Washburn University



Washburn UniversitySchool of NursingNU 607 Health Care Practicum II- Specialty (Family) Clinical Performance Tool(Completed by Student and Faculty)Student: Kathryn Hicks Semester: Spring 2013Agency: Shawnee County Health Agency (California)Instructor: Dr MansfieldClinical 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 a 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 experiencesCompetency NarrativeThe overall goal of the Clinical Performance Tool (CPT) is to assess the student’s progress throughout the practicum using a narrative description of each competency. To provide a description of the total progress, the student is expected to maintain a cumulative narrative of their performance. This is a self-assessment of performance and is considered as part of a total clinical evaluation by faculty and preceptors.With each competency and each submission, the student is expected to assign themselves a score from 0-5 (It is not expected that a student will have many scores of 4 or 5 with the first submission). Elements for each submission must be dated (colored ink is not available when the final CPT is printed out). Within the narrative, students are expected to briefly address the following 4 items: What does this competency mean? What challenges/strengths do I have related to mastery of this competency?Give 2-3 different examples for each competency that illustrate how you are performing the specific competency. New examples should be provided each time you score yourself in that competency area.What do I need to do to gain additional skills for this competency?What references/clinical guidelines/point of care tools have been helpful in the performance of this competency?GradingThe Clinical Performance Tool (CPT) is completed and submitted by the student. Submission one is due 2/22/13 and must address items 1-13. Submission two is due 4/5/13 and must address items 1-28. The final submission is due 5/3/13. The final submission is graded and must address all items. The first two submissions are formative and provide an opportunity for clinical faculty to guide the student. While the first two submissions are not graded, they must be turned in on time. Five points will be taken off the final CPT score for each day the first and second CPT submissions are late. The penalty for late assignments applies to the final CPT submission. 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 □ □ □ □ X/X Xprevention and health protection services for patients acrossthe life spanFirst Submission (2/24/13): A: Health promotion can be described as the application of practices that support physical and emotional well-being and increase the length and quality of life. Disease prevention focuses on helping people avoid contracting diseases, both in individuals and communities. Health protection works to prevent or minimize preventable illness or injury. Health protection is particularly concerned with risks to health over which individuals have little or no control, such as radiation, vehicle safety, disease outbreaks, or water quality. APRNs provide age appropriate health promotion, disease prevention, and health protection services for adults by identifying risk factors and accessing up-to-date, evidence-based resources, and then making recommendations based on those resources. Such recommendations might include positive lifestyle changes, appropriate screening examinations, and injury prevention. B: (2/24/13): On 2/6/13, I facilitated the ordering of a lipid panel for a 40 year old female patient to screen for hyperlipidemia because I identified her as having cardiovascular disease risk factors. Another example of health promotion services that I have provided occurred on 2/12/13 when I helped educate a 21 year old patient with asthma about smoking cessation strategies/recommendations and encouragement her to quit smoking. Additionally, on 2/18/13, I provided verbal and printed information on dietary and lifestyle modifications to a 22 year old female patient who was recently diagnosed with DM II.(3/29/13): On 3/19/13 I cared for a 72 year old female patient who came to the clinic for follow up on her asthma. In addition to monitoring her asthma, I made sure that she was up to date on all of the recommended health promotion activities for a woman her age. Her last mammogram was in 11/12 and was normal. She had not had a bone density test and needed lipids, TSH, and a Comp, so I made arrangements for her to get those done.On 3/28/13, I provided care to a 48 year old female patient who was being seen in the clinic for follow up on her diabetes and hypertension. I recognized that she hadn’t had a PAP or a mammogram for about 2 years. I sent a referral to the Women’s Health Clinic so she could have those done.