Assignment Prompt & Instructions
– ## FinalClinicalSummativeSelf-Evaluation_ADNG2100_ClinicalII.docx
– ## HolisticAssessment-FHP-HealthHistoryAssignmentGuide.docx
– HolisticAssessment-FHP.docx
**## FinalClinicalSummativeSelf-Evaluation_ADNG2100_ClinicalII.docx**
**Level 2:**
**Clinical Performance Evaluation- ADNG 2100 Clinical II**
· Student will complete a self-evaluation of each student learning outcome below using the criteria on the left found under each outcome. Briefly summarize, either in bullet point or paragraph form, your own evaluation of performance in each. Be specific, give examples. In areas you identify as needing growth, provide specific strategies for improvement in your next clinical course.
· Submit to the Clinical Performance Evaluation assignment folder in your clinical course by the assigned due date.
| | |
| — | — |
| **HUMAN FLOURISHING**<br>**Apply knowledge and skills learned in the program to uphold patients’ right of self-determination and promote holistic well-being of client and family.**<br>QSEN#1- Provide patient-centered care |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Apply therapeutic communication skills in interactions with client and family <br>· Identify behaviors that threaten or protect client autonomy, dignity, and rights<br>●Respect client autonomy and recognize opportunities for client advocacy<br>· Illustrate how individual differences and values affect client outcomes | |
| **Objective Data:** Holistic Assessment & Application of Nursing Process, Reflective Journal | |
| **NURSING JUDGMENT**<br>**Make judgments in practice, supported by evidence, that integrate nursing science in the provision of safe, quality care.**<br>QSEN#2- Safety, Patient and Healthcare Provider<br>QSEN#3-Informatics |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| ●Utilize the nursing process to develop an individualized plan of care<br>●Provide valid rationales for nursing interventions<br>●Communicate assessment findings to instructor and healthcare team members<br>●Submit daily care plan to instructor for review in post-clinical<br>●Utilize effective judgment and available<br>resources to provide interventions (mediation administration, dressing changes, catheterization, etc.) in a safe, efficient manner to assigned client<br>· Provide accurate client education when need arises<br>●Utilize the EMR to accurately document care provided | |
| **Objective Data:** EBP Project & Presentation, Holistic Assessment & Application of Nursing Process, Reflective Journal | |
| **PROFESSIONAL IDENTITY**<br>**Implement one’s role as a nurse in a manner that reflects the ideals of the profession while developing an identity committed to evidence-based practice, in the provision of compassionate, culturally sensitive, holistic care to a diverse population.**<br>QSEN#4- Teamwork and Multi-disciplinary Collaboration |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Actively participate in post-clinical discussion and learning activities<br>· Exhibit professional appearance and behavior (punctuality, uniform standards, equipment, etc.)<br>· Demonstrate behaviors that reflect the values and ethics of the nursing profession<br>· Exhibit professionalism in interactions with multidisciplinary team-members, peers, clients, and faculty<br>· Manages conflict effectively as it arises with mentoring from faculty and/or staff | |
| **Objective Data:** EBP Project & Presentation, Reflective Journal | |
| **SPIRIT OF INQUIRY**<br>**Examine the evidence that underlies clinical nursing practice to challenge the status quo, question underlying assumptions, and offer new insights to improve the quality of care for patients, families, and communities (NLN, 2010).**<br>QSEN #5- Quality Improvement<br>QSEN #6- Evidence based practice |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Identify opportunities to improve quality client care<br>· Accept responsibility for the learning process, utilizing feedback to improve practice<br>· Remain effective when confronted with change<br>· Utilize understanding of pathophysiology of disease to predict priority evidence-based interventions<br>· Apply knowledge of and appropriate use of asepsis to create a safe care environment that results in high quality patient outcomes (medication administration, handwashing, invasive procedures, etc.) | |
| **Objective Data:** EBP Project & Presentation, Holistic Assessment & Application of Nursing Process, Reflective Journal | |
**## HolisticAssessment-FHP-HealthHistoryAssignmentGuide.docx**
**HEALTH HISTORY BY FUNCTIONAL HEALTH PATTERN**
Assignment Guide
· Use this form to help guide interview questions and take notes during your client interview.
This sheet
**will be** turned into the assignment folder in D2L.
· Make sure to include both
**subjective** and
**objective** data. Subjective data is the information the client directly tells you. Objective data is information that you observe as a nurse. Objective data is in bold below.
