Final Clinical Evaluation

NUR 4216L BMC SBN 010 2/25/2014 Evaluation date: 4/16/2014 Evaluator: Harding, Deb (dharding@health.usf.edu) Evaluatee: Clark, Jaleesa (jclark13@health.usf.edu)

5-Outstanding: Exceeds Standards Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and self-directed in approach to learning. 4-Satisfactory: Meets Standards Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them. 3-Minimal Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities. Often focuses on the task or own behavior, not on the patient. 2-Unsatisfactory Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient. 1-Unsafe to Practice Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient. Standard I--Communication The student communicates pertinent information regarding the patient's condition/concern to health team members. Answer: 4 Satisfactory: Meets Standards Comment: Standard I--Communication The student communicates effectively in written form (Nursing Process Worksheet is organized and complete) (Comment Answer: 5 Outstanding: Exceeds Standards Required) Comment: Excellent growth in this area. Standard I--Communication The student communicates effectively in verbal form. Answer: 4 Satisfactory: Meets Standards Comment: Standard I--Communication The student initiates, maintains, and terminates the nurse-patient relationship using principles of therapeutic communication. Answer: 4 Satisfactory: Meets Standards Comment: Standard I--Communication The student functions as an advocate for the patient/family and

communicates family needs to other members of the health care team. Answer: 4 Satisfactory: Meets Standards Comment: Standard I--Communication The student examines the dynamic interactions between the patient, family, community, and society. Answer: 4 Satisfactory: Meets Standards Comment: Standard I--Communication The student initiates discussion to identify and resolve interpersonal problems that impact care. Answer: 4 Satisfactory: Meets Standards Comment: Standard I--Communication The student uses interpersonal skills to enhance patient/family coping abilities. Answer: 4 Satisfactory: Meets Standards Comment: Standard I--Communication The student discusses the ethical issues and approaches the ethical dilemmas that confront the patient/family and appropriately discusses experience with faculty/preceptor. Answer: 4 Satisfactory: Meets Standards Comment: Standard I--Communication The student delegates appropriately to patient care technician, family, or other team members. Answer: 3 Minimal Comment: This will come in Ms. Clark's preceptorship. Standard I-Knowledge The student applies knowledge of humanities, physical and social sciences, and nursing when providing patient care. Answer: 4 Satisfactory: Meets Standards Comment: Standard I-Knowledge The student applies knowledge of social, cultural, and genetic factors to the care of diverse populations. Answer: 4 Satisfactory: Meets Standards Comment: Standard I-Attitude The student does not in anyway demonstrate disrespect or inappropriate behavior to the patient, staff, or faculty (Comment Answer: 5 Outstanding: Exceeds Standards Required) Comment: Exceptionally respectful.

Standard I-Attitude The student is actively engaged in and seeks out opportunities for learning. (Comment Answer: 5 Outstanding: Exceeds Standards Required) Comment: Always seeking and learning. Standard II-Safety The student does not make judgmental, discriminatory, or prejudicial statements to the patient, staff, or faculty. Answer: 4 Satisfactory: Meets Standards Comment: Standard II-Safety The student applies principals of universal precautions, practices specific isolation techniques, and teaches the reasons for universal precautions. Answer: 4 Satisfactory: Meets Standards Comment: Standard II-Safety The student assesses patients for fall risk and applies principles of safe patient handling. Answer: 4 Satisfactory: Meets Standards Comment: Standard II-Safety The student maintains the patient's physical safety by protecting the patient from harm. Answer: 4 Satisfactory: Meets Standards Comment: Standard II-Safety The student maintains medical and surgical asepsis when doing procedures requiring sterile technique. Answer: 4 Satisfactory: Meets Standards Comment: Standard II-Safety The student properly identifies techniques and teaches the reasons for universal precautions. Answer: 4 Satisfactory: Meets Standards Comment: Standard II-Safety The student validates the accuracy and appropriateness of orders for nursing/medical care prior to initiating care. Answer: 4 Satisfactory: Meets Standards Comment: Under the guidance of her preceptor. Standard II-Safety The student implements orders accurately and efficiently. Answer: 4 Satisfactory: Meets Standards Comment: Under the guidance of her preceptor. Standard II-Safety The student is able to identify potential signs and symptoms of an emergent medical condition and promptly reports changes in the patient's health status to preceptor

