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Washburn UniversitySchool of NursingNU 608 Health Care Practicum III- Specialty (Family) Clinical Performance Tool(Completed by Student and Faculty)Student__Anna Marshall_________________Semester___Fall 2012______Agency__McLouth Medical Clinic______________Instructor_Dr. Jane Brown___Clinical performance is based on Universal Outcomes, End of Program Outcomes and National Organization of Nurse Practitioner Faculty Core Competencies of Nurse Practitioner Practice (2011). Nurse Practitioners must demonstrate care that is effective, patient-centered, efficient, timely, and equitable for the treatment of health problems and promotion of wellness. Universal Outcomes: Evaluating BehaviorUniversal Outcomes must be met in order to pass the course. Failure to meet any of the three Universal Outcomes will result in a grade of F. If an F is earned, the Core Competencies will not be consideredUniversal OutcomesDemonstrates honesty and integrity by submitting original work MetNot meton assignments and accepting responsibility for own actions taken/omittedPrioritizes patient safety as the primary consideration in all careMetNot metMaintains professional boundaries with patients, family and Met Not metstaff. Maintains confidentiality at all timesNurse Practitioner Core CompetenciesStudents must achieve an 80% on the final clinical evaluation tool to be successful in the course. These outcomes are only evaluated if the three Universal Outcomes are met. Students who do not meet the competencies within the required practicum hours may be required to successfully complete additional hours before a final grade will be awarded. Points are assigned as follows: Please rate your own performance using the descriptors listed below:0 = no opportunity to experience1 = defined as not meeting expectations; failing to initiate learning experiences; arriving late and unprepared; failure to effectively communicate with the patient, family, preceptor, staff and faculty2 = defined as inconsistently meeting expectations; requires much faculty/preceptor guidance in learning experience/support3 = defined as routinely meeting expectations yet requires more faculty/preceptor direction in learning experiences4 = defined as routinely meeting expectations with minimal support from faculty/preceptor5 = defined as consistently meeting expectations with little guidance; proficient; can perform independently; initiates learning experiences; is well prepared for learning petency NarrativeThe overall goal of the Clinical Performance Tool (CPT) is to assess the student’s progress throughout the practicum using a narrative description of each competency. To provide a description of the total progress, the student is expected to maintain a cumulative narrative of their performance. With each competency and each submission, the student is expected to assign themselves a score from 0-5 (It is not expected that a student will have many scores of 4 or 5 with the first submission). Within the narrative, students are expected to briefly address the following 4 items:. What does this competency mean? What challenges/strengths related to mastery of this competency are present at this point in time?Give 2-3 examples from this practicum experience that best illustrate how you are performing the selected competency and which support the score you assigned yourself?What do I need to gain additional skills to master this competency?What references/clinical guidelines/point of care tools (if appropriate) have been helpful in achieving this competency?GradingThe Clinical Performance Tool is completed and submitted by the student at the completion of 80 clinical hours, 160 clinical hours, and 225 for a total of three submissions. The first submission must address items 1-13. The second and final submission must address items 1-28. The final submission is graded.NONPF competencies addressed in this course include Independent Practice, Leadership, Quality, Technology/Information Literacy, and Ethics. Competencies are founded on an understanding of pathophysiology, patient presentation, differential diagnosis, patient management, surgical principles, health promotion, and disease prevention. Utilization of communication strategies, principles of quality care, information technology/literacy and ethical principles are expected. NP students are expected to demonstrate an investigatory and analytic thinking approach to clinical situations, professional behavior, effective communication, and a sensitivity and responsiveness to patient culture, age, gender, sexual orientation and ability.First submission = XSecond submission = XThird submission = XNP students are expected to:1.Develop individualized health promotion, disease □ □ □ X □ X □ X□prevention and health protection services for patientsacross the life spanFirst Submission 24 August-24 September 2012 - Developing individualized services for patients across the lifespan means taking into consideration every patients' health status at any particular point in time, the other factors influencing individual circumstances, as well as known risk factors. Individualizing care forces the practitioner to consider both what is evidence-based and what is effective. One challenge of the student practicum experience is that, initially, I am not familiar with any of the established patients, as my preceptor is, and do not always know best how to 'individualize' care. One of the beauties of primary care, is the relationship established between the health care team and the patient, seeing patients repeatedly, getting to know your patients, and what motivates them. I have spoken with numerous patients about routine lab results, and in particular, what to do about elevated lipids. One example involved a husband and wife who were in the room together for her appointment. The woman was 75 years old, and in relatively good health. In discussing her elevated lipids, she really did not want to start a medication to help lower cholesterol, and we agreed that it would be acceptable for her to try a dietary approach, rather than a medication. We talked about how this may be appropriate for her, but was not an appropriate approach for her husband, who also had elevated lipids, but was also diabetic, hypertensive, and had a history of CAD and bypass surgery. In primary care, counseling and health protection and promotion services are individualized; what may be acceptable for one patient may not be for another. When individualizing teaching about disease prevention for a young woman complaining of frequent urinary tract infections (UTI), I saw the opportunity to include not only teaching about ways to protect against UTIs, but also ways to protect against sexually transmitted diseases and avoiding unplanned pregnancy. In the future, I look forward to developing a patient population in a primary care setting, getting to know the patients as individuals, and providing meaningful services based on what I know about them. Second Submission 25 September- 22 October 2012 - A. Both acute and chronic visits allow the opportunity for the practitioner to develop health promotion, disease prevention, and health protection services for patients across the life span. Listening to patients, asking questions, addressing known risk factors, and being aware of evidence-based guidelines, are some of the ways to build and improve upon this competency. One strength, specific to the rural health clinic site, is the small town atmosphere where 'everybody knows everybody', and it seems easier to get to know the patients in order to better individualize care. After having been at this site for about 2 months now, I have gotten to know some of the patients better by having seen them a few times. On the other hand, the rural setting also presents some specific challenges related to the distance people must travel for certain services, and the risks associated with the higher rates smoking and obesity. B. I have had opportunities to practice this competency by performing a number of well-child exams and well adult (mostly women) exams throughout this period of time. This is generally a good time to talk about recommended health promotion and protection and disease prevention services for that individual. For example, a woman was asked about some moles that I noticed during a well woman exam. She was encouraged to come back or go to a dermatologist to have them excised because they were suspicious-looking and she was unsure about whether they had grown or changed. She did and one turned out to be malignant melanoma. Also, in patients who are being seen for follow-up discussion about annual lab work and with elevated lipids, I routinely talk with people about their dietary patterns, and incorporate information on low-fat, low-cholesterol diet into the patient education section of the discharge instruction paperwork. C. In the future, I will continue to reference guidelines for evidence-based recommendations, and will continue to read and study to stay abreast of changes. I hope to work in the primary care/family practice setting, and will work on developing individualized services with my own clientele, as I get to know individuals and available resources in the area. D. For these types of services, I refer to the guidelines and recommendations published by reputable sources, such as the US Department of Health and Human Services (USHHS), through the AHRQ, the CDC, the American Cancer Society (ACS), and the American College of Obstetricians and Gynecologists (ACOG), using the information as a guide, but allowing individual circumstances to drive care. Third submission 23 October - 19 November - A. Throughout this clinical experience, I have had numerous opportunities to develop health promotion, disease prevention, and health protection services for patients across the life span. I have been flexible and creative in developing individualized services, and have followed sound recommendations with the goals of protecting and promoting health and preventing disease. My preceptor has given me progressively more independence in this process, as I have gained confidence, gotten to know patients, and have progressed through this final clinical experience. B. Examples of this competency include one 23 year old patient who had come to the PAP clinic for a routine well-woman exam. She reported no concerns or complaints, but did wonder when she should begin getting mammograms since her mother had died at age 32 years of malignant breast cancer. She was instructed on the importance of performing regular self-breast exams, advised her to find out more information about the kind of breast cancer her mother had, and other pertinent family history (sisters, aunts), and that she should definitely not wait until the age of 40 to have her first mammogram, regardless. Since she was uninsured, she was also advised on assistance programs for getting an affordable mammogram (ie. EDW). Another example, a patient was given personalized information on reducing soda intake and the potential health benefits of doing so in effort to protect her health. About a month later, I followed up with the patient, and she told me that she had since significantly reduced her intake of soda beverages from about 10 a day to 1 or 2 at the most. C. Strategies for improving upon this competency in the future include ongoing efforts to see patients as individuals and understand their individual circumstances when designing care. I will make efforts to not get into a routine to the degree that I am not able to individualize care or become immune to individual factors. I will stay abreast of current recommendations for health promotion/protection services and disease prevention strategies as defined by reputable sources such as D. (USHHS), AHRQ, CDC, ACS, and ACOG, as mentioned above. Others include National Center for Chronic Disease Prevention and Health Promotion, KanQuit, Ferri's Clinical Advisor 2012 and more.2. Develop individualized anticipatory guidance and □ □ □X □ X □ X□ health counseling for patients across the life spanFirst Submission 24 August-24 September 2012 - Information gained via patient interviews, knowledge about human development, and epidemiology are some of the main factors that guide the development of anticipatory guidance and health counseling for patients across the life span. Valuable information can be gathered from a person's family, social and personal history. Well-child examinations, and other health maintenance visits for adults provide excellent opportunities to introduce and individualize anticipatory guidance and health counsel. I counseled the parents of a six month old child, during a well child visit, about upcoming developmental milestones to anticipate and prepare for, and ways to promote safety in their home environment. I also had the opportunity to counsel a patient with history of congestive heart failure about doing daily weight checks and calling in the event of weight gain greater than 5 pounds within a few days or a week. I provided the health counseling to a 38 year old woman who was being newly diagnosed as diabetic. At the visit, we reviewed her laboratory results, talked about diabetes and the associated long-term complications possible if not controlled. Anticipatory guidance and health counseling began with a discussion of long-term treatment goals, and the importance of blood sugar control. The discussion was individualized to her needs, as far as how and how much information was given initially, and how aggressively to begin with pharmaceutical therapy. In future practice, I hope to be able to be creative in individualizing services, and insightful in providing anticipatory guidance and health counseling to patients of all ages.Second Submission 25 September- 22 October 2012 - A.Developing individualized anticipatory guidance and health counseling for patients across the life span means that the practitioner must have a firm grasp on the expected developmental stages of the human life, and the activities associated with the various stages, being able to identify and make sense of variations from the expected, and counsel patients effectively. The advanced practice nursing role provides the opportunity to provide guidance and counsel to patients and families in anticipation of things to come, based on the known probability of how most people progress through the stages of life or through some other activity, or lifestyle change, such as smoking cessation. The availability and accessibility of evidence-based resources and tools that are helpful in achieving this competency is one strength of practicing in this time. B. Examples include the opportunity I had to counsel a 15-year-old girl who came in complaining of urinary symptoms, after she revealed to me that she had been sexually active, that she needed to have a pelvic exam with pap smear, and about the importance of guarding against pregnancy and sexually transmitted infections. I have had numerous opportunities to talk with patients with chronic low back pain about the efficacy of various treatments, including physical therapy and the importance of weight loss, when indicated. This fall, I have performed several physicals on young girls, ages 12-13, who were having pre-participation sports physicals done, prior to the start of the volleyball and basketball seasons at the local middle school. At this age, the opportunity presented in a comprehensive physical exam, for the APRN to provide anticipatory guidance and health counsel to the girls on topics such the onset of menses, and other issues related to sexual maturation must be used. C. In order to gain additional skills to master this competency, I will need to decide what set of tools I find most helpful to my practice, for both assessment and counseling purposes, adopt them for use, based on the specific setting and patient population being served. I will continue to read and learn about some of the various factors at play in these interactions, such as health literacy, the complexity of behavior modification, and the effectiveness of the various methods of patient education, applying this knowledge in an effort to make the greatest impact on the health and well-being of my patients. D. The Ages and Stages Questionnaire (ASQ) is the tool used by this agency for developmental screening in young children. I like the way this tool specifically assesses the language skills, the social-emotional functioning, and common developmental milestones of children, from one month to five years old. The Tanner Stages of sexual maturation are helpful in staging the development of adolescents/young adults, and has been used to both assess development and direct anticipatory guidance. I have also referred to information put out by the National Diabetes Education Program, and the National Cholesterol Education Program for help with learning how to educate and counsel patients on these topics. Third submission 23 October - 19 November - A. The development of anticipatory guidance and health counseling is guided by a variety of factors and those factors may differ from patient to patient, depending on individual factors and their position across the life span. I continue to seize the opportunities, as I see them, capitalizing on chances to influence patients and guide them in their quest for health. My preceptor is a good teacher and has good strategies for achieving this competency. I have learned a lot about providing guidance and counsel from her example. B. An examples of this, in a patient who had been diagnosed with a DVT, and placed on blood thinners at the hospital, my preceptor and I were working on the titration of his blood thinner. As we titrated his medications, he was counseled to watch for signs of over-coagulation, and what to do in the event of spontaneous bleeding. Another example was in an 18 year old patient who was in for a recheck four days following a rollover MVC, and who continued to complain of head and neck pain and right-sided pain. His previous CT scans of head, C-spine, abdomen and pelvis and plain film x-rays of T-spine and R knee were reviewed with him to reassure him, and he was counseled on the nature of traumatic brain injuries and the potentially long recovery time. Tanner Stages of Sexual Maturation used as guide in discussion with 12 year old girl about when she might expect her periods to start. C. Strategies to improve upon this competency in the future include ongoing efforts to learn about effective methods and strategies for teaching patients, and a mastery of the skills needed to provide anticipatory guidance and counsel to patients managing common chronic diseases. D. I have continued to use a variety of tools throughout my experience to develop anticipatory guidance and health counsel for patients, using appropriate developmental screening tools, and printable patient information materials on a variety of topics. 3.Prioritize differential diagnoses based on etiologies, □ □ □ □ X □ X X□ risk factors, underlying pathologic processes and epidemiology for medical conditions First Submission 24 August-24 September 2012 - The prioritization of differential diagnoses is an advanced skill that requires the application of diagnostic reasoning, and critical thinking to the decision-making process. This skill is based on an understanding of the etiologies, underlying pathologic processes, risk factors, and epidemiology of various medical conditions, and I recognize that I have come a long way toward gaining this competency, since my early clinical experiences. I continue to use various resources in the clinical setting to look things up, guide diagnostic reasoning, and to formulate diagnoses, but not nearly as much. In nearly every patient visit, I progress and grow in this competency, and expect to continue to do so throughout my career. Based on the fact that I am doing my clinical rotation in a rural, farming community, and the fact that we are coming off of a severe summer drought season, I have given high priority to the role of allergens in the many, many patients I have seen with upper respiratory, and congestion/cold-like symptoms in the past few weeks. and especially if a patient tells me they have a history of seasonal allergies. The differential diagnoses for a woman with difficulty breathing were prioritized based the fact that it was gradual in onset, was not accompanied by chest pain, and on her risk factors as a sedentary, overweight smoker, with a history of asthma, taking birth control, and being 6 weeks post-operative status post knee operation. The top three differential diagnoses were exacerbation of asthma, pulmonary embolism, and bronchitis. Sometimes, asking the patient, "What do you think is wrong?" is another way to help prioritize the various options being considered. Effective communication with patients is good practice, and is essential to this competency. Second Submission 25 September- 22 October 2012 - A. To prioritize differential diagnoses based on etiologies, risk factors, underlying pathologic processes and epidemiology for medical conditions means being able to think critically and reason through the complexity of certain medical conditions and the other factors involved in clinical decision-making. Having a preceptor that allows me to practice this skill with her patients, and with whom I feel very comfortable talking to and asking questions, has been a strength for me, throughout this experience. I can practice this skill openly and know that she will be thoughtful and direct in her evaluation of my ability to prioritize differential diagnoses, providing feedback and support. B. Examples of this from my current practicum experience include one patient form whom I was considering possible differentials for a patient who had been involved in a motor vehicle crash (MVC) 4 days prior, had been evaluated in the emergency department, and cleared of acute problems, but continued to have multiple complaints, including increasing symptoms of neck and head pain, post-concussive type complaints, blurred vision, and others. I saw him multiple times in the days following the MVC, and with careful consideration of possible complications, did a lot of reassuring and educating about what types of symptoms to expect after a concussion, and the expected duration of symptoms, but did end up referring him to the ophthalmologist after he complained of visual disturbances that caused his vision to appear as if there was a shade over half of his visual field, because of concern for a retinal detachment or tear. Differential diagnoses were prioritized in a patient with a history of type 2 diabetes, hypertension, hyperlipidemia, in addition to the risk factors of smoking, obesity, and other lifestyle and familial factors, when she presented with facial droop and sensory alteration in her face. Because of her risks, stroke was given the highest priority, although she was outside of the window of acute treatment, when she sought care, and bell's palsy was also considered to be a possibility. MRI was negative for signs of stroke, and the clinical exam supported the diagnosis of bell's palsy. Even so, she was advised to start taking aspirin, and counseled on doing what she could to reduce her modifiable risk factors. C. To gain additional skills to master this competency, I will need to continue to practice systematically, gaining confidence through practice in my instinctual and intellectual ways of prioritizing the possibilities. I will try to always gather a list of 3 differential diagnoses, based on the information provided by the patient as they describe their chief complaint, and the subjective data available, including personal and familial history, and other sources of risk. Always maintaining a sense of beneficence and non-maleficence can help guide this process, in the future, when there is uncertainty, or the best course of action is unclear. Keeping patient safety as the top priority will help to improve my ability as a practitioner to be competent in this. D. I frequently refer to my Ferri's Clinical Advisor to help me determine an appropriate list of differential diagnoses for a certain set of symptoms or complaint. I use a variety of clinical resources, including UpToDate and the VisualDx database for dermatological conditions to help prioritize diagnoses. Third submission 23 October - 19 November - A. Being able to prioritize differential diagnoses requires an advanced level of assessment, knowledge of disease processes, and critical thought, evident as being able to sort through a variety of complex factors, and make decisions in the health care setting. My confidence in my ability to perform this competency has grown exponentially as I have gained experience throughout my years in this program. B. Examples from this practicum that illustrate my ability to perform this competency are when I encountered a 62 year old woman who was in to establish care with my preceptor. We were able to review some of her previous records, so we were able to confirm her history of rheumatoid arthritis, Sjogren's Syndrome, type 2 diabetes, and pulmonary disease. When she complained of 'aches and pains in bilateral arms and legs' that had been worse the past few weeks. I was faced with prioritizing between differential diagnoses related to the pain being arthritic or neuropathic pain. Based on her presentation and my knowledge of these conditions, and the fact that she was on meds for her RA, I chose to treat the pain with neurontin, giving priority to the diagnosis of neuropathy as the cause. Another example of prioritizing differential diagnoses is illustrated in a patient with whom I ordered diagnostic tests to rule out cardiac causes of chest pain, because the patient was in a demographic that put him at risk, and had more than one other risk factors for having cardiac issues. In this case, cardiac conditions were given priority over other differential diagnoses, such as GERD or musculoskeletal causes of the pain. C. With every diagnostic decision in the future, I will consider each differential and think about each of the factors in this competency, always making sound decisions and avoiding assumptions. I will continue to gain knowledge about medical conditions, and will rely on my knowledge and instincts to prioritize diagnoses in the future. D. Throughout this experience, I have used a variety of references to achieve this competency, including Ferri's Advisor, UpToDate, VisualDx, Buttaro, and other tools for building differentials.________________________________________________________________________4. Perform comprehensive health history and physical exam □ □ □ □ X □ X X for patients across the life span First Submission 24 August-24 September 2012 - Comprehensive services for patients must include consideration of health history and thorough examination of the patient. I have performed comprehensive physical exams on young and old patients, and have gathered comprehensive health histories through review of charts, records, and patient interviews. Repetition of an organized head to toe exam has enabled me to be able to gain confidence in my ability to perform a comprehensive exam in a timely fashion. I have performed well child exams on patients ranging from 7 months to 10 years, and comprehensive physical exams on adult patients of varying ages between 20's and 70's. Comprehensive health history and physical exams are most frequently done when patients are seeking health clearance for school, sports activities, or pre-employment, and also for new patients and routine, annual health maintenance for some. In the future, it will be essential to incorporate the use of an organized and systematic approach to the collection of comprehensive health history from patients, including family, social, and medical histories. Second Submission 25 September- 22 October 2012 - A. Performing the comprehensive health history and physical exam means taking the time to gather information about a person's history, including their health history, family history, and social history, taking note of certain lifestyle factors that may be pertinent to health status, and performing a systematic and thorough assessment of physical characteristics. For me, the development of a systematic method for performing a comprehensive physical examination has been a strength, and has made it easier for me to be able to do this on a patient of any age, in a reasonable amount of time. The amount of time allotted for an office visit is a challenge to this competency, and some of the history gathering may need to be done outside of the office visit time, by questionnaire, etc. B. Examples of this in the current practicum experience include the opportunities I have had to perform comprehensive exams on patients for various reasons, including clearance for school and sports, clearance for the department of transportation, and well-child visits. I have also had the opportunity to participate in well-woman visits, performing a comprehensive physical exam, with a female focus, including assessment of gynecological health, and discussion of issues especially pertinent to a woman, including breast health, birth control, calcium and vitamin D recommendations. The screening and testing requirements may vary slightly depending on the reason for the comprehensive exam. C. My strategy for improvement in this competency includes the increased use of genograms for gathering and documenting information about family structure and medical history as part of this process. Also, I hope to start my advanced nursing career in a relatively general, family practice or primary care-type setting, allowing me to continue the practice and mastery of this competency. D. I carry Mosby's Physical Examination Handbook, a portable clinical reference on physical examination, and a reference book on the pediatric examination. Third submission 23 October - 19 November - A. Performing comprehensive health history and physical exam means being thorough in the questions asked to build a history, including health history, family history, and social history, and performing a systematic assessment of physical characteristics. The electronic record is a strength when it comes to my ability to achieve this competency, because of the way the chart is organized. B. Examples in my clinical time of how I have performed this competency are in the numerous patients I have had the opportunity to perform comprehensive well exams on, including a number of pediatric patients having well-child exams through the KanBeHealthy program, and for school-related reasons. I have also had opportunities to perform comprehensive history and physical exams with focus on women's health issues. C. Strategies for improvement include professional strategies and goals for beginning my practice as a nurse practitioner in a setting that allows me to continue to practice this competency, so as to not lose this skill. D. Throughout the entirety of this clinical experience, I have mainly used my Mosby's guide to physical examination, and a guidebook to pediatric exam. On occasion, I have used other tools to aide in the process of building a history, such as family mapping/genogram. ________________________________________________________________________5.Perform problem focused health history and physical exam □ □ □ □ X □X Xfor patients across the life span First Submission 24 August-24 September 2012 - Problem-focused health history and physical exams are appropriate when an established patient is seeking medical care for an acute problem or following up on a specific problem or health concern. My background as an emergency room nurse has enhanced my ability to be problem-focused during a patient visit, and I have had the opportunity to practice on a number of patients coming in for acute issues in the current clinical setting. During a problem-focused health history and physical exam, it is often useful to inquire about certain social and familial factors; the challenge is to know what factors may be pertinent, and how to best elicit useful information from patients while maintaining the focus. I have used the 2012 Ferri's Clinical Advisor to help guide my focus when I am unsure or not familiar with a condition or set of symptoms. I have had the opportunity to perform numerous problem-focused health histories and physical exams for dermatological conditions, and frequently refer to my clinical dermatology books and online resources for guidance. I have used the 'Visual Diagnosis' resource to help me in making a diagnosis based on data gathered through a focused history and physical exam. I will continue to work on my ability to be systematic and focused. Second Submission 25 September- 22 October 2012 - A.To perform problem-focused health history and physical exams for patients across the life span means focusing on a specific problem, the aspects of the physical exam that are pertinent to that problem, and pieces in the health history that will help with figuring out the cause of or solution to the problem. The use of accurate history and physical assessment techniques can support or lessen the supposed likelihood of the various options. B. Examples of problem-focused health history and physical examinations I have performed in the current practicum experience include musculoskeletal problems, dermatological problems, problems related to various infectious processes, and others. In one specific example, I gathered pertinent health history and performed a focused physical examination on an obese 75 year old male patient who complained of pain and swelling in the left lower extremity that had been gradually getting worse since he fell in a hole with that leg about two weeks before. He denied shortness of breath, and on examination, he had unilateral swelling, erythema, and pain in the left leg, palpable, but thready pedal pulses bilaterally, and a slow, but regular pulse rate of 48 beats/minute. He told me that also, a couple of weeks ago, he had gotten frustrated with his doctor (in another town), because he just kept putting him on more and more medications, and decided to quit taking his medication altogether. He was sent immediately for a venous ultrasound which revealed a large DVT in his left leg. In another example, a nine month old patient was brought in by his mother, because his daycare providers noticed that he had seemed more sleepy at daycare the past couple of days. Had I not known his pertinent health history of being a shaken baby, I would have not known the significance of this concern. I read in his health history about how he had spent roughly two months in Children's Mercy Hospital following the incident, and had a VP shunt in place because of the hydrocephaly. On exam, I noticed macrocephaly, but he appeared alert and appropriate for his developmental stage, and appeared to be neurologically intact. Examination and history gathering focused on identifying possible causes, such as neurological problems or possible infection. C. To gain additional skills in the mastery of this competency, I will continue to work on my assessment skills, and practice the use of various tests in the problem-focused exam for specific musculoskeletal problems. I will continue to learn more about a variety of problems, enabling me to be more effective at this competency. D. Reference materials include the same books on physical examination, as mentioned above, Fitzpatrick's reference on Clinical Dermatology, the VisualDx database, a book on the clinical assessment and management of Musculoskeletal problems, Ferri's Clinical Advisor, and others. Third submission 23 October - 19 November - A. To perform problem-focused health history and physical exams for patients across the lifespan means being direct in the approach to gain information and efficient in the sorting of