Washburn University



Washburn UniversitySchool of NursingNU 607 Health Care Practicum II- Specialty (Family) Clinical Performance Tool(Completed by Student and Faculty)Student__Jayne Dowell______________Semester_Spring ‘12____Agency__CMH Health Clinic, Marysville Instructor__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 75% 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 experiencesGradingThe Clinical Performance Tool is completed and submitted by the student at the completion of 60 clinical hours, 120 clinical hours, and all clinical hours for a total of three submissions. The first submission must address items 1-13. The second submission must address items 1-28. The final submission must address all competencies. 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.NP students are expected to: 0 1 2 3 4 51.Develop individualized health promotion, disease □ □ □ □ □ √prevention and health protection services for patients acrossthe life span27 February 2012, 1st submission: I have demonstrated this outcome effectively. In an attempt to develop individualized health promotion, disease prevention and health protection services for the patients I am seeing in this clinic setting, I approach each patient with the thought of “what can I do to ensure a better state of health for this patient as well as ongoing health”. The effectiveness of my efforts are often limited by the patients financial status. Individual consideration is given to what the patient can afford and efforts are made to accommodate the patient’s limited resource. If the patient is in need of lab work or x-rays the benefit vs. risk of these diagnostic studies is given and the client is given the opportunity to make an informed decision. One middle-age, uninsured lady who rarely sought healthcare presented with c/o of back pain x 2 to 3 months. She agreed to a UA and it was determined she had a UTI. She was in her late fifties and had not had any routine lab work such as a TSH, CMP or CBC or screenings such as mammography or pelvic exam because she did not have insurance or the money to pay for it. I encouraged her to attend the local health fair in which all these labs were available at a very minimal cost of $25 and to go to the local health department for a pelvic exam provided at a reduced cost based on income. Finances limited this patient’s access to health care but she was encouraged to take advantage of community resources available to her at a reduced cost. Consideration was also given to prescribing an appropriate antibiotic that was least costly. I also spent time explaining why women her age are more prone to UTIs (decreased estrogen leads to atrophy and fewer lacto bacilli in the vagina, coupled with the female anatomy = increased likelihood of UTIs). I gave her several suggestions/options to decrease her likelihood of future UTIs (estrogen cream, drinking 64 fl. oz. of water/day, good hygiene, etc.). She was grateful for the information provided and indicated she would attend the health fair and check into the health department for a pelvic exam. When reviewing the plan of care with the patients, I often write out the treatment plan for them. My personal experience has been that having it written out reinforces what I’ve been told and gives me a reference to look at if I can’t remember what I was told. For example, I cared for a one year old who I diagnosed with conjunctivitis and OM. I demonstrated to the parent how to instill the eye gtts and wrote out how often to administer the eye gtts as well as home care suggestions such as good hand washing to prevent spread of infection to other family members in the home, using warm compresses to the eyes, dosage of Tylenol and frequency of admin, using humidified air in the home/child’s room, etc. 26 March 2012, 2nd submission:I continue to demonstrate individualized health promotion, disease prevention and health protection to my clients. A recent example of demonstrating this outcome is my care of a 50 year-old female who presented to the clinic with chief complaint of elevated BP of 210/112 the previous day. She was concerned because her BP was normally “much better” in the 170/80 range. At the time of her visit, her BP was 152/78. Her BP on previous visits was in in the same range and she had previously been on HCTZ for hypertension but she quit taking it two years prior. In her ROS, she indicated she had a headache “all the time”, sometimes in the form of a migraine but always a “pressure or stabbing” type headache often associated with blurred vision as experienced the previous day. This patient’s visit was an opportunity to provide individualized health promotion, protection and disease prevention in the form of patient education related to hypertension, lifestyle modifications and medication treatment along with the likely consequences of doing nothing. I spent a considerable amount of time teaching her about hypertension and provided information printed from UpToDate. We discussed the definition of HTN and the fact her BP the previous day along with her symptoms could be classified as a hypertensive emergency. We discussed at length the reasons and measures to keep her BP under control for the sake of keeping her healthy and preventing end organ damage, which is likely if her BP continues to be out of control. Because she did not have insurance she was reluctant to have lab work done so she agreed to attend the community health fair to have lab work done. We discussed what the lab work would tell us, in addition to the importance in having baseline lab work to monitor her health. She also agreed to resume medication to treat her HTN, keep a daily journal of her BP and headaches and bring it to her follow-up appointment in one month. And she agreed to return or present to the emergency room if her BP was significantly elevated again with associated symptoms. Lifestyle modification was encouraged with recommendation of walking 20 to 30 minutes on most days and she was given a handout on the DASH diet. The care provided this patient demonstrates success in developing an individualized plan to prevent end organ damage resulting from HTN and promote and protect her health with lifestyle changes and BP control.26 April 2012, 3rd submission:Development of individualized health promotion, disease prevention and health protection services for patients across the life span was incorporated in my practice during this practicum experience. As a follow-up to the hypertensive patient mentioned above, I had the opportunity to see her in follow-up the last week of this practicum. She provided a diary of her recorded BPs for the previous month while on HCTZ and they were much improved but in the 140/80 range. As a result we elected to add lisinopril and wrote for lisinopril/HCTZ 10/12.5. She agreed to continue to randomly check her BP 2 to 3 times per week and report if they were consistently above 140/80 or below 100/60 with symptoms. In addition, she reported she was attempting lifestyle modification by walking 30 to 40 minutes 3 to 4 days per week. This example illustrates meeting outcome # 12 as well.In addition to the examples provided above, meeting this outcome can be demonstrated by the care provided to individuals across the life span from infants to the elderly. I had the opportunity to provide well child exams on several children as well as health exams on adults of all ages. With each exam I made it my goal to incorporate at least one health promotion, health protection or disease prevention measure into their visit. Examples include reviewing immunization schedules with parents of children under the age of 5 or reviewing safety measures such as wearing helmets when riding bikes, appropriate use of car safety seats or locks on medications and household cleaners. My experience in the ER has made me keenly aware of the importance of ensuring child safety at home, so I made this a priority in my discussions with parents. On several occasions, I shared experiences I’ve had in caring for children who were severely injured because they weren’t wearing a helmet or ingested a medication or household cleaner because it was easily accessible. One elderly couple in their early 70s presented for annual health exams. The husband had several actinic keratosis lesions on his head and face that had previously been treated with 5 FU cream but he developed a severe reaction to the treatment so it was stopped. On this visit he was treated with the alternative treatment of cryotherapy to destroy the lesions and he agreed to return after the summer mowing season for resumption of 5 FU cream. He was also counseled to wear sunscreen and a hat for protection from further damage. He was referred to a urologist for screening for prostate cancer based on his age and abnormal prostate exam. His wife was also seen for a health exam that included a clinical breast exam, scheduled mammography, referral for dexascan based on results of bone density screening and referral for colonoscopy. Both also had lab work to screen for lipid disorders, diabetes, or kidney function, etc. The care of this couple represents providing individualized health protection and disease prevention measure. 2. Develop individualized anticipatory guidance and □ □ □ □ □ √health counseling for patients across the life span27 February 2012, 1st submission:Developing individualized anticipatory guidance and health counseling is incorporated with all patient care. Depending on the reason for the visit, I try to incorporate some form of health guidance and counseling. For instance, during my assessment I will usually broach the subject of smoking especially if they smell like cigarette smoke. Often, if the patient doesn’t smoke, someone in the home does. If they’ve brought a child in with respiratory symptoms, I always ask about second hand exposure to smoke in the home. If they answer yes, I let them know that cigarette smoke, whether first or second hand, is a known respiratory tract irritant that leads to increased primary care visits compared to individuals who do not smoke or who are not exposed to second hand smoke. When appropriate, I will offer statistical information from the literature, such as 1 in 5 deaths in the US is related to cigarette smoking and long-term nicotine exposure affects many organ systems and has been associated with cancer, hypertension, cardiovascular disease and GI and reproductive disorders. I also usually discuss the fact that most smokers use tobacco because they become addicted to the nicotine but there are strategies that can be incorporated to help people stop smoking when they are ready and then I encourage them to discuss it when they are ready.Another example would be guidance and counseling offered during well woman exams. I use these exams as an opportunity to ask if they are doing monthly self-breast exams the week following their periods or on the same day each month. I encourage them to do monthly SBE because 70 to 90% of breast masses are found by women themselves and routine SBE can result in detection of tissue changes that are precancerous or in the early stages when treatment is more likely to be successful. I relate it to doing an annual PAP smear to screen for cervical cancer; a monthly self-breast exam is done to screen for breast cancer. I use the well woman exam, or a physical exam of any kind, as a key opportunity to provide health counseling regarding diet and nutrition, sun exposure, tobacco, alcohol or drug use, sexual practices or environmental hazards. Mammography screening for breast cancer is also included in the care of women over the age of 40 as well. In this clinic setting I’ve not had the opportunity to do a complete physical assessment on many males, however, I did incorporate a discussion on annual prostate screening exams with a gentleman in his mid-fifties who was being seen for back pain. In reviewing his chart I noted that he had not had a prostate exam or PSA test done. We talked about the guidelines that suggest having a digital rectal exam and PSA done annually after the age of 50. He acknowledged that he was aware of the need to do it but had been procrastinating in having it done. I encouraged him to have it done by his next birthday and reminded him there were male providers in the clinic he could see.26 March 2012, 2nd submission:Developing individualized anticipatory guidance and health counseling for adults continues to be demonstrated in my practice. There have been many patients who have presented to the clinic for pre-op H&Ps. With each patient I provide them with anticipatory guidance related to their upcoming procedure by discussing the importance and rationale for being NPO prior to surgery, encouraging a good nights rest prior to surgery and cessation of smoking to facilitate the healing process. To the extent of my knowledge, I discuss what they might expect after surgery in regard to