Clinical Activity

Professional Role Transition

Revised Critical Thinking Clinical Activity

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Description

The Critical Thinking Clinical Activity allows the Role Transition student to present a clinical case utilizing the nursing process to their clinical faculty and peers. The student will incorporate particular categories/subcategories from the NCLEX-RN test plan, as well as emphasize target interventions. The student will provide a written reflection on their experiences in clinical relating to their transition to practice.

 

Instructions

Select one patient on which to complete the Critical Thinking Clinical Activity. You will present to your clinical group and individual faculty via prearranged Zoom meeting. The clinical faculty will assess student work and provide feedback. See separate grading rubric for this activity.

 

Guidelines:

1. Complete information on your patient to provide your classmates and faculty with some context.

a. Background: age, sex, ethnicity, allergies, significant med/surg history

b. Reason for visit or hospitalization

c. Social history

2. Utilize the SOAP format to critically think through the nursing process related to the top priorities you have identified for this patient. Be sure that the content in the assessment and plan sections correspond to the information in the subjective and objective sections.

a. SUBJECTIVE is only what the patient tells you (statements or questions; complaints or concerns)

b. OBJECTIVE includes physical assessment data, interval test data, lab or blood work, other objective data, current orders, current medications

c. ASSESSMENT includes the interpretation of information in the previous two sections. This is your “summary” which includes medical/nursing diagnoses. Prioritize your patient’s problems or diagnoses. Clearly identify nursing priorities. Identify treatment goals for each problem or diagnosis.

d. PLAN includes the interventions which were/are/will be implemented. Be sure and establish priorities for the interventions. (You may notate them as #1, #2, #3, etc.). Provide a brief explanation as to why you have prioritized them this way.

e. Identify the following patient needs and provide specific information about each need:

i. Case management or discharge planning

ii. Patient education

iii. Psychosocial, spiritual, and/or family support

3. Complete the reflection at the end. (This is just for the clinical instructor and is not presented to the group during oral presentation.)

4. Students will present their SOAP activity (#1-2 above) orally to fellow clinical students and clinical faculty instructor. This is a graded activity, and successful completion is a requirement of Role Transition clinical.

 

NUR 4642: Professional Role Transition

Critical Thinking Clinical Activity

Student name:

(Refer to instructions and grading rubric when completing this activity.)

Patient initials: Date of care:
Background:

 

Reason for visit or hospitalization: schizoaffective disorder, bipolar type (HCC) currently with hallucinations and aggressive behavior

 

Pertinent social history, including living situation, for discharge planning or case management purposes:

 

 

S:30-year-old transgender female presenting with bizarre behavior talking to self and not caring for self. “ I am not thinking right, my head is wrong” patient unable to fully describe this, Patient presents tangential and disorganized at times with pressured speech and difficult to interrupt. Patient can become aggressive very suspicious of others with paranoid delusional thought content

 

O: Appearance; disheveled

Behavior: PMA, restlessness

 

A: Patient seen in room and selectively in milieu upon approach patient is cooperative, labile affect guarded, unkempt appearance. Patient with disorganize speech, paranoid, noticed watching other patient as they walk by her room, patient agreed to take medication this morning.

 

P: intervention therapy, patient to attend group therapy and milieu therapy, special precaution: q 15 minutes safety check

 

Case management or discharge planning needs: social worker and patient met to assess symptoms and discuss discharge planning. Patient stated that she has been homeless for 1-2 months, living with a friend. Patient stated that she was previously living at Greenwood care and signed out AMA, pt stated that was 1-2 month ago, social worker encouraged placement, patient agrreable stating she would like a new referral.
Patient education needs
Psychosocial, spiritual, and/or family support needs

 

 

 

Reflection: Provide your reflective responses to the following questions. Write a well-composed paragraph (approximately 4-6 sentences) for each set of questions. (Three paragraphs total.)

1. How do you feel about the experiences you are encountering in clinical? What are your strengths of performance and areas needing growth?

 

2. How have you integrated in the healthcare team? Provide examples. Describe the partnership/relationship you share with those preceptors /nurses with whom you work.

 

3. How would you characterize your transitioning to the role of professional nurse? What is helping or hindering your transition? What is your plan to continue to progress forward?