· Utilize information from this sheet to then neatly and succinctly type and summarize information on the FHP template; students are REQUIRED to use template for final submission.
| | |
| — | — |
| **1** | **Client Profile:**<br>Bio graphics- ethnic origin, level of education, reason for seeking care, current treatments & medications, summary of significant past medical history, and allergies. |
| **2** | **Developmental History:**<br>History of growth & development, any developmental handicaps, their stated goals in life, effect of current health/illness on goals. Does the individual function at the expected developmental stage? (State stage according to Erikson & evidence of positive or negative resolution) What issues might be impacting the developmental stage? If the client does not function at expected stage, state stage they are functioning and support with cues. |
| **3** | **Health Perception-Management Pattern:**<br>Describe your health- how would you rate it on scale of 1-10, now, 5 yrs ago, & 5 yrs ahead? Describe your illness (health problem). What do you believe caused your illness? How will you care for yourself (or others) at home? What do you do when you have a health problem? Are you able to state the names of current medications you take and their purpose?<br>If this person reports having allergies, what does she/he do to prevent them? Have there been any important illnesses or injuries in this person’s life?<br>Discuss dates & history of routine health exams. What do you do to maintain your health? Flu shot, Pneumonia or shingles immunizations? Do use any substances (drugs, caffeine, tobacco, etc.)? History of exposure to toxins? How well do they comply with treatment plans? <br>**General appearance (describe the individual objectively). Vital Signs: RR, HR, BP, T., & O2sats.** |
| **4** | **Nutritional-Metabolic Pattern:**<br>Assess dietary & fluid intake: what do you typically eat/drink in a day? When was last dental exam? Any difficulty eating/drinking? Any changes in eating or drinking? Assess for N-V, indigestion, use of antacids. What is current weight? Any recent weight gains or losses?<br>**List height, weight, and BMI. Include assessment of skin, hair, nails as condition can reflect nutritional status. List any feeding precautions or if the client receives, TPN or tube feedings, or uses supplemental beverages. List use of probiotics, prebiotics, vitamins etc. Blood sugar pattern. Note if client experiences adrenal insufficiency, takes corticosteroids, or has any other endocrine problems. Labs reflecting nutritional status: glucose, electrolytes, lipid panel, protein/albumin, & BUN.** |
| **5** | **Elimination Pattern:**<br>Describe typical bowel pattern. Have there been recent changes? Quality of stool? Do you do or take anything to facilitate BM? Any history of GI surgery? When was the last BM?<br>Describe usual urinary habits. Any recent changes? Quality of urine? Problems with urination (nocturia, incontinence, frequency, dysuria)? History of bladder surgery?<br>**Provide I & O data if relevant. Bowel sounds/abdominal assessment. If surgical client, describe surgical site. Dietary intake, nausea, vomiting. Objective assessment of the urine & stool by the nurse?** |
| **6** | **Activity-Exercise Pattern:**<br>Describe a normal day. Assess ability to complete ADLs- are they independent or do they require support? Who helps? Is there anything they would like to do at home that they are unable to do?<br>What do they do for fun? Hobbies? Exercise routine? What do they do for a living? What is the relationship between work and health?<br> <br>**Include data from Respiratory, Cardiovascular, and Musculoskeletal assessment. List presence of respiratory or cardiac interventions (Chest tubes, ventilator, CPAP, oxygen) Also hematology abnormalities?** |
| **7** | **Sexuality-Reproduction Pattern:**<br>Gather data relevant to gender & age: Females-menstrual history, obstetric history, menopause, BSE; males-erectile dysfunction, prostate problems, testicular changes, TSE. Discuss: contraceptive use, perception of sexual activities, impact of health on sexuality, STDs, & any history of sexual abuse. Has this person had any past negative experiences that could affect sexual health? <br>**If the client is OB or post-partum, assess perineum, lochia, uterus (fundus), & breasts.** |
| **8** | **Sleep-Rest Pattern:**<br>Describe usual sleeping time & habits. Do you use anything to help you sleep? How would you rate the quality of your sleep? Do you have difficulty sleeping? Have you noticed a change in sleeping pattern? <br>**Include objective cues that indicate fatigue.** |
| **9** | **Sensory-Perceptual Pattern:**<br>Describe your ability to see, hear, feel, taste, smell.<br>Share any difficulties you have in these areas. List any assistive devices utilized (glasses, hearing aids).<br> <br>**Include pain and neurological assessment.** |