(5/3/13): On 4/8/13 I cared for a 49 year old female patient who came to the clinic for follow up on her hypertension. In addition to monitoring her blood pressure and BP medication, I also checked to make sure she was up to date on her PAP and mammogram. I found no record of either in the electronic chart and the patient stated that it had been at least 2-3 years since she had them done. I explained that it was probably time to have those repeated and sent a referral for her to the Women’s Health Clinic.On 4/26/13, I cared for a 43 year old female that came to the clinic for follow up on her anxiety and for lab review. In addition to discussing her anxiety, we discussed her blood pressure (134/90) and that she needed to take steps to try to lower it with diet and exercise. We also discussed smoking cessation and I referred her to the Women’s Health Clinic for a mammogram and PAP, since her last mammogram was in 2010 and her last PAP was in March 2011. C: (2/24/13): I am continuing to familiarize myself with the appropriate health promotion/disease prevention interventions for each age group. Last semester, I created a tool for myself to use when I see patients. Among other things, it reminds me to look for dates of the patient’s last lab work, mammograms, PSAs, bone density tests, etc. That has helped me be more consistent in providing appropriate health promotion services. (5/3/13): At the conclusion of this clinical experience, I feel that I am able to consistently perform the objectives of this competency independently and proficiently. I use the ePSS app for almost every patient I see and try to cover as much health promotion/disease prevention as time allows. I will continue to strive to find ways to improve by actively looking for ways to provide age appropriate health promotion, disease prevention, and health protection services.D: (2/24/13): I have used the AHRQ ePSS app, the AAFP’s Summary for Clinical Preventative Services, the National Guideline Clearinghouse website, and our Ferry textbook as resources for meeting this competency.2. Develop individualized anticipatory guidance and □ □ □ □ X/X Xhealth counseling for patients across the life span. First Submission (2/24/13): A: Anticipatory guidance is defined as the preparation of a patient for an anticipated development and/or situational crisis. Health counseling is the procedure by which health care providers explain to patients the nature of health problems and aid in formulating a plan of action to solve the problems.B: (2/24/13): On 2/12/13 I helped care for a 56 year old female patient that had not been seen in the clinic for over 2 years. She was there for follow up on her diabetes, but while she was there we got her scheduled for a PAP, gave her instructions to come back in this month for lab work (fasting lipid panel, TSH, CBC, Comp, and microalbumin), and checked her blood pressure. On 2/19/13 I helped care for a 65 year old female patient who came to the clinic for follow up on ankle sprain. While she was there we checked her blood pressure (119/78), determined that her last colonoscopy was 2 years ago, and instructed her to come in this month to get lab work done (fasting lipids). (3/29/13): On 3/7/13, I provided printed and verbal information about high blood pressure to a 39 year old female patient diagnosed with hypertension during her office visit. I explained what high blood pressure is, why it is harmful, what her goal blood pressure is, and ways to decrease her blood pressure to reach her goal BP. On 3/28/13, I cared for a 58 year old African American female who came to the clinic for follow up on her hypertension. During the visit, I recognized that she had a significant family history of stroke. Her mother, father, and one of her siblings had all had strokes in the past. In addition to adjusting her medication to better control her blood pressure, I also started her on a baby aspirin daily. We discussed monitoring/lowering her sodium intake to help control her blood pressure as well.(5/3/13): On 4/3/13 I cared for a 23 year old African American male who came to the clinic for a physical. He had a past medical history of intermittent asthma, obesity, and he smokes. During the visit, I discovered that he has a significant family history of diabetes. During the physical exam I found that he has acanthosis nigracans around the posterior neck. I recognized that the most common cause of acanthosis nigricans is insulin resistance, so I began a discussion with him about diabetes and the things that he can do to help avoid becoming diabetic. We discussed weight loss, exercise, and nutrition, as well as smoking cessation to help his asthma symptoms. He was prescribed an albuterol inhaler to help with any asthma symptoms, so that he could be more physically active.On 4/23/13, I cared for a 57 year old female who was being seen in the clinic for medication refills and follow up on her blood pressure. Her blood pressure that morning was 150/95. Prior to seeing the patient my preceptor and I discussed that we should probably start her on Lisinopril, since her pressure had been elevated the last 2-3 times that she was seen in the office. When I told the patient that I felt that she needed to start taking blood pressure medicine, she was very reluctant. She argued that she is already on medication for lipids, and really didn’t want to add another medication. After some discussion/education about hypertension, the patient and I negotiated an individualized plan in which she would try diet, reducing salt intake, and exercise for three months. If her blood pressure was still elevated at the next visit, she agreed to start the Lisinopril. C: (2/24/13): I am, for the most part, comfortable in my ability to provide anticipatory guidance to patients on most subjects. I think that I can still improve how I approach certain subjects with patients. I have found that weight management tends to be a sensitive subject and I probably need to learn how to bring up the topic with a little more finesse. I think that with repetition and by watching how different providers approach it, I will improve in this area.