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NAPA VALLEY COLLEGE

ASSOCIATE DEGREE PROGRAM


IN NURSING

NURS 249 NURSING IN


HEALTH ALTERATIONS IV

SPRING 2013

NAPA VALLEY COLLEGE


ASSOCIATE DEGREE PROGRAM IN NURSING
Course Information ................................................................................................................... 1
Course Description .......................................................................................................... 2
Course Outcomes............................................................................................................ 5
Unit I Nursing Care of Children with Acute, Complex Illness ............................................. 6
Unit II Alterations in the Nervous/Sensory System ........................................................... 11
Unit III Alterations in the Integumentary System ............................................................... 17
Unit IV Alterations in Cellular Growth/Immunity ................................................................ 22
Unit V Alterations in the Endocrine/Metabolic System ...................................................... 29
Seminars.................................................................................................................................. 34
Helping children adapt to the hospital environment........................................................ 35
Organizing Client Care .................................................................................................. 36
Head Injury & Spinal Cord Injury.................................................................................... 41
Chronic Neurologic Alterations ...................................................................................... 44
Epilepsy / Seizure Disorders Across the Lifespan .......................................................... 46
Ethical Cases & Legal Cases ........................................................................................ 55
Burn and Inhalation Injury .............................................................................................. 58
Shock, Shock/MODS ..................................................................................................... 61
Prioritizing Care ............................................................................................................. 64
Using Nursing Process to Care for Clients Diagnosed with Cancer ............................... 65
Complimentary and/or Alternative Medicine................................................................... 66
Multidisciplinary Care for Clients with Cancer ................................................................ 67
Rectal Cancer Care ................................................ ..68
Cancer Presentation and Paper..................................................................................... 74
Endocrine Case Studies ................................................................................................ 77
Endocrine Disorders .......................... 81
Acute Liver Failure / Acute on Chronic Liver Failure ......................................................84
Alcoholic Liver Disease and ETOH Withdrawal
88
Assertive Behavior and Evaluation ................................................................................ 89
Delegating Nursing Care ............................................................................................... 91
Evaluating Performance ..92
Skills Lab ................................................................................................................................. 93
Peripheral Infusion Therapy........................................................................................... 94
Assumption of Risk Form............................................................................................... 98
Clinical Guidelines Medical/Surgical ................................................................................. 99
Kaiser Driving Directions ........................................................................................... ..100
Guidelines .. ... 101
Clinical Preparation and Written Assignments ............................................................. 102
Student Evaluation by RN...103
Clinical Self Evaluation ................................................................................................ 104
Medication Assignment Form ...................................................................................... 105
Specialty Rotation Guidelines .............................................................................................. 106
ICU .............................................................................................................................. 107
ER ............................................................................................................................... 108

Oncology Outpatient .................................................................................................... 109


Radiation Therapy ....................................................................................................... 110
Cardiac Catheterization Lab ........................................................................................ 111
Outpatient Surgery ...................................................................................................... 112
ER Ambulance Team ............................................................................................... 113
Clinical Experience in a Community Agency ................................................................ 114
Student Evaluations in Specialty Rotations .................................................................. 115
Clinical Evaluation Tool Medical/Surgical ........................................................................ 116
Pediatric Clinical Guidelines ................................................................................................ 125
Directions to Sutter/Sacramento Clinical Site............................................................... 126
Directions to: Childrens Hospital, Oakland ................................................................. 127
Guide for Health History & Interview of Child and Family ............................................. 128
Child Data Base .......................................................................................................... 129
Lab Values & Diagnostic Tests .................................................................................... 131
Medication Assignment Form ...................................................................................... 132
Nursing Care Plan ....................................................................................................... 134
Student Evaluation Pediatric Rotation....................................................................... 136
Clinical Evaluation Tool Pediatrics ................................................................................... 137

COURSE INFORMATION

NAPA VALLEY COLLEGE


ASSOCIATE DEGREE PROGRAM IN NURSING
COURSE NUMBER AND TITLE:

NURS 249 Nursing in Health Alterations IV

COURSE DESCRIPTION:

Focus is on the application of the nursing process for clients


with multiple complex health alterations. The student functions
in the roles of manager and provider of care.

PREREQUISITES:

NURS 246; 247; NURS 248


245 Advanced Placement LVN/Paramedic Bridge (as
applicable)

NUMBER OF HOURS:

Total Credit:
Class:
Clinical/Lab:

7 units
4 units (72 hours of lecture/seminar)
3 units (162 clinical hours)

NOTE: Clinical hours include Medical-Surgical and Pediatric


clinical rotations, orientation hours associated with these
rotations and Simulation hours as follows:
M/S Clinical
M/S Simulation
Pediatrics Clinical
Pediatric Simulation

104.0
6.5
45.0
6.5

Theory Classes
Monday 0800-1200
Thursday 1000-1200
Seminar
Monday 10-12
Clinical Hours
Per assigned facility
REQUIRED TEXT / ONLINE

Syllabus NURS 249


2011-2013 ADN Student Handbook

RESOURCES:
Ackley, B. J., & Ladwig, G. B. (2011) Nursing diagnosis
handbook: A guide to planning care. (9th ed.). St. Louis:
Mosby.
Ball, J.W., & Bindler, R.C., (2012). Pediatric nursing: Caring
for children (5th ed.). New Jersey: Prentice-Hall
Ball, J.W.,& Bindler, R. C., (2012). Clinical skills manual for
pediatric nursing. (5th ed.). New Jersey: Prentice-Hall.
Castillo, S. (2009). Strategies, techniques and approaches to
thinking. (4th ed.). Philadelphia: W.B. Saunders.
Ebersole, O., & Hess, P. (2009). Geriatric nursing & healthy
aging. St. Louis: Mosby. (3rd ed.)
2

Elkin, M. K., Perry, A. G., & Potter, P. A. (2012). Nursing


interventions & clinical skills. (5th ed.) St. Louis: Mosby.
Hogstel, M. O., & Curry, L. C. (2005). Practical guide to health
assessment throughout the lifespan. (4th ed.) Philadelphia: F.
A. Davis.
Lewis, S. M., Hertkemper, M., & Dirksen, S. R. (2011).
Medical-surgical nursing assessment & management of
clinical problems. (8th ed.) St. Louis: Mosby.
Nursing Skills Online course to accompany Fundamentals
Of Nursing
Ogden, S. J. (2007). Calculation of drug dosages.(8th ed.) St.
Louis: Mosby
Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing
(7th ed.). St. Louis: Mosby.
Purnell, L.D., (2009). Guide to culturally competent health
care. (2nd ed.)Philadelphia: F.A. Davis

DRUG REFERENCE
OPTIONAL TEXT

Ackley, B. J. & Ladwig, G. B., 2011. Nursing Diagnosis


Handbook: An Evidence Based Guide. (9th ed) St. Louis:
Mosby Elsevier
Deglin, J. H., & Vallerand, A. H. (2011). Davis drug guide for
nurses. (12th ed.). Philadelphia: F.A. Davis.
Elkin, M. K., Perry, A.G., & Potter, P. A. (2007), Nursing
Interventions and Clinical Skills. (4th ed) St. Louis: Mosby
Evolve/Reach HESI Ticket for online
Gahart, B. L., & Nazareno, A. R. (2013), Intravenous
Medications. (29th ed) St. Louis: Mosby
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., &
Camera, I.M. (2011). Medical-Surgical Nursing Assessment &
Management of Clinical Problems. (8th ed) St. Louis: Mosby
Elsevier
Mosbys 2011 Nursing Video Skills 3.0 DVDs
Skidmore-Roth. (2013) Mosbys nursing drug reference.(26th
Edition) St. Louis: Mosby.

Whitehead, D.K., Weiss, S.A., & Tappen, R.M. (2010).


Essentials of Nursing Leadership and Management. (5th ed)
Philadelphia: F. A. Davis Company
TEACHING METHODS:

The theory portion of this course is taught primarily by lecture,


class discussion, small group discussion, and seminars both in
person and on-line. The clinical portion includes simulation
and demonstrations in addition to the in hospital clinical
rotations.

EVALUATION:

To successfully complete this course, the student must achieve:


1. A minimum of 90.00% on the Drug Calculation Competency
Exam. Student may retest once and must have a minimum
of 90%.
2. A cumulative average of a grade of C (75.00%). This will
include all tests, papers, and presentations
3. A satisfactory summative clinical performance evaluation in
both Pediatric and Adult Medical-Surgical Clinical.
4. A satisfactory preparation for and participation in seminars.
5. A satisfactory completion of all written assignments on both
the theory and clinical components of the course.
6. A satisfactory background clearance.
7. Up-to-date health records and CPR card.
8. Satisfactory attendance (see below)
Class/Seminar Attendance:
Regular attendance in all classes is important for satisfactory
academic progress. The Napa Valley College attendance
regulations make provisions for a limited number of unavoidable
absences. However, a student who is absent for as many times
as a class meets each week will have exhausted this provision.
An instructor may request verification of those absences.
Further absences may cause the instructor to drop the student
from the class. An alternative assignment (for seminar), due at
the beginning of the next class will be given to students who are
absent. Students will be graded on participation, preparation
and compilation of assignments.

NAPA VALLEY COLLEGE


ASSOCIATE DEGREE PROGRAM IN NURSING
Course Outcomes
NURS 249 Nursing in Health Alterations IV

I.

Use the nursing process for the care of clients with multiple complex alterations in health

II.

Practice in accordance with safe, ethical, and legal guidelines in the Nurse Practice Act,
ANA Code of Ethics and Nurse Practice Standards

III.

Collaborate with clients and the interdisciplinary team using informatics and therapeutic
communication to promote client-centered care

IV.

Evaluate theory, quality monitors, and evidence-based knowledge for decision making to
guide nursing practice and client outcomes

V.

Manage client-centered care for clients with multiple complex alterations in health in
collaboration with client and interdisciplinary team

VI.

Demonstrate consistent commitment to continued professional growth and self-development

UNIT I NURSING CARE OF


CHILDREN
WITH ACUTE, COMPLEX ILLNESS

UNIT I NURSING CARE OF CHILDREN WITH ACUTE, COMPLEX ILLNESS


RELATED ACTIVITES ASSIGNMENTS

REVIEW:
Physical and psychosocial developmental tasks, fears, nutrition, and play/activities for each
age group: infant, toddler, pre-school child, school-age child and adolescent
CPR for infants and children
NURS 141, Unit II Health
Videos on Pediatric Assessment
Age-Specific Learning Resource Guide, NURS 141
Ball, J.W., Bindler, R.C., & Cowen, K. (2012), Principles of Pediatric Nursing: Caring for
Children. (5th ed) New Jersey: Pearson Education, Inc. Hall
o Chapter 1 Nurses Role in Care of the Child (Hospital, Community, & Home)
o Chapter 6 Introduction to Health Promotion and Health Maintenance
o Chapter 10 Nursing Considerations for the Child in the Community
o Chapter 12 Nursing Considerations for the Child with a Chronic Condition
o Chapter 13 The Child with a Life Threatening Condition and End of Life Care
o Chapter 14 Infant, Child, and Adolescent Nutrition
o Chapter 15 Pain Assessment and Management
o Chapter 17 Assessment and Management of Social and Environmental Influences
on Children
READ:
Ball, J.W., Bindler, R.C., & Cowen, K. (2012), Principles of Pediatric Nursing: Caring for
Children. (5th ed) New Jersey: Pearson Education, Inc. Hall
Chapter 11, The Hospitalized Child
WEB RESOURCES:
Iannelli, V Helping Your Child In An Emergency. Would you know what to do? (2006, June 14).
About.com Guide
http://pediatrics.about.com/cs/pediatricadvice/a/emergencies.htm
Roadmap to Teen Health. This counseling tool has been developed by the American Academy of
Nurse Practitioners (Supported by an educational grant from Merck)
http://www.aanp.org/images/documents/educadtion/RoadmapToTeenHealthFlipchart.pdf
Roadmap to Teen Health PowerPoint
http://www.aanp.org/education/education-toolkits
Safety Matter Pediatric Medication Guide from the American Academy of Nurse Practitioners and
National Association of Pediatric Nurse Practitioners
This flipchart is supported by an educational grant from McNeil Consumer Healthcare.
http://www.aanp.org/images/documents/education/safetymatterspediatricmedicationguide.pdf
SEMINAR:
Helping children adapt to the hospital environment

Theory Objectives
The student will (be able
to):

Content Outline

1. Describe how client


centered care, teamwork
& collaboration,
evidenced based
practice, quality
improvement, safety, and
informatics are used in
the nursing care of
children with acute,
complex illnesses

I. Nursing Care of Children with Acute,


Complex Illness

2. Describe the healthcare


needs of the children of
the 21st century.
3. Describe the leading
cause of death, accident
and injury in children at
each developmental
level.

4. Identify factors that


influence the nursing
care of children and their
families.

6. Describe how ANA


standards of Maternal
Child Nursing contribute
to quality of care for
children and their
families.

1.

Adapt the nursing


process to provide care
for children of all ages
and their families.

2.

Use information
technology and
communication
techniques, play therapy
and age specific
teaching strategies to
minimize the stress of
illness and
hospitalization and to
provide anticipatory
guidance for the child
and family.

3.

Provide client-centered
care that is comfortable,
safe, and accurate to
children and their
families.

4.

Use effective measures


to assess, intervene and
evaluate pain.

5.

Use legal reporting


requirements of the
nurse

A. Healthcare needs of children

B. Mortality
C. Morbidity
1. Developmental characteristics
that lead to accidents
2. Characteristics of accident
prone children
3. Prevention
4. School and community
agencies available
D. Influencing factors
1. Type of family group
2. Cultural heritage
a. Prevalent health problems
in specific cultures
b. Influence on health
behaviors
3. Socioeconomic status
4. Environment
5. Concept of time
E. Barriers to care

5. Describe some barriers


to healthcare of children.

Lab/Clinical Objectives
The student will (be able
to):

F. Quality of care ANA standards

G. Nursing process, guide to care,


assessment, and nursing
approach

Theory Objectives
The student will (be able
to):
7. Identify how nursing
process guides the
nursing care of the child
and their family in a
variety of settings.
8. Describe the care of a
child with a life
threatening illness or
injury.

Content Outline

H. Child with life threatening illness,


injury
1. Childs experience
2. Family experience
3. Stressors
4. Crisis
5. Common reactions
6. Nursing care
7.
Case management

I. Nutrition
1.
Dietary patterns
2.
Formula feedings
3.
Special diets
4.
Gavage
9. Describe methods of
feeding and common
problems the nurse will
solve in providing
adequate nutrition for the
child of any age.
10. Explain principles and
nursing responsibilities in
medication administration
& pre & post-operative
care.
11. Describe assessment
and management of
acute and chronic pain
and treatment.
12. Describe the use of
therapeutic play to
express feelings in
children of any age.
13. Develop teaching
strategies to be used in
providing health
promotion activities for
any age group.

J. Principles and nursing


implications
1. Medication Administration
a. Calculating dosages
b. Techniques of
administration
c. IV administration
2. Pre- and post-operative care
3. Management of pain

K. Therapeutic play
1. Types
2. Age-specific activities
L. Learning style, teaching
strategies
1. Infant
2. Toddler
3. Pre-School child
4. School age child
5. Adolescent
M. Treatments/Procedures
1. Oxygen administration
2. Apnea monitors
3. Telemetry
4. Resuscitation
5. Heel sticks

Lab/Clinical Objectives
The student will (be able
to):

Theory Objectives
The student will (be able
to):
14. Describe the care of the
child who requires
hospital care.

15. Compare the nursing


responsibilities for the
care of children in a
variety of settings:
outpatient clinics, home,
long term care, hospital,
emergency room,
intensive care.

Content Outline

6. Restraints
7. Transportation
N.
1.
2.
3.
4.
5.
6.

Care in a variety of settings


Outpatient clinic
Acute care
Emergency room
Intensive care
Home
Long term care

O. Legal & Ethical Issues


1. Informed consent

10

Lab/Clinical Objectives
The student will (be able
to):

UNIT II ALTERATIONS IN THE


NERVOUS/SENSORY SYSTEM

11

UNIT II ALTERATIONS IN THE NERVOUS/SENSORY SYSTEM


RELATED ACTIVITES ASSIGNMENTS
REVIEW:
Normal structure and function of the nervous/sensory system
NURS 141 Assessment and Health Promotion of the Nervous/Sensory System
Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R., OBrien, D.G., & Bucky L. (2011). MedicalSurgical Nursing Assessment & Management of Clinical Problems. (8th ed) St. Louis: Mosby
Elsevier
o Chapter 56 Nervous System
Ball, J.W. & Bindler, R.C. (2012), Pediatric Nursing: Caring for Children. (4th ed) New
Jersey: Pearson Prentice Hall
o Chapter 5 Pediatric Assessment
READ:
Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R., OBrien, D.G., & Bucky L. (2011). MedicalSurgical Nursing Assessment & Management of Clinical Problems. (8th ed) St. Louis: Mosby
Elsevier
o Chapter 57 Acute Intracranial Problems
o Chapter 58 Stroke
o Chapter 59 Chronic Neurologic Problems
o Chapter 61 Peripheral Nerve & Spinal Cord Problems
Ball, J.W. & Bindler, R.C. (2012), Pediatric Nursing: Caring for Children. (4th ed) New
Jersey: Pearson Prentice Hall
o Chapter 26 Alterations in Neurologic Function

CLINICAL EXPERIENCES:
Provide Pre and Post education for a client having a CT or MRI.
Observe a specialist in neurology perform a neurologic exam.
Assist with a lumbar puncture/ interpret the results.
Care for clients with head / spinal injury
Care for clients with long term or permanent neurologic deficits.
Present a case in post-conference for a client with neurologic injury using SBAR Format.
Include in your nursing care plan evidence of patient centered care and teamwork and
collaboration.
Visit an acute rehabilitation center. Discuss the philosophy of rehabilitation with a rehab
nurse.
SEMINARS:
Head Injury
Spinal Cord Injury
Epilepsy / Seizures Across the Lifespan
Chronic Neurological Deficits

12

Unit II Alterations in the Nervous/Sensory System


Theory Objectives
Content Outline
The student will (be able to):
1. Describe how client
centered care, teamwork
and collaboration, evidence
based practice, quality
improvement, safety and
informatics are used in the
nursing care of clients with
alterations in the
nervous/sensory system.

I. Alterations in Nervous/Sensory System

1.

Perform a neurologic
assessment according to
the guidelines given you.

2.

Recognize signs of
impending myasthenic or
cholinergic crisis and take
effective actions.

3.

Apply the nursing process


in planning for and caring
for a client with deficits in
neurologic function.

4.

Delegate interventions for


neurologic clients to team
members according to
their experience level.

5.

Institute measures to
preserve function at the
optimum level and prevent
further injury.

6.

Provide nursing care for a


client with an actual or
potential problem of
sensory deprivation.

7.

Identify support systems


available to the client.

8.

Identify factors that may


impede rehabilitation.

9.

Identify psychosocial
reactions to neurologic
alterations present.

Meningitis
Guillain Barr Syndrome
Multiple Sclerosis (MS)
Parkinsons (PD)

2. Describe how alterations in


the nervous/sensory
system can lead to illness.

Lab Clinical Objectives


The student will (be able to):

Myasthenia Gravis (MG)


Epilepsy

3. Describe the cause and


clinical course of acute and
chronic alterations in the
nervous/sensory system.
4. Compare chronic
neurologic conditions for
alterations in motor
function, muscle tone,
respiratory difficulty,
disorders of locomotion,
emotion and emotion
control, and sensory loss.

Encephalopathy (All Forms)


Hydrocephalus
Cerebral Palsy
Intracranial Hemorrhage
Epidural
Subdural
Subarachnoid
Intracerebral
Trauma

5. Identify populations at risk


for alterations in the
nervous/sensory system.
6. Describe health promotion
and prevention of
alterations or complications
in the nervous/sensory
system.
7. Explain the medical and
surgical management of
the client with acute or
chronic alterations in the
nervous/sensory system.
8. Describe the action, use
and the implications for
nursing of medications
used in the management of
nervous/sensory
alterations.

Fractures
Concussion
Contusion
Coup-contra coup
Epidural / Subdural
Herniation
Supratentorial
Infratentorial or Subtentorial
Uncal
Management of Increasing Intracranial
Pressure
Tumors
Primary, metastatic
Brain, Spinal cord
Spinal Cord Injury
Spinal Shock
Neurogenic Shock
Autonomic dysreflexia

9. Explain the difference in


13

Unit II Alterations in the Nervous/Sensory System


Theory Objectives
Content Outline
The student will (be able to):
cholinergic crisis and
myasthenic crisis.
10. Distinguish between
hemorrhagic and ischemic
stroke as to stroke
patterns, usual age group,
onset of symptoms,
medications, stages of
recovery and nursing
interventions.
11. Explain the difference in
symptoms and their
duration with transient
ischemic attacks (TIA), and
a completed stroke.
12. Explain the nursing care
before, during and after
diagnostic tests of the
nervous/sensory system.
13. Explain rationale for
significant findings from an
interview and physical
assessment of a client with
alterations in the
nervous/sensory system.

Diagnostic Tests
CT
MRI
LP, CSF
EEG (electroencephalography)
EMG (electromyogram)
Tensilon test

Neurologic Assessment
Neuro Specific Tests on Physical Exam
and equipment used
Cranial Nerve Assessment (12)
LOC
Glasgow Coma Scale
Cognitive function
Motor function
Sensory function
Cerebellar function
Cranial nerves
Reflexes
Vital signs
Pharmacology

14. Explain the progression of


symptoms with
supratentorial herniation.
15. Given several assessments
of a client, state whether
the clients condition is
improving or not.
16. Differentiate between the
early and late signs of
increasing intracranial
pressure and the signs that
indicate herniation is
occurring.
17. Choose the most important
nursing action to take when
an assessment indicates
change in status is
occurring.

AEDs
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Phenytoin (Dilantin)
Fosphenytoin (Cerebyx)
Gabapentin (Neurontin)
Levetiracetam (Keppra)
Topiramate (Topamax)
Diazepam (Valium)
Lorazepam (Ativan)
Midazolam (Versed)
Mannitol (Osmitrol)
Dexamethasone (Decadron)
Methylprednisolone (SoluMedrol)
Levodopa (Sinemet)
Benztropine (Cogentin)
Ropinirole (Requip)

18. Identify nursing diagnoses


14

Lab Clinical Objectives


The student will (be able to):

Unit II Alterations in the Nervous/Sensory System


Theory Objectives
Content Outline
The student will (be able to):
to be used for alteration in
Interferon beta 1a and 1b (Betaserson /
the nervous/sensory
Avonex)
system.
Glatiramer (Copaxone)
19. Describe with rationales
nursing care planning,
interventions and
evaluation of clients with an
alteration in the
nervous/sensory system.
20. Describe nursing
interventions with rationale
that will assist a client with
chronic neuralgic deficits to
maintain optimum health
and function as long as
possible.

Mycophenolate (Cellcept)
IVIG
Rocephin, Vanco, Zosyn, Acyclovir
Pyridostigmine (Mestinon)
Edrophonium (Tensilon)
rtPA (Alteplase)
Baclofen (Lioresal)
Legal/Ethical

21. Identify priorities in the


management of the multitrauma client.
22. Identify which nursing
interventions for the
nervous/sensory client can
be delegated to a unit
assistant or LVN.
23. State when and why the
nurse will increase or
decrease stimuli in the
clients environment.
24. Predict the effect of stress
on clients with
degenerative neurologic
alterations.
25. Describe the nursing
management of major
physical and psychosocial
problems for clients with
spinal cord injury (SCI)
during shock and after
recovery from shock.
26. Identify the overall goals of
rehabilitation.
27. Identify ways for the family
to be included in the
rehabilitative process.
15

Lab Clinical Objectives


The student will (be able to):

Unit II Alterations in the Nervous/Sensory System


Theory Objectives
Content Outline
The student will (be able to):
28. Identify statements that can
be made to a paraplegic
client regarding sexuality.
29. Outline essential content to
be included in client
education.
30. Describe home care
services to SCI clients.
31. Explain ethical/legal issues
related to care of clients
with nervous/sensory
alterations.