and/or clinical faculty member. Answer: 4 Satisfactory: Meets Standards Comment: Standard II-Safety The student adapts skill performance using principles of theory when necessary. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Assessment The student identifies data from the history and physical assessment to formulate appropriate nursing diagnoses. (Comment Answer: 5 Outstanding: Exceeds Standards Required) Comment: Ms. Clark's choice of nursing dx are very appropriate and listed in the order of airway, breathing, circulation, and Maslow's respectively. Standard III-Nursing Process:Assessment The student identifies the patient's health education needs. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Diagnosis The student synthesizes history and assessment data as well as diagnostic results into the development of nursing diagnoses. (Comment Answer: 5 Outstanding: Exceeds Standards Required) Comment: As above. Standard III-Nursing Process:Plan The student integrates psychosocial needs into care plan, identifies appropriate resources for the plan of care, and incorporates health education into the care plan. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Plan The student identifies measurable, expected patient outcomes that are realistic and individualized to the patient. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Plan The student identifies the discharge planning process and needs of the patient upon admission and throughout the hospitalization. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Plan The student demonstrates judgement in decision-making and priority setting. Answer: 4 Satisfactory: Meets Standards

Comment: Standard III-Nursing Process:Plan The student uses appropriate collaborative resources to personalize the nursing care the patient receives. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Intervention/Implementation The student demonstrates understanding of the principles underlying nursing actions appropriate for the student at this point in the curriculum. (Comment Answer: 5 Outstanding: Exceeds Standards Required) Comment: Has grown exceptionally in her critical thinking. Standard III-Nursing Process:Intervention/Implementation The student performs skills according to agency policy and procedure and clinical lab guidelines. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Intervention/Implementation The student implements the written action plan/protocol considering the priorities for each assigned patient. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Intervention/Implementation The student implements a teaching plan based on scientific knowledge and utilizes resources appropriately. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Intervention/Implementation The student incorporates evidence based research into nursing practice. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Intervention/Implementation The student practices individualized and culturally competent care. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Intervention/Implementation The student initiates appropriate referrals as needed. Answer: 3 Minimal Comment: Not much exposure or chance to implement. Standard III-Nursing Process:Evaluation The student evaluates the patient's response/outcome to the intervention.

Answer: 4 Comment:

Satisfactory: Meets Standards

Standard III-Nursing Process:Evaluation The student utilizes subjective and objective data to revise nursing actions (as appropriate for the student at that level of the curriculum). (Comment Answer: 5 Outstanding: Exceeds Standards Required) Comment: Ms. Clark is a very bright student and is above average. Standard III-Nursing Process:Organization The student provides organized, coordinated, and prioritized nursing care for the patients with a range of health problems. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Organization The student organizes time and resources effectively and efficiently. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Organization The student gathers and organizes equipment necessary for patient care/procedures. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Organization The student identifies and seeks appropriate resources during patient care provision. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Organization The student completes the daily clinical assignment in a timely manner. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Documentation The student appropriately develops long and short term patient oriented nursing care goals based on patient assessment and scientific principles of nursing practice. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Documentation The student documents problems and nursing care goals in the patient record (with co-signature). Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Documentation The student identifies and documents nursing

actions/orders initiated in implementing the plan of care. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Documentation The student correctly enters data into the patient record in a timely manner per agency protocol. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Documentation The student assures privacy of the patient record at all times. Answer: 4 Satisfactory: Meets Standards Comment: Standard III-Nursing Process:Critical Thinking The student utilizes critical thinking skills to prioritize patient needs based on the patient assessment. Answer: 4 Satisfactory: Meets Standards Comment: