The Hashemite University Faculty of Nursing Adult Care ...1. Apply the nursing process to the basic nursing care of individual adult clients with primary emphasis on the physiological

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The Hashemite University

Faculty of Nursing

Adult Care Nursing I / Clinical Book

Semester

Reviewed and updated by:

, RNMSNMaysoon Hani Rababah

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Course syllabus

Course Title: Adult Care Nursing I/ Clinical

1. Course Number: 0702243

2. Prerequisites: 0702241 (Fundamentals of Nursing)

3. Credit Hours: 3 Credit Hours

4. Faculty:

- Office hours: With arrangement with your instructor

- Course coordinator:

- Clinical Coordinator: Course Description:

This course designed to help students to utilize knowledge and skills from adult

nursing care theory course concepts and apply it in clinical area under supervision of

instructors. The course consists of three credit hours (12 hours/ week) and occurs

throughout the course as the learner applies the concepts of each module to an

identified group of patients.

The students expected to explore and gain insight about problems experienced by

adult ill clients. In addition, this course will provide the students with opportunity to

interact, communicate, and provide nursing care to highly diversified and carefully

selected clients with different diagnosis. Methods and skills for completing health

assessment emphasized. Students expected to utilize nursing process in implementing

appropriate nursing intervention for each client according to his/her needs based on

scientific knowledge. The course includes skill observation, practice, and

performance of skills in different clinical settings.

Course Intended Learning Outcomes (ILOs):

Caring:

1. Identify the nurse’s role in health care management (disease prevention, health

promotion, maintenance, and teaching) in adults who are acutely or

chronically ill or who have multiple health problems.

2. Integrate the concept of holistic care in dealing with adult clients

3. Utilize nursing process in planning care of adult clients in a variety of health

care settings.

Communication:

1. Realize how to exhibit caring behaviors through communication, and

providing comfort and privacy.

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2. Exhibit effective professional verbal and nonverbal communication with patient,

family peers, instructor, members of the health care team and administration.

3. Demonstrate organizational skills to plan, deliver, report, and document nursing

care.

Critical thinking:

1. Utilize critical thinking skills, nursing literature based on research findings,

psychosocial, and cultural knowledge in planning care for patients.

2. Utilize nursing science and diagnostic reasoning in theory based nursing care

of individual adult clients

3. Explain scientific principles supporting basic nursing skills.

4. Assume responsibility for self-development and continued learning through

identification of personal learning goals.

Nursing therapeutic intervention:

1. Apply the nursing process to the basic nursing care of individual adult

clients with primary emphasis on the physiological mode.

2. Identify the nurse’s role in health care management (disease prevention,

health promotion, and maintenance of health) in adults who are acutely or

chronically ill.

3. Demonstrate organizational skills to plan, deliver, report, and document

nursing care.

4. Integrate the concept of holistic care in dealing with adult clients.

5. Understand principles of safety in providing care to adults.

6. Incorporate universal precautions in nursing care

7. Recognize the need for client/family teaching for specific nursing

interventions.

8. Apply the legal and ethical principles related to the scope of nursing practice

in caring for adults with acute and chronic illness.

9. Identify the importance of nursing documentation and reporting of

significant data to the health care team and instructors in a timely manner.

10. Analyze physiological actions, side effects, rationale, and nursing

implications of pharmacological agents used in the care of clients with acute

and chronic illness.

11. Integrate appropriate pharmacological interventions, nutritional measures,

and patient teaching in the clinical care experience.

12. Develop teaching/discharge/referral plans for clients and their families to

facilitate adaptation to health alteration.

Leadership:

1. Understand the collaborative nature of the professional nurse’s role as a

member of a multidisciplinary health care team.

2. Apply the legal and ethical principles related to the scope of nursing

practice in caring for adults with acute and chronic illness.

Teaching Methods:

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Interactive discussion

Audio-visual aids

Critical thinking exercises and scenarios

Clinical practice in the critical care settings at different teaching hospitals

Teaching rounds

Written assignments

Student-led seminars

Case studies

Required Textbooks: _ Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Textbook of

Medical-Surgical Nursing- 13th ed) Thirteenth, North American Edition Edition

Philadelphia: J.B. Lippincott

_ Urden, L. D., Stacy, K. M., & Lough, M. E. (2002). Thelan’s Critical Care

Nursing (4th Ed.). St. Louis: Mosby.

Recommended Texts

_ Lewis, S., Heitkemper, M., & Direksen, S. (2000). Medical Surgical Nursing:

Assessment and Management of Clinical Problems. St. Louis: Mosby

_ Phipps, W., Sands, J., & Marek, J. (1999). Medical Surgical Nursing: Concepts

and Clinical Practice. St. Louis, Mosby

_ Monhan, F., & Neighbors, M. (1998). Medical Surgical Nursing: Foundations

for Clinical Practice. Philadelphia. Saunders

_ Timby, B., and Smith, N. (2003). Introductory Medical-Surgical Nursing, (8th

Edition). Lippincott Williams & Wilkins. Philadelphia.

Course Policies:

1. Attendance: students expected to attend all class sessions. If a student cannot

attend a class session, the instructor must be notified prior to that. Per the Hashemite

University’s rules and regulations, the student’s total absences must not exceed 15%

of the total class hours. This is equal to one day clinical. Students expected to take

written and clinical exams when scheduled. If a student cannot attend a testing

session, the faculty must be notified prior to the scheduled examination. Please refer

to the Hashemite University’s Student Handbook for further explanation. Also, please

note that it is a new university policy that if a student failed to take an examination as

scheduled, there will be one make-up examination. A committee of three examiners

will present the students with a set of oral and written essay type questions. Only

students with acceptable reasons (i.e., urgent medical condition approved by the

University Health Center, death of a first-degree relative, etc.) for absence will have

the opportunity for a make-up examination.

2. Practice: There is a set of guidelines for practical training that will also be

provided to each student on a separate sheet to keep with them at hospitals. These

guidelines include:

Practical training starts at 8:00 and ends at 2:00.

The student has to manage his/her own transportation to the hospital

The student has to wear the specified uniform and shoes at all times

while at the hospital. The uniform must be clean and ironed properly.

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All students have to maintain a professional appearance. This includes

shaving for male students who do not grow their beards, and a proper

haircut, and tied hair for female students, and for those who wear a

scarf, it should not be left dangling.

It is the student’s responsibility to maintain good personal hygiene.

Jean pants are not allowed as well as colored scarves other than cream

or page.

Students are not allowed to chew gum or smoke in the clinical areas.

Students should have their break time as scheduled and shall not

exceed that.

The following items are prohibited at clinical training: bracelets, rings

other than the wedding ring, high heels or sandals, nail polish, long

nails, and improper make-up.

Every student must have the following on a clinical day: a pocketsize

note book, a pen, scissors, a torch, and a stethoscope.

Either the student has to inform the nurse in-charge or the instructor

when leaving his/her assigned clinical area.

Clinical seminar and case studies will be started and ended according

to the schedule. Students are expected to report to these learning

activities on time.

Students are expected to use proper communication skills and to be

cooperative with their instructors, colleagues, and other health team

members.

Students Must NOT perform the following:

1. Perform venipuncture alone (without instructor or assigned nurse).

2. Take verbal orders or phone orders from physicians or laboratory reports.

3. Act as a witness to signing of documents (surgical permits, etc.)

4. Carry medication/narcotic keys.

5. Give any medications IV push alone (without instructor or assigned nurse)

6. Add anticoagulant or insulin to IV solutions.

7. Insert or remove intestinal decompression tubes.

8. Insert or remove small lumen feeding tubes.

Students With Special Needs: Students with special needs should consult

with their course coordinator to be able to provide them with resources and

help when needed.

