OB CLINICAL PERFORMANCE APPRAISAL TOOL The students should complete during the clinical period the following assignments: 1) Daily clinical log: Students will keep a daily clinical log on the provided form. Summary of strengths, weaknesses, areas for improvement, and overall impression of the day may be discussed. These will be TYPED and turned in during the semester to the clinical instructor. *This is a portfolio requirement. It should be completed and returned to the clinical instructor for a total of five clinical days (see page 3) 2) Patient teaching: The teaching plan should be done during the 6 th week of the clinical experience or by 2/27/09 (see page 4 for instructions) 3) Clinical Care Plans: There are two care plans required during the semester. The first care plan will be completed and posted on your clinical blackboard assignments by 3/27/09. The second care plan will be completed and posted on your clinical blackboard assignments by 4/17/09 (see page 5-9 for instructions and scoring) 4) Labor and Delivery, Postpartum and Newborn Assessments. Complete one assessment in each of the three areas. This information may be used to assist you in developing your first care plan. Complete and post on your clinical blackboard assignment links. (see page 11-32 for instructions) STUDENT RESPONSIBILITIES: 1. Assignments will be given for each unit by the clinical instructor. 2. Students are expected to arrive on the unit 15 minutes before the start of the experience and be ready to receive the assignment from the instructor. 3. Each student will be prepared for random oral inquiry regarding all facets of the assigned client's care utilizing the nursing process, during the clinical experience: a. nursing history and diagnosis b. family history c. physiological process d. nursing assessment e. planned nursing objectives and interventions f. significant laboratory findings 1
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OB CLINICAL PERFORMANCE APPRAISAL TOOL
The students should complete during the clinical period the following assignments:
1) Daily clinical log: Students will keep a daily clinical log on the provided form. Summary of strengths, weaknesses, areas for improvement, and overall impression of the day may be discussed. These will be TYPED and turned in during the semester to the clinical instructor. *This is a portfolio requirement. It should be completed and returned to the clinical instructor for a total of five clinical days (see page 3)
2) Patient teaching: The teaching plan should be done during the 6th week of the clinical experience or by 2/27/09 (see page 4 for instructions)
3) Clinical Care Plans: There are two care plans required during the semester. The first care plan will be completed and posted on your clinical blackboard assignments by 3/27/09. The second care plan will be completed and posted on your clinical blackboard assignments by 4/17/09 (see page 5-9 for instructions and scoring)
4) Labor and Delivery, Postpartum and Newborn Assessments. Complete one assessment in each of the three areas. This information may be used to assist you in developing your first care plan. Complete and post on your clinical blackboard assignment links. (see page 11-32 for instructions)
STUDENT RESPONSIBILITIES:
1. Assignments will be given for each unit by the clinical instructor.
2. Students are expected to arrive on the unit 15 minutes before the start of the experience and be ready to receive the assignment from the instructor.
3. Each student will be prepared for random oral inquiry regarding all facets of the assigned client's care utilizing the nursing process, during the clinical experience:
a. nursing history and diagnosisb. family historyc. physiological processd. nursing assessmente. planned nursing objectives and interventionsf. significant laboratory findingsg. client's medications: Each student is held responsible for verbalizing actions, indications, side
effects, contraindications, and nursing implications for all medications the client is to receive before administering medications. No medications are to be given unless discussed with instructor. Drug cards are recommended to facilitate the verbalization of medication information. The instructor will accompany each student, initially, during the preparation and administration of medications. Students are allowed to administer medications utilizing all routes with the exception of "IV push" medications.
h. specific nursing treatments: identify scientific principles and rationale, procedures (according to hospital policy), and needed equipment. If a student comes to clinical unprepared, the student will be asked to leave the unit and it will be counted as a missed clinical day.
4. A daily clinical log will be required for each student, for five of your clinical weeks. It may also include your thoughts of the day, assignment, etc. The log will be turned in throughout the semester for discussion with your
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clinical instructor. Completing the five logs at the end of the clinical will be unacceptable in passing the clinical experience.
5. Patient teaching the clients usually experience an array of new experiences during their hospital stay. The more knowledge and understanding of the various client experiences the student possess, the better the students ability will be to teach the client.
6. Clinical evaluations will be done at mid experience and at the end of the clinical experience. The clinical instructor will provide a sign-up sheet. Students are expected to come to the clinical evaluation session with a list of their strengths and a list of areas needing improvement.
Presentation of the postpartum discharge information will be done during the clinical rotation with the instructor
observing.
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CLINICAL CARE PLAN INSTRUCTIONS
1. Purpose: This activity enables the student to conduct an assessment of a childbearing woman and plan nursing care specific to that client, based on nursing research and Standards of Care. The assessment will include the physiologic, psychological, social, cultural, and environmental influences pertaining to the client and her family.