relevant factors, focusing only on factors directly related to the problem at hand, as opposed to a comprehensive approach. Sometimes, a focused exam is more difficult to perform than a comprehensive exam, and often requires more specialized assessment techniques and tests. B. There are numerous examples of my ability to perform problem-focused health history and physical exams for patients, as I reflect on the patients I have had the opportunity to treat for acute conditions in this clinical setting. One example that illustrates how I have grown in this competency throughout my clinical time, is in the improvements I have made in being able to narrow the focus in a patient visit, when a patient comes in with a 'bucket list' of complaints and 'dumps the bucket out' at a single visit, as one patient put it. I have learned to recognize this, and take early steps to prioritize the issues, telling the patient that today we will focus on only the top one or two problems, and then talking about future plans to focus on others. An example of this is when a middle-aged man came in, at the request of his wife, with the main complaint of anxiety. In my questioning him about his struggles with anxiety, he kept wanting to get off topic and bring up other issues. I had to keep redirecting the focus back to the primary topic (his anxiety) and the reason for the visit. On another patient, I referenced the technique for performing the Dix-Hallpike and Epley Maneuvers to diagnose and treat BPPV, once other less like causes of her vertigo were eliminated. C. Strategies for improvement in the future include plans to collaborate with other health professionals, continuing to learn tips from experts in a variety of specialty fields, learning how to better make focused assessments and specific techniques to aide in these assessments. In my own practice, I will need to be direct and honest with patients, setting limits on the number of issues that I am comfortable addressing in a single visit. D. References and point of care tools have been used throughout my clinical experiences, although I have gained confidence in my assessment skills and have needed to look things up less often than when I began. Again, my favorite tools, include: the Mosby Assessment and Physical Exam textbook, Fitzpatrick's reference on Clinical Dermatology, VisualDx database, a book on the clinical assessment and management of Musculoskeletal problems, and Ferri's Clinical Advisor 2012. ________________________6.Apply diagnostic reasoning and critical thinking □ □ □ X□X □ X □in clinical decision-making and development of a treatment planFirst Submission 24 August-24 September 2012 - Nearly all clinical situations involve some degree of diagnostic reasoning and critical thinking. These are critical components in both processes of forming diagnoses and developing treatment plans. There are many different approaches to clinical decision-making, and the practitioner should be aware of, and comfortable with his or her diagnostic reasoning and critical thinking skills. In the reality of actual clinical situations, making decisions can be quite complex, but the goal remains to choose the safest option. In this rural medical clinic, there is almost always only one provider present, so these skills have to be sound. I have applied diagnostic reasoning and critical thinking in the clinical setting on a daily basis. One illustration of this competency, is the practitioner's common dilemma of deciding what the most appropriate medications would be for various conditions based on individual and aggregate patient factors. For a pediatric patient with heavy cerumen build-up in his ears, and a case of otitis externa, I prescribed Floxin drops because I was unsure of the status of his tympanic membranes (TM). Since I could not visualize his TMs, and I was fairly certain that he was not going to tolerate a procedure to clear the canals, I chose an antibiotic drop that would be safe to use, in the event of a ruptured TM. In another example, I asked a patient with severe vertigo and 'head congestion' to return in 4-5 days after starting treatment with meclizine, Flonase, and amoxicillin, in order to re-evaluate and determine if the course of treatment was appropriate or if a different course should be pursued. His symptoms had improved, so we stayed the course. This competency represents a dynamic process, and every clinical experience is an opportunity to gain additional skills to master this competency. Second Submission 25 September- 22 October 2012 - A. Diagnostic reasoning and critical thinking in clinical decision-making means that in addition to the application of assessment skills and health-related knowledge to the decision-making process, the practitioner must also use sound reasoning and critical thinking skills when making decisions and throughout the process of planning for treatment. B. Examples of this from my current practicum are represented by the decisions about when to refer patients, when to recommend that patients seek emergency care, and with what frequency they should follow-up. Diagnostic reasoning and critical thinking are applied when deciding if antimicrobial therapy would be appropriate for a patient with symptoms of rhino-sinusitis, and if so, what agent would be most effective. In another example, a 75 year old male patient was referred for ultrasound to rule out a blood clot, when he complained of leg pain that had persisted for two weeks after having fallen and hurt the leg, but was getting worse. This was based on the history of his complaint, critical thought about the various differential diagnoses. In another example, diagnostic reasoning and critical thinking were used when trying to identify the cause of a 68 year old woman's complaint of pain with urination. She had recently been treated for a urinary tract infection(UTI) with an antibiotic, and urine dipstick analysis showed no infection now, but she complained of pain with both urination and defecation. When I looked further, I learned that the woman had also recently fallen and broken some ribs, and had been taking medication for the pain, and in talking to her learned that the pain was more consistent with constipation pain than UTI pain. Through reasoning and critical thinking, the decision was made to treat her symptoms for constipation rather than ongoing infection, and reevaluate in a week. C. Strategies for improvement for this competency involve the ongoing practice of diagnostic reasoning, and the improved ability to do this as more patients are seen. This is something that advanced practice nurses are involved in and practice daily. Increasing confidence in diagnostic reasoning skills, will contribute to my ability to guide the development of a treatment plan this with confidence and move forward despite uncertainties and unknown factors. Continued reading and learning opportunities will help me achieve this and master this competency. D. Ferri's Clinical Advisor is helpful in achieving this competency, as well as the dermatological database, VisualDx and the Fitzpatrick's dermatology reference. I use UpToDate, and a Musculoskeletal reference book, as well as various accepted clinical guidelines to guide my thinking and reasoning when considering diagnoses and developing a plan of care.Third submission 23 October - 19 November - A. The application of diagnostic reasoning and critical thinking in clinical decision-making means applying everything I have learned so far in my training to be a health care professional, including my undergraduate studies, nursing experiences, and graduate learning experiences into an organized thought process that enables me to be able to think through complex variables and individual patient factors. This is necessary to the performing the role of the nurse practitioner in the health care clinical setting, and critical to being able to work with patients for development of treatment plans. B. Examples of how I performed diagnostic reasoning and critical thinking in the current clinical setting, are illustrated in my handling of patients with a variety of complex conditions. These skills were performed with a 41 year old female patient who came to the clinic complaining of a variety of symptoms that resembled the classic symptoms of low thyroid function. She had clearly done her homework, being well-versed in the issues of hypothyroidism, and was frustrated by the fact that recent testing for thyroid dysfunction had been normal. I began asking her questions that would help me be able to think critically about her complaints, and apply diagnostic reasoning, sorting through the other possible causes of her symptoms. Her physical exam was unremarkable except for patches of eczema-like skin eruptions around both of her ankles. The plan of care we developed included consideration of the possibility that her symptoms may be due to an autoimmune process. C. In the future, I will strive to become an expert nurse practitioner by advancing my ability to perform these skills consistently, and will continue to read and study in support my ability to do these. With practice experience, I will be better able to apply these skills, counseling patients and working in collaboration to develop an organized plan of care. D. Well-validated clinical guidelines and diagnostic tools are accessible, and have been useful in helping me achieve this competency. I have accessed guidelines and tools through many major organizations, such as the American Diabetes Association, as well as through government-supported sites, such as the AHRQ and USPTF for guidance. Tools are helpful, as is consideration of social values and instinctual signals. 7.Implement screenings appropriate to differential diagnoses □ □ □ □ X □X XFirst Submission 24 August-24 September 2012 - Implementation of screenings appropriate to differential diagnoses is done on a recommended schedule, and can be used as a routine check to rule in or rule out certain possibilities. Practicing in a rural clinic means that, many times, to implement screenings, a patient must schedule, and travel to a larger urban area to have it done. Hearing, vision, and developmental screening are elements of a routine well child exam. Screening for cervical cancer is done routinely during well woman exams on women who are 21 years and older, and screening for breast cancer is done through routine mammography for women beginning around 50 years of age. Routine mammography was recommended as a screening tool for a 42 year old woman who, on her annual well woman exam, reported that she had noticed a change in a breast lump that had previously been examined by ultrasound. Blood work can be an excellent screening tool, and is useful in the primary care setting. Recommendations made by experts and professional organizations are often good guides to what and when screenings might be appropriate, and specific guidelines recommended through the federal Agency for Healthcare Research and Quality (AHRQ), the American Cancer Society (ACS) and the US Preventative Task Force (USPTF) can also be helpful. Second Submission 25 September- 22 October 2012 - A. To implement screenings appropriate to differential diagnoses means to consider the most likely differential diagnoses and know which screenings to recommend based on likely diagnoses and which screening tools are sensitive and specific for various conditions, and how they will help to differentiate the problem. B. One example of a time in this practicum experience when I was able to implement screenings appropriate to differential diagnoses was when I ordered a panel of lab work to screen for various things, such as thyroid dysfunction, anemia, and diabetes in a patient who complained of low energy/fatigue. This included a TSH, CBC with differential, and COMP. In another example, an obese 12 year old patient was screened for metabolic disorders, and problems with insulin sensitvity when she came in with dermatological complaints, including several boils in her axilla and groin regions that either wouldn't heal or kept coming back, and the darkening and thickening of her skin in various places, including the nape of her neck. Screening for diabetes is implemented on all overweight patients with more than one additional risk factor, and all patients, regardless of risk when they turn 45 years old. C. In the future, I will become increasingly familiar with the various sources for the recommendations for screening tests and will seek knowledge about the reasons behind the differences in recommendations when differences are noted. I will adopt guidelines to guide my ability to implement screenings and use diagnostic reasoning to determine what is appropriate in future situations. D. Some examples of the screening recommendations I use are those put out by the American Cancer Society, the American Heart Association, the American Diabetes Association, the American College of Ob/Gyn, those mentioned above, and others. Third submission 23 October - 19 November - A. Implementing screenings appropriate to differential diagnoses means being proactive to initiate health protection services, and to screen for problems, based on risk factors and consideration of likely differentials. A challenge that I face in my effort to do this consistently, is what feels like is a steep learning curve in that I am still learning the various indications for the many, many screening tests available, and the in some cases, learning how to interpret them. B. One example of how I performed on this competency in clinical, is demonstrated in a teenage female patient who complained of non-specific low abdominal, urinary complaints. A high suspicion was maintained for sexually-related issues, even though the patient denied sexual activity. Screening for pregnancy and STDs was initiated later when, without her mother in the room, the patient admitted to being sexually active. Another example is a 65 year old man who was asking if he should have a PSA done to screen for prostate cancer, not because of any kind of history risk, but because of his 'advanced age'. I told him that the USPTF does not recommend using PSA-based screening for prostate cancer as a routine measure, and that the harms of PSA screening are believed to be greater than the potential benefit. In the absence of symptoms, the evidence supports this as an appropriate screening decision. C. Strategies for improvement include the integration of an app or some other system of organizing the most current recommendations for common screenings into a reference tool for use in my practice. D. I have referred to the USPTF recommendations for various screening tests, and like the format of their clinical summary for clinical reference. I continue to consider the recommendations of various other reputable sources, (ACS, AHA, ADA, ACOG, etc.) as well, always looking for the differences in recommendations, and looking for rationales to explain differences. _____8.Initiate diagnostic strategies appropriate to differential □ □ □ X□ X □ X□diagnosesFirst Submission 24 August-24 September 2012 - Diagnostic strategies differ from screenings in that they are initiated when a problem has been identified, (as opposed to routinely, or on a schedule) and are used to help rule in or out various differential diagnoses, to determine what is going on, and to not miss serious, or potentially life-threatening conditions. Before initiating diagnostic strategies, it is important to consider how prudent or necessary it is, and how the information gained will influence or guide the plan of care. Another challenge is interpretation of results for various diagnostic tests one might consider. The clinic does have EKG capabilities, and I have implemented EKG on a few patients with complaints of chest pain and/or unexplained shortness of breath to help differentiate between possible diagnoses. When a sixteen-year-old female patient presented with an approximately six-week history of severe abdominal pain with intermittent bloody stools, labs were drawn and she was sent to have a CT scan. Then, a referral was sent to a gastrointestinal specialist, where further diagnostics were implemented, including a small bowel follow-through study, and eventually a colonoscopy. Diagnostic strategies for dermatological conditions requires prioritization of differential diagnoses, and must include biopsy if there is any concern for malignancy. In the future, as I become more practiced, I hope to become increasingly efficient in the selection of diagnostic strategies, and continue to learn more about the translation of results. I would like to become more experienced and comfortable in the area of radiological tests and become more proficient at interpreting x-rays. Second Submission 25 September- 22 October 2012 - A. To initiate diagnostic strategies appropriate to differential diagnoses means knowing what the best diagnostic tests and physical examination strategies are for various conditions, and how to initiate them. One of the biggest challenges for the advanced practice nurse in primary care is in deciding whether to initiate diagnostic strategies or simply refer the patient to a specialist, allowing them to guide the diagnostic work-up. B. An example of this competency is with the initiation of electrocardiogram (ECG) in a 48 year old patient with unexplained left arm pain that began earlier in the day when he was being physically active. This was to help differentiate between muscle strain and a myocardial event. Another example of this competency is in the initiation of computerized tomography (CT) scan in a patient with ongoing headaches and nausea following a football head injury in order to differentiate between an uncomplicated post-concussive syndrome and a complicated, more serious head injury. C. To gain additional skills in achieving this competency, I will continue to work on my physical assessment and history building skills, as many