16

Lab Clinical Objectives


The student will (be able to):

UNIT III ALTERATIONS IN THE


INTEGUMENTARY SYSTEM

17

UNIT III ALTERATIONS IN INTEGUMENTARY SYSTEM


RELATED ACTIVITES ASSIGNMENTS

REVIEW:
Structure and function of the skin.
Assessment of clients with integumentary alterations.
Nursing care of clients with integumentary alterations.
The assessment of the integumentary system.
Initiating a peripheral IV infusion.
Fluid and electrolytes.

READ:
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., & Camera, I.M. (2011). MedicalSurgical Nursing Assessment & Management of Clinical Problems. (8th ed) St. Louis: Mosby
Elsevier
o Chapter 25 Burns, pgs. 472-495
o Chapter 67 Shock, pgs. 1717-1743
Ball, J.W., Bindler, R.C., & Cowen, K. (2012), Principles of Pediatric Nursing: Caring for
Children. (5th ed) New Jersey: Pearson Education, Inc. Hall
o Chapter 31 Alterations in Skin Integrity, Burns, pgs. 1055-1065
o Chapter 21 Alterations in CV Function, Shock, pgs. 637-644
Current internet resources
AV MATERIALS:
NV 246 Critical Care: Emergency Burn Treatment
CASE STUDIES:
Case Study: Burn Trauma
Hypovolemic shock

CLINICAL EXPERIENCE:
Management of a client with multi-system failure related to an alteration in the
integumentary system.
Teach client and family methods of burn prevention.
Use the Rule of Nines and TBSA to determine extent of a burn injury.
SEMINARS:

Burn / Inhalation Injury


Delegating Nursing Care
Shock, Shock/MODS
Evaluating Performance

18

Theory Objectives
The student will (be able to):
1. Describe how client
centered care, teamwork
and collaboration,
evidenced based practice,
quality improvement,
safety, and informatics are
used in the nursing care
of clients with alterations
in the integumentary
system
2. Identify different
categories of burns and
the alterations in the
integumentary system that
could result.

3. Identify risk factors with


potential complications
due to an alteration in the
integumentary system
related to a burn injury.
4. Summarize the phases of
care a client with an
alteration in the
integumentary system,
due to a burn injury, will
experience.
5. Specify how the nursing
process can be used to
effectively manage the
outcome of a client with
alterations in the
integumentary system due
to a burn injury.

Content Outline
III. Alterations in the Integumentary
System

A. Categories of burns
1. Thermal
2. Chemical
3. Electrical
4. Radiation
5. Inhalation
B. Risk factors with complications
1. Location of burn
2. Pre-existing disorders
3. Trauma
4. Age
C. Burn phases
1. Pre-hospital care
2. Emergent
3. Acute
4. Rehabilitation

D. Nursing Process
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

6. Explain the classification


systems and diagnostic
tests used to determine
the severity of a burn
injury.

E. Classification and Diagnostic tests


1. Depth
2. Extent
3. Rule of Nines
4. TBSA
5. Laboratory tests

7. Describe potential
complications, treatment
and rationale for
managing the care of a

F. Potential complications
1. Fluid and electrolyte
imbalances
2. Shock
3. Renal failure
4. Hypothermia
19

Lab/Clinical Objectives
The student will (be able to):
1. Compose a teaching plan
for a burn client and family
about the four different
categories of burns.
Include at least one
preventative measure for
each category.
2. Delegate the care of a
burn client based on your
assessment and
knowledge of potential
complications and risk
factors.
3. Make a list of agencies or
resources in your
community available to
your client in the
rehabilitative phase of a
burn injury.
4. Formulate a plan of care
for a client with an
alteration in skin integrity
in each of the phases of a
burn injury.
5. Calculate the extent of a
burn injury by applying the
Rule of Nines and TBSA
classifications.
6. Manage the care of a
client who has developed
a complication due to an
alteration in the
integumentary system.
7. Prioritize your nursing
diagnoses using Maslows
hierarchy of needs to
manage the care of a
client who has an
alteration in the
integumentary system.

8. Explain to a client that has


an alteration in the
integumentary system the
importance of reporting

client with alterations in


the Integumentary system
due to a burn injury.
8. Develop nursing
diagnoses and outcome
criteria for the client with
an alteration in the
integumentary system due
to a burn injury.

9. Explain the potential for


fluid imbalance and
nutrition requirements in
each of the phases of
burn injury.

10. Summarize the impact


that alterations in the
integumentary system,
(burns), can have on other
body systems.

11. Describe pharmacological


interventions used for
treating the client with an
alteration in the
integumentary system
related to a burn injury.

12. Identify different wound


care considerations and
options for a client with an
alteration in the
integumentary system
related to a burn injury.

13. Explain legal and ethical


issues related to the care
of a client with an
alteration in the
integumentary system
related to a burn injury.

14. Describe the nursing

5.

Septic shock

G. Nursing Diagnosis
1. Fluid volume deficit
2. Pain
3. Self-care deficit
4. Altered nutrition
5. High risk for infection
6. High risk for impaired mobility
7. Anxiety
8. Knowledge deficit
H. Fluid imbalances & nutritional
requirements
1. Emergent
2. Acute
3. Rehabilitation
I.

Body systems
1. Cardiovascular
2. Respiratory
3. Renal
4. Endocrine
5. Gastrointestinal

J. Pharmacological interventions
1. Pain management
2. Topical antimicrobials
3. Antibiotics
4. Tetanus
5. Sedatives

K. Wound Care & Options


1. Infection control
2. Hydrotherapy
3. Debridement
4. Wound coverings

L. Legal & Ethical issues


1. Cost of care
2. Trained personnel
3. Right to life
4. Emotional support

M. MODS
1. Events
a. SIRS
b. Organ dysfunction
c. DIC
2. Mechanisms
20

significant weight
changes.

9. Manage the care of the


client who has multisystem failure.

10. Start peripheral IV using


guidelines taught in skills
lab.

11. Manage the care of a


client who has a complex
wound care regime due to
an alteration in the
integumentary system.
12. Describe the process for
reporting a legal or ethical
issue to a client or family
members in the health
care facility where you are
assigned.
13. Identify assessment data
that suggests a client is
developing MODS.

management of the client


with Multiple Organ
Dysfunction Syndrome
(MODS).

a.
b.
c.
d.

Change in circulating
volume
Tissue hypoxia
Myocardial depression
Hypermetabolism

3. Early signs & symptoms


a. Temperature
b. Heart Rate
c. Respiratory Rate
d. WBC
4. S & S of organ failure
a. Respiratory
b. Neurosensory
c. Renal
d. CV
e. GI
f. Liver
5. Progression
a. Adult
b. Child
6. Prevention
7. Nursing process
a. Assessment/early
detection
b. Planning
(1)
Prevent/treat
infection
(2)
Nutrition/
metabolic
support
(3)
Maintain tissue
oxygenation
(4)
Support for
individual
organs
c.
Collaboration

21

UNIT IV ALTERATIONS IN
CELLULAR GROWTH/IMMUNITY

22

UNIT IV ATERATIONS IN CELLULAR GROWTH/IMMUNITY


RELATED ACTIVITES ASSIGNMENT
REVIEW:
A & P of the Immune System
Mechanisms of Immunity
NURS 142
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., & Camera, I.M. (2011). MedicalSurgical Nursing Assessment & Management of Clinical Problems. (8th ed) St. Louis: Mosby
Elsevier
o Chapter 7 Community Based Nursing & Home Care, pgs. 85-93
o Chapter 11 End of Life & Palliative Care, pgs. 151-164
READ:
Potter, P. A. & Perry, A. G. (2009). Fundamentals of Nursing. (7th ed.) St. Louis: Mosby
Elsevier
o Chapter 7 Caring for the Cancer Survivor, pgs. 84-94
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., & Camera, I.M. (2011). MedicalSurgical Nursing Assessment & Management of Clinical Problems. (8th ed) St. Louis: Mosby
Elsevier
o Chapter 14 Genetics, Altered Immune Response & Transplantation, pgs. 206-234
o Chapter 16 Cancer, pgs. 260-300
Ball, J.W. & Bindler, R.C. (2012), Pediatric Nursing: Caring for Children. (4th ed) New Jersey:
Pearson Prentice Hall
o Chapter 23 Alterations in Cellular Growth, pgs. 837-901
Guidelines for Detection of Cancer, American Cancer Society.
o http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/america
n-cancer-society-guidelines-for-the-early-detection-of-cancer

SELECTED WEBSITES:
www.guidelines.gov
www.cancer.org
www.supersibs.org
CLINICAL EXPERIENCES:
Care for adults with cancer of the colon, lung, breast, bowel, prostate.
Care for children with leukemia, brain, bone and soft-tissue tumors.
Find out what services are in this community for the care of cancer clients.
Discuss alternative methods used to increase faith and hope.
SEMINARS:
Health Promotion in the Community Oral Presentation/Paper
Using Nursing Process to care for clients diagnosed with cancer
Multidisciplinary Care for clients with cancer
Rectal Cancer

23

Theory Objectives
The student will (be able to):
1. Describe how client
centered care, teamwork
and collaboration,
evidenced based
practice, quality
improvement, safety, and
informatics are used in
the nursing care of clients
with alterations in cellular
growth/immunity.
2. Describe how alterations
in the immune system or
in cell growth can lead to
illness.
3. Describe the cause,
symptoms and clinical
course for alterations in
the immune system.
4. Identify populations at
risk for alterations in the
immune system.
5. Explain the significance
of a depressed immune
system.
6. Describe health
promotion & prevention of
alterations or
complications in the
immune system.
7. Explain the medical and
surgical management of
the client with alterations
in the immune system.
8. Describe the action, use
and the implications for
nursing for medications
used in the management
of alterations of the
immune system or
cellular growth.

Content Outline

A. Alterations in Cellular Growth/Immunity


1. Exaggerated response
a. Anaphylaxis
2. Misdirected response
a. Autoimmune response
(1) Organ specific
(2) Systemic (Generalized Lupus
Erythematosis) (SLE)
b. Graft rejection
3. Deficient response
(Immunodeficiency)
a. Natural deficit
(1) Inherited severe combined
immunodeficiency disease
(SCID)
(2) Age
b. Acquired deficit
(1) AIDS
(a) Opportunistic infections
(b) Urgent care
(c) Kaposis Sarcoma
(2) Malnutrition
(3) Stress
(4) Pathologic
(5) Artificial
(6) Radiation
(7) Medications
4. Proliferative response
a. Incidence and mortality
b. Characteristics of malignancy
(1) Normal cells
(2) Cancer cells
c. Characteristics of malignancy
(1) Infiltration
(2) Metastasis
(3) Classification
(4) Phases
(a) In situ
(b) Localized
(c) Invasive
(d) Metastatic
(5) Types
(6) Method of spread
(7) Sties of metastasis
(8) Result if untreated
(9) Differences in children
(10) Grading and staging
(11) Complications of cancer
24

Lab/Clinical Objectives
The student will (be able
to):
1. Implement measures to
decrease the risk of
infection.
2. Prepare the client for
and care for them after
diagnostic tests.
3. Plan, implement and
evaluate care for clients
receiving cancer
therapy.
4. Assess clients for
presence of
complications or toxic
side effects of cancer
therapy.
5. Apply principles of pain
management used in
clients with cancer.
6. Assess clients
experiencing a change
in body image.
7. Formulate some
outcomes related to the
nursing diagnoses of
clients with cancer.
8. Implement measures to
maintain adequate fluid
and nutritional status.
9. Support client/families
in grief process.
10. Use therapeutic
communication to help
a client express
feelings about their
experience.
11. Develop and carry out a
group health education
program about the

Theory Objectives
The student will (be able to):

Content Outline

9. Explain rationale for


significant findings from
an interview & physical
assessment of a client
with an alteration in the
immune system.
10. Describe with rationale
nursing care planning,
interventions & evaluation
of clients with an
alteration in the immune
system.

B.

11. Identify body sites of


cancer incidence and
mortality in men and
women.
12. Compare benign and
malignant cells for growth
rate, spread and
recurrence.

C.

13. Describe ways cancer


spreads through the body
and what happens if not
treated.
14. Describe classification of
cancer by staging and
grading.
15. Describe prevention and
early detection measures
and nursing care for
cancer of the lung,
breast, colon, uterus,
skin.
16. Describe early detection
and nursing care for
childhood cancers:
leukemia, brain, bone and
soft tissue tumors.
17. Explain the nursing care
before, during and after

D.

E.

(a) Hypercalcemia
(b) Spinal cord compression
(c) Superior vena cava
compression
(d) Hyperuricemia
(e) Effusions
(f) Sepsis
(g) Renal failure
(h) Hyperkalemia
(i) Tumor Lysis Syndrome
Risk Factors
1. Heredity
2. Environment
3. Demographics
4. Geography
5. Cultural practices
6. Psychologic factors
7. Iatrogenic
8. Diet
9. Stress
10. Chronic irritation
11. Socioeconomic status
Prevention and Early Detection
1. Detection
a. ACS warning signs
b. Additional signs in children
2. Screening
a. Cultural factors
(1) Hispanic
(2) African American
(3) Asian
(4) American Indian
b. ACS guidelines for persons at
average risk
(1) Melanoma
(2) Breast cancer
(3) Colon
(4) Uterus
(5) Lung
c. Prevention
d. Late signs
Nursing Assessment of Alterations in the
Immune System
1. Significant findings
Diagnostic Studies
1. Tumor markers
2. Serum enzymes
3. Uric acid
25

Lab/Clinical Objectives
The student will (be able
to):
seven warning signs of
cancer or some
prevention or screening
methods.
12. Coordinate teaching,
referrals and discharge
planning with other
healthcare team
members.
13. Demonstrate
responsibility and
accountability in
functioning as a
member of the
healthcare team in this
community.

Theory Objectives
The student will (be able to):
diagnostic tests of the
immune system or those
used to detect abnormal
cell growth.
18. Describe the rationale,
side effects and toxic
effects of traditional and
current treatments for
cancer.
19. Describe the impact of
hope on the immune
system.
20. Explain the role of the
nurse related to
complimentary,
alternative and/or
unproven methods of
cancer therapy.
21. Summarize psychosocial
alterations for clients
diagnosed with cancer
and clients undergoing
therapy.
22. Formulate a list of
potential nursing
diagnoses when caring
for clients with alterations
in the immune system.
23. Evaluate the quality of
information available on
the Web for professionals
and clients.
24. Explain ethical/legal
issues related to care of
clients with immune
system alterations.

Content Outline

4. Cytology
5. Hormonal Receptor Assays
6. X-ray
7. Biopsy
8. Endoscopy
9. Bronchoscopy
10. Thoracentesis
11. Lymphangiogram
12. Anergy Panel
F. Nursing Care Planning, Implementation
and Evaluation
1. Current treatment modalities
a. Preference Sensitive cancer
decisions
b. Shared decisionmaking
approach
c. Chemotherapy
(1) Classic / Conventional /
Cytoxic
(a) Alkylating agents
(b) Plant alkaloids
(c) Antimetabolites
(d) Antitumor antibiotics
(e) Hormones
(f) Corticosteroids
(2) Cytoprotectants/ Antidotes
(3) New Age/Cytostatic
(a) Monoclonal Antibodies
(b) Small molecules
(c) Biologic response modifiers
(d) Hormones
(e) Vaccines
(4) Approaches
(a) Combination
(b) Adjuvant
(c) Palliative
(5) Schedule
(6) Routes
(7) OSHA guidelines
b. Radiation
(1) Targeted therapy
(2) Internal
(3) External
c. Surgery
d. Blood components
e. Bone marrow and stem cell
transplant
f. Nutrition
26

Lab/Clinical Objectives
The student will (be able
to):

Theory Objectives
The student will (be able to):

Content Outline

g. Medications (other)
h. Pain management
i. Marijuana use
j. Supportive therapy
(1) Therapeutic communication
(a) Cultural values
(b) Elements of a comforting
(healing) response.
(2) Palliative care
(3) Hospice
k. Complementary therapies
2. Coping mechanisms
3. Hope
4. Questionable methods of cancer
treatment (Quackery)
5. Rehabilitation
6. Life after cancer
(a) Sequelae
(1) Late effects
(2) Long-term effects
(b) Interview/assessment
(c) Childhood cancer survivors
7. Essential components of survivorship
care
8. Alternative/complimentary therapy
a. Nurse role
G. Toxic Effects of Chemotherapy and
Radiation
1. Cancer related fatigue & sleep
alterations
2. Targeted therapy side effects
3. Cytotoxic chemotherapy
(a) Agranulocytosis
(b) Depressed bone marrow
(c) Bleeding tendencies
(d) Anemia
(e) Nausea/vomiting
(f) Stomatitis
(g) Alopecia
(h) Constipation/Diarrhea
(i) Extravasation
(j) Immunosuppression
(k) Other systemic effects
(l) Sexual/reproductive effects
(m) Infertility
(n) Psychosocial effects
H. Safe Environment for Family and Nurse
(OSHA)
27

Lab/Clinical Objectives
The student will (be able
to):

Theory Objectives
The student will (be able to):

Content Outline

I.

Psychosocial Impact
1. Confront diagnosis
2. Develop strength
3. Maintain connections
J. Nursing Diagnoses
K. Teaching
L. Discharge Planning
1. Symptom prevention or control
2. Community agencies
3. Support groups
4. Referrals
5. Role of family/community
M. Legal/Ethical Issues
1. Principles
a. Autonomy
b. Beneficence
c. Fidelity
d. Sanctity of life
e. Veracity
2. Trends
a. Alternative medicine
(1) Implications for care
(2) No FDA guidelines
b. With HIV
(1) Client vs. hcw
(2) Confidentiality vs. disclosure
(3) Mandatory vs. voluntary
testing
c. With cancer, terminal illness
(1) Pain control
(2)
Euthanasia, mercy
killing

28

Lab/Clinical Objectives
The student will (be able
to):

UNIT V ALTERATIONS IN THE


ENDOCRINE/METABOLIC SYSTEM

29

UNIT V ALTERATIONS IN THE ENDOCRINE/METABOLIC SYSTEM


RELATED ACTIVITES ASSIGNMENTS

Review:
NURS 141 on endocrine system.
Normal function of endocrine system including synthesis, releasing mechanisms, target
organs, effect of hormones, negative feedback, renin-angiotensin-aldosterone-axis.
Major physiological functions of the liver.
Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R., OBrien, D.G., & Bucky L. (2011). MedicalSurgical Nursing Assessment & Management of Clinical Problems. (8 th ed) St. Louis: Mosby
Elsevier
o Chapter 39 Gastrointestinal System
o Chapter 48 Endocrine System
o Chapter 49 Diabetes Mellitus
Read:
Lewis, S. L., Heitkemper, M. M., & Dirksen, S. R., OBrien, D.G., & Bucky L. (2011). MedicalSurgical Nursing Assessment & Management of Clinical Problems. (8 th ed) St. Louis: Mosby
Elsevier
o Chapter 49 Diabetes Mellitus . 1242-1246 Acute Complications
o Chapter 50 Endocrine Problems
o Chapter 44 Liver, Pancreas, & Biliary Tract Problems
Ball, J.W. & Bindler, R.C. (2008), Pediatric Nursing: Caring for Children. (4 th ed) New Jersey:
Pearson Prentice Hall
o Chapter 29 Alterations in Endocrine & Metabolic Function
o Chapter 24 Alterations in GI Function, Viral Hepatitis
Seminars:

Legal-Ethical
Assertive Behavior
Endocrine Alterations / Endocrine Case Studies
Acute Liver Failure / Acute on Chronic Liver Failure
Alcoholic Liver Disease and ETOH Withdrawal

Hypofunction

Hyperfunction

Pancreas / Diabetes / Hypoglycemia

Pancreas/Diabetes / DKA, HHS

Adrenal Gland / Addisons Disease

Adrenal Gland / Cushings Syndrome

Thyroid /Hypothyroid/ Myxedema Coma

Thyroid / Hyperthyroid / Thyroid Storm

Pituitary Growth Hormone /Hypopituitarism

Pituitary Growth Hormone / Acromegaly

Pituitary Decreased ADH / Diabetes Insipidus

Pituitary Increased ADH / SIADH

30

Unit V Alterations in the Endocrine/Metabolic System


Theory Objectives
Content Outline
The student will (be able to):
1. Describe how client
centered care, teamwork
and collaboration,
evidence based practice,
quality improvement,
safety and informatics are
used in the nursing care
of clients with alterations
in the
endocrine/metabolic
system.
2. Delineate the major health
problems, risk factors, and
medical or surgical
interventions in alterations
of the endocrine system.
3. Predict the long-term
effects of
deficits/excesses of
hormones on the client
including effects on growth
and development.

See Table Previous Page

Lab/Clinical Objectives
The student will (be able to):
1. Apply nursing process
in planning and caring for
a client with a hormonal
imbalance.

Potential Complications
PC: Addisonian Crisis
PC: Electrolyte imbalance
PC: Thyroid Storm
PC: Cardiac Arrhythmias

Endocrine Diagnostic Studies /


Labs
CT Scan and MRI
Radioactive Iodine Uptake (RAI)
Serum and Urine Sodium / Other
Electrolytes / Osmolarity /
Osmolality
TSH, T3, T4
Cortisol
Suppression / Stimulation Tests

2. Develop a client centered


individualized nursing
care plan (including
cultural, ethnic practices,
psychosocial and learning
needs) for a client with an
endocrine/metabolic
alteration.
3. Set priorities for actions
using the problem solving
process.
4. Implement effective
nursing interventions for
clients with
endocrine/metabolic
alterations.
5. Evaluate the expected
outcomes of the nursing
intervention and revise
care plan.

4. Explain the expected


effects, side effects and
complications of
corticosteroid therapy.
5. Explain the significance of
diagnostic lab studies
frequently ordered to
evaluate the endocrine
system.
6. Explain rationale for
assessment findings of all
body systems when a
client has an alteration in
the endocrine system.
7. Explain the medical and
surgical management of
the client with an alteration
in the endocrine system.
8. Describe the action, use
and the implications for
nursing of drugs used in
the medical management
of endocrine alterations.
31

Theory Objectives
The student will (be able to):
9. Formulate outcome criteria
based on identified nursing
diagnoses.
10. Describe with rationale
nursing care planning,
interventions and
evaluation of clients with
an alteration of the
endocrine system.

Content Outline

Pharmacology Categories
Hormone replacement
Anti-glandular medications
Corticosteroids
Drug Therapy for Chronic Viral
Hepatitis
Drug Therapy for Cirrhotics

11. Identify priorities in the


management of clients
with alterations in the
endocrine system.

Use of Steroids

12. Develop a teaching plan


for a client with an
alteration in the endocrine
system.

Alterations in Liver Function


Acute Liver Failure / Acute on Chronic
Liver Failure
Cirrhosis
Compensated vs Decompensated
Symptoms of Hepatic Decompensation
Portal Hypertension
Third spacing Ascites
Esophageal Variceal Bleeding
SBP
Jaundice
Hepatic Encephalopathy

13. Identify resources


available to clients and
their families in dealing
with alterations in the
endocrine system.
14. Explain some of the legal
and ethical issues related
to the care of clients with
an alteration in the
endocrine system.
15. Describe how alterations
in the liver can lead to
illness.
16. Compare Hepatitis A, B, C
and D.