ملي لطلبة التمريض تعليمات التدريب الع

6102/7102

التعليمات

اإلجراءات في حالة المخالفة

اإللتزام بالزي العملي كامال حسب قوانين الكلية: 2

:اإلناث

o الطقم او الجلباب السكني حسب المواصفات المعلن عنها مسبقا

بيه يتم إعطاء تنفي المخالفة االولى

.أول

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وبطاقة مريول طبي ابيض يحمل شعار الجامعة الكلية، من قبل

حذاء ابيض مغلق. ابيض،ة حجاب أمير االسم،

o المناكير.يمنع وضع اي نوع من انواع المكياج او

o عمل اييمنع وضع البكل كبيرة الحجم تحت الحجاب أو غيره أو

تسريحة بالشعر.

o العين بشكل نهائي.وعدسات اإلكسسواريمنع لبس

o االظافر.االهتمام بالنظافة الشخصية مع تقليم

:الذكور

o سادة،فضفاض قماش بنطلون كحلي سماوي،قميص ازرق

كرافه كحليه )إختياري(، حذاء اسود، و مريول طبي ابيض يحمل

شعار الجامعة و بطاقة االسم.

o أن يكون الشعر قصير مع عدم وضع الجل وعدم تسريحه بطرق

غريبة.

o .حلق اللحية بشكل يومي أو تحديدها للملتحيين

o افر.االظاالهتمام بالنظافة الشخصية مع تقليم

كتاب العملي ،متر عقارب يجب أن يكون مع كل طالب سماعه طبية، ساعة ،

. كما يجب أن يتوفر مع كل مجموعة من الطلبة كتاب torch،مقص و

المادة.

على جميع الطلبه إغالق الهاتف الخلوي أثناء ساعات التدريب العملي

بإستثناء وقت اإلستراحة.

في المخالفة الثانية يتم إعطاء تنبيه

منواحدة ثاني ويخصم عالمة

comprehensive evaluation.

في المخالفة الثالثة يسمح للطالب

بدون عذر ويحتسب غياببالدوام

وعليه مراجعة المنسق العام للمادة

عالمة. 1.2حيث سيتم خصم

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حا مرتديا الزي العملي بالكامل ويستمر يبدا الدوام العملي الساعة الثامنه صبا

.الثانية تماماحتى

5:22في حال تأخر الطالب حتى

.إعطاء تنبيه أول االولى يتمللمرة

في التأخير الثاني يتم إعطاء تنبيه

منواحدة ثاني ويخصم عالمة

comprehensive evaluation.

في التأخيرالثالث يتم إعطاء تنبيه

منحدة واثالث ويخصم عالمة

comprehensive evaluation .

وعليه مراجعة منسق العام للمادة.

يحسب 0::5وفي حالةالتأخر بعد

غياب بدون عذر مع اكمال اليوم

العملي وعليه مراجعة المنسق العام

عالمة. 1.2للمادة حيث سيتم خصم

درجة ال يسمح للطالب الغياب إال في حالة دخول المستشفى أو حالة وفاة من ال :

.ومقنعاالولى ال سمح هللا أو ظرف طارئ

1.2في حالة الغياب بغير ذلك يتم خصم

comprehensiveعالمة من مجموع

evaluation عن كل غياب، ويحرم من

الواحد. المساق إذا تجاوز الغياب

ال يسمح للطالب مراجعة دكتور المساق النظري ألي أمر يتعلق بالمساق العملي 4

للمساق العملي ثم المنسق العام وثم المنسقمدرس العملي أوال جعةوعليه مرا

عن العملي.

يوجه تنبيه في حال عدم االلتزام.

على الطالب مراجعة لوحة اإلعالنات باستمرار وهو المسؤول عن أي امر معلن 2

ساعة كحد اعلى. 21فيها علما بأن مدة بقاء االعالن في اللوحة

ة عدم متابعة لوحة يتحمل الطالب مسؤلي

االعالنات.

عند استخدام حركة الباصات التي تقل الطلبة من الجامعة إلى أماكن التدريب 6

العملي:

على الطلبة التواجد في المكان المخصص الساعة الثامنة تماما

العملي.ملتزمين بالزي الرسمي للتدريب

كحد وعشر دقائقاالنطالق من المكان المخصص الساعة الثامنة

أقصى.

الطريق ألي سبب كان. والتنزيل علىعدم التحميل

داخل والمشروبات االطعمة وعدم تناولالحفاظ على نظافة الباص

الباص.

التحدث بصوت مرتفع وعدم عدم تشغيل االغاني على الموبايالت

ح للطالب الذي ال يرتدي الزي ال يسم

ويحتسب العملي بالصعود إلى الباص

بدون عذر. غياب

الطالب الذي ال يلتزم بالتعليمات اثناء

المنسق حيث سيمنع الباص يراجعركوبه

من استخدام الحركة ويتحمل مسؤولية

الوصول الي مكان التدريب العملي المحدد

له.

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داخل الباص.

.عدم التدخين داخل الباص

االلتزام بالزي الرسمي ذهابا وايابا.

من يخالف ذلك يحسب له غياب مع المنسق.ن الدوام العملي بدون إذن مسبق من ال يجوز الي طالب تغيير مكا 2

ضرورة إكمال اليوم العملي.

في حال وجود إمتحان على الطالب داخل الجامعة أثناء ساعات الدوام العملي، 5

عن هذا االمتحان قبل ومنسق المادةيجب على الطالب إبالغ مدرس العملي

ايات التنسيق لتأجيل اإلمتحان إلى يوم آخر غير اليوم ذلك لغبوع من عقده وأس

العملي.

من يخالف ذلك يحسب له غياب بدون

عذر.

seminar orإذا غاب الطالب بدون عذر رسمي ومقنع عن يوم كان عنده 9

case study or health education .او ماشابه ال يعوض له ذلك نهائيا

تحتسب له العالمه صفر

تأخر الطالب عن تسليم أو عمل متطلبات التدريب العملي حسب الموعد في حال 20

المحدد من قبل مدرس العملي أو المنسق فلن تستلم منه أبدا.

تحتسب له العالمه صفر.

في حالة وجود عذر مقبول عن الغياب يتم

تسليم متطلبات التدريب في اول يوم دوام

عملي بعد الغياب.

ب في حادثة غش )كأن يقوم بنقل ورقة عمل من زميل له في حال تم ضبط الطال 22

سبق التيفي موقع تدريب آخر او قام بتسليم متطلبات ال تخص الحالة المرضية

.استلمها(وان

سيتم رفع أسماء المشتركين في الغش إلى

رئيس القسم إلتخاذ اإلجراءات القانونية

بحقهم حسب قوانين الجامعه.

زام بالحالة المرضية التي يقوم المدرس بتسليمها له في مكان على الطالب اإللت 21

في او في االمتحانات العملية و التدريب العمليالتدريب العملي سواء كان في ايام

حال وجود أسباب قهريه تمنع الطالب من إستالمها فعليه إخبار مدرسه بها

لغايات إستالم حاله أخرى على الفور.

عينت له من قبل يتاقش في الحالة التي

المدرس.

من يتأخر عن العودة الى االقسام سيتم على الطالب اإللتزام بوقت االستراحة )نصف ساعة( يحددها مدرس العملي. :2

خصم عالمة من مجموع

comprehensive evaluation عن

كل خمس دقائق تأخير.

در داخل والكواوالزوار على الطالب التصرف بلباقة مع كل من المرضى 24

لذلك فيها،عدم إفتعال أي مشاكل أو التورط المستشفى والزمالء والمدرسين و

يتصرف بها أالمدرسه في حال وقع في أي مشكله و على الطالب أن يراجع

لوحده.

من يخالف ذلك سيتم رفع أسمه إلى منسق

اإلجراء التخاذ ورئيس القسم المادة

المناسب.

المستشفيات مثل سياسة عدم وسياسات م بقوانين على جميع الطلبة اإللتزا 22

عدم القيام بأي إجراء تمريضي يخص و المريض،على سرية والحفاظ التدخين،

المريض إال بوجود المدرس أو الممرض المسؤول عن الحالة.

