Study Learning Outcome

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Associate Degree Nursing Program: Moorhead Campus

NURS 2437: Nursing Clinical II

Course Outcome 10: Medical-Surgical (MS) Unit

Associate Degree Nursing Program Student Learner Outcomes:

1. Nursing judgment: Demonstrate the ability to make nursing judgments using evidence-based research and clinical reasoning for quality patient care across diverse populations.

1. Patient-centered care: Recognize the patient as the source of control and a full partner in providing compassionate and coordinated care based on respect for patient preferences, values and needs.
1. Teamwork and collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect and shared decisions to achieve quality patient care.
1. Safety: Promote quality care and a safe environment for diverse populations of patients, self and others through system effectiveness and individual performance.
1. Quality improvement: Participate in quality improvement to support effective and efficient health care services.
1. Professionalism: Demonstrate accountability to professional nursing values by adhering to legal and ethical principles and participating in continuous professional development.
1. Technology: Utilize information and technology to communicate, manage knowledge, mitigate error and support decision making.
1. Leadership: Apply nursing leadership concepts in the provision of high-quality care to individuals, families and communities.

Associate Degree Nursing Course Level Student Learning Outcomes:

1. Function competently within the scope of practice as a member of the health care team.

2. Model professional behaviors within the legal and ethical frameworks for nursing.

3. Provide holistic, patient-centered nursing care utilizing the nursing process.

4. Interpret holistic assessment findings for diverse patients, integrating pathophysiology.

5. Elicit patient values, preferences and expressed needs as part of the clinical interview, implementation of care plan and evaluation of care.

6. Plan care for diverse populations integrating patient values, clinical expertise and evidence-based practices.

7. Demonstrate competency in medication administration incorporating pharmacological principles.

8. Explore continuous quality improvement as an essential part of the daily work of all health professionals.

9. Demonstrate effective use of strategies to reduce risk of harm to self or others.

10. Implement professional communication strategies that promote safe, effective care.

11. Describe own strengths, limitations and values in functioning as a member of a team.

12. Apply technology and information management tools to support safe processes of care.

MSP Rotation Objectives:

1. Adhere to professional standards as stated in Nursing Handbook

2. Provide holistic and individualized assessment and care to 1-2 patients

3. Collaborate with patient and healthcare team to achieve desired outcomes

4. Communicate effectively with patients, staff, instructor, and peers

5. Prioritize patient care needs

6. Make safe clinical decisions with supervision

7. Modify the patient’s plan of care as needed

MSP Paperwork Objectives:

1. Incorporate pathophysiology of the medical diagnosis to the nursing plan of care

2. Document holistic assessment findings

3. Discuss pharmacological principles related to patient safety

4. Incorporate lab and diagnostic data to the nursing plan of care

5. Create a holistic, patient-centered plan of care utilizing the nursing process and evidence based research

Date of Care:

Pt. Initials: DJ

Admit Date: February 1, 2025

Age: 38 years old

Sex: Male

Diet: ( Pureed diet) level 4 with wire jaw

Activity: Stable with the assistance of two

Admitting Dx: Motor vehicle accident, Hyponatremia

Equipment/Treatment: Medications/ ambulation with the assistance of two using a walker and gate belt

Co-existing Dx & Chronic Problems: UTI, tracheoesophageal, leg syndrome, and hyponatremia

Allergies: No known

1. Admission and History of Current Health problem (in detail). Write a short paragraph about why the client is hospitalized at this time:

2. List the PRIMARY diagnosis: Motor Vehicle Accident and hyponatremia.

3. Brief pathophysiological description (at the cellular level) of the primary diagnosis: (Use your pathophysiology book for this)

4. Explain this diagnosis to your patient ( in your own words-layman’s terms):

5. Discuss at least 5 concepts of health promotion to teach to your patient about this disease.

6. Complete the chart below identifying the signs/symptoms of the medical diagnosis and the potential risks from the Primary Medical Diagnosis you chose from above and use of medications.

Anticipated signs and symptoms for ANY client with the above primary disease process ONLY

(Choose 7 of the 10 body systems):

Patient Assessment (complete ALL body systems after caring for the client):

Potential Risks/Complications from the disease and/or meds

(complete ALL body systems):

Neurosensory-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

CV/Hematology-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

Immune-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

Integumentary-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

M/S-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

Respiratory-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

GI-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

Endocrine-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

GU/Reproductive-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

Mental Health/Psychosocial-

Nursing Action:

Assessment Findings:

Risks/complications from the disease:

Possible side effects from meds:

Interventions for prevention of complications:

7. Complete the table below for all meds scheduled during your shift. Include frequent PRN’s. List the remainder of the meds below the table.

Medication Sheet

Med/Dosage/Route

Frequency

(Trade/Generic)

Action of Drug

(Pathophysiology)

Why is YOUR Pt. taking this med?

Nursing Implications

1.Teaching statement in quotes

2. Nursing Actions taken

Evaluation Data

(Proof of meds effectiveness for your pt., use real client specific data)

Rifaximin 550mg

Fluticasone propionate 50mcg

Acetylcysteine 20% 600mg(3ml)

Thiamine mononitrate (V1 + B1) 100mg

Sulfamethoxazole-trimeth 800-160mg

Spironolactone 25mg

Sodium chloride 100mg

Potassium chloride 20meq

Multivit-min/iron fum/folic acid

Methocarbamol 500mg

Lidocaine 5% applied R shoulder

Lactulose 20g/30ml

Gabapentin 300mg, give 600mg

Folic acid 1mg

Cyanocobalamin (vit B12) 250mcg

Bacitracin 500unit- topically to abrasion

Petroleum, topical ointment

8. Diagnostic studies (lab & radiology) used to assess the primary dx. List all lab and diagnostic tests that are pertinent to the primary diagnosis (list here):

Laboratory Findings and Diagnostic Tests

Date/Test

Norms

Pt. Results

What is the significance of this lab/diagnostic test to YOUR client?