conditions are diagnosed by history and clinical presentation alone. I will continue to learn more about various diagnostic tests, including what they cost, how the information gained can be used, and alternatives to certain tests and strategies. D. Again, I use Ferri's Clinic Advisor for reference and guidance for knowing what diagnostic strategies are appropriate for making or ruling out various diagnoses. Sometimes I reference the lab manual in the clinic, to know how to order specific tests, or know what they will cost. I have even 'googled' certain tests to learn more about how the test is performed or what is involved in a diagnostic procedure. Third submission 23 October - 19 November - A. Initiating diagnostic strategies that are appropriate to differential diagnoses means having a certain level of comfort with common diagnostic strategies and knowing when to consult the experts on other more specific or more invasive diagnostic decisions. One challenge in this clinical setting has been the limited capabilities for performing certain diagnostic tests on-site. We can draw labs, do EKGs, perform point of care CBGs and some urine tests on site. A courier comes to the clinic daily to collect specimens and there have been times that patients have had to be sent to another lab site, or told to come back if the courier had already gone for the day. This meant that patients either had to travel to another town, or wait. B. Examples of this in clinical include patients for whom point of care testing was done, such as rapid strep screening, rapid interpretation of influenza swab, and urine dipstick testing. I was able to obtain an EKG on a 52 year old woman who walked in to the clinic and wanted to be seen because she was feeling anxious and having substernal discomfort. Performing an EKG in the office was an appropriate strategy based on her presentation and the differential diagnoses I was considering. Her EKG was normal which helped me eliminate the differential of an acute myocardial infarct, and begin to work on an appropriate course of treatment. Another example of this competency is in a 13 year old patient who came in to the office with ankle pain after being involved in an ATV accident over the weekend. She was sent for outpatient x-rays at a nearby hospital and was put in an air cast with instructions to use crutches until the results of x-rays were received. When I got her results later and they were negative for fracture, she was instructed further on treatment and management of sprain and contusion. C. Reading the interpretations of various diagnostic tests in from of reports from other practitioners including specialists, and taking steps to learn about the elements of the test and resulting details that I do not know or understand is one way that I will continue to make progress in achieving this competency into the future. I will decide on appropriate diagnostic strategies based on the scientific support of certain tests and information about sensitivity and specificity of specific tests. D. Specific references and clinical tools that have been helpful in achieving this competency include a reference book I have titled, 'Laboratory Tests and Diagnostic Procedures', online sources of information, such as VisualDx for dermatologic conditions, Ferri's Clinical Advisor, and a point of care tool I use for reference on interpretation of EKGs. ______________________________________________________________________________9. Develop and evaluate the plan of care utilizing □ □ □ X □ X□ Xevidence-based practiceFirst Submission 24 August-24 September 2012 - The plan of care for both acute and chronic conditions, and for all interventions should be both evidence-based and effective. I strive to incorporate evidence-based guidelines into the development of a care plan for diabetic patients, because the effective management of diabetic patients within an organized system of care has been shown to improve outcomes. This applies not only to the recommended medication regimen, but also to the frequency of follow-up, and other important parts of the plan. The plan of care for diabetes is based on standards and guidelines set forth by the American Diabetes Association (ADA). Evidence-based guidelines and recommendations are important, but must always be applied to real life situations, and considered within the context of an individual's circumstances. The plan of care for patients with obstructive lung disease are based on recommendations of the GOLD initiative, and individualized to meet specific patient needs. It is the practitioner's duty to stay informed abreast of what is evidence-based practice. Second Submission 25 September- 22 October 2012 - A. To develop and evaluate a plan of care utilizing evidence-based guidelines means consideration of well-validated or evidence-based information when designing the plan of care, and when deciding on the goals of treatment. Being a nearly-new graduate, I have a fresh knowledge of many current evidence-based guidelines, which serves as a strength, but do not have the experience that is sometimes helpful in applying evidence-based guidelines to specific situations or straying from them with confidence, when appropriate. B. This competency was demonstrated by the use of evidence-based guidelines in developing a plan of treatment for a patient diagnosed with type 2 diabetes. The patient was initially started on metformin 500 mg bid, and his dose was increased at a two week check when his blood sugars checks continued to be outside of the desired range, based on well-validated recommendations. We continued to have the patient return to the clinic at regular intervals until his blood sugars were more consistently controlled. With another patient who complained of low back pain with radiation, and with no neurological 'red flags', a plan of care was developed to include non-steroidal anti-inflammatory medication and muscle relaxer along with physical therapy (PT), as the first line of treatment, because this is what is evidence-based, The patient wanted to have a MRI or referral to a spine surgeon from the beginning, but agreed to the recommended approach when I explained that this was well-validated and effective for many with similar symptoms. C. Strategies for improvement in this competency include maintaining an ongoing effort to stay abreast of current evidence-based guidelines, as well as maintaining a collaborative arrangement with patients to always consider individual needs over guidelines in the development and evaluation of care. D. Many guidelines are referenced through the AHRQ's National Guideline Clearinghouse. For example, I refer to ADA's the 'Standards of medical care in diabetes' guidelines for the prevention and treatment of diabetes and the American Heart Association's guidelines for the appropriate treatment of hypertension. Third submission 23 October - 19 November - A. Developing and evaluating a plan of care that utilizes evidence-based practice means being able to apply information and evidence about best practice to individual circumstances, making special considerations for individual patient needs, and applying critical thought to the processes of care planning and evaluation. B. The HPV vaccine was recommended and administered to a sexually active 20 year old, along with information about the recommended frequency of having pap screening, based on current, evidence-based guidelines by ACOG and the ACS. Evidence-based practice recommendations were applied a number of times to the development of plan of care with patients presenting with symptoms that were consistent with acute pharyngitis. Many times, patients seeking an antibiotic after only a day or two were advised on the 'watchful waiting' approach to antimicrobial treatment, given options for symptom management, and advised that the single best indicator of whether an infection was due to bacterial or viral causes was length of time it persisted. C. Strategies for gaining additional skills to master this competency include the systematic organization of care in support of best practice. I plan to negotiate with future employers for the benefit of clinical access to some form of electronic resources, (UpToDate, Epocrates, or others) as part of my practice arrangement, and will use it to access current best evidence standards for a variety of issues. As I start out in practice as an advanced practice nurse, I will strive to consistently integrate best evidence standards into care, using them to explain rationales to patients, but will keep these things in perspective, remembering to give adequate consideration to individual patient needs, and how personal factors relate to the development and evaluation of an effective plan of care. D. References that were helpful in my achievement of this outcome include: UpToDate, Epocrates, Ferri's, recent research published through CINAHL and Cochrane databases, as well as a variety of other professional organizations (JNC-7, ATP III, ADA, etc) that provide evidence in support of best practice. Evidence-based guidelines were accessed through the AHRQ's National Guideline Clearinghouse, and I used my on a variety of topics. __________________10. Prescribe medications based on cost, diagnoses, □ □ □ □ X □X Xefficacy, safety, and individual patient needsFirst Submission 24 August-24 September 2012 - It is often helpful to review what medications patients have taken in the past, and include this consideration of what has worked, and what has not, as well as what is indicated and what is affordable. Most of the patients I am seeing in this clinical experience are insured, which makes prescribing much easier. The options were much more limited when I was working with a predominantly uninsured population in past clinical experiences. In one example, I had the opportunity to recommend a change in medication for a diabetic patient with a history of CHF who was taking Actos. Another time, I had to change the antibiotic order on a patient one time after they arrived at the pharmacy and discovered that the medication was too expensive for them to purchase. I had not noted that the patient was uninsured until then. Other modifications have been made to the recommended, first line treatment regimens based on patient allergies, tolerance, and other individual needs. I continue to learn some of the particulars of how to prescribe controlled substances, including which prescriptions can be transmitted electronically, which can be faxed, and which must be hand-carried to the pharmacy. I primarily use printed versions of Sanford's guide to antimicrobial therapy, and the Monthly Prescribing Reference (MPR) as references at the point of care, and also use the UpToDate database and our Pharmacology for the Primary Care Provider text for looking things up. Second Submission 25 September- 22 October 2012 - A. Prescribing medications based on cost, diagnoses, efficacy, and individual patient needs means considering multiple factors at once when choosing a medication, and individualizing the decision to prescribe. What is most important for one patient may be less so to another, and making the decision about which pharmacological product best fits the defined criteria to order for a patient, requires careful weighing of risks and benefits. B. Examples of this in my current practicum are demonstrated by the many opportunities to prescribe medications for a variety of conditions, from a variety of chronic conditions and acute conditions. I have prescribed antibiotics, antidepressants, cardiac medications, psychiatric medications, and have counseled patients regarding appropriate over the counter (OTC) medications for certain symptoms and conditions. I have titrated and managed blood thinners, thyroid medications, and diabetes medications, to name a few examples. For the treatment of allergic rhinitis, which I have seen quite a bit this fall, I prescribe regular use of a corticosteroid nasal spray as a first line controller therapy, and recommend the use of an antihistamine, as needed, which is in line with both cost and efficacy, for most patients. Because of my preceptor's preference, I advised many patients on the use Dayquil and Nyquil-like products for symptoms of upper respiratory infection (URI) and/or complaints of congestion and cold-like symptoms. C. In order to gain additional competency in prescribing, I will become more familiar with the $4 list by keeping an up to date list, and will prescribe to the Monthly Prescribing Reference (MPR), and continue to use current reference materials, looking things up diligently, until I have gained more repetition in prescribing. D. My prescribing preferences for allergic rhinitis are based on the Joint Council of Allergy & Immunology's 2008 recommendations, but therapeutic decisions are made based on individual patient needs. I have referenced the Beers list for potentially inappropriate medications to use in older adults, and I continue to use the resources discussed in the first submission. Third submission 23 October - 19 November - A. Prescribing medications based on cost, diagnoses, efficacy, and individual patient needs has become less challenging as I have gained experience in practice. In this current clinical setting, most of the patients have been insured, making the issue of cost less of a challenge (compared to some of my previous clinical experiences). The integration of the factors stated above into clinical prescribing decisions requires the practitioner to demonstrate an advanced level of critical thinking and reasoning. B. Examples of this from my clinical experiences include the reassurance to a patient's mother that Amoxicillin remains the first choice of antibiotic for her otherwise healthy child (who has no known allergies) when diagnosed with strep pharyngitis. She was convinced that there must be something better, but I reassured her that Amoxicillin was a good choice based on efficacy and cost. A patient with symptoms of depression and issues related chronic pain was started on Cymbalta due to its effects as a mood stabilizer and effects on pain. The patient was first screened for suicidal tendencies and cautioned on the potential side effects of the medication, and agreed to return to the clinic in one month to evaluate the effectiveness of the medication. C. Strategies for future growth include my personal work to develop a 'bank' of medications that I like to use commonly for certain common conditions, just as my preceptor has certain medications that she likes better than others for various reasons. Experience will help to increase my familiarity with certain medications, and learn some of the subtle differences that set certain medications apart from others that are similar or related. I will also work to gain knowledge of combined effects of medications, learning more about drug interactions and synergy. D. References and clinical tools that have helped my ability to achieve competency in this include a variety of different drug POC reference materials including current lists of $4 medications from retail pharmacies, access to phone & fax numbers of area pharmacies, and current editions of the MPR, Sanford's Guide to Antimicrobial Therapy, Tarascon Pharmacopoeia guide, and Epocrates. Although large and heavy to carry around, I have found my Pharmacology for the Primary Care Provider textbook to be quite helpful in many clinical situations that involving complex decisions related to the prescribing of medication. It is one that I will keep in my practice in the future for reference.