2. For the first care plan, the student will select a patient who has a medical diagnosis of either:
The second care plan will be developed from a simulation case study which will include priority nursing diagnoses and plan of care for labor, immediate postpartum and transition of neonate. (See Simulation Blackboard Site)
3. Select and list three NANDA nursing diagnoses based upon assessment data
4. Nursing assessments must include both subjective and objective data which supports the nursing diagnoses
Examples of data include current pregnancy, past pregnancy history, gynecological history, medical history, intrapartum course, delivery summary, postpartum status, condition of the newborn and social/cultural beliefs, values, behaviors and traditions.
5. Select the one priority nursing diagnosis from your list of nursing diagnoses and formulate a plan of care for your first care plan. Three priority nursing diagnoses for the second care plan. See enclosed Nursing Care Plan Format.
6. Develop patient focused objectives that are realistic, measurable & written as client behaviors
7. Interventions must be guided by standards of care and comprehensive in meeting your objectives such as frequency of monitoring, medications used or anticipated use, therapies such as perineal care, breast milk pumping, sitz baths, and to include a minimum of one teaching intervention.
(Standards of Care are throughout your textbook titled “Expected Outcomes of Care, Protocols for Care, Plan of Care or Care Paths”). Examples are seen on pages 253, 254, 272, 276, 362, 383,384, 389, 406, 418, 420 etc. (Lowerdemilk & Perry, 2006)
8. Sources for rationale include current literature from maternity textbooks and professional journals (not magazines or websites). Two nursing journals must be included in your citations using APA format. One article must be a nursing research article. If you have any questions regarding your choice of articles please see your clinical instructor for approval.
9. Evaluation indicates how objectives were or will be achieved; including alternative recommendations if objectives are not achieved.
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10. Must be typed. Do not use client’s name—assign a number to represent the client.
11. **The most points fall under nursing interventions and rationales. This is the most important part of your care plan. Information in these sections must be detailed and in-depth!!!
12. Points will be deducted for not following APA format for grammar, spelling, sentence structure, font, citations and bibliography as this is a strong indication of a student’s ability to follow directions.
9. Your care plan must include:
1. Clinical subjective and objective assessments (See labor and delivery, postpartum or newborn assessments for content)
2. Priority Nursing Diagnosis3. Patient Objectives4. Comprehensive nursing interventions including a teaching intervention
for one nursing diagnosis (minimum of 10 interventions)5. Rationale supported by literature citations (Author, date)6. Evaluation results or anticipated achievement of plan7. References using APA format
10. Submit complete care plan to your clinical instructor as directed in print or safe assignment.Example:
Nursing Diagnosis – sleep pattern disturbance related to anxiety about safety of fetus & outcome of pregnancy as evidenced by facial grimacing, crying, inability to initiate self care.
Patient Objectives-[STG] – After teaching, patient demonstrates relaxation techniques[LTG] – By discharge, patient sleeps for uninterrupted periods of time
Nursing Intervention (one teaching plan example given; your plan will include more interventions including a teaching plan)
1. RN will teach relaxation techniques; a. Slow-chest breathing b. Imagery
Rationale - Using relaxation techniques release tension from the mind and body and are beneficial in enhancing regular rest periods to promote uterine and fetal oxygenation (Lowdermilk & Perry, 2006).
Evaluation – Patient states this “helps me sleep!” or should relax patient to sleep 3-4 hours uninterrupted.
References
Lowdermilk, D., & Perry, S. (2006). Maternity nursing (7th ed.). St. Louis: Mosby.
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Running head: SAMPLE TITLE PAGE
Header should be 1"from top edge of paper.Running head description should be flush at themargin and two lines below the header.
Center and beginapproximately
4-inches from topedge of paper.
Title of Paper
Student Full Name
Student ID#
Site (if appropriate)
Center and begin approximately
8-inches from the topedge of paper.
Submitted in partial fulfillment of the requirements in the courseCourse NUR 318: Clinical Management of the Childbearing Family
Client Objectives NURSING INTERVENTIONS RATIONALE FOR INTERVENTIONS
EVALUATION
Subjective:
Objective:
Short term:
Long term:
(Need to be specific to the maternity client.)
