Outcomes:

After completing this class, students should be able to:

• Continues to implement the five phases of the nursing process as a systematic approach to provide nursing care for the adult.
• Assessment
• Collects pertinent data by assessing one or two clients using the Assessment Data Collection Guide.
• Collects pertinent data from other sources:
• client’s record
• family members
• health team members
• Identifies changes in assessment data.
• Validates abnormal change in data.
• Organizes assessment data according to Maslow's basic needs.
• Nursing Diagnosis
• Begins to identify pertinent nursing diagnoses and their etiologies for the client:
• experiencing pain
• undergoing surgery
• undergoing gynecologic surgery
• with commonly occurring genitourinary, gastrointestinal, renal, pancreatic, liver, and biliary dysfunctions
• who has a fluid, electrolyte or acid-base imbalance
• who has diabetes mellitus
• Provides client-specific defining characteristics applicable to the nursing diagnoses
• Planning and 4. Outcomes
• Begins to prioritize nursing diagnoses.
• Begins to collaborate with client and/or family members to formulate expected outcomes that are:
• pertinent and related to nursing diagnoses
• realistic and measurable with critical times
• client-focused incorporating the family, sociocultural background, and spiritual beliefs
• Begins to select appropriate nursing actions that address nursing diagnoses of the adult client in a medical-surgical setting.
• Provides rationale for medications and therapeutic interventions.
• Incorporates the agency's plan of care.
• Implementation
• Performs selected nursing actions specific to expected outcomes (with occasional cuing)*. For example, postoperatively when the client returns to his room:
• positions client sidelying and assesses level of consciousness
• monitors and records vital signs q 15 min. X 1 hr., then q 30 min. X 2 hr. then q.1.h. X 4, then q.4.h. if stable
• assesses skin color and condition
• provides for warmth
• checks wound dressings and drainage systems to rule out hemorrhage and ensure patency and functioning of the latter
• maintains correct I.V. infusion at correct rate
• provides safe environment
• assesses comfort level and when client last received analgesic
• informs client of place and progress and reorients to environment.
• Involves family in nursing actions when appropriate.
• Provides for physical safety of the client.
• Documents relevant care provided.
• Evaluation
• Identifies client progress as related to expected outcomes (with occasional cuing*)
• Modifies plan of care to best meet the needs of the hospitalized adult (with occasional cuing*)
• Continues to demonstrate cognitive, psychomotor, and affective skills to ensure safe and effective practice.
• Identifies rationales for nursing actions and other therapeutic measures incorporating knowledge of relevant pathophysiology.
• Performs psychomotor skills learned in Nursing 100 safely with minimal cuing* and Nursing 101 safely with occasional cuing*.
• Applies principles of medical and surgical asepsis.
• Performs skills on time.
• Performs in a reasonable amount of time.
• Demonstrates organizational skill.
• Continues to improve dexterity.
• Begins to adapt performance to meet needs of client and/or situation.
• Administers parenteral and non-parenteral medications safely and in a timely manner
• States indications, action, contraindications, effects, and nursing considerations for prescribed medications.
• Uses effective communication techniques with clients, families, instructor, peers, and health care team:
• Recognizes a therapeutic relationship between student and client.
• Modifies environment to enhance nurse-client interaction.
• Participates in and supports constructive interaction with peers and instructor in the clinical setting and during conferences.
• Develops oral presentation skills by reporting clear, concise and relevant data to staff and instructor.
• As a Manager of care the student:
• Begins to collaborate as a health team member when providing nursing care in the medical-surgical setting.
• Begins to demonstrate organizational skill in the management of care.
• Begins to prioritize nursing care for a client in the medical-surgical setting
• Completes care for assigned clients
• Practices in a cost-effective manner:
• Organizes care to conserve time, energy and resources.
• Validates the use of supplies and equipment to minimize waste.
• As a Member within the Discipline of Nursing, the student:
• Continues to practice within the ethical and legal framework of nursing
• Follows established policies as outlined in the College and Nursing Program Student Handbooks.
• Follows established agency policies and procedures.
• Documents nursing care given with occasional cuing*
• using the agency format
• meeting legal standards
• clearly and concisely
• in a timely manner
• legibly with correct grammar and spelling.
• Reports pertinent data promptly to appropriate staff and instructor.
• Respects and supports the rights of the clients for privacy, confidentiality, and the right to refuse care.
• Begins to act as a representative of the adult client's needs and concerns when necessary. (Advocacy)
• Practices with knowledge of nurse's ethical and/or legal role/responsibility related to issues presented during previous courses.
• Continues to exhibit professional accountability
• Prepares for clinical assignment using appropriate resources.
• Seeks assistance when the clinical situation is beyond knowledge and experience.
• Seeks opportunities in the various clinical settings to enhance learning and pursue professional growth.
• Follows established lines of communication within the assigned clinical setting.
• Demonstrates reliability in completing client/clinical assignments.
• Evaluates own performance accurately.
• Accepts responsibility for own decisions/behaviors/actions while in clinical setting.
• Accepts feedback and makes appropriate changes in behavior.
• Identifies own strengths and areas for growth in adult health care settings.
• Definitions of cuing:
• No cuing: student will perform independently with no intervention by instructor.
• Minimal cuing: instructor will provide no more than 2 prompts.
• Occasional cuing: instructor will provide no more than 4 prompts