| **10** | **Cognitive Pattern:**<br>What is the highest level of education achieved? What is the client’s preferred learning method/style? How do they make decisions? As you interview, you can gather information below based on their ability to respond:<br>**Level of consciousness and orientation to person, place, time. Describe their ability to understand, communicate, and recall information. Assess their decision-making ability. What is their attention span? Perform a mental status assessment if appropriate.** |
| **11** | **Role-Relationship Pattern:**<br>Describe your family. Assess roles within the family. Explore extended family and relationships within family of origin (siblings, parents, grandparents). Identify the person(s) most important in life- best friends, work friends, etc. How is your family coping with your current state of health? How would you describe communication between family members? Discuss distribution of roles in family. Describe current or past occupation. How do you feel about your work? Who is the most important person in your life? What social groups or community activities do you participate in?<br> <br>**Does the client have visitors? Is there evidence of caring (cards, flowers, balloons, phone calls)? Post-partum client: note evidence of bonding. If partner present, assess interactions/family roles.** |
| **12** | **Self-Perception-Self-Concept Pattern:**<br>Describe yourself. Has illness affected this? What are your strengths & weaknesses? How do you feel about yourself? How do you feel about your appearance? Has this changed since your illness? If client is post-partum, how does she feel about role as parent (also assess partner if present)? <br>**Note client’s interest & participation in personal hygiene, wearing own robe, slippers, etc.** |
| **13** | **Coping-Stress Tolerance Pattern:**<br>Describe the most stressful situation in your life. How has illness affected stress and Stress affected illness? How big a problem is financing health care? Have you experienced any personal loss or major life change last year? How do you typically cope with problems? What relieves stress/tension? Who do you turn to when you have problems or pressure? Do you use any substances to help relieve stress? |
| **14** | **Value-Belief Pattern:**<br>What is most important to you in life? What do you hope to accomplish? What is your major source of hope & strength? Do you have a religious affiliation? How important is this to you? Any special requests? Would you like contact with minister, chaplain, priest, shaman, etc.). Are there health practices or restrictions important for you to follow while hospitalized?<br> <br>**Observe any artifacts or talismans (prayer books, tobacco, prayer rug, medicine bag, rosaries, etc.) at bedside that provide clues to spiritual beliefs. Listen for themes in communication that indicate values & beliefs important to client.** |
**Summary:** _Bullet point out the_
_significant health concerns,_
_opportunities for health improvement, and_
_client strengths/weaknesses. Summary should address_
_psychosocial as well as_
_physical concerns. The summary should make a case for your chosen diagnosis based on the data above._
When you have completed the assessment, identify problem areas. This may be areas where the client expressed dissatisfaction or a desire for improvement, it may be areas where there is a deviation from the client’s normal level of functioning (e.g. typically has BM daily, but has not had one in 3 days; typically eats 3 well-balanced meals with snacks, but recently has lost appetite; is typically independent in all areas of daily living (meal preparation, eating, bathing, dressing, ambulation), but currently requires assistance with ambulation and bathing; describes difficulty managing current levels of stress, etc.). It is important to look at the client’s “normal”, or desired level of health, and compare it to current status based on subjective and objective data collected. Summary should include holistic data, identifying significant physical, developmental, psychological, and social issues. Then summarize the strengths/weaknesses you identified in your data that can be an asset or detriment to the client in achieving their health goals.
**HolisticAssessment-FHP.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/holisticassessment-fhp-docx-10460735)
**HolisticAssessment-FHP.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/holisticassessment-fhp-docx-10460735)
**## FinalClinicalSummativeSelf-Evaluation_ADNG2100_ClinicalII.docx**
**Level 2:**
**Clinical Performance Evaluation- ADNG 2100 Clinical II**
· Student will complete a self-evaluation of each student learning outcome below using the criteria on the left found under each outcome. Briefly summarize, either in bullet point or paragraph form, your own evaluation of performance in each. Be specific, give examples. In areas you identify as needing growth, provide specific strategies for improvement in your next clinical course.
· Submit to the Clinical Performance Evaluation assignment folder in your clinical course by the assigned due date.
