laboratory and clinical booklet - Fort Scott Community College

LABORATORY AND CLINICAL BOOKLET
FOR
NURSING 2509
ACUTE AND EXTENDED HEALTH CARE ISSUES
FORT SCOTT COMMUNITY COLLEGE
NURSING EDUCATION
2108 SOUTH HORTON
FORT SCOTT, KANSAS 66701
FALL 2011
1

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING
NURSING 2509
GENERAL GUIDELINES FOR CLINICAL
1. Arrive on time for clinical and ready to take report. Arrival time is at least 15-30
minutes prior to start of shift. Repeated tardies will result in an unsatisfactory
clinical experience.
2. Report absence to the nursing unit on which you are assigned for the day at least
one (1) hour before clinical. Failure to report absence from clinical will result in an
unsatisfactory clinical day (client abandonment) for each occurrence.
620-235-0020 - Cornerstone Village, Inc., Pittsburg, Kansas
620-724-8291 – Girard Medical Center, Girard, Kansas
620-223-2200 – Mercy Health Center, Fort Scott, Kansas
620-223-8090 - Mercy Home Health, Fort Scott, Kansas
417-667-3355 – Nevada Regional Medical Center, Nevada, Missouri
620-231-6100 - Via Christi Hospital, Pittsburg, Kansas
3. Students assigned to CCU will choose one CCU client and have sufficient
information to be prepared for clinical (see Clinical Tools). Student leaders will
assign the clients. Students will be able to verbalize information about their clients‟
medications on the day of clinical. Students scheduled for other clinical experiences
are to review expectations of the clinical rotation prior to experience.
4. NURSING CARE PLAN BOOKS CAN BE USED ONLY AS REFERENCE.
Use your textbooks and other resources, stating the author and pages from which
information was obtained.
5. Safety of client and student is a primary concern.
Students will not give care to clients unless an instructor or preceptor is in
the facility.
Use universal precautions for all clients.
Wash hands before and after all procedures including going to the linen cart.
Cleanse stethoscope, penlights, caliper, and bandage scissors with soap and water
before and after use.
If you are injured, report to your instructor and student leader IMMEDIATELY.
If you make an error of any type, notify your instructor and student leader
IMMEDIATELY.
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Students will do only procedures which have been satisfactorily completed
in lab unless an instructor is present to guide the student through it. Contact your
instructor and student leader before performing any procedure.
Students will verbalize information about all the medications his or her client is
receiving (to another licensed nurse or NUR 2510 student) prior to administering
them. If a student cannot verbalize the information, they will not give the
medication that day. Information to know: name of drug (generic and trade),
classification, action, side effects, special nursing implications, usual dosage,
and how you will know the medication was effective. All medications will be
checked by the instructor, nurse or a second student prior to administration.
Students will have an R.N. present when administering I.V. medications or fluids.
The above information must be included in the Client Assessment Form for each
client.
No visitors at clinical.
6. For clinical, dress in complete uniform including name pin. Shoes will be kept clean
and polished. Hair will be off the collar. If earrings are worn, they must be very
small. Necklaces or other jewelry are not permitted (except watch and wedding
rings). Do not wear colored nail polish or false nails. (See Student Handbook.) Do
not wear stethoscopes around your neck.
7. If you can‟t find your instructor in emergency, dial “O” and ask operator to page
them.
8. Students may NOT leave any clinical assignment without instructor‟s permission.
9. Space at all facilities is limited. Carry only essential materials and supplies.
10. No theory studying at clinical.
11. Post-conference times: According to instructor‟s schedule.
12. Students are responsible for obtaining any other additional report from primary nurse
after general report. Students will give report to student leader responsible for his/her
area prior to end of shift. Student will give report on her/his assigned clients to the
day-shift nurse, as well as the nurse on the following shift.
13. One clinical make-up will be scheduled after the end of the semester for time missed.
Clinical papers will be assigned by the instructor. NO EXCEPTIONS: DUE ON
MONDAY FOLLOWING WEEK IN WHICH THE MAKE-UP IS SCHEDULED,
OR AT THE DISCRETION OF THE INSTRUCTOR.
14. Students will come prepared to clinical knowing what is expected of them that day as
stated in the clinical tools. All clinical tools have clearly defined instructions
regarding assignments due and the times they are to be handed in.
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15. Clinical papers – whether it is the Client Assessment Sheet/Nursing Care Plan or the
required paper from ER, Outpatient Surgery, or Home Health – are due the following
week, at the start of your next clinical day. You may hand papers in prior to that date.
However, any papers handed in after that time will be given zero points.
There are a total of 9 clinical papers due: 4 medical/surgical, 1 critical care unit
(CCU), 1 outpatient surgery (OP), 1 emergency room (ER), 1 student leader (SL), and
1 home health (HH) or wound care (WC). The student has the option of determining
which clinical dates to write the 9 required papers out of 12 possible dates.
16. Home Health rotation students in observational experiences will be allowed to take
vital signs only. Reference KBSN 60-1-104.
17. All written assignments will be on proper forms, legible, and neat or they will be
returned to student ungraded. Follow grading criteria carefully.
The total average of clinical tool grades and the total average of all clinical papers are
combined for a final clinical grade. To pass this course, students must pass clinical
papers with an 80% combined grade.
18. A nursing preceptor experience will be given each student in NURSING 2509 not to
exceed 24 hours of clinical rotation. Reference KSBN 60-1-104.
19. During the clinical rotations, no students will be allowed to leave the facility.
20. Each student will have 30 minutes for lunch on days with clinical hours greater than
five-hour shifts.
21. Students will not go to lunch at the same time. Students are expected to cover each
other for lunch breaks. The student leader will assign lunches.
22. Students who smell of cigarette smoke or heavy perfume will not be allowed on the
clinical floor and will receive an unsatisfactory for the day.
23. Students are subject to rules and regulations of each facility, i.e. drug testing,
bloodborne pathogen testing, confidentiality, etc.
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NURSING 2509
PRE-CLINICAL COMPETENCY CHECKOFFS
IV Insertion _________
Male Foley Insertion _______
Female Foley Insertion __________
Intradermal Injection __________
Intramuscular Injection __________
Subcutaneous Injection __________
I have practiced and checked off proficiency of the listed
procedures in the Learning Lab of FSCC.
Student: ________________________
I have witnessed competent completion of the listed
procedures in the Learning Lab of FSCC.
Student: _________________________
5

ARTERIAL BLOOD GAS REVIEW
(1)
pH 7.34
pCO 2 33.9
HCO 3 18.2
BE +6.2
pO 2 85.2
(4)
pH 7.17
pCO 2 69.3
HCO 3 21.0
BE -5.5
pO 2 40.9
(7)
pH 7.45
pCO 2 27.0
HCO 3 19.1
BE -3.5
pO 2 65.5
(10)
pH 7.39
pCO 2 39.0
HCO 3 23.4
BE -1.0
pO 2 61.2
(13)
pH 7.44
pCO 2 27.8
HCO 3 19.2
BE -4.0
pO 2 100
(16)
pH 7.18
pCO 2 42.0
HCO 3 15.0
BE -12.5
pO 2 69.0
(19)
pH 7.52
pCO 2 31.0
HCO 3 26.4
BE +2.7
pO 2 100
(2)
pH 7.34
pCO 2 40.3
HCO 3 21.4
BE +3.6
pO2 41.0
(5)
pH 7.07
pCO 2 11.4
HCO 3 31
BE -26.3
pO 2 115.1
(8)
pH 7.28
pCO 2 79.5
HCO 3 37.1
BE +8.4
pO 2 30.0
(11)
pH 7.31
pCO 2 58.5
HCO 3 26.1
BE +1.6
pO 2 74.5
(14)
pH 7.36
pCO 2 75.1
HCO 3 40.6
BE +11.9
pO 2 65.2
(17)
pH 7.36
pCO 2 30.0
HCO 3 15.0
BE -12.0
pO 2 80.0
(20)
pH 7.08
pCO 2 54.0
HCO 3 15.0
BE -15.5
pO 2 54.0
(3)
pH 7.59
pCO 2 49.0
HCO 3 48.2
BE +21.6
pO 2 58.7
(6)
pH 7.25
pCO 2 74.3
HCO 3 12.4
BE -13.4
pO 2 29.1
(9)
pH 7.51
pCO 2 39.4
HCO 3 31.3
BE +7.5
pO 2 77.3
(12)
pH 7.46
pCO 2 34.0
HCO 3 26.0
BE +2.0
pO 2 43.8
(15)
pH 7.44
pCO 2 48.0
HCO 3 32.6
BE +7.3
pO 2 63.6
(18)
pH 7.42
pCO 2 39.0
HCO 3 25.4
BE +1.1
pO 2 92.0
6

Arterial Blood Gas Answer Key
1. Partially Compensated Metabolic Acidosis with normal
oxygenation.
2. Uncompensated Metabolic Acidosis with severe hypoxemia.
3. Partially Compensated Metabolic Alkalosis with hypoxemia.
4. Combined Metabolic and Respiratory acidosis with severe
hypoxemia.
5. Partially Compensated Metabolic Acidosis – the patient is
hyperventilating, causing an elevated PaO 2 .
6. Combined Metabolic and Respiratory Acidosis with severe
hypoxemia.
7. Fully Compensated Respiratory Alkalosis with hypoxemia.
8. Partially Compensated Respiratory Acidosis with severe
hypoxemia.
9. Uncompensated Metabolic Alkalosis with hypoxemia.
10. Normal Arterial Blood Gas with hypoxemia.
11. Uncompensated Respiratory acidosis with hypoxemia.
12. Uncompensated Respiratory Alkalosis with severe
hypoxemia.
13. Fully Compensated Respiratory Alkalosis with normal
oxygenation.
14. Fully Compensated Respiratory Acidosis with hypoxemia.
15. Fully Compensated Metabolic Alkalosis with hypoxemia.
16.Uncompensated Metabolic Acidosis with hypoxemia.
17. Fully Compensated Metabolic Acidosis with normal
oxygenation.
18. Normal Arterial Blood Gas with normal oxygenation.
19. Combined Alkalosis with normal oxygenation.
20. Combined Acidosis with hypoxemia.
7

Name: ____________________
Date: __________________
PERFORMANCE CHECKLIST
PROVIDING SITE CARE FOR A CENTRAL VENOUS CATHETER
1. Assessed for allergy to betadine.
2. Gathered information regarding last dressing change &
condition of insertion site.
3. Ensured that all tubing connections are securely
fastened.
4. Explained procedure to client & helped client
assume supine or semi-Fowler‟s position.
5. Washed hands. Asked client to turn head away from
insertion site. Put on clean gloves.
6. Opened sterile supplies & placed within easy reach.
7. Removed dressing from insertion site & disposed of
properly.
8. Assessed condition of insertion site & inspected
condition of catheter. Remove gloves.
9. Applied sterile gloves.
10. Cleansed skin properly around insertion site.
11. Cleansed proximal tubing correctly.
12. Removed gloves & applied new pair of sterile gloves.
(Optional – not necessary if sterile technique is
maintained)
13. Applied sterile occlusive dressing correctly.
14. Removed & discarded gloves. Washed hands.
15. Labeled dressing correctly.
16. Documented procedure correctly.
S U
Comments
8