____________________________________________________________________________11. Perform medical and surgical procedures as appropriate □ □ □X □ X □X □First Submission 24 August-24 September 2012 - Common medical and surgical procedures performed by advanced practice nurses in the outpatient/primary care setting include point of care urinalysis, collection of specimen for culture, rapid strep screen, electrocardiogram, assessment of peak flow meter, pelvic exam with collection of specimen, incision and drainage, and suturing, to name a few. In this clinical setting, I have not had a lot of opportunity to perform medical and surgical procedures, but have assisted in the removal of an IUD, assisted in the incision and drainage of a cyst, and have performed a few pelvic exams, including the collection of cervical cells for analysis. Many procedures are within the scope of practice of the advanced practice nurse, but are not performed frequently. Therefore, it is helpful to keep a book of common procedures around for reference and review of how to perform certain medical and surgical procedures in the primary care setting. I was disappointed to have to call a patient back after having performed a pelvic exam and then getting the report that there were not enough cells present to analyze her pap smear. I need more practical experience performing medical and surgical procedures. Second Submission 25 September- 22 October 2012 - A. Performing medical and surgical procedures in the outpatient clinic/primary care setting means doing things like simple incision and drainages, excisions of skin lesions, occasional suturing, and other point of care testing, as previously mentioned. B. I have performed numerous pelvic exams and clinical breast exams on women, collected specimens, and had one opportunity to suture, putting 3 stitches in a woman's thumb.I assisted my preceptor with the excision of two moles from a 42 year old woman, to find out that one of them was a malignant melanoma. The margins appeared to be clear, and this was confirmed when she went later for a wider excision and lymph node biopsy. I have also had the opportunity to cauterize small skin lesions and verruca plantaris. C. In the future, I hope to have more opportunities to do some of the medical and surgical procedures that are within my realm of practice, and recognize the importance of having a good reference manual detailing how to do common clinical procedures, for review. Depending on where I end up getting a job, I may look into the option of placing peripherally inserted central catheters (PICC), as this is a procedure that I already know how to do, and is a billable service as an advanced practice intervention. D. A reference that I used for this competency is my preceptor's book, 'Common procedures in primary practice'. I also used the online reference 'UpToDate' to look things up related to performing medical and surgical procedures. Third submission 23 October - 19 November - A. Having the opportunity to perform medical and surgical procedures is important, and my preceptor has been very willing to allow me to either perform independently or be an active participant in medical and surgical procedures as appropriate. When approached with confidence, most patients have been willing to have me (a student) perform or participate in medical and surgical procedures on them. One challenge has been the relatively few chances I have had overall due to being in an outpatient primary care setting. One strength related to my mastery of this competency at this point in time is my part-time employment as an emergency nurse. At work I am able to observe and assist practitioners with a variety of medical and surgical procedures there, which is a huge benefit. B. Examples from this clinical rotation that illustrate my ability to perform this competency are the numerous clinical breast exams and pelvic exams that I have done in addition to the several opportunities I have had to use local anesthetic on patients to perform foreign body removal, suture repair, or simple excisions of skin lesions. I assisted my preceptor in doing a nerve block, injecting lidocaine into an index finger prior to laceration repair. I have also done things like perform venipuncture for lab draws, and administered medications and vaccines by injection. C. I will need additional experiences in the future to gain additional skills to master this competency. Experience and repetition are keys to becoming truly competent at performing procedures. I will try to gain additional experiences under the direction of a mentor or preceptor at first when I begin my career as an advanced practice nurse. D. When I am not familiar with a procedure, am doing something for the first time, or am out of practice with a certain procedure, I will be sure to reference a good procedural guide, such as the book 'Common procedures in primary practice', or look it up in some other way for refreshment. 0 1 2 3 4 5______________________________________________________________________________12.Interpret patient responses to treatment and recommend □ □ □ □ X □X X□changes to the treatment plan as indicatedFirst Submission 24 August-24 September 2012 - Follow-up, in one form or another, is required for the interpretation of patient response to treatment. Changes are made, based on effectiveness of the plan, feasibility, and the patient's tolerance of treatments. Examples of patients I have followed in this clinical experience include patients with uncontrolled diabetes, ongoing pain, and hyperlipidemia. A patients with elevated cholesterol, LDL, and triglycerides was asked to return to the clinic in six months to evaluate response to proposed lifestyle modifications, since she was resistant to the idea of drug therapy. In six months, we agreed to re-evaluate, and determine if lifestyle changes alone would be enough, or if medication would be indicated. An elderly male patient, taking medication for his blood pressure began to experience symptoms of hypotension. He was evaluated, and it was determined to decrease the dose of his beta blocker from 100 mg daily, to 50 mg daily, and recheck in one week. After a week of decreased dose, the patient's symptoms had resolved and his blood pressure was 112/76. I recommended that he continue taking the beta blocker at the 50 mg dose and call if he had further problems. Changes to diabetic treatment plans have been recommended based on the analysis of food diaries and the tracking of blood sugars. Interpretation requires being diligent and attentive to patients, as well as being pro-active in making changes when things are not working. In the future, I hope to become more and more aware of what types of patient responses to assess for, how to best interpret different responses, and the various options for change, if change is indicated. Second Submission 25 September- 22 October 2012 - A. When interpreting the patient's responses to treatment the practitioner must have an idea of both the positive and negative responses that would be possible with treatment, and open to accepting the unusual. Recommending changes to the treatment plan based on these interpretations, requires timely and effective communication between the health care provider and patient. Furthermore, changes to the treatment plan should be thoroughly explained, so that patients at least have a basic understand of treatment rationale. B. Examples in these clinical hours demonstrating my ability to interpret patient responses to treatment responses and recommend changes, when indicated, include efforts to remain in contact with patients, advising patients to call the clinic if a condition changed or worsened, advising patients to return to the clinic for follow-up within a specified time period, or advising patients to go directly to the emergency department if certain things occurred. I have had the opportunity to evaluate a couple of patient on Coumadin, monitoring their PT/INR, and making adjustments to the dose in order to have these values be therapeutic. Another example is a patient who came in for evaluation of an abscess, and ended up having an incision and drainage in the office and started on oral antibiotics. She was told to return to the clinic in two days for re-evaluation, and when the site looked worse than it had, she was referred to the hopsital for evaluation in the emergency department. Also, I have adjusted many antihypertensive medications, trying to get a person's blood pressure under control. C. In order to improve in this competency, I will always attempt to be up front with patients when I anticipate that treatments may need adjusting, and explain things effectively, so that patients are able to understand the rationales for treatment decisions. I will continue to become more familiar with recommendations for the frequency/schedule of checking in with patients when treatments are initiated or changes are made. D. When evaluating patient response to treatment, I use commonly accepted norms. For example, the blood pressure ranges defined by the American Heart Association and JNC-7, goals for blood glucose and hemoglobin A1c values as defined by the American Diabetes Association, and lipid management as outlined by the National Heart, Lung and Blood Institute in the ATP-III guidelines.Third submission 23 October - 19 November - A. Interpretation of patient responses to treatment requires the practitioner to know expected responses to specific treatments, be able to recognize when changes are indicated, and know what changes should be made. B. Examples from my clinical experience that illustrate how I am performing this competency include C. In the future, when I am the one responsible for the care of very ill patients, I will need to establish a level of comfort, deciding how and when to follow up for reevaluation and interpretation of response to treatment. Most likely, when I see acutely or seriously ill patients, I will want them to return for a recheck 24-48 hours later, or at least will want to make contact by phone or teleweb, if not able to materially revisit the patient in a timely fashion. Every situation will need to be evaluated, and a determination made on individual factors and gut instinct. D. References and guidelines that have been helpful in achieving this competency include those that provide succinct information on the interpretation of diagnostic tests and information on potential desirable and undesirable effects, including the most common and most dangerous patient responses possible with certain treatments. Treatment algorithms are helpful in organizing care and can guide the practitioner in making logical changes to the treatment plan, as indicated. ____________________________________13.Document using professional terminology, □ □ □ □ X □ X Xformat and technology (ie: ICD9, E/M coding, CPT)First Submission 24 August-24 September 2012 - The documentation for advanced nursing practice is somewhat different than the documentation required of nurses. It goes beyond the identification and recording of subjective and objective data to then address the assessment and agreement on a plan, based on the data. The use of professional terminology and organized format demonstrates a certain level of professionalism and conveys expertise. I am able to document using my preceptor's login and password in the computerized system (Powerchart, by Cerner), which happens to be the same electronic system I use at work. I find the system to be user friendly and easy to navigate, for the most part. When documenting, suggested terminology is mostly provided, but the system also allows for 'free-texting', which I use frequently to add comments and additional detail. The statement written to describe the history of present illness (HPI), represents the most difficult part of documenting for me. In practice, I will need to be more focused and brief in recapping the HPI. I had the opportunity to accompany my preceptor to the Jefferson County Health Department one afternoon for a free monthly medical clinic; there, we documented in a paper and pencil chart, using the SOAP format. It was good practice for me to do this without the aid of prompts and the built-in charting structure I have gotten used to, as a guide to documentation. Practice, over time, will make this easier to do.Second Submission 25 September- 22 October 2012 - A. To document using professional terminology, format and technology means adapting to whatever system is used by the clinical site, and applying knowledge of terminology to descriptively describe and document conditions and symptoms. The format is generally dictated by the documentation system used, whether it be an electronic system or a paper form. One strength of the system I have been using is that I get to choose from a pool of pre-populated terms to document on certain systems and conditions with the option to free-text. B. Examples of this in my clinical include my use of the electronic documenting system (PowerChart by Cerner), and I continue to document independently by signing in using my preceptors username and password and then saving it; she then reviews, makes any modifications and signs it. Another example that demonstrates my ability to document using professional terminology is when I have accompanied my preceptor to the county health department for a clinic, and was required to document in the SOAP note format in the paper and pen charting system. I got used to documenting in a system that supplies most of the preferred terminology, and so I felt this was good practice, forcing me to me to come up with the appropriate terminology, and correct format independent of prompts. Another example is of a 42 year old male who 'didn't like going to the doctor' and tried to avoid it as much as possible. So, he informed me, he had brought in 'a bucket list of complaints' that he had been saving up, and dumped out multiple issues at once, including follow-up on problems he was having following a traumatic brain injury he had sustained a few weeks before, wanting to talk about his struggles with anxiety, and a suspicious lump he had noticed in his breast, all in a single visit. Because of this, he was coded as a 99214. C. In the future, I will continue to learn new terminology, and will adapt to whatever system of documentation is used by my place of employment. I feel comfortable with electronic documentation, and look forward to expanding my ability to document and communicate electronically in the future. D. My preceptor has a couple of reference manuals for looking up current CPT codes for various procedures and interventions. Also, the computer system has a bank of ICD-9 codes with a search feature that allows me to search for codes that way. I have referenced my Health Assessment and Physical Exam textbook and a handbook that I carry for clues on professional terminology when I cannot recall a specific term. Third submission 23 October - 19 November - A. To document using professional terminology, format and technology means being clear, concise, and medically accurate in all examples of professional documentation, adapting to different ways of organizing patient data, and utilizing technological tools, as appropriate. Documentation should reflect a higher degree of clinical knowledge and an advanced understanding of health care systems. An organized system of documentation, as provided with the PowerChart electronic medical record (EMR) system is a strength to my ability to do this consistently. Generally, I appreciate the help provided by computers and EMRs. B. Examples that illustrate how I have performed this competency throughout this clinical include the completion of this comprehensive evaluation, and other professional reflections I have written about my clinical performance and experiences. Other examples can be found in the electronic charting that I did throughout this experience on all of the patient encounters I was involved in. To chart, I would first select a template from among a bank of templates (general exam, sore throat, hypertension, well woman visit, etc.), then using the structure provided, document the elements of my exam, and select the proper E/M code and CPT codes. My instructor would review, and (infrequently) make changes or additions before signing and closing out the chart. I spent a day doing well woman exams at the health department had to document these in a paper and pen chart which seemed much harder than the documentation I have grown accustomed to using the EMR. C. I will continue to gain skills using professional format and terminology in my documentation as I gain additional experience, and will make efforts to adapt to whatever system I am required to use, as dictated by my future practice setting. I will do whatever is necessary to adapt to ICD-10 when it comes out in October, 2013. D. References include the help provided by the computer and the EMR system with formatting and coding in the patient chart. I have also learned to use my preceptor's procedural- and medical coding books that she has for reference when trying to determine the appropriate coding. 14. Initiate referrals by collaborating and consulting with □ □ □ □ X □ X □members of the health care teamSecond Submission 25 September - 22 October 2012 - A. Collaboration and consultation with other members of the health care team is key to the process of initiating referrals, and is necessary for the sustainability of advanced nursing practice. It is important to establish collaborative relationships in practice, and to utilize the skills and specialized knowledge of other professionals as well as the knowledge and skill of the support staff to arrange referrals and work out the details. Referrals for preventative services as well as services for specialized care are relatively common from my experiences in the primary care setting, and the initiation of referrals begins with the judgment of the advanced practice nurse, and is sometimes at the request of the patient. B. I have worked with members of the health care team on the initiation of referrals for physical therapy services, and have had multiple opportunities to recommend this as an option for patients with low back pain. I initiated a referral to a pediatric endocrinologist for a patient who was tested for insulin resistance because she had several risk factors (overweight, sedentaryism, family history of PCOS and diabetes, truncal obesity, etc.) and was already (at age 12 years) exhibiting signs of impaired glucose metabolism. For this, I chose to refer her to Children's Mercy, taking advantage of the relative proximity, and trusting their reputation for providing specialized pediatric services. In another example, I consulted with members of the radiology team to confirm what images to order on a patient with shoulder pain, in order to get the best view of the area in question. C. In the future, I will be involved in the health care community in the area where I practice, in order to be continually establishing and strengthening the collaborative relationships that will make it easier to know where and when to refer patients. The importance of having a supportive relationship with my collaborating physician will be one of my main concerns as I approach the process of finding my first job as an APRN. D. References for this competency mostly come from the network of health professionals that I already know, because I work at the hospital that this clinic is associated with (and live in the area), so I know many of the specialists and know many of the options for therapy services in the area already. My preceptor has the name of a few other health professionals that she likes for various services, including a pediatric psychiatric specialist at KU Med Center, and a pediatric endocrinologist in Kansas City that she has worked with before. Third submission 23 October - 19 November - A. To initiate referrals by collaborating and consulting with members of the health care team means to be the one to initiate and facilitate connections for patients, sending them out in the right direction when they need something that I cannot provide. B. Examples of how I have demonstrated this competency include instances when I recommended referral to patients for various reasons. Most commonly, referrals were initiated