| | |
| — | — |
| **HUMAN FLOURISHING**<br>**Apply knowledge and skills learned in the program to uphold patients’ right of self-determination and promote holistic well-being of client and family.**<br>QSEN#1- Provide patient-centered care |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Apply therapeutic communication skills in interactions with client and family <br>· Identify behaviors that threaten or protect client autonomy, dignity, and rights<br>●Respect client autonomy and recognize opportunities for client advocacy<br>· Illustrate how individual differences and values affect client outcomes | |
| **Objective Data:** Holistic Assessment & Application of Nursing Process, Reflective Journal | |
| **NURSING JUDGMENT**<br>**Make judgments in practice, supported by evidence, that integrate nursing science in the provision of safe, quality care.**<br>QSEN#2- Safety, Patient and Healthcare Provider<br>QSEN#3-Informatics |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| ●Utilize the nursing process to develop an individualized plan of care<br>●Provide valid rationales for nursing interventions<br>●Communicate assessment findings to instructor and healthcare team members<br>●Submit daily care plan to instructor for review in post-clinical<br>●Utilize effective judgment and available<br>resources to provide interventions (mediation administration, dressing changes, catheterization, etc.) in a safe, efficient manner to assigned client<br>· Provide accurate client education when need arises<br>●Utilize the EMR to accurately document care provided | |
| **Objective Data:** EBP Project & Presentation, Holistic Assessment & Application of Nursing Process, Reflective Journal | |
| **PROFESSIONAL IDENTITY**<br>**Implement one’s role as a nurse in a manner that reflects the ideals of the profession while developing an identity committed to evidence-based practice, in the provision of compassionate, culturally sensitive, holistic care to a diverse population.**<br>QSEN#4- Teamwork and Multi-disciplinary Collaboration |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Actively participate in post-clinical discussion and learning activities<br>· Exhibit professional appearance and behavior (punctuality, uniform standards, equipment, etc.)<br>· Demonstrate behaviors that reflect the values and ethics of the nursing profession<br>· Exhibit professionalism in interactions with multidisciplinary team-members, peers, clients, and faculty<br>· Manages conflict effectively as it arises with mentoring from faculty and/or staff | |
| **Objective Data:** EBP Project & Presentation, Reflective Journal | |
| **SPIRIT OF INQUIRY**<br>**Examine the evidence that underlies clinical nursing practice to challenge the status quo, question underlying assumptions, and offer new insights to improve the quality of care for patients, families, and communities (NLN, 2010).**<br>QSEN #5- Quality Improvement<br>QSEN #6- Evidence based practice |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Identify opportunities to improve quality client care<br>· Accept responsibility for the learning process, utilizing feedback to improve practice<br>· Remain effective when confronted with change<br>· Utilize understanding of pathophysiology of disease to predict priority evidence-based interventions<br>· Apply knowledge of and appropriate use of asepsis to create a safe care environment that results in high quality patient outcomes (medication administration, handwashing, invasive procedures, etc.) | |
| **Objective Data:** EBP Project & Presentation, Holistic Assessment & Application of Nursing Process, Reflective Journal | |
**## HolisticAssessment-FHP-HealthHistoryAssignmentGuide.docx**
**HEALTH HISTORY BY FUNCTIONAL HEALTH PATTERN**
Assignment Guide
· Use this form to help guide interview questions and take notes during your client interview.
This sheet
**will be** turned into the assignment folder in D2L.
· Make sure to include both
**subjective** and
**objective** data. Subjective data is the information the client directly tells you. Objective data is information that you observe as a nurse. Objective data is in bold below.
· Utilize information from this sheet to then neatly and succinctly type and summarize information on the FHP template; students are REQUIRED to use template for final submission.
| | |
| — | — |
| **1** | **Client Profile:**<br>Bio graphics- ethnic origin, level of education, reason for seeking care, current treatments & medications, summary of significant past medical history, and allergies. |
| **2** | **Developmental History:**<br>History of growth & development, any developmental handicaps, their stated goals in life, effect of current health/illness on goals. Does the individual function at the expected developmental stage? (State stage according to Erikson & evidence of positive or negative resolution) What issues might be impacting the developmental stage? If the client does not function at expected stage, state stage they are functioning and support with cues. |
| **3** | **Health Perception-Management Pattern:**<br>Describe your health- how would you rate it on scale of 1-10, now, 5 yrs ago, & 5 yrs ahead? Describe your illness (health problem). What do you believe caused your illness? How will you care for yourself (or others) at home? What do you do when you have a health problem? Are you able to state the names of current medications you take and their purpose?<br>If this person reports having allergies, what does she/he do to prevent them? Have there been any important illnesses or injuries in this person’s life?<br>Discuss dates & history of routine health exams. What do you do to maintain your health? Flu shot, Pneumonia or shingles immunizations? Do use any substances (drugs, caffeine, tobacco, etc.)? History of exposure to toxins? How well do they comply with treatment plans? <br>**General appearance (describe the individual objectively). Vital Signs: RR, HR, BP, T., & O2sats.** |