Name: ____________________
Date: __________________
PERFORMANCE CHECKLIST
ADMINISTERING WHOLE BLOOD AND PACKED RED BLOOD CELLS
1. Assessed order, reason for transfusion and client‟s
history of prior transfusions
2. Explained procedure to client & obtained
informed consent
3. If IV is in place, assessed site for patency and
appropriate-sized IV catheter. If no IV in place,
performed venipuncture with appropriate-sized
catheter.
4. Obtained baseline vital signs & breath sounds.
5. Obtained & properly identified blood in
laboratory. Checked the cross-match slip with a
licensed person on the unit. Checked blood with
client‟s armband.
6. If administering whole blood, gently invert bag
several times to mix blood.
7. Washed hands and applied gloves.
S U Comments
Administering Whole Blood With Y-Tubing
8. Closed clamps on Y-tubing & inserted one spike
into normal saline.
9. Primed tubing with normal saline to remove air.
Inserted free spike into blood bag.
10. Started infusion of blood at keep-open rate for
first 15 minutes & assessed patient for signs of
reaction. Obtain vital signs as per protocol.
11. If no signs of reaction after 15 minutes, increased
flow to prescribed rate. Obtain vital signs as per
protocol.
12. Follow agency policy for remainder of blood
transfusion.
13. At completion of blood transfusion, document
client status, including vital signs & breath
sounds.
9

Name: ____________________
PERFORMANCE CHECKLIST
MANAGING A CHEST TUBE
1. Assess client:
Vital signs, auscultate lungs, pain level, observe chest
wall, assess dressing at insertion site.
2. Ensured that necessary equipment was at client‟s bedside
in case of emergency (i.e., rubber-shod Kelly clamp,
sterile petrolatum gauze dressing, extra drainage
system.)
3. Assess drainage system:
Keep tubing straight or loosely coiled. No kinks in
tubing.
Check all connections between chest tube, drainage,
tubing, drainage collection unit. Should be tightly
sealed/taped.
Observe and document color/description/amount of
drainage, noting any changes in characteristics.
4. Assess water-seal chamber – should be tidaling, air leak
is present if there is continuous air-bubbling.
Water-seal level should be at the appropriate level.
5. Assess suction control chamber (wet system):
Maintain water at ordered level.
Maintain connection to wall suction.
Suction control chamber should have constant bubbling.
6. Assess drainage chamber:
Determine that measurement occurred at end of previous
shift.
Assess amount of additional drainage.
Keep below level of client‟s chest.
Mark level of meniscus at end of shift.
Document total output for your shift.
7. If air leak present (i.e., continuous bubbling in the waterseal
bottle/chamber), checked for location of leak by
occluding chest tube near client‟s chest with rubber-shod
Kelly clamps. Did not leave clamps in place longer than
one minute.
a. If leak in drainage system (i.e., bubbling continued
with clamps in place), checked integrity of
connections & retaped them. Replaced drainage
system if necessary.
b. If leak at chest tube insertion site (i.e., bubbling
stopped with clamps in place), reinforced the
occlusive chest dressing. Notified physician if leak
continued.
10
Date: __________________
S U
Comments

8. If drainage bottle/chamber full, set up new drainage
system, put on gloves & replaced old system with new
one. Clamped chest tube just long enough to disconnect
old/connect new drainage system. Checked integrity of
new system & reassessed patient condition.
9. Documented any trouble-shooting activities/procedures
including assessment data, and client response.
11

NEURO ASSESSMENT
Assessment of the Neurological System includes:
1. Mental and Emotional Status
2. Cranial Nerve Function
3. Motor Function
4. Reflexes
5. Sensory Function
I. Mental Status includes:
1. Level of Consciousness
2. General Appearance
3. Speech
4. The ability to pay attention
5. The ability to remember
6. The ability to understand
II.
Cranial Nerves
I. Olfactory
a. Function: Sensory
b. Action: Sense of smell
c. Testing Method: Have patient smell aromatic
substances, such as coffee or vanilla
II. Optic
a. Function: Sensory
b. Action: Vision
c. Testing Method: Test visual acuity with Snellen Eye Chart.
Check visual fields from eight directions.
III. Oculomotor
a. Function: Motor
b. Action: Extraocular eye movement, pupil constriction
and dilation
IV. Trochlear
a. Function: Motor
b. Action: Upward and downward movement of the eyeball
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V. Trigeminal:
a. Function: Sensory & Motor
b. Action: Sensory nerves to the skin of the face.
Motor nerves to the muscles of the jaw.
c. Testing Method: Motor: Palpate temporal muscle and
masseter muscles as client clinches her teeth. Assess strength.
Sensory: Touch forehead with pin, then cheeks. Alternate
blunt end with sharp and ask the client to differentiate.
Check light touch. Touch face with cotton. Ask client
When he/she feels it. Eyes should be closed. Assess corneal
reflex. Touch cornea with wisp of cotton. Client should blink.
Check both eyes.
VI. Abducens:
a. Function: Motor
b. Action: Lateral movement of eyeballs
(Cranial Nerves III, IV & VI are tested together)
c. Testing Method: Check pupils reaction to light,
direct and consensual. Have client follow your
finger as you move it in from a distance to the bridge of the
nose. Have client follow your finger through six cardinal fields
of gaze. Look for ptosis of the eyelid.
VII. Facial:
a. Function: Sensory & Motor
b. Action: Facial expression and taste
c. Testing Method: Observe face at rest an during normal
conversation, then have her raise her eyebrows, smile, frown,
clench teeth, and puff out cheeks. Look for weakness. Have
patient close both eyes tightly. Test strength by attempting to
open eyes.
Taste: Have client identify sweet or salty substances.
VIII. Auditory (Acoustic)
a. Function: Sensory
b. Action: Hearing
c. Testing Method: Occlude one ear, whisper softly toward the
opposite ear. If the client has a hearing loss, test with Rinne or
Weber Test.
13

IX.
Glossopharyngeal:
a. Function: Sensory & Motor
b. Action: Taste and the ability to swallow and move tongue
c. Testing Method: Listen to voice, ask client to swallow,
elicit gag reflex with tongue depressor. Have client
identify salty, sweet, sour or bitter taste.
X. Vagus:
a. Function: Motor & Sensory
b. Action: Sensation of the pharynx, ability to swallow,
movement of the vocal cords
c. Testing Method: Have client say “ah” or yawn while you look
at the pharynx and observe pharyngeal movement. Elicit gag
reflex with tongue depressor.
XI. Spinal Accessory
a. Function: Motor
b. Action: Movement of the head and shoulders
c. Testing Method: Place hands on client‟s shoulders and ask
him/her to shrug them against your hands. Note strength of the
trapezius muscle. Place hand against the client‟s face, ask
him/her to turn his/her head against your hand. Note
contraction of opposite sternocleidomastoid muscle and note
strength of movement against your hand.
XII. Hypoglossal:
a. Function: Motor
b. Action: Position of tongue
c. Testing Method: Look at the tongue for atrophy or
fasiculations. Have the client stick out his/her tongue and look
for atrophy or deviation. Ask client to move his/her tongue
from side to side. Note symmetry of movement.
14

III. Motor
1. Assess position sense and coordination
a. Assess gait, have client walk across the room back. Look for
lack of balance and coordination.
b. Have client walk heal to toe in a straight line, then on toes and
then heels. Assess antiflexion and dorsiflexion of ankles and
balance.
c. Have client hop in place on each foot in turn.
d. Have client do shallow knee bends, one leg, then the other.
e. Perform Romberg Test. Have client stand with feet together
and eyes closed. Watch for swaying. Protect client from falls.
f. Perform pronation drift. Have client stand with arms
outstretched with palms up, have the client close his/her eyes.
Maintain position for 20-30 seconds.
g. With hands and arms in the same position and eyes closed, tap
his/her arms in brisk downward motion. Arms should return
to the horizontal position.
h. Have the client raise his/her arms over his/her head with palms
forward. He/she should be able to hold this position 20-30
seconds. Drifting is abnormal.
TO FURTHER ASSESS COORDINATION:
a. Ask client to repeat movements as rapidly as possible. First pat
knee with palm up, then palm down. Watch for speed and
coordination.
b. Have him/her tap thumb‟s distal joints with index finger as rapidly
as possible. Observe speed and smoothness.
c. Do point to point testing. Have client alternate touching her
index finger and her nose several times.
d. To assess point to point on legs, have the client place one heel
on the opposite knee and slide his/her heel down the leg to the
toes. Repeat with other leg.
e. To assess involuntary movement, observe the client throughout
the exam.
2. Assess Muscle Bulk:
Look at the size and contours of the muscles. Flatten contours
with fasciculations may indicate lower motor neuron disease.
15

3. Assess Muscle Tone:
Feel muscle resistance to passive strength in both upper
and lower extremities. Put extremity through ROM.
4. Assess Muscle Strength by assessing strength of grips:
a. Cross middle finger over index finger and ask client to
squeeze your fingers. Grip should be strong and equal.
b. Other tests for muscle strength in which the client pulls
or pushes against your resistance:
1. Flexion at the elbow
2. Extension at the elbow
3. Opposition of the thumb
4. Flexion at the hip
5. Extension at the knee
6. Flexion at the knee
7. Dorsiflexion at the ankle
8. Plantar flexion at the ankle
GRADE MUSCLE STRENGTH 0 – 5 = 5 BEING NORMAL
IV.
Reflexes
1. Patellar – Tests L, 2, 3, 4
1. Biceps – Tests C 5 & Y
2. Triceps - Tests C 6 & 7
3. Bracheoradialis – Tests C 5 & 6
4. Ankle (Achilles) – Tests S 1
Superficial Reflexes:
1. Abdominal (Upper abdomen) Tests % 8, 9, 10
(Lower abdomen) Tests T 10, 11, 12
a. Testing Method: Stroke abdomen with wooden end of a Q-Tip
watch for contractions of the abdominal muscles
2. Plantar: Tests L 5, and S I
a. Testing Method: Stroke the sole of the foot along the outer
aspect heel to across toes. Normal, watch for flexion of the
great toe. Abnormal, dorsiflexion of great toe and fanning of
other toes
16

