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Redwood Clinical Paperwork

Syllabus for Redwood Med Surg 2B Clinical


Batch 13

Med Surg 2B

Redwood Convalescent Hospital

 Institute of Medical Education

San Jose Campus

Erika Mauersberger


Email Address:

Web Site:

Medical Surgical 2B Clinical Rotation


Using the skills learned during fundamentals and clinical rotation 2A, you the student nurse, will begin to use that knowledge and critical thinking to provide nursing care to patients at the level of a novice nurse.  You will begin to make connections from theory to on the floor actions and be able to describe rationale behind everything you do.  You will, through your actions, demonstrate the two core principles that define excellent patient care: Patient Safety and Patient Advocacy.  This is done through:

1.   Utilizing Maslow’s hierarchy of needs to assess clients with emphasis on health promotion throughout        the life span.

2.   Involve the client in participating in his or her own health care.

3.   Apply the components of the nursing process as related to the care of clients

4.   Perform essential nursing skills according to critical requirements.

5.   Utilize therapeutic communication techniques.

6.   Exhibit caring behaviors.

7.   Identify legal and ethical parameters of nursing practice.

8.   Identify situations beyond one’s knowledge and experience and seek appropriate assistance;

9.   Provide safe nursing care to clients.

10.   Recognize socio-cultural differences in assigned clients.

11.   Accept responsibility for personal and professional behaviors.

12.   Exhibit preparation for planned learning experience using required resources, prepared with required paperwork when due.



By the end of this module, you should be able to work as a novice nurse on any floor of a skilled nursing facility.  You will have the rudimentary knowledge required to pass medications, know what those medication effects are, what to watch out for, assess patients for changes to baseline status and know the appropriate actions to take when issues develop.  This will include (some opportunities will not be provided due to the client population but all efforts will be made to provide you with a wide variety of skills)

  • Competence in administering p.o., oral, eye, topical, otic, inhalant, SQ and IM, ID  and GTube medications.
  • Demonstrate the 6 rights of medication administration
  • Accountability for doses of controlled substances
  • Manage bowel and bladder problems
  • Safely administer 02 therapy
  • Collect assessment data pertinent to a patient with an o2 disorder
  • Safely assess residents risk for aspiration and methods for feeding residents with dysphagia.
  • Demonstrate concentrated system-specific physical assessments.
  • Demonstrate Gtube care , continuous feeding , intermittent, and bolus. Gtube medications and flushing standards.
  • Collection of various lab specimens
  • Accurate measurements of blood glucose and accurate insulin administration
  • Basic wound care with documentation of findings and measurement

This is a basic list.  You will find some things are added and some things due to the patient population not done.



Each week students will be required to come fully prepared for their shift with all tools needed to perform their job competently and safely this includes but not limited to:

  • Proper uniform
  • Hair off of the shoulders and pulled back
  • White closed shoes
  • White socks
  • Clean nails that are cut short. (no artificial nails allowed)
  • Name badge
  • Watch with second hand and numbers.
  • Stethescope
  • Blood Pressure Cuff
  • Pen light
  • Black Pens
  • Binder  to be used as your clinical workbook/resident chart. ( I suggest at least a one inch)
  • Patient information sheets, worksheets, clinical notebook, resource materials, notebook to write down v.s., and other information you assess during your interaction with residents.
  • Positive attitudes with providing the resident with the most nurturing, caring experience. These residents crave your attention.  Making one smile means that you have improved someones life that day.
  • No negative attitudes, laziness and uncooperativeness are tolerated on the clinical floor.
  • If asked to do something, please do it immediately.  Things are asked because resident’s care depends on it.  Should rationale not be given immediately when asked, it will be provided after completion, sometimes action needs to be taken quickly.
  • Performing skills: before you perform a skill you will need to find your instructor and be able to show what supplies are needed, discuss the steps of the procedure and any pertinent things to watch out for.  You will then be allowed to tend to your patient as your instructor observes from a distance.  Please do not be offended if the instructor steps in or makes a suggestion.  This is a learning experience.  The only time this should happen if it will cause the resident harm. Any other input from the instructor will occur after you have left the room and then you and your instructor will evaluate the skill.
  • Mondays before you step on the floor you are required to be able to give a report on your resident and have all patient worksheets filled out .  What does a report include?
  • Patient information
  • Pathophysiology of primary diagnosis with secondary diagnosis to follow starting the third week
  • Lab values that you would look for when caring for a patient with this diagnosis
  • Any symptoms that  should be watched for when dealing with this disease process.
  • Medications that this resident takes, the reason for the medication, any nursing implications and any adverse reactions to look out for.
  • Previous medical history that is pertinent to their current condition.

Why must you have all this information? You need it to provide quality care.  The Team Leader needs it to effectively supervise and delegate.