| **4** | **Nutritional-Metabolic Pattern:**<br>Assess dietary & fluid intake: what do you typically eat/drink in a day? When was last dental exam? Any difficulty eating/drinking? Any changes in eating or drinking? Assess for N-V, indigestion, use of antacids. What is current weight? Any recent weight gains or losses?<br>**List height, weight, and BMI. Include assessment of skin, hair, nails as condition can reflect nutritional status. List any feeding precautions or if the client receives, TPN or tube feedings, or uses supplemental beverages. List use of probiotics, prebiotics, vitamins etc. Blood sugar pattern. Note if client experiences adrenal insufficiency, takes corticosteroids, or has any other endocrine problems. Labs reflecting nutritional status: glucose, electrolytes, lipid panel, protein/albumin, & BUN.** |
| **5** | **Elimination Pattern:**<br>Describe typical bowel pattern. Have there been recent changes? Quality of stool? Do you do or take anything to facilitate BM? Any history of GI surgery? When was the last BM?<br>Describe usual urinary habits. Any recent changes? Quality of urine? Problems with urination (nocturia, incontinence, frequency, dysuria)? History of bladder surgery?<br>**Provide I & O data if relevant. Bowel sounds/abdominal assessment. If surgical client, describe surgical site. Dietary intake, nausea, vomiting. Objective assessment of the urine & stool by the nurse?** |
| **6** | **Activity-Exercise Pattern:**<br>Describe a normal day. Assess ability to complete ADLs- are they independent or do they require support? Who helps? Is there anything they would like to do at home that they are unable to do?<br>What do they do for fun? Hobbies? Exercise routine? What do they do for a living? What is the relationship between work and health?<br> <br>**Include data from Respiratory, Cardiovascular, and Musculoskeletal assessment. List presence of respiratory or cardiac interventions (Chest tubes, ventilator, CPAP, oxygen) Also hematology abnormalities?** |
| **7** | **Sexuality-Reproduction Pattern:**<br>Gather data relevant to gender & age: Females-menstrual history, obstetric history, menopause, BSE; males-erectile dysfunction, prostate problems, testicular changes, TSE. Discuss: contraceptive use, perception of sexual activities, impact of health on sexuality, STDs, & any history of sexual abuse. Has this person had any past negative experiences that could affect sexual health? <br>**If the client is OB or post-partum, assess perineum, lochia, uterus (fundus), & breasts.** |
| **8** | **Sleep-Rest Pattern:**<br>Describe usual sleeping time & habits. Do you use anything to help you sleep? How would you rate the quality of your sleep? Do you have difficulty sleeping? Have you noticed a change in sleeping pattern? <br>**Include objective cues that indicate fatigue.** |
| **9** | **Sensory-Perceptual Pattern:**<br>Describe your ability to see, hear, feel, taste, smell.<br>Share any difficulties you have in these areas. List any assistive devices utilized (glasses, hearing aids).<br> <br>**Include pain and neurological assessment.** |
| **10** | **Cognitive Pattern:**<br>What is the highest level of education achieved? What is the client’s preferred learning method/style? How do they make decisions? As you interview, you can gather information below based on their ability to respond:<br>**Level of consciousness and orientation to person, place, time. Describe their ability to understand, communicate, and recall information. Assess their decision-making ability. What is their attention span? Perform a mental status assessment if appropriate.** |
| **11** | **Role-Relationship Pattern:**<br>Describe your family. Assess roles within the family. Explore extended family and relationships within family of origin (siblings, parents, grandparents). Identify the person(s) most important in life- best friends, work friends, etc. How is your family coping with your current state of health? How would you describe communication between family members? Discuss distribution of roles in family. Describe current or past occupation. How do you feel about your work? Who is the most important person in your life? What social groups or community activities do you participate in?<br> <br>**Does the client have visitors? Is there evidence of caring (cards, flowers, balloons, phone calls)? Post-partum client: note evidence of bonding. If partner present, assess interactions/family roles.** |
| **12** | **Self-Perception-Self-Concept Pattern:**<br>Describe yourself. Has illness affected this? What are your strengths & weaknesses? How do you feel about yourself? How do you feel about your appearance? Has this changed since your illness? If client is post-partum, how does she feel about role as parent (also assess partner if present)? <br>**Note client’s interest & participation in personal hygiene, wearing own robe, slippers, etc.** |
| **13** | **Coping-Stress Tolerance Pattern:**<br>Describe the most stressful situation in your life. How has illness affected stress and Stress affected illness? How big a problem is financing health care? Have you experienced any personal loss or major life change last year? How do you typically cope with problems? What relieves stress/tension? Who do you turn to when you have problems or pressure? Do you use any substances to help relieve stress? |
| **14** | **Value-Belief Pattern:**<br>What is most important to you in life? What do you hope to accomplish? What is your major source of hope & strength? Do you have a religious affiliation? How important is this to you? Any special requests? Would you like contact with minister, chaplain, priest, shaman, etc.). Are there health practices or restrictions important for you to follow while hospitalized?<br> <br>**Observe any artifacts or talismans (prayer books, tobacco, prayer rug, medicine bag, rosaries, etc.) at bedside that provide clues to spiritual beliefs. Listen for themes in communication that indicate values & beliefs important to client.** |