V. Sensory Function:
Screening Exams for Sensory:
1. Pain
2. Vibration
3. Light Touch
More Detailed:
1. Temperature
2. Position
3. Two point discrimination
When assessing pain, temperature and touch, compare distal to
proximal. Compare symmetrical areas to each side of the body.
Scatter the stimuli to assess most of the dematomes.
a. To assess skin sensation (pain), ask the client to close his/her
eyes. Touch skin with open safety pin. Ask her to tell you
whether it is sharp or dull. Occasionally, substitute the blunt end
of the pin. Compare areas.
b. To assess touch, have the client close her eyes and lightly
touch her skin with a fine wisp of cotton. Ask her to respond when
she feels the cotton.
c. To test temperature, touch the client with a test tube filled with
hot water. Ask the client to identify whether it is hot or cold.
Repeat the test using a tube filled with cold water.
Test distal areas first. If distal areas are normal, proximal
areas will also be normal.
d. To assess vibration, tap a low pitched tuning fork on your hand.
Place it on a distal interphalangeal joint of the client‟s finger.
Ask how it feels. Also place the vibrating tuning fork on the
interphalangeal joint of the big toe and ask her how it feels.
Should feel the vibration.
e. To test position, grasp the big toe and pull it away from the other
toes. Ask client to close her eyes and tell you whether the toe is
up or down. Repeat other side.
17

f. Test discrimination sensations, but only if touch and position
sense is intact. Assess discrimination by assessing stereognosis
(the ability to identify an object by feeling it.) To do so, have the
client close her eyes and place a familiar object, such as a paper
clip in her hand and ask her to tell you what it is. If the client
can‟t identify the object, test her ability to identify numbers which
is called graphesthesia. Draw numbers on her hand and ask her to
identify them.
OTHER TESTS:
a. Two Point Discrimination
b. Point Localization
c. Extinction
18

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
NURSING 2509
GLASGOW COMA SCALE
EYE OPENING
spontaneous 4
to sound 3
to pain 2
never 1
swollen 0
MOTOR RESPONSES
obeys commands 6
localizes pain 5
flexion withdrawal 4
abnormal flexion 3
extension 2
none 1
VERBAL RESPONSE
oriented 5
confused 4
inappropriate words 3
incomprehensible words 2
none 1
ET tube or trach
T
19

NUR 2509 – CASE STUDY #1 - ENDOCRINE
You are working with a home care nursing agency. One of your clients is J.S., a 60-yearold
man suffering from COPD. He has been on home oxygen, 2 L O 2 /nc, for several
years. Approximately 2 months ago, he was started on steroid therapy. Medications
include metaproterenol (Alupent) inhaler, theophylline (Theo-Dur), prednisone, digoxin,
and furosemide (Lasix). Not surprisingly, he also has a 50-pack-year history of cigarette
smoking. On the way to visit J.S., you remember he has been progressively exhibiting s/s
of Cushing‟s syndrome. You suspect J.S. occasionally forgets to take his medication
because he always seems to have “extra” pills in the bottle at the end of the month.
1. After you meet J.S., you begin an assessment and note the following findings.
Circle the s/s that characterize Cushing‟s syndrome:
Barrel chest
Acne
Full-looking face (“moon facies”) Diminished breath sounds
BP 180/94
Truncal obesity with fat around
Pursed-lip breathing,
clavicles and the neck
especially when patient is stressed Weakness and fatigue
Thin arms and legs
Impaired glucose tolerance
Bruising on both arms
2. Differentiate between the cause of Cushing‟s syndrome and Cushing‟s disease.
3. Identify three to four general topics to be included in a teaching plan for J.S.
4. Identify possible consequences of suddenly stopping the prednisone therapy.
5. The home care nurse informs the physician of the client‟s s/s. The physician
decides to change J.S.‟s prescription to prednisone given on alternate days.
Explain the rationale for this change.
6. It is easy to forget what medications have been taken when – especially when
there are several different drugs and times involved. List at least three ways
you can help J.S. remember to take his pills as prescribed.
7. J.S. states that his appetite has increased but he is unable to satisfy his appetite
because of SOB and he has been losing weight. How would you address this
problem? How might his diet be modified?
8. You advise J.S. to take his prednisone in the morning with food and then ask him a
series of questions r/t his vision. Discuss the rationale behind these nursing care
actions.
9. Review J.S.‟s list of medications. Based on what you know about the side effects of
loop diuretics and steroids, discuss the potential problem of administering these
in combination with digoxin.
10. Realizing that clients like J.S. are susceptible to all types of infections, you write
guidelines to prevent infections. Identify four major points that these guidelines
will include:
20

NUR 2509 – CASE STUDY #2 - ENDOCRINE
You are working in a community outpatient clinic where you perform the intake
assessment on R.M., a 38-year-old woman who is attending graduate school. Her CC is
overwhelming fatigue that is not relieved by rest. She is so exhausted that she has
difficulty walking to classes and studying. She has coarse, sparse scalp hair; scaly skin;
slightly slurred speech; thick tongue; a hoarse voice; puffiness around the eyes;
yellowish-colored skin and nails; and swollen neck. Initial VS were 92/64, 56, 12, 96.8
degrees F.
1. Compare her VS with those of a healthy person her same age:
2. List eight general questions you might ask R.M. to get a “ball park” idea of what is
going on with her:
3. You know that some of R.M.‟s symptoms could be caused by depression,
hypothyroidism, anemia, cardiac disease, fluid and electrolyte imbalance, or allergies.
As part of your screening procedures, how would you begin to investigate which of
these conditions probably do not account for R.M.‟s symptoms?
You find no obvious irregularities in R.M.‟s cardiopulmonary assessment.
4. Unnecessary diagnostic tests are expensive. What tests do you think would be the
most important for R.M., and why?
R.M.‟s TSH comes back 10.9; the family nurse practitioner diagnoses R.M. with
hypothyroidism and places her on thyroid replacement therapy.
5. R.M.‟s TSH level is increased. Explain the relationship between these lab results
and hypothyroidism:
6. What client teaching needs will you review with R.M. before she leaves?
Remember medication issues.
7. Why would you want to obtain a complete drug history on R.M.?
8. What general teaching issues would you address with R.M.?
9. R.M. wonders whether she should take iodine supplements if she decreases her salt
intake. She recognizes that salt is a significant source of iodine in her part of the
country. What would you explain to her?
10. What should you teach R.M. regarding prevention of myxedema coma?
11. Before R.M. leaves the clinic, she asks how she will know whether the medication is
“doing its job.” Outline simple expected outcomes for R.M.:
12. Several weeks later, R.M. calls the clinic stating she can‟t remember whether she took
her thyroid medication. What additional data should you obtain, and how would you
advise her?
21

NUR 2509 – CASE STUDY #3 - ENDOCRINE
You are working on an oncology unit and will be receiving a client from recovery room.
The PACU RN gives the following report: 50-year-old female, total thyroidectomy
(multinodular goiter), left superior and right inferior parathyroidectomy because of
adenoma. Estimated blood loss of 25 ml. Vital Signs: 130/82, 88, 20. Peripheral IV of
D5 ½ NS + 20 mEq KCL and 10 mEq calcium gluconate infusing at 100 ml/hr. Has
received total of 50 mg Demerol IVP. PMH: TAH for fibroids and low-level radiation
treatments to neck 38 years ago for eczema. Medications include estradiol, lovastatin,
and levothyroxine. Preop labs: Ca 11.2 mg/dl, phosphorus 2.4 mg/dl, Cl 106 mmol/L,
alkaline phosphatase 162 U/L, elevated parathyroid hormone (PTH) and TSH levels,
creatinine 1.4 mg/dL.
1. What preparations will you take before CP arrives?
2. You receive CP from the recovery room. How will you focus your initial assessment
and why?
3. During your initial assessment, you document negative Chvostek‟s and Trousseau‟s
signs. Describe data that would support this conclusion.
4. Explain why CP would have been taking Synthroid preoperatively.
5. Why would the alkaline phosphatase be elevated?
6. Identify the major risk factor that may have contributed to the development of
parathyroid adenoma in CP.
7. Identify 4 nursing issues related to CP‟s care.
8. Identify 4 nursing actions you should include in the post-op care of CP.
9. Identify nursing care measures that reduce the risk for post-op swelling.
10. Twenty-four hours after surgery, CP calls you to her room c/o numbness around her
mouth and tingling at the tips of her fingers. She appears restless but is AAO.
Realizing that CP may be experiencing hypocalcemia, you decide to notify the
physician. What should you do in the interim before the physician returns your call?
11. What emergency equipment should you gather?
12. CP is given supplemental calcium gluconate and recovers. Now being discharged 48
hours post-op. She states that she can‟t wait until she can stop taking Synthroid.
How would you respond to her statement?
22

NUR 2509 – CASE STUDY #4 - ENDOCRINE
K.B. is an 80-year-old woman admitted to the hospital following a 5-day episode of the
“flu” with c/o DOE (dyspnea on exertion), palpitations, chest pain, insomnia, and fatigue.
Her PMH includes congestive heart failure (CHF) and hypertension (HTN) requiring
antihypertensive medications (she states that she has not been taking these medications
on a regular basis.) K.B. was diagnosed with Graves‟ disease 6 months ago and was
placed on propylthiouracil (PTU) 100 mg PO q6h. Assessment findings are as follows:
Ht. 5‟2”, Wt. 100 lb. Appears anxious and restless. Loud heart sounds. VS are 150/90,
104 irregular, 20, 100.2 degrees F; 1+ pitting edema noted in lower extremities.
Diminished breath sounds with fine crackles in the posterior bases. K.B. states she
recently lost her husband. Laboratory findings: Hgb 11.8 g/dL, Hct 36%, erythrocyte
sedimentation rate (ESR) 48 mm/h, Na 141 mmol/L, Cl 101 mmol/L, BUN 33 mg/dL,
creatinine 1.9 mg/dL. T 4 14.0 g/dL, T 3 230 mg/dL.
1. Of the physical assessment and laboratory findings, which represent manifestations
of hypermetabolism?
2. What additional subjective and objective data would you gather for someone with
Graves‟ disease?
3. After AM rounds, the physician leaves the following orders. Which of the orders
would you question and why?
Propranolol (Inderal) 20 mg PO q6h
Dexamethasone (Decadron) 10 mg IV q6h
Verapamil (Calan SR) 120 mg PO qd
Diet as tolerated, high-protein
STAT ECG
Up ad lib
4. Develop four priority nursing problems r/t K.B.‟s care:
5. Later on your shift, you note that K.B. is extremely restless and is disoriented
to person, place, and time. VS are 104/62, 180 and irregular, 32 and labored,
104 degrees F. Her ECG shows atrial fibrillation. What do these findings indicate?
6. What would you do first?
K.B. is in thyroid crisis. The physician orders the following: STAT ABGs; digoxin
(Lanoxin) 0.125 mg IVP q8h x 3 doses; IV of D 5 W at 100 ml/h; Lugol‟s solution (strong
iodine) 10 drops PO tid; increase propylthiouracil (PTU) to 200 mg PO qid;
hydrocortisone (Hydro-Cort) 100 mg IVP q8h; cardiac monitor; absolute bed rest;
cooling blanket for temp > 102 degrees F; acetaminophen (Tylenol) 650 mg PO prn temp
> 100 degrees F.
7. Identify four nursing measures that would be essential in caring for K.B.:
8. Identify two possible contributing factors that may have precipitated K.B.‟s thyroid
storm:
9. Before discharge, the physician discusses 2 treatment options with K.B. and her
family: radioactive iodine (RAI) therapy using 131 l, and subtotal thyroidectomy. K.B.
is fearful of radiation treatment and asks you for your opinion. How would you
respond?
10. K.B. decides to receive RAI. Discuss discharge teaching.
23

