Documento Clínico Clinical Documents NURS 304 304 DLP... · Estudios de caso Simulación de la ejecución Plan de cuidado de enfermería (SBAR) Informe Transferencia del paciente

NURS 304 CLINICAL DOCUMENTS 1

Sistema Universitario Ana G. Méndez, Inc.

School of Health Sciences

Department of Nursing

Continental USA Branch Campuses

Universidad del Turabo

Documento Clínico

Clinical Documents

NURS 304

© Ana G. Méndez University System, Inc. 2018

All rights reserved.


TABLA DE CONTENIDO/TABLE OF CONTENTS

PÁGINA/PAGE

INFORMACIÓN GENERAL DEL CURSO .................................................................................. 3

GENERAL COURSE INFORMATION ......................................................................................... 5

WORKSHOP TWO ......................................................................................................................... 8

TALLER TRES ............................................................................................................................... 9

WORKSHOP FOUR ..................................................................................................................... 11

TALLER CINCO ........................................................................................................................... 12

WORKSHOP SIX ......................................................................................................................... 13

TALLER SIETE ............................................................................................................................ 15

CLINICAL EVALUATION TOOLS ............................................................................................ 16


I. INFORMACIÓN GENERAL DEL CURSO

A. Objetivos Clínicos

Al finalizar el curso, el estudiante será capaz de:

1. Aplicar el proceso de enfermería interviniendo con mujeres y recién nacidos.

2. Evaluar el rol profesional en la atención al paciente desde la preconcepción.

3. Aplicar las habilidades de pensamiento crítico y el juicio clínico en la toma de decisiones

mediante intervenir con mujeres y recién nacidos.

4. Use los principios éticos y legales para ser considerado en la toma de decisiones en

llevando a cabo sus intervenciones de enfermería.

5. Demostrar habilidades de liderazgo al proporcionar cuidados de enfermería a mujeres y

recién nacidos.

6. Aplicar habilidades de resolución de problemas integrando el equipo de salud.

7. Use los estándares de práctica para guiar la atención centrada en la mujer y el recién nacido.

8. Demuestra competencia en habilidades de enfermería y uso de tecnología para brindar

atención a mujeres y recién nacidos.


F. Evaluación

El componente clínico del curso, será evaluado basado en una calificación de “PASS” o “Fail”.

Es un requisito pasar el componente clínico del curso.

PRÁCTICA CLÍNICA

CRITERIOS DE EVALUACIÓN

CRITERIOS DESCRIPCIÓN ESPECÍFICA TALLER(ES)

Examen de cálculo

de dosis

Los estudiantes presentarán la prueba durante el primer día del

curso clínico. La prueba debe aprobarse con un mínimo de 80 %

para poder continuar con el componente clínico.

Nota: Tendrás dos intentos: el primer intento en la semana 1

y un segundo intento en la semana 7 del curso clínico. De no

aprobar el mismo, el estudiante no podrá practicar en el área

clínica y fracasará el componente de laboratorio.

1 y 7 P

Pruebas cortas Pruebas cortas semanales para evaluar habilidades clínicas. 2-6 P

Prueba de práctica

de habilidades

durante el taller

Demostración final de habilidades seleccionada al azar. 7 P

Actividades previas

relacionadas a los

trabajos asignados

para atender

clientes

Planes de cuidado

Estudios de caso

Plan de enseñanza

Plan nutricional

Evaluación de Competencia Cultural

Recursos: Clinical Essentials, libro de texto del curso

2 - 15 P

Práctica clínica

diaria y simulación

durante la práctica

clínica

Estudios de caso

Simulación de la ejecución

Plan de cuidado de enfermería

(SBAR) Informe

Transferencia del paciente

Documentación del paciente

Recursos: Clinical Essentials

8 - 15 P

Rendimiento

clínico durante el

taller

Evaluación del rendimiento del alumno durante la práctica

clínica. Se basa en el instrumento Clinical Evaluation Tool for

Midterm and Final.

11 Midterm

12.5%

15 Final 12.5%

P

Calificación Pass/Fail


I. GENERAL COURSE INFORMATION

A. Clinical Objectives

Upon completing this course, the student will be able to

1. Apply the nursing process by intervening with women and newborns.

2. Evaluate the professional role in patient care from preconception.

3. Apply critical thinking skills and clinical judgment in decision-making by

intervening with women and newborn.

