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ANDREWS UNIVERSITY - SCHOOL OF NURSING

NURSING CARE PLAN WORKSHEET


PATIENT WORKSHEET # 1
Student: Josip Benko
9-25-2012

Date:

Patient #: n/a Age: 51 Room # : 66

Vital signs: every 4 hours

Allergies: NKA
Code Status: FULL
Yes ( ) No ( )

Fall precaution: Yes ( ) No ( )

Restraints: Yes ( ) No ( )

Pain management:

History of present illness: Loss of protein in Urine, generalized edema, Anasarca, Worsening SoB, patient feeling tired, and
gaining weight rapidly
Medical diagnosis (es): Nephrotic Symdrome
Past Medical/Surgical History: hypothyroidism, proteinuria, hypertension, obstructive sleep apnea, anasarca

Diet: NPO Clear Liquids Regular


Left

Activity: Independent, Bed Rest

IVs: Peripheral line ante cubital

Treatments: Oxygen, medications, telemetry,


Special procedures for today: Kidney Biopsy, CPAP
SBAR (Situation, Background, Assessment, recommendations): Patient is a 51-year-old Caucasian gentleman with a
history of recently diagnosed nephrotic syndrome with range proteinuria and obstructive sleep apnea. He is doing well
went down this morning at 8:00am for a kidney biopsy and is not on a regular diet. No complaints of pain and vitals are
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within range for his condition. However, he did vomit twice (once at 6:00am and again at 11:00am) today unexpectedly.
Continue to monitor I&O, vitals, and teach patient about diet.
DVT PREVENTION: (YES)

(NO)

GASTRIC PROTECTION: (YES)

(NO)

ANDREWS UNIVERSITY - SCHOOL OF NURSING


PATIENT WORKSHEET # 2
PATIENT DIAGNOSIS/SITUATION
Medical diagnosis/es:

TEXTBOOK PICTURE
Diagnosis/es definition and pathophysiology:

Nephrotic Syndrome

Nephrotic syndrome is a group of symptoms that include protein in


the urine, low blood protein levels, high cholesterol levels, high
triglyceride levels, and swelling
The thickening of part of the glomerular basement membrane
causes membranous nephropathy. The glomerular basement
membrane is a part of the kidneys that helps filter waste and extra
fluid from the blood. The exact reason for this thickening is not
known.

Patient signs and symptoms:

Book description of typical sign and symptoms:

Generalized edema
Vomiting
Protein urea
Shortness of breath

Swelling (edema) is the most common symptom. It may occur:

In the face and around the eyes (facial swelling)


In the arms and legs, especially in the feet and ankles

In the belly area (swollen abdomen)

Other symptoms include:

Patients potential/actual disease etiology/cause:

Foamy appearance of the urine


Poor appetite

Weight gain (unintentional) from fluid retention

Disease etiology/cause:
Genetic disorders

Exposure to hydrocarbon solvents

Immune disorders

Dehydration

History of cancer

Infections (such as strep throat, hepatitis, or mononucleosis)


Use of certain drugs

Diagnostic tests scheduled or performed:

Diagnostic test suggested:

Kidney Biopsy

Results not known at the time

List of actual patient medication (name and dose):

Medication suggested for the diagnosis:

On following pages

On following pages

Actual patient treatments (medical and nursing):

Suggested treatments:

Laxis
Low sodium diet
Bed Rest to help form blood clot from kidney biopsy

Help patient with weight loss


Measure I&O
Daily weight

Actual nutrition ordered:

Suggested nutrition:

NPO before Kidney Biopsy


Clear Liquids for 4 hours postop
Regularafter 4 hours of observation

Low sodium diet possibly

Patient teaching needs:


Teach patient about low sodium diet
Teach patient about importance of deep breathing and active ROM

MEDICATION LIST
Trade name

Generic
name

Dose
ordered

Route
ordered

Time of
administration

Drug action/indications

Nursing implications, considerations, side


effects to look for, Pt. education

Levothyroxi
ne

Synthroid

0.1mg =
1Tab

PO

AC+Brea
kfast

Indications: Thyroid
replacement supplement
Action: Stimulates
metabolism of all body tissues
by acceleration rate of cellular
oxidation

-Nervousness, insomnia, headaches,


tremors, arrhythmias, cardiac arrest
-Do not use to treat obesity or for weight
loss
-Patients with diabetes may need
increased antidiabetic doses when
starting treatment
-Patients taking anticoagulants may need
their dosage modified and require careful
monitoring of coagulation status

Heparin

heparin

5,000units
= 0.5mL

SubQ
Injectio
n

Q12H

-fever, rhinitis, hyperkalemia


-must evaluate risks and benefits
-instruct patient and family to watch for
signs of bleeding or bruising and to
notify prescriber immediately if any occur
-dont change concentrations of
infusions unless absolutely necessary

Furosemide

Lasix

80mg =
8mL

IV
Push

BID

Indications: full dose


continuous IV therapy for
deep vein thrombosis
Action: accelerates formation
of antithrombin III-thrombin
complex and deactivates
thrombin, preventing
conversion of fibrinogen to
fibrin
Indications: acute pulmonary
edema
Action: inhibits sodium and
chloride reabsorption at the
proximal and distal tubules
and the ascending loop of

-vertigo, headaches, fever


-drug is potent diuretic and can cause
severe diuresis with water and electrolyte
depletion
-advise patient to take drug with good to
prevent GI upset, and to take drug in
5

Henle

morning to prevent need to urinate at


night
- monitor glucose levels
-fatigue, dizziness, depression
-when stopping therapy, taper dosage
over 1 to 2 weeks. Abrupt discontinuation
my cause exacerbations of angina or
myocardial infarction
-always check patients apical plus rate
before giving drug
-instruct patient to take drug exactly as
prescribed and with meals
-headaches, somnolence, fatigue, edema
-monitor patients carefully, monitor blood
pressure
-notify if signs of heart failure
-caution patient to continue taking drug,
even when he feels better

Metoprolol

Metoprol
ol
Tartrate

25mg = 1
Tab

PO

Q12H

Indications: hypertension,
early intervention in acute MI
Action: unknown; a selective
beta blocker that selectively
blocks beta receptors

AmLODIPin
e

Norvasc

5mg =
1Tab

PO

Daily

Indications: chronic stable


angina, vasospastic angina,
hypertension
Action: inhibits calcium ion
influx across cardiac and
smooth-muscle cells, dilates
coronary arteries and
arterioles and decreases
blood pressure and
myocardial oxygen demand
MEDICATION LIST

Trade name

Generic
name

Dose
order
ed

Route
ordere
d

Time
of
admini
stration

Drug action/indications

Nursing implications, considerations, side effects


to look for, Pt. education

MethylPREDNISolo
ne

SoluM
EDROL

1Gm
=
8mL

IVPB

Daily

Indications: severe
inflammation or
immunosupression
Action: decreases inflammation

-arrhythmia, heart failure


-medrol may contain tartrazine. Watch for
allergic
-tell patient not to stop drug abruptly or
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without prescribers consent


-instruct patient to avoid exposure to
infection
Acetaminophen

Tylenol

650m
g=
2Tab
s

PO

Q4H

Ondansetron

Zofran

4mg
=
2mL

IV
Push

Q6H
PRN +
Nause
a and
Vomiti
ng

senna

senoko
t

1Tab

PO

BID

0.5mL

IM

Injecti
on

Prior
to
disch
arge

Pneumococcal 23valent vaccine

Indications: mild pain reliever,


fever reducer
Action: thought to produce
analgesia by inhibiting
prostaglandin and other
substances that sensitive pain
receptors. Drug may relieve
fever through central action in
the hypothalamic heatregulating center
Indications: to prevent nausea
and vomiting from highly
emetogentic chemotherapy
Action: may block 5-HT3 in the
CNS in the chemoreceptor
trigger zone and in the
peripheral nervous system on
nerve terminals of the vagus
nerve
Indications: stimulant laxative,
prescribed for constipation
Action: chiefly on the lower
bowel, it is especially suitable
in habitual costiveness.
Increases the peristaltic
movements of the colon by its
local action upon the intestinal
wall.
Indications: serious long-term
health problems, smokers,
children older than two years
with serious long-term health