Expected effects
Side effects, complications

Hepatitis General
Classifications
Mode of transmission
Markers
When infective /risks of transmission
Clinical characteristics
Preventive/post exposure therapy
Prognosis
Risk Factors
Alcohol, chemicals
Drug overdose
Iatrogenic
IVDU, others

32

Lab/Clinical Objectives
The student will (be able to):

Theory Objectives
The student will (be able to):
17. Identify factors that place
clients at risk for liver
failure.
18. Explain the significance of
the results of diagnostic
studies ordered to evaluate
clients with alterations in
liver function.
19. Explain rationale for
assessment findings of all
body systems when a
client has liver failure.
20. Explain the medical and
surgical management of
the client with an alteration
in the metabolic system
(liver).
21. Describe the action, use
and implications for nursing
of drugs used in the
medical management of
clients with alterations in
the liver.
22. Formulate outcome criteria
based on identified nursing
diagnoses.
23. Describe with rationale
nursing care planning,
interventions and
evaluation of clients with
an alteration of the liver.

Content Outline
Diagnostic Lab
ALT (SGPT)
AST (SGOT)
Alkaline phosphatase
GGT
Cholesterol
Hepatitis markers
H&H
WBC
Platelets
Blood Ammonia
Albumin
PT/INR
Bilirubin
Direct (conjugated)
Indirect (unconjugated)
Medical/Surgical Management
Liver Biopsy
Endoscopy
Blakemore-Sengstaken tube
Surgical
Shunts - TIPS
Medications
1. Vasopressin
2. Diuretics
3. Antibiotics
4. Neomycin
5. Lactulose
6. Fresh blood
Nutrition
Transmission Precautions

24. Identify priorities in the


management of clients with
alterations in the liver.

Risks of Alcohol Withdrawal


Legal/Ethical

25. Identify resources available


to clients and their families
in dealing with alterations
in the liver.
26. Explain some of the legal
and ethical issues related
to the care of clients with
an alteration in the liver.
33

Lab/Clinical Objectives
The student will (be able to):

SEMINARS

34

SEMINAR: HELPING CHILDREN ADAPT TO THE HOSPITAL ENVIRONMENT

OBJECTIVES:
1. Identify the major biologic, psychosocial, cognitive, and social developments for children.
2. Discuss the development and relationships of personality, cognitive, language, moral, spiritual
and self-concept.
3. Describe the role of play in the growth and development of children.
4. Describe guidelines for communication and interviewing.
5. Describe nursing strategies to promote optimal nutritional/fluid balance.
6. Describe pain management strategies.
PREPARATION:
1.
2.

Divide into groups.


Choose one of the following hospitalized children to present:

8-month-old with diarrhea and dehydration

Toddler with Cystic Fibrosis

5-year-old with leukemia

Fifth-grader with diabetes

Pregnant 15-year-old

PRESENTATION: Time allotted is 20 minutes for A and B


A.

For the age group selected:


1. Provide description of disease process, signs and symptoms, statistics, and nursing
implications.
2. Bring a game or project and give rationale for choice.
3. Identify gross and fine motor development.
4. Identify cognitive and social development.
5. Identify anticipatory guidance for injury prevention and safety.
6. Cite resources (APA format) during the presentations and make available to participants.

B.

For the age group selected:


1. Plan a lunch menu (suggest bring sample food items, poster or a collage).
2. Identify dietary requirements from each of the food groups.
3. Identify fluid requirements (oral and parenteral). Provide example and calculations.
4. Identify anticipatory guidance for nutritional requirements and discharge instructions.
5. Cite resources (APA format).

35

SEMINAR: ORGANIZING CLIENT CARE

Using the nursing unit below, complete the following process for organizing client care:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Establish a philosophy for the care of children in your unit.


Write specific outcome statements for each client and for each team member.
Write 1-2 high priority nursing diagnoses, identify what client is at risk for and how to prevent
it.
Consider if room assignments are appropriate.
List all of the activities in the care of each client for the shift.
Identify all general or routine unit activities that will occur during the shift, i.e. refill water
pitchers, stock cabinets, etc.
Identify any major concerns for the day that will influence your assignment.
Make assignments according to usual job descriptions and Nurse Practice Act.
Identify delivery care model.
TEAM MEMBERS
Jean

RN, worked on unit for 2 years, very capable

Paul

UA, worked on unit for 1 year, prefers younger children

Sue

RN, 2 years experience

Allen

Child life therapist will make rounds

Kathy RN, Head Nurse, experienced pediatric nurse


QUESTIONS:
1. Are room assignments satisfactory? What changes would you make, if any?

2. What changes might you make if Melissa was developmentally delayed?

3. A client care conference is scheduled for today at 1:30. Choose a client to present. What will
be the issues/concerns, priorities, and plans?

4. According to the Nurse Practice Act, what is the role of the nurse?

5. What are the standards of competent performance? (Title 16 Section 1443.5)


36

NURSING UNIT
You are Kathy the shift lead today 7-3:30 pm for this group of 10 clients on a pediatrics unit.

Private rooms:
Susan

Age 11, appendectomy admitted to OR last night and transferred from PACU at 3 am

Patrick

Age 14 months, admitted yesterday with croup with blow-by oxygen and IV steroids,
would probably be discharged tomorrow

Russell

Age 14, cystic fibrosis, fourth hospitalization this year, critically ill, prognosis guarded;
Parents at bedside, 2 younger children at home, RT scheduled at 9 am

Laura

Age 6 months, with failure to thrive (FTT), birth weight 7 lbs., currently weighs 10
lbs., gained 3 ounces in last 24 hours

Shane

Age 2 years, diarrhea from salmonella

Stephanie

Age 13 with anorexia nervosa

Sharing rooms:
Tony

Age 4, osteomyelitis left great toe and bottom of foot, on multiple IV antibiotics, daily
wound packing and wet to dry dressing bid

Peter

Age 5, asthma exacerbation

Tonya

Age 9, fell off bicycle, suffered concussion, going home today

Melissa

Age 6, cerebral palsy, had bilateral heel cord lengthening 2 days ago, in casts,
discharge planning in progress.

37

WORKSHEETS

UNIT PHILOSOPHY:

OUTCOMES FOR ALL CLIENTS:


1. SUSAN
2. PATRICK
3. RUSSELL
4. LAURA
5. SHANE
6. STEPHANIE
7. TONY
8. PETER
9. TONYA
10. MELISSA
GOALS FOR TEAM MEMBERS:
KATHY, RN CHARGE
JEAN, RN
PAUL, UA
ALLEN, CHILD LIFE THERAPIST
SUE, RN

UNIT ACTIVITIES (REFILL WATER PITCHERS, STOCK CABINETS, ETC.):

DELIVERY CARE MODEL:

38

STAFF

CLIENT

LUNCH TIMES:

NURSING
DIAGNOSES

OUTCOMES ACTIVITIES

BREAK TIMES:
39

COMMENTS

UNIT II SEMINAR: HEAD INJURY

Bobby, 17 years old, falls off the roof of his house and hits his head on the pavement. He is
unconscious for about 5 minutes. Upon awakening, he is able to walk into the house. After 30
minutes he begins to be confused and irritable. He complains of a headache with nausea and
vomiting. He arrives at the ER after about 90 minutes. In the ER, Bobby was able to move all of
his extremities and was combative and confused. His pupils were equal at 3mm and reactive to
light. GCS of 10.
ER Assessment:
GCS drops to 7 and he is comatose. An ET tube was placed and an orogastric tube was inserted.
He was admitted to the unit.

1.

What is the significance of a GCS of 7? What is the significance of a GCS of 3 ?

2.

What neurologic parameters would you continue to monitor on admission?

3.

How would the nurse recognize the early signs of increasing intracranial pressure?

4.

What further assessments were indicated when his condition deteriorated?

5.

What other complications could occur? How could you prevent them? What interventions
would help to decrease mortality and failure to rescue?

6.

Which initial assessment findings would lead you to suspect epidural hematoma?

7.

Describe the pathophysiology of an epidural bleed.

8.

What is meant by uncal herniation?

9.

Were the symptoms described the classical symptoms described in the text?

10.

Why were pupil changes ipsilateral and motor changes contralateral?

11.

Why did he need the ET tube and an orogastric tube?

12.

Explain the normal homeostatic regulatory mechanisms that maintain normal intracranial
pressure.

13.

Describe the nursing management of Bobby and his head injury. Name the desired
outcomes and why your nursing measures work.

14.

Why might mannitol be ordered?

15.

What measures can the nurse take to control the environment for Bobby?

40

16.

When a client is completely sedated and paralyzed or in a barbiturate coma, what are the
advantages and disadvantages for the client and nurse?

17.

What is the significance of a Cushing reflex?

18.

What does the family of a critically head injured client need from the nurse?

19.

What is the nurses role when providing interdisciplinary care to the client and family?

20.

If the client survives this injury and is able to be discharged home, what instructions should
the family receive about Post Traumatic Brain Injury (PTBI)?

21.

List six nursing diagnoses that apply to this client.

22.

What is the most common cause of head injury?

23.

What is the morbidity and mortality within your community?

41

UNIT II SEMINAR: SPINAL CORD INJURY

Respond to the following case scenario.


A 19 year old college student is brought to the unit after a rock climbing accident. He fell 30 feet to
the ground. He was found lying in a supine position, unable to move any extremities and
complaining of neck pain. He is alert and oriented, his conversation is appropriate. He complains
that he cannot feel his arms or legs. His pupils are equal and reactive to light. VS are BP 110/72,
HR 82, R 18 Paramedics apply a surgical collar, place him on a backboard, immobilize his head
and transport him to the hospital.
An assessment in the emergency room reveals that his sensory perception ends at an imaginary
line across his chest about 3 inches above the nipple line. He has some sensation in his arms and
can raise his shoulders but not his arms. His lower extremities are flaccid. VS are BP 94/55, HR
64, RR 24, shallow. O2 sat is 92% on room air. Temp is 102 degrees F. Color is dusky, skin warm
and dry. No history of neurological or metabolic disease.
X-ray revealed a fractured vertebra, decreased lung expansion upon inhalation. Blood tests were
normal except pH = 7.25.
Methylprednisolone (Solu-medrol) 30mg/kg IV was given over a period of one hour. An infusion of
5.4mg/kg/hr. was then started to continue for 23 hours. Protonix was also ordered. Tongs were
placed, with 20 pounds of weight.
He is on a Stryker frame, is receiving oxygen at 4 liters via nasal cannula with peripheral IV 0.9 NS
at 42 ml/hr.
He was transferred to the trauma unit. Hgb and Hct were normal. Blood sugar was 562mg/dL, was
repeated and was accurate. Ketones were negative. Blood alcohol was normal.
One week later his vital signs are normal. There is no change in arm strength or sensation. He has
marked spasms and exaggerated stretch reflexes in his lower extremities. He has urinary
incontinence and a Foley catheter is required.

1.

How many spinal cord injured clients are living in the US? What is the initial hospitalization
and average lifetime cost?

2.

Why did his heart rate and blood pressure fall during this emergency? Why was his
breathing rapid and shallow? Why was the blood pH below normal?

3.

What other clinical examination findings were present and why?

4.

What is your interpretation of the elevated blood glucose in a person with no history of
metabolic disease? What would you anticipate the doctor ordering? Why would Protonix be
ordered?

5.

Explain the pathophysiology of spinal shock.

42

6.

For what treatment/interventions will you set up?

7.

How long might this shock last?

8.

One week after the injury, his signs and symptoms had changed. Explain these findings?

9.

Why did he suffer from urinary incontinence?

43

UNIT II SEMINAR: Chronic Neurologic Alterations


Parkinsons Disease
John Smith, age 67, an African-American gentleman is seen in a clinic. His chief complaint is
tremors that have progressively gotten worse over the last six months. His handwriting has also
become almost illegible. His wife describes him as depressed, with a blank look on his face and
slowed speech. An assessment reveals tremors, movement of the thumb and index finger in a
circular movement; shuffling gait, fatigue, drooling, rigidity during ROM, voice weak and soft,
constipation, difficulty moving from sitting to standing position, and unable to perform rapid
alternating movements. He is admitted for adjustment of his medications. When discharged, he
will be receiving carbadopa/levodopa 25/100 bid PO and Benadryl 25 mg PO qhs.
1. Mr. Smith was diagnosed with Parkinsons disease. What data was collected that supports
this diagnosis?
2. What additional information could be used to confirm that diagnosis?
3. What are the nursing considerations for Mr. Smith?
4. Develop 2 nursing diagnoses from the data provided and explain.
5. Describe the process of medication reconciliation. Identify questions you would want to
know have been answered.
6. Develop a teaching plan (outcomes and content) for a community group that provides
information that will increase knowledge about PD and its management.
Outcomes
1.
2.
3.
4.
Content
Guillain Barr
Client, age 60 became ill and was admitted to the hospital 5 days later. He had been running a
fever, had chills, abdominal discomfort and sinus congestion and fatigue. While in hospital, he had
lab tests, x-rays and an MRI. After 2 days he had sudden bilateral lower extremity paralysis and
was diagnosed with GB. His past medical history was not significant. He did have mild COPD. He
is married and has 3 children
1. What specific assessments would the nurse make immediately?
2. What is in this clients history that suggests GB?
3. What is the likely progression and prognosis for this client?

44

4. Discuss the purpose the nursing implications of each of the medical therapies that might be
prescribed.
a. Immune-related treatments corticosteroids, IVIG, plasmapheresis
b.

Meds Protonix, LMWH, Lexapro, Restoril

5. What complications would you observe for and how could you prevent them?
Myasthenia Gravis
A 30 year old woman is admitted with muscle weakness in the face that has been getting worse
over the past 2 months. She says her jaws get tired as she chews, and swallowing has become
difficult. She notices that she has diplopia after reading for a while. Her assessment reveals ptosis
of the eyelids, mild muscle weakness that is progressive as movement continues. An EEG reveals
progressive weakness. Her symptoms are reversed in 40 seconds after an IV dose of Tensilon, an
acetylcholinesterase inhibitor (anticholinesterase). She is diagnosed with MG and started on
pyridostigmine bromide and prednisone. When her symptoms become severe she undergoes
plasmapheresis. She uses atropine as needed to decrease nausea, abdominal cramps and
salivation which she experiences as side effects of the anticholinesterase.
1. Why is she experiencing difficulty chewing and swallowing?
2. How do anticholinesterase medications improve skeletal muscle function?
3. Why is atropine beneficial in treating side effects experienced?
4. How does the corticosteroid benefit the client?
5. Why does plasmapheresis help her?
6. Why is she at increased risk for respiratory failure?

45

UNIT II SEMINAR: Epilepsy / Seizure Disorders Across the Lifespan


Group One Case Study Febrile Seizure
Minimum # of Students 5
Objectives:
1. Demonstrate how a focus on the QSEN competencies of Safety, Teamwork and Collaboration,
Evidence Based Practice, Quality Improvement and Informatics enable the nurse to provide Patient
Centered Care.
2. Demonstrate appropriate teaching to the patient and family after a child presents to the
Emergency Room with a febrile seizure.
Primary Method: Role playing
Additional Methods: Utilization of Web Resources
Present this case to the class with each student assuming a role:
Narrator: Reads the case study to the class. Keeps track of time (15) for presentation.
Summarizes the important points and demonstrates QSEN Competency by providing additional
Evidence Based Information found in a web search.
Registered Nurse #1 You have taken the History / Performed the Physical Exam (The PE is
normal). Tell the class what questions you asked and why when taking the history. State the
findings for each body system examined on your head to toe assessment (all are normal). Describe
how you approached the patient from the QSEN Competency of Safety during the exam.
Mother Age 18, did not graduate from high school but working on GED- Develop questions to ask
the nurse after the H&P is completed about what is happening to your child and why. Show a
willingness to learn to assume role of a participant as a valued member of the Team using the
QSEN competency of Teamwork and Collaboration.
Registered Nurse #2 Answers mothers questions. Describes lumbar puncture procedure for the
pediatric patient. Research guidelines for lumbar puncture taking into consideration the QSEN
competency of Quality Improvement.
Case Manager / Discharge Nurse : Reviews with mother the results of the examination and the
information the physician has already given the mother (all lab tests are normal and LP is normal)
Child may go home: what to expect, how to care for child. Discuss how both the mother would use
the QSEN Competency of Informatics to assist her in communicating with her health care provider
after discharge and also enhancing her understanding of the discharge advice. Provide one web
based resource for the mother.

46

Case Study
You are working in the Emergency Room. A 7-month-old boy is brought in by his mother @ 4 PM.
She states he had a runny nose and fever for 2 days . His pediatrician saw him @ 10 AM today
and diagnosed URI. He received Tylenol, no antibiotics. Later in the afternoon while sitting on her
lap he began to stare and had a generalized tonic-clonic seizure. The entire episode lasted about 5
minutes she thinks. He fell asleep after the seizure and was brought to the ER.
PMH: Normal development (describe this)
Vital Signs T 102 F, HR 124, R 30 BP 90/50
Wt 7.9 Kg (50%) Ht 66.5 cm (50%) HC 44 cm (50%)
Labs have been drawn and the physician has asked for assistance performing a Lumbar Puncture
Teaching Points:
The most common type of seizure in the pediatric age group, febrile seizures are usually benign.
Though associated with fever, there is no evidence of intracranial infection or defined cause.
Febrile seizures are triggered more by how fast the temperature increases than the absolute height
of the temperature.
Children have a higher susceptibility to seizure activity in the brain -- a lower seizure threshold -because of their age and the immaturity of their body's immune system. Complicated by a rapidly
rising fever and possibly the general condition of health, a febrile seizure may occur.
A family history of epilepsy has not been shown to be a risk factor for first febrile seizures but a
family history of febrile seizure is a risk factor, together with male sex and the height of the
temperature (usually > 102F).
Several other factors may increase the risk of seizure: chronic maternal ill health, parental fertility
problems, breech birth, Caesarean birth, small birth weight, developmental delay, and cerebral
problems may increase the incidence of febrile seizures. Smoking and drug intake (including antiepileptic drugs) during pregnancy can further increase the risk.
Febrile seizures are age dependent, are rare before 9 months and after 5 years with the peak age
9-20 months. They are most commonly generalized tonic-clonic (aka Grand Mal) with a duration of
usually less than 5 minutes and no greater than 15 minutes. Risk of recurrence is 35-50% with
most recurrences within 6-12 months. The diagnosis of Febrile Seizure is one of exclusion ie.,
other potentially serious illnesses must be ruled out before this diagnosis is made. The American
Academy of Pediatricians strongly recommends that a Lumbar Puncture be performed if the child is
< 12 months.
Although seizures look different, they have certain things in common: During a seizure, a client
may stop breathing, generally only for only a few seconds. Although some can last as long as 3-5
minutes, most seizures only last 1-2 minutes. The brain almost always stops the seizures safely
and naturally.

47

Few things are more frightening to parents than to witness their child having a seizure. 10% of
ambulance calls are for children having seizures but most seizures resolve in the pre-hospital
setting. Words parents might use to describe a seizure include a fit, an attack, a spell, or a
convulsion
Febrile Seizure Management What Advice Should I give to Parents?
http://www.cks.nhs.uk/febrile_seizure/management/detailed_answers/advice_for_parents
Inform parents about the nature of febrile seizures:
o Although short-lasting seizures are frightening to watch, they are not harmful to the
child, do not cause brain damage, and will not cause the child to die.
o The child may be sleepy for up to an hour after the seizure.
o Febrile seizures are not the same as epilepsy. Epilepsy may develop later, but this is
rare the chance is about 1 in 50 for children who have had one simple febrile
seizure. No treatment is available to reduce this risk.
Advise parents on the future management of a fever. Explain that controlling fever does not
prevent recurrence but does make the child more comfortable if they are distressed.
Explain that febrile seizures may recur about 1 in 3 children will have another febrile
seizure.
Explain that immunization is still advised after a febrile seizure even if, as rarely happens,
the febrile seizure followed an immunization.
Advise parents or caregivers looking after a feverish child at home:
o To encourage their child to drink more fluids and consider seeking further advice if
they detect signs of dehydration.
o How to identify a non-blanching rash.
o To check their child during the night.
o To keep their child away from nursery or school while the child's fever persists, and
to notify the school or nursery of the illness.
Explain that the aim of controlling fever is to ease symptoms and to prevent
dehydration
o Do not use antipyretic drugs with the sole aim of reducing body temperature or of
preventing febrile seizures
o Consider acetaminophen or ibuprofen if the child is distressed or unwell
o Do not over- or under-dress a child with fever
o Tepid sponging, fanning and cold bathing are not recommended].
o Ensure an adequate fluid intake
Explain how to manage a recurrent seizure. Parents should:
o Place the child in the recovery position on a soft surface, lying semi-prone with the
face turned to the side. This prevents the inhalation of vomit, keeps the airway open,
and prevents the child from injury.
o Not force anything into the child's mouth.
o Note the time that the seizure started, and stay with the child.
o Telephone their HCP for advice if the seizure has stopped and has lasted for less
than 5 minutes.
Request an urgent ambulance if the seizure continues for more than 5 minutes.
Febrile seizures have an excellent outcome and population studies show normal intellect
and behavior even after complex seizures is important because the anxiety and fear
experienced by parents whenever their child develops a fever can potentially interfere with
daily family life
The risk of epilepsy after a febrile seizure is small.
There is NO evidence of:
o Subsequent impaired intelligence or poorer academic achievement

48

o
o

An increased risk of neurological deficits, such as hemiplegia


An increased risk of death, even in children who have febrile status epilepticus.
Acetaminophen and ibuprofen are useful in relieving the discomfort of a febrile child.
However rigorous attempts to lower temperature should not be attempted as no evidence
exists that antipyretics reduce the number of febrile seizures .
There is evidence to suggest that immunizations DO NOT increase the risk of recurrent
febrile seizures.
Group Two Epilepsy School-Aged Child and School Administration of Diastat
4-5 Students

Objectives:
1. Increase knowledge of the Nurse Practice Act and medication administration guidelines for
licensed personnel.
2. Consider the legal and ethical ramifications of lay people and UAPs in a school setting
administering medications.
Method: Moderate a discussion with the class covering the following topics (each student in the
group takes at least one topic):
1. Summarize background information about new legislation passed in the State of California
January 2012 (see below and add any information you might find)
2. Describe Diastat administration (find a protocol using web based resources).
3. Present the viewpoint of the advocates of this legislation (See below and using web based
resources find out if there has been additional legislative action)
4. Present the viewpoint of nursing leaders about this legislation as it relates to the Nurse
Practice Act (see below and review the July 25 th Agenda Item Summary).
5. Summarize the Position Paper of the NASN Emergency Medication (Posted on
Blackboard). Lead discussion for/against this position paper. Summarize key points.
Background Information
Adapted from: http://www.ocregister.com/articles/school-322987-diastat-nursing.html

SB161 is a state bill that allows non-licensed school personnel to administer an anti-convulsion
medication to students in an emergency. Gov. Jerry Brown signed the bill into law Oct. 7, 2011
despite fierce opposition from nursing unions and their allies, and it took effect Jan. 1, 2012.
SB 161 authorizes public schools in California to offer voluntary, optional Diastat training to school
employees. Parents of children with a Diastat prescription must request that their child's school
offer this training to employees, and no employee can be forced or coerced to participate, according
to the new law.