pain, incision(s), return to activities, etc. With each patient, I continue to attempt to include anticipatory guidance. I have made it a point to ask patients, young and old, about appropriate vaccinations from routine childhood immunizations to the flu, pneumonia, Herpes Zoster or HPV. Anticipatory guidance is also provided for women presenting for Well Woman exams by discussing guidelines for mammogram, colonoscopy, monthly self-breast exams, skin cancer screening, etc. 26 April 2012, 3rd submission:Developing individualized anticipatory guidance and health counseling for patients across the life span has been incorporated during this clinical practicum. Another example involved the care of a 24 year old that presented with a gaping 2 cm open wound in her antecubital fossa that had a foul, purulent drainage with marked erythema and edema of her upper and lower arm. This individual had an admitted history of IV meth use but claimed to be clean for the past four years. Her situation presented multiple opportunities for anticipatory guidance and health counseling. She was admitted to the hospital and prior to her admission she was provided anticipatory guidance regarding her care and treatment while in the hospital. Anticipatory guidance included what to expect after she was admitted from being NPO to IV antibiotics and the probability of multiple surgeries. Health counseling regarding the effects of illicit drug use was broached despite her adamant denial of using drugs. Results of her urine drug screen were positive for marijuana, methamphetamine and opiates. Another example includes the care of a perimenopausal woman in her late forties who presented with left lower quadrant pain and dysfunctional uterine bleeding. Her visit provided an opportunity to provide anticipatory guidance and health counseling related to her pain, bleeding as well as menopause. I was able to answer many of her questions related to menopause by providing her with a printed material from UpToDate related to menopause that included the definition of menopause, the average age of onset of menopause and what to expect with menopause. 3.Prioritize differential diagnoses based on etiologies, □ □ □ □ √ □ risk factors, underlying pathologic processes and epidemiology for medical conditions including acuteand chronic dermatologic conditions, anxiety, depressionbipolar disorder, fractures/sprains/stains, back pain, connectivetissue disease, sexually transmitted infections, incontinence,and men’s health issues.27 February 2012, 1st submission:Prioritizing differential diagnoses based on etiologies, risk factors, underlying pathologic processes and epidemiology for various medical conditions is probably one of the most challenging aspects of the practicum experience. I am learning so much about so many different conditions that at times it seems overwhelming to keep what I do know in the foreground of my knowledge base, while being ever aware and fearful of what I don’t know. A fine balance but I do, however, believe I have been successful in meeting this outcome as illustrated by the following examples: Last week, I saw a patient who two weeks prior had stents placed in his left carotid artery after a failed carotid endarterectomy. On presentation, he had a rash behind his left ear on the posterior aspect of the pinna and on the side of his head that he noticed the previous night. He denied having much pain with it, just a tingling sensation on the lateral aspect of his head followed by intense itching behind his ear. On exam, he had maculopapular lesions along with lesions that were vesicular in nature with evidence of lymphadenopathy to the post-auricual nodes. In ROS, he denied any fever, fatigue, malaise, headache, or GI symptoms and had minimal pain. Given my physical exam along with the fact he had recently been under the stress of surgeries on that same side and his age (incidence increases of with age), along with previous varicella virus as a child, my priority differential diagnosis was Herpes Zoster. Other differential diagnoses considered were an allergic reaction or contact dermatitis from tape or other products used during his procedure.A few weeks ago, I cared for a 16-year old patient who presented with RLQ pain, nausea, and malaise with sudden onset the previous night. Her LMP was 2 weeks prior, she denied being sexually active and was not on any medications. She denied a fever but described pain with urination as well as frequency. Differential diagnoses included appendicitis, UTI, ovarian cyst. A pelvic sonogram was done that day which revealed a 6 cm septated right ovarian cyst. She was placed on oral contraceptives and referred to an Ob-GYN. Another patient in her late fifties was seen recently with c/o sudden onset of right great toe pain for two days duration with redness, tenderness to palpation and edema to the metatarsal-phalangeal joint. She denied known injury to her toe or foot. Based on her age, consideration was given to differential diagnoses of a fracture, cellulitis, septic arthritis and gout. She declined an x-ray, lab work due to not having insurance but by exam, because only one joint was affected and it occurred with an abrupt onset of that particular joint which was warm to touch and very painful, the diagnosis of gout was determined. She was prescribed Naprosyn 500 mg BID after being offered a steroid injection of the joint, which she declined.26 March 2012, 2nd submission:Prioritizing differential diagnoses based on etiologies, risk factors, underlying pathologic processes and epidemiology for various medical conditions continues to be one of the most challenging aspects of the practicum experience. Nonetheless, I’ve been able to develop this skill significantly with the variety of clients who present with each of the conditions mentioned in this outcome. I’ve had multiple experiences with orthopedic injuries and have demonstrated my ability to prioritize differential diagnoses with each. One patient in her early 30s recently presented with an injury to her left knee sustained while entering the driver’s seat and turning to reach for something in the back seat with her left foot firmly planted on the floorboard. Because it was such a low impact injury in a youthful, healthy woman without any medical conditions, the differential diagnosis of fracture was prioritized lower on the list of possible differential diagnoses. Her exam suggested a greater likelihood of MCL and/or medial meniscus injury. Obtaining an x-ray to determine possible fracture was presented as an option, however, differential diagnosis prioritization was given to soft-tissue injury based on exam and description of injury. Given her uninsured status and desire to avoid unnecessary costs, this was acceptable to the patient.26 April 2012, 3rd submission:Prioritization of differential diagnoses based on etiologies, risk factors, underlying pathologic processes and epidemiology for a variety of medical conditions was met during this practicum experience. Over the course of this experience, I have become increasingly proficient at meeting this outcome. I was fortunate to have seen multiple patients with acute and chronic dermatological conditions and value the experience this provided because dermatological conditions are challenging to accurately diagnose in my opinion. One example is of a15 year-old male athlete currently involved in track who came in with complaint of a rash on the bottom of his feet. On exam, I initially thought it was plantar warts as they were located on the plantar surface fat pad and toes and had the appearance of plantar warts in regard to having pin-point black dots in the lesions but at the same time, they were pitted and clustered together which I had not seen with plantar warts. So, to Fitzpatrick’s and my preceptor’s dermatology book (which I don’t recall the name of) I went. I included tinea pedis and plantar warts in my differential diagnosis but wasn’t convinced it was either. Fortunately, my preceptor recalled seeing a similar condition called pitted keratolysis and wondered if it could be that. After researching each condition we were able to agree it was pitted keratolysis which is common in young males who wear occlusive footwear and has the appearance of crater like pits in the skin that can become confluent and are more common on pressure areas such as the ball of the foot and interspaces of toes. Correct diagnosis necessary to ensure appropriate treatment which for this condition was application of Drysol 20% and measures to prevent the condition such as changing to dry socks after workouts and less occlusive footwear. With the guidance of my preceptor I was able to prioritize the differential diagnoses based on epidemiology and risk factors for developing this condition. This is probably one area in which most guidance is required simply because of inexperience in having seen some conditions. Continued experience will ensure growth and proficiency in meeting this outcome.________________________________________________________________________4. Perform comprehensive health history and physical exam □ □ □ □ □ √on patients across the life span27 February, 2012, 1st submission: My performance in completing a comprehensive health history and physical exam has definitely become more organized and systematic compared to my clinical experience last semester. I have gained significantly more confidence in performing physical exams and health histories, as well as in interpreting my findings to develop appropriate differential diagnoses. This is primarily the result of the opportunity this clinical experience has given me in terms of being able to practice these skills along with feedback provided to me by my preceptor. Last semester’s experience gave me an opportunity to experiment with various approaches and techniques to figure out what works and what works better. I’ve done several pre-op physical assessments and sports physicals for patients in my preceptor’s practice that require a comprehensive head to toe assessment in addition to several well woman exams. Just the other day, I was thinking about how Shirley Dinkel made a comment to me last semester that I listened to heart and lungs first in my assessment during her site visit. Honestly, that was probably a bad habit picked up from my preceptor last semester that I have been able to change. My comprehensive physical exam is much more refined in a true head to toe progression that enables me to be more efficient. Occasionally, I get ahead of myself, but feel comfortable going back and completing what I left out. Ongoing experience and the opportunity to look at a few hundred ears, noses and throats or to listen to a few hundred heart sounds, as an example, that are both healthy and not so healthy has provided me with the needed experience to recognize the effects of illness compared to what healthy looks like. As a result, my assessment skills are becoming much more refined and I’m gaining confidence in them each day. If I ever have a questionable finding, I never hesitate to bring my preceptor in and ask her opinion. For example, there are two patients I did well woman exams on in which I had findings that were questionable. I found a breast mass in one patient who was in her early thirties that I thought was likely cystic in nature but it wasn’t anything the patient had noted previously. I asked my preceptor to come in and give me her opinion. She agreed with my finding of a 2 to 3 cm mass at 11:00 o’clock just above the areola on the right breast and agreed with my suggestion to send her for an US. The US did confirm the mass as being cystic in nature and the patient was counseled by my preceptor to watch it, avoid caffeine, etc. I did another well woman exam on a young lady in her late twenties who had had a Roux en Y gastric bypass three years prior. On exam of her abdomen, I felt a small mass in her LUQ that was painful to deep palpation with guarding on exam. When questioned further she did note that she had been having intermittent pain in her LUQ that radiated to her back. Again, I asked my preceptor to assess the patient and she agreed with my findings so the patient was scheduled for an US on 2/24/12. At this time I’m not aware of the US results but it’s experiences like these that validate my assessment skills and create greater confidence in myself in having what it takes to be successful in this role. This experience has provided many challenging patients and proficiency will be gained with continued practice and experience that enables me to refine and improve all aspects of my assessment skills.26 March 2012, 2nd submission:There have been many opportunities to perform comprehensive health history and physical exams in this clinic setting with a number of patients who present for pre-operative H&Ps, well woman exams and even a few sports physicals. Each time I perform a comprehensive exam