(5/3/13): At the conclusion of this clinical experience, I feel that I am able to consistently perform the objectives of this competency independently and proficiently. I use the ePSS app for almost every patient I see and try to cover as much health guidance/counseling as time allows. I will continue to strive to find ways to improve by actively looking for ways to individualize the plan of care as I provide anticipatory guidance and health counseling for patients across the life span.D: (2/24/13): For this competency, I found the CDC website is useful for immunization schedule information. I have also used the AHRQ ePSS app.3.Prioritize differential diagnoses based on etiologies, □ □ □ X/X X □ 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.First Submission (2/24/13): A: Etiology is defined as the cause of a disease or abnormal condition. A risk factor is something that increases your chances of getting a disease. Pathologic processes are the typical behaviors of a disease. Epidemiology deals with the incidence or distribution of a disease in the population. As a provider, it is important to keep all of these factors in mind when evaluating a patient. With many of the illnesses listed above, the patient may not have symptoms at first. It is up to the provider to be aware of the particular conditions that the client is at risk for and screen for them as indicated. B: (2/24/13): On 2/6/13 I helped care for a 40 year old patient that came to the clinic for follow up on her diabetes. She also mentioned that she had a lump behind her left ear that was tender and getting larger. It could have been an enlarged lymph node, but because her DM was uncontrolled (her Hgb A1c was 10), I became suspicious that she had an abscess even before I did the physical exam. We diagnosed her with cellulitis and started her on Bactrim for the infection.On 2/19/13, I cared for a 35 year old female patient with c/o right hand pain. Prior to going into the room, I started formulating a list of possible diagnoses that it could likely be. My list included trauma/injury, infection, or an inflammatory process (such as RA). After gathering history from her (this had been an ongoing problem for several years, no trauma, illness, or injury, symptoms were worse at night), I felt that she likely had carpal tunnel syndrome and proceeded with my exam based on the information she had provided.(3/29/13): On 3/19/13, I cared for a 46 year old female who came to the clinic with c/o back pain. She stated that she was doing laundry and bent over when she “felt something pull”. Her pain was worse with activity, relieved with rest, and she reported no numbness, burning, or change in sensation in her back or legs. She did have some tenderness with palpation. I felt that she likely had muscle strain, however she could have also had arthritis, spinal stenosis, or a herniated disk. Also on 3/19/13, I helped care for a 39 year old male who came to the clinic for follow up on his diabetes and hypertension. During the ROS, he told me that he often has to get up 4 times during the night to urinate. He denied pain with urination, urgency, burning, or blood in his urine. Based on the patient’s symptoms, my differential diagnoses included BPH, diabetes (although his A1C was 5.6, which told me his diabetes was well controlled), and caffeine use. After some discussion, he remembered that he had seen urology in the past and had to have his “bladder stretched”. We checked his PSA and gave him a referral to urology.(5/3/13): On 4/24/13, I helped care for a 37 year old white female patient who was being seen at the SCHA’s Women’s Health Clinic for a rash on her face. She had been seen at another clinic and was given a prescription for Bactrim at that time. The patient stated that the prescription wasn’t helping the rash. The patient had two large nodules on her left cheek/jaw line, as well as scattered papules and pustules on bilateral cheeks. Based on the lesions present on her face, my list of differential diagnoses included acne vulgaris, rosacea, and folliculitis. Since rosacea characteristically involves the central region of the face and causes persistent redness or transient flushing, mainly the forehead, the chin, and the lower half of the nose, I suspected that her rash was probably not rosacea. Because of the variety of lestions present, I suspected acne vs. folliculitis. We treated her for acne vulgaris with doxycycline and clindagel.C: (2/24/13): I feel that I have a fairly good baseline understanding of the etiologies, risk factors, and pathologic processes for acute and chronic dermatologic conditions, anxiety, depression, bipolar disorder, fractures/sprains/stains, back pain, connective tissue disease, sexually transmitted infections, incontinence, and men’s health issues. However, it is early in the semester and there is a lot of material left to cover. I will continue to prepare for learning experiences by using of outside resources and pre-experience research to assist in meeting this competency.D: (2/24/13): I have used our Dunphy textbook and our Ferry textbook as resources this semester. For musculoskeletal issues, I have used the Essentials of Musculoskeletal care textbook as well. I also have a differential diagnosis app that I use sometimes. 