49

The legislation was proposed after the state Board of Registered Nursing declared in September
2009 that no one but a registered nurse could lawfully administer Diastat. Many local schools
stopped training laypeople to administer Diastat. But some local schools continued to train
laypeople in the intervening years, using outside resources such as Diastat training courses offered
by the Epilepsy Alliance of Orange County. Now, with the law clarified, advocates hope more
school districts will embrace the new legislation when it formally goes into effect Jan. 1.
"I imagine it will happen rapidly," Cabanillas said. "My gut feeling is most school districts will be
happy to go back to the way it used to be."
Proponents of SB161
Gianna DeLorenzo, age 9, has frequent seizures because of a genetic disease called tuberous
sclerosis complex. Her parents, Pat and Aina, were vocal advocates for passage of SB161.
Pat DeLorenzo said he feels "extremely relieved" at the passage of SB 161. Though Gianna has a
full-time nurse at her school, Mission Viejo's Reilly Elementary, even so, DeLorenzo said he is
reassured to know six laypeople at Reilly also are trained as backups. "You shouldn't have to worry
about your child's life when you send them to school," DeLorenzo said. "The biggest problem now is
educating parents to be aware of their rights. I can only hope that the districts will provide the
ample services the bill entails."
"We're just overjoyed," said Jill Cabanillas, executive director of the Epilepsy Alliance of Orange
County. "It's hard enough to have a child with special needs parents already have to fight the
insurance companies and bureaucracy to get services to their children. This is just one less thing
they have to fight for now."
Leading pediatric neurologists and epilepsy advocates say a seizure that is not stopped
immediately with Diastat could cause permanent brain injury or even death, before paramedics
even arrive on scene.
The Nurse Practice Act
California nursing leaders say the new law does not change the state's Nursing Practice Act, which
prohibits a nurse from training a non-licensed individual to engage in the practice of nursing. Thus,
school nurses are not the ones training their non-licensed colleagues to administer Diastat, the
brand name for diazepam rectal gel.
"It's not a political issue; there is nothing in this bill to change the Nursing Practice Act," said Tricia
Hunter, executive director of the American Nurses Association's California chapter. "All this law
says is that a parent can designate a school employee to give Diastat. The law does not allow
nurses to train non-licensed personnel to administer Diastat.
Nursing unions and their allies have vociferously disputed the risks of administering Diastat, saying
that it could be given mistakenly to a convulsing student who does not need it or by a layperson
who panics under pressure and delivers the wrong medication or dosage.
"The sad part is that this law opens the door for irresponsible schools not to include a school nurse
in their school district, let alone their school site," Hunter said. "We think it takes away a parent's
federally given right to have an appropriate person on their child's campus to give this medication."
Hunter said that with patience and guidance, it is possible for a school district to apply for and
obtain special federal funding that can pay for adequate school nursing staff. The key is knowing
how to apply for these funds, Hunter said; organizations like the American Nurses Association's
California chapter can assist in that effort.

50

Diastat
Diastat is administered by inserting a plastic syringe with a pre-measured dose into the patient's
rectum. The experts have testified that the risk of incorrectly administering Diastat is extremely low
and is far outweighed by the benefits of administering the medication in a timely fashion, even if by
a non-licensed school worker in the absence of a school nurse.
Group 3 New Onset Seizure in an Elderly Patient
4-5 Students
Objectives:
1. Provide an opportunity for the student to increase knowledge about driving safety in the setting of
a seizure disorder or epilepsy.
2. Explore your own attitudes about operating a motor vehicle in the various elder decades, ie., a
septuagenarian (someone between 70 and 79 years of age), an octogenarian (someone between
80 and 89 years of age), nonagenarian (someone between 90 and 99 years of age) and
centenarian (someone 100 years old now) with a neurologic disease which may cause an altered
level of consciousness.
3. Increase skills in communication with elders and their families about loss of autonomy with aging
and neurologic diseases such as epilepsy.
Method: Discuss the following topics. One student acts as moderator and the others in the group
take at least one topic to present
1. Moderator: Presents the case study and keeps track of time, summarizes the discussion
a. What new knowledge do you have
b. Have your attitudes changed?
c. What communication skills (active listening, reflection, etc.) work best with elders?
2. Student Topics
a. Reasons for new onset seizures in an elderly patient
b. Rationale for Anti-Epileptic Drugs prescribed after a single seizure
c. Factors to take into account with geriatric populations when discussing medications
d. Issues about driving summarize the guidelines
Case Study
A 76-year-old male retired phone company executive is on vacation and experiences right occipital
and cervical pain. He thought his left arm was weak for about 30 minutes but did not want to
interrupt his holiday and the motor deficit subsided completely.
8 months later he told his wife that his left arm was jerking for a minute. These episodes
continued weekly for about a month and with the last episode he seemed befuddled for 30-45
afterwards.
He was referred to a neurologist who ordered an MRI which showed an infarct in the right temporaloccipital watershed and an EEG showed appropriate slowing but no epileptiform discharges. He
refused medication and it was not strongly recommended in any case because he has never had a
seizure before and the EEG was not diagnostic for epilepsy.

51

4 months later he was standing on a platform near the entrance to the DeYoung Museum when he
experienced a generalized tonic-clonic seizure. He was transported to UCSF in Status Epilepticus.
He was given IV fosphenytoin and his seizures ceased. He was then placed on a low dose of an
AED and discharged the next day. He has been home now and wants to drive his car to the Napa
Valley to visit his daughter. He has stopped taking his AED. His father is 96 and still drives his
Prius.
Seizure Disorders in the Elderly Some Facts
More common after the age of 60
1. Acute insult to the central nervous system (CNS)
subdural hematoma, stroke (post stroke = majority), and CNS infection
2. During an acute metabolic disturbance
uremia, hyperglycemia, hypoglycemia, hyponatremia, ETOH withdrawal.
3. 14 % brain tumors (meningiomas, malignant gliomas, and brain metastases)
4. 50 % no identifiable cause.
Overall probability of a recurrence in a person > 65 years of age is 40-50%
Question: Why treat a first seizure in an elderly person with long term AED therapy ?
Tonic-clonic seizures
Elderly with cardiac disease major cardiac stressor
Risk of falling
Especially elderly women with osteoporosis
Driving
Elderly needing to drive
Employment
Many elderly depend on employment
Issues With Anti-Epileptic Drugs (AEDs) in the Elderly

Slower metabolism
Decreased protein binding
Other medicines
Other illnesses
Compliance
Age-related changes in hepatic, renal, and gastrointestinal function
Drug toxicity

Goal of antiepileptic drug (AED) therapy is twofold: control seizures + preserve quality of life
One drug therapy is preferred at the lowest dosage that will prevent seizures
The sedation and impairment of cognition seen with AEDs are dose dependent
Newer agents cost significantly more. First-line single agents include carbamazepine, valproic acid,
oxcarbazepine, gabapentin, and lamotrigine

52

Seizures and Motor Vehicle Operation

State driving laws must be reviewed carefully with the patient who has seizures and
with the patients family. Information about these laws can be obtained from the Epilepsy
Foundation (www.efa.org) but should be verified by contacting your own states Department of
Motor Vehicles. Revocation of driving privileges, along with loss of independence, can
have significant psychosocial implications for an elderly patient, especially when adequate
and secure public transportation is not available or the patients family cannot provide as needed
transportation.
Reporting Rules:
Patient responsibility
(most states)
Physician responsibility
(6 states)
CA, DE, NE NJ, OR, PA
State of California Driver Safety Information
Lapses of Consciousness Disorders
http://www.dmv.ca.gov/dl/driversafety/lapes.htm
Disorders characterized by lapses of consciousness result from many medical conditions. Epilepsy
is the most common disorder seen by the department. Regulations governing lapses of
consciousness disorders are contained in Article 2.4, Sections 110.01 and 110.02, of Title 13,
California Code of Regulations.
Epilepsy is not a disease. It can occur at any age and can also remit spontaneously. Epilepsy is a
condition characterized by two or more recurring seizures. While the causes of epilepsy are not
always known, seizures can be caused by anything that impairs normal brain function such as
trauma, tumor, infection, genetics, stroke, injury, and injury at birth, metabolic imbalances, high
fever, or an overdose of toxins from alcohol or drugs. Sleep disorders can also manifest themselves
as a loss of awareness or loss of consciousness. Some lapse of consciousness disorders cannot
be corrected.
Actions Appropriate to Lapse of Consciousness Disorders
The guidelines describe different situations in which the following actions should be taken after
evaluating a driver with a lapse of consciousness disorder.
No action
Medical probation Type II
Medical probation Type III
Suspension
Revocation
A medical probation allows the department to monitor the driver's medical condition on an ongoing
basis.
There are two medical probations that are appropriate for drivers with lapse of consciousness
disorders, Medical Probation Type II and Type III.
Placing a person on medical probation allows drivers with controlled epilepsy and other disorders
characterized by a lapse of consciousness to continue driving. A medical probation is only to be
used when control of a lapse of consciousness disorder has been achieved for at least three
months.

53

Medical probation Type II is for drivers who have achieved three to five months of control.
The driver is required to authorize his/her treating physician to complete the Driver Medical
Evaluation (form DS 326) and submit it to the department on a prescribed basis.
The decision to place a driver on Medical probation Type II should be based on a combination of
considerations. The main factors include but are not limited to:
Seizure type
Seizure manifestations
Seizure, medical and lifestyle history
The seizure-free period prior to the last episode
Medical probation Type III is for drivers who have achieved six or more months of control,
but due to contributing factors there is a slight possibility of another seizure. Medical
probation Type III requires the driver to report, in writing, on a regular basis to the
department on the status of his/her disorder. The Medical Probation Reporting form (DS
346) is used by drivers on Type III probation, and the driver must sign the form under
penalty of perjury under the laws of the State of California that the information provided is
true and correct. (See Appendix B.) The decision to place a driver on Medical probation
Type III should be based on the driver's medical history and established reliability. The main
medical factors to consider include, but are not limited to:
Seizure type
Seizure manifestations
Seizure, medical and lifestyle history
The seizure-free period prior to the last episode
The major reliability factor to consider is the driver's likelihood of complying honestly. Medical
Probation Type III should be considered self-monitoring and should not be imposed if the driver has
exhibited past evidence of:
Noncompliance
Withholding information from a physician or the department
Inconsistent statements
No probation is needed for drivers who have achieved six or more months of control and there are
no coexisting medication conditions that would aggravate the driver's seizures or impair the driver's
ability to safely operate a motor vehicle.
The department has the authority under Vehicle Code Section 14251 to terminate or modify the
conditions of probation whenever good cause exists. If it appears that a driver's lapse of
consciousness disorder has become unstable or it is suspected that the information reported is
fraudulent, the driver will be requested to have his/her physician complete a Driver Medical
Evaluation. If necessary, a reexamination will be scheduled or an immediate suspension of the
driving privilege imposed.

54

UNIT II SEMINAR: Legal/Ethical Issues

ETHICAL CASES
CASE 1
Mr. C is a 39-year-old white man admitted following a body-surfing accident. His diagnosis on
admission is a C1-2 injury with complete transection of the spinal cord. He is admitted to the
neurotrauma center 12 hours after the injury. He is ventilator dependent and is receiving
10ug/kg/min of dopamine to maintain a mean arterial blood pressure of 80 mm Hg. He is awake,
alert, and able to communicate with an artificial larynx. On the third day after admission, Mr. C asks
that his life support be withdrawn. His family opposes the decision.
1.

What should have been done ethically in this case?

CASE 2
Mrs. D is a 29-year-old white woman who was involved in a motor vehicle accident. She sustained
a severe head injury and was admitted to the neurotrauma unit following a craniotomy for the
removal of a large subdural hematoma and right temporal lobe resection. Mrs. D is 14 weeks
pregnant and an uncontrolled diabetic. She is pronounced brain dead 72 hours after admission. Her
husband wants all life support maintained until the baby can be delivered.
1.
How would different ethical theories (utilitarianism, teleology, deontology) be applied in this
case?

CASE 3
Mr. L is an 18-year-old white man brought to the trauma center with a gunshot wound to the head.
He had been shot by the police as he fled the scene of a robbery in which the store owner was
killed. Mr. L is not doing well, and a discussion regarding a no resuscitation order is held with the
family. The family wants everything to be done should a cardiac arrest occur.
1.

How can ones own ethics make this an ethical dilemma?

55

LEGAL CASES

Case 1
Ms. Dorcas is an experienced critical care nurse who has just taken a charge nurse position in a
large urban hospitals intensive care unit. The unit is a 24-bed mixed medical/surgical ICU with
critical care fellow coverage present in the unit. This is the end of Ms. Dorcas first month and she
has been pleased with her choice of positions.
After rounds one morning, Dr. John asks Ms. Dorcas to remove Mrs. Smoots pulmonary artery (PA)
catheter because she did not need it any longer and he had to go to medical grand rounds to
present. In her previous hospitals ICU, Ms. Dorcas occasionally removed the PA catheter with the
resident supervising her, so she felt comfortable doing the procedure.
As the nurse attempted to remove the catheter, the tip broke off. Dr. John was STAT paged, and
Mrs. Smoot required surgery to remove the tip of the catheter.
Mrs. Smoots family sued Dr. John for malpractice following her death from sepsis postoperatively.
While investigating the case, it was discovered that hospital policy specifically forbids nurses from
removing initial PA catheters.
1.

What is Ms. Dorcas responsibility in this case?

2.

Is she liable in this case?

3.

Does the doctrine of respondent superior apply in this case? Why or why not?

Case 2
Mark is a 14-year-old boy who was thrown from an all-terrain vehicle. He suffered a broken left wrist
and a significant head injury. Following 10 days in the intensive care unit, Mark was stable enough
to be transferred to the intermediate care unit. While in ICU, Mark awoke but was confused most of
the time. He exhibited impulsive behavior that forced the nurses to restrain him while in bed. He
was taking solid food at the time.
Marks nurse on the intermediate care unit decided to get him out of bed for his breakfast on his
third day on the unit. He had been quite cooperative during his bath. He appeared more oriented
this day. With the help of a second nurse, Mark was placed in a chair to await his breakfast. The
two nurses observed Marks behavior while they made his bed and felt that he was calm enough to
be left alone while sitting up. His hands were restrained to the arms of the chair.
About 20 minutes after leaving Marks room, Marks nurse in the nurses station heard a crash
coming from his room. She entered the room and noted that Marks bedside table and tray of food
had been knocked over. She also noted that Mark had pulled his chair over on top of himself, and
he was lying with his face on the floor.

56

Radiography following Marks return to bed revealed that he had a fracture of his cervical spine with
no deficit. This injury required 6 additional weeks of hospitalization.
1.

Is Marks nurse guilty of malpractice?

2.

What was the duty owed to the client?

3.

What was the breach of duty, if any?

4.

Is there a causal connection between the nurses conduct and the injury?

5.

Was there injury to the client?

6.

Could the incident have been prevented?

7.

If so, how?

57

SEMINAR
Case Study Burn and Inhalation Injury
Client Profile
Arthur Jefferson, a 65-year old married white man, is brought to the emergency department with burns to
his arm, hand, and face from a kitchen grease fire. He arrives with an 18-guage IV infusing Lactated
Ringers solution at 100mL/hr, and is receiving 100% humidified oxygen by mask.
Subjective Data
Complains of impaired vision and having swallowing difficulties
Cannot remember the accident
Expresses a great deal of fear
Objective Data
Physical Examination
Is awake, alert, and oriented but in obvious distress
Has irritated eyes, hoarseness, and shivering
Nasal hair is singed, with blisters on the face and mouth
Face appears sunburned; arm and hand have shiny, bright red and wet wounds
Answer the following questions:
1. What are the priorities of care in the pre-hospital environment?
2. How should his airway, breathing, and circulation be managed?
3. What factors place Arthur at high risk for an inhalation injury? What initial interventions can be
anticipated?
4. What pain medications might be considered to promote his comfort?
5. Which of the criteria for burn unit referral does Arthur meet for admission to the hospital burn unit?
6. What metabolic disturbances would be expected soon after Arthurs hospitalization? Explain the
physiologic basis for these changes.
7. What measures should be taken to support Arthurs family?
8. Based on the assessment data presented, write one or more appropriate nursing diagnoses. Are
there any collaborative problems?

58

Case Studies
Alteration in Skin Integrity: Burns
Case Study I:

A. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher L., & Camera, I.M. (2011). Case study: Burn
and inhalation injury. Medical-Surg Nursing. P. 506
B. Read and review case study on Arthur Jefferson
C. Answer questions 1-7
D. Additional questions:
8. What is burn shock?

9. How is depth of burn injury determined?

10. What is Rule of Nines?

Using the following formula, calculate fluid requirements for the first 24 hours from the time of injury:
4mLs Ringers Lactate x kg body weight x % TBSA. (Arthur weighs 165 lbs)
11. Give in the first eight hours: ________________________mLs.
12. Give in the next eight hours: ________________________mLs.
13. Give rest in the last eight hours: ________________________mLs.
Plasma 0.5 mL/kg body weight x % TBSA: follow with D5W titrated to UO and electrolytes.
14. How much plasma will you give?

15. How would you know if the client is adequately resuscitated?

16. How do you know when an escharotomy is needed?

17. Why would tetanus toxoid be given?

18. What are the properties of Silvadene?

59

Case Study II:

Ball, J.W., Bindler, R.C., & Cowen, K. (2012), Principles of Pediatric Nursing: Caring for Children.
(5th ed) New Jersey: Pearson Education, Inc. Hall p. 1071

A. Read and review case study on Joshua.


B. Answer questions 1-4.
C. Additional questions:
5. Using the Lund and Browder chart calculate the total body surface area (TBSA) for Joshua, if he was 5
years old and sustained burn injuries to bilateral hands and forearms, chest and abdomen, and bilateral
upper thighs (front only).
TBSA: _________________
6. Using the following formula, calculate fluid requirements for the first 24 hours from the time of injury:
4mLs Ringers Lactate x kg body weight x % TBSA (Joshua weighs 55 lbs).
7. Give in the first eight hours: ________________________mLs.
8. Give in the next eight hours: _______________________mLs.
9. Give rest in last eight hours: _________________________mLs.
Case Study III:
Four year old Alex is brought to the emergency department with burns to his hands. Paramedics report
that he was found in a closet by his mother after she noticed smoke coming from the closet. Alex had
been playing with matches. Alex presents with wheezing, stridorous respirations, use of accessory
muscles, nasal flaring, and is drooling. His face is bright red in color and O2 sat is 98% on 100% O2.
1. Write the alteration that occurs with inhalation injury.

2. What are the symptoms of inhalation injury?

3. What happens in carbon monoxide poisoning, and what are the symptoms?

4. Write nursing diagnosis(es) for each phase of the burn injured client.

60

Seminar
Shock/MODS
Case 1
Seventy-five year old woman hospitalized for dehydration, hypotension (BP-50/0), hypothermia (32
C), and mental confusion.
Two years before admission she had been treated for bladder stones and E. coli urinary tract
infection. One week before admission she was treated with antibiotics for E. coli urinary tract
infection.
Despite vasopressor drugs, fluid replacement, and peritoneal dialysis, her systolic blood pressure
never exceeded 50 mmHg.
Laboratory data included:
a. WBC 20,000 with 94% neutrophils
b. Blood culture E. coli
c. Serum creatinine and blood urea nitrogen 6x normal
d. Stool positive for occult blood
e. Liver enzymes in blood increased
f. Serum lactate 4x normal
g. Platelets 20% of normal. Fibrin split products, indicating lysis of thrombi, were present in the
serum
The client died two days after admission.
Answer the following:
1. What is the most likely cause of this clients shock?
2. What effects of shock did this client manifest?
a. ________ Brain effects
b. ________ Cardiac infarction
c. ________ Pulmonary effects
d. ________ Renal tubular necrosis

e.
f.
g.
h.

________
________
________
________

Intestinal necrosis
Hepatic damage
DIC
Pancreatic necrosis

3. What is the most likely organism responsible for _______________ shock in this client?
4. What is the most likely primary site of the infection?
5. Why did this client have blood in the in the stool?
6. Why did this client have an elevated WBC?
7. Why was the serum lactate elevated?
8. List at least 3 primary nursing diagnoses.

61
Reproduced from Case Studies-Shock & Heart Failure by Anna R. Graham, M.D.

Case 2
Sixty-three year-old man was hospitalized for a three-day history of chest pain which was not
relieved by nitroglycerine.
BP was 130/80. EKG showed an acute inferior myocardial infarction. Serum enzymes, which are
characteristically released by necrotic myocardium, were markedly elevated. The following day, the
EKG indicated that the infarct had extended to involve the anterior myocardium.
His BP fell to 70/0 and remained at the level despite therapy with vasopressors and
counterpulsation balloon. He became comatose. He developed pulmonary rales. He suffered a
series of cardiac arrhythmias.
By the tenth day his respiratory status had deteriorated to the point that his PO 2 was 55% despite
artificial ventilation with 100% oxygen. He died on the 14 th hospital day.
Answer the following:
1. What was the cause of this clients shock?
2. What effects of shock did this client manifest?
a. ________ Brain effects
b. ________ Cardiac infarction
c. ________ Pulmonary effects
d. ________ Renal tubular necrosis

e.
f.
g.
h.

________
________
________
________

3. What organs were affected by shock?


4. Why did the client have rales?
5. List all of the appropriate nursing diagnosis for this client.

62
Reproduced from Case Studies-Shock & Heart Failure by Anna R. Graham, M.D.

Intestinal necrosis
Hepatic damage
DIC
Pancreatic necrosis

Case 3
Forty-three year-old man was hospitalized for signs and symptoms of acute aortic insufficiency and
septicemia. Several studies indicated that a prosthetic aortic valve, replaced several weeks
previously, had torn loose from its base and was infected.
Subsequent surgery required several hours on cardiac by-pass and replacement of 5 liters of blood.
During surgery the systolic BP dropped to 40mmHg.
Following surgery, the client was comatose; the urine output fell to 50ml/24hours; serum creatinine
was 5x normal; serum bilirubin was 10x normal. He was only moderately hypotensive, BP 90/50.
Despite hemodialysis, he died on the sixth day after surgery.
Answer the following:
1. What was the cause of this clients shock?
2. What effects of shock did this client manifest?
a. ________ Brain effects
b. ________ Cardiac infarction
c. ________ Pulmonary effects
d. ________ Renal tubular necrosis

e.
f.
g.
h.

________
________
________
________

Intestinal necrosis
Hepatic damage
DIC
Pancreatic necrosis

3. What organs were affected by shock?


4. What were all the contributory factors for shock in this client?
5. What were the major effects of shock?
6. What is the primary therapeutic requirement for clients with hypovolemic or endotoxic shock?
7. What are the primary therapeutic requirements for clients with cardiogenic shock?
8. List the appropriate nursing diagnosis for this client.

63
Reproduced from Case Studies-Shock & Heart Failure by Anna R. Graham, M.D.

SEMINAR: Prioritizing Care

Review methods of prioritizing activities

An exercise will be provided

64

SEMINAR: USING NURSING PROCESS TO CARE FOR CLIENTS


DIAGNOSED WITH CANCER

Choose one of the following activities. Work in small groups to complete the activity and present
your plans during the seminar. Apply one of the QSEN Competencies to your selection. You will
use the nursing process for care planning and teaching.
1. Home care of a Client following Radical Surgery.
Choose a problem for a client having a colostomy. Research the clients home care needs,
equipment available in stores, resources available in the community. Write a one page
paper with 3 paragraphs, (a) preparation prior to surgery, including teaching and emotional
needs; (b) immediate postoperative care; (c) discharge planning and home care, including
use of community agencies. QSEN Competency chosen.
2. Plan for Client with Breast Cancer, Post Mastectomy, Receiving Radiation.
Write a plan to assist the following client to maintain or improve her self-concept, and use
her identified strengths and healthy coping mechanisms. Include information about risk
reduction of a major complication (lymphedema). QSEN Competency chosen.
Your client is a woman who is receiving radiation treatments for breast cancer after a right
radical mastectomy. She is 38 years old, married, with 3 teenagers. She is being
discharged and will continue radiation therapy on an outpatient basis. She has been very
quiet and has shown little interest in her appearance or therapy. She does not appear eager
to go home. QSEN Competency chosen.
3. Write a teaching plan to meet this clients need for further information and teaching.
You have been caring for a 56 year old client with cancer of the larynx. The diagnostic tests
have just been completed and the decision has been made to have radical surgery. The
doctor has told the client that he will have a total laryngectomy and radical neck dissection
which means he will lose his ability to speak and will have a tracheostomy and feeding tube
in place after surgery. QSEN Competency chosen.
4. Sign up one week ahead of time in small groups to review one of the Unit IV Culture and
Cancer research articles posted in Blackboard Unit IV. Each group should select a different
article. Identify at least 5 best nursing practices based on reviewing the article.