1. 2/1/2025/ Sodium

2. Chloride

3. CO2

4. BUN

5. Glucose

6. Creatinine

7. Calcium

8. Albumin

9. Magnesium

10. BUN/Create

11. Vitamin

12. Anion Gap

13. AST

14. Bilirubin

15. RBC

16. Hemoglobin

17. Hematocrit

18. MCHC

19. RDW-SD

20. Platelets

21. RDW

22. WBC

1. 130 (L)

2. 119 (H)

3. 21 (L)

4. 17

5. 101 (H)

6. 0.43(L)

7. 7.4 (L)

8. 1.7 (L)

9. 1.5 (L)

10. 16.7

11. 9 (L)

12. 4 (L)

13. 74 (H)

14. 2.0 (H)

15. 2.73 (L)

16. 8.3 (L)

17. 26.5 (L)

18. 31.3 (L)

19. 68.4 (H)

20. 116 (L)

21. 19.1 (H)

22. 3.7 (L)

If labs/diagnostic tests are not complete, which diagnostics do you think would be important to monitor?

Use the ISBARR template to help you prepare to give a complete, accurate, and pertinent report to the staff nurse (if able) at the end of your shift. Your instructor will observe this report and use the ISBARR grading rubric.

9. Give an example of how you collaborated with members of the health care team to provide safe, effective, and holistic care.

10. Give an example of how you efficiently communicated complete, accurate, and pertinent information.

11. Give an example of how you used appropriate channels of communication.

12. Give an example of how you communicated the care you provided.

13. Discuss how you documented complete, accurate, and pertinent information according to institutional policies.

14. Give 2 examples of how you used 2 different therapeutic communication techniques.

Include Bibliography

Minnesota State Community and Technical College - 1 - NURS2437 Nursing Clinical II

© (2025 AP, RT, MW). No portion of this syllabus may be used or shared without express permission of the author.

Revised 01/25 RT

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Use ISBARR to communicate patient status either to your primary nurse or provider before you leave the unit.

I = Identify

· Identify yourself: name, title, unit

S = Situation

· State patient name, age, reason for admission

· State the situation or problem concisely.

· What is going on with the patient right now?

B = Background

· What is the background and history of this patient?

· What has happened up to this point?

· State any relevant issues from patient’s history and present condition

· Review the chart and anticipate questions

A = Assessment

· Provide observations and evaluations of the patient’s status.

· What do you think the issue is regarding the patient’s condition?

· Do you have any concerns?

R = Recommendation

· Offer suggestions regarding what should be done to meet the patient’s immediate needs.

· What should be done to respond to this situation?

· What nursing diagnoses have been identified?

· What interventions are needed?

· Are there any interventions that should be implemented immediately?

R = Readback

· Read back any orders given to you, to be sure you understand what you are to do

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ISBARR Grading Rubric

Criteria

Unsatisfactory

Needs Improvement

Satisfactory

Introduction

Does not identify self (name, title) and unit/location

Does not identify self (name, title) or unit/location

Identifies self (name, title) and unit/location

Verbal Communication Professional, Clear, Concise, Relevant and Understandable

Does not use appropriate, professional language to communicate patient data and is difficult to understand or omits relevant patient data.

Does use clear, understandable, appropriate, professional language to communicate. Includes all relevant data with excessive irrelevant data or is not concise.

Does use clear, understandable, appropriate, professional language to communicate. Includes all relevant data without excessive irrelevant data. Communication is both clear and concise.

On time Communication

Does not notify proper team member(s).

Notifies proper team members but not in timely manner.

Notifies proper team members in a timely manner.

Situation

Demonstrates difficulty identifying patient situation or omits the situation.

Demonstrates ability to identify the patient situation but struggles with organizing data.

Demonstrates ability to identify the patient situation and organize patient data properly.

Background

Demonstrates difficulty in researching patient history and patient background to situation or omits the background information.

Demonstrates ability to research and identify patient history and patient background. However had difficulty organizing patient data.

Demonstrates ability to research and identify patient history and patient background. Able to organizing patient data properly.

Assessment

Unable to assess patient and include all important data or omits assessment data.

Able to assess patient, however missing some key data to communicate to the team member(s).

Able to correctly assess patient and communicate all important patient data to the team member(s).

Recommendations

Unable to identify what appropriate interventions are for patient.

Able to identify an intervention for patient however missing some interventions for patient condition.

Able to correctly identify all interventions appropriate for patient condition.

Read Back

Unable to correctly transcribe verbal order or did not read back verbal order(s) or incorrectly read back order(s) to provider.

Able to successfully take verbal order, used read-back and transcribe provider’s order with supervision. However, does not understand what to do with all orders.

Able to successfully take verbal order, used read-back and transcribe provider’s order with supervision. Understands what to do with all orders.

Reference:

Dunker, K. (2014). Teaching pre-licensure nursing student to communicate with SBAR in the clinical setting.

Retrieved from http://qsen.org/teaching-pre-licensure-nursing-students-to-communicate-in-sbar-in-the-clinical-setting/

Modified November 15, 2014 by Alicia Swanson and December 19, 2017 by Angie Mohr.