Short Term:
Long Term:
Grade Sheet for Care Plan
Student TotalScore Possible
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________ 5 1. Subjective Assessment Data Age, Gravida/Para, obstetrical history, gynecological history, prenatal history, past medical
history, surgical history, family history, labor and delivery summary including date & time psychosocial and cultural history, allergies, medications, ETOH, drugs, smoking, concerns, discomforts, knowledge deficits
________ 5 2. Objective Assessment Data Vital signs, laboratory data, physical assessment findings, fetal monitoring if indicated
3. Nursing Diagnosis (3)
2 A. Appropriate for assessment data
3 B. Prioritizes significant diagnosis 5
5. Objectives
5 A. Realistic, measurable & written as client behaviors
6. Nursing Interventions
_________ 10 A. Adheres to Standards of Care
__________ 15 B. Comprehensive including teaching outline
___________ 15 C. Individualized & specific to the nursing diagnosis40
7. Rationale
_______ 10 A. Current Literature focused upon the childbearing family______ 10 B. Relevant to interventions______ 5 C. Includes relevant research and nursing journal articles
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_______ 10 8. Evaluation of how objectives were met or expected and alternative recommendations if not
Due Date: (LMP)_______ (Ultrasound)_________ Gestational Age ________ Prenatal Care Began_____________
Number of prenatal visits___________Childbirth education classes_________________
Marital Status/Significant Other_____________________________________________ Religious Preference_____________________________________________________
Admission Date____________ Admitted from: home Dr.’s office Other_________
Past Obstetrical History: Include dates of previous deliveries, Cesarean or vaginal births, forceps or vacuum extractions, length of labor, analgesia/anesthesia used, term or pre-term, weights of babies, health of infants at birth, abortions/miscarriages.
Complication(s) of this pregnancy: Include both concurrent medical diagnoses, such as diabetes, as well as problems directly caused by the pregnancy, such as PIH. Define and describe the condition(s) and current medical treatment.
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Prenatal Laboratory Findings: Postpartum Medications (Attach drug cards)
Compare the laboratory findings and describe the changes after birth. Explain if this finding is normal or abnormal:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name Dosage Route
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Past Medical/Surgical History: Summarize significant past illnesses, hospitalizations, surgeries, and/or injuries. Include dates.
PSYCHOSOCIAL ASSESSMENT : Include significant family dynamics, medical/genetic history, and psychosocial/spiritual stressors. Explain cultural beliefs that may affect the intrapartum or postpartum experience of this patient.
Ages and relationships of persons living in household:
Pregnancy planned? _________
Alcohol use: Before pregnancy? _______During pregnancy? _________________ If yes: type, frequency, amount_________________________________________ Tobacco use: Before pregnancy? _________ During pregnancy? __________ If yes: Type, frequency, amount (packs per day)__________________________ Illegal drug use: Before pregnancy? _______ During pregnancy? ___________If yes: type, frequency, amount ________________________________________ Have siblings been prepared for new baby?____How?______________________
Family Dynamics:
Medical/Genetic History:Stressors:
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Labor/Delivery Summary:
Labor began (contractions 10 min. apart and regular):
Describe FHR characteristics, including baseline rate, variability, periodic changes, and interventions if nonreassuring:______________________________________________
Coping mechanisms used during labor:_______________________________________
How was labor tolerated by this client?_______________________________________
Who provided the most support to her during labor?_____________________________
Describe what this person did that was helpful:_________________________________
Analgesia/anesthesia: Include medications, dosages, times, routes of administration, cervical dilation, effacement, and station when administered (attach cards):
Chest Circumference__________Gestational Age ________ weeks (circle one): SGA AGA LGA
Apgars: _________ 1 min. ________ 5 min. Breastfeeding Bottlefeeding
Complications of labor/delivery: ______________________________________________________________________
Length of labor: 1st Stage ___________2nd Stage___________3rd Stage_____________
Was her labor typical considering her gravida and para? ______________________________________________________________________
POSTPARTUM ASSESSMENT:
MATERNAL PHYSIOLOGIC ASSESSMENT DATACARDIOVASCULAR/ RESPIRATORYVital signs date & time ______________ T____ P____ R_____ BP_________ Heart sounds ________________ Lungs_______________________________Color of skin/ mucous membranes ______________________________________________________________
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Pre-pregnant wgt ______ Current wgt ______ Total wgt gain________________ Edema: location & amount____________________________________________ Pedal pulses _______________________________________________________Capillary refill _______________ seconds Patient questions or concerns? _______________________________________
Identify actual or potential problems related to above data and state why:
