTS - NI AND NP CLINICAL OBJECTIVES P NP REQUIRES EXPLANATION NI

V. ASSUME ROLE AS MEMBER WITHIN THE PROFESSION

*1. Communicates learning goals to instructor in writing on last page of ______evaluation…………………………………………………………….. *2. Uses additional learning resources available...... ______C. Evaluates learning experiences and objectively assesses own progress regularly with the instructor *1. Completes self evaluation and learning goals at end of the course or as otherwise indicated by ______instructor...... **2. Modifies performance based on previous evaluation of clinical performance and current feedback...... ______**3. Takes corrective actions when in error; reports such to the instructor and follows through with appropriate written ______report...... D. Is accountable for his/her professional behavior *1. Is punctual for clinical (cannot be late more than two times)...... ______*2. Is punctual for post-conference (cannot be late more than two times without prior agreement with ______instructor.)...... **3. Is punctual in submitting written assignments...... ______*4. Completes clinical make up assignments according to policy...... ______**5. Is punctual with medication and treatments...... ______**6. Follows correct procedure for notifying agency regarding absences from clinical ______areas...... **7. Follows dress code as described in the Nursing Student ______Handbook... Nurs 222 Clinical Evaluation 7 MIDTERM:

______DATE STUDENT (Signature indicates only that this evaluation has been read.)

______DATE INSTRUCTOR COMMENTS: STUDENT:

FACULTY:

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______DATE STUDENT (Signature indicates only that this evaluation has been read.)

______DATE INSTRUCTOR COMMENTS: STUDENT:

FACULTY:

STUDENT LEARNING GOALS:

01/15 N222 Clinical Evaluation