4. Use the ethical and legal principles to be considered in decision-making in

carrying out their nursing interventions.

5. Demonstrate leadership skills by providing nursing care to women and newborns.

6. Apply problem solving skills integrating health team.

7. Use the standards of practice to guide the women-centered care and newborn.

8. Demonstrates competency in nursing skills and use of technology to provide care

to women and newborns.


B. Evaluation

The clinical component of the course will be evaluated on a Pass or Fail basis. It is required to

pass the clinical component in order to pass the course.

EVALUATION TABLE

CLINICAL PRACTICE

CRITERIA SPECIFIC

DESCRIPTION

WORKSH

OP (S)

WEIGHT

Dosage calculation

exam

The students present the test during the first day of the

clinical course. The test must be passed with a minimum

of 80 % in order to continue to the clinical component.

Note: You will have two attempts to take the test.

First attempt on week one and second attempt on

workshop seven.

* If the student fails to achieve an 80% on the test, he

will not be able to proceed with the clinical practice

and will fail the Clinical Component of the course.

1 & 7 P

Quizzes Weekly skills quizzes. 20% 2-6 P

Skills Practice Test

During Workshop

Final demonstration of randomly selected skill. 20% 7 P

Patient Workload

Assignments

Before Workshop

Care Plans

Case Studies

Teaching Plan

Nutritional Plan

Cultural Competency Assessment

Resourses: Clinical Essentials, Course Textbook 20%

2 - 15 P

Daily Clinical Practice

and Simulation

During Workshop

Case Studies

Simulation Execution

Nursing Care Plan

(SBAR) Report

Patient Transfer

Patient Documentation

Resourses: Clinical Essentials 20%

8-15 P

Clinical Performance

During Workshop

Evaluation of the student performance during clinical

practice. Is based in the instrument Clinical Evaluation Tool

for Midterm and Final 20%

11 Midterm

12.5%

P

15 Final

12.5%

Total Pass/ Fail %


TALLER UNO

Durante la práctica en el laboratorio de destrezas, se espera que:

1. El facilitador discuta los siguientes temas:

a. Examen físico e histórico del sistema reproductivo femenino

b. Examen de senos

c. Examen vaginal

d. Métodos contraceptivos

e. Regla de Naegele para estimar la fecha probable de parto

f. Signos y síntomas del embarazo.

g. Gravidez y paridad (GTPAL) & (GP) [5 digits; 2 digits]

h. Adaptaciones fisiológicas durante el embarazo

i. Necesidades nutricionales durante el embarazo

j. Evaluación prenatal

2. Los estudiantes tomen apuntes y participen realizando preguntas para aclarar dudas que

puedan tener.

3. Los estudiantes reciban la orientación del laboratorio de simulación que incluirá el

componente discusión post-conferencia.

4. Actividad de Simulación: Observación y manejo del simulador obstétrico.

A. Referencias específicas del taller

Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and

Women’s Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc.


WORKSHOP TWO

After the completion of the Laboratory and Simulation Skill, the students will be able to:

1. Understand and discuss the following topics:

a. Leopold maneuver

b. Fetal heart rate / Electronic Fetal Monitoring (EFM)

c. Non-stress test (NST)

d. Oxytocin stress test

e. Antepartum care and assessment

2. Will practice all the discussed activities in the High Definition Clinical Simulators.

Simulation Skills for the scenarios

A. Simulation Scenario #1

1) Prepare and conduct an assessment using breast and

Papanicolaou test (60 min).

A. Specific Workshop References

Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and Women’s

Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc.

Khan Academy Medicine. (2015, March 19). Diabetes in pregnancy: Reproductive system

physiology NCLEX-RN [Video file]. Retrieved from

https://www.youtube.com/watch?v=N3jnRuzseoM&feature=youtu.be

https://www.youtube.com/watch?v=N3jnRuzseoM&feature=youtu.be


TALLER TRES

Luego de finalizado el laboratorio de destrezas, se espera que los estudiantes:

1. Discutan con el facilitador los siguientes temas o destrezas:

a. Cuidados intraparto y parto

b. Cuidado perianal

c. Laboratorios

d. Asistir con amniotomía

e. Inserción de Foley catéter

f. Evaluación de cambios de la frecuencia fetal

g. Educación al paciente

h. Documentación la historia medica

Durante la discusión, los estudiantes tomarán apuntes y realizarán preguntas para aclarar

dudas que puedan tener.