- hypoglycemia, leukopenia
- many OTC and prescription products
contains acetaminophen; beware of this when
calculating total daily dose
- tell parents to consult prescriber before
giving drug to children younger than age 2
- advise parents that drug is only for short
term use
-fatigue, headaches, arrhythmias
-monitor liver function test results. Dont
exceed 8 mg in patients with hepatic
impairment
-instruct patient to immediately report
difficultly breathing after drug administration
-tell patient to report of discomfort around IV
insertion site
-heart palpitations, dizziness, fainting
-avoid long-term use of this medication
-may lead to electrolyte imbalance
-inform patient to store in a cool place

- Approximately half of people who receive


PPSV experience pain and soreness at the
vaccination site. Fewer than one percent
develop a fever and/or muscle aches
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problems,
Action: vaccine against
Streptococcus pneumoniae.

- Approximately half of people who receive


PPSV experience pain and soreness at the
vaccination site. Fewer than one percent
develop a fever and/or muscle aches

DIAGNOSTIC TESTS
Include all normal and abnormal values that may be significant for the patient. Include Laboratory test, CT scan, MRI,
endoscopies, XRs, intervention radiology procedures, or any other significant test for the patient
Name of the test and date
Chemistry
Potassium
Sodium
Chloride
Calcium

Patient result

Normal value

Significance for the patient

5.4mEq/L
136mEq/L
105mEq/L
7.5mg/dL

3.6-5.2 mEq/L
134-145mEq/L
96-108mEq/L
8.2-10.4mg/dL

Phosphorus
Cholesterol
Triglycerides
Hematology
WBC count
RBC count
Albumin
Protein
Eosinophil Absolute

5.4mg/dL
592mg/dL
1208mg/dL

2.6-4.5mg/dL
120-199mg/dL
0-150mg/dL

High: acute renal failure


Normal
Normal
Low: Low blood protein levels, especially a low level of albumin.
Underactive parathyroid gland, Increased levels of phosphorus
High: Kidney failure, Hypoparathyroidism
High: glomerulonephritis, hypothyroidism, nephrotic syndrome
High: nephrotic syndrome, hypothyroidism, obesity,

6.96thou/mcL
4.58mill/mcL
0.6gm/dL
4.3gm/dL
0.71 thou/mcL

4-11thou/mcL
3.9-5.9mill/mcL
3.5-5.2gm/dL
6.2-8.1gm/dL
0.110.5thou/mcL

Normal
Normal
Low: parasitic infection, thyroid disfunction, protein urea
Low: glomerulonephritis, nephtotic synrome
High: allergy, drug reaction, parasitic infection

Urinalysis
WBC Urine
RBC Urine
AST
ALT
Sedimentation Rate
Creatinine
BUN
Fine Granula Cast
Hyaline Casts

17/hpf
0-5/hpf
High: infection, tubulointerstitial nephritis
6/hpf
0-4/hpf
High: focal glomerulonephritis, infection,
24IU/L
0-40IU/L
Normal
33IU/L
30-65IU/L
Normal
80mm/hr
0-20mm/hr
High: inflammation
1.52mg/dL
0.7-1.5mg/dL
High: glomerulonephritis, pyelonephritis
47mg/dL
8-23mg/dL
High: impaired kidney function,
2/ipf
?
?: (No normal range found)
renal disease, viral infections
25/ipf
0-4/ipf
High: renal disease, viral infections
ANTICIPATED DISCHARGE PLAN (CHECK APPROPRIATE DESCRIPTIONS)

Destination:

Care level:

______ Home

______ Self

______ Extended care

______ Assisted

______ Rehabilitation

______ Family

Needs:
_____ Equipment
_____ teaching
_____ Relocation

CLINICAL DAY REVIEW


Discuss this weeks clinical experience, positive and negative aspects. What new things did you do or learn? Review the
clinical evaluation tool and explain how well you have met the outcomes:
Todays clinical was just awesome! One positive aspect of clinical was that I finally got my username and password, but
also was able to see a kidney biopsy being performed. One negative aspect of clinical was that I wanted to see the results
of the biopsy because the whole time I was thinking about what could have caused the sudden protein urea. Today I relearned that the cause of the sudden generalized edema was due to loss of protein in the vessels because protein helps
fluid stay in the vessels, which prevent fluid to spill into the surrounding tissue.