  • Times medications are to be given.
  • If the patient is diabetic or not, and what time is the blood glucose t o be checked.
  • Any treatments scheduled for that resident that day and when are they due.
  • When are their shower days
  • Last  lab values
  • Last set of vitals.
  • After pre-conference, you are to do an ABC check on your resident, and then politely find the nurse and ask if there are is anything to report that you should be made aware of.  If there is you need to alert the team leader and your clinical instructor.
  • Your vital signs and head to toe assessment must be done and reported to the clinical instructor and team leader by 1600.
  • On the week you are not with the med pass group you will be required to keep an eye on the med pass group’s residents during the med pass.  We work as a team, everyone’s resident is ours. The same will be done for you and after med pass, the med pass group will watch over your residents as you do wound care and blood glucose checks
  • All Call lights will be answered within two minutes.  If you are unable to complete the residents request confidently please do not hesitate to find the clinical instructor , if you assess the request and need just an additional pair of hands find a classmate.  I will be more than happy to help you with any issue, from changing briefs ,getting water, changing a bed to helping with an agitated resident.
  • We will assist with dinner feedings.  When the trays come out to the floor we must ensure that all linen barrels and dirty utilities are placed in the dirty utility closet.
  • Ensure that you are giving the proper diet to the proper resident.  If you assess that the resident you are assisting is coughing and/or showing signs of swallowing difficulties please alert the nurse and your clinical instructor.  You very well may have saved a life by catching this early sign of being at risk for aspiration and all its problems.
  • Assess resident environment and correct any safety issues.
  • Formulate a plan of action for the day to help structure yourself.  Please keep in mind, that no matter how hard we try and plan for time management, this is healthcare and things happen.  Your clinical instructor understands this and will take that into account.
  • You will be paired up into groups of two.  Per the facility no hanging out in clusters in the hallway.  No loud talking in the hallways (we are going to be there at bedtime, we don’t want to keep the residents riled up…trust me on this!)
  • The floor nurses can provide you with information but per the facility they are not there to be your instructor.  Please bring all concerns to your clinical instructor and she will approach the staff.  If it is something quick such as how many person assist, diet, liquid thickness etc, the staff member can answer.
  • Per the facility , we will not be charting in their charts.  I&O’s will be reported to your team leader who will then report that to the residents usual C.N.A. and /or nurse.  Any emerging condition will be reported immediately and the clinical instructor will make any necessary notation in thepatients chart and alert the floor nurse.
  • You will utilize your partner to aid you in critically thinking through an issue.  If the two of you are unable to come to an agreement on how best to move forward or if it will severely impact  the clients health, find the clinical instructor and they will assist you in working through how best to handle a situation.  You may use any and all resources to assist you with this.
  • Admission Database: you will fill this out during the first day you have with the resident.  This is a full and complete head to toe assessment of a new patient.  You will  not be required to fill out the head to toe assessment work sheet on this day, since it is all in the Admission database.  This then becomes your baseline for your resident.  You can refer to this whenever you believe there is a change in status.
  • You will be required to chart through out  your shift.  Q2h charting and a head to toe narrative for each day on your patient.  Head to toe narrative example will be provided to you to aid you with this.  Q2hr charting is your way to showing that you have continued the standard of care required by law.  It also will show any treatments you have done.  This also is a way to cover yourself should any questions arise.  What you write down is a legal documentation of your work as a student nurse.
  • You will do a pain assessment flow sheet.  If your patient  is nonverbal or not oriented enough to use the regular 1-10 pain scale please refer to your PAINAD hand out the clinical instructor provided during Fundamentals skills lab.
  • You will use a meal intake flow sheet to chart  meal intake
  • You will use an I&O sheet to document the output  vs. input for your resident for that day.  Should your resisdents output be less than 30 ml per hour during our shift you will immediately alert the team leader  and clinical instructor so they can alert the staff nurse.
  • Team Leader will be assigned each week. Duties include:
  • Taking report on every students assigned patient
  • Documenting treatments and procedures and times that they are ordered for each students resident
  • Delegate any procedures that come up
  • Assist fellow classmates with any needs
  • Ensure that all procedures, treatments are done within designated time frame
  • Ensure that medications are given within appropriate time frame and that everything has been charted in mar and properly signed.
  • Help with any emerging issues and report to clinical instructor and nurse.
  • Write a short nurses note on the back of each patients report sheet .
  • Act in a decisive, confident, charge nurse fashion.
  • Demonstrate leadership qualities.
  • Attention to detail and assist in ensuring that all classmates are on time with documentation.
  • Tend to another classmates resident should that classmate call out of clnicals.
  • You will be able to place your bags in the faculty lounge.
  • After dinner, you will be able to use the back feeding room for charting, paperwork will be responsible for keeping an eye on call bells.
  • Team Leader will make note of how quickly call bells are answered.
  • Team leader will also be responsible for ensuring that the beds are down, side rails up and call bell within reach for residents.