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
NUR 2509 – ACUTE & EXTENDED HEALTH CARE ISSUES
CASE STUDY HIV#1
Scenario: You are working at a physician‟s office, and you have just taken C.Q., a 38-
year-old woman, into the consultation room. C.Q. has been divorced for 5
years, has 2 daughters (ages 14 and 16), and works full-time as a legal
secretary. Two weeks ago she visited her doctor for a routine physical
examination and requested that an HIV (human immunodeficiency virus) test
be performed. C.Q. stated that she was in a serious relationship, is
contemplating marriage, and just wanted to make certain she was “okay”. No
abnormalities were noted during C.Q.‟s physical examination and blood was
drawn for routine blood chemistries, hematology studies, and an ELISA
(enzyme-linked immunosorbent assay) test, also known as the EIA (enzyme
immunoassay) test. C.Q. is at the office to receive her lab results. The
physician informs you that C.Q. EIA was positive.
1. What is an EIA test? Does a positive EIA mean that C.Q. definitely has HIV?
2. You explain to C.Q. that one of her tests needs to be repeated and you need to draw
another blood sample. Why wouldn‟t you tell C.Q. that her first test result was
positive and that another test is needed before the diagnosis can be confirmed?
The physician informs you that C.Q.‟s Western blot test results confirm that she is HIVpositive;
he requests that you be present when he talks to her. Before leaving C.Q.‟s
room, the physician requests that you obtain another blood sample for further testing,
give C.Q. verbal and written information about local AIDS support groups, and help C.Q.
call a friend to accompany her home this evening. She looks at you through her tears and
states, “I can‟t believe it. J. is the only man I‟ve had sex with since my divorce. He told
me I had nothing to worry about. I can‟t believe he would do this to me.”
3. C.Q.‟s statement is based on three assumptions: that J. is HIV-positive, that he
intentionally withheld the information from her, and that he intentionally transmitted
the HIV to her through unprotected sex. Based on your knowledge of HIV infection,
how would you counsel C.Q.?
24

4. In addition to offering alternative explanations and exploring options, what is your
most important role at this time?
5. Identify at least three nursing issues r/t to C.Q.‟s care:
6. C.Q. has had a positive EIA test and is seropositive for HIV. Why doesn‟t she have
s/s of AIDS?
7. What assessment findings would support a diagnoses of AIDS?
8. Why is it a good idea that someone C.Q. trusts escort her home this evening?
C.Q. gives you the name and phone number of a relative she wants you to call. You
remain with her until she leaves with her relative.
9. Has C.Q.‟s right to privacy been violated? Explain why or why not?
10. C.Q. returns to the office 4 days later to discuss her diagnosis. What issues will you
discuss with her at this time?
11. Does C.Q. have a legal responsibility to inform J. of her HIV status?
Two weeks later C.Q. visits the office and asks to speak to you in private. She thanks
you for talking to her the day she received the news of her diagnosis. She pulls a gun
from her purse and states, “I was going to go out into the waiting room and blow J. away,
because I thought he was cheating on me.” She tells you that J. confessed to her he was
afraid to tell her about his hemophilia because she might leave him. J. is tested for HIV
at regular intervals and his last HIV test, 6 months ago, has been negative. J. was
retested, and this test was positive for HIV. J.‟s doctor discussed the possibility of
transmission through recombinant factor VIII products. C.Q. tells you that they are going
to get married and invites you to the wedding. She stops at the door and says, “At least
we won‟t have to worry about „safe sex‟ with each other!”
25

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
NUR 2509 – ACUTE & EXTENDED HEALTH CARE ISSUES
CASE STUDY HIV #2
Scenario: K.D. is a 36-year-old gay professional man who has been HIV-positive for
6 years. Until recently, he demonstrated no s/s of AIDS. The appearance of
purplish spots on his neck and arms persuaded him to make an appointment
with his physician. Upon arrival at the doctor‟s office, the nurse performs a
brief assessment. His VS are 138/86, 100, 30, 100.8 degrees F. K.D. states
that he has been feeling fatigued for several months and is experiencing
occasional night sweats but he also has been working long hours, has skipped
meals, and has been particularly stressed over a project at work. K.D.‟s
physical is WNL except for his low-grade fever and skin lesions. The doctor
orders a CBC, lymphocyte studies, and a PPD. K.D. made an appointment to
return in 5 days to discuss the results of his tests.
Over the next 2 weeks, K.D. develops a fever of 101 degrees F.,
nonproductive cough, and increasing SOB. Late one night he becomes
acutely SOB, so his roommate, J.F., takes him to the ED where he is
subsequently admitted to the hospital with probable Pneumocystis carinii
pneumonia. Bronchoalveolar lavage examined under light microscopy
confirms the diagnosis. K.D.‟s admission WBC and lymphocyte studies
demonstrate an increased pattern of immunodeficiency from earlier studies.
K.D. is placed on nasal oxygen, IV fluids, and IV
trimethoprim/sulfamethoxadole.
1. What is Pneumocystis jiroveci pneumonia (PCP)?
2. What is the significance of the purplish spots over K.D.‟s neck and arms?
3. Identify four nursing diagnoses for K.D.:
4. What precautions will you need to use when caring for K.D.?
5. What will be the focus of your ongoing assessment? (list five.)
6. What major side effects of his antibiotic should you monitor K.D. for?
26

7. Differentiate between HIV-positive status and AIDS:
8. Why is K.D.‟s development of PCP of particular importance in light of his HIV
status?
9. K.D. has been seropositive for several years, yet he has been asymptomatic for AIDS.
What factors may have influenced K.D.‟s development of pneumocystis?
K.D. is responding well to treatment, and plans are being made for discharge. He will be
started on standard therapy, with follow-up on an outpatient basis. Since “standard
therapy” changes in response to developments in clinical research, you will have to look
up the most recent recommended treatment.
10. K.D. was taught about disease transmission and safe sex, and encouraged to maintain
moderate exercise, rest, and dietary habits when he was first diagnosed as HIVpositive.
Give at least four additional topics that should be discussed with K.D.
before he goes home.
11. What laboratory data will most likely be monitored on K.D. in the future?
12. List at least five other opportunistic infections that K.D. is at risk for developing:
27

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
NUR 2509 – ACUTE & EXTENDED HEALTH CARE ISSUES
CASE STUDY HIV #3
Scenario: D.C. is a 32-year-old white clerical worker who lives with his 76-year-old
grandmother, his primary caregiver. He was diagnosed as being HIV-positive
3 months ago and has been under close outpatient medical supervision for the
past 3 weeks because of persistent fever, pulmonary infiltrates, and
nonspecific flu-like symptoms. He is admitted to your nursing unit for fever,
chills, sweats, myalgias, malaise, chest pain, dry nonproductive cough,
axillary adenopathy, N/V, and sever diarrhea. Admission VS are 108/84, 104,
30, 103.5 degrees F. Following aggressive diagnostic workup, D.C. is
diagnosed with AIDS complicated by Pneumocystis carinii pneumonia,
cryptosporidiosis, oral candidiassis, and cytomegalovirus (CMV) infection.
Today is D.C.‟s third day postadmission to the hospital. He remains acutely
ill; however, his hydration status has improved, and he is experiencing fewer
than 8 diarrhea stools per day. He is not yet able to keep food or fluids down;
therefore, TPN is being considered. D.C. has c/o headache, nausea, continued
fatigue, and muscle soreness. He is able to ambulate to the bathroom with
assistance.
1. Why was D.C. diagnosed as having AIDS rather than complicated HIV infection?
2. Considering D.C.‟s AIDS status, what findings are likely to be present when you
receive the results of his lymphocyte studies?
3. Provide a possible explanation for D.C.‟s rapid conversion from HIV positive to
AIDS:
4. As D.C.‟s nurse, list at least two observations you would monitor in relation to
each of the following infections: cryptosporidiosis, candidiasis, and CMV:
28

5. Given the previous possible problems that D.C. could encounter, which of the
following nursing orders would be appropriate? Label each with “A” for appropriate
or “I” for inappropriate and correct the inappropriate orders.
____ Monitor VS q 12h
____ Assist with ADL as needed
____ Keep perineal area clean and dry; use protective skin cream
____ Regular diet
____ Monitor lungs, skin, abdomen, and urine output once per shift
____ Use toothettes or soft-bristled brush for oral hygiene
____ Exclude diarrhea stool from I & O measurements
____ Monitor IV site for signs of inflammation; change site if red or swollen
6. D.C. is restless at times because of his muscle soreness. Upon entering his room,
you note that he has pulled out his peripheral IV and is bleeding. How should you
respond?
7. Cite at least five findings that would indicate D.C.‟s condition is stabilizing
or improving:
8. What assessment findings would the physician take into consideration when making
the decision to place D.C. on TPN?
9. Given that D.C.‟s grandmother is his primary caregiver, discuss the implications of
D.C.‟s diagnosis of AIDS.
10. Would D.C. require additional teaching regarding his ability to transmit HIV now that
he has AIDS?
11. D.C. begins to slowly respond to treatment, and discharge plans are begun. Identify
at least three ways that D.C.‟s post-AIDS care will differ from his pre-AIDS care:
29

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING
NURSING 2509
QUALITY IMPROVEMENT PROJECT
Definition of Quality Improvement according to QSEN: “Use data to monitor the
outcomes of care processes and use improvement methods to design and test changes to
continuously improve the quality and safety of health care systems.”
Quality Improvement Process: PDSA
P (Plan) – D (Do) – S (Study) – A (Act)
1. Identify a concern within the nursing unit or define a problem.
2. Perform a literature review/search to relevant evidence. (Can look at national patient
safety goals)
3. Collect data.
4. Conduct a root cause analysis using Quality Improvement tools. (Run charts,
fishbone diagrams, etc.)
5. Evaluate change.
6. This will be a group project.
7. Project will be due by the end of the first 6 weeks of clinical.
8. More detailed information will be available at the beginning of the semester.
30