because of the need for specialized care (dermatologist, neurologist, orthopedist, etc.) or when patients were in need of services that could not be provided in this outpatient primary care setting (endoscopy, radiology). In one example, I initiated consultation and collaboration with a hospitalist physician, asking for advice on management strategies for a patient's anticoagulant therapy following his admission to the hospital for a DVT in his leg. He was happy to talk with me about it and through collaboration, I was able to provide better, more coordinated patient care. C. To gain additional skills to master this competency, I will need to become familiar with the network of health care services, providers, and community resources available to me as a provider and my patients as consumers. As I begin my career in advanced nursing practice, I will collaborate with other members, and do my best to provide comprehensive and coordinated services. D. References and tools that have been helpful in achieving this competency include the directory of services and specialty service providers that my preceptor keeps This system organizes the contact information of some of her favorites, and makes it easier to access information and contact other members of the health care team when collaboration and consultation are needed. _____________________________________________________________________________15. Incorporate access, cost, efficacy and quality when □ □ □ □ X □ X□making care decisionsSecond Submission 25 September- 22 October 2012 - A. The incorporation of access, cost, efficacy, and quality applies to the decision-making process on topics ranging from decisions about what medications to prescribe, to decisions about how to best provide patient education. Access to certain services is often a challenge when practicing in a rural setting, but is perhaps less of a challenge for patients in McLouth, KS than in other more isolated rural areas, because the town is relatively close to Kansas City, Topeka, Lawrence, Leavenworth, and Atchison (all areas with more services). A high percentage of the patients are insured, making cost less restrictive, but always a consideration. B. I have had to change medication orders when the pharmacy called to say that the out of pocket expense to the patient was going to be unaffordable. In another incident, prescriptions for a Z-pak and albuterol inhaler were going to be $76 for an uninsured patient, and he simply couldn't afford to get it filled. For a patient with chronic low back pain that was getting worse, I encouraged her to try physical therapy (PT). When she voiced concern about being able to make it around her work schedule, I told her about an alternative site for therapy that was located in the town where she worked, and that would have hours outside of those that she worked and on what day. We discussed the efficacy of PT for low back pain, and she agreed to try it. In the future, I will continue to incorporate these elements of decision- making into all clinical care opportunities, and be a well-informed provider. I often refer to the $4 list, and the prescription ordering system used by the clinic, which has an indicator that shows whether or not a medication will be on-formulary for the patient, and approximate cost, which I refer to as well. C. In the future I will continue to incorporate access, cost, efficacy, and quality into the decision-making process by keeping track of the current generic and $4 list, reading journals and professional updates, and questioning pharmaceutical representatives about the above factors. D. I refer to various sources for information about the efficacy and quality of services, including professional journals and articles in current publications. The pharmacy is also used as a reference for questions about cost of medications, and patients are often advised to call their insurance companies to inquire about cost and access factors. Third submission 23 October - 19 November - A. To incorporate access, cost, efficacy and quality when making care decisions means taking these things into consideration when engaged in the process of making clinical decisions, weighing the importance of each factor against the next and being careful to never compromise quality. Throughout this clinical experience, my preceptor has shared her expertise, helping me learn how to better incorporate these things when making care decisions. B. Examples from this practicum that best illustrate my ability to perform this competency include thoughts on diagnostic strategies for the uninsured patient that comes in because he has been miserable for about 4 days, and is sure that he has strep throat or mono or something, because he feels just awful. I opt not to perform a rapid strep screen or monospot at this time because of efforts to contain costs for the patient. Instead he is given a prescription for amoxicillin because it is cheap and should be effective against group A streptococcal organisms, which represent a possible causative pathogen, and one that should be covered. He is counseled on the importance of following a specific treatment regimen, and checking back in approximately 48 hours if symptoms do not improve or if he gets worse in the meantime. This approach is reasonable, and incorporates consideration for access, cost, efficacy and quality into the process of making decisions. In another patient, I explained why radiologic imaging was not indicated for evaluation of her back pain. I explained to her about the problem with it not being supported by evidence-based guidelines when certain neurological and musculoskeletal red flags were not present, and about how it is a very expensive way to go, and probably would not tell us much. When it was explained like that, she was much more likely to accept alternative ideas for making care decisions. C. To gain additional skills to master this competency, I need to continue to read and learn, staying abreast of changes to recommendations and issues of cost and accessibility, and be thoughtful in my consideration of all factors involved in making care decisions. D. References and clinical guidelines often provide a structure to help with the organization of various factors that contribute to the process of making care decisions. Online resources are useful in achieving this competency as they frequently represent some of the most current and dynamic tools to help with this. ______________________________________________________________________________16. Perform care in a timely manner □ □ □ □ X □ XSecond Submission 25 September- 22 October 2012 - A. Performing care in a timely manner means doing things on a daily basis to be timely with patient flow, and having a system in place to respond to patient questions/requests, document, and follow-up on issues in a timely fashion. I think this clinic does a good job of performing care in a timely manner, keeps the patient flow going, and is usually able to work patients in for same day appointments. B. I have been able to see up to 8-10 patients in a day, performing care in a timely manner, and maintaining a reasonable flow by saving the bulk of my documenting until I have a break in patients. I take brief, written notes during the patient visit, and then refer to the notes later, when I go back to document in the chart (over lunch or at the end of the day). One challenge arises when a procedural appointment is scheduled in the midst of a busy schedule of visits. This clinic is not always good to block enough time for these or to schedule them at the end of the day, as some other clinics I have been at have done. This can create a timeliness issue. On a few occasions, I have not had enough time throughout the day to document, and had to leave documentation undone at the end of the day, finishing it the next day. C. I will continue to work on my ability to perform care in a timely manner, getting faster and more efficient as I gain experience, and look things up less often. D. I use the clock, and the patient board to show me when a patient is ready, and keep things flowing in a timely fashion. The documentation system moves pretty quickly, allowing documents to be saved and returned to, so that the flow of patients can be maintained. Third submission 23 October - 19 November - A. To perform care in a timely manner means doing all of the things indicated to perform care on behalf of the patient, and doing them in a timely manner. This means being organized and efficient, taking enough time to do a good job, and making the patient feel attended to while being careful not to waste time and taking purposeful steps to reduce inefficiencies. B. Examples from this practicum experience that illustrate my ability to perform this competency are given. First, my ability to multi-task has improved and I became better able manage the care of multiple patients at once as I have progressed through this experience. I can now comfortably move from one patient to the next, allowing time for things to be done with the first patient before moving back to them to finish up, and then back again to the other. This is a hectic pace to keep, but by taking good notes, I have been able to keep the flow of patients moving smoothly, going back in during non-patient times to catch up on the documentation of care. A couple of times, I have gotten caught up in things that took much longer than the time allotted, or have simply gotten behind schedule. Luckily, I have had a preceptor to back me up when this has happened, to step in and work alongside of me to get us back on track. C. To gain additional skills to master this competency, I will need practice and repetition, in addition to strategies that promote efficiency and timeliness of providing care. Certain strategies to organize patient visits will be employed, including the preferred scheduling of things that are anticipated to take longer around blocks of time that could be infringed on, such as right before the lunch hour and at the end of the day. I will be open to the exploration of new and improved methods for performing care, and will consider the timeliness of providing care to patients in groups. D. References that have been helpful in achieving this competency include the 'pocket' point of care tools that synthesize data efficiently making it easier to be efficient and timely when I perform care. Examples include the pocket Tarascon Pharmacopoeia guide, and pocket reference for assessment and physical exam of patients. Other easy-to-use resources such as VisualDx and UpToDate have contributed to my ability to do this as well. ______________________________________________________________________________17. Maintain confidentiality and privacy □ □ □ □ □ □XXSecond Submission 25 September- 22 October 2012 - A. Maintaining confidentiality and privacy means having respect for what is communicated by patients, treating information as if it is entrusted to us, and shared in the confidence that it would not be divulged to others unnecessarily. I do not find this to be a challenging competency, and am able to do this consistently for all patients by complying to the HIPPA regulations, and maintaining personal values. B. I do not discuss private patient matters with anyone who does not need to know, and always discuss patients with my preceptor in her (private) office, located in the back of the clinic, where being overheard is not a problem. On occasion, the daughters of the clinic's medical assistant (MA) will come and 'hang out' at the clinic after school. Sometimes, they will want to come and 'hang out' back in the office where my preceptor and I discuss patient care. We are careful to always ask them to leave before talking about patients. I knock prior to entering patient rooms, and ensure that patients are adequately draped during assessments. C. In the future, I will continue to value the patient's right to confidentiality and privacy, practicing with respect to these things, and will maintain an awareness of the laws and regulations related to confidentiality and privacy that apply to my area of practice. D. The HIPPA regulations and institutional policies are good reference for how to maintain confidentiality and privacy in clinical practice. Third submission 23 October - 19 November - A. To maintain confidentiality and privacy means adhering to the highest personal and professional standards when it comes to protecting private health information for individuals, and sharing it appropriately. As always, I adhered to HIPAA, the agency's requirements as well as WU's and the school of Nursing's expectations for adhering to certain "Student Responsibilities", as outlined in the MSN student handbook throughout the entirety of this experience. B. Examples of this can be found in every patient and health care interaction I have had in this practicum. I never discuss things with patients, my preceptor, or the staff in the hallway, and always shut the door as I go into patient rooms, in order to ensure privacy and confidentiality in this very small clinic. I never took patient identifiable information out of the clinic, but always made my notes with respect to patient privacy and confidentiality, and disposed of things properly. C. In the future, I will need to continue these efforts to maintain the highest standards in every health care interaction, and especially when it comes to protecting personal patient health information. D. Guidelines and tools that have been helpful in achieving this competency are somewhat helpful, but most of the skills associated with this competency seem to be common sense. ______________________________________________________________________________18.Demonstrate professional behavior □ □ □ □ □ □XXSecond Submission 25 September- 22 October 2012 - A. Demonstration of professional behavior means that one must not only conform to the technical and ethical standards of the profession, but do so in a way that conveys intelligence and poise. I conform to the ANA Code of Ethics for Nurses, and am dedicated to professionalism. In a profession that deals with people, many of the aspects of professional behavior are to do with being respectful and courteous to others. I am able to do this consistently, despite, at times, encountering certain personalities and situations that are challenging. B. I am able to communicate effectively with most patients, and am always polite and under control. I dress professionally, arrive on time, and am courteous to the clinic staff. I am accountable, receptive to feedback, and maintain a professional relationship with my preceptor. C. In the future, I will strive to demonstrate professional behavior by maintaining professional boundaries, being accountable for my actions, and living up to the responsibilities of the role. D. My training and principles serve as the greatest guide to the demonstration of professionalism. Third submission 23 October - 19 November - A. To demonstrate professional behavior means a lot of things, but most importantly, it means to behave in a way that is in line with the technical and ethical standards of the profession, and reflects on certain levels of professionalism. B. Examples of how I have done this throughout this clinical experience include my consistent ability to be on time, finish tasks in a timely manner, treat others with dignity and respect. I have consistently demonstrated the ability to get along with others while demonstrating a high degree of expertise and skill in the tasks associated with the advanced practice role. C. In order to gain additional skills to master this competency, I will continue to engage in professional strengthening activities, forever striving to become more actively involved in health care communities at both local and global levels. D. References that have been helpful in my ability to achieve this competency include all of the sources and educational training I have done throughout my career in support of professionalism, including P. Benner's book From Novice to Expert, and my graduate studies on professional roles and responsibilities. ______________________________________________________________________________19. Demonstrate emotional resilience and stability □ □ □ □ □X X□adaptability, flexibility and tolerance of ambiguitySecond Submission 25 September- 22 October 2012 - A. Emotional resilience and stability is demonstrated by a person's ability to remain emotionally balanced and stable through adversity, and despite being faced with situations and tested with decisions that challenge and stretch us emotionally. Being adaptable, flexible, and tolerant of ambiguity requires a person to not be rigid or set in a particular way, but to be open to the variability of human interactions, and to be tolerant of the unknown. My personality and experiences are advantageous in this area, but that my inexperience also presents a certain challenge, in that I am still trying to establish my routine, and am perhaps more susceptible to being 'thrown off' of my routine. B. An example of my ability to demonstrate emotional resilience and stability in the clinical setting is in my willingness to adapt to my preceptor's schedule, as needed when she needed to take a short leave of absence, and follow it with alternative opportunities. I am able to absorb the wrath of a patient and his family members when they want referrals to specialists and multiple, expensive diagnostic tests to investigate the pains he is having five days after a motor vehicle accident (after he had already been evaluated the day after the MVC). I did not get angry or emotionally charged when the patient and family members got angry, but calmly explained what would be an expected course of symptoms following a rollover MVC, and what kinds of things would warrant additional testing. I was tolerant of the small amount of ambiguity that remained, because I was reassured by his physical examination. I am