I review the patient’s current allergies, medications, medical, surgical history and family history prior to performing a physical exam. With the physical exam, I perform a systematic head to toe assessment and document my findings. I am confident in my assessment skills and this practicum experience has given me opportunity to implement into practice skills learned in health assessment.26 April 2012, 3rd submission:My performance in completing a comprehensive health history and physical exam to formulate a differential diagnosis has been organized and systematic. I have gained significant confidence in performing physical exams and health histories independently, as well as in interpreting my findings with little guidance, to develop appropriate differential diagnoses. This is primarily the result of the opportunity this clinical experience has given me in terms of being able to practice these skills and feedback given to me by my preceptor. Continued practice with patients of all age groups, gender, cultural and ethnic backgrounds will ensure meeting this outcome in future practicums. This practicum has provided excellent opportunity to meet this outcome and I am hopeful my final practicum will offer the same challenging patients and experiences. Proficiency will be gained with continued practice and experience that enables me to refine and improve all aspects of my care. I am confident in my ability to perform a comprehensive history and physical exam, yet I am aware of my limitations related to experience and always seek advice or consult with my preceptor if ever I question my exam findings. An example is of the gentleman in his 70’s that I did a prostate exam on. Because of my limited experience in performing this aspect of the exam I sought my preceptor’s opinion. She elected to defer to the collaborating physician who agreed with my exam finding a 5 mm nodule on the prostate and the patient was referred to a urologist for consult. ________________________________________________________________________5.Perform problem focused health history and physical exam □ □ □ □ □ √ on patients across the life span 27 February, 2012, 1st submission:It’s been so helpful to have the opportunity to apply what was learned in Advanced Health Assessment in every day practice in the clinic. Over time, I’ve become more organized and detailed in performing a problem-focused history and PE and have improved in my ability to think in terms of differential dx. Before seeing each patient, I review their past medical history, VS and stated c/o and then establish in my mind at least three differential dx for the stated complaint. This has required re-training how my mind thinks as I am now the one diagnosing and prescribing treatments but it becomes easier with continued experience. I’ve been surprised how many times I’ve walked away from performing a health history and PE with a completely different dx than what I had previously established before seeing the patient. As an example, I saw a patient last week in his mid to late fifties who came in for a rash on his neck and face following a procedure on his left carotid artery. My initial thought was an allergic reaction to tape following an invasive procedure. On assessment of the patient, I learned the procedure was a minimally invasive procedure in which they placed a stent in his carotid artery after a failed carotid endarterectomy one-year prior. That threw my allergic reaction to tape differential diagnosis out the window. My problem assessment focused on onset of the rash, its severity, location, associated symptoms, what made it worse and what made it better and if he had ever experienced any previous episodes of the same rash. My objective assessment of a maculopapular rash with areas of raised vesicles filled with serous fluid, limited to one dermatone that developed after a fairly stressful event in this man’s life lead me to identify herpes zoster as my primary differential diagnosis. My preceptor is really good with dermatologic problems so I did not hesitate to have her confirm my diagnosis and she agreed. She also confirmed there was no eye involvement and he was given a prescription for Zovirax and Lortab for pain control and instructed to follow-up if his symptoms did not improve. I believe this example illustrates my ability to perform a problem-focused assessment that includes relevant system assessment. I performed a dermatologic/skin assessment but also included relevant assessment of HEENT, local lymph nodes in addition to heart, lungs and constitutional assessment with particular attention devoted to his ear and eye due to possible complications of their involvement. 26 March 2012, 2nd submission:I have the opportunity to perform problem focused health histories and physical exams multiple times during each clinical day. Sufficient practice with a challenging, widely variant patient population has been a key factor in developing proficiency in meeting this outcome. In comparison to my performance at the beginning of last semesters practicum, I consider myself to be proficient at performing a problem focused health history and physical exam and determining appropriate differential diagnoses. Examples of meeting this outcome during this practicum include caring for patients with URIs, orthopedic injuries to ankles and knees, low back pain and surprisingly a lot of dermatology cases to include allergic contact dermatitis after exposure to poison ivy, classic atopic dermatitis in a one-year old, dishidrotic eczema, herpes zoster and HSV II to name a few. I continue to be organized and detailed in performing a problem focused health history and exam and proficient in developing at least two to three differential diagnoses during my assessment. 26 April 2012, 3rd submission:My performance in completing a problem-focused health history and physical exam to formulate a differential diagnosis has become organized, efficient and systematic since the beginning of this clinical experience. I have gained significant confidence in performing a problem-focused physical exam and health history, as well as in interpreting my findings, to develop appropriate differential diagnoses. Sufficient practice with a varied patient population was again a key factor in becoming more proficient. In comparison to my performance at the beginning of this practicum, I consider myself to be proficient at determining appropriate differential diagnoses. Last semester, there was a significant mind re-training process that took place to just think in terms of differential diagnoses. By the end of this experience, it seems almost second nature to think in terms of differential diagnoses with each problem-focused history and physical exam completed. If I have one fault in meeting this outcome, it may be that I want to be more comprehensive in my exam than I probably need to be. I would attribute that to being obsessive compulsive about not wanting to miss anything, which probably is not a bad thing at this point in my practice as long as it doesn’t detract from the outcome or delay the schedule. To become more proficient in meeting this outcome in future practicums, I’m hopeful to have continued practice with large number of patients of all age groups, gender, cultural and ethnic backgrounds. ________________________6.Demonstrate diagnostic reasoning and critical thinking □ □ □ □ □ √in the development of a treatment plan27 February, 2012, 1st submission:Diagnostic reasoning and critical thinking are vitally important skills that involve intuitive and analytical processes used to make a clinical decision in regard to a developing a patient’s diagnosis and treatment plan. I have always seemed to have a good sense of intuition and have only had problems when I didn’t follow that intuitive sense in my care. Critically analyzing a presenting problem from all aspects is necessary to make good clinical decisions in the care of patients. This is an area in which continued experience and growth is required to become a better diagnostician. Many of the patients I have cared for in this practicum have challenged my ability to think critically to analyze their problems. Every patient encounter during this practicum presented at least one, if not more, problems to critically analyze. Critical thinking is a learned behavior and continued experience in being able to critically analyze a problem using knowledge from EBP and the patient’s history and physical exam will only enhance this skill. I previously discussed a young woman in her late twenties who had a previous Roux en Y gastric bypass. She had previously been diagnosed with hypothyroidism and was on Levothyroxine prior to her bypass surgery but had not been on it since her surgery three years prior. When she presented for her well woman exam, she related a 15 to 20 # weight gain over the past year, LUQ pain as well as cramping and twitching in her legs that occurred primarily at night. She indicated her legs hurt so much at night she couldn’t even tolerate a sheet on them. She attributed her weight gain to poor eating habits and the stress of her current job but was concerned about her “aching” leg cramps and the cause. My first inclination was to obtain a TSH level along with a CMP with electrolytes and vitamin D and B 12 levels. A history of hypothyroidism, along with gastric bypass surgery, recent work related stress and poor eating habits lead me to think about nutrient deficiencies and chemical imbalances as well as the effects of an elevated TSH as the cause for her leg cramps. On follow-up, I learned her TSH was high and her vitamin D and B-12 levels were low so she was placed on levothyroxine, a vitamin supplement and instructed to follow-up in 6 weeks for repeat lab work. She was also encouraged to add Calcium to her diet as well. I’m curious to know her progress when she follows up but I think her story illustrates my ability to demonstrate diagnostic reasoning and critical thinking when developing a treatment plan. 26 March 2012, 2nd submission:I continue to demonstrate diagnostic reasoning and critical thinking with proficiency to develop appropriate treatment plans for the patients cared for in this clinical practicum. The best example in meeting this outcome is my case study patient. This patient had been seen in the clinic on at least three other occasions during my practicum for a paronychia x 2 and URI so I was familiar with his history. I think my preceptor’s impression was that his “heart palpitations” were probably nothing of any concern. In caring for this patient, I demonstrated critical thinking and diagnostic reasoning based on the information gained in performing a detailed focused health history and exam. My intuition told me there was probably something real going on with this patient, but proving it with an EKG or Holter monitor was what I thought would be the challenge since his symptoms were intermittent. Once the EKG confirmed a diagnosis of WPW, I knew a referral to a cardiologist was the next step, I just wasn’t sure how emergent the referral should be or what activity limitations might be required for this patient. In conjunction with the collaborating physician and pediatric oncologist, and after review of EBP, a treatment plan was developed for this patient. The most satisfying aspect of this experience was that it proved my ability to critically think and diagnostically reason with minimal initial guidance. My preceptor was busy with another patient so I proceeded to order the EKG without consulting her and knew immediately after looking at it the collaborating physician needed to read it as well. The PR interval was shortened and the QRS was abnormal. Critical thinking in my initial review of the EKG indicated this was probably not a normal EKG for a 16 year old and referral was likely.26 April 2012, 3rd submission:Diagnostic reasoning and critical thinking are concepts that make being a FNP student challenging, yet fun. It is challenging to be presented with a patient’s history and physical exam that requires much critical thinking and reasoning to develop a differential diagnosis. I may have used the example of the 14 year old with suicidal ideation in another outcome but it’s appropriate for this outcome as well. From her research on the internet, she was concerned she was experiencing problems related to her thyroid and brought a long list of symptoms that included irritability, insomnia, mood changes with associated anger among others. Her case required critical thinking and diagnostic reasoning on my part to develop a differential diagnosis. Having reviewed her chart before seeing her, I knew she had had a TSH level 4 months prior that was WNL and at the same time she was switched to a different BCP, which she was taking for heavy menstrual periods. Based on her presentation, affect and history, I was able to critically think and establish differential diagnoses