Rev. JD/2.28.21

 

 

Professional Role Transition

Critical Thinking Clinical Activity Rubric

 

Instructor has the right to assign 0 points for any category that is not addressed at all.

 

Criteria for Assessment Mastery

10 points

Competent

9 points

Needs Improvement

8 point

Total

Points

PATIENT INFORMATION

· Background

· Reason for visit or hospitalization

· Social history

Includes all criteria Missing or incomplete data for one criterion

 

Missing or incomplete data for two or more criteria  

/10

SUBJECTIVE

· Patient-provided data:

· Statements or questions

· Complaints or concerns

Complete; includes all pertinent subjective information Partial summary of pertinent subjective information

 

Poorly organized and/or limited summary of pertinent subjective information  

/10

OBJECTIVE

· Physical assessment data

· Interval test data

· Lab or blood work data

· Other objective data

· Current orders, including medications

Complete; includes well-organized summary of pertinent objective data Includes a mostly complete summary of pertinent objective data; may be missing one data point and/or may be lacking in organization Poorly organized and/or limited summary of pertinent objective data  

 

/10

ASSESSMENT

· Interprets information from previous S and O sections:

· Primary Medical diagnosis and three nursing diagnoses

· Nursing diagnoses are prioritized

· Treatment goals for each nursing diagnosis are identified

· Accurately interprets information from S and O sections

· Lists four nursing diagnoses with appropriate prioritization

· Identifies appropriate treatment goals for each nursing diagnosis

· Interprets most information from S and O sections accurately; generates a mostly complete list of nursing diagnoses; most are appropriately prioritized

· Identifies appropriate treatment goals for most nursing diagnoses

· Does not accurately interpret information from S and O sections; incomplete list of nursing diagnoses; is not prioritized appropriately

· May not identify appropriate goals for problems/diagnoses

 

 

/10

PLAN

· Summarizes nursing treatment plan

· Prioritizes nursing interventions and provides explanation for priority order

 

· Summarizes overall nursing treatment plan clearly and concisely

· Prioritizes specific interventions and explains priority order

· Includes a complete list of all pertinent interventions with all relevant information, including complete medication information, if applicable

· Summarizes overall treatment plan

· Lists interventions but may not accurately prioritize or explain priority order

· Lists interventions but may be missing 1 or 2 pertinent ones; may not include complete medication information

· Incomplete summary of treatment plan

· Incomplete list of interventions; lack of prioritization or explanation of priority order

· Missing 3 or more pertinent interventions

 

 

/10

PATIENT NEEDS

Identifies patient needs and provides specific information about each:

· Case management or discharge planning

· Patient education

· Psychosocial, spiritual, and/or family support

Adequately addresses specific patient needs related to case management or discharge planning; patient education; psychosocial, spiritual, and/or family support Addresses all but one specific patient needs Missing two or more specific patient needs  

 

/10

REFLECTION

· Feelings about experiences in clinical; strengths and areas for growth

· Integration into healthcare team with examples; relationship with clinical partners or preceptors

· Characterizes transitioning experience; helping/hindering transition; plan for forward progress

Addresses all prompts thoroughly and completely; provides specific examples and descriptions Addresses all prompts but may be missing a specific example or description Does not address all prompts and/or missing specific examples or descriptions  

 

 

/10

WRITING Clear writing and organization; no more than two spelling or grammatical errors Adequate writing and organization; no more than three spelling or grammatical errors Writing lacks clear organization and/or more than four spelling/grammatical errors  

/10

ORAL PRESENTATION Mastery Competent Needs Improvement  
  10 points 9 points 8 points  
CONTENT

Patient Information, Subjective, Objective, Assessment, Plan, Patient Needs

Addresses each section in a concise and knowledgeable manner; can answer questions succinctly if appropriate Addresses most sections; may be missing complete information in 1 or 2 areas Missing complete information in 3 or more areas  

/10

  5 points 4 points 3 points  
ELOCUTION Excellent oral presentation skills: professional and clear speech; appropriate volume and pace of speaking Adequate oral presentation skills; may need to be reminded to speak clearly, increase volume, or slow down Oral presentation skills need improvement; may be lacking in professionalism; speech may be difficult to hear or understand  

/5

  5 points 4 points 3 points  
TIMING 10 minutes or less More than 10 but less than 12 minutes More than 12 minutes /5
   

TOTAL POINTS:

 

/100

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