2. Estén preparados para realizar las destrezas de simulación:

a. Edad gestacional

b. Preparación para una cesárea

c. Evolución fetal

d. Educación al paciente

e. Documentación en la historia médica

3. Realicen el siguiente escenario de Simulación:

a. Escenario #2 Examen de non-estrés (60 minutos)


Boral, B. M, Williams, D., & Boral, L. I. (2016). Disseminated intravascular coagulation

from. American Journal of Clinical Pathology, 146 (6), 670-680. Recuperado de


https://academic.oup.com/ajcp/article/146/6/670/2703125/Disseminated-Intravascular-

Coagulation

Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2013). Maternal child nursing

care. (5ta ed.). Atlanta, GA: Elsevier.

Sinaí, M. (2013, febrero 7). Hiperemesis gravídica [Archivo de video]. Recuperado de

https://www.youtube.com/watch?v=MU-y5L6qIJE&feature=youtu.be

https://academic.oup.com/ajcp/article/146/6/670/2703125/Disseminated-Intravascular-Coagulation

https://academic.oup.com/ajcp/article/146/6/670/2703125/Disseminated-Intravascular-Coagulation

https://www.youtube.com/watch?v=MU-y5L6qIJE&feature=youtu.be


WORKSHOP FOUR

The facilitator will discuss the following nursing skills (competencies):

a. Newborn nursing care

b. Neonate physical assessment

c. Apgar score, weight and body measurements and vital signs

d. Cord blood collection for banking or Rh-

e. Pharmaceuticals and immunizations

f. Medical record documentation

g. Client education (breastfeeding)

2. Simulation skills for the scenarios:

a. Skills that will be completed on week four for scenario #4:

i. Delivery preparation for normal vaginal birth

ii. Care of neonate

iii. Pharmacological and non-pharmacological pain management

3. Simulation scenario:

a. Scenario #3- Admission and preparation of patient for cesarean section (60

minutes).

G. Specific Workshop References



Khan Academy Medicine. (2015, March 19). Labor- Reproductive system physiology NCLEX-

RN [Video file]. Retrieved from https://youtu.be/Bf04LcSBpDw

https://youtu.be/Bf04LcSBpDw


TALLER CINCO

El facilitador discutirá las siguientes destrezas de enfermería:

a. Evaluación del fondo uterino post parto vaginal o cesárea

b. Evaluación de sangrado y perineo

c. Evaluación de los cambios en la loquia

d. Cuidado post episiotomía o laceración

e. Administración de Rogan

f. Educación al paciente

g. Documentación de la historia médica

Durante la discusión, los estudiantes tomarán apuntes y realizarán preguntas para

aclarar dudas que puedan tener.

1. Destrezas de simulación:

a. Cuidado de perineo inmediato (hemorragia)

b. Signos vitales y evaluación del flujo vaginal

c. Manejo farmacológico y no farmacológico del dolor

2. Escenario de simulación:

a. Escenario #5 Hemorragia post-parto (60 minutos)


Lowdermilk, D.L., Perry, S.E., Cashion, K. & Alden, K.R. (2016). Maternity and

Women’s Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc.


WORKSHOP SIX

The facilitator will discuss the following nursing skills and competencies:

a. Newborn identification and foot prints

b. Apgar score

c. Suctioning with bulb and nasogastric tube

d. Thermoregulation and temperature

e. Weight and length measurements

f. Erythromycin ointment application

g. Vitamin K administration

h. Hepatitis B vaccine administration (if required)

i. Umbilical cord care

2. Simulation skills for the scenarios (Skills will be completed on week six for scenario #6):

a. Comprehensive newborn assessment

b. Vital signs assessment

c. Weight and length measurements

d. Suctioning with bulb and nasogastric tube

e. Umbilical cord care

f. Medication administration

g. Medical Record documentation

3. Simulation scenario #5:

a. Post-partum hemorrhage (60 minutes)


Specific Workshop References

Ascott0222. (2014, November 10). Chapter 15 fetal assessment during labor [Video file].