65

SEMINAR: COMPLIMENTARY AND/OR ALTERNATIVE THERAPIES

Choose an example from one of the following and present information to the group:
1.
2.
3.
4.
5.
6.

Alternative Medical System (homeopathic medicine, Chinese Medicine)


Mind-body intervention (meditation, prayer, music)
Biologically based therapies (herbs, diet, dietary supplements)
Manipulative and body-based methods (movement, osteopathic manipulation)
Energy therapies (therapeutic touch, Reiki, magnetic fields)
Other, such as culture based therapies, prayer.

Use this information to present to group:

Explain the therapy and how it works


Explain the goal of the therapy
Prevalence of use
List some conditions for which it is helpful
How might it work together or interfere with Western medicine
Cost of Service

66

SEMINAR: MULTIDISCIPLINARY CARE FOR CLIENTS WITH CANCER

Preparations:
1) Examine the disciplines involved in the care of the client with Cancer as related to their role in
client care. Talk to one of these professionals to gain insight into their role in client care and
how nurses can work with them.
a) Physical Therapist (PT)
b) Occupational Therapist (OT)
c) Speech Therapist
d) Dietician
e) Social worker
f) Psychiatric clinical specialist
g) Unlicensed Assistive Personnel (UAP)
h) Oncology certified nurse
i) Pharmacist
j) Nurse Practitioner or Clinical Nurse Specialist
k) Hospice Nurse
l) Clergy
2) Interview one client who uses Medicare. Describe briefly their experience and views regarding
financing health care. What would happen if the client had a chronic, long term illness that
requires chemotherapy or radiation? Make notes and bring to group.
3) Find out how case management can benefit the client.
4) Discuss discharge planning and the referral process for a client in need of home health
services.
5) Attend a multi-disciplinary conference to discuss client care. Identify advantages for clients
based on conferences you attended.
In Seminar you will share and compare your experiences and identify ways the nurse can
participate in an interdisciplinary conference.

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SEMINAR: RECTAL CANCER CARE


Epidemiology
1. What is the rate of colorectal cancer in Napa?
2. How does it compare with colorectal cancer in the nation?
3. What could be done to improve outcomes?
Case Study
1. From the following scenarios, make a list of what went right in the best-case scenario and what
went wrong in the worst-case scenario.
2. Apply the QSEN principles to help evaluate what steps need to be taken for the ultimate benefit
of Mr. Esteban.
a. Identify gaps between local and best practice. ~QSEN Quality Improvement
Competency
b. Seek information about quality improvement projects in the care setting. ~QSEN
Quality Improvement Competency
c. Initiate effective treatments to relieve pain and suffering in light of patient values,
preferences, and expressed needs. ~ QSEN Patient Centered Care (PCC)
Competency
d. Engage patients or designated surrogates in active partnerships that promote health,
safety and well-being, and self-care management. ~ QSEN Patient Centered Care
(PCC) Competency
e. Communicate care provided and needed at each transition in care. ~ QSEN PCC &
Teamwork & Collaboration Competencies
f. Follow communication practices that minimize risks associated with handoffs among
providers and across transitions in care. ~ QSEN Teamwork & Collaboration
Competency
g. Locate evidence reports related to clinical practice topics and guidelines. ~ QSEN
Evidence Based Practice (EBP)
h. Demonstrate effective use of technology and standardized practices that support
safety and quality. ~ QSEN Safety Competency
i. Demonstrate effective use of strategies to reduce risk of harm to self or others.
~QSEN Safety Competency.
j. Navigate the electronic health record. ~ QSEN Informatics Competency
(http://www.qsen.org/teachingstrategy.php?id=207)

68

The Patient
Jorge Esteban, who lives in Napa County, was rushed to the local emergency room by his
coworkers after he was found at his desk doubled up in pain. His wife had been encouraging him to
seek help for the persistent abdominal discomfort he had been experiencing, but the 53-year-old
had resisted going to the doctor. He lacked health insurance and had hoped that the pain would go
away on its own. The emergency doctor quickly found the source of Mr. Estebans pain, a large low
rectal tumor.
Despite his poor rural upbringing in Guatemala and his struggles as a young undocumented worker
on arriving in California 25 years ago, Mr. Esteban has become a permanent US resident and
succeeded as the owner of a small general contracting company. However, neither he nor his
employees have health insurance coverage. The premiums associated with the group policies
available through the business were too expensive for Mr. Esteban and his relatively low-wage
employees.
Mr. Esteban has been married for 21 years and has 2 children aged 14 and 18 years. The Esteban
family speaks mainly Spanish at home and receives episodic medical care at the local community
hospital.
A Worst-case Scenario
Mr. Esteban is transferred from the local hospitals emergency department to the nearby university
hospital where he is seen in consultation by a team of house officers, the medical oncology fellow,
and one of a group of local surgeons who provide care to uninsured clients. The team confirms the
presence of a 6 cm tumor within 7 cm and nearly blocking the external anal opening. A radiologic
study identifies enlarged lymph nodes in the immediate vicinity of the tumor.
The physicians agree on a treatment plan to immediately deal with the near obstruction. They
would first perform emergency intestinal bypass surgery and create a temporary colostomy and
then later treat the tumor definitively. The house officer briefly explains the treatment plan to Mr.
Esteban and then, as best he can, translates the operative consent form written in English into
Spanish. Mr. Esteban signs the form but is confused about the cause of his abdominal pain and
unsure of the meaning of colostomy. He is taken to the operating room, and the bypass
procedure is performed.
Following his recovery from surgery, Mr. Esteban starts a course of chemotherapy and is
subsequently referred to a local radiation oncologist. While he is able to communicate with the
Spanish-speaking nurse in the medical oncology clinic, he is unable to communicate with anyone at
the radiation center and is both confused and fearful about the diarrhea, fatigue, and skin reaction
that bother him during the 5.5 weeks of radiation treatment.
Four weeks after the completion of the radiation therapy, Mr. Esteban returns to the surgical clinic
for follow up. The chemotherapy and radiation therapy had succeeded in shrinking the tumor, and
the surgeon schedules Mr. Esteban for a tumor resection in 2 weeks. The surgeon removes the
tumor and is able to spare any damage to the rectal sphincter. Unfortunately, however, the nerves
that enervate penile erection must be removed with the tumor. Because the tumor is so close to the
rectal sphincter musculature, the surgeon elects to keep the colostomy to divert the fecal stream,

69

allow the connection to heal, and close the colostomy later. All of these eventualities had been
explained to the client before the surgery when the informed consent form was reviewed, but given
the complexity of the discussion, the unsatisfactory translation of the form into Spanish, and his
unfamiliarity with medical terms, Mr. Esteban has only a limited understanding of what occurred
during the operation and what to expect afterward.
The pathologist concludes that the surgery effectively removed the tumor with clean margins but
indicates that 6 of the 15 lymph nodes obtained with the specimen contained metastatic cancer.
With the evidence of metastases, the medical oncologist recommends additional chemotherapy.
The pathologists findings and the plan for additional chemotherapy are explained to the patent by
the medical oncology fellow, but Mr. Esteban does not really understand why chemotherapy is
necessary and is left fearing that the operation was not a complete success.
Over the next 6 months, Mr. Esteban adheres to the chemotherapy regimen, but the accompanying
side effects take their toll, and he begins to dwell on the likelihood of lifelong disability and a
premature death. He is ashamed to have his wife see him undress and lives with the mistaken
belief that the colostomy is permanent. Adding to his growing sense of depression is his erectile
dysfunction, which he is too embarrassed to discuss with his doctors. None of the doctors ask him
about this or how the cancer and its treatment are affecting his life.
At the conclusion of his treatment, Mr. Esteban is told he has no sign of cancer and that it is likely
that he has been cured of his disease. He is relieved to learn that the colostomy was only
temporary and to have it surgically closed. He is, however, unprepared for the year-long period of
embarrassment caused by his inability to control his bowel movements. Mr. Estebans impaired
sexual function continues to be a source of shame. He does not seek help for these problems
because he assumes nothing would help. The lack of control he feels over his most basic bodily
functions contributes to persistent distress, and he becomes despondent and withdrawn. His
previously successful business begins to fail as he loses interest in actively managing it. Mounting
financial pressures, strained communications with his children, and a loss of the closeness and
intimacy he shared with his wife contribute to a severe and prolonged depression.
A Best-case Scenario
A year ago, Mr. Esteban secured employer-based health insurance for his family with the
assistance of a state-sponsored program. One of the programs counselors outlined available
insurance options and facilitated the purchase of a plan suitable for his small contracting company.
A managed health care plan (HMO) was chosen that had reasonably priced premiums and featured
the availability of Spanish-speaking primary care physicians, advanced practice nurses, and social
workers practicing as part of a collaborative team. At his first visit, David Hernandez, the advance
practice nurse working with his primary care doctor, discussed ways for him to maintain his health,
including getting checked for colorectal cancer after age 50 years. He had been alerted to the
possibility of preventing colon cancer by an ACS informational spot that had aired during his favorite
Spanish-language television program. Although hesitant to undergo the unpleasant-sounding test,
Mr. Esteban, with the encouragement of Nurse Hernandez and his wife, decided to take advantage
of this preventive screening test. Nurse Hernandez provides information about the colonoscopy
preparation, answers questions about the procedure, and coordinates this procedure with the
colonoscopy center nurse.
The colonoscopy performed a few weeks later revealed a tumor of the low rectum that appeared to
be attached to the sacrum but not obstructing his gastrointestinal tract. The results of the
colonoscopy were entered into the HMOs EMR so that the surgeon and medical oncologist

70

scheduled to see Mr. Esteban later that week would have all the information necessary to plan his
treatment. In advance of his specialty appointments, Nurse Hernandez called Mr. Esteban to
discuss the findings, elicit his concerns, and describe what to expect at his upcoming visit with the
surgeon and medical oncologist. With the arrangements for clinical care made, Nurse Hernandez
mentioned how valuable it often is to talk to a social worker familiar with cancer-related issues and
the distress that often accompanies a cancer diagnosis. Mr. Esteban was encouraged to bring his
wife to the upcoming visit and to request a visit with a social worker if desired.
Mr. Esteban, accompanied by his wife, listens to the recommendations of the surgeon and medical
oncologist but has several questions that, with his limited English and lack of familiarity with medical
terminology, are difficult to communicate to doctors. A summary of the details regarding his
diagnosis and the recommendation to administer preoperative chemotherapy and radiation are
entered into the electronic record. Nurse Hernandez is able to access the summary from his office
and then act as translator and facilitator to ensure that all of Mr. and Mrs. Estebans questions are
answered. Appropriate staging studies are performed, and the pathology results are subsequently
communicated to the client by the medical oncologist, with the assistance of Nurse Hernandez.
Nurse Hernandez also helps Mr. Esteban make appointments for his chemotherapy and radiation
therapy.
At both the chemotherapy and radiotherapy clinics, physicians communicate with the Estebans with
the aid of Spanish-speaking nurses. The nurses also function as educators, providing Mr. Esteban
with detailed information related to side effects that can be expected and how to manage them
should they occur. The nurses provide resources for dietary needs and emotional support. The
Estebans receive a written summary that explains what treatments were administered, the
anticipated immediate effects of treatment, potential late effects, and contact information for
Spanish-speaking personnel in case of an emergency. Mr. Esteban tolerates the chemotherapy
and the radiation therapy without experiencing any unusual side effects. Nurse Hernandez follows
Mr. Estebans progress through messages received through the HMOs EMR system. He calls the
Estebans periodically during treatment to ensure the effective management of treatment-related
symptoms and to assess the familys distress levels and ability to cope.
Following the preoperative treatment, Mr. Esteban returns to the surgeon, who informs him that his
response to treatment was excellent but that despite the administration of chemotherapy and
radiation, there is evidence that some cancer remains. The surgeon informs Mr. Esteban that
additional chemotherapy will be needed after the surgery. The tumor is removed, and it becomes
apparent that a diverting colostomy is needed given the proximity of the excision to the lowest
portion of the rectum and to the anus. Unfortunately, nerves controlling sexual function were
embedded in fibrous extensions of the tumor and damaged as the tumor was being removed. The
pathologist examining the removed tissue concludes that the proximal, distal, and radial margins
are clear and that 4 of the 15 lymph nodes contain cancer.
The medical oncologist and Nurse Hernandez visit Mr. and Mrs. Esteban in the hospital following
the procedure to review the pathology findings and discuss the need to administer additional
chemotherapy to decrease the likelihood of a recurrence of the cancer. With this additional
treatment, they inform Mr. Esteban of his excellent chance of having his cancer cured and a
complete recovery. When he is discharged from the hospital, the nurse provides Mr. Esteban with
a written updated treatment plan and information on what to expect after surgery, management of
side effects, and a follow-up plan that includes appointments for wound checks. The surgeon
explains the potential for erectile dysfunction and gives Mr. Esteban the name of an urologist in
case the problem occurs.

71

At Mr. Estebans follow-up primary care visit, Nurse Hernandez reinforces the surgeons
conclusions and recommendations, reviews instructions on maintenance of the temporary
colostomy, and discusses Mr. Estebans fears about sexual dysfunction.
Mr. Esteban tolerates his additional chemotherapy without significant problems. At the completion
of the chemotherapy, the medical oncologist gives Mr. Esteban an updated treatment summary and
a detailed survivorship document (in Spanish) explaining the entire treatment course and outlining
how he would be followed by the primary care physician and nurse, the medical oncologist, the
surgical oncologist, and the radiation oncologist. Mr. Esteban had been informed that the
treatments might be debilitating in the short term, so he made arrangements for his brother and his
foreman to maintain the business. As his strength and stamina improved, he returned to work
helping his brother and the foreman supervise at the job site.
With the colostomy reversed following the chemotherapy, Mr. Esteban is seen by a nurse at a
rehabilitation clinic. The Kegel exercises he learned there aided his recovery and rectal function.
He discusses his sexual dysfunction with Nurse Hernandez and is prescribed a drug to help with his
erections. Nine months after his surgery, Mr. Esteban is cancer-free, back at work, and fully
functional.

72

Seminar: Rectal Cancer Care Application of the Six QSEN Competencies


What Went Right
What Went Wrong
Best-case Scenario
Worst Case Scenario
Patient Centered Care How was the patient included in the team/decision making?

Teamwork - Collaboration

Evidence-Based Practice

Quality Improvement

Safety

Informatics

73

SEMINAR: CANCER PRESENTATION/PAPER


The project will include both a presentation and a short paper (2-4 pages) on the topic. The paper
must be easily readable and any handouts to the audience should be attached. The group oral
presentation must be informative and use audio-visuals i.e. posters, self-made videos, power point,
or overheads.
Description: Small groups of 2-4 students (depending on class size) will develop a 15 minute
presentation for a community group. You will sign up for a type of cancer (breast, lung, colorectal,
prostate, leukemia, melanoma).
Guidelines: The presentation should be developed for a targeted population in the community
(example: high school gym class, senior citizen group, teen mothers, college class, church group,
etc.)
Information to include in the presentation:
Persons at increased risk
Preventive guidelines
Screening recommendations (not diagnostic tests)
Earliest signs, symptoms
Content of Paper:
Define the audience, relevant history, culture, norms and events that will affect
presentation.
State the learner outcomes in behavioral and measurable terms.
Provide an outline of the content that reflects the outcome statements.
Identify the learning principles and teaching strategies you will use.
Describe your plan to evaluate if learning has occurred. Include evaluation tool.
Use at least 3 resources other than your textbook. Information should be less than 5
years old.
After presentation, think back on your preparation, group work and presentation,
include a short paragraph about what you might have done differently to improve it.
Submission of Work: Only one paper will be accepted from each group. Even though different
members may contribute to the paper, it should look organized and have a consistent format/style
throughout. Submit paper in a folder.
Grading Criteria: The teaching project is worth 15 points (Fifteen points will be added to the total
possible points for the course). The due date will be ______(See calendar for due date).
Oral presentation:
Written paper:
Total

70 points (See Criteria for Oral Presentation)


30 points (see Criteria for grading teaching learning paper)
100 points x 0.15 = grade (total possible 15)

74

CRITERIA FOR ORAL PRESENTATION


Content
Knowledge and
appropriateness of content
for audience
Completes presentation
without reading, with
enthusiasm
All members of the group
share equally in the
presentation, evident
teamwork, collaboration,
practice
Organization includes an
introduction and a
conclusion and smooth
transitions between
speakers
Creative, well designed
use of graphics that
summarize key points
Presentation took no less
than 10 minutes and no
more than 15 minutes
Group members looked
professional during
presentation
All members have
thorough knowledge of the
content, able to answer
questions
Interacts with audience,
prepared discussion
questions
Evidence of scholarly
research noted in
presentations
Total Points

Total Points

Earned Points

10

10

10

10

5
70

75

Comments

CRITERIA FOR GRADING:


TEACHING LEARNING PAPER
Content
Target audience defined.
Content appropriate to
audience

Total Points
3

Content accurate, well


organized and easy to
follow

Learner outcomes are


specific, measurable,
realistic, behavioral

Content outline reflects


outcome statements

Teaching strategies are


best strategies to present
content and for learning
needs of audience

Plan to evaluate if learning


has occurred

Earned Points

Written work free of


grammatical errors, no
spelling errors

Reference list included

Measures to improve
presentation

Total Points

30

76

Comments

UNIT V SEMINAR: ENDOCRINE CASE STUDIES

There are 6 Case Studies in this seminar. In groups of 2-4, develop a 15 minute class presentation
on the case assigned to your group. Base your presentation on the questions below.
1.

Identify the endocrine alteration your group hypothesizes is the most likely diagnosis given
the information provided.

2.

Discuss the most likely pathologic cause of the clients symptoms.

3.

Present the diagnostic studies that would probably be ordered for the hypothesized
endocrine alteration.

4.

What diagnostic results would support your groups identified health alteration? Why?

5.

Interpret the implications of the available objective data. Explain if the data supports or
weakens your hypothesis?

6.

Discuss the anticipated additional collaborative care the client will likely receive for the
identified endocrine alteration (e.g., invasive procedures, medications, etc.). Why?

7.

Based on the assessment data presented, formulate two (2) nursing diagnoses pertinent to
this clients endocrine alteration while hospitalized. Provide at least 2 nursing actions
relevant to the diagnoses that you will include in your nursing plan of care.

8.

Identify potential issues related to the culture of the client that might impact the medical and
nursing plans of care.

9.

Include at least two current research articles (from professional sources) that are within the
last two years. Cite your resources and include in your presentations.

77

1. Client Profile
Martha Castle, a 58 year old female Filipino nurse admitted yesterday from her home for
constipation / abdominal pain. She is a full code. Admitting diagnosis is possible paralytic ileus.
Subjective data
Ive been feeling really run down for the last few months, but I think I have anemia.
Im having a problem thinking lately. You know. I cant seem to remember things like I used
to and I just could care less about my job or life in general.
Reports symptoms that include fatigue, muscle weakness, Unintentional weight gain,
sleepiness, and cold intolerance
Could I get a couple of extra blankets?

Current Objective Data


Physical Examination
Has a puffy face, eyelids, hands, and feet
Has not had a bowel movement in 5 days
Has blood pressure of 120/88, Pulse of 58, and respiratory rate of 14, Sp0 99%
Has a distended abdomen with hypoactive bowel sounds
Has thick, dry coarse skin
Collaborative Care
IV of D/5/.45 NS w/20 mEq of KCL at 50 ml/hr.
CBC, CMP, Calcium, Magnesium, TSH, T4, ESR, EKG, CT of the abdomen
NPO
2. Client Profile
Victor Gutierrez is a 55 year-old Hispanic man admitted yesterday from home with a diagnosis of
small cell carcinoma of the right lung. He is a full code. He is scheduled for a right lower
lobectomy tomorrow.
Subjective Data
Yeah, I guess all those years of smoking have finally caught up to me.
During admission assessment, reported symptoms that include a recent onset of
generalized muscle cramps with some abdominal cramping. Mr. G also states a recent
unintentional weight gain and feeling a decrease in his normal energy level.
A couple of days ago, I felt very nauseous and vomited. Maybe Im coming down with the
flu.
Im not urinating much lately. Do you think its my prostate?
Current Objective Data
Physical Examination
Latest vital signs : T: 99.0; P: 72; R: 18: 130/82; Sp0: 94%
This AMs labs: Hg: 12.0 g/dl; Hct: 38%; WBC 4.5; Platelets 234,000; Na: 104 mEq/L; K: 3.9
mEq/L; BUN: 6 mg/dl; Creatinine: 1.1 mg/dl; Ua negative for glucose, ketones, nitrates, WBCs,
RBCs, S.G. 1.001
AM assessments: - Lethargic and disoriented to time and place
- C/o nausea
- Urine output 60 ml for the prior 8 hrs

78

Collaborative Care
Preoperative EKG, chest CT ordered and PFTs for today
3. Client Profile
Linda Truble, a 35-year old Caucasian female, was admitted yesterday from We Care (an
addiction and recovery program) for probable active tuberculosis. She is a full code.
Subjective Data
Ive been feeling really run down for the last few months, but I think its cause of the
diarrhea Im having lately.
Ive lost 10 pounds in a month. I guess its because Ive lost my appetite and have so much
diarrhea.
Reports having frequent episodes of coughing and nausea.
Current Objective Data
Physical Examination
Recent positive PPD with positive QuantiFERON-TB Gold (QFT) and abnormal CXR,
sputum pending
On admission appeared sick, malnourished, and dehydrated with bronze skin darkening of
the elbows and palms
Latest vital signs: T: 98.0, P: 80; R: 24; BP: 76/50; Sp0; 93%
This AMs labs: Hg: 8.0 g/dl; Hct: 38%; Na: 132 mEq/L; K: 4.9 mEq/L; BUN: 19 mg/dL;
Creatinine: 1.0 mg/dL
Collaborative Care
Pulmonary function tests scheduled this afternoon
Respiratory isolation
CT of the chest this AM
4. Client Profile
Yvonne Quillala, a 55-year-old high Native American school teacher, was admitted yesterday
from her hotel in Napa where she was attending a conference. She is a Full Code. She
presented in the ER complaining of back pain for the last 12 hours. One hour earlier she had
slipped on some steps and the back pain worsened. She lives in Oklahoma where she resides
with her husband of 30 years and their 2 dogs. Cervical and lumbar spine films were negative.
CT of the abdomen revealed a 3 mm non-obstructing right ureteral stone with several additional
stones in the renal calyx.
.
Subjective Data
My back is hurting something terrible. Can I have a shot of Demerol?
Reports having a recent onset of frequent episodes of an acid stomach.
Only takes OTC medication (eg. TUMs, acetaminophen)
History significant for a fractured ankle during a ski vacation in January
Current Objective Data
Physical Examination
Latest vital signs: T: 98 F; P: 80; R: 20; BP: 134/90; Sp0: 93%
AM labs: Hg: 13.0 g/dl; Hct: 42%; Na: 142 mEq/L; K: 4.9 mEq/L; Ca: 15 mg/dl BUN: 19
mg/dL; Creatinine: 1.8 mg/dL. Phosphorus: 2.5 mg/dL; UA negative except for 3+ RBCs

79

Collaborative Care
IV: D5W 0.45NS w/20 mEq of KCI at 100 mL/hr
MS 2 mg. IV q 1 h.
Strain all urine
Ultrasonic lithotripsy scheduled for tomorrow
5. Client Profile
Dean Swarz, a 34-year-old African American man who works as a general contractor, was
admitted yesterday from home for a diagnostic evaluation of recurrent chest pain, hyperglycemia
and sleep apnea. He is a full code.
Subjective Data
Ive been feeling really run down for the last few months, but I think its cause my sugar is
high.
My ex-wife says Ive changed. I admit my nose has gotten a little bigger and my voice kinda
deeper, but I think shes full of crap otherwise!
Reports having frequent episodes of shortness of breath of the job
Current Objective Data
Physical Examination
Reports recent onset of swelling in the extremities and thickening of facial features
Latest vital signs: T: 98.80, P: 72; :20;BP: 146/94; Sp0: 97%
This AMs labs: Na: 140mEq/L; BUN: 19mg/dL; Creatinine: 1.0 mg/dL; Glucose: 357; normal
CBC
AM Assessment: S1 & S2 present & very loud
Collaborative Care
ABGs, MRI of the Brain, cardiac ultrasound and stress test
Glucose Tolerance Test in AM
SSI ac and hs
Sleep study as an outpatient

80

UNIT V SEMINAR: ENDOCRINE DISORDERS


1.