**Summary:** _Bullet point out the_
_significant health concerns,_
_opportunities for health improvement, and_
_client strengths/weaknesses. Summary should address_
_psychosocial as well as_
_physical concerns. The summary should make a case for your chosen diagnosis based on the data above._
When you have completed the assessment, identify problem areas. This may be areas where the client expressed dissatisfaction or a desire for improvement, it may be areas where there is a deviation from the client’s normal level of functioning (e.g. typically has BM daily, but has not had one in 3 days; typically eats 3 well-balanced meals with snacks, but recently has lost appetite; is typically independent in all areas of daily living (meal preparation, eating, bathing, dressing, ambulation), but currently requires assistance with ambulation and bathing; describes difficulty managing current levels of stress, etc.). It is important to look at the client’s “normal”, or desired level of health, and compare it to current status based on subjective and objective data collected. Summary should include holistic data, identifying significant physical, developmental, psychological, and social issues. Then summarize the strengths/weaknesses you identified in your data that can be an asset or detriment to the client in achieving their health goals.
**HolisticAssessment-FHP.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/holisticassessment-fhp-docx-10460735)
**## FinalClinicalSummativeSelf-Evaluation_ADNG2100_ClinicalII.docx**
**Level 2:**
**Clinical Performance Evaluation- ADNG 2100 Clinical II**
· Student will complete a self-evaluation of each student learning outcome below using the criteria on the left found under each outcome. Briefly summarize, either in bullet point or paragraph form, your own evaluation of performance in each. Be specific, give examples. In areas you identify as needing growth, provide specific strategies for improvement in your next clinical course.
· Submit to the Clinical Performance Evaluation assignment folder in your clinical course by the assigned due date.
| | |
| — | — |
| **HUMAN FLOURISHING**<br>**Apply knowledge and skills learned in the program to uphold patients’ right of self-determination and promote holistic well-being of client and family.**<br>QSEN#1- Provide patient-centered care |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Apply therapeutic communication skills in interactions with client and family <br>· Identify behaviors that threaten or protect client autonomy, dignity, and rights<br>●Respect client autonomy and recognize opportunities for client advocacy<br>· Illustrate how individual differences and values affect client outcomes | |
| **Objective Data:** Holistic Assessment & Application of Nursing Process, Reflective Journal | |
| **NURSING JUDGMENT**<br>**Make judgments in practice, supported by evidence, that integrate nursing science in the provision of safe, quality care.**<br>QSEN#2- Safety, Patient and Healthcare Provider<br>QSEN#3-Informatics |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| ●Utilize the nursing process to develop an individualized plan of care<br>●Provide valid rationales for nursing interventions<br>●Communicate assessment findings to instructor and healthcare team members<br>●Submit daily care plan to instructor for review in post-clinical<br>●Utilize effective judgment and available<br>resources to provide interventions (mediation administration, dressing changes, catheterization, etc.) in a safe, efficient manner to assigned client<br>· Provide accurate client education when need arises<br>●Utilize the EMR to accurately document care provided | |
| **Objective Data:** EBP Project & Presentation, Holistic Assessment & Application of Nursing Process, Reflective Journal | |
| **PROFESSIONAL IDENTITY**<br>**Implement one’s role as a nurse in a manner that reflects the ideals of the profession while developing an identity committed to evidence-based practice, in the provision of compassionate, culturally sensitive, holistic care to a diverse population.**<br>QSEN#4- Teamwork and Multi-disciplinary Collaboration |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Actively participate in post-clinical discussion and learning activities<br>· Exhibit professional appearance and behavior (punctuality, uniform standards, equipment, etc.)<br>· Demonstrate behaviors that reflect the values and ethics of the nursing profession<br>· Exhibit professionalism in interactions with multidisciplinary team-members, peers, clients, and faculty<br>· Manages conflict effectively as it arises with mentoring from faculty and/or staff | |
| **Objective Data:** EBP Project & Presentation, Reflective Journal | |
| **SPIRIT OF INQUIRY**<br>**Examine the evidence that underlies clinical nursing practice to challenge the status quo, question underlying assumptions, and offer new insights to improve the quality of care for patients, families, and communities (NLN, 2010).**<br>QSEN #5- Quality Improvement<br>QSEN #6- Evidence based practice |
| **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
| · Identify opportunities to improve quality client care<br>· Accept responsibility for the learning process, utilizing feedback to improve practice<br>· Remain effective when confronted with change<br>· Utilize understanding of pathophysiology of disease to predict priority evidence-based interventions<br>· Apply knowledge of and appropriate use of asepsis to create a safe care environment that results in high quality patient outcomes (medication administration, handwashing, invasive procedures, etc.) | |
| **Objective Data:** EBP Project & Presentation, Holistic Assessment & Application of Nursing Process, Reflective Journal | |
**## HolisticAssessment-FHP-HealthHistoryAssignmentGuide.docx**
**HEALTH HISTORY BY FUNCTIONAL HEALTH PATTERN**
Assignment Guide
· Use this form to help guide interview questions and take notes during your client interview.