that included depression. When I began to probe down that avenue, it became very evident she was deeply depressed to the point she had two fairly detailed plans in mind for harming herself. It took critical thinking and diagnostic reasoning on my part to distinguish all aspects of her presentation and history to establish an accurate diagnosis from the differential diagnoses. This example demonstrates my ability to effectively meet this outcome.7.Initiate screenings appropriate to differential diagnoses □ □ □ □ □ √for medical conditions including acuteand chronic dermatologic conditions, anxiety, depressionbipolar disorder, fractures/sprains/stains, back pain, connectivetissue disease, sexually transmitted infections, incontinence,and men’s health issues.27 February, 2012, 1st submission:The best example of initiating screenings appropriate to differential diagnoses is a 50-year old patient who called into the clinic with sudden acute onset of chest pain that radiated to her back on the left. She was told by the triage nurse to come in ASAP to be evaluated. Her history was significant only for GERD and moderate obesity. Her family history was significant for a father and older brother who both had MIs in their early 50s. She rated the pain as 9/10 and described it has a “pressure”. Upon arrival to the clinic, an EKG was performed and she was given 325 mg of ASA and a SL nitroglycerin tablet that decreased her pain significantly to a 3/10. Lab was drawn to include a CBC, CMP, Cardiac markers, lipase, amylase and lipid profile. Prior to her arrival, my preceptor and I were discussing probable differential diagnoses for this patient and plan of care based on those differential diagnoses. Given her age and personal health history of GERD, I was able to identify GI related problems such as heartburn, esophageal spasm, gall bladder disease or pancreatitis as possible differential diagnoses but a cardiac event had to be ruled out with appropriate screening measures such as the EKG and diagnostic lab work. After initial work up in the clinic, she was admitted to the hospital for observation. A chest x-ray was obtained on admit and an ECHO with cardiologist consult and EGD were scheduled for the following day. In the end, her cardiac findings were all negative but her EGD indicated she had Barrett’s esophagus lesion and her chest pain was determined to be non-cardiac in nature, likely attributed to GERD or esophagitis. In addition to illustrating implementing screenings appropriate for differential diagnoses, I believe this example is relevant to outcome # 6 as well in that it demonstrates my diagnostic reasoning and critical thinking skills. 26 March 2012, 2nd submission:Initiating screenings appropriate to differential diagnoses can be demonstrated by ordering an EKG for my case study patient as well as with a 50-year old patient who was diagnosed with CAP and placed on Zithromax. The CAP patient returned 10 days later for a CDL physical with some improvement but his lung sounds remained course and he continued to have a cough. Because of his history of tobaccoism, I ordered a chest x-ray to screen for unresolved pneumonia vs. an underlying mass. His x-ray report indicated pneumonia but the radiologist questioned a possible underlying mass and recommended a chest CT for further evaluation. Other screenings are often routine such as screenings for cervical, breast, and skin cancer done with annual well woman exams. 26 April 2012, 3rd submission:The example given in outcome 6 of the depressed 14 year old further demonstrates my ability to initiate screenings appropriate to differential diagnoses. In this example, she was screened for depression using a tool my preceptor often uses and then referred to a mental health facility for further screening to determine her need for inpatient or outpatient treatment. Another example is the gentleman in his 70s who was referred for further evaluation of his prostate after his prostate screening exam was questionable for a nodule. Overall, I have been able to effectively initiate appropriate screening for multiple medical conditions throughout the course of this practicum with minimal guidance from my preceptor. I have an app downloaded on my phone that lists all the AHRQ guidelines for recommended screenings based on the patient’s gender, age, use of tobacco, sexual activity and pregnancy. This has been very helpful in this practicum to help me ensure I’m recommending appropriate screenings for patients. It’s also been a good tool for providing anticipatory guidance in educating the patient on recommended screenings. ____________8.Initiate diagnostic strategies appropriate to differential □ □ □ □ □ √Diagnoses27 February, 2012, 1st submission: The example described above in #7 effectively illustrates my ability to initiate diagnostic strategies appropriate to differential diagnoses. Prior to the patient’s arrival, I was able to verbalize to my preceptor what our initial diagnostic work up for this patient would be including EKG, cardiac enzymes, CBC, CMP, Chest X-ray, ASA, Nitro SL, GI cocktail, etc. prior to the patient’s arrival. Although this example was a joint effort that involved my preceptor and collaborating physician, I believe I would have been very comfortable and confident if placed in this scenario as the sole provider. Another example is of a woman in her mid-thirties who presented with sudden onset of illness that morning of fever, malaise, nausea and vomiting. Her fever had been as high as 104. Her history was significant for ovarian cancer treated with surgical TAH and subsequent chemo and radiation. She subsequently developed renal insufficiency of her left kidney was only 10% effective and she had a left ureteral stent placed 3 months prior after becoming uroseptic from stasis in the left kidney. Her temperature remained elevated, she had LLQ pain and she was hypotensive and tachycardic. Differential diagnoses included recurrent urosepsis, UTI/pyelonephritis, or some unknown bacterial infection. Labs were drawn including blood cultures, CBC, CMP, and UA and she was placed on antibiotics (if I remember correctly 1 gm rocephin IM in the office, and po cipro and Septra DS). Consideration was given to admitting her to the hospital but she declined and agreed to have someone with her through the night, increase her po fluids (she was also given Zofran) and to present to the ER if she was not able to keep flu ids down or her symptoms did not improve. She was instructed to follow up in the office the following day. On return to the office she had developed an erythematous, macular-papular indurated rash around a small pimple in her groin where she had recently shaved. These symptoms were not present on her first office visit so cellulitis was not included in her differential diagnosis. Following her surgery, chemo and radiation therapy, she had suffered from significant lymphedema to her groin and extremities and her bodies reaction to an infected hair follicle was exaggerated as a result. Despite being tripped up on the differential diagnosis, I believe this example illustrates initiating diagnostic strategies based on appropriate differential diagnosis. 26 March 2012, 2nd submission: Initiating diagnostic strategies appropriate to differential diagnosis is evident in daily practice. Examples of meeting this outcome are demonstrated in the many patients who present with URI symptoms. Based on the patient’s presenting symptoms, diagnostic strategies such as strep screen, flu swab or mono spot are initiated as appropriate. Another example in which this outcome is demonstrated is with the 92 year old female who presented with sudden onset of abdominal pain localized to the RUQ. On exam, she had a positive Murphy’s sign, tenderness and guarding on her right side. Her surgical history included appendectomy and hysterectomy. Differential diagnoses included cholecystitis, acute pancreatitis, gastric ulcer, bowel obstruction, and GI malignancy. Based on her presenting symptoms, history and physical exam, a CBC, CMP, amylase and lipase lab work were ordered. She was sent home with instructions to return or present to the ER if her symptoms returned or worsened. An abdominal sonogram was scheduled when her lab work showed a mildly elevated alkaline phosphatase, bilirubin and aminotransferase. 26 April 2012, 3rd submission:Initiating diagnostic strategies appropriate to differential diagnosis has continued to be met as evidenced by ordering an x-ray of for an 18 year-old male who came in following an injury to his left hand after striking a wall. He had ecchymosis and edema over the 4th and 5th MCP joints. My differential diagnoses included boxer’s fracture and contusion. His x-ray was negative leading me to diagnose him with a contusion; he was sent home in an ace wrap with instructions to RICE. Throughout the semester I have effectively met this outcome with similar examples. The main concern I have is fear of not initiating a diagnostic study that I should have thought to do. Due diligence to consult available resources used frequently, such as Epocrates, and consulting the collaborating physician or peers when there is concern or question will aid in ensuring this outcome is always met.______________________________________________________________________________9. Develop a plan of care utilizing evidence-based practice □ □ □ □ □ √27 February, 2012, 1st submission:Evidence based practice is effectively incorporated in developing the plan of care for all patients. I honestly can’t think of a patient in which EBP is not used in the care of a patient. In terms of resources used, Epocrates Online is probably the most common resource used to look up medication dosages, interactions, safety and side effects as well as diseases and recommended treatment and differential diagnoses. On line resources such as Up to Date, ARHQ, and the CDC website are frequently accessed for practice guidelines. Other sources of EBP used in this clinical setting included Buttaro and The Sanford Guide. I also frequently refer to Mosby’s physical exam pocket handbook that I purchased for Adv. Health Assessment especially when I’m about to do an exam that I don’t often do such as the Neer or Hawkins exam of the shoulder. My preceptor and I recently researched the ATP guidelines for treatment of elevated LDLs last week for a patient my preceptor had seen. We also utilized Up to Date to research oral treatment recommendations for a client who had onychomycosis of their toenails. My preceptor has provided me with various copies of resources she references to appropriately treat abnormal PAP results as well as an algorithm for treatment of hypothyroidism. She often references Essentials of Musculoskeletal Care as well which is a resource I’ve identified I need to get. 26 March 2012, 2nd submission:Evidence based practice continues to be effectively incorporated in the care of each patient in developing the plan of care. Again, the before mentioned case study patient diagnosed with WPW syndrome is a perfect example of meeting this outcome. Up To Date and Mayo Clinic were accessed to inform myself about the diagnosis of WPW to develop the patient’s plan of care and to provide the family with basic information about the diagnosis and it’s treatment. In this example, expert consultation was also utilized to develop the plan of care for this patient by consulting the collaborating physician and pediatric cardiologist. The EBP resources mentioned in the first submission of this CPT continue to be utilized each day. To this list I would add Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. This resource has been utilized frequently to make a diagnosis and develop a plan of care. An example of utilizing Fitzpatrick’s includes a 7 year old who presented with her mother who reported fever, malaise, headache and cough x 2 days. On initial exam, she was noted to have erythematous plaques on her cheeks. Reticulated, erythematous macules were also noted on her chest and arms. Based on her presenting symptoms and exam, Fitzpatrick’s was consulted to confirm differential diagnosis of Erythema Infectiosum or Fifth Disease and to develop the treatment plan for this patient. The pictures in Fitzpatrick’s were shared with the mother along with the treatment plan of symptomatic management.26 April 2012, 3rd submission:Evidence-based practice has been incorporated in developing a plan of care for all patients during this practicum. The resources mentioned in previous submissions have been a huge part of my care during this practicum. I used to worry about how I would ever remember all I need to know to be a good FNP. I still worry about it, but I have great comfort in knowing there are great resources providing evidence-based practice guidelines and I know what they are and where to find them. As time passes, additional evidenced based practice resources will likely be