This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
วทยาลยพยาบาลและสขภาพ มหาวทยาลยราชภฏสวนสนนทาประมวลรายวชา NUR 4307 ฝกปฏบตการพยาบาลสขภาพจต
College of Nursing and Health (MIDTERM, FINAL) คดเปนรอยละ 100
1. Demonstrates professional behaviors 2. Assessment: Collects and Analyzes comprehensive client data3. Nursing diagnosis and Plans appropriate client care4. Provides safe client-centered care5. Engages in systematic and ongoing evaluation of the plan of care6. Applies knowledge relevant to client care
7. Communicates effectively 8. Uses teaching-learning process when providing
individualized client/family/group education 9. Exhibits caring to facilitate physical, mental, and
ก า ร ว น จ ฉ ยโ รค ....................................................................................................................................อาการสำาคญทนำามาโรงพยาบาล (Chief Complaints).................................................................................................................................................2. Physical and Development of the Client2.1 Present Illness and Therapies .................................................................................................................................................2.2 Past Illness and Therapies .................................................................................................................................................2.3Perception of Health Status.................................................................................................................................................2.4 Risk Factors and Drug Allergies .................................................................................................................................................2.5 Family Health History.................................................................................................................................................
.................................................................2.8 Members of Household and Marital Problems...........................................................................................................................2.9 Ability to Complete Activities of Daily Living (ADL’S)............................................................................................................................................2.10 Communication Pattern.............................................................................................................................................2.11 Long Term and Recent Memory............................................................................................................................. 2.12 Review of Systems
1) General Appearance ...........................................................................................................................................
3) Circulatory and Cardiovascular System.............................................................................................................................................
......................................................................3.8 Problem Solving.................................................................................................................................................3.9 Sexuality (การรบรเกยวกบแบบแผนทางเพศของตนเอง).................................................................................................................................................3.10 Intelligent Development (พฒนาการทางสตปญญา ผลการเรยน/ประวตการศกษา/ระดบสตปญญา).................................................................................................................................................4. Social Pattern4.1 Financial Status ...................................................................................................................................................
4.2 Recreational Activities.................................................................................................................................................4.3 Cultural Influences.................................................................................................................................................4.4 Community Resources.................................................................................................................................................4.5 Environmental Risk Factors.................................................................................................................................................4.6 Social Relationships................................................................................................................................................4.7 Family Structure and Support
......................................................................5. Spiritual Pattern5.1 Beliefs and Meaning................................................................................................................................................5.2 Religious Experiences................................................................................................................................................5.3 Fellowships................................................................................................................................................6. Mental Status Examination6.1 General Appearance1) Appearace ……………………………………………………………………………………… 2) Attitude
6.2 Speech and stream of talk1)Rate ……………………………………………………………………………………………2)Rhythm………………………………………………………………………………………………3)Volume………………………………………………………………………………………………
27
4) ความผดปกตของคำาพด………………………………………………………………………………………........... 5) Stream of talk …………………………………………………………………………………………...... 6.3 Emotion 1) Mood................…………………………………………………………………………………… 2) Affective expression …………………………………………………………………………………………..... 3) Appropriation ………………………………………………………………………………………….....6.4 Perception............................................................................................................................................6.5 Thought 1) Stream of thought …………………………………………………………………………………………..... 2) Content of thought …………………………………………………………………………………………....., 3) Abstract thinking …………………………………………………………………………………………....... 4) Concentration
28
………………………………………………………………………………………………..