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والتجمع لدى على جميع الطلبة االلتزام بعدم التواجد خارج غرف المرضى 16

لألقسام، تحت طائلة رف األطباء والتمريض او الدرج استراحات المرضى او غ

المسؤولية التأديبية.

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Evaluation Methods

Item Grade Due date Special notes

Comprehensive

clinical evaluation

10*2 Once per Rotation

Nursing Care Plan

and nursing note 5 2nd Rotation

Health Education 5 1st Rotation

Case study

2nd Rotation 10

2nd Rotation

To be

determined later

for each student

The presentation will be

bedside, individually, 30 min

for discussion, and no written

part.

Seminar

1st Rotation 5

To be determined later

for each student

*You need to submit written

part 48 hrs.before the day of

presentation.

Nursing Process

(SOPIE)

10

5

Two for evaluation at

the 1st rotation in

addition to trial one.

Once at the 2nd rotation

Bedside nursing

Care 5*2

Whole period of

training Twice per rotation

Final written exam 10 Announcement later

Final Clinical Exam 20

The last two weeks of

clinical training

Total 100%

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.

Marks distribution

Mark 2nd 1st Items

20% 10% 10% Comprehensive Evaluation 1

5% 5% Seminar 2

10% 10% Case study 3

10% 5% 5% Bed side nursing care 4

5% ------ 5% Health Education 5

15% 5% 10% Nursing Process 6

5% 5% ----- Nursing Care Plan and Notes 7

10% 10% Final written Clinical exam 8

20% Final Exam 9

100% Total Mark

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Course calendar

Monday

Tuesday

Wednesday

Thursday

1st week

2nd week

First rotation

1st week

2nd week

3rd week

4th week

5th week

Second rotation

1st week

2nd week

3rd week

4th week

5th week**

final clinical Final clinical

* simulation day for each hospital will be determined

later.

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FIRST ROTATION

Marks

Grade Student’s

Grade Item #

10% Comprehensive Evaluation 1-

5% Seminar 2-

10% Nursing Process (SOPIE)

twice / rotation 3-

5% Bed-Side Nursing Care 4-

5% Health education 5-

35% Total

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*Weekly Objectives

Date: (1st week)

Students' Objectives including :Nursing

procedure (skill), Knowledge, Health education

,Physical exam

At the end this week I will be able to :

Instructor's evaluation

goal met/ not met… as evidence

by:

1.

2.

3.

Date: (2nd week)



,Physical exam




by:

1.

2.

3.

Date: (3rd week)



,Physical exam




by:

1.

2.

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3.

Date: (4th week)



,Physical exam




by:

1.

2.

3.

Date: (5th week)



,Physical exam




by:

1.

2.

3.

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SECOND ROTATION

Marks

Grade Student’s

Grade Item #

10 Comprehensive Evaluation 1

10 Case Study 2

5 Bed-Side Nursing Care 3

5 Nursing Care Plan and note 4

5 Nursing process (SOPIE) 5

35 Total

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*Weekly Objectives

Date: (1st week)



,Physical exam




by:

1.

2.

3.

Date: (2nd week)



,Physical exam




by:

1.

2.

3.

Date: (3rd week)



,Physical exam




by:

1.

2.

3.

16

Date: (4th week)



,Physical exam




by:

1.

2.

3.

Date: (5th week)



,Physical exam




by:

1.

2.

3.

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STUDENT SUMMARY LOG (DAILY)*

interaction on each clinical date) for each patient(*List all activities

Student name:……………..........................................

Hospital name:……………………………………………………….

Instructor Notes

BRIEF summary of clinical experience

(list activities toward course objectives)

Patient case Date& date Student name

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Evaluation Tools

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Faculty of nursing

Adult Care Nursing / I

Nursing Process (SOPIE)

*Instructor's notes:…………………………… Total mark: ___/8 = ( / 5)

Medical diagnosis:

………………………………………………………

Chief complaint:

………………………………………………………………………………………….

…………………………………………………………………………………………

…………………………………………………………………………………………

Medications

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Abnormal findings in:

1. Lab results:

……………………………………………………………………………………….

…………………………………………………………………………………………

…………………………………………………………………………………………

2. Diagnostic procedures:

…………………………………………………………………………………………

…………………………………………………………………………………………

……………………………………………………………………………………….

3. physical exam

:…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

4. v/s:

………………………………………………………………………………………

Instructor sign: ……………………….

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Demographical Data:

A-Student Profile:

Student Name: ……………………………. University No.: ………………..

Instructor Name: ……………….. Date of Receiving Patient: ………………..

Area of Practice: ……………….. Rotation No: ………………..

B-Client Profile (1):

Client Name: ……………… Sex: …….. Age: …….. Unit: ………………..

Marital Status: ……………….Admission Date: ………………..

Source of Data: ……………….. Medical Diagnosis: …………………….

Chief complaint (2):

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………..

ASSESSMENT

A-Subjective Data (current health status) (2):

Statement 1. …………………………………………………………………………….

…………………………………………………………………………………………..

Statement 2…..................................................................................................................

…………………………………………………………………………………………..

B-Objective Data (10):

Physical Exam

General Appearance (1)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

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…………………………………………………………………………………………

………………………………………………………………………………………....

Findings of systems review (3)

Affected systems

“ determined according to

the case”

Normal findings Abnormal findings

Skin:

Inspection

Palpation

System of……

Inspection

Palpation

Percussion

Auscultation

System of……

Inspection

Palpation

Percussion

Auscultation

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Vital Signs (1):

Blood pressure temperature Pulse Respiratory rate

Lab-Results (2)

Test name result Test name result

Diagnostic Results (1):

Diagnostic test: ( ECG, X ray,

Ultrasound, echo…………..etc)

Results

Medication Order (2):

Scientific name Trade name frequency Route of administration

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DIAGNOSIS (3): Priority

…………………………………………………………………………………………

…………………………………………………………………………………………

PLANNING (2.5):

A-Goal (1):

…………………………………………………………………………………………

B-Objective (1.5):

………………………………………………………………………………………….

IMPLEMENTATION (6):

Interventions (With Rational) (6):

1- ………………………………………………………………………………...

…………………………………………………………………………………….

……………………………………………………………………………………..

2- …………………………………………………………………………………

………………………………………………………………………………………

………………………………………………………………………………….......

3- …………………………………………………………………………………

……………………………………………………………………………………….

Evaluation & Evidence (1.5):

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………………………….

24

Nursing Notes

Date ………………………………..

Sign

(0. 5)

*Receiving: level of consciousness & orientation, position, Present of lines, access &its patent, v/s, general appearance:

hygiene, skin color and cooperation, consideration notes (falling down, NPO, shunts, sensitivity, planned procedures….. )&

major complaint. (2)

*Nursing care: nursing assessment (focus on health problem by mention subjective and objective data, physical exam), &

Nursing planning and intervention in treating health problem at specific time. (All nursing interventions during clinical day

physically and psychological care). (4)

*Follow up care: Evaluation of patient condition related to previous nursing assessment and interventions. How the patient

health status improved. Health education (disease process, medications, diet, exercise) and discharge plan.

(3)

Organization and spelling (English wise) (2)

Time

(0.5)

25

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26

Comprehensive Evaluation Form (weekly)

Student’s Name: ……………………………... Instructor name:……………………..