surviving graduate school, which is, in itself a demonstration of emotional resilience and stability, adaptability, and flexibility. C. In the future, I will strive to maintain an awareness of this competency, in order to be able to discuss personal and sensitive matters with patients, without becoming emotionally involved. Also, I will take measures to maintain my own personal health, maintaining emotional health and promoting my ability to achieve this competency. D. My experiences, personality, and world view contribute to my ability to achieve emotional resilience and stability, adaptability, flexibility, and tolerance of ambiguity. Well-validated reference materials support my ability to be tolerant of ambiguity. Third submission 23 October - 19 November - A. The demonstration of emotional resilience and stability, adaptability, flexibility and tolerance of ambiguity means maintaining professionalism and stability of character in the face of difficulty, and acting as a stronghold for patients. At this point in a hectic final semester and upon reaching #19 on this CPT tool, the strength of this competency is thoroughly tried and tested and my emotional resilience and stability has been bent but not broken, and I haven't gone over the edge yet :). B. When an 80 year old man came to the clinic complaining of sore throat, difficulty breathing and swallowing, I had several differential diagnoses in mind before I ever even saw him. Turns out, he was acutely depressed, and had just 12 days earlier lost his wife of 63 years. Although the symptoms he was describing to me could have been indicative of a number of bad things, he agreed to pursue the idea of depression management, agreed to start on an antidepressant and a visit to a grief counseling and support group was probably what would benefit him the most. I also treated him for pharyngitis, and when he came back to follow-up, he was better on all accounts. In another example, I demonstrated adaptability and flexibility in this clinical experience, adapting to changes in scheduling and being willing and able to shift things around in my schedule when my preceptor needed to take an unexpected leave of absence for about 2 weeks right in the middle of my experience. C. In the future, I will need to work continuously on achieving this competency, as it is a dynamic thing, and there are ongoing tasks associated with the demonstration of this competency. D. Point of care tools and references that have been helpful in achieving this competency include the use of organizational tools and methods to aid in stress reduction, such as humor and relaxation techniques. ______________________________________________________________________________20. Employ effective communication methods with patients, □ □ □ □ X □ X□families, preceptor, and staffSecond Submission 25 September- 22 October 2012 - A. To employ effective communication methods with patients, families, preceptor and staff generally means using a variety of methods of communication, depending on the situation and the needs of the individual(s) with whom you are attempting to communicate. I have more than eight years of nursing experience, which has provided me the opportunity to practice this competency, and has been a strength for me as I learn new and advanced methods of communicating with patients, families and staff. B. Sometimes I am challenged to explain things in the most common terminology when talking with patients, and always make sure to reinforce key ideas with a written and verbal reminder at discharge. A number of methods are used to communicate with patients and families. for example, two sets of written instruction were given to the mother of an ill 4 year old, so that she could give one to the father when the child went to her father's house. C. In the future, I will study issues contributing the health literacy of my patients and use the information to ensure that communication methods are effective. I will make efforts to follow up with patients making sure they are heard. D. References and clinical guides that help me in being able to achieve this competency include the patient education materials that I use to meaningfully communicate key teaching points with patients. Third submission 23 October - 19 November - A. To employ effective communication methods with patients, families, preceptor, and staff means to use a variety of strategies and styles of communication to convey information to and receive information from others. My ability to communicate effectively with others has translated into the ability to work successfully with patients, families, preceptor and staff on common goals. B. Examples of my ability to perform this competency include interactions with patients and family members on a variety of topics. I generally try to teach patients and explain things to them at various stages throughout a visit. For example, a patient being treated for knee pain was given printed material on therapeutic exercises to do at home, and was instructed on the importance of strengthening exercises to help her, since we talked about how to manage and improve her condition, working with limited resources. A 47 year old deaf patient came in at the end of the day one Friday afternoon, and, through his wife, (also deaf, but with some verbal abilities), expressed the complaint of left arm pain that radiated to his chest wall that began suddenly while he was out mowing. This was the perfect example of my ability to employ effective communication methods in a situation that presented some unique challenges, and opportunities to practice this. I was able to communicate effectively with them using written methods, and the little bit of American Sign Language that I know, supplemented with some finger spelling. C. Strategies to gain additional mastery of communication skills will demand further attention to the art of communication, and challenges related to the literacy of patients, and will require additional work to become effective in these efforts. D. Tools used to help me achieve effective communication with patients and families, include the use of explain/teach back methods, motivational interviewing, and printed education materials for patients to take home. Most communication with my preceptor and staff was done verbally, and by email and text, which worked well for all. ______________________________________________________________________________21. Assess the agency for cultural competence □ □ □ □ □X X □Second Submission 25 September- 22 October 2012 - A. Assessment of cultural competence requires a look at the agency's ability to interact effectively with people of different cultures. I have not encountered much ethnic diversity in this rural, northeast Kansas setting, but have seen a fair amount of cultural diversity, including religious, sexual orientation, age, educational background, socioeconomic status, and more. B. I am happy to say that the agency staff has handled cultural diversity appropriately and professionally. Most of the patients I have seen during this rotation have been white, and the most ethnic diversity I have seen here has been in the pediatric population. I saw a couple of African American children who were in the foster are of a white couple, and another couple of Native American children, who were also in the foster care of a white couple, both in for well-child exams. In both instances, both children came in together, and both children opted to be seen together, in the same room, rather than separately, which was understood and accommodated by the staff. The agency has an interpreter line available to use, but I have not had to use it. Also, there are options for providing discharge instruction/paperwork in Spanish, but again, I have not had to use this feature. C. In the future, I will work to maintain an awareness of cultural differences and similarities, and demonstrate respect for others, no matter what. D. The US Department of Health and Human Services' definition of cultural competency is considered when making this assessment. I have evaluated the agency's point of care resources for tailoring services to cultural differences. These include the use of an interpreter line and the option to provide patient teaching tools in English and Spanish. Third submission 23 October - 19 November - A. To assess an agency for cultural competence means to look objectively at a particular agency, noting the presence or absence of certain factors that are important to providing culturally competent services. Cultural competence can be determined by the ability to adapt to cultural, ethnic, linguistic, religious, and social differences, all while maintaining a sense of what is appropriate, and what is not when it comes to providing sound patient care. B. Examples of this in this practicum are demonstrated in my ability to assess the patient population for cultural diversity and recognize differences in the seemingly homogenous population of patients. I frequently ask patients questions about themselves that might help me assess their cultural preferences or practices that might affect their health. In one patient, we talked about his preference to not take thyroid medication despite having a TSH lab value of 6.31 previously. He had run out of the synthroid medication, a few months back and had quit taking it believing that he could change some other things in his life, getting things back into balance, and eliminating the need for it. At first, I was skeptical, but demonstrated cultural competence when I agreed to support him in his efforts, and rechecked a TSH level that was now normal. C. In order to gain additional skills to master this competency, I will need to gain exposure to a wide variety of organizations and agencies, establishing observations on which to make comparisons and assessing the different practices and styles. D. Helpfulness of references, clinical guidelines, and tools continues to come from the continued use of materials, as described above, to help the agency, and me as a representative of the agency to be competent in caring for diverse patients. ______________________________________________________________________________22. Communicate practice knowledge effectively both □ □ □ □ □X X□orally and in writingSecond Submission 25 September- 22 October 2012 - A. Being able to communicate practice knowledge effectively means being able to explain things in common terms, and being able to discuss practice issues intellectually, using professional medical terms, as well as being able to effectively write an organized assessment and plan. B. I ask questions clearly and directly, and make it a point to explain things to patients in common terms. I take the time to ensure that the patient understands what is being discussed, and always provide a recap and review of important points, typed in bold, 20-point type within the general written discharge instructions. I provide oral reports to my preceptor after going in an seeing the patient independently at first, reporting to her in the SOAP format, and then am able to document my findings and assessments in the patients electronic chart, using mostly supplied terminology and some free-text. This is always reviewed by my preceptor prior to being signed (by her). C. In the future, I will be able to do this more effectively as I gain experience, and practice this competency. Listening to the ways that other health care professionals explain things is another good way to improve in this competency. D. I use the 'teach-back' method with patients frequently to ensure that I have communicated knowledge effectively, and that patients truly understand what is being said. Third submission 23 October - 19 November - A. To communicate practice knowledge effectively involves the use of both oral and written methods to share information. This has been done with increasing confidence throughout my practical experiences, and I have gotten to the point that I am able to do this consistently, including tactful ways of telling patients that I do not know something, and will need to do further research or referral to find an answer. B. Examples of this have been demonstrated in clinical by the ways I have reinforced important teaching points by summarizing and individualizing key ideas in bold type, added to the printed discharge instructions. This provides a platform for me to be able to achieve this competency. Documentation in patient charts, elogs, and completion of the CPT are also examples of my ability to demonstrate this competency. C. To gain additional skills to master this competency, I will need to continue to work on my ability to be succinct and organized when participating in the verbal report of patients to other practitioners, and will continue to work on ways to improve my documentation and ability to write effectively. D. References and tools that help me be able to communicate practice knowledge effectively include the many articles, reference books, and communication tools that I have used and studied throughout, to help me with the organization of care, and of prioritization knowledge that is important to communicate. The SOAP tool is one example of this.______________________________________________________________________________23. Integrate best available evidence to continuously □ □ □ □ □ X X□Improve quality clinical practiceSecond Submission 25 September- 22 October 2012 - A. Integration of best available evidence to continuously improve quality clinical practice means applying the best available knowledge from sources that are reputable and up to date to continually improve clinical practice. Having recently gone through school, I have recently learned about the best available, most up to date evidence on subjects, which is a strength when it comes to integrating standards into practice. B. Examples of ways in which I have integrated best available evidence to continuously improve my clinical practice include decisions made in regard to the management of diabetic patients, and the definition of goals. C. In the future, I will work continuously to integrate best available evidence in to my practice, and will be vigilant about ways to continuously improve. D. References and clinical guidelines that have helped me achieve this competency include relevant clinical guidelines from the National Clearinghouse Guidelines, and other sources of up to date guidelines, and the use of UpToDate database, and other current sources. Third submission 23 October - 19 November - A. The integration of best available evidence should be done continuously, and should be done with the overall goal of improving the quality of clinical practice. The quality of practice can be improved by efforts to base care decisions on the best available evidence, and should be framed within individual patient circumstances. B. Examples of this include the utilization of current printed and electronic resources to keep me abreast of changes and additions to recommendations as they relate to my ability to provide evidence-based care to patients in my practice. To illustrate my performance in this competency, I can cite an example of the efforts I made to integrate best available evidence in the acute and ongoing management of a patient with traumatic brain injury. I looked to the literature to learn more about how to handle this patient, since it is a hot topic with evidence emerging at a rapid pace to assist in the assessment of TBI patients and tasks associated with management of long-term effects. C. In the future, I will continue to grow in this competency, maintaining the strong desire to learn, as a lifelong challenge, and taking steps to stay up-to-date on topics relative to my practice. D. A wide array of references and clinical care guidelines have been accessed throughout this experience, and have been used to assist in decision-making processes. Again, these include the AHRQ National Clearinghouse Guidelines, information accessed through the UpToDate database, and the most current editions of a variety of other sources. ____________________________________________________________________________24. Analyze agency educational tools □ □ □ □ X □ X□Second Submission 25 September- 22 October 2012 - A. To analyze agency educational tools means to examine in detail the elements, and usefulness of the tools used to educate patients on a variety of topics. This agency has the benefit of having a large pool of educational tools for a wide range of topics, and an electronic system that makes it easy to access and share educational materials with patients. B. Examples include my use of photocopies from a clinical reference book of exercises for low back pain (LBP) to give to a patient who was being educated on the benefits of certain exercises to improve LBP. Also, I was able to analyze a number of the educational tools built into the electronic database related to dietary recommendations, and make judgments about the quality of the information. For example, I printed and distributed the information for the 1200-calorie diabetic diet to a patient who was expressing the strong desire to lose weight and wanting education about dietary approaches to doing so. It seemed to be good information, and the patient seemed pleased with it. C. In the future, I will work to maximize the available resources, and will always strive to provide patients with tools for education that are based on best available evidence, and are presented in the most useful and effective way known. D. References used to provide educational tools include the use of the tools built into the PowerChart system, the use of a clinical reference book that contains assessments and exercises for musculoskeletal issues, and other internet sources of educational tools. A couple of times, I have supplemented with the educational materials found in the UpToDate database. Third submission 23 October - 19 November - A. To analyze