Retrieved from https://www.youtube.com/watch?v=1BGXxRK-tFM&feature=youtu.be



https://www.youtube.com/watch?v=1BGXxRK-tFM&feature=youtu.be


TALLER SIETE

El facilitador discutirá las siguientes destrezas de enfermería:

a. Evaluación de paciente con pre-eclampsia

b. Monitoreo de los signos y síntomas de complicaciones de pre-eclampsia

c. Manejo de la Pre-eclampsia

d. Evaluación de los reflejos profundos y clonos

e. Evaluación fetal

Durante la discusión, los estudiantes tomarán apuntes y realizarán preguntas para aclarar dudas que

puedan tener.

1. Se ofrecerá un examen práctico e individual acerca de todas las destrezas que los alumnos

han estudiado y repasado durante las primeras seis semanas del curso (instrucción

práctica). El examen se calificará como “aprobado o desaprobado” y se considerará como

requisito para continuar participando en la parte clínica de la clase.



Healthcare. (11th ed). Wt. Louis, MO: Elsevier, Inc


Clinical Evaluation Tools


Guide to the Nursing Process

This guide will be of help to your organization in the preparation of the Nursing Process. You should start

preparing it as soon as you select your client. If in doubt, consult your teacher.

1. Presentation page - See APA.

2. Table of Contents - See APA.

3. Introduction - Give the reader a general idea of the content of the work.

4. Customer Profile - It is a spoken portrait of your client. You must include customer identification data such

as: age, sex, religion, marital status, medical diagnoses, days of hospitalization, reason for hospitalization, signs

and symptoms that the client presented at the time of admission and when you intervened with him or her ,

medicines he/she uses and special treatments..

5. Data Analysis - You must use a table format (see table I attached). Remember to cite the source used when

doing the analysis. The analysis is to compare the data obtained from the client with the data of the literature and

to establish the relationship between the two.

6. Laboratory and studies performed - Includes laboratories significant to the condition of the client with their

results. It will include the description of the laboratory or study, the values obtained by the client, the normal

values and the relationship of these results with the condition of the client. See Table II.

7. Medications - Include the medications the client is currently using. Includes complete medical order (name,

dose, route, frequency), indication, side effects, nursing responsibility and relation to the client. See Table III.

8. List of problems or needs (current and potential), strengths (resources) and limitations (weaknesses) - You

must organize it in order of priority. It includes everything that helps or supports the client to satisfy or solve

their needs or problems, as well as what prevents or limits. See Table IV.

9. Care Plan - Use the format given in class. The diagnosis of nursing must be separated from the analysis of

previous data and the identification of problems or needs. Select the highest priority nursing diagnoses (current,

potential and health promotion) and submit it with the PES system. Prepare the plan of care for nursing

diagnoses. Remember to write the objective (s) correctly using the five elements: subject, verb, situation

(condition), adequacy (criteria) and time (see the notes of the Class and textbook). Care plans will be delivered

using Docu Care

10. Conclusion of the work - Includes a summary of the content of the work and its

usefulness for professional development.

11. References - These must be updated (last 5 years), written according to APA and there must

be at least 5 references. All references cited in the Data analysis should be included in the

list of references.

12. Appendix - Health history and physical examination will be delivered using Docu Care. The

appendices contain any other material used to provide a client care. Example:

Information materials, whether brochures, Pamphlets, information taken from the Internet. |

Remember to quote the appendices and identify them correctly. The last part of the appendix

are the Evaluation Criteria.

*Check the work before submitting it (wording, sequence, spelling, etc.).

Also use the criteria to verify that the work includes all parts which will be evaluated. Hand in the

work at the time that stipulates the norms of Course. Below is a model of the tables that should be

included.


I. Table for Presentation and Analysis of Data

Data Analysis

Client Information

Some data to analyze:

Examples:

A) Age (use theorists

like: Erick Erickson).

B) Gender

C) Place of Residence

D) Civil Status

E) Academic level

F) Religion

G) Occupation

H) Previous hospitalizations

I) Medical Diagnosis

Current

J) Significant findings

of physical examination

Perform an assessment of Needs according to Maslow

Theories and sources of reliable information should

be apply in data analysis.