Total average mark: (total score/ no. of week2) = /10

th6

week

th5

week

th4

week

rd3

week

nd2

week

st1

week Criteria

Date

1= on time

0 = late

Professionalism

2----0 1= complete

uniform

0= any

contravention

0=none

1=weak

2=fair

3=good

4=v.good

5=excellent

Assignments

(written part

required)

5 -0

0=none

1=weak

2=fair

3=good

4=v.good

5=excellent

Daily objectives

5 -0

0=none

1=weak

2=fair

3=good

4=v.good

5=excellent

municationCom

0 - 5

0= none

0.5= fair

1= good

2= v.good

3= excellent

Knowledge

*According any

part of schedule

3 -0

For each week

(total/ 2 = 10)

Total mark

27

Bedside Nursing Care Criteria (twice per rotation)

Student name: ………………………………… Medical diagnosis: ………………..

Day and Date: ………………………………… Total Mark: ( )/6 = ( )

Instructor name: …………………………….. Week number: ………………

Item In

stru

cto

r

No

tes

Fa

iled

Wea

k

Fa

ir

Go

od

V.

Go

od

Ex

cell

ent

1. Collect subjective and objective

data effectively. 0 1 2 3 4 5

2. Measure vital signs correctly. 0 1 2 3 4 5

3.Apply physical examination

appropriately 0 1 2 3 4 5

4 .Patient teaching and education

according to the needs 0 1 2 3 4 5

5. Nursing skills (insert or check cannula, blood withdrawing, suctioning….)

- Identify the unit equipment and

devices

0

.25

.75

1

1.5

2

- Provides verbal rational for the

overall procedure & its steps

0

.25

.75

1

1.5

2

- Identify nursing skill steps

according to standardized policy

0

.25

.75

1

1.5

2

- Perform nursing skills in safe,

organized and efficient way.

0

.25

.75

1

1.5

2

- Show correct understanding and

interpretation of result

0

.25

.75

1

1.5

2

28

Health Education Form

Student’s Name: …………………………….. Day and Date: …………………

Hospital name: ……………………. Medical diagnosis: ………………..

Instructor name: ……………………Total Mark = ( ) / 2= ( / 5)

Patients’ Education (once)

- Group is cooperative and

organized Notes 0 .25 .75 1 1.5 2

- Content of education is complete

and related to the patient's need

0

.25

.75

1

1.5

2

- Presentation is organized and it

shows attention

0

.25

.75

1

1.5

2

- Present materials that facilitate

understanding of the patient

(Pamphlet and brochures).

0

.25

.75

1

1.5

2

- Time management 0 .25 .75 1 1.5 2

29

Seminar Evaluation Criteria

Student’s Name: ……………………………... Day and Date: …………………

Instructor name: …………………… seminar topics: …………………..

Total Mark = ( ) / 26

Evaluation Criteria (Seminar)

Items

Grades’ scale

Failed Weak Fair Good Very

Good Excellent Instructor notes

Outline 0 1 2 3 4 5

Objectives 0 1 2 3 4 5

Introduction 0 1 2 3 4 5

Core knowledge

Thorough knowledge 0 1 2 3 4 5

Organized 0 1 2 3 4 5

Critical thinking 0 1 2 3 4 5

Nursing focusing 0 1 2 3 4 5

Presentation

Use audiovisual aids effectively 0 1 2 3 4 5

Initiate & encourage discussion 0 1 2 3 4 5

Use proper presentation skills

Proper eye contact 0 1 2 3 4 5

Clear voice 0 1 2 3 4 5

Response to questions 0 1 2 3 4 5

Accepting constructive criticism 0 1 2 3 4 5

Speak in clear & simple Language 0 1 2 3 4 5

Team work

Presenters work together well 0 1 2 3 4 5

Equal distribution of material among presenters

0 1 2 3 4 5

Effective time management & organization

0 1 2 3 4 5

Conclusion or summary 0 1 2 3 4 5

References (Specific)

E.g., (www.google .com) isn’t accepted 0 1 2 3 4 5

Written seminar ( *not the presentation material)

Complete out line 0 1 2 3 4 5

Introduction related to the core of seminar

0 1 2 3 4 5

Thorough knowledge 0 1 2 3 4 5

Organization 0 1 2 3 4 5

Research article or Pamphlet , or

brochure…etc 0 1 2 3 4 5

Conclusion or summary 0 1 2 3 4 5

References 0 1 2 3 4 5

31


Faculty of Nursing

Adult Care Nursing I/ Clinical

Clinical Care Plan

2014-2015

Instructor's notes: total mark: (-------/ 20) = ( -----/ 5%)

Medical diagnosis:

………………………………………………………

Chief complaint:

………………………………………………………………………………………….

…………………………………………………………………………………………

…………………………………………………………………………………………

Medications

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Abnormal findings in:

1. Lab results:

…………………………………………………………………………..

…………………………………………………………………………………………

2. Diagnostic procedures:

…………………………………………………………………………………………..

3. physical exam

:…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

4. v/s:

…………………………………………………………………………………………

…………………………………………………………………………………………

Instructor sign: ……………………..

Note: written part will be submitted at the same day of presentation, Submitting papers after dead lines & before non- acceptance

date.

31

1-Assessment sheet:

Demographical Data

Student profile:

Student Name……………………University No…………………………………

Instructor name: ………………… Date of receiving patient: ……………………..

Area of Practice………………… Rotation No: …………………………….…….

Client profile :( 1)

Client Name……………………… Age…………………………………….

Marital Status…………………… Medical diagnosis…………………………

Admission Date………………….. Diet (specify)……………………….….……

Source of data…………………… Date of current Surgery (if available)……

Blood Group………………………. Educational level………………

Religion……………………………………..

Assessment (subjective data)(1)

Health related habits

A: Smoking …………………………….……..

Cigarettes/day……………………………..

B: Alcohol……………………………….……..

C: Allergy………………………………………

Nutritional/metabolic pattern (1)

A: Diet :( at home)……………………….…… Prescribed Diet

………………………………………

B: Appetite…………………………………………

C: Weight changes within last 6months: …………………………………..…

D: Abnormal finding: No……. Yes (describe)

…………………………………………………………………………………………

Elimination pattern (1)

A: Bowel habits

Number of bowel movement/day …………. Last bowel movement………….

32

Abnormal finding: No……. Yes

(describe)………………………………………………………….

…………………………………………………………………………………………

B: Urinary Habits: (1)

Frequency (times/day)…………………… color……………………

Abnormal finding: No……. Yes

(describe)………………………………………………………….

…………………………………………………………………………………………

Socio-economic factors (1)

Income (average)………………..……….

Occupation………………………………..…………..

No. of household………………………………………………………….…………….

Job Satisfaction / concerns& it’s relation to present illness

…………………………………………………………………………………………

……….………… (Specify the patient own words towards his / her occupation)

Sleep/rest pattern (1)

A: Sleeping hours at night……., Am Naps……, Pm naps……

B: Medication Used: No………, yes (describe)……

C: Disturbing Factors: ………………………………

Current Health status:

Chief complaint :( 2)

(Use the patient word and try to describe the problem)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………

History of present illness :( 4)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

33

…………………………………………………………………………………………

………………………………………………………………………………………

…………………………………………………………………………………………

Current complaint (sub &obj data): (6)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Past health history

Past health problem :( co-morbidities) (2)

…………………………………………………………………………………………

……….…………………………………………………………………………………

………………………….………………………………………………………………

…………………………………………….…………………………………………..

…………………………………………………………………………………………

…………………………………………………………………………………………

34

Family History (2)

Draw family tree at three generations: Grandparents, Parents, Siblings, Children and

Grandchildren. Indicate health status of each as age and (alive or dead, Cause of death

and significant illness or problems).

Key (1):

35

Physical Exam (to general survey, integumentary system and affected systems)

A. General Survey (3)

B. Integumentary system(3)

C-affected system :-( contains inspection, palpation, auscultation, percussion

and abnormality for affected system) (6)

36

Intake/Out put

Date

and

Time

Intake (2 )

Total

intake/hrs

(1)

Output (2)

Total

output/hrs

(1)

IVF

1 n

ame

……

……

……

IVF

2 n

ame

……

……

……

Blo

od p

roduct

Infu

sed R

x

NG

T

Oral

Vom

it

Sto

ol

Drain

s

Urin

e

8 am

9 am

10am

11am

12

MD

1pm

2pm

Total

intake

Total output

Balance (1 )

………………………………………………………………………………………………….………

…………………………………………………………………………………………………….……

………………………………………………………………………………

Plan (3)

………………………………………………………………………………………………….………

…………………………………………………………………………………………………….……

……………………………………………………………………………………………………….…

………………………………………………………………………………………………………….