incorporated in my care. The AHRQ screening guidelines app mentioned in a previous outcome can be added to the list of resources utilized. As an example, I used the AHRQ app to help a woman in her mid-forties understand what screenings she should anticipate in the future. We plugged in her information and based on the recommendations planned a lipid disorder screening and mammogram with her well woman exam and CBE. __________________10. Prescribe medications based on cost, diagnoses, □ □ □ □ □ √efficacy, safety, and individual patient needs27 February, 2012, 1st submission:As I reflect on this outcome and compare my performance to last semester, I have with certainty, improved in my ability to recommend medications based on diagnosis, efficacy, safety, cost and individual patient needs. The first thing I check and verify with the patient is medication and food allergies. Then I look at the medications they are currently with consideration of interactions and contraindication, followed by determining the most efficacious medication for their condition. Cost is usually the last consideration only because the majority of patients in this clinic do have insurance, however, if they don’t, I will look up the cost of a medication in Epocrates while my preceptor calls their pharmacy for local pricing. As an example, I saw a teenage patient who had been seen two times previously in the past month for cough, nasal congestion, fever, and viral- type symptoms. Her mother states she had not given her Mucinex as recommended on her previous two visits because she could not afford it. I made the decision to treat her with an antibiotic based on her exam and ongoing symptoms. Amoxicillin 500 mg TID dosing was chosen because that dose was on the $4 list at Wal-Mart. I informed the patient and her mother my rationale in prescribing that dosing regimen, which required TID dosing vs. BID dosing for a stronger dose and asked the patient to assure me the TID dosing would work with her schedule. It can be challenging to take all these factors into consideration when prescribing medications but I believe I have consistently been able to meet this outcome with some guidance from my preceptor based on her knowledge and experience and available resources.26 March 2012, 2nd submission:Prescribing medications based on diagnosis, cost, efficacy, safety and individual patient needs can be demonstrated with every patient for whom medications are prescribed in this practicum. Epocrates is the primary EBP resource utilized when medications are prescribed. Meeting this outcome is demonstrated in the care given to an uninsured 49 year old female who presented to the clinic with a congested, productive cough of green sputum, fever and feeling SOB x 2 weeks. Lung sounds were course on the right and diminished in the bases, O2 saturation was 95% on room air. She had a history of asthma and was using her albuterol inhaler 3 to 5 times each day compared to previous use of once every other day. Diagnosis was based on her presenting symptoms and exam. A chest x-ray was offered for confirmation of pneumonia but declined due to her financial status and lack of insurance. Consideration of medication treatment was given to prescribing an effective antibiotic in treating community-acquired pneumonia that was inexpensive. Doxycycline, which is on the $4 Wal-Mart list, rather than the more expensive option of Azithromycin, was chosen for medication treatment of this patient’s diagnosis. Consideration of safety is also given with each prescription by verifying patient allergies and current medications to ensure there are no contraindications related to allergies or drug interactions with the newly prescribed medication. Current medications are also reviewed with each patient visit and consideration is given to whether their presenting symptoms are a result of the patient’s medication. An example of this is a 42-year old female who presented with a sensation of a foreign body in her throat and hoarse voice x 2 weeks. She described a feeling of having “something hanging down on my vocal cords”. In reviewing her medications she was noted to be on Lisinopril for the past 2 months. In developing differential diagnoses, consideration was given to side effect of angioedema related to Lisinopril. As a result, she the Lisinopril was stopped to see if her symptoms resolved. 26 April 2012, 3rd submission:Prescribing medications based on cost, diagnoses, efficacy, safety and individual patient needs has been an ongoing consideration in my care. One patient presented with a request for medication refills that were prescribed by another provider in the town she previously lived in. She was requesting refills on Ritalin ER and Wellbutrin but she was uncertain about the dosages. Both my preceptor and I had concerns about filling the Ritalin because she was a newly established patient. This required legwork to ensure we received the appropriate records from the previous prescribing provider and a call to the pharmacy where she had her meds filled previously to ensure we prescribed accurately. This example demonstrates diligence in ensuring the appropriateness of her being on these medications as well as ensuring the appropriate dosage was prescribed. Prescribing medications is a part of my practice that is taken very seriously; ensuring safety, efficacy and accuracy cannot be over emphasized. In my practice as a RN, I made one medication error that scared the living life out of me and I am resolved to carry that fear with me into my future practice as an APRN to provide the safest, most effective care possible._____________________________________________________________________________11. Perform medical and surgical procedures as appropriate □ □ □ □ □ √27 February, 2012, 1st submission:Meeting this outcome make me smile! I love to do anything that is procedural or invasive on a patient such as suturing wounds, injecting joints, lancing abscesses or even simply freezing warts. A few weeks ago, a woman presented to the clinic with a labia that, in my preceptor’s words, “resembled a testicle”. It was markedly erythematous, indurated and painful and covered the majority of her left labia majora. It initially appeared as a “pimple” 2 days prior and had grown and become much more painful after the patient (who is a health care worker) attempted to “squeeze the heck out of it”. Because it was not very fluctuant, my preceptor didn’t think we would get much out of it so we elected to use an 18 gauge needle rather than a knife blade to open the abscess. It seems rather insignificant, but it was satisfying to express a large amount of purulent drainage while at the same time providing pain relief for the patient. I’ve also had the opportunity to perform a few digital blocks to remove a splinter and abscess under a patient’s nail bed and I did a steroid injection on an elderly ladies arthritic knees. I wish there were more procedural opportunities or opportunities to suture lacerations but I’ll probably manage.26 March 2012, 2nd submission:Performing medical and surgical procedures as appropriate continues to be one of the favorite aspects of the clinical practicum. I have had the opportunity to perform steroid injections for osteoarthritis symptoms of a knee joint for at least four patients. The technique used each time is one my preceptor learned at an orthopedic conference that is very simple and effective. On two occasions, I saw the patients in clinic for other reasons and was pleased to hear the joint injections were effective in relieving their joint pain. 26 April 2012, 3rd submission;Again, this outcome has been my favorite because it allows me to describe what I like doing most. I have had the opportunity to remove a foreign body from a construction workers eye using a magnet and more recently drained an abscess on the arm of a 4-year old. According to the mother, the child refused to let anyone touch her arm so I was prepared for a bit of a struggle by calling in reinforcements. Amazingly, with the use of distraction, I was able to lance the abscess with an 18-gauge needle with the return of a significant amount of purulent drainage that was sent for C&S. If there is one thing disappointing about this practicum, it is not having had more experiences in performing procedures such as suturing lacerations, but the experience I have gained has been valuable. I was hopeful to have the opportunity to perform an endometrial biopsy on a 50 something woman who presented with uterine bleeding after having been without a period for over one year. I was so prepared to perform this procedure…I arrived early that day to read from my preceptor’s procedure book how to perform the procedure and practiced using the device used to obtain the biopsy. Unfortunately, the patient requested my preceptor perform the procedure; disappointing but understandable. Future practice will likely give me additional opportunity to perform medical and surgical procedures.12.Interpret patient responses to treatment and recommend □ □ □ □ □ √changes to the treatment plan as indicated27 February, 2012, 1st submission: Most patients are instructed to follow up by returning if symptoms persist or do not improve. Patients like the young woman mentioned in outcome # 8 who was thought to be uroseptic (her urine was clear BTW on dipstick analysis and did not grow anything on culture) was seen the following day in the clinic and had marked improvement of her symptoms probably because she was on Septra DS and had been given Rocephin. It was in follow-up that she revealed she had broken out in a rash in her groin, a symptom that was not present the previous day. Follow-up with the patient who presented with chest pain was done in the hospital. She demonstrated much improvement and went home on meds to control her GERD the following day with instructions to follow-up in the office in 4 to 6 weeks. There are several patients who are scheduled for follow-up after being placed on medications such the young woman who was started back on Levothyroxine after her TSH came back elevated.26 March 2012, 2nd submission:Ongoing evaluation of the patient’s response to treatment allows for identification of needed changes in the treatment plan. There are many ways to evaluate a patient’s response to treatment. Subjective and objective assessments obtained during the history and physical exam, combined with findings from lab and diagnostic exams, will most likely give the best indication of the patient’s response to treatment. When prescribing medications such as antibiotics during this clinical experience, patients are instructed to call back if their symptoms do not improve after 48 hours on the medication. Providing this education allowed the patient to be seen for follow-up to re-evaluate the treatment The patient described in outcome #10 on Lisinopril is an example of interpreting patient response to treatment and recommendation of change to treatment plan. A possible adverse reaction to the medication was identified and the medication was stopped followed by relief of symptoms. An alternative medication for control of BP was subsequently prescribed. Often patient’s who present with symptoms of bronchospasm or asthma exacerbation are given an albuterol and atrovent nebulizer treatment in the office and the effectiveness of the treatment is evaluated. Another example is a young woman in her 30s who presented with symptoms of being easily fatigued, mildly depressed with recent unexplained weight gain. She was placed on levothyroxine after being diagnosed with hypothyroidism based on symptoms and an elevated serum TSH. Her TSH was measured 4 weeks after initiation of therapy and adjusted to incrementally to normalize her TSH level. 