4. Perform comprehensive health history and physical exam □ □ □ □ X/X Xon patients across the life span First Submission (2/24/13): A: A comprehensive health history is a holistic assessment of all factors affecting a patient's health status, including information about social, cultural, familial, and economic aspects of the patient's life as well as any other component of the patient's life style that affects health and well-being. The health history is designed to evaluate teaching needs and to serve as the basis of an individualized plan for addressing wellness. Based on the health history, the review of systems, and the findings of the physical exam, the provider can then determine which, of two or more diseases with similar symptoms, is the one from which the patient is suffering. This systematic comparison and contrasting of the clinical findings is the differential diagnosis. B: (2/24/13): I was able to perform a comprehensive health history and physical examination on a 51 year old male patient who was being seen in the clinic for anxiety. He was having symptoms 3-4 days per week and his symptoms were lasting for at least an hour on the days he had symptoms. This patient was also being treated for HTN, which was adequately controlled at 128/78. I worked with my preceptor to develop a plan of care for treating his anxiety, which included starting him on Buspar. On 2/12/13 I saw a 43 year old male with diabetes who was a new patient to the clinic. He was being seen in the clinic so that he could get a prescription for a new glucometer and get his medications refilled. I performed a comprehensive health history (HTN, asthma, hyperlipidemia) and review of symptoms (negative except for c/o night time urination), and physical exam (including diabetic foot exam). We checked his Hgb A1c (7.1) and FSBS (110). We did not make any changes to his current medications and made an appointment for him to follow up again in 6 months.(3/23/13): On 3/5/13, I helped care for a 54 year old white female that was new to the clinic. She had recently been discharged home from a nursing home following several months of hospitalization at KU, Kindred, and KRH (after jumping off of a bridge). I performed a comprehensive health history (HTN, chronic back pain, depression, anxiety, and hearing loss), review of symptoms (negative except for muscle weakness, ambulates with a walker, incontinence, and memory loss), and physical exam. With my preceptor, we identified that she was in need of home health services (for help with ADLs and nutrition), follow up with psych for depression (referral to Valeo), and we asked her to follow up with us again in 2 weeks to make sure her transition home was going well. On 3/19/13, I cared for a 5 year old child in foster care who was being seen in the clinic for KBH well child exam. I performed a comprehensive health history (negative to the best of the foster mother’s knowledge and no current medications), ROS (negative), and physical exam (all within normal limits). (5/3/13): On 4/23/13, I cared for a 13 year old female patient that was a new patient being seen in the clinic for KBH well child exam. I performed a comprehensive health history (Mosaic Down’s syndrome, asthma, current medications Asmanex and Flovent), ROS (negative except runny nose, watery eyes), and physical exam (WNL except for pale nasal mucosa with clear drainage). We prescribed albuterol and Flonase (new diagnosis of seasonal allergies), discontinued her flovent and refilled her Asmanex. We asked to follow up with her in 2 months to check on her asthma. C: (2/24/13): Although I have not had very many opportunities to perform comprehensive health histories, mostly because the majority of our patients have been established patients, I feel that I do pretty well gathering medical history information. I will probably continue to use a health history form as a guide, so that I don’t forget to ask any important questions. I will continue to seek out experiences to perform comprehensive health history and physical examination to formulate basic differential diagnoses.D: (2/24/13): For this competency, I used a health history form as a guide for gathering past medical information. 