Week 3 Clinical Performance Assessment Worksheet
Week 3 Clinical Performance Assessment Worksheet
Hello. This is a nursing course. I need a detail care plan write up for my virtual patient as notified in the case study document. I need you to be creative in doing your assessment. My professor will not mind you creating assessment information to use in the care plan as long as the information makes sense and is chronological. You will have to assess the mom and the new born and write out 3 priority nursing diagnoses each for mom and baby. Making a total of 6 priority nursing diagnoses (including R/T and AEB). Now, as you feel the Care plan template, you will chose one nursing diagnosis for mom and write long term and short term goals, write 5 intervention and 5 rationales. Do the same thing for the baby. make sure you do in-text citations and references. Do well to answer every question that in the care plan. When you’re done send me back the filled template with the responses.
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CLINICAL PERFORMANCEASSESSMENT WORKSHEET
Student Name: Date: ________________ Week ________
Rating Scale
| Subscales |
Grade |
Comments |
| 1. ASSESSMENT– Gathered data on the pathophysiology of the illness/disease, medications, culture/spiritual factors, and nutritional status. Incorporated and interpreted new data correctly. Also, gathered information regarding epidemiology & stratification as it applies to client. | ||
| 2. ANALYSIS/NURSING DIAGNOSIS – Formulated nursing diagnoses for actual & potential health problems relating to health promotion behaviors, growth and development, medications, nutrition, and cultural and spiritual awareness; prioritizes problems according to clients’ needs. | ||
| 3. PLAN/GOAL – Developed client and family goals that promoted progression toward health. Goals are individualized and SMART (Specific, Measurable, Attainable, Realistic, Time Frame) | ||
| 4. INTERVENTIONS – Nursing interventions are individualized for the client. Each intervention implements care which reflects planning, organization & flexibility to meet client’s needs that promotes standards of care and practice. | ||
| 5. RATIONALE – Identified rationale for nursing actions that support the plan of care with current professional literature and research findings. Has significant and complete information regarding health promotion, growth and development, pathophysiology of the illness/disease, medications, nutrition, and treatments; calculates dosage, knows appropriate sites for drug administration, and calculates IV drip rates correctly (if applicable). | ||
| 6. EVALUATION – Facilitated alteration of care plan to reflect evaluation of client’s progress toward goals; evaluates effectiveness of specific interventions; evaluates ways to maintain standards of care & practice; evaluates criteria that are congruent with clients’ health goals. Applies concepts of health promotion & dimensions of health when evaluating care & client outcomes. Reflections of own performance demonstrates self awareness and identifies areas for growth as well as reflects systematic movement to meet course learning objectives | . | |
| 7. NURSING SKILLS – Performed skills safely & correctly at reasonable speed; adapts to changes from learned sequence; organizes equipment & supplies involved in client care; recognizes obvious breaks in technique. Efficient in use of technology for client care. Demonstrates use of Presence to promote health and healing. | ||
| 8. COMMUNICATION – Reported & documented medications, procedures, treatments & changes in client’s condition & client responses to care & interventions. Effectively communicated with clients, staff, & faculty. Maintained confidentiality & adherence to information management policies. | ||
| 9. PROFESSIONALISM – Prepared to give safe care; adhered to policies & reported own errors; assumed responsibility for maintaining safety; took extra precautions to maintain client’s confidentiality; used appropriate channels to promote a high level of care for the client; selected learning experiences which require additional preparation; demonstrated prudent judgment in unfamiliar situations; was punctual; maintained a professional appearance; promoted the client’s welfare & upheld dignity & professional boundaries; reflected consideration of cultural and spiritual differences when interacting with clients & members of the interdisciplinary team. | ||
| 10. INTERPERSONAL RELATIONSHIPS – Used communication skills in therapeutic relations; adapted communication to client’s developmental level; promoted positive group & learning activities & staff relations; was able to accurately assess own abilities & began to plan for growth in self.. Reflected consideration of cultural and spiritual differences when interacting with clients & members of the interdisciplinary team. |
KEY: F= Failing (1); MI = Must Improve (2); A=Acceptable (3); C=Commendable (4); and E=Excellent (5)
Houston Baptist University
NURS 4434 Care of Childbearing Family
Postpartum Care Worksheet
| Student Name | Date of Care | Pt Initials | Rm# | Age | EDC | Wks. Gestation | |||
| GTPAL after delivery | Allergies | Diet | Marital Status | Current Wt. | Pre-pregnant Wt. | ||||
| Delivery Date & Time | Vaginal/CS | Birth Wt | Gender M/F | Breast/Bottle | Baby’s Blood type | ||||