26 April 2012, 3rd submission:Interpreting the patient’s responses to treatment and recommending changes to the treatment plan has been effectively met during this practicum. One patient that can be used to illustrate meeting this outcome is a 44 year-old who was seen because she was experiencing dizziness at work when bending over with a sensation of the room spinning. She was currently on antibiotics for a sinus infection, which she said was improving. The Dix-Hallpike maneuver elicited nausea and 2 to 3 beats of nystagmus to the left. The Eppley maneuver was then performed with relief noted of her symptoms in the office. She was given a handout on how to perform the maneuver at home to relieve her symptoms by repeating 2 to 3 times per day. This example also illustrates meeting other outcomes including outcome 11 that addresses performing medical procedures such as the Eppley maneuver. ____________________________________13.Document using professional terminology, □ □ □ □ □ √format and technology (ie: ICD9, E/M coding, CPT)27 February, 2012, 1st submission:In this clinical setting, SOAP notes are dictated and placed in the patient’s chart. I’m very grateful to have the opportunity to be able to use this type of documentation but I have to admit, it was very intimidating initially. Because I felt so intimidated and disorganized with my first few attempts at dictating SOAP notes, I felt like I needed a guide to help me organize my health history and physical assessment so I could dictate in an organized fashion. Hence, I created a one-page cheat sheet that I use as a guide during my assessment, primarily to take notes so I remember everything I need to dictate. It also is a visual reminder during my assessment to ask appropriate questions. Often, I jot notes while I’m obtaining subjective HPI from the patient and then jot notes about my physical assessment after I leave the room. It also suffices to record the information needed to enter elogs including E/M and CPT codes ,which I usually look up later using an app on my phone based on my assessment. It’s been very helpful to me in organizing my thoughts to dictate. I’m always very impressed that my preceptor can see a few patients and go back later in the day to dictate and remember everything. My goal is to get to that point but that may be awhile. I’ve talked with some of my peers about using this guide sheet. In my current practice as a staff nurse, I can rattle off several questions when obtaining my assessment on patients in the ER and go back later and document my findings later without taking notes. Maybe it’s just fear of forgetting something important in my documentation or insecurity in my new role and new method of documentation (which I really like by the way) but, my goal is to become more organized in my mind so that I can dictate in an organized fashion without the use of a cheat sheet to keep my organized. The transcriber makes a copy of all my dictations for me and my preceptor to review each day. I can tell I’ve made great progress in improving my dictations already. I think I’ve done well using professional terminology but there have been a few times I’ve caught myself using incorrect terminology. For, example, I used “shingles” in my dictation rather than “Herpes Zoster”. It really helps to go back and read what you spoke. Sometimes I think “did I really say that”? And I’m sure the transcriber loves me…thank goodness she leaves all the “uhhhs” out of my dictation.26 March 2012, 2nd submission:I have made significant improvement in my ability to document using the technology of dictating SOAP notes in this clinical setting in addition to use of appropriate professional terminology. I recently reviewed SOAP notes from my first week in this clinic and then reviewed my recent documentation. It was rewarding to realize a significant improvement in regard to using more succinct wording, descriptions and professional terminology in my transcribed dictations. Even more rewarding was having the transcriber tell me I’ve improved a great deal as well. I’ve also noticed that I am no longer intimidated to dictate and the words seem to flow easily as I dictate in manner that is organized and yet succinctly detail oriented. Further, I’ve noticed that I rely less on my notes as I am more organized and better able to “see in my mind” what I want to dictate. Occasionally, I have to look up appropriate terminology but I consistently use appropriate terminology in my documentation. Identifying appropriate E&M, ICD9 and CPT codes is also becoming a consistently easier, more accurate process. My level of understanding of ICD9 and E&M coding has improved significantly since the beginning of my first practicum experience. In the beginning, I had several questions about coding. As time has passed and I have gained more experience, it has become much easier. One important consideration when documenting is to avoid any appearance of fraud and to ensure the practice is reimbursed correctly for services provided. Documentation goes hand in hand with coding in that the documentation must reflect what is being coded or billed for. 26 April 2012, 3rd submission:I was very surprised, yet pleased on the last day of my practicum when the transcriptionist gave me a big hug and said, “you struggled a little at first with dictating but I have been very impressed with how thorough you are...your patients will be lucky to have someone as thorough as you caring for them”. She also said she had to look up several new words she’d never heard before. It made me laugh but at the same time it confirms that I’ve successfully met this outcome. _______________________________________________________________________14. Recognize need for referrals by collaborating □ □ □ □ □ √and consulting with members of the health care team_26 March, 2012, 1st submission:Recognizing need for referrals by collaborating and consulting with members of the health care team is again demonstrated with the case study WPW patient. Other examples include a number of patients who were referred to an orthopedic surgeon for various orthopedic related injuries and complaints. A 35 year old woman who works with her hands in a local manufacturing business was referred to a neurologist for EMG for symptoms of carpal tunnel syndrome which included numbness and tingling of her hands that seemed worse at night and + Tenel and Phalen signs. After EMG indicated median nerve damage and conservative measures were unsuccessful, the patient was referred to an orthopedic surgeon. Another patient with knee pain and edema following a twisting injury and subsequent instability and “popping” had a whose normal knee x-ray. MRI indicated a medial meniscus tear and consult with an orthopedic surgeon was arranged. A 7-year old patient brought in by his mother with concern related to the size of his tonsils was referred to an ENT specialist. On exam his tonsils were 3+ on the right, 4+ on the left and “kissing” each other. Although he had only presented with tonsillitis and strep on two occasions in the past two years, there was concern by history of airway obstruction at night with snoring and difficulty swallowing and choking on certain foods such as meat. He was referred to ENT who recommended tonsillectomy.26 April 2012, 3rd submission:I am confident I have been able to effectively recognize the need for referral and consult with other members of the team. The gentleman with the abnormal prostate exam is an excellent example of meeting this outcome. In addition, the post menopausal woman who my preceptor performed an endometrial biopsy on was referred to an Ob-GYN for follow up based on the result of her biopsy. Another patient in her mid-thirties with an abnormal PAP (ASCUS) was also referred to an Ob-GYN for colposcopy. I knew immediately the 24 year old with cellulitis and an open wound in her antecubital fossa was going to be admitted to the hospital with a surgical consult. I am always willing to seek second opinion from my preceptor about my findings on exam and have done this on multiple occasions, especially with dermatological conditions. Collaboration with other health professionals is an integral factor associated with the FNP role to ensure safest, most effective care for patients and will continue to be a part of my practice._____________________________________________________________________________15. Discuss access, cost, efficacy and quality when □ □ □ □ □ √making care decisions26 March 2012, 2nd submission:Consideration is given to access, cost, efficacy and quality with each patient encountered. Patients are given recommendations or suggestions for their treatment with consideration of insurance coverage or ability to pay out of pocket with careful thought in ensuring the most efficacious treatment and quality care. One example is of a 48 year old male who had returned with ongoing ankle pain resulting from an injury that occurred years prior. He works as a farm laborer and was seen in the clinic one month prior for ankle pain and increased swelling when an x-ray was recommended. Due to being uninsured, he elected to try pain medications and conservative, less costly measures. He was given Naproxen and Lortab at that time with instructions to return if his pain persisted or worsened. On return, he was having significant pain and swelling and requested an x-ray. The x-ray confirmed a severely deformed, arthritic ankle with evidence of previous misaligned, healed fractures. Referral to an orthopedic surgeon was recommended, unfortunately, the orthopedic surgeon declined to see him due to an outstanding, unpaid bill. Referral to another orthopedic surgeon was accepted and he is planning to have an ankle arthrodesis in the near future with help from his employer in paying the bill. He was grateful with the willingness to refer him to another orthopedic surgeon who was willing to work with him. This was a hard working, sincere person who was trying to make an honest living, working in an environment that had to contribute to the pain he experienced. It was rewarding to know he would be able to receive appropriate treatment for his pain.26 April 2012, 3rd submission:Consideration of a patient’s access to health care combined with cost, efficacy and quality was given to each patient. It can be a challenge to offer the best care when a person’s resources are limited by lack of insurance or financial resources. I sometimes struggled with the fact it seems unfair to be able to offer one patient an MRI to diagnose the cause if their knee pain while another patient without insurance may not be able to afford it. Nonetheless, the goal is always to provide a well thought out, individualized plan that will ensure the most efficacious, affordable, quality plan of care. The other part to this outcome is giving the patient autonomy in making an informed decision about their plan of care. The options are outlined and the patient is given the option to choose the direction of their care. Often, there are several possible options to offer that effectively meet the patients needs. As health care providers, we are sometimes forced to practice defensive medicine when in fact our assessment skills often provide us with enough information to treat the patient safely and effectively without using expensive diagnostic studies such as an MRI to determine a plan of care. ______________________________________________________________________________16. Perform care in a timely manner □ □ □ □ □ √26 March 2012, 2nd submission:Performing care in a timely manner was something I really struggled with last semester. In the current practicum I have been consistently successful in accomplishing this objective with minimal difficulty. I’m conscientious about ensuring I stay on schedule and don’t hinder the progress of the patient schedule. Most days I feel like I’m helping to keep the clinic schedule on time rather than delaying it. Meeting this outcome effectively can be attributed to working in a more organized approach and developing the ability to maintain the focus of the visit. I’m aware of patients who bring up multiple complaints other than the initial stated complaint and when appropriate, I suggest their additional concerns be the focus of another visit if reasonable. I try to utilize time between patients effectively by dictating on each patient so I’m not behind at the end of the day. 26 April 2012, 3rd submission:I have been pleased with my progress in performing care in a timely manner during this practicum experience. I have continued to be conscientious of the time spent with patients and have become effective in guiding the HPI to stay focused on the stated complaint. I was able to consistently stay on schedule and when circumstances out of my control, such as add on patients, threw me off I was able to catch up, complete dictations during down time and leave on time. ______________________________________________________________________________17. Maintain confidentiality and privacy □ □ □ □ □ √26 March 2012, 2nd submission:This outcome has consistently been accomplished in this practicum experience. As an example, I identify and log each patient by a chronological number with an associated date. The notes I take to help me log each patient have no specific patient or clinic identifiers other than the assigned chronological number. Discussion of patient is limited to a private area, such as my preceptor’s office, or behind a closed door in a softened tone of voice. 26 April 2012, 3rd submission:I have consistently maintained privacy and confidentiality of patients cared for in this practicum without guidance from my preceptor. Meeting this outcome is a priority in every health care environment. Discussion of patients outside of the exam room was carried out in the privacy of my preceptor’s office in a low tone of voice. As a provider, this will always be of significant priority in the care I give. _________________________________________________________________________18.Demonstrate professional behavior □ □ □ □ □ √26 March 2012, 2nd submission:Professional behavior is a consistent behavior I easily demonstrate and deem a priority. My dress attire and actions are professionally appropriate manner and I adhere to clinic and the school of nursing policies. My interactions with patients, preceptor and clinic staff are performed with the intent of always being professionally kind, courteous and respectful. 