……………………………………………………………………………………………………………

.…………………………………………………………………………………………………………

….………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

37

……………………………………………………………………………………………………………

Test name

Lab results

(1)

Normal

value (2)

(1)

Date

&

results

Date &

results

Nursing intervention for normal and abnormal results

(2)

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

Test name

Diagnostic

procedures

Normal

value

Date

&

results

Date &

results Nursing intervention for normal and abnormal results

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

/ /14 / /14 …………………………………………………………

…………………………………………………………

…………………………………………………………

……

/ /14 / /14 …………………………………………………………

38

…………………………………………………………

…………………………………………………………

……

39

Medications

NO Name (Trade

And Scientific)

Classification

(3)

Dose,

Frequency,

and Route

(3)

Indications

(2)

Major side

Effects

(2)

Contraindications

(2)

Major nursing interventions

(3)

1

2

3

4

5

6

Nursing Process:

List the most important nursing diagnosis (priority):

Actual diagnosis:-

First Nursing Diagnosis (3)

…………………………………………………………………………………………

…………………………………………………………………………………………

Nursing Goal (1)

…………………………………………………………………………………………

Nursing Objective: (2)

…………………………………………………………………………………………

…………………………………………………………………………………………

Interventions and rationales: (3)

1. ………………………………………………………………………………

………………………………………………………………………………

2. ………………………………………………………………………………

………………………………………………………………………………

3. ………………………………………………………………………………

………………………………………………………………………………

Evaluation and Evidence: (2)

…………………………………………………………………………………………

Second Nursing Diagnosis (3)

…………………………………………………………………………………………

…………………………………………………………………………………………

Nursing Goal: (1)

…………………………………………………………………………………………


…………………………………………………………………………………………

…………………………………………………………………………………………

41

Interventions and rationales (3)

1. ………………………………………………………………………………

………………………………………………………………………………

2. ………………………………………………………………………………

………………………………………………………………………………

3. ………………………………………………………………………………

………………………………………………………………………………


…………………………………………………………………………………………

Third Nursing Diagnosis: (3)

…………………………………………………………………………………………

…………………………………………………………………………………………

Nursing Goal: (1)

…………………………………………………………………………………………


…………………………………………………………………………………………

…………………………………………………………………………………………

Interventions and rationales: (3)

1. ………………………………………………………………………………

………………………………………………………………………………

2. ………………………………………………………………………………

………………………………………………………………………………

3. ………………………………………………………………………………

………………………………………………………………………………


………………………………………………………………………………

………………………………………………………………………………

42

Case Study Evaluation Form

Student’s Name: …………………………….. Day and Date: …………………

Hospital name: ……………………. Medical diagnosis: ………………..

Instructor name: ……………………Total Mark = ( ) / 2.5 = ( / 10)

Items Mark Student Mark Notes

Demographical data 0.5

Chief complain 1.5

Histo

ry Present illness

1.5

Past illness 1

Family history 0.5

Assessm

ent

Subjective data (bedside) 1

Objective data

General appearance (bedside)

Vital signs (bedside)

Physical exam (bedside)

laboratory studies

diagnostic procedures

medications

0.5

1

1.5

1

0.25

0.75

Nursin

g care p

lan Tow Nursing diagnosis

priorities

statement

patient assessment derived

3

Goal and objective 2

Three Interventions and rationales 3

Evaluation and evidence 1

Questio

ns

(integ

rated)

Theoretical tow questions

Clinical and calculations

(bedside)

Critical thinking and challenges

2

2

1

43

skills Nursing

1. IV care, preparing for insertion of a peripheral IV cannula , IV cannula dressing -

Removal of a peripheral IV cannula - Preparation for IV therapy - Calculation of

infusion rates - Changing an IV solution, management the complications of IV access

(phlebitis, thrombophlebitis, extravasations).

2. V/S, glucocheck.

3. Preparation, administration and calculation medication.

4. Oxygenation and O2 therapy, O2 device, pulse oximeter, nebulizer, chest

physiotherapy.

5. Pre and post nursing operative care (Included Recovery room).

6. Insertion and checking cannula, withdrawing blood sample and distinguish blood

tubes.

7. Dressing and wound care (Included diabetic foot).

8. ECG procedure, basic interpretation (ECG paper component), heart rate calculation

regularly and irregularly.

9. Bedding.

10. Physical exam weekly (concordance with university labs).

11. Suction, and specimens' collection.

12. Infection control

13. Nursing intervention for normal and abnormal lab and diagnostic results

14. Nursing interventions for hypervolemia and hypovolemia.

16. NGT insertion, removing and care

17. Catheters and access care

18. Nursing implementation during pre, intra, post blood transfusion (Sample

collection - Collection of blood from storage - Pre-transfusion checks - Transfusion

monitoring - Managing acute transfusion reactions).

19. Catheterization + colostomy care

20. Documentation.

44

Seminar Topics

O2 Therapy (2nd week)

1. Indications

2. Oxygen Delivery Systems

3. Types of delivery device

4. Hazards & precaution

5. Nebulizers and inhalers

Blood components Transfusion

(3rd week)

1. Definition

2. Indications and types

3. Procedure

4. Nursing Interventions (Pre-Intra-

Post)

5. Complications

Cardiac catheterization (4th

week)

1. Definition

2. Procedure

3. Pre-operative nsg. Care

4. Intraoperative and post-

operative care

5. Complications

endoscopy and colonoscopy (5th

week)

1. Definition

2. Procedure

3. Pre-operative nsg. Care

4. Intraoperative and post-

operative care

5. Complications

45

Appendix

46

Obtaining a History of Present Illness for Pain

(PQRSTU)

P (Provocation and Palliation)

What seems to trigger it? Stress? Position? Certain activities?

Arguments?

Does it seem to be getting better, or getting worse, or does it remain

the same?

What relieves it: changing diet? Changing position? Taking

medications? Being active? Resting?

What makes (the problem) worse?

Q (Quality)

How does it feel, look or sound?

Is it sharp? Dull? Stabbing? Burning? Crushing?

If describing a discharge: Thick? Runny? Clear? Colored?

R (Region and Radiation)

Where is it?

Does it spread?

Where does the pain radiate?

S (Severity and Scale)

How does it rate on a severity scale of 1 to 10?

T (Timing and Type of Onset)

When did it begin?

How often does it occur?

Is it sudden or gradual?

How long does it last?

U (understand patients perception)

What do you think it means?

Other questions to ask:

Associated factors.

Location of pain

47

Obtaining Past History

Serious or chronic illnesses

Past surgical history

Allergies

Previous hospitalization

Accident and injuries

Family history

Medication taken at home

Pain assessment tool

Numeric scale

0 1 2 3 4 5 6 7 8 9 10 No

pain

Mild pain Moderate pain Severe pain Very sever

pain

Worst

possible

pain

Normal range of vital signs

Normal range of vital signs

Vital sign Normal value

Temperature 36.6 -37.5 °C orally

Blood pressure

category Systolic BP

(mmHg)

Diastolic

BP(mmHg)

normal <120 <80

Pre-hypertension 120-139 80-89

Stage 1 hypertension 140-159 90-99

Stage 2 hypertension ≥160 ≥100

Pulse 60-100 beat/min

Respiratory rate 12-18 breath/min

48

Guideline in writing objectives: 1. The student must write at least 4 weekly objectives

2. Objective should include new learning that student need to identify or perform

them ideally.