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING
NURSING 2509
TEACHING PROJECT
POINTS:
____ 1. Provide a description of the disease process (pathophysiology). Include
reference material [i.e., asthma]. (10 Points)
____ 2. Identify the area of focus and state the proposed client education topic.
Include learning objectives and rationales for the teaching project [i.e.,
Improve asthma control through proper use of a peak flow meter]. (10 Points)
(Refer to Chapter 5 in Lewis)
____ 3. Provide specific client education information, including rationales that support
evidenced-based practice. Include a discussion of the teaching methods, such
as handouts. Specify the steps of demonstration, if applicable. Attach any
written materials utilized. (50 Points)
____ 4. Discuss evaluation of the teaching process. Include test questions, steps of a
demonstration the client must complete, or develop a client education brochure
to insure that the learning objectives have been met. (10 Points)
____ 5. Bibliography: Minimum of five (5) sources; one from a nursing or medical
journal; four from other medical resources.. Use sources dated within the last
3 years. All sources must be cited in body of paper.* (10 Points)
____ 6. Correct format, grammar, punctuation, neatness (10 Points)
____ 7.
Include this grading sheet with submission of your paper.
31

APA Format for Teaching Plan.
FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING
NURSING 2509
STYLE FOR TEACHING PLAN
Margins should be 1 inch on all sides.
Double-space all lines. 12 Point Font.
Paragraphs consist of a minimum of three sentences.
Indent each new paragraph.
All references must be cited in the body of the paper.
Separate page for alphabetical references
When a direct quotation is used, always include the author, year, and page
number as part of the citation.
Examples of citations within the body of the paper:
Brunner & Suddarth (2002) state, “Mary had a little lamb.”
One plus one equals two (Smartypants, 2004).
Examples of References:
Smeltzer, S.C., & Bare, B.G. (2002). Medical Surgical Nursing, 2 nd
edition. Philadelphia, PA: Lippincott.
Morrow, A.B. (2002). The good nurse learns all. Journal of Good
Nursing, 32 (3), 14. Retrieved December 25, 2004, from
http://www.whereyoufindit.com
Author (Year). Title of article. Name of journal, volume (issue),
pages.
32

Title Page Example
Teaching Plan for Diabetes Mellitus
Terry Ghost
Fort Scott Community College
Class
Teacher‟s Name
Date
33

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING
CLINICAL EVALUATION CRITERIA
CLINICAL WRITTEN WORK RATINGS
5 INDEPENDENT Outstanding effort and thought are obvious. All required areas are addresses in a
complete and thorough manner. Information is accurate and presentation is
professional in appearance.
Assignments are turned in on or before due date.
4 SUPERVISED Overall, written work is complete and accurate, but lacks depth. Considerable
thought and effort is evident. Presentation is professional in appearance.
Assignments are turned in on or before due date.
3 ASSISTED Most of the assigned areas are addresses, but there are obvious gaps. Information
is missing and/or not factual. Presentation is acceptable, but improvement needed.
Assignments are turned in per faculty instructions.
2 MARGINAL Large or important pieces of information are missing and/or not factual. Little
effort or thought is evident. Presentation is non-professional.
1 DEPENDENT Most of the information that was required has not been completed.
Assignments are turned in greater than 48 hours late.
CLINICAL PERFORMANCE EVALUATION CRITERIA
SCALE/LABEL
INDEPENDENT
5
SUPERVISED
4
ASSISTED
3
MARGINAL
2
DEPENDENT
1
STANDARD
PROCEDURE
Safe
Accurate
Safe
Accurate
Mostly safe and
accurate
Questionable safe
and questionable
accurate
Unsafe
Inaccurate
PERFORMANCE QUALITY
Proficient, coordinated, confident.
Expedient use of time.
Efficient, coordinated, confident.
Expedient use of time.
Partial demonstration of skills.
Inefficient or uncoordinated. Delayed
time expenditure.
Unskilled and inefficient.
Considerable and prolonged time
expenditure.
Unable to demonstrate procedures.
Lacks confidence, coordination and
efficiency.
ASSISTANCE
Without direction.
With occasional
physical or verbal
direction.
Frequent verbal and/or
physical direction.
Continuous verbal
and/or physical
direction.
Continuous verbal
and/or physical
direction.
PERFORMANCE RATING MUST BE AN AVERAGE OF 3 OR ABOVE TO RECEIVE A
PASSING GRADE FOR THE COURSE IN BOTH WRITTEN AND CLINICAL EVALUATION
AREAS.
Clinical Evaluation Criteria Form developed by MSU Northern Department of Nursing.
34

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
CLINICAL EVALUATION TOOL
(SECOND LEVEL)
STUDENT: ________________________________ COURSE: Acute & Complex A
INSTRUCTOR: ____________________________ Semester/Year: FALL 2011
SCALE/LABEL
INDEPENDENT
5
SUPERVISED
4
ASSISTED
3
MARGINAL
2
DEPENDENT
1
CLINICAL PERFORMANCE EVALUATION CRITERIA
STANDARD PERFORMANCE QUALITY ASSISTANCE
PROCEDURE
Safe Proficient, coordinated, confident. Without direction.
Accurate Expedient use of time.
Safe
Efficient, coordinated, confident. With occasional
Accurate Expedient use of time.
physical or verbal
Mostly safe and
accurate
Questionable safe
and questionable
accurate
Unsafe
Inaccurate
Partial demonstration of skills.
Inefficient or uncoordinated. Delayed
time expenditure.
Unskilled and inefficient.
Considerable and prolonged time
expenditure.
Unable to demonstrate procedures.
Lacks confidence, coordination and
efficiency.
direction.
Frequent verbal and/or
physical direction.
Continuous verbal
and/or physical
direction.
Continuous verbal
and/or physical
direction.
CLINICAL OBJECTIVES
1. Demonstrate independent clinical decision-making
while providing nursing care to promote, maintain
and restore health of the acute and complex patient
in acute care and outpatient care settings.
a. Obtains assessment and health information to
develop appropriate patient centered nursing
care plan
b. Demonstrates nursing interventions which are
individualized and pertinent to patient‟s
nursing diagnosis
c. Performs nursing skills and procedures safely
when caring for a patient in acute care and
outpatient settings
Student
Self-
Evaluation
Instructor
Evaluation
35

CLINICAL OBJECTIVES
2. Utilize critical thinking in meeting nursing needs of the
acute and complex patient in acute care and outpatient
care settings.
a. Applies information from the basic sciences and
nursing theory to support rationale for nursing
care provided
b. Determines appropriate priorities when providing
nursing care
3. Communicate assessment and evaluation findings
to appropriate members of the health care team.
a. Communicates assessment findings
appropriately with instructor, student leader,
primary nurse, and other health care team
members.
4. Demonstrate maintenance of patient records and
current trends in relation to facility format.
a. Documents accurate patient information in a
secure and timely manner according to agency
guidelines
5. Manage and delegate nursing care for the acute
and complex patient in acute care and outpatient
care settings.
6. Provide ideas and problem solves in an organized
manner to provide safe care for the patient and
family.
a. Utilizes evidence-based research findings to
solve problems and answer questions
concerning nursing care of the adult patient.
Student
Self-
Evaluation
Instructor
Evaluation
36

CLINICAL OBJECTIVES
7. Demonstrate behavior based on ethical codes and
standards of care.
a. Incorporates ethical and legal standard of
nursing practice when providing patient care.
8. Develop a quality improvement project based on
an identified concern within the nursing unit.
Student
Self-
Evaluation
Instructor
Evaluation
COMMENTS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Student Signature: ____________________________________
Instructor Signature: __________________________________
Date: _________
Date: __________
37

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
CLINICAL EVALUATION TOOL
(SECOND LEVEL)
STUDENT: ________________________________ COURSE: Acute & Complex B
INSTRUCTOR: ____________________________ Semester/Year: FALL 2011
SCALE/LABEL
INDEPENDENT
5
SUPERVISED
4
ASSISTED
3
MARGINAL
2
DEPENDENT
1
CLINICAL PERFORMANCE EVALUATION CRITERIA
STANDARD PERFORMANCE QUALITY ASSISTANCE
PROCEDURE
Safe Proficient, coordinated, confident. Without direction.
Accurate Expedient use of time.
Safe
Efficient, coordinated, confident. With occasional
Accurate Expedient use of time.
physical or verbal
Mostly safe and
accurate
Questionable safe
and questionable
accurate
Unsafe
Inaccurate
Partial demonstration of skills.
Inefficient or uncoordinated. Delayed
time expenditure.
Unskilled and inefficient.
Considerable and prolonged time
expenditure.
Unable to demonstrate procedures.
Lacks confidence, coordination and
efficiency.
direction.
Frequent verbal and/or
physical direction.
Continuous verbal
and/or physical
direction.
Continuous verbal
and/or physical
direction.
CLINICAL OBJECTIVES
1. Provide a comprehensive assessment of the adult
patient with acute and complex health care needs.
a. Obtains assessment and health information to
develop a patient centered nursing care plan
b. Performs nursing skills and procedures safely
with increasing independence, confidence,
and competence when caring for the adult
patient
c. Demonstrates a comprehensive assessment on
a simulated patient with critical care needs
Student
Self-
Evaluation
Instructor
Evaluation
38

CLINICAL OBJECTIVES
2. Utilize critical thinking skills to question, explore and
provide effective care for the patient with acute and
complex health care needs.
a. Recognizes patients at risk, identifies changes in
health status and sets appropriate priorities for
nursing care.
b. Utilizes clinical decision making skills when
providing care for adult patient with critical care
needs.
c. Evaluates efficacy of pharmacologic therapies and
calculates medication dosing with 100% accuracy.
3. Communicate status of the patient while
collaborating with other health care providers.
a. Reports patient condition changes in a timely
manner to primary nurse, instructor, student
leader and other health care team members.
4. Demonstrate maintenance of patient records and
current trends in relation to facility format.
a. Documents accurate patient information in a
secure and timely manner according to agency
guidelines.
5. Evaluate the plan of care for the patient with acute
and complex health care needs.
a. Evaluates care and makes changes as needed
when caring for patients with complex health
care needs.
6. Analyze evidence-based research in the nursing
care for patients with acute and complex health
care needs.
a. Utilizes research to provide care to the patient
with critical care needs.
Student
Self-
Evaluation
Instructor
Evaluation
39

CLINICAL OBJECTIVES
7. Discuss ethical issues related to care of those with
acute and complex health care needs.
a. Applies ethical principles when caring for
patients with ethical concerns; especially
advanced directives, do-not-resuscitate orders,
and other end-of-life care concerns.
Student
Self-
Evaluation
Instructor
Evaluation
COMMENTS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Student Signature: ___________________________________
Instructor Signature: _________________________________
Date: ___________
Date: ___________
40

Setting: All Clinical Facilities
FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
NURSING 2509
Student Leadership
Plan: Each student will be assigned as leader for at least one clinical day
Activity: Student will be responsible for overseeing the care of that group of
clients in collaboration with the head R.N. or primary R.N. Student
leader should arrive approximately 30 minutes prior to start of shift in
order to select and assign clients.
OBJECTIVES:
Upon completion of this experience, the student will be able to:
1. Organize care for groups of ten (10) or more clients.
2. Utilize the nursing process in providing care for groups of clients.
3. Select appropriate clients for various levels of health care workers.
4. Select clients who are experiencing medical problems related to current topics
covered in class.
5. Collaborate with other team members for delivery of client‟s care.
6. Prioritize client needs and select nursing actions with supervision of an
experienced nurse.
7. Coordinate and evaluate the delivery of client‟s care provided by nursing staff.
8. Provide complete, accurate reports on assigned clients to other health team
members.
9. Record actual client responses, nursing actions, and other information relevant
to implementation of care.
Written Assignment: A summary of your experiences and thoughts following this
leadership experience. Your summary should be approximately 2 or more pages.
Student Leader = 100 Points
41