26 April 2012, 3rd submission:Professional behavior continues to be a priority and I have continued to demonstrate it as mentioned above. Because I have consistently maintained a high degree of professionalism, I have been able to establish professional relationships that will likely continue beyond this clinical experience with my preceptor and other providers in this clinic, including the physicians and other APRNs. Our profession demands providers to be responsible, accountable, motivated, and self-directed individuals. Professionalism speaks to being responsible and accountable for individual nursing practice including a responsibility to maintain a sense of integrity, trust, safety, competence, and to continue to progress in personal and professional growth. In this clinical practicum, I have demonstrated professionalism by arriving promptly to each clinical experience prepared for the day. I have exhibited courteous behavior to patients, staff, my preceptor and other providers and maintained a high level of integrity and competence resulting from a desire to learn and further my personal and professional growth. ______________________________________________________________________________20. Employ effective communication methods with patients, □ □ □ □ □ √families, preceptor, and staff26 March 2012, 2nd submission:Effective communication is required for success in healthcare. I am an effective communicator with all members of the health care team in the clinic setting as well as with patients, family members and school of nursing faculty. With patients it is important to communicate in terms they can understand and comprehend, however, that can be a great challenge when there are communication barriers such as language or hearing. I have developed a good rapport with many patients and helped them to feel comfortable and at ease despite the fact they get a little uneasy when their regular provider (my preceptor) doesn’t come into the room initially. Effective communication methods commonly incorporated with patients/families, clinic staff, including my preceptor and faculty include good eye, active listening, summarizing and repeating what was said and often times a little light-hearted humor when appropriate. Most of the time, my humor is directed at making fun of myself or giving examples of my personal experiences when appropriate. I try to be aware of non-verbal communication such as posture, facial expressions and general professional appearance. I commonly use phrases such as, “Just so I’m clear, you just said….” or “Can you describe to me what that pain feels like”. Often, I relate personal experiences related to weight issues and exercise or experiences with my children in relation to childhood illness as an opportunity for education. Use of personal experience often eases the patients concern for their personal experience.In communicating with my preceptor I have worked at being succinct, straightforward, clear and concise in the delivery of my exam findings and recommendations for treatment. 26 April 2012, 3rd submission:Effective communication is an integral part of this profession. Effective communication requires using a variety of tools and techniques, some of which are discussed in the above examples, in an effort to gain trust, respect and participation in conversation with patients, families, staff, faculty and preceptors. In most instances, I have a good intuitive sense of what will be effective or ineffective in terms of communication based on the other person’s response or presentation. If a patient can relate to something positive in another person, it helps the patient feel more at ease with their personal situation or concern. A positive, confident and calm presence in all circumstances creates an environment conducive to effective communication. I have been successful in demonstrating effective communication throughout this practicum by utilizing appropriate techniques and demonstrating an awareness of my personal presentation. My preceptor has been an excellent role model for me in demonstrating effective communication. I have found myself modeling her communication style, which seems to be very effective in maintaining a rapport with her patients. Often, I have heard patients comment they really like her because she is “no non-sense” or “she gets straight to the point and doesn’t try to BS you”. Her mannerisms are laid back, yet you know she is solely focused on the patient based on her eye contact and use of appropriate touch. Recently, I had two patients tell me in the same day they liked me because I was a lot like my preceptor in that I was very thorough in my exam and questions and I was very informative and clear about what the plan was for their care. Another patient told me they hoped I could get a job in that clinic because they really liked me as I reminded them of my preceptor whom they really like. I consider their comments to be great complements as I have a high degree of regard and respect for my preceptor’s communication style and approach to caring for her patients. They also confirmed my ability to communicate effectively.Although I can only recall one patient who did not speak English during this practicum experience (a 16-year old newly transplanted from Russia with his mother and her new husband), in the future, depending on where I practice, I would likely benefit from learning Spanish. Learning this language would allow me to communicate more effectively with the Hispanic population that seems to be growing in areas where I may practice. ______________________________________________________________________________21. Provide culturally competent care to patients □ □ □ □ □ √and families and negotiates a mutually acceptableplan of care26 March 2012, 2nd submission: Providing culturally sensitive care in this clinic setting has been met with success. This clinic is considered a rural area with a local critical access hospital. The variety of ethnic cultures represented in this clinic are not as varied compared to my previous practicum experience, however, this rural setting has provided the opportunity to provide culturally sensitive care to patients across the age continuum who face multiple challenges including disabilities, limited socioeconomic status or access to health care and even language barriers. This practicum has given me the opportunity to provide culturally sensitive care to a diverse group of patients and families. One family presented an interesting cultural challenge when they brought their teenage son in for a school sports physical. The father was a bachelor local farmer in his early 50s who had just married what the community called a “mail order bride” from Russia. The bride came with a 16-year old son who was now in the local school system. It was a challenge because I speak no Russian and the husband didn’t speak it very well and he was the best available interpreter. I asked the new father what they were doing to help him adjust to a new country, new language, new culture, new everything. His response was just to take each day as it comes. I suggested they meet with the school counselor for guidance in making the transition easier for the patient. It was a very interesting and challenging encounter in that I felt communication was limited but I had personal concern for how the patient would adjust to so many new changes but the new Dad really didn’t seem to think there would not be any problems. And maybe he was right…kids are very resilient and seem to tolerate more than adults.I am most taken back by the number of patients with limited resources who are challenged to make ends meet and take care of their health due to lack of resources. Personally as well as professionally, it is a great experience to be able to provide care to these patients due to the challenges it created. I have become more sensitive to the needs of this rural patient population and developed a better understanding of the loop-holes and hoops that have to be maneuvered in an effort to provide these patients the best and safest care possible. 26 April 2012, 3rd submission:Providing culturally competent care to patients and families and negotiating a mutually acceptable plan of care has been accomplished during this practicum experience. Culturally competent care requires a commitment to understand and be responsive to the different attitudes, values, verbal cues and body language. Cultural competence includes understanding the different ways patient act in a clinical setting and communicating effectively with patients to ensure the best possible clinical outcomes. Although the culture of this community was primarily that of a population of lower to middle class working, white Americans in a rural community, I intuitively understand their value systems and traditions from having grown up in a similar community. Several members of this community were farmers or grew up on a farm with a strong work ethic and only accessed health care when it was absolutely necessary. Local manufacturing facilities also employed a large portion of the population, creating many blue-collar jobs for members in the community. One patient, who was a local farmer, came in with an injury to his back that was limiting his ability to work in a season when there was a lot of work to be accomplished. He was in his mid-fifties and had only been seen in the clinic a few times for injuries or illnesses that limited his ability to work. After evaluating and offering treatment for his stated complaint I encouraged him to consider making an appointment in the near future for a routine health exam that included lab, prostate exam and other screenings recommended for his age. He acknowledged the need to do that but he had put it off for several years. He did agree to make an appointment for later in the year after fall harvest and planting. This example demonstrates my ability to recognize and establish an acceptable plan of care that met the values and attitudes of this individual who was committed to his work as a farmer. ______________________________________________________________________________22. Communicate practice knowledge effectively both □ □ □ □ □ orally and in writing26 April, 2012, 3rd submission:I have been able to communicate practice knowledge effectively during this clinical experience as evidenced by this outcomes evaluation and in communications with patients and my preceptor. The examples provided in this clinical performance tool demonstrate my increasing practice knowledge. I have been able to effectively communicate the findings of my PE and history as well as recommendations for treatment. My patient documentation also reflects my ability to communicate practice knowledge effectively. As I’ve completed this evaluation and read back through my previous evaluations of each of the outcomes, it is clear that I have progressed in practice knowledge and my ability to communicate effectively. With the help of my instructor and preceptor, my ability to communicate practice knowledge effectively via oral presentation has developed greatly this semester as well. I have used SBAR (Situation, Background, Assessment, Recommendation) format when presenting patients to my preceptor and it seemed to be effective and concise. Again, the comments made to me by the transciptionist in this clinic confirm my ability to communicate practice knowledge effectively.