3. It include:

Nursing procedure (skill): dressing, ECG, suction, invasive line…)

Knowledge: identify diseases process, cause of disease,

management…)

Teaching patient or health education

Physical exam

4. The student must accompany supported materials with their planned

objectives: eg. Health education materials, steps of ideal nursing procedure…

Guideline in writing nursing note:

General concepts

1. Besides the initial entry and assessment, nursing notes include all patient care

activities such as diet, hygiene, ambulation, elimination, visits from health

care professionals or family, tests, specific problems, how addressed and how

resolved. All entry are signed and dated. Every timed entry must have a

legal signature: 1st initial, last name and legal status. “M. Nurse, BCNS”

2. Each page of nursing notes is a legal document must be dated–and signed.

3. Safety checks: Most hospital protocols require you to document that your

patient has been checked for safety at the initial entry, q 2 hours and the last

entry. This must also be included in your nursing notes.

4. When referring to another nurse in your documentation, include her 1st initial,

last name and legal title. “Pt c/o shortness of breath, P. Smith, RN notified”.

Initial entry:

When you perform your initial assessment, you will take vital signs, briefly assess the

patient’s status in all systems, and check that all ordered modalities, equipment, and

treatments are in place and properly functioning. Your initial entry will include: level

of consciousness; ability to follow directions; general status of the skin, respiratory

system, cardiac system, and bowel sounds; the status of systems related to current

diagnosis or surgery; any untoward findings; the status IVs, drainage tubes, dressings,

and any special equipment; and then end with a safety check.

07:30 Alert, awake, orientated to person place and time. Follows commands.

Skin warm and dry. Respirations unlabored @18. Apical Pulse = 82, regular.

Bowel sounds absent. Hand grasps equal. O2@ 4L via nasal cannula. IV

D5/1/2NS infusing @100 to R forearm via pump. Site clean and dry with no

swelling or redness. Abdominal dressing dry and intact. Foley draining clear

amber urine. Bed in low position, call bell in reach, siderails.____________

M. Nurse, BCNS

49

Documenting diet:

The amount of fluid in mL is recorded in the I&O sheet. In the nursing note

document the type of diet, percentage consumed, and any pertinent information :

08:00 Took 100% of low sodium, soft diet. Had difficulty swallowing chopped

meat____________________________________________________________M.

Nurse, BCNS

Documentation of complete physical assessment:

Complete your assessment before 9 a.m. and before giving any medications or

treatments. It may not all be actually completed at the same time, but

document it in one paragraph making sure that any abnormal or critical

findings are documented and reported immediately.

Ask the patient specifically when he had last BM. In addition to stating “no

complaints of constipation diarrhea or flatus”, describe your patient’s specific

status.

08:30 Awake, alert, oriented to person, place & time. Skin warm and dry.

Turgor recoil brisk. Face symmetrical. PERRLA. EOM intact. Follow spoken

commands. Mucous membranes pink & moist. Swallows without difficulty.

Neck supple, trachea midline, carotids equal, no cervical nodes palpated. JVD (-

) @ 45°. Respirations even and unlabored, rate 16. Breath sounds clear

bilaterally & A&P. Apical Pulse=72, regular. Abdomen soft, non-tender, bowel

sounds present in all 4 quadrants. No complaints of constipation, diarrhea,

flatus. States last BM yesterday evening. Urine amber, no complaints of

burning. Peripheral pulses 2+. Homan’s sign (-). Capillary refill brisk. Bed in

low position, call light within reach.

___________________________________________________________M. Nurse,

BCNS

Documentation of hygiene care:

Most institutions have a check-off list of nursing interventions for hygiene, such as

back care, pedicure, Foley care, mouth care. However, they should be included in a

nursing note. Also indicate how much of the care the patient did independently and

any pertinent observations.

09:30 Complete bath care given with mouth care, peri-care, Foley care, back

care___________________________________________________________ M.

Nurse, BCNS

Documenting ambulation:

Describe gait, strength, amount of assistance needed, how tolerated.

09:30 OOB to chair with the assistance of two staff members. Gait steady, but

51

slow. Ambulated in hallway 5 minutes. C/O “feeling tired.”, assisted back to

bed___________________________________________________________M.

Nurse, BCNS

Documenting a problem such as pain:

State the problem, what was done to solve it, and record result.

10:15 States “sharp pain” points to LLQ of abdomen, 8 on a scale of 1-10.

States “gets a little better when lying on left side.” Respirations 20. Demerol 75

mg IM R ventral gluteal site by M. RealNurse, RN. Side rails, bed in low

position, call light in

reach______________________________________________________M. Nurse,

BCNS

And the result (or evaluation of whether your intervention was successful):

11:00 States pain 3 on scale of 1-10. Watching TV______________M. Nurse,

BCNS

Documenting a physician visit, a test, therapy, treatment, specimen:

10:30 Dr. Jones in to see patient___________________________________M.

Nurse, BCNS

10:40 To x-ray via w/c for chest x-ray____________________________M. Nurse,

BCNS

11:45. Sputum Specimen to lab__________________________________M. Nurse,

BCNS

12:00 Abdominal dressing change. 8" midline, vertical abdominal incision well-

approximated. Staples intact. No redness, swelling or drainage noted. Dry sterile

dressing applied__________________________________________________M.

Nurse, BCNS

FINAL ENTRY: Verify status of your patient and include safety check

12:15 States pain “almost gone”, now a 1 on 1-10 scale. Husband visiting.

Watching TV. Side rail call bell in reach, bed in low position M. Nurse,

BCNS

51

Oxygen Delivery Systems

Method

Amount delivered FiO2

(Fraction Inspired

Oxygen)

Priority Nursing

Interventions

Nasal cannula

Low flow

1 L/min = 24%

2 L/min = 28%

3 L/min = 32%

4 L/min = 36%

5 L/min = 40%

6 L/min = 44%

Check frequently that both

prongs are in patient's

nares. Never deliver >2–3

L/min to patient with

chronic lung disease.

Simple mask

Low flow

6–8 L/min = 40–60%

Monitor patient frequently

to check placement of the

mask. Support patient if

claustrophobia is a

concern. Secure

physician's order to replace

mask with nasal cannula

during meal time.

Partial rebreather mask

Low flow

8-11 L/min = 50-75%

Set flow rate so that mask

remains two thirds full

during inspiration. Keep

reservoir bag free of twists

or kinks.

Non rebreather mask

Low flow

12 L/min = 80–100%

Maintain flow rate so

reservoir bag collapses

only slightly during

inspiration. Check that

valves and rubber flaps are

functioning properly (open

during expiration and

closed during inhalation).

Monitor SaO2 with pulse

oximeter.

Venturi mask

High flow

4–8L/min = 24–40%

Requires careful

monitoring to verify FiO2

at flow rate ordered. Check

that air intake valves are

not blocked.