Mark: Adrenal Crisis


Mark, a 40-year old Caucasian man, develops hypotension and electrolyte imbalances two
days following an uncomplicated surgical procedure. He is lethargic but oriented. He is
unable to lift his legs against resistance. He denies incisional pain but complains of acute
abdominal pain and nausea. Telemetry shows S. tachy with tall T waves. Breath sounds are
clear. Urine output is sufficient but is dark yellow without sediment. His skin is pale, cool,
hyperpigmented in the inner arms. Bluish spots are visible on his lips.
An IV of D5/NS was started. An ACTH stimulation test was ordered.
VS: BP 80/48, HR 126, RR 18, T 100.6
Lab data: Na 123, K 6.6, Glu 60, BUN 30, Creat 1, Hgb 15.
What caused Marks adrenal crisis?

Why are corticosteroids commonly used in many other diseases?

How long after receiving steroids does a client have adrenal suppression?

What are the signs and symptoms of adrenal crisis?

What factors predispose a client to adrenal crisis?

What diagnostic tests would be helpful in determining why a client has adrenal crisis? Which
would differentiate primary from secondary causes?

Explain how to schedule corticosteroid therapy to match the normal cortisol levels
throughout the day.

What are the 3 most important topics to include in client and family teaching.

2.

Melissa: Hyperthyroidism
After presenting to the Emergency Room with Thyroid Storm, Melissa is treated and
subsequently undergoes partial thyroidectomy. She then requires lifelong hormone
replacement therapy.
How can the nurse modify the environment for the hyperthyroid client?

81

Explain what results would be expected if T 3 or T 4 and TSH were available.

Identify some ways the hypothyroid client fails to adapt to the physical and emotional
environment.

What points would be most important to include in the teaching plan for the client on
levothyroxine?

3.

Mabel: Head Trauma / DI


Following an MVA with head trauma, Mabel is diagnosed with DI and has a high urine
output.
What hormone is involved?

Is there an excess or deficit?

What nursing interventions are indicated?

4.

Miranda: Hyponatremia
Miranda is admitted with an 8# weight gain in one week. She complains of fatigue and a
headache. Her sodium level is low. She has decreased urine output.
What hormone could likely be involved?

Is it an excess or deficit?

What nursing interventions are indicated?

Compare DI with SIADH

What is the most important nursing diagnosis in DI?

82

5. Marshall: Type II DM
Marshall arrives in the Emergency Room with a blood sugar of 750 mg/dl. He has Diabetes,
Peripheral Vascular Disease and Osteoarthritis, He states he has been compliant with his
medications and has not taken any OTC meds even though he has had a URI for the past 5
days and has also had some anorexia, mild nausea and 2 episodes of vomiting.
Given the above history would you expect Marshall to have ketones in his urine?
Compare DKA to HHNK by completing the table posted on Blackboard.

83

UNIT V LIVER SEMINAR:


Acute Liver Failure / Acute on Chronic Liver Failure
Case Study
Mabel, a 58-year-old Caucasian female, Full Code, is admitted to your unit with a diagnosis of
Acute Hepatitis A. She lives at home with her spouse and 2 dogs. She works full time in a real
estate office as a secretary. She has a distant 10 year history of IVDU (1964-1974) but has been
clean and sober for 38 years. She was diagnosed with Chronic Hepatitis C in 1996 at which time
she was told her liver was fine. However, last year she was advised to seek treatment because
her tests showed she had early cirrhosis. She was also referred to a gastroenterologist to have an
Upper Endoscopy to check for esophageal varices. Since she had lost her insurance when her
department was downsized and she was asked to work part time, she was referred to a community
clinic to coordinate her care and assist with funding. Concerned she might lose her job during
treatment because of side effects, she did not go to the clinic.
She has never drunk ETOH to excess, has had no DUIs, no blood transfusions, and is a lifelong
non-smoker. Her 3 children and her husband are all HCV negative. Aside from some mild
seasonal allergies she has been in excellent health.
Last month she travelled to New Orleans for a family wedding. About 2 weeks later she felt
nauseated with recurrent vomiting and diarrhea that lasted 5 days. She became very dehydrated
and noticed that her eyes looked yellow 10 days later. She went to the community clinic and was
diagnosed with Acute Hepatitis A. Her ALT and AST were 400/ 350 but liver function tests were
normal. She did not tell the health care provider that she had a history of Chronic Hepatitis C.
Since she was feeling a bit better and had started eating again it was felt she could continue to rest
at home and follow-up in the office in 5 days or sooner should she not continue to improve. Several
days later when her husband returned from work he found her lying on the couch in the living room.
She was difficult to arouse and somewhat confused and her breath smelled funny. He brought
her to the ER thinking she might have diabetes as their 40 year old son had recently been
diagnosed with this disease.
Her Assessment Reveals:
Neuro: unintelligible speech, hyperactive reflexes, and asterixis.
CV: S. tach, S1, S2, occasional PVCs, 1+ peripheral edema
Respiratory: rapid, shallow breaths, clear breath sounds to bases
GI: Fetor hepaticus, good dentition. No bowel sounds, abdomen NTTP
Integ: scleral icterus; Spider angiomata across upper anterior chest.

Vital Signs
BP 98/40 HR 110 RR 24 Sp02 97% on room air

84

Labs
WBC 12.1 H&H 12.1 35.6 Platelets 100
Na 126 K 2.9 Gluc 80
BUN / Creat 21/1.4
AST 25 ALT 43 Alk Phos 150
Total Bilirubin 5 mg
PT/INR 11 / 1.5
Albumin 2.9
Serologies:
HAV Antibody IgM+
HBsAg neg, HBcAb Total neg HBsAb neg
HCV Antibody positive, Genotype 1b, HCV Viral Load 1,200,000 IU
HIV neg
ABGs
pH 7.5 PaCO2 30 HCO3 30 PaO2 85 SaO2 95%
Others
S. Ammonia 220
Abdominal Ultrasound shows small liver, splenomegaly and ascites, portal hypertension
Chest X-ray normal
A Foley catheter was inserted and drained 100 ml dark amber urine.

DISCUSSION/QUESTIONS:
1. Why did this patient become so sick?

2. Which of the lab tests tell you the most about her liver function?

85

3. Explain the significance of her ammonia level. What is the significance of her breath smelling
funny?

4. Given her PE and labs, what is her most urgent problem? What medication would you expect to
be ordered to help this problem the most? By what route?

5. What is her 2nd most urgent problem? What medication would you expect to be ordered to help
this problem the most? By what route?

6. You have an order to calculate her MELD score. Why? What is it?

7. Why is her serum sodium 125 mEq/liter?

8. What is making her urine dark and why?

9. What testing needs to be done for her Chronic Hepatitis C?

86

10. Do you think it is likely this patient has esophageal varices? Why or why not? Is she at risk for
bleeding? What lab tests are most important to monitor for bleeding?

11. She has the nursing diagnosis of Risk for Infection. Give one example of an infection she might
get while in the hospital related to her liver disease.

12. As you care for her through the day what will you include in your neurological assessment?

13. What medications would you question giving this patient for pain?

14. How might the attitudes of the patient or the nurse influence her care?

87

UNIT V LIVER SEMINAR:


Alcoholic Liver Disease and ETOH Withdrawal

Learning Objectives:
1. Be able to state the signs and symptoms that develop when alcohol use is stopped abruptly
after a period of heavy drinking.
2. Attain familiarity with the use of the CIWA and R.A.S.S. tools as quantitative instruments to
measure the severity of alcohol withdrawal (QSEN Informatics).
3. Define the learning principles, teaching strategies and learner outcomes that occurred in a
sample video.
4. Review and assess the development of your own teaching and learning processes
throughout the ADN program
Preparation Before Class:
Print out CIWA-A.pdf and RASS.pdf (Posted on Blackboard)
Watch the video from CPMC
http://www.youtube.com/watch?v=NUKigZjcGy4
(A little over 18 minutes long)
Come to class with your critique of this video and its effectiveness as a learning tool in your
future practice as a Registered Nurse.
Be prepared to reminisce about your experiences in each semester of the program that
prepared you for your professional teaching role.

88

SEMINAR: ASSERTIVE BEHAVIOR AND EVALUATION

ROLE-PLAY: Take 10 minutes to prepare to assume the roles in the situations below. Role-play
each of the situations. Discuss the strengths and weaknesses of each.
ASSERTIVE BEHAVIOR
Situation 1:
You are working on a surgical unit, partnered with Sam, an RN you have been working with for the
past year. Your easygoing style has led to a comfortable working relationship and a feeling that you
know what each other expects. Tonight you are walking down the hall intent on medicating one of
your clients. A PACU nurse is bringing one of your clients back from surgery. As Sam approaches
you, you say, Sam, the post op is back in room 2224."
Thirty minutes later you are standing at the nurses station charting. You ask Sam how the client in
room 2224 is doing. You expect a brief report and are surprised when Sam says, I dont know. I
thought you were going to take him."
What went wrong?
Situation 2:
You are a registered nurse working in the Step Down Unit. Your client develops a ventricular
arrhythmia. The resident tells you he will start procainamide to suppress it. Since you know that
lidocaine is easier to titrate and less likely to cause hypotension, you say to the resident, May I
suggest lidocaine instead? The resident responds, If I want your advice, Ill ask for it!"
Discuss the effectiveness of the responses.
DOING EVALUATIONS
Situation 1:
You are the head nurse. You are conducting a routine performance evaluation of Mabel Brown, RN.
Her strengths are that she is prompt, well-organized and makes good nursing assessments. Her
weaknesses are that she chews and cracks her gum, she often comes to work in a dirty uniform
and she talks very loudly.
You are Mabel Brown, RN. You have identified your own strengths: prompt, make good nursing
assessments, well organized. You expect you will be reprimanded for talking loud and making jokes
with the doctors. You resent it when the head nurse mentions any other weaknesses and you react
accordingly.
Situation 2:
You are the head nurse. You have evaluated Nancy Adams, UA. There are multiple problems,
which you have identified. You have held many previous conferences and at the last one you
clearly indicated that Nancys performance had to improve or she would be terminated. You
terminate her in the conference today.

89

You are Nancy Adams, UA. You know that you have been skating on thin ice but you have always
been given one more chance and that is what you expect to happen today. During the conference,
you cry and beg to keep your job. You promise you can do better. Your goal is to make the head
nurse change her mind and not terminate you.
Situation 3:
You are the head nurse. Jane Jones, LVN, is to have a routine evaluation. She gives good nursing
care. Her weaknesses include aggressive behavior and performing tasks that are outside the scope
of practice for an LVN.
You are Jane Jones, LVN. You have been employed 7 years, which is longer than the head nurse.
You think you can perform other duties that those stated in the job description and you argue that
point. You want more authority and responsibility and you request them.

90

SEMINAR: DELEGATING NURSING CARE

Jim Henderson, with cancer of the colon is complaining of pain. Carol Green is recovering from a
craniotomy and needs to be ambulated. Pat Johnson, post op graft for a burn, on TPN needs a
blood sugar test. Mrs. Davis reports that her husbands (SCI injury) sacral area looks red.
1.

Which of these tasks could the nurse delegate and which must the nurse do?
(Review BRN website about delegation)

2.

What process is used to make the decision?

3.

Who does the term unlicensed assistive personnel (UAP) refer to?

4.

What training have they received?

5.

What should the nurse know about each individual UAP?

6.

What are the advantages of using assistive staff?

7.

Why do nurses have difficulty delegating?

8.

How much supervision should the nurse provide?

9.

What communication is important?

10.

What strategies could be used for success in delegating and supervising client care?

11.

What happens when a nurse fails to appropriately delegate to a UAP and harm occurs to a
client?

12.

Describe a situation in which someone delegated a task to you. Was an explanation given?
Did you receive too much information? Not enough? Was supervision appropriate for task
and your abilities? What was the outcome?

91

SEMINAR: EVALUATING PERFORMANCE

Objective: Students will analyze, justify and evaluate their decision in a difficult situation.

Students will work in groups of 3 or 4.

Use Handout to be distributed in seminar.

Discussion:
1. What evaluation methods have you seen used at work or at school? Which ones were the
best?

2. If you are responsible for evaluating your employees, how would you evaluate their clinical,
technical, and interpersonal skills?

3. What are the signs of substance abuse? Have you seen someone with those symptoms? What
happened?

4. For what reasons have you been absent from work or school? If you are a nurse manager,
what would you do to decrease absenteeism?

5. As a manager, what actions could you take to retain staff?

92

NAPA VALLEY COLLEGE


SKILLS LAB

93

Peripheral Infusion Therapy


Outcomes and Related Activities
At the completion of this skills lab, the student will (be able to):
List indications for IV therapy and associated risks.
Describe appropriate measures to avoid / prevent complications.
State the RN and LVN scopes of practice with regard to IV therapy.
Initiate peripheral infusion therapy with over the needle catheter including appropriate documentation.
To prepare for this lab:
a. Look at multiple resources (see below). Compare methods suggested for IV starts.
Determine which procedure would work for you. Make a list of questions about what you
see or read that you do not understand and bring to the Skills Lab with you.
b. Identify types and characteristics of infusion devices (including IV catheters and IV pumps).
c. Identify peripheral veins appropriate for venipuncture.
d. Identify key components of documentation of an IV start.
e. Name six local and 4 systemic complications that can occur.
f. Describe special considerations for successful venipuncture of the neonate, infants and
geriatric clients and come prepared to discuss in class.
g. Write a narrative documentation entry for an IV insertion and bring with you to share during
post session discussion.
Review:
Anatomy and physiology of the venous system
Read:
Elkin, M.K., A.G. Perry, & P.A. Potter, 2007. Nursing Interventions and Clinical Skills (4 th ed.), St.
Louis, Mosby. (Includes 2006 Standards of Practice from Infusion Nursing Society, CDC guidelines).
Recommended Website:
www.enw.org (ENW = Emergency Nursing World) Click on IV Starts
Also, see Evolve online skills and media clips.
Journal Articles Posted on Blackboard:
In folder Prepare for Skills Lab Nursing 249
Post Session Discussion:
A pediatric client admitted with pneumonia has an order for a peripheral IV.

What is the probable rationale(s) for this order?


What equipment would you choose for this infusion and why?
What safety factors would you consider?
What education would you provide the parents?

Discuss your findings related to preparation above.


What can the nurse do to prevent local and/or systemic complications?
How will this procedure need to be adapted for various age groups?
Were the journal articles and websites helpful

94

Share your experiences today practicing IV starts


Compare findings from your practice starting IVs
What was the best experience and what offered the most challenges
How can you make your first IV start a positive successful experience?
IV Start Quiz
True/False
1. LVN's , regardless of whether or not Certified in IV therapy, are responsible for monitoring of
intravenous infusions in progress; e.g. observation of the client, maintaining proper solution flow,
discontinuing an IV, recording and reporting. T F
2. IV solutions not completely infused within 24 hours, from the time started, must be discarded. T F
3. When restarting an IV, change the entire infusion system. T F
4. A phlebitic site (or suspected phlebitic site) should be re-sited using all new components regardless
of the length of use of the reservoir bottle and administration set. T F
5. If an IV site is not dated, the nurse is to determine the date of insertion and write it on the tape. T F
6. IV catheters inserted in emergency situations (i.e., by Paramedics, during resuscitation, etc.) with
possible improper aseptic technique should be changed as soon as a satisfactory site can be
established elsewhere. T F
7. The recommended technique to palpate a vein is to:
a. Firmly press with all your fingers over the vein
b. Rest one or two fingers on the vein and press lightly
c. Use your thumb and press lightly on the vein
d. Use your ring finger to press hard over the vein
8. Avoid venipuncture at vein valves because damage to a valve may lead to:
a. Hemorrhage
b. Muscle atrophy
c. Nerve damage
d. Thrombosis
9. The vessel you find feels pulsatile, so you know it is:
a. An artery
b. A sclerosed vein
c. A tendon
d. An excellent vein for venipuncture
10. To promote vasodilation before venipuncture:
a. Apply a warm compress to the site for 10-15 minutes
b. Elevate the arm on two pillows
c. Have client drink a glass of water
d. Have client take a cool shower

95

11. Which is the best site choice for a venipuncture:


a. A hemiplegic arm
b. An arm with a dialysis fistula
c. An arm site above a previous infiltration
d. An arm on the same side as a previous mastectomy
12. The preferred site for a peripheral infusion site in an infant younger than 9 months is:
a. Frontal vein in scalp
b. Dorsum of foot
c. Dorsum of hand
d. Occipital vein on head
13. In a dark-skinned person, the best method for locating an accessible vein is:
a. Multiple tourniquets
b. Tangential lighting
c. Direct overhead lighting
d. Light application of a tourniquet
14. Which of the following is the most appropriate cannula size for use on a 2 month old infant?
a. 18-gauge over-the-needle catheter
b. 23-25 gauge scalp vein needle
c. 16-gauge scalp vein needle
d. 22-24 gauge over the needle catheter
15. All of the following are signs of phlebitis EXCEPT:
a. tenderness
b. pain at IV site
c. skin feels cool around IV site
d. redness and/or swelling noted at IV site
16. Observation and evaluation of the peripheral IV site in adults and its surrounding tissue
should be done every:
a. 2 hours
b. 4 hours
c. 8 hours
d. 30 minutes
17. The nurse should change peripheral IV tubing every:
a. 12 hours
b. 24 hours
c. 72 hours
d. 4 times a week

96

18. On a medical-surgical ward, an antibiotic order should be renewed after:


a. 3 days
b. 5 days
c. 7 days
d. 10 days
19. The physicians orders for administration of a blood product must state all of the following
EXCEPT:
a. number of units to be infused
b. type of blood/blood product to be given
c. rate of infusion if not given over usual time frame
d. specific intervals when vital signs should be taken
20. All of the following staff may verify the information on the Transfusion Record form, the
blood label on the unit, and the clients identification band prior to administration EXCEPT:
a. RN/RN
b. RN/LVN
c. LVN/LVN
d. RN/MD
21. The tubing and filter used to administer total parenteral nutrition is to be changed how
frequently?
a. Every 24 hours
b. Every 36 hours
c. Every 48 hours
d. Every 72 hours
22. Cannulation of the lower extremities in adults should be avoided because of the high risk of:
a. embolism
b. thrombophlebitis
c. both a and b
d. neither a or b
23. Symptoms associated with complications to a peripheral IV include all of the following
EXCEPT:
a. pain
b. redness
c. tenderness
d. crepitation
24. A PICC line is:
a. a central line
b. a peripheral line
c. inserted directly into the superior vena cava
d. not confirmed by x-ray for placement

97

Napa Valley College


Associate Degree Program in Nursing
Assumption of Risk for Invasive Procedures Scheduled by the
Associate Degree Program in Nursing (ADN) in the College Nursing Lab

Students in the ADN Program are required to learn and practice nursing skills and procedures prior to
performing them on clients in the clinical setting. The undersigned agrees that he/she understands that
students practice these skills on each other and this activity may be accompanied by potential dangers
as identified below:

I understand and acknowledge that as a part of the ADN Program, I will be required to learn skills
necessary for practice as a registered nurse.

I understand that these skills will include fingersticks and venipuncture.

I understand that nursing students will practice these invasive procedures on each other.

I understand that, prior to the skill practice; students will receive instruction from the ADN
Registered Nursing Faculty regarding the skills to be practiced including information on safety and
the potential dangers inherent in such procedures.

I understand and acknowledge that such activities by their very nature can be very dangerous and
involve the risk of serious injury/illness and/or death.

I understand that the risk of injury/illness may include, but is not limited to, blood-borne pathogen
infections, phlebitis, thrombophlebitis, septicemia, hemorrhage, tissue sloughing, nerve damage
and loss of limb.

This agreement shall continue and remain in full force and effect for the full term of my enrollment in
the program.

I agree to assume liability and responsibility for any and all potential risks which may be associated with
participation in such educational activities. Moreover, I understand and agree that I will indemnify and
hold harmless the Napa Valley Community College, California Board of Registered Nursing, Officers,
Agents, and employees and that other students shall not be held liable for injury or illness which is
incidental to or associated with the preparation for and the participation in these learning activities and
which may be sustained by me.

Date:
Students PRINTED name

mm/dd/year

Students signature

98

CLINICAL GUIDELINES
MEDICAL/SURGICAL

99

Kaiser Vacaville Driving Directions


2277 Napa Vallejo Hwy, Napa, CA 94558-6236
1. Start out going south on Napa Vallejo Hwy / CA-221 S toward
Streblow Dr.

2.1 mi
2.1 mi total

2. Turn left onto CA-29 S / CA-12 E.

1.5 mi
3.6 mi total

3. Turn left onto Jameson Canyon Rd / CA-12.

5.8 mi
9.4 mi total

4. Merge onto I-80 E.


5. Take the Leisure Town Road exit, EXIT 57, toward Vaca Valley
Pkwy.
6. Turn left onto Leisure Town Rd.

7. Leisure Town Rd becomes Vaca Valley Pky.

8. Turn left onto Quality Dr.


9. 1 QUALITY DR is on the right.

1 Quality Dr, Vacaville, CA 95688-9494


Total Travel Estimate: 27.97 miles - about 31 minutes

100

17.9 mi
27.3 mi
total
0.2 mi
27.6 mi
total
0.2 mi
27.8 mi
total
0.1 mi
27.9 mi
total
0.07 mi
28.0 mi
total

NAPA VALLEY COLLEGE


ASSOCIATE DEGREE PROGRAM IN NURSING
NURS 249 NURSING IN HEALTH ALTERATIONS IV
GUIDELINES FOR CLINICAL ROTATIONS
UNIT I NURSING CARE OF CHILDREN WITH ACUTE, COMPLEX ILLNESS

Adapt the nursing process to provide care for children of all ages and their families

UNIT II ALTERATIONS IN THE NERVOUS/SENSORY SYSTEM

Apply the nursing process in planning and caring for a client with deficits in neurologic function:
Comatose
Increased intracranial pressure
Seizure activity
Weakness or paralysis
Loss of sensation
Recognize the presence of increased intracranial pressure
Use nursing measures to prevent increase in intracranial pressure
Institute measures to preserve function at the optimum level and prevent further injury
Provide nursing care for a client with an actual or potential problem of sensory deprivation

UNIT III ALTERATIONS IN THE INTEGUMENTARY SYSTEM

Manage the care of a client who has developed a complication due to an alteration in the
integumentary system
Manage the care of the client who has multi-system failure
UNIT IV ALTERATIONS IN CELLULAR GROWTH/IMMUNITY

Formulate some outcomes related to the nursing diagnoses of clients with cancer
Implement measures to maintain adequate fluid and nutritional status
Demonstrate responsibility and accountability in functioning as a member of the healthcare
team in this community

UNIT V ALTERATIONS IN THE ENDOCRINE/METABOLIC SYSTEM

Apply the nursing process in planning and caring for a client with an endocrine disorder
Formulate a care plan for a client with liver failure

101

NURS 249
CLINICAL PREPARATION AND WRITTEN ASSIGNMENTS
For medical/surgical, specialty and pediatric clinical rotations, due weekly:
I

Complete a self-evaluation with three learning goals using the format in the syllabus

II

Complete the Medication Assignment for a minimum of one patient.