Literature review data are compared with client data.

II. Table of Laboratories

Name and

Description

Results client's Values Normal Values Relationship with

Client’s Condition

Example: "Complete

Blood Count "

(CBC) - Explain the

Components of the

Lab and the

importance.

Ex: Hemoglobin

(HGB) = 13.5 g / dl

Write the rank of

Values expected.

Ex: Men:

12.4-14.9 g /DL Women:

11.7 to 13.8 g /

DL

Explain the relationship of

the results with the

Current condition of the

patient

III. Table of Medications

Name, Dose,

Via and

Frequency

Indication Secondary Effects Nursing

Responsibility

Relationship

with the

Client

Tylenol 500mg

PO Every 6 hours

Explain how to use

and for what is use

Write the

Adverse effects

reactions

Common and the

more

Dangerous for

Each system.

Which are the

Aspects / care

that the nursing

personal should

take into account

to administer this

medicine?

What

purpose is use

in the client?

(take in account

the health history.

and

current status)


IV. Table Problems of the Client

EXAMPLE

OF WHAT TO INCLUDE IN THE CARE PLAN

Problems Resources Limitations

Must be arrange in priority.

The student must place all

Problems identified in a list

that is divided into current and

potential

Aspects that

support the client to

solve his/her needs.

Aspects that prevent or

limit the client.

Nursing Diagnosis Client’s Objectives Nursing

Interventions

Rationale Evaluation

P - Problem

E - Etiology

S - Signs and

Symptoms that show

the

existence of the

problem

Format of

Potential Problem:

P - Problem

E - Etiology

Each objective

Should:

1. Be directed

to the patient.

2. Have a verb

(Measurable).

3. Present one

situation.

4. Have

Adequacy.

5. Have a period of

time to achieve the

objective

Include what the

Nursing Professional

will do to

direct the client to

achieve the

objectives.

Classify

independent /

Collaborative

Explain the reason

and importance

of each

intervention

It must be grounded

and

justified the

explanation of

each nursing

intervention

Indicate to what

extent the objectives

were achieved

through

each nursing

intervention.

There must be a

explanation of how

the evaluation

was done for each

objective.


Evaluation Criteria for the Nursing Process

Name___________________________ Date___________________

Professor___________________________ Points/ Grade_____________

Criteria 4 3 2 1 0 N/A Comments

I. Competent Practice

A. Make a nursing assessment

1. Writes a complete patient profile.

2. Writes: nursing history, physical

examination, and data relevant to the patient's

current condition in the electronic record.

3. Describes the significant findings of the

patient's nursing history and physical

examination correctly and relates them to the

current problem.

II. Critical Thinking

A.Interprets significant data from the nursing

assessment related to the current situation or

problem

1. Analyze laboratory results and / or

studies.

2. Analyze medications used by the patient.

3. Analyze the pathophysiology of the medical

diagnoses

4. Analyzes the stage of growth and

development according to Eric Erikson and the

impact of health condition.

5. Apply Abraham Maslow's theory of needs

satisfaction to the patient's current situation to

Identify and explain affected needs

6. Identify current and potential list of nursing

problems by considering the patient as a

holistic being.

7. Writes nursing problems in priority order.

8. Describe patient's strengths and limitations

to work with the health situation or problem.

III. Clinical Judgment

A. Design a nursing care plan for the nursing

diagnoses and

Solution of the patient's highest priority

problems.


1. The identified diagnoses contain the

necessary elements (problem, etiology, signs

and symptoms).

a. Performs a minimum of three nursing

diagnoses; one diagnosis focused on a current

problem, another diagnosis related to a risk

(potential problem) and one in health

promotion. You must present justification for

not having each type of diagnosis indicated.

2. Writes observable objective behavior

(includes 5 components of objectives).

3. Write nursing interventions for the

identified diagnosis (classified in independent

and collaborative).

4. Describe the scientific rationale for

designed nursing actions

5. Establish the aspects to be considered as

nursing professionals in the evaluation of the

objective (s).

6. Writes a conclusion with a reflection on the

client's situation, the role of the nursing

professional in his care and his/her learning as

a student.