52

Bloom's Taxonomy Verbs

Apply Analyze Synthesize Evaluate Knowledge Comprehend

Act

Administer

Articulate

Assess

Change

Chart

Choose

Collect

Compute

Construct

Contribute

Control

Demonstrate

Determine

Develop

Discover

Dramatize

Draw

Establish

Extend

Imitate

Implement

Interview

Include

Inform

Instruct

Relate

Report

Select

Show

Solve

Transfer

Use

Utilize

]Paint

Participate

Predict

Prepare

Produce

Provide

Break down

Characterize

Classify

Compare

Contrast

Correlate

Debate

Deduce

Diagram

Differentiate

Discriminate

Distinguish

Examine

Focus

Illustrate

Infer Limit

Outline

Point out

Prioritize

Recognize

Research

Relate

Separate

Subdivide

Adapt

Anticipate

Categorize

Collaborate

Combine

Communicate

Compare

Compile

Compose

Construct

Contrast

Create

Design

Develop

Devise

Express

Facilitate

Formulate

Generate

Incorporate

Individualize

Initiate

Integrate

Intervene

Invent

Make up

Pretend

Produce

Progress

Propose

Rearrange

Reconstruct

Reinforce

Reorganize

Revise

Rewrite

Structure

Substitute

Model

Modify

Negotiate

Organize

Perform

Plan

Validate

Appraise

Argue

Assess

Choose

Compare

Criticize

Critique

Decide

Defend

evaluate

Interpret

Judge

Justify

Predict

Prioritize

Prove

Rank

Rate

Reframe

Select

Support

Count

Define

Describe

Draw

Enumerate

Find

Identify

Label

List

Match

Name

Quote

Read

Recall

Recite

Record

Reproduce

Select

Sequence

State

Tell

View

Write

Classify

Cite

Conclude

Convert

Describe

Discuss

Estimate

Explain

Generalize

Give examples

illustrate

Interpret

Locate

Predict

Report

Restate

Review

Summarize

53

Classification of Nursing Diagnoses by Functional Health

Patterns Health Perception-Health Management:

Health-See king Behavior (Specify)

Altered Health Maintenance.

Ineffective Management of Therapeutic Regimen, Individual

Effective Management of Therapeutic Regimen, Individual

Ineffective Family management of Therapeutic Regimen.

Ineffective Community Management of Therapeutic Regimen.

Noncompliance (Specify).

Risk for Infection.

Risk for Injury.

Risk for Trauma.

Risk for Preoperative Positioning Injury.

Risk for Poisoning.

Risk for Suffocation.

Altered Protection.

Energy Field Disturbance.

Risk for Altered Body Temperature.

Nutritional-Metabolic:

Altered Nutrition: More than Body Requirements.

Altered Nutrition: Risk for More than Body Requirements.

Altered Nutrition: Less than Body Requirements.

Ineffective Breastfeeding.

Interrupted Breastfeeding.

Effective Breastfeeding

Ineffective Infant Feeding Pattern.

Impaired Swallowing.

Risk for Aspiration.

Altered Oral Mucous Membrane.

Fluid Volume Deficit.

Risk for Fluid Volume Deficit.

Fluid Volume Excess.

Risk for Impaired skin Integrity.

Impaired Skin Integrity.

Impaired Tissue Integrity.

Ineffective Thermoregulation.

Hyperthermia.

Hypothermia.

Elimination:

Constipation.

Colonic Constipation.

Perceived Constipation.

Diarrhea.

Bowel Incontinence.

54

Altered Urinary Elimination.

Functional Incontinence.

Reflex Incontinence.

Stress Incontinence.

Total Incontinence.

Urge Incontinence.

Urinary Retention.

Activity-Exercise:

Activity Intolerance.

Risk for Activity Intolerance.

Fatigue.

Impaired Physical Mobility.

Risk for Disuse Syndrome.

Self-Care Deficit, Bathing/Hygiene.

Self-Care Deficit, Dressing/Grooming.

Self-Care Deficit, Feeding.

Self-Care Deficit, Toileting.

Diversional Activity Deficit.

Impaired Home Maintenance Management.

Ventilatory weaning Response, Dysfunctional.

Inability to Sustain Spontaneous Ventilation.

Ineffective Airway Clearance

Ineffective Breathing Pattern.

Impaired Gas Exchange.

Decreased Cardiac Output.

Altered Tissue Perfusion (Renal,

Cerebral,Cardiopulmonary,Gastrointestina,Peripheral).

Dysreflexia.

Disorganized Infant Behavior.

Risk for Disorganized Infant Behavior.

Potential for Enhanced Organized Infant Behavior.

Risk for Peripheral Neurovascular Dysfunction.

Altered Growth and Development.

Sleep-Rest:

Sleep-Pattern Disturbance.

Anxiety.

Energy Field Disturbance.

Fear.

Dysfunctional Grieving.

Relocation Stress Syndrome.

(See also Self-Perception - Self-Concept)

Cognitive-Perceptual:

Pain.

Chronic Pain.

Sensory/Perceptual Alterations (Specify)

Unilateral Neglect.

Knowledge Deficit (Specify).

55

Altered Thought Processes

Acute Confusion.

Chronic Confusion.

Impaired Environmental Interpretation Syndrome.

Impaired Memory.

Decisional Conflict (Specify).

Decreased Intracranial Adaptive Capacity.

Self – Perception – Self – Concept:

Fear.

Anxiety.

Risk for Loneliness.

Hopelessness.

Powerlessness.

Self – Esteem Disturbance.

Chronic Low Self - Esteem

Situational Low Self – Esteem.

Body Image Disturbance.

Risk for Self – Mutilation.

Personal Identity Disturbance

Role – Relationship:

Anticipatory Grieving.

Dysfunctional Grieving.

Altered Role Performance.

Social Isolation.

Impaired Social Interaction.

Relocation Stress Syndrome.

Altered Family Processes.

Altered Family Processes: Alcoholism.

Altered Parenting.

Risk for Altered Parent Infant/ Child Attachment.

Caregiver Role Strain.

Impaired Verbal Communication.

Risk for Violence.

Sexuality – Reproduction:

Altered Sexuality Patterns.

Sexual Dysfunction.

Rape – Trauma Syndrome.

Rape – Trauma Syndrome: Compound Reaction.

Rape – Trauma Syndrome: Silent Re action.

Coping – Stress Tolerance:

Ineffective Coping (Individual).

Defensive Coping.

Ineffective Denial or Denial.

Impaired Adjustment.

Post – Trauma Response.

Defensive Coping.

Family Coping: Potential for Growth.

56

Ineffective Family Coping: Compromised.

Ineffective Family Coping: Disabling.

Ineffective Community Coping.

Potential for Enhanced Community Coping.

Value – Belief:

Spiritual Distress (Distress of Human Spirit).

Potential for Enhanced Spiritual Well-Being.

57

Glossary

COPD Chronic Obstructive Pulmonary Disease

HF Heart Failure

CHF Congestive Heart Failure

IHD Ischemic Heart Disease

MI Myocardial Infraction

US Unstable Angina

SA Stable Angina

CABG coronary Artery Bypass Graft

CAD Coronary Artery Disease

CRF Chronic Renal Failure

ARF Acute Renal Failure

CVA Cerebral Vascular Accident

DM Diabetic Mellitus

HTN Hypertension

TB Pulmonary Tuberculosis

HAP Hospital Acquired Pneumonia

DKA Diabetic Ketoacidosis

ESRD End Stage Renal Disease

PT Prothrombin Time

PTT Partial Prothrombin Time

BT Bleeding Time

RBCs Red Blood Count

WBCs White Blood Count

HB Hemoglobin

KFT Kidney Function Test

LFT Liver Function Test

BUN Blood Urea Nitrogen

CRE Creatinine

58

PPD Purified Protein Derivative

BCG Bacilli – Chalmette Guerin

IS Incentive Spirometry

CT chest tube, computed tomography

U/S Ultrasound

DX Diagnosis

ERCP Endoscopic Retrograde

Cholangiopancreatography

NPO Nothing by Mouth

N&V Nausea & Vomiting

ICP Intracranial Pressure

ICU Intensive Care Unit

IDDM insulin dependent diabetes mellitus

ARDs Acute Or Adult Respiratory Distress

Syndrome

BA Bronchial Asthma

CF Cystic Fibrosis

PTCA Percutaneous Transluminal Coronary

Angiography

PCI Percutaneous Coronary Intervention

CO Cardiac Output

SV Stroke Volume

SOB Shortness of Breath

ACS Acute Coronary Syndrome

DOE Dyspnea on Exertion

PND Paroxysmal Nocturnal Dyspnea

DVT Deep Vein Thrombosis

DF Diabetic Foot

UGB Upper Gastrointestinal Bleeding

PE Pulmonary Edema

Pulmonary Embolism

CAP Community Acquired Pneumonia

59

ALP Alkaline Phosphatase

ALT Alanine Transaminase, Alanine

Aminotransferase

AST Aspartate Aminotransferase

C&S Culture and Sensitivity

CBG Capillary Blood Glucose

CBC Complete Blood Count

BS Blood Sugar

ABGs Arterial Blood Gases

FBS Fasting Blood Sugar

RBS Random Blood Sugar

LDL Low Density Lipoprotein

HDL High Density Lipoprotein

INR International Normalize Ratio

CPT Chest Physiotherapy

MV Mechanical Ventilator

ICD Implantable Cardioverter Defibrillator

CXR chest x-ray

DIC Disseminated Intravascular Coagulation

FX fracture

KVO keep Vein Open

ADH Antidiuretic Hormone

IBD inflammatory bowel disease

IVP intravenous pyelography

KUB kidney, ureter, bladder

61

Normal value of diagnostic study

HEMATOLOGY VALUES

Red Blood Cell Values

4.6 – 6.2 * 10*12/L RBC (Male)