FORT SCOTT COMMUNITY COLLEGE
NURSING 2509
INSTRUCTOR: _____________________________
Comments to Nursing Staff:
DATE: ________________
Client
Room
Number
Student
Break/
Lunch
FORT SCOTT COMMUNITY COLLEGE
NURSING 2509
INSTRUCTOR: _____________________________
Comments to Nursing Staff:
DATE: ________________
Client
Room
Number
Student
Break/
Lunch
42

Room #: ______ Client Name: __________________ Male Female Age: ______ PRNs ________________
Physician: _____________________________ Diagnosis: _____________________ _____________________
#1 IV Solution: ________________ Rate: _________ Amt. Remaining: ___________ _____________________
#2 IV Solution: ________________ Rate: _________ Amt. Remaining: ___________ _____________________
I&O: Q ______ Hour Shift Total In: ________ Out: ______ Weight: __________ _____________________
Vital Signs Q ____ Hr. _________________/_________________/_________________ _____________________
Diet Order: _______________________________ Diet Held? Yes No NPO: Yes No _____________________
Tests Order: Lab __________________________ Findings: _____________________ _____________________
X-ray: __________________________________ Findings: _____________________ _____________________
Procedures: ______________________________ Findings: _____________________
Medications 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Room #: ______ Client Name: __________________ Male Female Age: ______ PRNs_________________
Physician: _____________________________ Diagnosis: _____________________ ______________________
#1 IV Solution: ________________ Rate: _________ Amt. Remaining: ___________ _____________________
#2 IV Solution: ________________ Rate: _________ Amt. Remaining: ___________ _____________________
I&O: Q ______ Hour Shift Total In: ________ Out: ______ Weight: __________ _____________________
Vital Signs Q ____ Hr. _________________/_________________/_________________ ______________________
Diet Order: _______________________________ Diet Held? Yes No NPO: Yes No ______________________
Tests Order: Lab __________________________ Findings: _____________________ ______________________
X-ray: __________________________________ Findings: _____________________ ______________________
Procedures: ______________________________ Findings: _____________________
Medications 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Room #: ______ Client Name: __________________ Male Female Age: ______ PRNs _________________
Physician: _____________________________ Diagnosis: _____________________ ______________________
#1 IV Solution: ________________ Rate: _________ Amt. Remaining: ___________ ______________________
#2 IV Solution: ________________ Rate: _________ Amt. Remaining: ___________ ______________________
I&O: Q ______ Hour Shift Total In: ________ Out: ______ Weight: __________ ______________________
Vital Signs Q ____ Hr. _________________/_________________/_________________ ______________________
Diet Order: _______________________________ Diet Held? Yes No NPO: Yes No ______________________
Tests Order: Lab __________________________ Findings: _____________________ ______________________
X-ray: __________________________________ Findings: _____________________ ______________________
Procedures: ______________________________ Findings: _____________________
Medications 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900
______________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
43

CHANGE-OF-SHIFT REPORT
The change-of-shift report should be thorough yet concise. It should be organized
and delivered quickly. The change-of-shift report typically includes the following
information:
1. Your name, student nurse, client group you‟re reporting
2. Room number, client‟s name, age, sex, admit date
3. Physician‟s name
4. Medical diagnosis, surgeries, dates, other procedures performed
5. Allergies, code status, fall risk, wound isolation
6. Diet and assistance needs
7. Intake and output order status and results
8. Activity restrictions and physical therapy treatments – assistance needs, how
tolerates
9. Oxygen therapy and respiratory treatments
10. IV site – fluids, rate
11. Daily weight order status – current weight, any changes
12. Vital signs – frequency, significant readings
13. Review of normal findings of body systems
14. Telemetry – pattern, changes
15. Pain control – medications, dosing times, responses
16. Special treatments – ie, CPM, Ted hose, SCDs, dressing changes,
wound care
17. Tests, procedures, or surgery scheduled
18. New therapies ordered, such as medications and doses or intravenous
fluids, rates of all IV fluids, TPN, blood, etc….
19. Significant abnormal lab results
20. Significant medications and their effects, times recently given, if appropriate
21. Client‟s response to nursing care, measures and therapies
22. Teaching plan if appropriate
23. Ongoing discharge plan
24. Significant information concerning family members
It is especially important to report any recent changes or priority situations
concerning the client‟s condition. Be sure to address the client’s main
problem.
44

DEPARTMENT OF NURSING EDUCATION
NURSING 2509
OUTPATIENT SURGERY ROTATION
____ 1. Describe the general assessment performed for all clients entering
OPS. (5 Points)
____ 2. Describe the discharge criteria, which must be met by all clients
being discharged from OPS. When would it be necessary to admit
a client to the hospital? (5 Points)
____ 3. Discuss general pre-discharge teaching that the nurses perform for
all clients being discharged from OPS. (10 Points)
____ 4. Describe the role of the nurse in OPS. How is their role different
from one similar to that of other nurses in the hospital. What additional
training or certification is required in order to work in this area?
(10 Points)
5. For all clients, complete:
____
a. Pre-operative assessment and patient preparation provided before
surgery. Document specific findings and care given for each client.
(30 Points)
____ b. Client reaction (5 Points)
____
c. Family reaction (5 Points)
____ d. Two nursing diagnoses pertinent to each client (10 Points)
____ e. Nursing care provided after surgery. Include client education
materials, if available (10 Points). If client is sent to another area for
recovery, discuss general care given.
____ f. Disposition of client (i.e. discharge and follow-up teaching)
(10 oints)
6. Include this grading sheet with submission of your paper.
Outpatient Surgery Rotation = 100 Points
45

1. Complete the following for each client:
(Describe a minimum of 4 clients)
FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
NURSING 2509
EMERGENCY ROOM ROTATION
____ a. Assessment done. Include chief complaint, history of present
illness, vital signs, allergies, assessment findings of affected body
systems, diagnostic tests obtained and the results. Final medical
diagnosis. (40 Points)
____ b. Two nursing diagnoses (10 Points)
____ c. Emergency treatment given and equipment used [i.e., labs &
x-rays ordered, medications administered, breathing treatments]
(10 Points)
____ d. Client‟s response (5 Points)
____
e. Family reaction (5 Points)
____ f.
Legal implications [i.e., HIPAA, EMTALA, Advanced Directives,
documentation of interventions and client teaching, pregnancy status,
reportable abuse/neglect] (5 Points)
____ g. Disposition of client, i.e. admitted, referred or discharged. (5 Points)
If discharged, include:
1) Follow-up plan [i.e., physician appointment]
2) Teaching given to client &/or family
____ 2. Describe triage. State how you would have triaged the clients admitted
during your experience if they had all been admitted at once. Give
rationale for decisions. (10 Points) Refer to Chapter 69 in Med-Surg text
for discussion on triage. Describe facility disaster plan.
____ 3. Identify the nurse’s role in giving emergency care. What additional
training or certifications are required in order to work in this area?
(10 Points)
____ 4. Include this grading sheet with submission of your paper.
ER Rotation = 100 Points
46

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
NURSING 2509 - CLINICAL
HOME CARE OBJECTIVES
The student will successfully:
____ 1. Describe the difference between caring for a client in the home
and in a health care facility. (5 Points)
____ 2. Discuss the role of the nurse in the home care setting. What
additional training or certifications are required in order to work in
this area? (5 Points)
____ 3. Describe documentation of home care. Familiarize yourself with
the documentation format/procedures utilized by the agency you
visit. (5 Points)
____ 4. Relate how infection control is maintained in the home. (5 Points)
____ 5. Explain the measures necessary to insure safety for both the client
and the nurse. (5 Points)
____ 6. Discuss how confidentiality is maintained in home care. (5 Points)
____ 7. Discuss the client rights and responsibilities. (5 Points)
____ 8. Provide list of clients visited (use age and gender of client to
identify: Include client‟s diagnosis, living arrangement, services
provided, follow-up plan. (15 Points)
____ 9. Complete a Nursing Care Plan for one of the Home Health clients
visited. Your care plan does not need to be one currently being
utilized with the identified client in Home Health. Use the Care
Plan form at the end of Med-Surg clinical paperwork. Identify
which of the clients you are making a care plan for. (50 Points)
____ 10. Include this grading sheet with submission of your paper.
*Utilize information from Chapter 7 in your Med-Surg text for discussion on Home
Health nursing. Also note differences you personally observed.
Home Health Experience = 100 Points
47

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
CCU OBJECTIVES
1. Complete the same paperwork utilized for Med-Surg.
2. Plans and provides care for one critical care client.
3. Selects five appropriate nursing diagnosis for assigned client.
4. Updates client‟s problem list.
5. Identifies the monitor rhythm of assigned client and updates the
interpretation if client‟s condition changes.
6. Identifies pathophysiology of client‟s disease process/dysrhythmia
of assigned client.
7. Will administer medications under the supervision of the R.N.,
including IV medications.
8. Verbalizes the medication information for assigned client to include
medications used in a code blue if appropriate.
9. Documents all client information accurately and efficiently.
10. Verbalize report to the assigned R.N. at the end of shift.
11. Utilize evidenced-based research to support nursing interventions
(cite research appropriately.)
CCU Experience: PAS/NCP = 100 Points
48

ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT
Trust Versus Mistrust (Birth to 1 Year)
Relationship to care giver
Autonomy Versus Doubt and Shame (1 to 3 Years)
Success in gaining control of bodily functioning
(including dressing, feeding, talking, walking)
Beginning independence
Initiative Versus Guilt (3 to 6 Years)
Trying out new things
Imagination
Using language more effectively to meet needs
Industry Versus Inferiority (6 to 12 Years)
Achieving recognition for skills and accomplishments
in “the world”
Involved in school and group activities with peers
Identity Versus Role Confusion (Puberty to 18 to 21 Years)
Continued involvement with peers
(important to be a part of peer group)
Experiencing body changes associated with puberty
Exploring relationships with those found sexually attractive
Beginning to consider vocation/career
Intimacy Versus Isolation (18 to 21 to 40 Years)
Forming and maintaining intimate relationships with
significant other(s) and family
Forming relationships with peers at work
Generativity Versus Self-Absorption (40 to 65 Years)
Reconsideration of life direction and goals
Consideration of changing appearance and functioning as ages
Broadening circle of concern to include the future of the
community and/or world
Ego Integrity Versus Despair (65 to Death)
Examining life and satisfaction with “contributions”
Interest in “nurturing” the next generation
Sense of Integrity and fulfillment versus dissatisfaction with life
49