5.Perform problem focused health history and physical exam □ □ □ □ X/X X on patients across the life span First Submission (2/24/13): A: In practice, clinicians must learn to focus their physical assessment skills and make the examination appropriate to the patient’s complaint and history. If the patient complains of headache, then a review of head, eyes, ears, nose, and throat and a neurologic examination are indicated, as well as a skin survey. For joint pain, a review of musculoskeletal tenderness, range of motion, and strength might be indicated. The body systems that are examined depend on the working hypothesis list (differential diagnosis list) that the clinician has generated (Dunphy, 2011).B: (2/24/13): On 2/13/13 I helped care for a 50 year old female patient who came to the clinic with c/o congestion and cough for 1 week. I performed a problem focused health history and discovered that she had been running a fever and had a sore throat as well. The patient also had a history of COPD. The exam I performed consisted of HEENT, neck, CV, and lungs. The physical exam revealed fluid and bubbles behind her right TM, red swollen turbinates, and some coarseness in her lungs. On 2/18/13, I cared for a 45 year old patient with c/o diarrhea, sore throat, head & body aches, cough, and runny nose. I did a problem focused health history and discovered that her symptoms started 5 days earlier. She suspected that she had a fever, but did not have a thermometer to take her temperature with. She had been treating her symptoms with Nyquil, Dayquil and ibuprofen. The physical exam I performed consisted of HEENT, neck, CV, lungs, and GI. The patient’s pharynx and turbinates were red, TMs were normal, lungs were WNL except for a cough. We felt she likely had influenza, since her symptoms were consistent with other cases of influenza seen there recently. (3/29/13): On 3/5/13 I cared for a 49 year old female patient that had come to the clinic with c/o congestion and cough. Her past medical history included hypertension, asthma, bipolar disorder, PTSD, and she smokes. The patient stated that she had been coughing up brown/green/yellow phlegm and also felt chest “tightness” like she was being squeezed. She denied fever, sore throat, N/V/D, or any urinary changes. She stated that she was short of breath, was coughing a lot, and had noticed some wheezing. When asked if she had been taking any medication to help with her symptoms, she told me that she had been using her Flovent inhaler about 5 times per day. Her physical exam was within normal limits, except for expiratory wheezing and diminished lung sounds bilaterally. We gave her an albuterol treatment in the office and ordered an albuterol inhaler for her to use at home. We also did education on how Flovent should be used and smoking cessation. (5/3/13): On 4/2/13, I cared for a 44 year old African American gentleman who came to the clinic with complaints of stomach pains, diarrhea, and chills. Four days earlier, he began having chills and feeling tired. His past medical history includes hypertension and hyperlipidemia. He does not smoke and he describes his alcohol consumption as rare. Review of systems includes fatigue, diarrhea when he eats, “slimy stools”, and abdominal pain. He states that he has had heartburn more often than he use to. He denies any urinary symptoms or blood in his stools. He does not know if he had a fever. No recent weight loss. He does not associate his symptoms with anything that he ate. Physical exam was within normal limits except for some LLQ abdominal tenderness. On 4/23/13, I cared for a 6 year old female patient that was brought to the clinic for complaints of bilateral ear pain that started four days earlier. She had no past medical history, only current medication was Tylenol as needed for pain/fever. Review of systems was negative for fever, sore throat, coughing, N/V/D, and urinary symptoms. She did have some nasal stuffiness and drainage. Her physical exam showed bilateral effusions behind the TM’s, but no erythema. Her nasal mucosa was swollen with mild erythema and clear drainage was present. Her pharynx had clear/white drainage along posterior wall. I felt that her ear pain was likely caused by pressure from the fluid behind her TM’s, and started her on loratadine to help what appeared to be seasonal allergy symptoms. C: (2/24/13): I will probably continue to use a health history form as a guide, so that I don’t forget to ask any important questions.D: (2/24/13): For this competency, I used a health history form as a guide for gathering past medical information.6.Demonstrate diagnostic reasoning and critical thinking □ □ □ X X/X □in the development of a treatment planFirst Submission (2/24/13): A: Once the health history and physical exam has been completed, clinical judgement about how best to manage the identified problems is addressed. For an APRN student, this involves taking all of the data collected in history and physical assessment (including risk factors such as genetics, social factors, and exposure) organizing the content, formulating a differential diagnosis list and then presenting the major findings in a coherent way to the preceptor so that the preceptor can then verify findings and act on the students recommendations, as long as those recommendations are reasonable for the patient and situation.B: (2/24/13): On 2/19/13 I cared for a 45 year old female patient who came to the clinic with c/o cold symptoms. She had nasal stuffiness and drainage for 3 days. ROS revealed nausea and diarrhea for 2 days. Her physical exam was normal except for red swollen nasal turbinates. I told my preceptor that the patient likely had a viral infection and that I didn’t think an antibiotic was warranted at this time. We recommended that the patient get plenty of rest, fluids, and vitamin C and that she call the clinic if her symptoms did not improve or got worse over the next few days. Another patient that I saw on 2/19/13 was a 13 year old female who came to the clinic for a KBH exam. The patient complained of an itchy rash on her hands and back. The physical exam revealed that the patient had eczema. Upon discovery of the eczema, I questioned the patient about seasonal allergy and asthma symptoms. The patient denied asthma symptoms, but stated that she did have problems with itchy watery eyes and nasal drainage. I recommended that she take loratidine to help relieve her allergy symptoms. For the eczema, we gave her triamcinolone cream and recommended using mild soaps and unscented lotion such as Lubriderm. (3/29/13): On 3/5/13, I cared for a 42 year old Hispanic female that had come to the clinic for concerns about a mass she felt in her abdomen. Her medical history was minimal and only included G3P2. The patient had felt the mass on the right side of her abdomen the day before, however she was not able to palpate it today. She reported that it hurt to bend forward, but otherwise she had no discomfort. Her ROS was negative for fever, N/V/D, recent unplanned weight loss, and fatigue. She did report recent problems with constipation and heartburn. Her physical exam was WNLs, her abdomen was soft, non-tender, no palpable masses. Differential diagnoses for her included constipation, a lipoma, or a tumor. Since neither of us could palpate the mass at that time and she had reported having problems with constipation lately, I was reasonably certain that the mass she had felt was stool. We discussed some things she could do to relieve the constipation, including increasing fiber in her diet, drinking plenty of water, and getting exercise. On 3/26/13 I cared for a 43 year old Hispanic male patient that was being seen for a rash on his head. The rash was on his posterior scalp in the hairline behind his right ear. The rash was a red, circular, macular rash approx 2-3 cm in diameter with central clearing. My priority differential diagnosis for this patient was ringworm or tinea capitis. Since topical treatments are not recommended for tinea capitis, we prescribed oral antifungal medication (Lamisil 250mg daily x 21 days) to treat the infection. We also ordered a comp panel to check his kidney and liver function prior to starting the medication. (5/3/13): On 4/16/13 I cared for a 47 year old female patient that had come to the clinic with c/o numbness and tingling in her left arm. The patient reported that the numbness and tingling in her arm would come and go depending on her anxiety level. This had been occurring for several weeks. PMH included pustular psoriasis, diabetes, rotator cuff surgery on the right shoulder, and she smokes. ROS was negative for fever, fatigue, headaches, dizziness, chest pain, or irregular heartbeats. She did state that she would feel a “twinge” along the left side of her neck from time to time. Her VS were WNL. The physical exam revealed weakness in her left shoulder, arm, and hand grip. Her pupils were equal and reactive, her tongue was midline without deviation, LE’s had equal strength. There was no tenderness in her cervical spine to palpation and no pain with active or passive ROM. My primary differential diagnosis for her was neuropathy because of the weakness that was present in the LUE. Because of her smoking history, I was concerned about stroke and cardiac disease, but felt they were less likely due to the absence of other symptoms. I also felt her symptoms could be related to anxiety. I decided to get an x-ray of her c-spine to look for changes that would cause neuropathy and also ordered a CBC, Comp, lipid panel, and TSH to look for abnormalities that could cause muscle weakness or changes in sensation. C: (2/24/13): Repetition is how I plan to improve in this area. My preceptor told me that “the more patients you see, the more comfortable you’re going to get”. (5/3/13): At the conclusion of this clinical experience, I feel that I am able to meet the expectations of this competency with minimal support from my preceptor during the majority of my patient encounters. I am able to demonstrate diagnostic reasoning and critical thinking consistently, but am also willing to ask for help when I get stuck. One of my favorite things about the field of nursing, and the nurse practitioner role in particular, is that I get to use critical thinking everyday and each day is a learning opportunity. D: (2/24/13): I have used several resources including our Ferry textbook, our Dunphy textbook, the National Guideline Clearinghouse, Epocrates, and the differential diagnosis app on my phone to meet this competency. 