4.2-5.4 * 10*12/L RBC (Female)

White Blood Cell Values

4.500-11.00/cu mm WBC

45-73% Neutrophils

20-40% Lymphocytes

2 - 8% Monocytes

0-4% Eosinophils

0 -1% Basophils

Hemoglobin Values

13 - 18 g/dL Hgb (Male)

12 - 16 g/dL Hgb (Female)

Hematocrit Values (HCT) or packed

cell volume (PCV)

42-52% Hct (Male)

35 - 47% Hct (Female)

KFT:kidney function test

(0.7-1.4) mg/dl. Creatinine

10-20 mg/dl Blood Urea Nitrogen (BUN)

135-145 mEq/L Sodium (Na+)

3.5-5.0 mEq/L Potassium (K)

2.5-8mg/dl uric acid

LFT : liver function test

Total: 0.3 -1.0 mg/dl

Direct(conjugated): 0.1-0.4 mg/dl

Indirect (unconjugated): 0.1-0.4 mg/dl.

Bilirubin:

3.5-5.5 g/l Albumin

male 10-40u/ml

Female 15-30u/ml

AST(SGOT)

male 10-40u/ml

Female 8-35u/ml

ALT (SGPT)

50-120 u/m Alkaline phosphatase

ELECTROLYTE

2.5-4.5mg/dl. Phosphorus

8.6 -10.2 mg/dl Calcium (Ca)

97-107 mEq/L Chloride (Cl)

1.3-2.3 mg/dL Magnesium

2.5 - 4.5 mg/dL Phosphorus

LIPID profile

150-200 mg/dL Cholesterol (total)

Male 35-70 mg/dL

Female 35-85 mg/dL High density lipoprotein : HDL

61

Desirable level:

Less than 160 mg/dl if no

coronary artery disease or less

than 2 risk factors.

Less than 130 if no coronary

artery disease and 2 or more risks

factors.

Less than 100 mg/dl if coronary

artery disease present.

Low density lipoprotein : LDL

100-200 mg/dL

Triglycerides

COAGULATION

21 - 35 seconds PTT

140,000 - 450,000 / ml Platelets

9.5-12 seconds PT

Lower limit of normal :20-25 seconds

Upper limit of normal:32-39 second PTT

1.0

2-3 for therapy in AF, DVT and PE.

2.5-3.5 for therapy in prosthetic heart

valves

INR

1.5-9.5 minutes Bleeding time

CEREBRAL SPINAL FLUID

Clear Appearance

40 - 80 mg/dL Glucose

70 - 180 mm/H2O Pressure

16 - 45 mg/dL Protein

0 - 5 cells Total cell count ( WBC's)t

ARTERIAL VALUES

7.35 - 7.45 pH

35 - 45 mm Hg PaCO2

19-25 mEq/L HCO3

95 - 99% O2 sat

85 - 95 mm Hg PaO2

-5 to +5 mmol/L

BE

URINE VALUES

Straw Color

1.003 - 1.040 Specific Gravity

4.6 - 8.0 Ph

75-200 mEq/24hr Na

26-123mEq/24hr K

150 mg/24hr Protein

250-900 mOsm/kg Osmolality

CARDIAC MARKERS

<0.35 ng/ml Troponin I

< 0.2 ng/ml Troponin T

62

5-70 ng/ml Myoglobin

Male:50-325 mU/ml

Female:50-250 mU/ml Creatine phosphokinase (CPK)

GENERAL CHEMISTRY

15-45 mg/dL Ammonia

60-160 U/dL Amylase

Fasting 60 - 110 mg/dL .

Postprandial(2hr)65-140 mg/dL Glucose

275 - 300 mOsm/kg Osmolarity

6-8 gm/dL Protein (total)

Reference:

Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Textbook of

Medical-Surgical Nursing- 13th ed) Thirteenth, North American Edition Edition

Philadelphia: J.B. Lippincott

_ Urden, L. D., Stacy, K. M., & Lough, M. E. (2002). Thelan’s Critical Care

Nursing (4th Ed.). St. Louis: Mosby.

63

Medications Assignment 2016/2017

At the end of the training, the nursing student should know the following

information about this medications list: Trade name

Scientific name

Classification

Indication

Side effect

Nursing consideration

Medication List: 1. aspirin(salicylic acid) 2. paracetamol (acetaminophen) 3. atenolol (hypoten) 4. angiotic (enalopril) 5. plasil (metaclopramide) 6. zantac(rantidine) 7. insulin 8. daonil (glibenclamide) 9. ventolin (sulbutamol) 10. hydrocortisone 11. lasix (frusamide) 12. aldactone (spironalctone) 13. heparine 14. warfarin 15. atropine 16. adrenalin 17. digoxin 18. isosorbid dinitarate (isoket) 19. diclofanic sodium (voltarin) 20. morphine 21. pethidine 22. ampicillin 23. flagyl 24. ceftriaxone 25. vancomycin

64

Clinical Training Schedule for nursing skills

Date Week

Number Skills

Rotation one:

. week st1 vital signs

week nd2 I.V fluids (types, calculation, cannula dressing and

insertion)

week rd3 Medication checklist, orders, and oral medication

administration

week th4 Pre-operative and post-operative nursing receiving

week th5 O2 Therapy, nebulizers and inhalers

Rotation two:

week th6 Glucocheck

S.C and insulin therapy

week th7 I.M injection

Blood sampling and tubes

week th8 ECG & HR calculation

week th9 Medication preparations from ampules and vials

Sensitivity test & I.D injections

week th10 Wound dressing

Schedule of physical exam application

65

Date Week

Number Skills

Rotation one:

. week st1 General appearance

week nd2 Skin, nails and hair

week rd3 Respiratory system

week th4 Cardiac system

week th5 Head and neck

Rotation two:

week th6 Peripheral Vascular system

week th7 Abdomen

week th8 Musculoskeletal system

week th9 Neurological system

week th10 Revision for all systems

Schedule for medications discussion

66

Date Week

Number Skills

Rotation one:

. week st1 aspirin(salicylic acid)

paracetamol (acetaminophen)

week nd2

atenolol (hypoten)

angiotic (enalopril)

daonil (glibenclamide)

week rd3 lasix (frusamide)

aldactone (spironalctone)

week th4

diclofanic sodium (voltarin)

morphine

pethidine

week th5 ventolin (sulbutamol)

hydrocortisone

Rotation two:

week th6

insulin

heparine

warfarin

week th7 ampicillin

ceftriaxone

week th8 flagyl

vancomycin

week th9 digoxin

isosorbid dinitarate (isoket)

week th10 plasil (metaclopramide)

zantac(rantidine)

Documents

The Hashemite University Faculty of Nursing Adult Care ...1. Apply the nursing process to the basic nursing care of individual adult clients with primary emphasis on the physiological