| Test and result/date | Test and result/date | ||
| Blood type | Rubella | ||
| Rh factor | HIV | ||
| Antibody screen | RPR/VDRL | ||
| Hgb | HbSAg | ||
| Hct | Gonorrhea | ||
| WBCs | Chlamydia | ||
| Platelets | GBS | ||
| Interpretation of abnormal lab results: | ||
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| Rhogam | Needed? | Given? |
| Brief Pregnancy history. Feelings about pregnancy. Family configuration. (prior obstetric history. |
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| Brief Labor History (if C-Section, why?). |
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| Present Postpartum history, including level of Activity. |
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| Vital Signs | ||||||
| Date | Time | Temp | Pulse | Respirations | BP | Pain 0/10 Site |
| Treatment for pain & time: | Reassessment of pain (Time and Results) |
| Physical Assessment (BUBBLE – HEE) | |
| Breasts |
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| Nipples (condition, secretion) |
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| Abdominal Incision (color, discharge, approximation) | |
| Fundus (consistency, height, position) | |
| Bowel (sounds, flatus, stool) |
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| Hemorrhoids |
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| Urinary Elimination |
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| Signs of UTI |
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| Costovertebral Angle Tenderness | |
| Lochia (type, amount) |
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| Perineum/Episiotomy (REEDA) | |
| Signs of Thrombophlebitis (redness, swelling, warmth, or pain) | |
| Edema (site, extent) |
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| Emotions (explain evidence of (+) or (-) bonding) |
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| Teaching Needs: |
| What is your patient’s culture and what information did you learn about the patient’s culture to assist you in delivering culturally competent care? |
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Infant Intake and Output: |
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| Time: |
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| Type of Feeding | |||||
| Amount or # of Minutes | |||||
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Voids |
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Stools |
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| Newborn Assessment: Male/Female Apgar’s: 1 min _______ 5 min _______ | ||
| Put an X by the ones that apply | Additional Notes when needed: | |
| ACTIVITY: | ||
| Quiet | ||
| Alert/Active | ||
| Sleeping | ||
| Lethargic | ||
| TONE: | ||
| Normal | ||
| Jittery | ||
| Hypo/Hyper | ||
| Reflexes (+) | ||
| CRY: | ||
| Strong | ||
| Weak | ||
| High-pitched | ||
| COLOR: | ||
| Pink | ||
| Pale | ||
| Acrocyanosis | ||
| Jaundiced | ||
| Meconium stained | ||
| Mottled | ||
| SKIN: | ||
| Warm | ||
| Bruising | ||
| Cool | ||
| Petechiae | ||
| Newborn Rash | ||
| HEAD: | ||
| Fontanel Soft/Flat | ||
| Other | ||
| Skull molded | ||
| Caput/Cephalohematoma | ||
| Forcep marks/Abrasions | ||
| EYES: | ||
| Clear | ||
| Other | ||
| CHEST: | ||
| Breath Sounds Clear/Equal | ||
| Decreased R/L | ||
| Rales/Rhonchi | ||
| Grunting | ||
| Nasal Flaring | ||
| Retractions Mild/Moderate | ||
| Heart Sounds Regular/Irregular | ||
| Murmur (-) absent / (+) present | ||
| Vital Signs: | T______ P______ R______ | |
| ABDOMEN | ||
| Soft | ||
| Distended | ||
| Bowel Sounds (-) absent / (+) present | ||
| GENITOURINARY (Circle the one that applies) | ||
| Male testes descended/undescended | ||
| Female normal/discharge | ||
| Prioritized Problem List/Nursing Diagnoses, R/T and AEB: (two for Mom and one for baby): |
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This section is for any additional evaluation of yourself that you may want to share with the instructor
Nursing Skills:
Strengths:
Opportunities for Improvement:
Comments:
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Initial Assessment Data r/t Priority Nursing Dx: For the MOM
Highest Priority Nursing Dx:
Plan: Short Term/ Long Term Goal:
Interventions:
1.
2.
3.
4.
5.
Initial Assessment Data r/t Priority Nursing Dx: for the BABY
Highest Priority Nursing Dx:
Plan: Short Term/ Long Term Goal:
Interventions:
1.
2.
3.
4.
5.
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Rationale for Nursing Dx #1:
1.
2.
3.
4.
5.
Evaluation:
Skills Used for this Nursing Dx:
Explore potential Legal/Ethical Issues r/t caring for patient:
Safety Concerns when caring for this patient:
Rationale for Nursing Dx #1:
1.
2.
3.
4.
5.
Evaluation:
Skills Used for this Nursing Dx:
Explore potential Legal/Ethical Issues r/t caring for patient:
Safety Concerns when caring for this patient:
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Houston Baptist University NURS 4434
SCHEDULED MEDICATION WORKSHEET
Student __________________________________ Date______________________________ Unit & Room ______________________________
| Drug Name
(Generic & Trade Name) |
Class/Action | Side Effects | Dose/
Route |
Recmd
dose |
Rationale for your Patient | Frequency & Times | Military Time You Will Give | Lab values/ Nursing implications |
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Week 3 Clinical Performance Assessment Worksheet