All class procedures are subject to change.


  • Attendance policies per school rules except for tardiness
  • You must alert clinical instructor three hours in advance if you will be absent from the clinical that day.  You can text her phone or email her at her email address.  Your partner is counting on you, so incase of necessary absence (life happens) alerting me to it early will allow me to rearrange and reassess the strategy for the day.  The facility schedules their staff with the information I provide the week before of how many residents we will be handling.
  • If you are not at the site and ready for pre conference by 1245, you will be asked to leave.
  • Having said that, life happens, so everyone gets one time where they may be late ..but no more than fifteen minutes.  You must get a hold of the instructor before 1245 to give an estimated time of arrival so that accomadations can be made for your residents care.
  • Please review the clinical makeup policy you received in your orientation packet during orientation for 2A



The purpose of the Clinical Performance Review is to evaluate student’s progress towards meeting each clinical objective.  The student is expected to demonstrate competencies in each course by meeting the clinical objective specified in the course outline and syllabus.  Students are expected to progress in performance as they advance through each course and the program.

The following criteria, based on the nursing process, will form the guidelines for the student’s performance in all client-care situations:

1.   Utilize learned scientific and behavioral principles to identify needs of adult patients experiencing common health stressors with progressive ability.

2.   Utilize the nursing process in meeting the priority needs of the patient with progressive ability. Emphasis is to be placed on priority nursing diagnoses, including physiological needs, ego integrity and teaching/learning.

3.   Perform all learned nursing skills (including medication administration) safely and therapeutically under supervision of an instructor with progressive ability.

4.   Function as an accountable member of the health care team.

Redwood Convalescent Hospital/Med Surg 2B Rotation

Explanation of Rating Scale


(S) Satisfactory  =                    Clinical performance is safe and student adequately demonstrates application of the nursing process, required skills, and expected synthesis of learning appropriate to level in the program.

(U) Unsatisfactory  =               Clinical performance is unsafe and inadequately demonstrates application of the nursing process, required skills, and expected synthesis of learning appropriate to level in the program.

Clinical instructors will provide weekly written feedback for clinical objective(s).

Accomplishment of the clinical objectives will be evaluated at midterm and final conferences. When the student successfully meets the clinical objectives of the course, percentage grade will be given. When a student is unsatisfactory at meeting the clinical objectives, a conference will be scheduled with the faculty. The student and faculty will develop a clinical contract that outlines activities to assist the student to correct the identified deficiencies.

You will also be given a final percentage grade at the end of your term.  The Break down for that is as follows:

  1. 60% clinical work, clinical paperwork, attendance, professionalism, attitude
  2. 20% homework assignments and quizzes
  3. 20% End of clinical exam may be one or the other or consist of both of the following : practical /written and evaluation of your clinical notebook. ( neat,, organized, complete, all necessary paperwork filled out and checked off by instructor)

You will be given an opportunity to review the final evaluation with your clinical instructor the last week of clnicals.  These forms are for you to keep track of your progress or deficiency.  The final evaluation tool will be done in a percentage grade.

Please see the clinical performance forms provided.


Please refer to the course calendar found at :  Once on the website please enter in the calendar reference number of 265605 for all assignments and weekly quizzes.Each Wednesday you must turn in to the teachers office your clinical workbook with all paperwork included.  There will be a box for you to place them in.  Any information needed for the following week will be ready for you to pick up from there.

Weekly clinical notebook should have included:

  • Admission database
  • Medication sheets
  • Patient information sheet
  • Pathophysiology
  • Pertinent labs
  • Nursing interventions
  • Care plan
  • Head to toe assessment
  • Weekly self evaluation sheet
  • Nursing narrative
  • Q2hr charting
  • I&0
  • Pain assessment flow sheet

Every Monday you will receive your notebooks back with your weekly evaluation and any notes, comments or corrections .

Your clinical instructor is always available to go over anything with you one on one. Just ask and a time will be arranged.

SAFETY and HIPPA compliance:

Due to the nature of our environment , for patients safety you must be prepared with all necessary information to give care.  So, if for any reason the clinical instructor feels you are not able to do so, they have the right to dismiss you for the day.  HIPPA is a very serious compliance issue.   Therefore there shall be no cell phones allowed at clinicals.  Your clinical instructor will have a cell phone with her at all times to field any emergency calls.  It is always best to utilize another person during patient care, that is why you are teamed up in duos with a team leader to assist whenever necessary.

Weekly Topics You Will Be Tested On:

Please find these on the assignaday website .


          Attachments will be emailed usally as pdf or worddoc so that you may always access and download as needed.












About underpaidnurse

underpaid and overworked! former nursing instructor now Dir. of Residential Services at a place that is driving me to drink but not leaving me any time to consume!


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