How was the concept of restoration to the Image Of God portrayed in the clinical settings? Describe the situation,
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assessment, intervention made, and evaluation. What was your role?


The way I would like to believe we restored the image of God back to the patient was in providing him with some answers
for his worry of his current condition. When the patient was admitted, he did not know what was going on with him, but
soon after the doctors began to tell him about why he is experiencing edema and that he was going to figure this all out.
Seeing the doctor assure the patient and the patient just simply trusting him reminded me of the story of the cripple who
sat by the pool and then one day Jesus simply told him to get up and walk. I began to tell the patient everything I knew
(soon as the doctor left and because the patient kept asking me questions) about the renal system and how protein affects
the fluid in the blood vessels. His worry was turned away from fear and anxiety and he was at peace in at least
understanding now how this happened.

Discuss the cultural assessment of this patient. Did the patient have special cultural needs? Were there interventions
needed related to these needs?
Patient is a 51-year-old Caucasian male. He is married and lives with his wife. Has two kids, speaks English, and has never
drank or smoked. He is cabinetmaker and enjoys hunting deer and golfing. He is also a Christian and reads his Bible
weekly.

NURSING CARE PLAN


Nursing diagnosis: Knowledge Deficit

Related to [etiology]: New condition and treatment

As evidenced by [defined characteristics]: Verbalizing confusion, questioning members of health care team, and expressing anxiety
Relevant data

Patient goals and outcomes


in priority order. (able to be
measured and with
appropriate timing) (The
patient will)

Nursing interventions (related to


the nursing diagnosis and
patient ability to do it) (The
nurse will)

Evaluation (Did the patient


achieved the pertinent goals
and outcomes?)

Rationale (why the


intervention is needed)

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Verbalizing
confusion,
questioning
members of
health care team,
and expressing
anxiety

The patient will


verbalize understanding
of new condition and
treatment by the end of
shift

Nursing diagnosis: Risk for Falls

1. The nurse will


assess motivation
and willingness of
the patient and
caregiver to learn
2. The nurse will
assess ability to
learn, remember, or
perform desired
health-related care
3. The nurse will
identify priority of
learning needs
within the overall
care plan
4. The nurse will
encourage
questions
5. The nurse will teach
about adjusting
patients regular diet
to a low sodium diet

The patient has achieved


the pertinent goals and
has verbalized
understanding of subject

1. Adults must see


a need or
purpose for
learning
2. Cognitive
impairment need
to be identified
so an appropriate
teaching plan can
be designed
3. This information
provides the
starting base for
education
sessions
4. Questions
facilitate open
communications
between patients
and health care
professionals
and allow
verification of
understanding of
give information
and the
opportunity to
correct
misconceptions
5. Having a low
sodium diet will
help with renal
dysfunction

Related to [etiology]: Pholypharmacy

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As evidenced by [defined characteristics]:


Relevant data

Patient goals and outcomes


in priority order. (able to be
measured and with
appropriate timing) (The
patient will)

The patient will not


sustain a fall during the
morning shift

Nursing diagnosis: Risk for Skin Integrity


edema

Nursing interventions (related to


the nursing diagnosis and
patient ability to do it) (The
nurse will)

1. The nurse will


assess unsafe
clothing
2. The nurse will
assess environment
for factors known to
increase fall risk
3. The nurse will
ensure appropriate
room lighting,
especially at night
4. The nurse will
encourage the
patient to
participate in a
program of regular
exercise and active
ROM

Evaluation (Did the patient


achieved the pertinent goals
and outcomes?)

Rationale (why the


intervention is needed)

The patient did no


sustain a fall

1. Poor-fitting socks,
long robes, or long
pants legs can limit a
persons ambulation
and increase fall risk
2. Patients who are not
familiar with the
placements of furniture
and equipment in their
room are more likely to
experience a fall
3. Older adults with
reduced visual capacity
will benefit from
adequate lighting.
4. Evidence suggests
that people who engage
in regular exercise and
activity will strengthen
muscles, improve
balance, and increase
bone density

Related to [etiology]: generalized

As evidenced by [defined characteristics]:


__________________________________________________________________________________________________________

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Relevant data

Patient goals and outcomes


in priority order. (able to be
measured and with
appropriate timing) (The
patient will)

The patients skin will


remain intact by the end
of the morning shift.