Assessment: Directions: Add up the total points, a perfect score is 23. A high score
means lower risk for pressure ulcer. A low score means higher risk for pressure ulcer.
BRADEN-SCALE – PRESSURE ULCER RISK – Assess Prior to Clinical
Client‟s Name: __________________ Evaluator‟s Name: _________ Date of Assessment:__________
SENSORY
PERCEPTION
Ability to respond
meaningfully to pressurerelated
discomfort
MOISTURE
Degree to which skin is
exposed to moisture
ACTIVITY
Degree of physical
activity
MOBILITY
Ability to change and
control body position
Nutrition
Usual food intake pattern
FRICTION AND
SHEAR
1
Completely Limited:
Unresponsive (does not moan,
flinch, or grasp) to painful
stimuli, due to diminished level
of consciousness or sedation:
OR
Limited ability to feel pain
over most of the body surface.
Constantly Moist:
Skin is kept moist almost
constantly by perspiration,
urine, etc. Dampness is
detected every time client is
moved or turned.
Bedfast:
Confined to bed
Completely Immobile:
Does not make even slight
changes in body or extremity
position without assistance.
Very Poor:
Never eats a complete meal.
Rarely eats more than 1/3 of
any food offered. Eats 2
servings or less of protein
(meat or dairy products) per
day. Takes fluids poorly. Does
not take a liquid dietary
supplement.
OR
Is NPO &/or maintained on
clear liquids or IVs for more
than 5 days.
Problem:
Requires moderate to
maximum assistance in
moving. Complete lifting
without sliding against sheets
is impossible. Frequently
slides down in bed or chair,
requiring frequent
repositioning with maximum
assistance. Spasticity,
contractures, or agitation leads
to almost constant friction.
2
Very Limited:
Responds only to painful
stimuli. Cannot
communicate discomfort
except by moaning or
restlessness, OR
Has a sensory impairment
which limits the ability to
feel pain or discomfort
over ½ of the body.
Moist:
Skin is often but not
always moist. Linen
must be changed at least
once a shift.
Chairfast:
Ability to walk severely
limited to nonexistent.
Cannot bear own weight
and/or must be assisted
into chair or wheelchair.
Very Limited:
Makes occasional slight
change in body or
extremity position but
unable to make frequent
or significant changes
independently.
Probably Inadequate:
Rarely eats a complete
meal & generally eats
only about ½ of the food
offered. Protein intake
includes 3 servings of
meat or dairy products
per day. Occasionally
will take a dietary
supplement.
OR
Receives less than
optimum amount of
liquid diet or tube
feeding.
Potential Problem:
Moves freely or requires
minimum assistance.
During a move skin
probably slides to some
extent against the sheets,
chair, restraints, or other
devices. Maintains
relatively good position
in chair or bed most of
the time but occasionally
slides down.
3
Slightly Limited:
Responsive to verbal
commands but cannot always
communicate discomfort or
need to be turned, OR
Has a sensor impairment
which limits ability to feel
pain or discomfort in 1 or 2
extremities.
Occasionally Moist:
Skin is occasionally moist,
requiring an extra linen
change approximately once a
day.
Walks Occasionally:
Walks occasionally during
day but for very short
distances, with or assistance.
Spends majority of each shift
in bed or chair.
Slightly Limited:
Makes frequent though slight
changes in body or extremity
position independently.
Adequate:
Eats over half of meals. Eats
a total of 4 servings or protein
(meat, dairy products) each
day. Occasionally will refuse
a meal, but will usually take a
supplement if offered.
OR
Is on a tube feeding or TPN
regimen, which probably
meets most of nutritional
needs.
No Apparent Problem:
Moves in bed and in chair
independently and has
sufficient muscle strength to
lift up completely during
move. Maintains good
position in bed or chair at all
times.
4
No Impairment:
Responds to verbal
commands. Has no sensory
deficit which would limit
ability to feel or voice pain or
discomfort.
Rarely Moist:
Skin is usually dry; linen
requires changing only at
routine intervals.
Walks Frequently:
Walks outside the room at
least twice a day and inside
room at least once every 2
hours during waking hours.
No Limitations:
Makes major and frequent
changes in position without
assistance.
Excellent:
Eats most of every meal.
Usually eats a total of 4 or
more servings of meat &
dairy products. Occasionally
eats between meals. Does not
require supplementation.
TOTAL POINTS:
Braden scale for pressure ulcer assessment. (From Braden, B, and Bergstrom, N: In Bryant, RA (ed): Acute and Chronic
Wounds: Nursing Management, Mosby, St. Louis, 1992)
50

Medical Diagnosis:
Pathophysiology:
Signs and Symptoms:
Diagnostic Studies:
51

Student Name:
Age: Gender:
Admission Date:
Surgery Date:
Type of Surgery:
Advanced Directive:
Yes No
Type:
FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
CONCEPT MAP
Chief complaint on
admit:
Admitting Diagnosis:
Clinical Date:
Allergies with Reactions
Meds:
Food/Insect/Other:
History of Presenting
Illness: (Personal Story)
PMH – Medical/
Surgical History with
Dates (if known)
New Orders:
Home Meds:
(Drug/Dose/Route/Time Only)
Client Activities or
Changes During Shift
Women: LMP:
Gravida: Para: AB:
Discharge Planning
Potential Referrals:
Social Services DME
Home Health Dietician
PT OT RT ST
Describe:
Client Education
Activity Level:
Up ad lib BRP
BSC Chair Bedrest
Strict BR
Turning Schedule:
Assist: Indep 1 2 3 3+
Up in chair X _____/day
Ambulate in hallway X
_____/day
Bath: Shower Shampoo
Partial bed bath or Total
Perineal Care:
self assist staff
Cath Care: Yes No
Oral Hygiene:
self assist staff
Denture Care:
Linens:
Occupied Unoccupied
52

Vital Signs/Time:
T - P –
R - B/P –
O 2 Sat.: Apical:
Vital Signs/Time:
T - P –
R - B/P –
O 2 Sat.: Apical:
Vital Signs/Time:
T - P –
R - B/P –
O 2 Sat.: Apical:
Vital Signs/Time:
T - P –
R - B/P –
O 2 Sat.: Apical:
Assessment Database/Pain
Location/Rating/Quality/
Times
Constant
Intermittent
Factors that increase pain:
Factors that diminish pain:
Relief Measures:
Pharm: analgesic and adjunct:
(include all ordered and
drug/dose/schedule/actual
time(s) given)
Non-Pharm:
Evaluation
(after each intervention):
Assessment Database
Psychosocial
Family Structure:
Social Activities:
Culture:
Spiritual Base:
Support Structure:
Living arrangement:
Work History
Developmental Stage:
w/description (1):
Language:
English
Other:
Education Level:
Ethol/Drug Use:
Alcohol: Denies Past Use:
What: ______ Amt ____
How Often:
Drugs (Illicit/Prescript Abuse)
Denies What: _____
How often:
Past Use:
Assessment Database
Respiratory
Rate (range): ____ to ____
Depth: shallow regular
deep
Effort: easy labored
regular irregular
orthopnea pursed lip
irregular or regular
Use of Access Muscles:
No Yes
Breath Sounds:
CTA all lobes ____ or
Right Upper:
Right Middle:
Right lower:
Left Upper:
Left Lower:
Cough:
Productive Nonproductive
Dry Hacking
Occasional
Sputum: Color:
Amt: Frequency:
Consistency:
O 2 @ ____ L via ______
O 2 saturation ranges:
____________
O 2 Sat w/out
supplemental O 2 : ____
Chest Tube:
Resp tx (drug, dose,
route, time):
Assessment Database
Cardiovascular
Heart Sounds:
S1 S2 S3 S4
Murmur Gallop
Distant Muffled
Rate: (radial range)
____ to ____
Apical _____ Reg. Irreg.
Quality (radial):
+1 +2 +3 +4
Requires Doppler
Pulse Deficit: _____
Pulse Pressure: ____
B/P range - ______ to _____
MAP: _____
Orthostatic BP:
Lying: ____ Sitting:____
Standing:_____
Cap. Refill:
< 3 sec >3sec sluggish
Neck Veins:
Sunken WNL JVD
Edema: Location –
Trace +1 +2 +3 +4
TEDs: thigh knee
SCD: leg foot
Peripheral Pulses:
Pedal:
R: diff to palpate +1 +2
L: diff to palpate +1 +2
Telemetry/Pattern:
Antiplatelet:
Anticoagulant:
Nail Bed Color:
Cyanosis: Location
Tobacco Use:
Yes Never Quit
Packs/Day ____ Yrs ___
Age Started ____
Age Quit ___
Antihypertensive:
Digoxin:
53

Assessment Database
Abdominal/Nutritional
Abd: soft firm rigid
flat rounded
distended pendulous
Non-tender or tender:
Location:
Bowel Sounds (full description
Continent: Yes No
Last BM: ____
Describe:
Normal habit:
Hgt: _____ inches
Admit Weight: _____
Follow-Up Weight:
_____/Date _____
Weight change from
Normal: _____
Loss/Gain:
_____ # from admit
BMI: ____
Diet: _____________
% B ____ #L ____
%D ___
NPO – since ______
Feed: Self Assist
Total
Supplements: (vitamins,
minerals, etc.)
Home Diet: (full description):
Recommended home
diet changes:
Diabetic: Type I Type 2
Blood sugar/Schedule
Range (day of care):
Range (entire hospitalization):
Insulin: Scheduled
and Sliding Scale:
Sliding Scale given:
Oral agents:
IV: IV SL Central
PICC Port
Location:
IV fluid:
Rate:
Pump in Use: Yes No
TYP/PNN Rate:
Lipids:
Tube feeding:
Rate/Order:
Via: Gastric/PEG/NGT
NG suction:
H L Cont. Intermit
Amount:
Description:
Nausea:
Yes No Freq:
Emesis: Y N Describe:
Anatiemetic
(drug/dose/route/time given):
Other GI meds:
Swallow: Normal/ Intact /
Dysphagia / odynophagia
Choking precaution:
Yes No
Oral Condition:
Mucosa:
Lips:
Teeth:
Dentures:
Full Partial U L
With client: Yes No
Assessment Database
Urinary
Urine Color:
Character:
Odor:
24 Hour.
Intake: ____ Out: ____
Today
In: ______ Out _____
Voiding
Continent: Yes No
Dysuria: Yes No
Frequency: Yes No
Dribbling: Yes No
Hesitancy: Yes No
Nocturia: Yes No
Change in stream:
Yes No
Foley Catheter: Yes No
How long ____
Incont. Brief: Yes No
Perineal assessment:
CBI: Type: _______
Rate ____
Bladder Irrigation
Yes No
Bladder Training
Yes No
Strain urine: Yes No
History of:
BPH Cancer
Cystocele Stones
Diuretic:
Other urinary meds:
54