6.6 Sensorium and cognitive 1) Conciousness.………………………………………………………………………………………. 2) Orientation -Time………………………………………………………………………………………-Place………………………………………………………………………………………-Person………………………………………………………………………………………
3) Memory- Immediate retention and recall ……………………………………………………………………………………… - Remote memory ………………………………………………………………………………………4) Intellectual function ………………………………………………………………………………….......6.7 Judgement………………………………………………………………………………………..6.8 Insight and motivation
10. โรคและการเปรยบเทยบกรณศกษากบพยาธสภาพของโรค..............................................................................................................................................11. Problem Lists สรปประเดนปญหาของผใชบรการ(เรยงตามลำาดบความสำาคญของปญหา)
4. สรปการเยยมบานและสรปโครงการ ( เอกสาร 1-4)นำาเสนอเปนสอการสอน CD 1 แผน
SSRU, College of Nursing and Health(CNH)PSYCHITRIC NURSINGUNDERGRADUATE CLINICAL EVALUATION TOOL
Student Name ………………………………………….Instructor/Preceptor……………………………………
Course:PSYCHITRIC NURSING NUR 4307 ฝกปฏบตการพยาบาลสขภาพจตฯSemester: ……………. Year: …………….Ward:……………….
Introduction:This clinical evaluation tool consists of 9 essential competencies with specific performance criteria. The 9 competencies were drawn from: terminal outcome objectives for the BNS program at SSRU, College of Nursing and Health. The performance criteria for each competency include cognitive, affective, and psychomotor domains of learning and provide a complete evaluation of an individual student’s clinical performance. The use of thisclinical evaluation tool makes it possible to see the student’s development over time as he/she progresses through the specific course, as well as through the nursing curriculum. It also provides standard measures for student, course, and program evaluation
This tool is to be used in each clinical course. A formal evaluation is completed and shared with the student at the conclusion of the rotation. In some courses, faculty will also use this tool for mid-rotation evaluation. The tool can also be used at other times during the rotation and can serve as the basis for a learning contract.
Note: Note: ALL text boxes in this document will expand as needed when comments are added.
Instructions: Faculty will rate students on each of 9 competencies using the
designated rating scale, considering the quality of the performance (Almost Never Exhibits to Almost Always Exhibits) and the amount of guidance required (Almost Always Requires to Almost Never Requires).
Referring to the scale below, as students improve in accuracy, safety, and efficiency, it is expected that they will require less guidance.
To determine the rating for each competency, faculty will consider student performance on the specific performance criteria and will arrive at a rating for each competency using the 1-5 scale. Instuctor/preceptor should also include comments related to each competency.
At the end of this clinical evaluation tool, faculty should write summary comments and document recommendations for further development/improvement. The faculty who wrote the evaluation will review it with the student and document the date of the meeting. Students may be asked to complete a self-evaluation at midterm and final.
Clinical faculty should discuss the tool with students at the beginning ofeach clinical rotation and describe how and when it will be used.NOTE: In these competencies:-
1.client is defined as the recipient of professional nursing services and may be an individual, family, or group.
2.Facultyis defined as the instructors or preceptors.
The Rating Scale
Self-Directed (5)
Expected Levels of
Performance: For the Final Evaluation:
Students must achieve the minimal expected level of performance for each competency in order to be determine to receive the grade of any course
Grade
Expected Level Performance
Minimum Score
Upon Completion of:
Almost Never Requires(<10% of the time)
Almost Always Exhibits(>90% of the time)
directionguidance
monitoring support
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
Supervised (4)Occasionally Requires(25% of the
time)Very Often Exhibits (75% of the time)
directionguidance
monitoring support
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
Assisted (3)Often Requires(50% of the time) Often Exhibits(50% of the time)
directionguidance
monitoring support
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
Novice (2)Very Often Requires(75% of the
time)Occasionally Exhibits(25% of the time)
direction
guidance
monitoring support