______________________________________________________________________________23. Apply available evidence to continuously □ □ □ □ □ improve quality clinical practice26 April 2012, 3rd submission:I have practiced using best available evidence by using resources that are reputable and the newest edition available. Examples of resources utilized on a daily basis for most patients include Epocrates, National Clearinghouse Guidelines, Up to Date, as well the newest editions of the Sanford, Tarascon Pharmacopeia, Butarro, Fitzpatrick and Ferri’s. These resources provide the best available evidence and were referenced frequently to improve the quality of my practiceMy increased sense of confidence is probably the best indication of improved quality of my clinical practice. The opportunity to practice everything involved in providing care to patients has helped in building that sense of confidence. Feedback from my preceptor and patients has also been an indicator of my improved quality in clinical practice. It was so gratifying to have more than one patient tell me they wanted me to be their NP in future visits. The feedback from my preceptor, both verbally and in her final written evaluation of me, demonstrates my growth in the quality of my clinical practice. In a note given to me on the final day my preceptor wrote “your nursing experience is great and you will be a great nurse practitioner”. Coming from a nurse practitioner who I greatly respect, her message was very reassuring. Other providers in the clinic were aware of my enthusiasm and desire to learn and were always willing to look for me when there was an interesting case to share. In an effort to improve the quality of my practice, I will continue to utilize every resource and reference available to make sure I have thought of everything in my approach to caring for a patient. As an example, before I would see a patient, I would look up their condition or stated complaint in an available reference, usually Epocrates, to ensure I incorporated all appropriate assessments, differential diagnoses, etc in my care. If they came in with complaint of shoulder pain, I would pull out my Mosby’s Physical Exam handbook and review techniques to examine the shoulder. I did this to ensure I didn’t leave any stone unturned in my assessment and to ensure I was performing exams correctly. Additionally, I will continue to graciously accept constructive criticism from preceptors, instructors, and peers to improve the quality of my practice.______________________________________________________________________________24. Utilize appropriate agency educational tools □ □ □ □ □ to provide effective, personalized health care topatients and caregivers26 April 2012, 3rd submission:Utilizing appropriate agency educational tools to provide effective, personalized health care to patients and care givers can be demonstrated by care provided to two patients seen in clinic on the same day with symptoms consistent with thoracic outlet syndrome. Information from “Essentials of Musculoskeletal Care” was copied and given to the patient that included exercises that could be used to relieve the symptoms. On another occasion, a patient with carpal tunnel syndrome was given a copy of information from the same source related to carpal tunnel syndrome. Fitzpatrick’s was another agency educational tool utilized frequently for patients presenting with dermatological conditions. Often, this book was taken into the room to show the patient pictures, descriptions that were consistent with their condition and recommended treatments. An example of this was an elderly lady who presented with a rash on her chest and arms consistent with lichen planus. We looked it up in Fitpatrick’s and took the book into the room to show her the pictures and treatment recommendations. The internet was another agency tool frequently utilized to educate myself as well as the patient and their family. On more than one occasion, I researched the patient’s condition and made copies from UpToDate or Mayo Clinic to give the patient in an effort to provide effective, personalized care. Other resources utilized were professional contacts such as drug representatives who provided literature on medications and local pharmacists who were frequently consulted about prescribing medications appropriately to meet the patient’s care needs. Recognition of and use of these tools in future practicums will continued to ensure effective, personalized patient care. ______________________________________________________________________________25. Coach the patient and caregiver for positive □ □ □ □ □ √behavioral change26 April 2012, 3rd submission: Coaching patients seems to go hand in hand with assessing and addressing a patient’s education needs. Coaching is the guidance provided the patient in an effort to assist them in improving their health status and has been incorporated in my care during this practicum by encouraging smoking cessation and offering measures to assist in smoking cessation. I made it a point to ask each patient if they smoked and how much each day. If they were smoking, I would ask them directly what their intentions were in terms of quitting or cutting back. If they indicated a definitive lack of interest, I would simply state that if they decided they were willing to give it consideration for the benefit of improving their overall health, they could be assisted in the clinic with various resources or measures based on their needs. Patients who were overweight were similarly asked about their desire to lose weight and measures taken to lose weight. If they did not have an interest or desire to lose weight, they were also encouraged to use the clinic as a resource in obtaining assistance when they were ready. Many patients who were overweight and desiring weight loss to improve their overall well-being were coached on weight loss and life style modification measures or use of available resources. One patient came in with concern because she had been exercising for almost two months and had not lost any weight but rather gained a few pounds. After reassuring her efforts were not in vain, we talked about how exercise should go hand in hand with maintaining appropriate calorie consumption. Her workout routine included lifting weights which could have been the cause of her weight gain in muscle mass. She had a smart phone with her so I had her download the My Fitness Pal application and instructed her to accurately track “everything” she ate as well as her exercise and follow-up in three months. I explained that using this tool would help make her aware of how she was doing in terms of meeting her goals for weight loss. I also encouraged her to exercise with a friend as evidence shows people who exercise or diet with a friend are held more accountable to meeting their goals. Offering praise for achieving goals and ongoing encouragement in meeting weight loss goals was incorporated in the care of this patient by focusing on her successes and encouraging continued strength and vigilance to meet her goals. She was receptive and grateful for providing her a tool to use to help focus her weight loss efforts and also identified further changes such as decreasing carbohydrate consumption, she could make in her diet to assist with weight loss. Coaching the patient and caregiver for positive behavioral change is a challenging task when considering emotional, cultural and spiritual needs. It can most effectively be accomplished by offering guidance and support to encourage positive behavioral change. It may involve referral to community resources, support groups, clergy, counselors or providers who may be more experienced or effective in meeting the patient’s needs. There were a number of patients in this clinic who were seen for emotional or mental health issues. I assisted in providing care to a 14-year old patient who was seen in the clinic the last day. She came in alone with a typed list of symptoms she had been experiencing which she thought were consistent with hypothyroidism. During our discussion, she seemed very sad and I thought it was strange that she came in alone while her mother waited in the waiting room. It all came down to the fact she was severely depressed with suicidal ideation and a well thought out plan. She was tearful, scared and reluctant to tell her mother or seek professional help. I recognized the need to pull my preceptor in for assistance in assuring this patients needs were met. It took some coaching on our part to encourage this young lady to talk with her mother and seek help for her mental well-being but we eventually were able to help her talk to her mother who was shocked and willing to help her seek the help she needed. Her mother took her immediately to a local agency for screening by a mental health provider. In this example, we were able to give support and encouragement to this young lady and her mother and direct them to a provider capable of helping her meet her mental health needs. ______________________________________________________________________________26. Demonstrate information literacy skills in complex □ □ □ □ □ √ decision making26 April 2012, 3rd submission:Information literacy in this clinical practicum has been demonstrated by my ability to define patient problems and apply a systematic approach to obtaining a detailed history and performing a physical exam based on their presenting problem. Processing the information obtained from this process was evaluated to develop complex decisions regarding the patient diagnosis and most effective treatment plan. Meeting this outcome has been demonstrated with all patients and is represented in the many examples provided in this evaluation.My preceptor was always impressed with my ability to utilize technology to assist me in my care decisions. I effectively demonstrated my ability to obtain information from multiple resources to develop an individualized, well thought out plan of care for all patients.______________________________________________________________________________27. Integrate ethical principles in decision-making□ □ □ □ □ √26 April 2012, 3rd submission: The primary and basic ethical principles that I have integrated into the care of patients during this practicum include respect for patient autonomy, beneficence and justice. Integrating these principles ensures the best decisions are made for the patient, their health and well-being. Veracity and confidentiality and fidelity were also incorporated into the care of my patients. Respecting their sense of confidentiality and adhering to the truth in our relationship are ways in which I integrated these principles in decision-making regarding patient care. My actions in providing patient care have been with the intent of respecting their autonomy while providing care with a sense of kindness and consideration of decisions that will be of most benefit for the patient.As an example, I took care of a patient who presented with abdominal and back pain that had been present for over 6 months along with an unexplained weight loss. Her primary complaint was the back pain because it was limiting her ability to work as a painter. She was self-employed and had no insurance, smoked 1 ? ppd and had a strong family history of ovarian and colon cancer so I was very truthful with her in relating my concern. I was forth-right in telling her that any unexplained weight loss is cancer until proven otherwise. I presented her with my recommendations for diagnostics exams and lab work after discussing her case with my preceptor and allowed her the autonomy to make an informed decision. In this example, I demonstrated autonomy, beneficence and veracity._____________________________________________________________________________28. Demonstrate respect, compassion and integrity□ □ □ □ □ √26 April 2012, 3rd submission:Demonstrating respect, compassion and integrity in caring for patients is met without fail. Respect is demonstrated by a formal introduction of myself, either personally or by my preceptor. I explain my position as a student nurse practitioner working under the guidance of my preceptor and request their permission to provide their care. Respect was demonstrated by shaking hands or acknowledging, providing an introduction in a culturally sensitive and appropriate manner. Compassion comes from the heart. It falls in line with the Golden Rule to do unto others as you would have them do unto you. Sometimes patients can make it difficult to have compassion if their behavior is inappropriate or they are non-compliant, but I always try to remember that every person has a son, daughter, mother or father who loves them and desires them to be well. I try to put myself in the position of their loved one and approach care from that perspective. I would want whoever cared for me to have a sense of compassion regardless of my behavior or condition. Without walking in someone’s shoes, it’s difficult to know where they’ve been in life or where they’re going. I try to think of it as a privilege to help improve a person’s physical or mental state of well-being. A sense of integrity it key to developing a positive APRN/patient relationship. My desire to always portray a high level of integrity, respect and compassion will continue to ensure meeting this outcome.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 clientsX?Submission #1 after 60 hours of practicumStudent Signature___Jayne Dowell__________________Date___2/27/12_________________Faculty Signature______________________________________Date____________________Submission #2 after 120 hours of practicumStudent Signature___Jayne Dowell_____________________ Date___3/26/12____________Faculty Signature_____________________________________Date____________________Final SubmissionStudent Signature____Jayne Dowell____________________Date__5/4/12__________________Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade:November, 2011Revised 1/23/12 ................
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