BREASTSPreferred method of infant feeding: Breast Bottle UndecidedPrior experience with preferred method? Yes NoIf yes, describe _________________________________________________________________ Breast size, symmetry, fullness _________________________________________________________________ Support bra available? _______ On?___ Breast pump needed? _______________Measures in use for lactation suppression_________________________________Presence of: Colostrum _____ Mature milk______ Engorgement __________If breastfeeding, shape of nipple (erect, flat, inverted). Nipples intact? Y N Patient questions or concerns? ________________________________________________________________
Identify actual or potential problems related to above data and state why:
UTERUS/ LOCHIALocation & firmness of fundus_________________________________________Uterine cramping? Y NIf yes, pain rating (0-10 scale):_________________________________________Methods used for pain relief & effectiveness______________________________Lochia: Color ___________ Amount _______________ Odor ________________ # pads saturated in 8 hours _______________________ Any clots?____________ Patient questions or concerns? __________________________________________________________________
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Identify actual or potential problems related to above data and state why:
INCISION (Cesarean or episiotomy)Episotomy: type _______________ Other lacerations/ extensions_____________ If C/S, type (location) ___________________ Dressing? Y N Describe incision using REEDA Redness ___ Edema ___ Ecchymosis ___ Drainage ___ Approximation______ Pain from incision / episiotomy? Y N Pain rating on 0- 10 scale __________
Pain relief methods used: Effectiveness:1. 1.2 2.3. 3.(use additional paper or back of page as needed) Patient questions or concerns? _______________________________________
Identify actual or potential problems related to above data and state why:
PERINEUM/ ELIMINATIONAny swelling, lesions, venereal warts, condyloma, hemorrhoids, etc.? __________ If yes, describe______________________________________________________ Urine: Color, odor, amount ____________________________________________ Difficulty or discomfort with voiding? Y N Bladder palpable? Y N
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Interventions to promote voiding Effectiveness1. 1.2. 2.3. 3.
Bowel sounds ____ Flatus ___ Last BM (color/ consistency/ amount)__________ Abdominal tenderness? _____ Abdomen distended?______ Patient questions or concerns? _______________________________________
Identify actual or potential problems related to above data and state why:
LOWER EXTREMITIESHoman’s Sign: R _______ L ________DTR’s : R _______ L _______ Clonus: R _______L _______ Antiembolism stockings on? Y N If yes, reason_________________________ Patient questions or concerns? _______________________________________
Identify actual or potential problems related to above data and state why:
NUTRITION/ SLEEP & RESTDiet type _____________% taken at last meal _______ Patient’s satisfaction with food served _______________________________ Cultural/ ethnic food preferences (what does patient think that a postpartum woman should eat or not eat?) __________________________________________________________
Any nausea? Y NAny vomiting? Y N Fluid intake in last 8 hours: Oral ________ IV _________ Number of hours sleep since delivery ______ Naps? _______ Feel rested?______
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What interrupts sleep?________________________________________________ Patient questions or concerns? _________________________________________
Identify actual or potential problems related to above data and state why:
TEACHING & DISCHARGE PLANNING NEEDSWhat specific teaching needs does the mother and/or family have during the hospital stay?
Mother’s or family’s opinion:
Health care provider opinion:
Your opinion:
Observe and describe each family member’s interactions with infant: Behavior Mother Father Other(Siblings, Grandparent, etc.)
Position while holding:
Response to infant cries:
Infant’s response
Proximity to infant crib:
Response to infant feeding:
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Communication with infant:
Acceptance of sex of infant:
Positive/negative comments about infant:
Evidence of bonding:
Patient concerns or questions:
Identify actual or potential problems related to above data and state why: Describe your findings as it relates to Maternal Role Attainment Theory):
Learning Needs/Discharge Planning: List three specific priority learning needs of this patient. Identify a discharge planning need other than teaching/learning:1.2.3.Discharge Planning Need
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Current Medical Orders (Lists each order excluding medications)
Patient’s order Rationale for this patient
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MEDICATION LIST(Add additional pages as needed for all sections)
Medication Dose Time Route Side Effects Significance for client
Nursing Implications
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IV Therapy
Solution Site Amount Frequency Infusion Pump
Significance for client
LABORATORY AND DIAGNOSTIC TESTS* Include prenatal labs ** Explain what the result indicates about the client’s condition
Test Date Norms* Pt results Interpretation/Analysis **
Chemistry:
Glucose
BUN
Uric Acid
Liver enzymes:
SGOT
SGPT
LDH
CBC:
Red blood cell count
Hematocrit *
Hemoglobin *
White blood cell count:
Differential
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Erythrocyte
Sed rate
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Test Date Norms* Pt results Interpretation/Analysis **
Drug therapeutic levels:
Mg SO4
Culture results:
Syphillis-VDRL/RPR/ Serology *
Chlamydia
GC
Group Beta STREP
Blood Type/Rh *
Atypical Antibodies
Urinalysis:
Urine C&S
Ultra-sound: Biophysical Profile
Fetal breathing
Fetal movement
Fetal tone
Amniotic fluid volume/index
(AFV/AFI)
Non-stress test:
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Test Date Norms* Pt results Interpretation/Analysis **