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
Dependent (1)Almost Always Requires(>90% of
the time)Almost Never Exhibits(<10% of the time)
directionguidance
monitoring support
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
B- Assisted 2.00
B Assisted — Supervised 2.50
B+ Supervised 3.00
A- Supervised — Self-directed 4.00
A Self-directed 4.50
1. Demonstrates professional behaviorsPerformance Criteria: Professional behaviors
a.Follows university, CNH, and hospital policies b. Practices within ethical frameworks of nursing
c. Assumes accountability for own actions and practices( รบผดชอบในหนาททไดรบมอบหมาย และสงทไดกระทำาลงไป)
d..Treats all individuals with dignity/respect( เคารพนบถอในความเปนปจเจกบคคล ใหเกยรต ยกยอง แนะนำาชอและ
ตำาแหนงหนาทของตนเอง เรยกชอผรบบรการ และบอกใหทราบกอนใหการพยาบาลทกครง)e. .Demonstrates cultural sensitivity( แสดงทาทยอมรบในวฒนธรรม ความเชอ ศาสนา ลทธการเมอง ชนชนf. Protects client rights (privacy, autonomy, confidentiality)g. Demonstrates initiative in seeking learning opportunities and resourcesh. Analyzes personal strengths and limitationsin providing care (จดดอย- จดเดน ในการใหบรการสขภาพ)
i.Incorporates constructive feedback for performance j. Maintains professional appearance, attitude, behavior( พฤตกรรมดานกาย วาจา ใจทเหมาะสม และทศนคตทด) k.Arrives on time for clinical (มาและกลบตามเวลาทกำาหนด)l. Notifies faculty in a timely manner if he/she will be absent or late
m. Prepares for clinical practice n. Identifies situations in which assistance is needed or
appropriatelyseeks assistance o. Report all pertinence information to the instructor/preceptor ( เชนอาการเปลยนแปลงทสำาคญ การแกปญหาทแรงดวน ฯลฯ ) p. Report to the instructor /preceptor
Faculty Comments MIDTERM Student CommentsRating:
…………………………………………………………………… …………………………………………..…………………………………………………………………… ………………………………………….. Faculty Comments FINAL Student Comment
5. Engages in systematic and ongoing evaluation of the plan of carea. Evaluates nursing interventions based on expected outcomesb. Analyzes client data for accuracy and completeness( ยายไป 2)c. Revises plan of care based on evaluation and consultationd. Involves client, significant others and health team members in evaluation process as relevant
6. Applies knowledge relevant to client carea. Demonstrates initiative to obtain needed knowledgeb. Evaluates sources of data for appropriateness,
usefulness, and accuracy
e.Integrates concepts of healthf. promotion and prevention into client careh. Identifies issues/problems in nursing
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5
1 2 3 4 5
1 2 3 4 5 1 2 3 4 5
1 2 3 4 5 1 2 3 4 5
1 2 3 4 5 1 2 3 4 5
c. Integrates theory from nursing, natural andsocial sciences to enhance client care
d. Relates pathophysiology and epidemiology ofDisease to clients’ assessment findings,medications, laboratory and diagnostic testand nursing interventions
(Case conference, Nursing care plan, case study, health teaching,group therapy, community mental Health,Portfolio)
practice that need to be improvedI. Evaluates nursing practices based on current research evidence
7. Communicates effectivelya. Demonstrate a therapeutic relationship with
clientsb. Produces clear, relevant, organized, and thorough
writingc. Exhibits timely, legally accurate, and appropriate
Documentationd. Communicates therapeutically with clients
utilizingverbal and nonverbal skills ;trust;empthy.
Listens attentively and respectfully to otherse. Is actively involved in
team building, fostering collegiality, and encouraging cooperation
f. Contributes insight and helpful information to the healthcare team/group conferences
g. Utilize correct abbreviations and medication terminology
Faculty Comments MIDTERM Student CommentsRating:
……………………………………………………………
Rating:
………………………………………………………………… … Faculty Comments FINAL Student CommentsRating:
………………………………………………………………..
Rating:
…………………………………………………………….
8. Uses teaching-learning process when providing individualized client/family/group educationa. Assesses learning needs of clients, families, and
groupsb. Assesses readiness for and barriers to learningc. Considers appropriate client characteristics in
teaching(culture, age, developmental level, and educational level)
d. Develops an appropriate teaching plan for learner needs
e. Specifies rea e. Specifies reasonable& appropriate outcome measures f. Utilizes f.Appropriate principles of teaching/learningwhen implementing a teaching plan
g. Evaluates learner outcomes, provides feedback and revises teaching plan as needed