IV. Research Skills

A. Evidences the search and use of relevant

and scientific literature when relating

information from the literature with findings

found in the assessment

V. Presentation of Paper

A. The use of the APA format is evidenced.

B. Has a clear introduction.

C. Makes use of grammar rules.

D. Has clear and coherent ideas.

E. The references used in the preparation of

the work:

1. Diversity of professional sources

2. Complete and correct

3. Last 5 years.


Scale:

4 - Has complete mastery of the knowledge and / or skills required all the time

3 - Has mastery of the knowledge and / or skills required most of the time.

2 - Has mastery of knowledge and / or skills required sometimes.

1 - Has mastery of the knowledge and / or skills rarely required.

0 - No evidence of any knowledge or skills in its execution.


Evaluation Criteria Leadership Role Competencies

Name: _________________________________ Date ____________________________

Professor: ________________________________ Grade: ______ % ______

*During the clinical practice of this course the student is expected to achieve the competences with minimum

or no teacher help.


I. COMPETENT PRACTICE

A. Communication Skills (15%)

1. Shows therapeutic communication skills with:

a. Patient

b. Family

c. Professor

d. Peers

e. Interdisciplinary Health team

2. Demonstrates appropriate communication:

a. Tone

b. None verbal language

c. Professional vocabulary

d. Follows communication channels

3. Written Communication with minimal or no help from the teacher.

a. Task assignment

b. Weekly work plan

c. Writes modifications to the nursing plan

d. Evaluates own implementation of the plan

B. Cultural and ethical sensitivity (5%)

1. Respets cultural preferences, values, beliefs and behaviors of the patient,

family, peers and interprofessional team

2. Demonstrates an ethical behavior in the care and management of

patients in their professional role by respecting values (Respect for

Human Dignity, Responsibility, Commitment, Honesty, Integrity,

Loyalty, Justice, Equity, Authenticity

C. Leadership (60%)

1. Supervision

a. Arrives early (1 hour before)

b. Notify teacher in time when unable to assist the clinical

c. Wears full and clean uniform with identifications.

d. Brings complete equipment to the clinical setting

e. Report to teacher when task begins or ends

f. Oversees team members to carry out their tasks

g. Demonstrates Leadership Qualities

a. Demonstrates initiative in the execution of task



b. Keeps control of emotions

c. Handles unexpected events

according to the qualities of a leader.

h. Deliver data relevant to continuity of care to the leader of the next

shift.

i. Provides complete and organized documentation to the teacher

(Portfolio-1 week after completing his / her leader role)

2. Work Assignment

a. Carries out the essential elements of planning, organization, direction

and evaluation of the team in charge

a. Verify patient census

b. Verify the work program of the unit's staff

c. Evaluates the level of staff preparation when assigning the task

d. Establish the categorization of patients according to individual needs

e. Assign other tasks related to patient care

f. Assigns tasks related to patient safety and care environment

g. Assign tasks related to quality improvement

h. Distributes tasks evenly

1.Provides specific oral instructions on allocation

2. It takes into consideration the location of

patients

3. Is available to answer question that may arise

4. Assigns lunch time and break

i. Includes infection control management in assignment of tasks

3. Team / patient education

a. Estimate the educational need

b. Plan ahead

c. Write the objectives, content, educational strategies and the evaluation

plan

1. Promotes educational activity

d. Discuss the subject and content with the teacher prior to the activity

e. Facilitates assistance to team members

f. Has mastery of content

g. Stimulates audience participation

h. Answer related questions of the topic

i. Evaluates the educational activity

D. Management of information systems (5%)

1. Complies with the regulations and rules of the HIPAA Act)

2. Complies with the regulations of the Institution

E. Patient Care Technologies

1. Demonstrates knowledge and skills in the use of technologies for patient

care (technological equipment for patient care)


II. CRITICAL THINKING

A. Autoevaluación Objetiva (10%)

1. Engages in an objective self-evaluation process considering their beliefs

and values and how they relate to their practice as a leader.