Nursing diagnosis: Spiritual Distress

Nursing interventions (related to


the nursing diagnosis and
patient ability to do it) (The
nurse will)

1. The nurse will


assess general
condition of skin
2. The nurse will
assess for edema
3. The nurse will
reposition patient
every 2 hours
4. The nurse will avoid
soaps or lotions
with perfumes/dyes
or alcohol

Evaluation (Did the patient


achieved the pertinent goals
and outcomes?)

Rationale (why the


intervention is needed)

Patients goal was


achieved and patients
skin remained intact

1.healthy skin varies


among individuals but
should have good
turgor, feel warm, and
dry to the touch
2. Skin stretched tautly
over edematous tissue
is at risk for impairment
3. Turning every 2 hours
will help relieve
pressure and prevent
skin compromise
4. the perfumes or dyes
may cause skin
irritation, and the
alcohol can lead to skin
dryness

Related to [etiology]: Physical and Psychological stress

As evidenced by [defined characteristics]: Expressions of concern about current health condition

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Relevant data

Expressions
of concern
about current
health
condition

Patient goals and outcomes


in priority order. (able to be
measured and with
appropriate timing) (The
patient will)

Nursing interventions (related to


the nursing diagnosis and
patient ability to do it) (The
nurse will)

The patient will


verbalize increased
sense of self-concept
and hope for future
before the end of shift.

1. The nurse will


Determine clients
religious or spiritual
orientation, current
involvement, and
presence of
conflicts.
2. The nurse will
establish
environment that
promotes free
expression of
feelings and
concerns. Provide
calm, peaceful
setting when
possible.
3. The nurse will
assist client to
develop goals for
dealing with life
situation.
4. He nurse will
identify and refer to
resources that can
be helpful such as
pastoral or parish
nurse, religious
counselor

Evaluation (Did the patient


achieved the pertinent goals
and outcomes?)

Patient has verbalized a


sense of peace and has a
positive view of what the
future will hold.

Rationale (why the


intervention is needed)

1. Provides
baseline for
planning care
and accessing
appropriate
resources.
2. Promotes
awareness and
identification of
feelings so they
can be dealt with.
3. Enhances
commitment to
goal, optimizing
outcomes and
promoting sense
of hope.
4. Specific
assistance to
resolve life
stressors such
as relationship
problems,
substance abuse,
or suicidal
ideation are
important to
advance recovery
process.

CARE PLAN GRADE


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ASSESSMENT
0=
Rarel
y

1=
Sometimes

2=
Most of
the time

3=
Consistentl
y

Total
points

0=
Rarel
y

1=
Sometimes

2=
Most of
the time

3=
Consistentl
y

Total
points

1. Consults appropriate sources (Nursing books, nursing Dx books, medical


dictionary). Patient worksheet # 2 complete? Medication list complete?
2. Seeks and identifies appropriate sources (H & P, Physicians orders,
Progress notes, diagnostic test results, vital signs, patient assessment data,
worksheet # 1 complete)
3. Data sufficiently and exclusively supports Nursing Diagnosis (relevant data
supports nursing Dx)
4. Distinguishes between normal and abnormal findings (patient laboratory
and diagnostic test results (Lab, CXR CT scan, etc.) including the normal
values)
5. Accurately identifies and labels abnormalities (diagnostic test specific
significance for the patient, and related to the patient diagnosis, medications
and treatments)
6. Identifies and addresses cultural needs (Specifically writes about patient
cultural status and needs, see appropriate description)

NURSING DIAGNOSIS

1.Analyzes thoughtfully and accurately (Sufficient, accurate and specific data


to support nursing diagnosis)
2. Recognizes and obtains needed knowledge (collects all the data necessary
to support the nursing diagnosis)
3. Identifies and prioritizes appropriate Nursing diagnosis for the patient
(Nursing diagnosis measures patient priority status)
4. Constructs nursing diagnosis correctly (nursing diagnosis, Related To, As
evidenced By)