III.

Return the Student Evaluation form completed by your partner RN.

III

Written critical thinking/self-reflection papers (2 pages) are required each week, and
described below:
Critical Thinking Self Reflection Paper
This paper is intended to enhance your awareness, practice and documentation of critical
thinking skills. Your reflective self-watches your action self and offers suggestions.
It is a thinking paper about your experiences, and should show how they are connected to
what you have learned from textbooks or reflect on the experience and identify new
learning. The paper is not only a description of your experience but also refers to study from
texts, questions still unanswered and connects previous knowledge with new information.
Include at least one of the 6 QSEN competencies and/or the Six Aims from the IHI / IOM.
Specialty Clinical Rotation Papers
For those weeks when you participate in a specialty rotation, your Critical Thinking Self
Reflection should also include the specific written assignment for that rotation as well as the
above guidelines.
One paper is required each week.
Criteria for Satisfactory Paper
If a satisfactory grade is not achieved, the assignment will need to be redone until it is
satisfactory. Papers are due during the weeks assigned in clinical (medical/surgical,
pediatrics, specialty rotation.) All weekly clinical assignments will be submitted in a folder.
Previous assignments will be kept in folder along with new assignments and will be
submitted on assigned day (to be determined by clinical instructor).

IV.

Formative/Summative Evaluation: Submit completed student self-evaluation with


comments/examples of how clinical objectives were met, then schedule meeting with
instructor. These are due at the midway point for medical/surgical and pediatric clinical
rotations, using respective evaluation form (Medical/Surgical and Pediatric). Summative
Evaluation will be due at the end of the medical/surgical and pediatric clinical rotations.
Refer to Student Handbook for additional information/requirements.

102

NAPA VALLEY COLLEGE


ASSOCIATE DEGREE IN NURSING PROGRAM
NURS 249 Nursing in Health Alterations IV
STUDENT EVALUATION BY RN PARTNER
Student_________________________________________Clinical Area____________________

Date

Day

Time
In

Time
Out

Student Signature/RN
Signature

Needs
Improvement

Satisfactory

Excellent

1. Use the nursing process for the care of clients with


multiple complex alterations in health
2. Practice in accordance with safe, ethical, and legal
guidelines in the Nurse Practice Act, ANA Code of
Ethics and Nurse Practice Standards
3. Collaborate with clients and the interdisciplinary
team using informatics and therapeutic
communication to promote client-centered care
4. Evaluate theory, quality monitors, and evidencebased knowledge for decision making to guide
nursing practice and client outcomes
5. Manage client-centered care for clients with
multiple complex alterations in health in
collaboration with client and interdisciplinary team
6. Demonstrate consistent commitment to continued
professional growth and self-development

Comments:

Note: At the completion of the experience, return this form to the student who will submit it to their
clinical instructor with their written work.

103

NURS 249 NURSING IN HEALTH ALTERATIONS IV


CLINICAL SELF EVALUATION
These are the Course Objectives for N249. Evaluate each clinical based on these criteria. Identify
your personal strengths and weaknesses. Include specific experiences beneficial to your learning.
and give an example of how you met each objective.

1. Use the nursing process for the care of clients with multiple complex alterations in health

2. Practice in accordance with safe, ethical, and legal guidelines in the Nurse Practice Act, ANA
Code of Ethics and Nurse Practice Standards.

3. Collaborate with clients and the interdisciplinary team using informatics and therapeutic
communication to promote client-centered care.

4. Evaluate theory, quality monitors, and evidence-based knowledge for decision making to guide
nursing practice and client outcomes

5. Manage client-centered care for clients with multiple complex alterations in health in collaboration
with client and interdisciplinary team

6. Demonstrate consistent commitment to continued professional growth and self-development

THREE LEARNING GOALS FOR NEXT WEEK


1.
2.
3.
104

Napa Valley College Associate Degree Nursing Program


Medication Assignment Form NURS 249
Clients Initials:________________
Age:________________________
Allergies:____________________
Height:________ Weight:_______
BMI: ____________

Date
Ordered

Medication: Trade & generic name,


dose ordered, route, frequency, safe
range, your calculations, age
consideration (pediatrics, pregnant,
elderly)

Admitting Diagnosis:___________
____________________________
____________________________
Other Medical History:__________
____________________________
____________________________

Times
Given

Action/use
for this
Client

105

Student Name:______________________
Instructor:__________________________

Common Side Effects

Nursing
Implications

Expected
Outcomes

Evaluations

SPECIALTY ROTATION GUIDELINES

106

NURS 249 NURSING IN HEALTH ALTERATIONS IV


GUIDELINES FOR SPECIALTY ROTATIONS
ICU
PREPARATION
REVIEW general standards of care/practice for ICU
REVIEW the clinical objectives in your NURS 249 syllabus
CHOOSE a client and prepare your NCP in advance as per instructor
EXPERIENCE
You will be a participant/observer in the care of clients who require intensive care
You are not responsible for the total care of the client
You are expected to do care you have previously learned how to do
Meet with your assigned nurse and agree upon what you are going to do
Tell the nurse what you can do and what you want to learn
There will be time for you to observe other clients and procedures
Know what learning experiences are available and ask to participate
Do only those skills you have completed successfully
LEARNING EXPERIENCES
Observe instrumentation and invasive monitoring equipment (oscilloscope, transducer and alarm
functions) used to measure, display and record assessment variables
Look for examples of how alterations in one system affect other systems
Participate with a nurse in the management of clients with neurologic problems, regulation of fluid
and electrolyte disturbances, alterations in cellular growth and immunity, in shock, and in multisystem failure
OBJECTIVES
Collaborate with other members of the health care team to restore and maintain clients health
Seek solutions to the problems of the ICU client including sensory deprivation and overload
Provide physical and psychological safety in the intensive care environment, including the use of
electrical and mechanical equipment and the prevention of nosocomial infections
Assist in fostering interpersonal relationships between the client, the family and the nurse
Compare assessment and charting of ICU clients with that of other clients
Participate in Interdisciplinary Rounds
WRITE
1 2 page paper. Address each objective

107

NURS 249 NURSING IN HEALTH ALTERATIONS IV


GUIDELINES FOR SPECIALTY ROTATIONS
EMERGENCY ROOM
PREPARATION
REVIEW Standards of Care / Standards of Practice for clients in the Emergency Department
(ie., Stroke protocol, ACS, etc. )
REVIEW the clinical objectives listed below.
EXPERIENCE
You will be a participant/observer in the care of clients who require emergency care
You will assist a nurse with the care of clients admitted to the Emergency Department
Do only those skills you have completed successfully with an instructor
Any IV push medications must be given with RN supervision
LEARNING EXPERIENCES
Observe the role of the nurse and participate in interdisciplinary communication
Participate/observe the assessment of clients, examining how assessment compares with that of
clients on the hospital units
Assist with client examination, emergency procedures and treatments
Review code procedures, triage guidelines, emergency drugs and procedures
OBJECTIVES
Compare the roles of nurse managers in different settings of your clinical rotations
Use effective interviewing and assessment skills to plan, give and evaluate care for a client with a
complex alteration in the cardiovascular system
Assess a client who is experiencing chest pain
Observe and assist in fostering communication between the client, family and nurse
Care for a client with cardiac problems using written standing orders or protocols
Manage the care of client receiving telemetry
Initiate teaching that is clear and at the clients level of understanding
Teach client about safe use of drugs at home
Coordinate discharge planning and teaching with other health care personnel
WRITTEN WORK
Compare the assessment of clients in the Emergency Department with that of clients on acute care
units
Describe an initial assessment and the further ongoing assessments that you participated in. Tell
how priorities of care are established

108

NURS 249 NURSING IN HEALTH ALTERATIONS IV


GUIDELINES FOR SPECIALTY ROTATIONS
ONCOLOGY OUTPATIENT DEPARTMENT
EXPERIENCE
Demonstrate care of clients; observe the treatment, techniques, equipment used in giving
chemotherapy
Observe OSHA guidelines used with chemotherapeutic agents
Maintain client/family confidentiality
Observe the responsibility/accountability of the nurse manager
PREPARATION
Look up and be prepared to give medications except chemotherapy by the intravenous route. You
cannot give chemotherapeutic medications and will be observing their use. You are expected to
know about how to give them and the nursing implications
Review unit on Alterations in Cellular Growth/Immunity. Note in particular the care of the client with
breast or colon cancer and the clinical objectives
Review infusaport access, handling of chemotherapeutic drugs by the nurse and blood transfusion
therapy
NOTE: Students will not give chemotherapeutic agents.

WRITTEN WORK
Describe the nurses responsibility in assessing, teaching and providing emotional support

109

NURS 249 NURSING IN HEALTH ALTERATIONS IV


GUIDELINES FOR SPECIALTY ROTATIONS
RADIATION THERAPY

PREPARATION
READ Radiation Therapy & You: A guide to Self-Help Cancer Treatment at http://www.cancer.gov
(article available in skills lab)
READ about radiation therapy in your text
READ binder Radiation Therapy located in Skills Lab

EXPERIENCE
HOURS: TBA
LEARNING EXPERIENCES
Demonstrate knowledge about the process, treatment, techniques, and equipment used in radiation
therapy
Participate/observe in the interview and physical assessment made to identify client needs,
concerns, nutritional issues, sexuality, and physical and emotional side effects of therapy
Participate/observe in the planning and implementation of client care from initial interview through
preparation for therapy, care during therapy and follow-up
Participate/observe with an interdisciplinary team conference and work together to plan and
implement client care
WRITTEN WORK
What specifically did you learn and how will you apply this knowledge to your future practice

110

NURS 249 NURSING IN HEALTH ALTERATIONS IV


GUIDELINES FOR SPECIALTY ROTATIONS
CARDIAC CATHERIZATION LAB
PREPARATION
REVIEW procedures in your textbook (Cardiac Cath and Nursing Care, PTCA, pacemaker
insertion, EPS studies, cardioversion, ICD, stent placement)
EXPERIENCE

LEARNING EXPERIENCES
Observe and participate in the nurses activity and the collaborative relationship between team
members
Participate/observe admission assessment, nursing interventions, discharge of clients
Review code procedure, emergency drugs
Observe procedures and how client experiences them
OBJECTIVES
Compare the role of the nurse in this setting with that of nurses on your assigned unit
Use effective interviewing assessment skills in giving client care
WRITTEN WORK
Analyze what happened and explain what you came away with that you can use in the care of
future clients

111

NURS 249 NURSING IN HEALTH ALTERATIONS IV


GUIDELINES FOR SPECIALTY ROTATIONS
OUTPATIENT SURGERY DEPARTMENT
OBJECTIVES
Describe and use protective measures to ensure
safety for the client during the perioperative
experience.
Apply the nursing process to maintain
physiological stability of the client.
Identify client and family emotional, sociological
and spiritual responses to surgery. Use nurse
responses that teach, support client rights and
ethics.
Use legal/ethical guidelines to provide safe,
responsible nursing care.
Describe the health system in which perioperative
care is provided.

CLIENT OUTCOMES
Client will be free of signs or symptoms of
acquired physical injury
Clients physiological responses to surgery are
expected.
Clients rights, ethics are supported.
Client has knowledge of the perioperative process
and post-op instructions.

Client and community achieve health care goals.

PREPARATION:
Review: Perioperative care of clients, informed consent, required lab values, types of anesthesia,
post anesthesia complications, their assessment and interventions, surgical hand scrub, maintaining
a sterile field, conscious sedation, malignant hypertension, prevention of fires in the OR.
Wear your uniform to clinical. Do not wear any jewelry, including rings and watches. Change to
surgical attire upon your arrival.
DO NOT ADMINISTER CONSCIOUS SEDATION.
EXPERIENCE:
Identify measures that ensure safety: positioning, transfer/transport: chemical, electrical, laser,
radiation hazards; safe medication administration, surgical asepsis and sterile technique, airway
management, sterilization and disinfection.
Assist with measures that promote physiological safety: correct site surgery, assessment of
respiratory, cardiovascular and neurological systems: pain control; infection risk, prophylaxis;
normothermia; tissue perfusion; fluid and electrolyte, acid-base balance.
Provide individualized care and teaching, considering dignity, privacy, nonjudgmental behaviors to a
diverse population.
Identify behaviors that indicate sensory impairments, barriers to communication, readiness to learn,
and coping mechanisms used.
Review staffing ratios, pre-admission assessment, pre-op assessment, pre-op teaching, anesthesia
evaluation, communication and reporting between the team, evaluation criteria for discharge,
documentation of nursing care using nursing process.
Name factors that place nurses at high risk for work-related injuries.
Assess your interest in perioperative nursing.
WRITTEN WORK
Briefly describe the procedures that you observed. Compare what you saw to your text and lectures.
What is the nurses responsibility in assessing, teaching and providing emotional support?
Describe some specific examples of how you saw the nurse function in the areas where you worked
and how you saw them functioning with the team.
Describe what you have learned that you can use when taking care of clients before and after
surgery

112

NURS 249 NURSING IN HEALTH ALTERATIONS IV


GUIDELINES FOR SPECIALTY ROTATIONS
EMERGENCY EXPERIENCE - AMBULANCE TEAM
PREPARATION
REVIEW Emergency care outside the acute hospital
EXPERIENCE
HOURS: TBA
This is an experience that is available to any citizen that informs them about what the community
provides. You may arrange to do this on your own as a citizen and you would present yourself in
proper attire as an interested citizen.
If you want to use this to meet requirements of clinical, you must first seek approval from your clinical
instructor.
OBJECTIVES
Identify how persons in the community summon help in an emergency
Outline the sequence of events that occurs once an emergency call is made
Identify the role of the ambulance personnel in an emergency situation
Identify the equipment available in the ambulance for use by ambulance personnel
Compare to the hospital how the equipment works in the ambulance
Describe the use of CPR and assessment in an emergent situation
Write the information that is conveyed by the ambulance enroute to the hospital and upon arrival
WRITTEN WORK
Write a summary of your experience as it relates to the objectives above

113

NURS 249 NURSING IN HEALTH ALTERATIONS IV


GUIDELINES FOR SPECIALTY ROTATIONS

CLINICAL EXPERIENCE IN A COMMUNITY AGENCY


OBJECTIVES
Identify direct services provided
Identify health promotion, maintenance, restoration activities
Identify which segment of the community uses these services
Identify strategies used to incorporate cultural beliefs while providing health care
Evaluate the role of case management and early intervention in providing care
Describe the role of the nurse as related to the community
Identify major ethical/legal issues that confront nurses in the community health setting
Identify any current issues (state or national) where legislation impacts nursing
ASSIGNMENT
Arrange an observational clinical experience at any community agency or service which might be
used in discharge planning or referrals. (Examples: support group, outpatient clinic, health
education service, home health care). Observation experience must have prior approval of the
instructor.
WRITE
A paper that addresses the objectives.
Participate in a post conference and orally present a description of the agency visited, the goals and
methods of achieving those goals, your impression of the effectiveness of the service.

114

NAPA VALLEY COLLEGE


ASSOCIATE DEGREE IN NURSING PROGRAM
NURS 249 Nursing in Health Alterations IV
STUDENT EVALUATION BY RN PARTNER

Specialty Clinical Area:_________________________________

Date

Day

Time
In

Time
Out

Student Signature/RN Signature

Student_______________________________

Needs
Improvement

Satisfactory

Excellent

1. Use the nursing process for the care of clients with


multiple complex alterations in health
2. Practice in accordance with safe, ethical, and legal
guidelines in the Nurse Practice Act, ANA Code of
Ethics and Nurse Practice Standards
3. Collaborate with clients and the interdisciplinary
team using informatics and therapeutic
communication to promote client-centered care
4. Evaluate theory, quality monitors, and evidencebased knowledge for decision making to guide
nursing practice and client outcomes
5. Manage client-centered care for clients with
multiple complex alterations in health in
collaboration with client and interdisciplinary team
6. Demonstrate consistent commitment to continued
professional growth and self-development

Comments:

Note: At the completion of the experience, return this form to the student who will submit it to their
clinical instructor with their written work.
115

Clinical Evaluation Tool


Medical-Surgical

116

NAPA VALLEY COLLEGE


ASSOCIATE DEGREE IN NURSING PROGRAM
CLINICAL EVALUATION TOOL

Course:
Semester:

NURS 249 Nursing in Health Alterations IV Medical/Surgical Rotation


4

Student:

________________________________________

Clinical Evaluation
Clinical performance is evaluated by the clinical instructor and is based on the six course objective
derived from the program outcomes. The student also evaluates clinical performance using the
same performance objectives. Clinical evaluation tools are used to document student progress in
meeting clinical objectives for each course. These clinical evaluation tools are found in each course
syllabus. The clinical evaluation tool includes formative and summative evaluation. The evaluation
is to be in writing, discussed with the student and signed by both the instructor and the student.
Formative Evaluations
Formative evaluation monitors progress and provides direction for learning throughout the course.
It provides feedback to the student and shall include their strengths and positive accomplishments
as well as their deficiencies and performance that needs to be improved. It informs the student as
to their progress in meeting clinical objectives, identifies where further learning is needed and
makes recommendations for ways to improve and meet objectives.
The formative evaluation will be done at the mid-way point of the medical-surgical clinical rotation.
Additional formative evaluations may be done at the discretion of the clinical instructors.
In the formative evaluation, the performance is rated as follows:
S

Satisfactory demonstrates a consistent performance of the objective


according to criteria or guidelines given. When errors are made they are
recognized and corrected.

NI

Needs Improvement is defined as performance that impedes progress


toward meeting clinical objectives and must be improved to be satisfactory
at the summative evaluation.

NO

Not Observed behavior is defined as a behavior that should have occurred


but was not observed and indicates an area to be given attention.

NA

Not Applicable means a behavior that was not expected of the student.

Unsatisfactory is defined as inconsistent performance, does not meet


criteria for performance, errors were made and not recognized or were not
performed at all.

117

Summative Evaluations
Summative evaluation occurs at the end of the course and/or the end of the medical-surgical clinical
rotation to determine if the clinical objectives have been achieved and establish the grad for clinical
practice.
The criteria for evaluation will be rated as follows:
S

Satisfactory is defined as consistent performance of the objectives


according to criteria or guidelines given. When errors are made they are
recognized and corrected.

Unsatisfactory is defined as inconsistent performance, does not meet


criteria for performance, errors were made and not recognized or were not
performed at all.

An unsatisfactory rating in any one or more evaluation criteria will result in failure of the course.
In addition to receiving a satisfactory evaluation in clinical, a student must demonstrate 75% or
better in theory.
Clinical Skills Performance
Students are expected to maintain a satisfactory level of performance in all previously learned
clinical skills from one semester to another. The student is responsible to assess and remediate
any skill deficiencies in the nursing skills lab.
Faculty may assign a student to perform these skills without advance notice and the student is
expected to perform these skills satisfactorily.
Safe Nursing Practice
The nursing faculty has the responsibility to determine whether practice is safe or whether it is
unsafe and professional. They also have an obligation to protect the client and society against
harm. Therefore, if necessary, faculty can send students away from clinical area and recommend
suspension of students from clinical for unsafe, unprofessional, dishonest and/or disruptive conduct.
Unsafe Nursing Practice
The major areas of concern for safe practice are:
1.

Medical asepsis is the prevention of transfer of organisms.

2.

Physical jeopardy is any action or inaction that threatens a clients physical health.

3.

Emotional jeopardy is any action or inaction that threatens a clients emotional health.

118

Napa Valley College


Associate Degree Program in Nursing
Date:

Self Eval
(S, NI, NO, NA, U)

Date:

Student
Comments/Examples

Date:

Formative

Summative

NURS 249 - Nursing in Health Alterations IV


Formative/Summative Evaluation Tool Adult MedSurg
S
1. USE THE NURSING PROCESS FOR THE CARE OF
CLIENTS WITH MULTIPLE COMPLEX
ALTERATIONS IN HEALTH
Assessment
a. Collects all assessment data relevant to clients
alterations in health
b. Predicts when potential complications can occur
c. Detects early and subtle signs of change
d. Identifies client needs for teaching
Nursing Diagnosis
a. Analyzes assessment data to formulate accurate
nursing diagnoses
Planning
a. Develops individualized plan based on identified
health alterations
b. Makes judgments about rapid changes in client
health status
c. Establishes priorities of care
d. Revises priorities based on changes in client
condition
e. Allows client to choose from alternative actions
Implementation
a. Carries out care plan according to established
priorities
b. Allows client to make choices in plan of care
c. Takes instant action in a crisis
d. Calculates, measures, administers and records
drugs and IV fluids correctly
e. Provides safety and comfort at all times

119

NI,
NO,
NA

Faculty Comments

Self Eval
NURS 249 - Nursing in Health Alterations IV

(S, NI, NO,


NA, U)

Student
Comments/Examples

Formative

Formative/Summative Evaluation Tool


S
1. USE THE NURSING PROCESS FOR THE CARE
OF CLIENTS WITH MULTIPLE COMPLEX
ALTERATIONS IN HEALTH (cont.)
Implementation
f. Maintains sterile technique during sterile
procedures
g. Prepares clients correctly for tests and
procedures
h. Performs all skills correctly
i. Identifies needs and makes referrals to hospital
and community resources
Evaluation
a. Uses established criteria for evaluation
b. Includes client and family in evaluation of
outcomes
c. Evaluates client observations with members of
the health care team
2. PRACTICE IN ACCORDANCE WITH SAFE,
ETHICAL, AND LEGAL GUIDELINES IN THE
NURSE PRACTICE ACT, ANA CODE OF ETHICS
AND NURSE PRACTICE STANDARDS
a. Assumes responsibility to draw upon school and
agency policies and procedures to clarify and guide
actions
b. Accepts responsibility of own limits of knowledge
and skill when providing care
c. Assumes responsibility to intervene in situations
that could lead to legal action
d. Accepts responsibility of involving clients, family
and health care team in ethical decision-making
e. Supports clients in decision-making relative to
their care
f. Assumes responsibility for care given to clients

120

Summative
NI,
NO,
NA

Faculty Comments

Self Eval
NURS 249 - Nursing in Health Alterations IV

(S, NI, NO, NA, U)

Student
Comments/Examples

Formative

Formative/Summative Evaluation Tool Adult MedSurg


S
2. PRACTICE IN ACCORDANCE WITH SAFE,
ETHICAL, AND LEGAL GUIDELINES IN THE
NURSE PRACTICE ACT, ANA CODE OF ETHICS
AND NURSE PRACTICE STANDARDS (Cont.)
g. Assumes responsibility to report quality of client care
concerns to the appropriate person
h. Accepts the advocacy role in consistently protecting
clients rights, confidentiality and care
i. Assumes responsibility for identifying ones own values
and biases that may affect assessment
3. COLLABORATE WITH CLIENTS AND THE
INTERDISCIPLINARY TEAM USING INFOMATICS
AND THERAPEUTIC COMMUNICATION TO
PROMOTE CLIENT-CENTERED CARE
a. Uses appropriate verbal / non-verbal communication
b. Uses time with clients to focus on client
c. Validates meaning of clients behavior
d. Communicates feelings, opinions, attitudes
effectively
e. Follows guidelines for oral and written reports
f. Oral and written reports show evidence of nursing
process
g. Documentation facilitates communication between
members of the health care team
h. Collaborates with health care team to establish or
revise the nursing care plan
i. Acknowledges peer contributions to client care
4. EVALUATE THEORY, QUALITY MONITORS, AND
EVIDENCE-BASED KNOWLEDGE FOR DECISION
MAKING TO GUIDE NURSING PRACTICE AND
CLIENT OUTCOMES
a. Examines how alterations in one system can affect
other systems
b. Specifies risks for complications and preventive
nursing measures

121

NI,
NO,
NA

Summative

Faculty Comments

Self Eval
(S, NI, NO, NA, U)

Student
Comments/Examples

Formative

Summative

NURS 249 - Nursing in Health Alterations IV


Formative/Summative Evaluation Tool Adult MedSurg
S
4. EVALUATE THEORY, QUALITY MONITORS, AND
EVIDENCE-BASED KNOWLEDGE FOR DECISION
MAKING TO GUIDE NURSING PRACTICE AND
CLIENT OUTCOMES (cont.)
c. Specifies effect of drugs on clients, potential
complications and nursing implications
5. MANAGE CLIENT-CENTERED CARE FOR
CLIENTS WITH MULTIPLE COMPLEX
ALTERATIONS IN HEALTH IN COLLABORATION
WITH CLIENT AND INTERDISCIPLINARY TEAM
a. Gives care conserving time, energy, resources
b. Provides for continuity of care
c. Coordinates activities of health care team
members to implement plan of care
d. Supports peers and other health care team
members in the delivery of client care
e. Manages plan of care in a timely manner
f. Prepares a rationale for decisions based on the
decision-making process
g. Arrives at a safe decision
6. DEMONSTRATE CONSISTENT COMMITMENT TO
CONTINUED PROFESSIONAL GROWTH AND
SELF-DEVELOPMENT
a. Manages own physical and emotional health to
appear alert with ones emotions under control
b. Accepts responsibility for expanding knowledge
for client with multiple complex health alterations
c. Tests new ideas/nursing approaches for
effectiveness
d. Identifies strengths and weaknesses in the
clinical leadership role
e. Uses constructive criticism to improve nursing
practice
f. Demonstrates behavior change as a result of
experiences

122

NI,
NO,
NA

Faculty Comments

Self Eval
(S, NI, NO, NA, U)

Student
Comments/Examples

Formative

Summative

NURS 249 - Nursing in Health Alterations IV


Formative/Summative Evaluation Tool Adult MedSurg
S
6. DEMONSTRATE RESPONSIBILITY FOR
CONTINUED PERSONAL AND PROFESSIONAL
DEVELOPMENT (cont.)
g. Takes risks, fails, evaluates and tries again
h. Participates in self-evaluation
i.

