Description
Summary Information Regarding Clinical Focus Assignments
• Clinical faculty may adjust clinical assignments to individual student needs, and may adjust due dates for students who are absent or participate in OR experience.
• Assignments are due as per the course calendar. Work that is late or incomplete may receive an “Unsatisfactory” grade, which will be represented on the clinical evaluation tool. It may also lose points from the grade according to the rubric, which may result in an unsatisfactory grade.
• All assignments must be submitted electronically and will be graded electronically on Blackboard.
• All assignments must be word processed (typed) and in .doc or .docx format.
• Templates of all forms are on Blackboard so that you can make copies as needed.
• You will need to review protected patient health information to complete all of your written assignments. This information should NOT leave the unit in printed form. In the event that unit staff decide to provide you with any printed patient health information, make sure all patient identifiers have been cut off the papers – this includes name, account numbers, room numbers, and physicians. Failure to remove patient identifiers constitutes a HIPPAA violation and can result in dismissal from the nursing program. It will result in an “Unsatisfactory” grade under Professional Behaviors for that day.
Clinical Focus Assignments. You are required to complete all sections of this assignment on one client under your care. These assignments are due twice a semester, and are graded by a rubric, found below. Edit-ready form templates are posted on Blackboard and assignments should be word-processed. Please keep all answers thorough, but brief. A breakdown of clinical focus assignment questions follows.
1. Medical/Surgical Diagnoses: List primary diagnosis in the patient’s chart. DEFINE the medical/surgical diagnosis and provide a reference as the definition source.
2. Client Alteration/Risk: Use client’s diagnosis, nursing report, and your assessment and laboratory data to evaluate this.
3. Laboratory Or Assessment Values: Any laboratory data, assessment data, or results from diagnostic tests applicable to your focus go in this space
4. Treatments: Fill in relevant treatments specified on sheet, in addition to other relevant treatments client is receiving. This may include (but is not limited to) medications, IV therapy, oxygen therapy, and safety/infection precautions.
5. Priority Nursing Diagnosis: The most important nursing diagnosis having to do with the concept of focus (your chosen clinical focus assignment). This may not be the same as your overall priority nursing diagnoses for the client (which you must list in your Level II project). “As evidenced by” means that you observed it or the client stated it. ‘At risk’ or ‘potential for’ nursing diagnoses do not have signs or symptoms or clinical manifestations, so they do not have data under “as evidenced by.”
6. Outcome: Should include some kind of goal or outcome statement and explain why you chose it and why it is the priority. It must be connected correctly to the interventions and should be time-modified and measureable. Consult Ackley’s NOCs for ideas
7. Nursing Interventions: 2 nursing interventions that should be derived from the above diagnoses.
8. Evaluation: This is where you state how you would evaluate your outcome (did the interventions work? how do you know?). A correct evaluation should directly restate the outcome and whether or not it was met.
9. Medication Administration Worksheet: See below—this is 20% of the assignment and must be included.
Medication Administration Worksheet You will need multiple copies – can be single or double-sided. Most students use 2-3 per week. Graded by rubric
➢ The Medication Administration Worksheet should be turned in with eachclinical focus assignment, and should include all medications given during your shift for that client. PRNs are not included unless they are administered. It is important to know this information before you give medications and to organize it well.
➢ Prior to administering the medication, if possible, complete the first 7 columns. Be sure to complete “What should be assessed prior to administration” (column 6) followed by “Assessment Results” (real data) in the next column before administration of the medication. Example:
➢ What should be assessed?Assessment Results
➢ Blood pressure (should be > 100/60)Pt. blood pressure 140/84 – safe
➢ The last column “Follow up assessment “ is completed after the medication is given and answers the questions – was the drug effective? – were there any side effects or adverse reactions? Again, use rea data. If you do not know how you would evaluate effectiveness, ask your instructor before you turn it in. If you were not able to evaluate effectiveness, explain how you would do so.
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Harford Community College
NURS 105: Medical-Surgical Nursing 1
Clinical Focus Assignment 5: Safety & Risk Management
(Infection, Perioperative, Oncology)
1.) Client’s primary medical-surgical diagnosis: (with citation, list reference in APA format on the back)
Mass of colon
2.) Does this client have a risk for infection or other safety risk, such as falls/harm from falls? (Yes/No, then explain)
3.) List and explain any laboratory or assessment values that may be related to such risks. If N/A, which values might change?
4.) Is the client receiving antibiotics and/or on any precautions (falls, transmission, leukopenic, bleeding)? What is the purpose of this therapy?
5.) What is the priority safety or risk nursing diagnosis for this client?
6.) Select a priority outcome for this client based on the nursing diagnosis above and explain why you chose it.
7.) What priority nursing interventions would you derive from this outcome (name 2) Each intervention should have a rationale.
8.) Evaluate the nursing outcomes you created/ State how you would evaluate them. Be specific!
12/12, 1/19, 12/22
MEDICATION ADMINISTRATION WORKSHEET
Guiding Question: Is it safe to give this drug to this client?
MEDICATION
USUAL (TOP) DRUG
GENERIC (TOP)
AND PATIENT CATEGORY
AND
(BOTTOM)
AND
TRADE NAME(S)
DOSE,
MECHANISM
(BOTTOM)
ROUTE,
OF ACTION
FREQUENCY
____________
PURPOSE OF
DRUG (ALSO
SPECIFY FOR
THIS
PATIENT)
MAJOR
RISKS/
SIDE AND
ADVERSE
EFFECTS
WHAT SHOULD BE
ASSESSED BEFORE
ADMINISTRATION?
(VS, BREATH
SOUNDS, PAIN
LEVEL)
ASSESSMENT
RESULTS
(USE REAL DATA
COLLECTED
BEFORE
ADMINISTRATION)
FOLLOW UP
ASSESSMENT
(USE REAL DATA)
WAS THE DRUG
EFFECTIVE?
SIDE EFFECTS?
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