agency educational tools means to carefully examine the tools used by this particular agency to determine if they are used in a meaningful way, and if they do what they are intended to do. One strength in this clinical setting is the integration of patient educational materials into the packet of information that is provided to patients at discharge. B. Examples from this clinical that illustrate how I have performed this competency include my assessments of the tools preferred by my preceptor on providing nutritional information to patients engaged in weight loss efforts, and my recommendations to her on the supplementation of materials with other dynamic and functional educational tools available through the ADA, (both Am. Diabetic Assoc. and the Am. Dietetic Association), the AHA, and other professional organizations with stakes in making recommendations related to dietary practices and health. C. In the future, I will take more time to analyze and judge the effectiveness and user-friendliness of apps and other electronic and online sources of patient education, making recommendations based on these analyses and data gathered through feedback from patients. D. Again, I have used and analyzed a variety of educational tools during this semester between my clinical experiences and my work on the graduate project. The tools provided through the PowerChart EMR system are good, but seem to be a bit generic in the information provided on some topics. The tools are usually supplemented with a few hand-typed notes, which I feel are helpful to personalize and reinforce the information for patients and bring light to what is most important. ______________________________________________________________________________25. Evaluate the outcomes of coaching patients □ □ □ □ X □ X □Second Submission 25 September- 22 October 2012 - A. Evaluating the outcomes of coaching patients means assessing this, determining the value and effectiveness of teaching by looking at patient outcomes. B. Examples of this include the ongoing evaluation of a patient for whom coaching and support were being offered. The patient was being coached on cessation strategies and, after several weeks, the patient reported to no longer be using the nicotine patches, using the Chantix, and not smoking. This patient was motivated by the desire to have bariatric surgery. In another example, the outcomes of coaching are evaluated when a patient being seen for dietary surveillance and counseling comes in for a monthly check, and is assessed for progress toward weight loss goals, including changes toward a healthy lifestyle. C. In the future, I hope to become a better and more effective coach, using this skill to empower and enable patients. I know that this will come, as I gain experience, and hopefully have the opportunity to develop a clientele in a primary care setting. Evaluation of outcomes can be done in a variety of ways, and I will engage in further exploration, in the future. D. References include the many articles and manuscripts I have read about techniques such as motivational interviewing, goal setting/action planning, telephone interventions, and others. Referrals are made for psychiatric and behavioral support, including to the counseling center and sometimes the office staff (ie. medical assistant) are utilized for follow-up and evaluation of patient outcomes. Third submission 23 October - 19 November - A. To evaluate the outcomes of patient coaching means having a system in place to make some form of follow-up contact with patients, whether it be in person, or by phone, to inquire about what happened as a result of a particular interaction or coaching related to the implementation of plan of care. This is an important step of the process, and should not be overlooked in the providers' ongoing efforts to provide comprehensive and effective care. B. Examples of my ability to demonstrate this competency include the evaluation of patients who come in for monthly follow-up on weight loss efforts. These patients are praised for progress made, encouraged to continue efforts that are congruent with the desired outcomes, and challenged to set goals and take specific actions to modify behaviors that are not helping. Another way, in this clinical setting, that my ability to achieve this competency has been demonstrated is in the way I have evaluated patient outcomes, looking at the acceptability of outcomes from the patient's perspective in addition to my clinical perspectives. One patient was coached on strategies to help her with smoking cessation, and the outcomes of these efforts were evaluated in the context of her goals. She was motivated to quit smoking by an ultimatum she had received from the surgeon, stating that she had to do this prior to having weight loss surgery. D. References and guidelines that I have used to help me in achieving this competency include the materials I have studied, and strategies I have employed to help me in my role as a coach and support person for patients. I have read and studied a variety of methods, such as motivational interviewing and others, in an effort to guide coaching efforts and guide the evaluation of patients. ______________________________________________________________________________26. Integrate appropriate technology for knowledge □ □ □ □ X □ X □ management to improve health careSecond Submission 25 September- 22 October 2012 - A. To integrate appropriate technology for knowledge management means to use the technology available to help with the organization and transfer of knowledge. When done effectively, health care should be improved. One small challenge that I have encountered in this setting, is that I get no service to my smart phone at this site, and so I have not had the chance to practice using certain technology applications that I like, and might find useful in the future. B. This competency is demonstrated by examples of being able to navigate the electronic chart, and integrate fax, phone, print, and copy capabilities in this clinical setting, to better manage patient information, and improve the efficiency of care. Also, I have integrated several of the online databases available to me as a Washburn student to gain additional knowledge in the clinical setting on dermatologic conditions and other complex topics, as needed. I was able to integrate the technology available at the clinic, which includes internet access, a sophisticated electronic medical record system that is connected to a larger network of providers and services through its affiliation with a nearby community hospital. The appropriate use of available technology for knowledge management promotes continuity of care, and in turn, contributes to the improvement of health care. C. In the future, I will continue to use technology appropriately, integrating tools that will help me with organization, management, and transfer of knowledge, all while remaining vigilant about protecting privacy and confidentiality, and taking the necessary precautions to protect personal health information. D. The use of a laptop during my time in this clinical, and open access via my preceptors' credentials have been helpful in achieving this competency, and I have had access to any and all available technology during my time here. Third submission 23 October - 19 November - A. Integration of appropriate technology for knowledge management to improve health care means the appropriate use of technology to aid the practitioner in practice by improving the functional ability to manage a large amount of knowledge on a variety of topics, and apply knowledge logically, making improvements to the tasks involved in providing patient care, and educating patients on the skills necessary to manage their health. B. Examples of this include my work to create and share an electronic file containing a wealth of patient education materials related to diabetes care and self-management that could be accessed in the clinical setting and shared easily with patients to increase their knowledge and ultimately improve health care. Another example of this is the recommendation for a patient to explore some good apps, and use I-phone technology to help manage knowledge and skills related to the making and charting of progress toward specific goals related to behavior modification and efforts to increase physical activity and make therapeutic nutritional changes. C. Strategies for the future definitely include taking time (after school) to familiarize myself with the variety of applications for technology and the appropriate and useful use of technology as it applies to the management of knowledge and the improvement of health care efforts. D. References and point of care tools that I have used include the EMR that I have used to organize patient assessments and notes about patient encounters throughout this experience. The electronic transfer of information has been used, as appropriate, and, in most cases, has contributed to improvements in the efficiency and quality of services being provided. ______________________________________________________________________________27. Integrate ethical principles in decision making □ □ □ □ □ □XXSecond Submission 25 September- 22 October 2012 - A. The integration of ethical principles in decision making means taking certain things into account when making decisions to ensure that the best decisions are made in support of patient well-being. A clear understanding of ethical principles and consistency in the application of principles is a strength when faced with making difficult decisions. First and foremost, there must be respect for human dignity in all decisions made. B. One example of my ability to integrate ethical principles in decision making was demonstrated when I refused to write an antibiotic for a patient who had been seen by my preceptors' collaborating physician at a different clinic earlier in the same day for symptoms of upper respiratory infection. He had recommended a watch and wait approach with supportive care for symptom management, but did not think an antibiotic was indicated. The patient wanted an antibiotic, but ethically, I was not willing to go over his head just to please the patient. Instead, I did some further education about viral versus bacterial causes, the importance of watching for certain signs, waiting longer and pursuing antimicrobial treatment after a 7-10 day 'watch and wait' period, reinforcing that if symptoms persisted or worsened, despite certain attempts to alleviate and manage symptoms, return to the clinic and reconsider. She accepted this when it was explained and reinforced. In another example, a patient's autonomy was respected when a 48 year old male, at his wife's urging, came in to talk about his issues with anxiety, and being short-tempered. We talked about his issues, and discussed different options. In the end, he was resistant to any of the pharmaceutical options that were discussed, and also to any counseling options, but said that he would work on the some of the issues willfully. Because of autonomy, and respect for his right to make his own decisions, we respected and supported his choices. C. In the future, I will always integrate ethical principles in decision making. I will hold fast to the concepts that I have certain responsibilities to myself, to patients and to society, and will seek ethical and legal guidance when needed. D. Concepts described by the American Nurses Association (ANA) Code of Ethics have been applicable to me as I work to achieve this competency, including the ethical concept of respect for patient autonomy, the right to self-determination, the importance of interdisciplinary collaboration, and professional accountability. Third submission 23 October - 19 November - A. To integrate ethical principles in decision making means viewing decisions through a critical lens, putting issues into the context of what is right, what is ethical, and what is in the best interest of the patient. I have practiced the integration of ethical principles into decision making throughout my life and career as a nurse, which has been a strength to me in consistently achieving this competency at this level. B. Examples of this include the application of ethical principles in a situation where a patient wanted to talk about available strategies to help him cope with and manage symptoms of anxiety. His wife was adamant that he be started on medication to help with the problem, but he did not want to go that route. Through further discussion, he was able to logically present the reasons behind his hesitations, and had good rationales for them. In the end, his rights to be autonomous were upheld, and he was given information about a variety of other options that might help his situation. Ethical principles were applied to scenarios of patients coming in to request support for and documentation of conditions that were chronic and debilitating, and to request FMLA paperwork related to their inability to perform their duties at work due to the conditions. In one case, I did not feel that the condition was such that the patient needed to be placed on leave and faced the ethical dilemma of doing it based on what the patient's desires and reports of the nature of the condition, or relying on my professional opinion about it and my nursing instincts. In this case, a compromise was made, allowing the patient a short extension of leave (not as long as she had wanted) and having her come back in one week for reevaluation and at time she was released back to work. discussion about management of anxiety came to a being considered C. Strategies for improvement in the future include taking time for personal and professional self-reflection and ongoing consideration of ethical principles in the context of clinical decision-making. My efforts to adhere to ethical principles will not be compromised as I move forward, and ability to do this competently will continue to grow as I grow in my role. D. References and guidelines to guide the application and integration of ethical principles in clinical decision-making include familiarity and adoption of the ANA's Code of Ethics, as well as other professional sources of information on these topics. ______________________________________________________________________________28. Demonstrate respect, compassion and integrity □ □ □ □ □ □XXSecond Submission 25 September- 22 October 2012 - A. The demonstration of respect, compassion, and integrity means that these things are exhibited in every patient encounter and also in the interactions with colleagues. As a nurse, I pride myself in my ability to do these things consistently, which is a strength for me in achieving this competency. B. Examples of this in my current clinical setting include my ongoing respect for my preceptor and the other health care professionals with whom I have had contact, compassion for patients and families, regardless of their background, and integrity always. I demonstrated these virtues in an interaction with a patient who was having an extreme exacerbation of back pain, by offering her a place to lay down, an injection of Toradol for relief in the office, and demonstrating integrity in the way I explained things to her, required her to have a safe ride home before leaving, and documented her condition. C. In the future, I will continue to meet this competency without fail. A good rule of thumb is to treat every individual as you would want a member of your own family to be treated, with respect, compassion, and integrity. D. Personal experiences and moral character are as much of a reference and guide for achieving this competency as any other. Third submission 23 October - 19 November - A. To demonstrate respect, compassion and integrity means to have these things underlying all that is done, and to do so consistently and gracefully in all interactions. By nature, I am able to do all of these things well, and have found this to be a strength in my ability to connect with and care for patients of all ages and backgrounds. B. Examples of my ability to demonstrate respect, compassion, and integrity are illustrated in the connections I made with patients both young and old, and my ability to put patients at ease and contribute to the establishment of an environment that makes them feel comfortable sharing personal and sometimes volatile information. I demonstrated compassion for patients when I participated in care decisions for patients at the end of life, making changes to the plan of care, as needed, with the goal of keeping patients comfortable. C. Strategies for future growth, and improvements in my abilities to demonstrate respect, compassion, and integrity will be based on the application of morals and professional values and ethical principles. I will continue to hold this competency in high regard and do these things without fail. D. References, guidelines, and clinical tools should all be evaluated for their ability to provide support to practitioners and be congruent with efforts to demonstrate respect, compassion and integrity in every example of human contact. YIPPEE! State Board of Nursing RequirementKSBN Requirements for Nurse PractitionersMetNot Metor N/ACommentsDemonstrates advanced practice roleXDisplays ability to decide to order and/or perform diagnostic proceduresXAble to interpret diagnostic and assessment findingsXSelects and provides prescription of medications and other treatment modalities for clientsXSubmission #1 after 80 hours of practicumFaculty Signature______________________________________Date____________________Submission #2 after 160 hours of practicumFaculty Signature_____________________________________Date____________________Final Submission after 225 hours of practicumStudent Signature__Anna E. Marshall _____________Date___05. Dec. 2012______Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade: ................
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