15

PLANNING
0=
Rarel
y

1=
Sometimes

2=
Most of
the time

3=
Consistentl
y

Total
points

0=
Rarel
y

1=
Sometimes

2=
Most of
the time

3=
Consistentl
y

Total
points

1.Considers and selects appropriate culturally appropriate options, reflecting


good judgment
2. Prioritizes intentionally (Priority level written in order?)
3. Collaborates with appropriate sources (Health care team members)
Sets realistic, measurable goals (measurable and timed, patient should be
able to accomplish the goals and outcomes)

IMPLEMENTATION

1.Kows what should be done and intervenes appropriately (Specific


interventions written in care plan, and student work directly related to the
patient on the nursing unit)
2. Initiates actions in a timely manner (Student starts interventions and
patient care as soon as the patients needs any planned or new interventions,
it will be observed during direct patient care)
3. Provides appropriate health teaching (teaching done related to the patient
specific situation to the patient directly and written in the care plan)
4. Uses professional/suitable vocabulary (The student uses the specific
professional vocabulary when interacting with the Instructor, other students,
unit nurses and other health care team, and when writing the care plan)
5. Shares appropriate information with appropriate persons (shares
information with respiratory therapist, Laboratory personnel, charge nurse,
floor nurse, Instructor)
6. Documents accurately, legibly, and uses appropriate abbreviations
7. Documents promptly (immediately after assessment, and/or vital signs)
8. Works with dexterity (student knows what needs to be done and intervenes
appropriately in an independent manner)
9. Demonstrates thoroughness and neatness (patient and patients room in
perfect clean appearance)

16

EVALUATION
0=
Rarel
y

1=
Sometimes

2=
Most of
the time

3=
Consistentl
y

Total
points

1.Notes and evaluates outcomes appropriately (Writes specific evaluations


relates to the goal/outcomes)
2. Measures patient status correctly (assessment data supports nursing
diagnosis, patient able to reach the goals and is able to accomplish and
follow the described interventions)
3. Thoughtfully reflects on experience (see clinical day review, student
describes what she/he did learn with that specific client, positive and
negative outcomes)
Christian service grade: __________________ (Total possible points: 6)
Professional behavior: ___________________ (Total possible points: 8)
Safety: ________________________________ (Total possible points: 10)
Care plan: _____________________________ (Total points possible: 78)
Total points for the clinical day and care plan: ___________ (total possible points: 102)
The clinical grade is calculated by adding the weekly evaluation scores. A grade of 90% is necessary to pass the clinical experience.
(Ex. If the student one week has a percentage of 88%, it is below passing ranges, but that scores will be added to the rest of the weeks,
and student needs to have a 90% at the end of the clinical experience to pass the clinical and the class)

COMMENTS:
_________________________________________________________________________________________________________
_
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________
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Instructor signature: ____________________________________

Date: _________________________

ANDREWS UNIVERSITY
NURSING STUDENT EVALUATION FOR ROTATION CLINICAL EXPERIENCE
Semester of Experience: _____________________ Date: ____________________________________
Hospital: _______________________ ________ __ Unit: ____________________________________
Student name: -_______________________________________________________________________
Instructions: Please indicate your response by writing YES or NO according to student accomplishment

Christian Services
YES
(1
point)

NO
(0
points)

Not
Total
applicabl points
e

1.Demonstrates appropriate self control and self discipline


2. Places welfare of others ahead of own personal interest
3. Is helpful to others- going beyond the minimum that is required
4. Demonstrates respect for others
5. Conveys enthusiasm, warmth, concern
6. Recognizes and responds to spiritual needs appropriately

Professional Behavior
1.Arrives on time, appropriately prepared and present throughout clinical
2. Conducts self in confident, dependable, professional manner
3. Follows established standards of care (policies, procedures)
4. Recognizes and responds to ethical issues appropriately
5. Demonstrates personal initiative
6. Attends and contributes positively in clinical experience and conference/s
7. Maintains client confidentiality
8. Maintains personal appearance according to the policies of the School of Nursing and
affiliated agencies

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RN Signature: _______________________________
Date: __________

Instructor Signature: ___________________________________

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