Makes constructive use of clinical time

j.

Participates in a constructive manner in clinical


conferences

k.

Identifies own learning goals for each clinical


experience

l.

Identifies whether learning goals were met

m. Uses faculty, syllabus, texts, library and


multimedia as resources

123

NI,
NO
,
NA

Faculty Comments

Napa Valley College


Associate Degree Program in Nursing
NURS 249 - Nursing in Health Alterations IV
Semester 4 Medical/Surgical
Formative Evaluation
Week(s) ________________________
Student Comments and Goals:

Instructor Comments:

*Student ______________________
Date _________________________

Instructor ________________________
Date: ___________________________

Summative Evaluation:
Week(s) ________________________
Student Comments and Goals:

Instructor Comments:

*Student ______________________
Date _________________________

Instructor ________________________
Date: ___________________________

My signature does not mean I agree or disagree, only that I have read and understood the Clinical
Evaluation Form
124

PEDIATRIC
CLINICAL GUIDELINES

125

SUTTER MEMORIAL HOSPITAL


5151 F St
Sacramento, CA 95819-3223
60.56 miles / 1 hour 8 minutes

2277 Napa Vallejo Hwy, Napa, CA 94558-6236


1. Start out going south on Napa Vallejo Hwy / CA-221 S toward Streblow Dr.

2.1 mi
2.1 mi total

2. Turn left onto CA-29 S / CA-12 E.

1.5 mi
3.6 mi total

3. Turn left onto Jameson Canyon Rd / CA-12.

5.8 mi
9.4 mi total

42.5 mi
4. Merge onto I-80 E.
52.0 mi
total
5.2 mi
5. Keep left to take US-50 E / Capital City Fwy / I-80-BR E toward Sacramento / South
57.2 mi
Lake Tahoe.
total
1.6 mi
6. Merge onto Capital City Fwy / I-80-BR E toward Reno.
58.8 mi
total
0.2 mi
7. Take the H Street exit.
59.0 mi
total
1.4 mi
8. Turn right onto H St.
60.4 mi
total
0.1 mi
9. Turn left onto 51st St.
60.5 mi
total
0.02 mi
10. Turn right onto F St.
60.6 mi
total
11. 5151 F ST is on the left.

5151 F St, Sacramento, CA 95819-3223

126

Children's Hospital & Research Center


Oakland
747 52nd Street, Oakland, California,
94609
Download map PDF
Download map PDF - Spanish
From North via Interstate 80:
Stay left on I-80 in Emeryville, but not farthest
left laneit is a carpool only lane to SF. Take
I-580 Hayward exit, then merge to right lane
and take Berkeley/Walnut Creek Hwy. 24 exit.
Take the 51st/Martin Luther King exit (exit is to
the right just as connector ramp straightens
out). Bear left (under freeway) onto Martin
Luther King Jr. Way and turn right on 52nd
Street. The hospital will be on your right,
parking on your left.
From Central Contra Costa County Hwy
24: Take Telegraph Avenue exit. Turn left on
Telegraph and turn right on 52nd Street. The
hospital will be on the left, parking on your
right.
From South Nimitz Freeway (880): Follow
signs for I-980 to Berkeley/Walnut Creek Hwy.
24. Exit at 51st/Martin Luther King. Bear left
(under freeway) onto Martin Luther King, Jr.
Way and right on 52nd Street. The hospital will
be on your right, parking on your left.
From South Interstate 580: Take
Berkeley/Walnut Creek Hwy. 24 exit, stay in
connector ramp lane (dont merge left onto
Hwy. 24) and take 51st/Martin Luther King exit.
Bear left (under freeway) onto Martin Luther
King Jr. Way and turn right on 52nd Street. The
hospital will be on your right, parking on your
left.
From San Francisco Bay Bridge: Stay in
the right three lanes coming off the bridge.
Take I-580 toward Hayward, exit
Berkeley/Walnut Creek Hwy. 24. Take
51st/Martin Luther King exit (exit is to the right
just as connector ramp straightens out). Bear
left (under freeway) onto Martin Luther King Jr.
Way and turn right on 52nd Street. The
hospital will be on your right, parking on your
left.

View Larger

127

GUIDE FOR HEALTH HISTORY AND INTERVIEW OF CHILD AND FAMILY


Current Health Status
Reason for hospitalization/surgery (child or parents own words)
Child/parents perceived needs/concerns about hospitalization
Health History
Present illness
Previous illnesses, surgeries, hospitalizations
Growth and development
How is child doing in school
Habits: sleep, naps, behavioral (thumb sucking)
Tolerance of pain, reaction to hurtful situations
Prior hospital experience
If hospitalized before, what is remembered?
Worst part.
Best part.
Clients or parents Statement about current hospitalization
What words best describe how you are feeling right now?
What have you been told about being in the hospital (or having surgery, etc.)?
Some kids your age have concerns or worries about ____________. Have you any concerns?
What are things you think might worry kids your age about _________?
What do you think is the best thing about being in the hospital? What is your worst fear?
How do you think you are handling being in the hospital?
Has being here been better or worse than you expected? In what way?

128

Student Name_______________
Clinical Dates________________
Napa Valley College
Associate Degree Program in Nursing
NURS 249 Nursing in Health Alterations IV
Child Data Base
Child Initials
Room #
Admit Date:
Allergies:
Dx:
Age: Days_____ Months ______ Years_____
Schooling: Nursery____ Preschool_____
Grade_____
Day Care_____ Home Taught_______
Insurance:
Yes____ No____
Ethic Identity:
Primary Language
Cultural Practices:
Family Structure: Lives ____parent
____parents
_____grandparent
____foster parent
____extended family
_____institution
____# siblings
____age
of parent
Family Recreational Activity:
Childs category of play:
Behavior Patterns:
____Thumb sucking
____Nail biting
_____Security Blanket
_____Temper Tantrum
Usual response to
stress_______________________________
____Sleep: Hours: Noc. Naps: _____AM
_____Afternoon
Environmental Data: Housing:
Social Support: Needs help with:
Religion:
Nursing Interventions:
Family Hx: _____Stroke
_____Heart Disease
_____Diabetes
_____Hypertension
_____Cancer
_____Epilepsy
_____Alcoholism
_____Recreational
Drugs _____Smoking
_____Chemical Dependency _____Tuberculosis
_____Sickle Cell
_____Mental/Emotional Problems
Medication & Dose:
Frequency:
Reason for taking

CURRENT HEALTH STATUS:

CLIENTS STATEMENT ABOUT CURRENT


HOSPITALIZATON

T
Ht.

Apical
Wt.

R
BP
Head Circum.
Last 24 hours: I:
O:

BMI
Fluid Maintenance Requirements:

INTRAVENOUS SOLUTIONS:
Site:
Rate/hr:
Heploc:

129

Solution:
gtts/min:
Flush:

CURRENT TREATMENT ORDERS: (From Kardex)


Eriksons Developmental Level:
Tasks:
Nursing Considerations:

Birth History: _____Birthweight


_____Apgar
Prior health history (major illness, surgery, injury,
infections)
_______#hospitalizations, accidents.
Prior hospital experience

Immunizations: Age months/years:____DPT


____HBCV
____OPV ____MMR
Code Status
_____Full Code
_____DNR (Written)

Resp: O2:
O2 sat:
FIO2:
____suction
CV:
Feedings:____ Breast Feeding
_____Bottle for
milk
GI: ____Snacks
____Feeds self
Feeding:
Type of food:
Type of formula _____________________
Last BM: _______
BM__________

Childs term for

for
Urination_________
GU: Cath:
Type:
Irrig:
Voids:
____Diapers ____@Noc ____Age Potty
trained
MS: Activity: ____Rolls over ____Sits ____Stands
____Walks with stroller ____Walks alone
Scheduled Diagnostic Tests:

130

Napa Valley College


Associate Degree Program in Nursing
NURS 249 Nursing in Health Alterations IV
LAB VALUES & DIAGNOSTIC TESTS
NAME OF TEST

CHILDS VALUES

NORMAL RANGE
FOR CHILD THAT
AGE
DATE

DATE

131

ANALYSIS

DATE

Napa Valley College Associate Degree Nursing Program


Medication Assignment Form -- NURS 249
Initials:________________________
Age:______________________
Allergies: ____________________________
Height:__________ Weight: ____________
BMI:_________________

Date
Ordered

Medication: Trade & generic name,


dose ordered, route, frequency, safe
range, your calculations, age
consideration (pediatrics, pregnant,
elderly)

Admitting Diagnosis:__________
___________________________
___________________________
Other Medical History:_________
___________________________
___________________________

Times
Given

Action/use
for this
Client

Common Side Effects

132

Student Name:_______________________
Instructor:___________________________

Nursing
Implications

Expected
Outcomes

Evaluations

Napa Valley College Associate Degree Nursing Program


Medication Assignment Form -- NURS 249
Initials:________________________
Age:______________________
Allergies: ____________________________
Height:__________ Weight: ____________
BMI:_________________

Date
Ordered

Medication: Trade & generic name,


dose ordered, route, frequency, safe
range, your calculations, age
consideration (pediatrics, pregnant,
elderly)

Admitting Diagnosis:__________
___________________________
___________________________
Other Medical History:_________
___________________________
___________________________

Times
Given

Action/use
for this
Client

Common Side Effects

133

Student Name:_______________________
Instructor:___________________________

Nursing
Implications

Expected
Outcomes

Evaluations

Napa Valley College


Associate Degree Program in Nursing
Nursing Care Plan
Clients Initials: ___________ Date: ____________________ Students Name: ___________________________________________
Nursing Diagnosis

Outcomes

Nursing Interventions

134

Rational/Scientific
Principles

Evaluation

Nursing Diagnosis

Outcomes

Nursing Interventions

135

Rational/Scientific
Principles

Evaluation

Napa Valley College


Associate Degree Program in Nursing
NURS 249 Nursing in Health Alterations IV
Clinical Area: _____________________________
Date

Day

______
______
______
______

______
______
______
______

Time
In
______
______
______
______

Time
Out
______
______
______
______

Student Signatures/RN Signature


________________________
________________________
________________________
________________________

STUDENT EVALUATION
Student____________________________

Needs
Improvement

Satisfactory

Excellent

1. Use the nursing process for the care of clients with


multiple complex alterations in health
2. Practice in accordance with safe, ethical, and legal
guidelines in the Nurse Practice Act, ANA Code of
Ethics and Nurse Practice Standards
3. Collaborate with clients and the interdisciplinary
team using informatics and therapeutic
communication to promote client-centered care
4. Evaluate theory, quality monitors, and evidencebased knowledge for decision making to guide
nursing practice and client outcomes
5. Manage client-centered care for clients with
multiple complex alterations in health in collaboration
with client and interdisciplinary team
6. Demonstrate consistent commitment to continued
professional growth and self-development
Comments:

Note: At the completion of the experience, return this form to the student who will submit it to
their clinical instructor with their written work.
136

CLINICAL EVALUATION TOOL


PEDIATRICS

137

NAPA VALLEY COLLEGE


ASSOCIATE DEGREE IN NURSING PROGRAM
CLINICAL EVALUATION TOOL

Course:
Semester:

NURS 249 Nursing in Health Alterations IV Pediatrics Rotation


4

Student:

________________________________________

Clinical Evaluation
Clinical performance is evaluated by the clinical instructor and is based on the six course objective
derived from the program outcomes. The student also evaluates clinical performance using the same
performance objectives. Clinical evaluation tools are used to document student progress in meeting
clinical objectives for each course. These clinical evaluation tools are found in each course syllabus.
The clinical evaluation tool includes formative and summative evaluation. The evaluation is to be in
writing, discussed with the student and signed by both the instructor and the student.
Formative Evaluations
Formative evaluation monitors progress and provides direction for learning throughout the course. It
provides feedback to the student and shall include their strengths and positive accomplishments as well
as their deficiencies and performance that needs to be improved. It informs the student as to their
progress in meeting clinical objectives, identifies where further learning is needed and makes
recommendations for ways to improve and meet objectives.
The formative evaluation will be done at the midway point of the pediatric clinical rotation. Additional
formative evaluations may be done at the discretion of the clinical instructor.
In the formative evaluation, the performance is rated as follows:
S

Satisfactory demonstrates a consistent performance of the objective


according to criteria or guidelines given. When errors are made they are
recognized and corrected.

NI

Needs Improvement is defined as performance that impedes progress


toward meeting clinical objectives and must be improved to be satisfactory
at the summative evaluation.

NO

Not Observed behavior is defined as a behavior that should have occurred


but was not observed and indicates an area to be given attention.

NA

Not Applicable means a behavior that was not expected of the student.

Unsatisfactory is defined as inconsistent performance, does not meet


criteria for performance, errors were made and not recognized or were not
performed at all.

138

Summative Evaluations
Summative evaluation occurs at the end of the course and/or the end of the pediatric clinical rotation to
determine if the clinical objectives have been achieved and establish the grad for clinical practice.
The criteria for evaluation will be rated as follows:
S

Satisfactory is defined as consistent performance of the objectives


according to criteria or guidelines given. When errors are made they are
recognized and corrected.

Unsatisfactory is defined as inconsistent performance, does not meet


criteria for performance, errors were made and not recognized or were not
performed at all.

An unsatisfactory rating in any one or more evaluation criteria will result in failure of the course.
In addition to receiving a satisfactory evaluation in clinical, a student must demonstrate 75% or better in
theory.
Clinical Skills Performance
Students are expected to maintain a satisfactory level of performance in all previously learned clinical
skills from one semester to another. The student is responsible to assess and remediate any skill
deficiencies in the nursing skills lab.
Faculty may assign a student to perform these skills without advance notice and the student is expected
to perform these skills satisfactorily.
Safe Nursing Practice
The nursing faculty has the responsibility to determine whether practice is safe or whether it is unsafe
and professional. They also have an obligation to protect the client and society against harm. Therefore,
if necessary, faculty can send students away from clinical area and recommend suspension of students
from clinical for unsafe, unprofessional, dishonest and/or disruptive conduct.
Unsafe Nursing Practice
The major areas of concern for safe practice are:
1.

Medical asepsis is the prevention of transfer of organisms.

2.

Physical jeopardy is any action or inaction that threatens a clients physical health.

3.

Emotional jeopardy is any action or inaction that threatens a clients emotional health.

139

NURS 249 Nursing in Health Alterations IV

Student Self Evaluations


Comments/
Examples

(S,,NI,NO,
NA, U)

Formative

Formative/Summative Evaluation Tool Pediatrics

S
1. USE THE NURSING PROCESS FOR THE CARE OF
CLIENTS WITH MULTIPLE COMPLEX ALTERATIONS IN
HEALTH
Clinical Preparation and Planning
a. Completes assigned reading
b. Hands in work on time
c. Participates in pre and post conference
Assessment
a. Collects data relevant to childs alteration in health.
b. Uses assigned format for data collection.
c. Recognizes variations from normal.
d. Identifies level of growth and development.
e. Identifies parents need for anticipatory guidance.
Nursing Diagnoses
a. Analyzes assessment data to formulate accurate
nursing diagnosis.
Planning
a. Ranks nursing diagnoses in order of priority.
b. Determines measurable, realistic outcomes with
child and family.
c. Uses developmental level in planning care.
d. Sets behavioral limits for child.
Implementation
a. Uses standard precautions and infection
transmission control measures.

140

NI,
NO,
NA

Summative

Faculty
Comments

Napa Valley College


Associate Degree Program in Nursing
Date:
NURS 249 Nursing in Health Alterations IV

Date:

Student Self Evaluations


Comments/
Examples

S,,NI,NO,
NA, U)

Formative

Formative/Summative Evaluation Tool Pediatrics

S
1. USE THE NURSING PROCESS FOR THE CARE OF
CLIENTS WITH MULTIPLE COMPLEX ALTERATIONS IN
HEALTH
Implementation (cont.)
b. Maintains sterile technique with all sterile procedures.
c. Provides safety and comfort at all times.
d. Checks identification band of child.
e. Keeps crib rails up on infant and toddlers cribs.
g. Positions child correctly for feeding.
h. Checks safety of toys brought to hospital for child.
i. Calculates, measures, administers and records drug
dosages correctly.
j. Prepares clients correctly for test and procedures.
k. Performs all skills taught in prerequisite courses
correctly.
l. Adapts care to individual and developmental level.
m. Includes family in nursing interventions.
Evaluation
a. Evaluates child and family responses.
b. Validates findings with instructor/staff.
c. Revises care plan as indicated by evaluation.

141

Date:

Summative
NI,
NO,
NA

Faculty
Comments

NURS 249 Nursing in Health Alterations IV

Student Self Evaluations


Comments/
Examples

S,,NI,NO,
NA, U)

Formative/Summative Evaluation Tool Pediatrics

Formative

2. PRACTICE IN ACCORDANCE WITH SAFE, ETHICAL, AND


LEGAL GUIDELINES IN THE NURSE PRACTICE ACT, ANA
CODE OF ETHICS AND NURSE PRACTICE STANDARDS

a. Acquaints self with school and agency policies and


procedures to clarify and guide actions.
b. Complies with own limits of knowledge and skill when
providing care.
c. Accepts responsibility for identifying situations that
could lead to legal action.
d. Accepts responsibility of involving clients, family and
health care team in ethical decision-making.
e. Supports parents in decision-making relative to their
childs care.
g. Assumes responsibility to report concerns regarding
quality of client care to the appropriate person.
h. Accepts the advocacy role in consistently protecting
clients rights, confidentiality and care.
i. Establishes own value system while being receptive to
the values of others.
3. COLLABORATE WITH CLIENTS AND THE
INTERDISCIPLINARY TEAM USING INFOMATICS AND
THERAPEUTIC COMMUNICATION TO PROMOTE CLIENTCENTERED CARE

a. Uses therapeutic techniques when interacting with child


and family.
b. Supports the child & family in adjustment to the
hospital.
c. Explains care at level of child or parents understanding.

142

Summative
NI,
NO,
NA

Faculty
Comments

NURS 249 Nursing in Health Alterations IV

Student Self Evaluations


Comments/
Examples

Formative

Summative

S,,NI,NO,
NA, U)

Formative/Summative Evaluation Tool Pediatrics

3. COLLABORATE WITH CLIENTS AND THE


INTERDISCIPLINARY TEAM USING INFOMATICS AND
THERAPEUTIC COMMUNICATION TO PROMOTE CLIENTCENTERED CARE

d. Facilitates expression of feelings about illness and


hospitalization.
e. Reports client condition to designated persons
f. Reports any abnormal assessment finding immediately
to nursing instructor and health care team members
g. Reports accurate assessments and interventions.
h. Records data, client care, client response using
correct format.
4. EVALUATE THEORY, QUALITY MONITORS, AND
EVIDENCE-BASED KNOWLEDGE FOR DECISION
MAKING TO GUIDE NURSING PRACTICE AND CLIENT
OUTCOMES
a. Uses knowledge of growth and development and health
alterations as a basis for decision-making.
b. Explains how childs treatment and nursing care relates
alteration in health.
c. Creates a NCP for the clients benefit based on health
alterations and nursing process, culture, health beliefs,
and individual needs.
d. Explains rationale for priorities and decisions.
e. Summarizes action/use and nursing implications for
drugs given to children.
f. Applies teaching learning principles to provide
anticipatory guidance to families.

143

NI,
NO,
NA

Faculty
Comments

NURS 249 Nursing in Health Alterations IV

Student Self Evaluations


Comments/
Examples

S,,NI,NO,
NA, U)

Formative/Summative Evaluation Tool Pediatrics

Formative

5. MANAGE CLIENT-CENTERED CARE FOR CLIENTS


WITH MULTIPLE COMPLEX ALTERATIONS IN HEALTH IN
COLLABORATION WITH CLIENT AND
INTERDISCIPLINARY TEAM
a. Functions as a team member
b. Establishes priorities of care for children and their
families.
c. Completes assignments in timely manner.
d. Demonstrate an appropriate level of autonomy during
clinical.
6. DEMONSTRATE CONSISTENT COMMITMENT TO
CONTINUED PROFESSIONAL GROWTH AND SELFDEVELOPMENT
a. Accepts responsibility for expanding knowledge and
skills required for care of the pediatric client.
b. Uses a variety of resources to improve nursing care for
the pediatric clients.
c. Assess new ideas for effectiveness.
d. Participates actively in all clinical activities.
e. Uses constructive criticism from faculty.
f. Develops a plan of action for success based on own
learning needs.

144

NI,
NO,
NA

Summative

Faculty
Comments

Napa Valley College


Associate Degree Program in Nursing
NURS 249 - Nursing in Health Alterations IV
Semester 4 Pediatrics
Formative Evaluation
Week(s) ________________________
Student Comments and Goals:

Instructor Comments:

*Student ______________________
Date _________________________

Instructor ________________________
Date: ___________________________

Summative Evaluation:
Week(s) ________________________
Student Comments and Goals:

Instructor Comments:

*Student ______________________
Date _________________________

Instructor ________________________
Date: ___________________________

My signature does not mean I agree or disagree, only that I have read and understood the Clinical
Evaluation Form
145