2. Entrega reflexión final que refleje su desarrollo profesional al profesor

1. Intervenes using critical judgment according to institutional standards

2. Promotes the defense of patient's rights

III. RESEARCH SKILLS

A. Uses relevant literature (5%)

1. Uses reliable and relevant scientific literature to apply it in its role as

leader

2. Demonstrates skills in finding, evaluating, and synthesizing evidence to

improve care outcomes with minimal assistance and support

3. Integrates non-traditional alternatives for the solution and improvement of

situations involving patients or interprofessional team

Professor’s Signature: _______________________ Student’s Signature:

_________________________

Date: ______________________

Scale:

4 - Has complete mastery of the knowledge and / or skills required all the time

3 - Has mastery of the knowledge and / or skills required most of the time.

2 - Sometimes has mastery of knowledge and / or skills required.

1 - Rarely has mastery of the knowledge and / or skills required.

0 - No evidence of any knowledge or skills in its execution.

Critical judgment and decision making






Evaluation Criteria for Documentation in the Electronic Record

Name___________________________ Date___________________


Scale:

Yes (1 point) - The criterion is fully completed and as indicated.

No (0 point) - Does not take into account the criterion.

N / A- Criterion does not apply

Criteria Yes No N/A Comments

1.Competent Practice

A. Nursing Documentation

1.Writes relevant data that reflects the current

condition (nursing assessment) of the patient

2. Evidence of nursing interventions

according to identified problems

3. Evidence of the patient's response to the

nursing interventions offered.

4. Entries in the electronic record are complete

5. The information is presented in logical order

(nursing note).

6. Nursing notes follow grammatical rules

(consistent in syntax, spelling).

7. Deliver on time the documentation made.


Bachelor Degree of Science Nursing

Clinical Teaching Plan

Student Name: ____________________________Date: _________________ Time:

____________

Client Initials: ____________________________ Sex: __________________

Age: _____________

Behavioral Objectives/Goals:

__________________________________________________________________________________

____________________________________________________________________

Readiness to Learn:

__________________________________________________________________________________

__________________________________________________________________________________

_____________________________________________________________

Barriers to Learning:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

______________________________________________________


Nursing Teaching Plan of Care

Assessment

Nursing

Diagnosis

Nursing Intervention/

Implementation

Scientific

Rationale

Evaluation Date Modification

Subjective

Data:

Objective

Data:


Evaluation Criteria for Education Plan

Name___________________________ Date___________________



Critical Thinking

I. Planning

A. Select topic according to needs of

the patient

B. Coordinates the activity with

members of the health team.

C. Prepares the physical and

psychological environment to

facilitate learning.

D. Discuss the detailed outline with

the teacher one week in advance

(subject, plan, visual and

demonstrative material).

II. Content:

A. Selects the content relevant to the

topic.

B. Writes objectives in terms of

observable behavior

C. The content is in accordance with

the objectives formulated.

D. Presents the content in a logical

sequence.

III. Method - Strategies:

A. Selects the strategies that most

facilitate the

presentation of the content and shows

creativity.

B. The method is selected according

to the number and characteristics of

the clients for whom the activity is

planned.

Professional Competence

C. Implements the selected strategy.


IV. Development of the Plan:

A. Faces the clients

B. Gets the attention of the clients.

C. Speaks clearly and slowly.

D. Discusses planned educational

material.

E. Uses a simple language in tune

with the learner's educational level.

F. Pays attention and listen to the

group's reactions as he/she speak.

G. Clarifies the scientific terms used

in the presentation

H. Offers opportunity for

participation.

I. Uses quality audiovisual material

(clear and of adequate size).

J. Remains within the allotted time

limit.

K. Clarifies other situations brought

by clients

L. Creates quality written material

that meets the established objectives.

M. Demonstrates mastery of content.

N. Closes the topic by mentioning

the most important points.

V. Evaluation:

A. Performs assessment of learning

at the end of the educational activity.

B. Carries out the evaluation

according to the objectives outlined.

C. At the end of the activity, leaves

the area used in order.

VI. Written and oral presentation: A. Follows the rules for submitting

papers

according to APA style.

B. Completes the teaching plan

format.

C. Follows grammatical rules.

D. Expressed correctly.


E. References.

1. Recent dates (last 5 years).

2. Correct and complete

Research Skills

Evidences the search and use of

diverse, relevant and scientific

literature when preparing the

content of the educational activity

(minimum 3 sources).

Scale:

4 - The criteria are complete.

3 - The criteria almost complete.

2- The criteria partially complete.

1- The criteria are not complete

N / A - Does not apply.