Assessment Database
Skin
Color: Temp:
Turgor:
Lesions:
Rash:
Bruise(s):
Other:
Wound Assessment –
Age of wound:
History of wound if non-surgical:
Location:
Braden scale score: ______
Wound care orders:
Dressing:
CMS Check (if extremity
involved)
Drain: Penrose Bulb
Hemovac Gastric
T-tube J-tube
Amount:
Description:
Assessment Database
Musculoskeletal
Gait: stable unstable strong
coordinated other (describe):
Other: (describe:
Mobility deficit:
Activity Tolerance (describe):
Distance:
Assistive Devices:
Assist: None 1 2 3 3+
Standby only
PT Orders:
OT Orders:
AROM: R L
PROM: R L
Upper Lower
Deficits:
Positioning devises:
Self/assist
CPM Right Left
Schedule: ________
Degree of flexion ____
Abduction Pillow:
Assessment Database
Mental/Neuro/Safety
LOC:
alert drowsy sedated
lethargic anxious
talkative flat affect
non-responsive cooperative
resistant to care combative
Oriented:
___ Person ___ Place
___ Time ___ Situation
Deficit:
Alzheimer‟s Dementia
MR HOH Blind
Vision Impaired
Stroke: R L TIA
Aphasia
Glasses: Yes No
With client: Yes No
Hearing Aid: Yes No
With Client: Yes No
Pupils
R PERLA _____ mm
L PERLA _____ mm
If not PERLA, describe:
Glaucoma: Yes No
Cataracts: OD OS OU
Surgical removal
Grips: Equal Unequal
R: weak strong equal
L: weak strong equal
Leg strength:
Equal
Unequal
R: absent weak strong
L: absent weak strong
Glasgow Coma Scale:
Seizure History:
Yes No
Seizure Precautions:
Yes No
Fall Risk: Yes No
Fall Precautions:
Yes No
Describe:
Environment:
Room: Cluttered Neat
Bedside Equipment:
Roommate: Yes No
55

Copy Right: Pamela Schuster, PhD, RN From Concept Mapping: A Critical Thinking Approach to Care
Planning, F. A. Davis
Worksheet – Carry in Pockets at all times!
Key Problem #
Key Problem #
I don‟t know how this fits
with the problems ? ? ?
Key Problem #
Key Problem #
Reason For Needing Health Care:
Medical Diagnosis/Surgical Procedure:
Allergies:
Key Assessments:
Key Problem #
Key Problem # Key Problem #
56

Copy Right: Pamela Schuster, PhD, RN From Concept Mapping: A Critical Thinking Approach to Care
Planning, FA Davis, 2007.
Final Edition
# Key Problem/ND
I don‟t know how this #
fits with the problems
Supporting Data:
???
Key Problem/ND
Supporting Data:
#
#
Key Problem/ND:
Supporting Data
Reason For Needing Health Care
(Medical Diagnosis/Surgical Procedure)
Key Problem/ND
Supporting Data
Allergies:
Key Assessments:
#
Key Problem/ND
Supporting Data:
#
Key Problem/ND
Supporting Data:
#
Key Problem/ND
Supporting Data:
57

NEUROLOGICAL ASSESSMENT
Oriented to: Person ____ Place ____ Time ____ Situation ____
Level of Consciousness: ____ Speech: ____ Left Hand Grasp: ____
1. Alert 1. Clear Right Hand Grasp: ____
2. Arouses to painful stimuli 2. Aphasic 1. Firm
3. Arouses for brief time 3. Comatose 2. Weak
4. Arouses to verbal stimuli 4. Dysphasia 3. Absent
5. Comatose 5. Garbled 4. N/A
6. Confused 6. Intubated
7. Drowsy 7. Mute Hand Grasps: ____
8. Lethargic 8. Expressive aphasia 1. Equal
9. Non-responsive 9. Receptive aphasia 2. Unequal
10. Sleeping 10. Slurred
11. Sedated 11. Slow
Left Upper Extremity Movement: ____ Size of Left Pupil: _____ (mm)
Right Upper Extremity Movement: ____ Size of Right Pupil: ____ (mm)
Left Lower Extremity Movement: ____ Reaction Left Pupil: ____
Right Lower Extremity Movement: ____ Reaction Right Pupil: ____
1. Full 1. Brisk
2. Weak 2. Sluggish
3. Limited 3. Fixed
4. Flaccid 4. N/A
5. No voluntary movement Pupil Equality: ____
6. Involuntary movement 1. Equal
7. N/A 2. Unequal
Glasgow Coma Scale Total: ____
Eye opening response: Spontaneous 4
To voice 3
To pain 2
None 1
Best verbal response: Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response: Obeys command 6
Localizes pain 5
Withdraws 4
Flexion 3
Extension 2
None 1
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MEDICATIONS:
Generic/Trade Name
Dose and Route
CLASSIFICATIONS:
Actions and Indications
POTENTIAL
Adverse/Side
Effects
PROBLEM:
Nursing
Diagnosis
NURSING INTERVENTIONS:
What do you do, assess, monitor,
observe?????
59

LAB WORKSHEET
CBC W/DIFF RESULT FLAG REFERENCE RANGE
Male Female
WBC 4.0-10.8 4.0-10.8
RBC 4.7- 6.1 4.2 - 5.4
Hemoglobin 14.0-18.0 12.0-16.0
Hematocrit 42 – 52 37 – 47
MCV 80.0-94.0 81 - 99
MCH 27 – 33 27 – 33
MCHC 32 – 35 32 – 35
RDW 12.7-16.5 12.1-16.7
PLT 130 – 400 130 - 400
Auto Neutro % 37.0-75.0 37.30-75.0
Auto Lymph % 10-50.0 10-50.0
Auto Mono % 0.0-12.0 0.0-12.0
Auto EOS % 0.0- 7.0 0.0 – 7.0
Auto BASO % 0.0- 2.5 0.0 – 2.5
Significance to
Client
CHEMISTRY RESULT FLAT REFERENCE RANGE Significance to
Client
Glucose 70 – 110 mg/dl
Blood Urea
7.0 – 20 mg/dl
Nitrogen
Creatinine 0.6 – 1.0 mg/dl
Bun/Crea Ratio 12 – 25.0 mmol/L
Sodium 135 – 145 mmol/L
Potassium 3.5 – 5.1 mmol/L
Chloride 98 – 107 mmol/L
Carbon Dioxide 22 – 31 mmol/L
Anion Gap 4 – 20.0
Calcium 8.5 – 10.1 mg/dl
Albumin 3.4 – 5.0 g/dl
Total Protein 6.4 – 8.2 g/dl
Globulin
A/G Ratio
Total Bilirubin

ROUTINE RESULT FLAG REFERENCE Significance to Client
UA/DIPSTICK
RANGE
Urine Glucose Negative mg/dl
Urine Bilirubin
Negative
Urine Ketones Negative mg/dl
Urine Specific
Gravity
Urine pH
Urine Protein Negative mg/dl
Urine
Urobilinogen 0.2 – 1.0 EU/dl
Urine Nitrite
Negative
Urine Blood
Negative
Leuko. Esterase
Negative
UA Microscopic Result Flag Reference Range Significance to Client
WBC 0 – 5 HPF
RBC 0 – 3 HPF
Epithelial Cells
WBC Clumps Negative LPH
Casts 0-4 Hyaline LPF
Urine Bacteria
Negative
Comments
Coagulation RESULT FLAG REFERENCE RANGE Significance to Client
Prothrombin Time 9.7 – 11.7 sec
INR – Normal 1.0
INR – Therapeutic 2.0 – 3.0 Sec
APTT 26 – 36 Sec
ABG RESULT FLAG REFERENCE RANGE Significance to Client
pH 7.35 -7.45
pO2 80 – 100
pCO 2 35 – 45
HCO 3 22 - 26
Base Excess
O 2 Saturation 90 – 97 %
Allens Test
Draw Site
CARDIAC RESULT FLAG REFERENCE RANGE Significance to Client
WORKUP
Troponin-I, 0 hr. 0 – 1.5 ng/ml
MYO- O hr. 9 – 83.0 ng/ml
BNP
CK
CK-MB
61

DIAGNOSTIC TESTS
(X-ray, EKG, US, Scope, CT, MRI)
Obtained since admission
DATE AND TEST RESULTS SIGNIFICANCE TO
CLIENT’S
CONDITION
Teaching:
Pre- or Post-Prep:
Teaching:
Pre- or Post-Prep:
Teaching:
Pre- or Post-Prep:
62

OUTCOMES - INTERVENTIONS - EVALUATION
NURSING DIAGNOSIS
Outcome
1 – Short term:
Measurement Criteria:
1.
2.
3.
Time Frame:
2 – Short term:
Measurement Criteria:
1.
2.
3.
Time Frame
Long term:
Measurement Criteria:
1.
2.
3.
Time Frame
NURSING INTERVENTIONS (Minimum of 10)
Assess/Monitor (labs/x-ray/LOC/response to meds, etc)
63

Provide/Perform (diet/linens/hygiene/wound care/resp tx/ OT/ PT):
Administer (meds/O 2 /IV):
Teach (min 2):
Citation of Evidenced-Based Research:
64

EVALUATION:
1 – SHORT TERM: Met Not Met When Re-evaluated:
As evidenced by:
Modify Plan of Care if Unmet (add or delete):
2 – SHORT TERM: Met Not Met When Re-evaluated:
As evidenced by:
Modify Plan of Care if Unmet (add or delete):
LONG TERM: Met Not Met Ongoing
As evidenced by:
Modify Plan of Care if Unmet (or ongoing):
65

FORT SCOTT COMMUNITY COLLEGE
DEPARTMENT OF NURSING EDUCATION
WOUND CLINIC ROTATION
____ 1. Describe general assessment performed for all clients entering
wound clinic. (10 Points)
____ 2. Describe the role of the nurse in wound clinic. What additional
training or certification is required in order to work in this area?
(10 Points)
____ 3. Describe discharge criteria for the wound clinic client. When
would a client be admitted to the hospital after being seen in the
wound clinic? (10 Points)
4. For 4 clients, complete the following:
____ a. A complete wound assessment, include stage of wound, [I, II, III,
IV or unstable], location of wound, type of wound [pressure,
venous stasis, surgical wound, etc.], wound composition [% of
granulation tissue, eschar, slough, epithelialization]. Any
undermining, tunneling or sinus tracts – include location and
measurement [i.e., 6 o‟clock]. (30 Points)
____ b. Risk factors and causative factors that contributed to wound
formation and possible delays in healing process [diabetes, PVD,
immobility, smoking, lab abnormalities]. (10 Points)
____ c. Describe wound treatments used on your clients today – include
product, name, information, and rational for use. (10 Points)
____ d. List 2 nursing diagnoses pertinent to each client. (10 Points)
____ e. Describe any necessary client teaching related to wound care at
home. (5 Points)
____ f. Client follow-up. When is next scheduled appointment? (5 Points)
____ g. Include this grading sheet with paper.
66