This sheet
**will be** turned into the assignment folder in D2L.
· Make sure to include both
**subjective** and
**objective** data. Subjective data is the information the client directly tells you. Objective data is information that you observe as a nurse. Objective data is in bold below.
· Utilize information from this sheet to then neatly and succinctly type and summarize information on the FHP template; students are REQUIRED to use template for final submission.
| | |
| — | — |
| **1** | **Client Profile:**<br>Bio graphics- ethnic origin, level of education, reason for seeking care, current treatments & medications, summary of significant past medical history, and allergies. |
| **2** | **Developmental History:**<br>History of growth & development, any developmental handicaps, their stated goals in life, effect of current health/illness on goals. Does the individual function at the expected developmental stage? (State stage according to Erikson & evidence of positive or negative resolution) What issues might be impacting the developmental stage? If the client does not function at expected stage, state stage they are functioning and support with cues. |
| **3** | **Health Perception-Management Pattern:**<br>Describe your health- how would you rate it on scale of 1-10, now, 5 yrs ago, & 5 yrs ahead? Describe your illness (health problem). What do you believe caused your illness? How will you care for yourself (or others) at home? What do you do when you have a health problem? Are you able to state the names of current medications you take and their purpose?<br>If this person reports having allergies, what does she/he do to prevent them? Have there been any important illnesses or injuries in this person’s life?<br>Discuss dates & history of routine health exams. What do you do to maintain your health? Flu shot, Pneumonia or shingles immunizations? Do use any substances (drugs, caffeine, tobacco, etc.)? History of exposure to toxins? How well do they comply with treatment plans? <br>**General appearance (describe the individual objectively). Vital Signs: RR, HR, BP, T., & O2sats.** |
| **4** | **Nutritional-Metabolic Pattern:**<br>Assess dietary & fluid intake: what do you typically eat/drink in a day? When was last dental exam? Any difficulty eating/drinking? Any changes in eating or drinking? Assess for N-V, indigestion, use of antacids. What is current weight? Any recent weight gains or losses?<br>**List height, weight, and BMI. Include assessment of skin, hair, nails as condition can reflect nutritional status. List any feeding precautions or if the client receives, TPN or tube feedings, or uses supplemental beverages. List use of probiotics, prebiotics, vitamins etc. Blood sugar pattern. Note if client experiences adrenal insufficiency, takes corticosteroids, or has any other endocrine problems. Labs reflecting nutritional status: glucose, electrolytes, lipid panel, protein/albumin, & BUN.** |
| **5** | **Elimination Pattern:**<br>Describe typical bowel pattern. Have there been recent changes? Quality of stool? Do you do or take anything to facilitate BM? Any history of GI surgery? When was the last BM?<br>Describe usual urinary habits. Any recent changes? Quality of urine? Problems with urination (nocturia, incontinence, frequency, dysuria)? History of bladder surgery?<br>**Provide I & O data if relevant. Bowel sounds/abdominal assessment. If surgical client, describe surgical site. Dietary intake, nausea, vomiting. Objective assessment of the urine & stool by the nurse?** |
| **6** | **Activity-Exercise Pattern:**<br>Describe a normal day. Assess ability to complete ADLs- are they independent or do they require support? Who helps? Is there anything they would like to do at home that they are unable to do?<br>What do they do for fun? Hobbies? Exercise routine? What do they do for a living? What is the relationship between work and health?<br> <br>**Include data from Respiratory, Cardiovascular, and Musculoskeletal assessment. List presence of respiratory or cardiac interventions (Chest tubes, ventilator, CPAP, oxygen) Also hematology abnormalities?** |
| **7** | **Sexuality-Reproduction Pattern:**<br>Gather data relevant to gender & age: Females-menstrual history, obstetric history, menopause, BSE; males-erectile dysfunction, prostate problems, testicular changes, TSE. Discuss: contraceptive use, perception of sexual activities, impact of health on sexuality, STDs, & any history of sexual abuse. Has this person had any past negative experiences that could affect sexual health? <br>**If the client is OB or post-partum, assess perineum, lochia, uterus (fundus), & breasts.** |
| **8** | **Sleep-Rest Pattern:**<br>Describe usual sleeping time & habits. Do you use anything to help you sleep? How would you rate the quality of your sleep? Do you have difficulty sleeping? Have you noticed a change in sleeping pattern? <br>**Include objective cues that indicate fatigue.** |
| **9** | **Sensory-Perceptual Pattern:**<br>Describe your ability to see, hear, feel, taste, smell.<br>Share any difficulties you have in these areas. List any assistive devices utilized (glasses, hearing aids).<br> <br>**Include pain and neurological assessment.** |
| **10** | **Cognitive Pattern:**<br>What is the highest level of education achieved? What is the client’s preferred learning method/style? How do they make decisions? As you interview, you can gather information below based on their ability to respond:<br>**Level of consciousness and orientation to person, place, time. Describe their ability to understand, communicate, and recall information. Assess their decision-making ability. What is their attention span? Perform a mental status assessment if appropriate.** |
| **11** | **Role-Relationship Pattern:**<br>Describe your family. Assess roles within the family. Explore extended family and relationships within family of origin (siblings, parents, grandparents). Identify the person(s) most important in life- best friends, work friends, etc. How is your family coping with your current state of health? How would you describe communication between family members? Discuss distribution of roles in family. Describe current or past occupation. How do you feel about your work? Who is the most important person in your life? What social groups or community activities do you participate in?<br> <br>**Does the client have visitors? Is there evidence of caring (cards, flowers, balloons, phone calls)? Post-partum client: note evidence of bonding. If partner present, assess interactions/family roles.** |
| **12** | **Self-Perception-Self-Concept Pattern:**<br>Describe yourself. Has illness affected this? What are your strengths & weaknesses? How do you feel about yourself? How do you feel about your appearance? Has this changed since your illness? If client is post-partum, how does she feel about role as parent (also assess partner if present)? <br>**Note client’s interest & participation in personal hygiene, wearing own robe, slippers, etc.** |
| **13** | **Coping-Stress Tolerance Pattern:**<br>Describe the most stressful situation in your life. How has illness affected stress and Stress affected illness? How big a problem is financing health care? Have you experienced any personal loss or major life change last year? How do you typically cope with problems? What relieves stress/tension? Who do you turn to when you have problems or pressure? Do you use any substances to help relieve stress? |
| **14** | **Value-Belief Pattern:**<br>What is most important to you in life? What do you hope to accomplish? What is your major source of hope & strength? Do you have a religious affiliation? How important is this to you? Any special requests? Would you like contact with minister, chaplain, priest, shaman, etc.). Are there health practices or restrictions important for you to follow while hospitalized?<br> <br>**Observe any artifacts or talismans (prayer books, tobacco, prayer rug, medicine bag, rosaries, etc.) at bedside that provide clues to spiritual beliefs. Listen for themes in communication that indicate values & beliefs important to client.** |
**Summary:** _Bullet point out the_
_significant health concerns,_
_opportunities for health improvement, and_
_client strengths/weaknesses. Summary should address_
_psychosocial as well as_
_physical concerns. The summary should make a case for your chosen diagnosis based on the data above._
When you have completed the assessment, identify problem areas. This may be areas where the client expressed dissatisfaction or a desire for improvement, it may be areas where there is a deviation from the client’s normal level of functioning (e.g. typically has BM daily, but has not had one in 3 days; typically eats 3 well-balanced meals with snacks, but recently has lost appetite; is typically independent in all areas of daily living (meal preparation, eating, bathing, dressing, ambulation), but currently requires assistance with ambulation and bathing; describes difficulty managing current levels of stress, etc.). It is important to look at the client’s “normal”, or desired level of health, and compare it to current status based on subjective and objective data collected. Summary should include holistic data, identifying significant physical, developmental, psychological, and social issues. Then summarize the strengths/weaknesses you identified in your data that can be an asset or detriment to the client in achieving their health goals.
**HolisticAssessment-FHP.docx**
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