7.Initiate screenings appropriate to differential diagnoses □ □ □ X/X X □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.First Submission (2/24/13): A: Screening refers to the application of a medical procedure or test to people who as yet have no symptoms of a particular disease, for the purpose of determining their likelihood of having the disease. The screening procedure itself does not diagnose the illness. Those who have a positive result from the screening test will need further evaluation with subsequent diagnostic tests or procedures. The goal of screening is to reduce morbidity or mortality from the disease by detecting diseases in their earliest stages, when treatment is usually more successful.B: (2/24/13): The Shawnee County Health Agency uses the 2 question depression screen on all clients that are seen in the clinic there. On 2/18/13, I helped care for a 56 year old male patient who was being seen in the clinic for his DM. I was able to suggest that we check a PSA when he gets his other lab work drawn. (3/29/13): On 3/4/13 I cared for a 64 year old white male that c/o joint pain in his knees and feet. Although he did not have the symptoms of an acute gout attack (red, swollen painful joints) at the time of the visit, we ordered a uric acid level to screen for gout.On 3/6/13, I cared for a 44 year old white female patient that was being seen in the clinic for lab review. During the visit the patient stated that her legs had been swelling and were painful at times. The physical exam revealed some swelling without erythema in her left knee. The patient was a rather poor historian and did not recall any trauma or injury to her knee. We ordered an ANA, CRP, RF, uric acid, and sed rate to screen for connective tissue disease and gout.(5/3/13): On 4/24/13 I helped care for a 20 year old female who was being seen in the Women’s Health Clinic for her annual exam. Because she was under the age of 25 years, we were required by the state to do an STD screen (for Chlamydia and Gonorrhea) in addition to her PAP (to screen for HPV/cervical cancer). Also on 4/24/13, I helped care for a 35 year old female patient that was seen in the Women’s Health Clinic for her annual exam. Because she had multiple partners and inconsistent condom use, we did an STD screen in addition to a pregnancy test and her PAP. C: (2/24/13): I have not had the opportunity to screen for STDs yet, but I am hoping to spend some time this semester with April in the Women’s Health area and gain some experiences there. (5/3/13): I was able to spend a day at the Women’s Health Clinic with April and got the opportunity to perform several screenings for STDs. At the conclusion of this clinical experience, I feel that I am able to consistently perform the objectives of this competency independently, proficiently, and require minimal support from my preceptor. I use the ePSS app for almost every patient I see and try to cover as many of the recommended health screenings as appropriate and time allows. I will continue to strive to find ways to improve by actively looking for new ways to screen for disease and incorporate those screening tools into my practice.D: (2/24/13): I have found the AHRQ ePSS app very helpful in meeting this competency.8.Initiate diagnostic strategies appropriate to differential □ □ □ X/X X □diagnosesFirst Submission (2/24/13): A: Diagnostic tests can be used to confirm or to rule out diagnostic hypotheses and vary in their usefulness based on their sensitivity, specificity, and their predictive value. When deciding whether to order a test, cost, convenience, sensitivity and specificity, and risk of missing a condition are considered.B: (2/24/13): On 2/6/13 I helped care for a 67 year old female patient with c/o congestion and difficulty breathing for 4 months. We had her do peak flow spirometry in the office which showed a significant decrease in volume. After completing her history, ROS, and physical exam, we were suspicious that she may have COPD, so we made the decision to send her for pulmonary function tests at the hospital. On 2/18/13 I cared for a 68 year old female patient with c/o hip and back pain. After obtaining her medical history, ROS, and doing the physical exam, I felt that her pain was probably nerve pain that was radiating into her hip and groin. My preceptor and I ordered an X-ray of her lumbar spine and discussed ordering an MRI depending on the results of the x-ray. We also ordered physical therapy and asked her to follow up with us in 1 month so that we can evaluate her progress.(3/29/13): On 3/7/13, I helped care for a 10 year old male who came to the clinic for a chief complaint of “fell on finger a week ago and now it looks crooked”. While examining the boy’s hand, I found the right DIP joint to have swelling and a nodule. My preceptor and I ordered an X-ray of his right hand to assess for fracture or other abnormality.On 3/11/13, I cared for a 36 year old female that came to the clinic for complaints of pain in her neck and upper back. The history and ROS revealed that she had numbness and slight weakness in her left hand and her pain was worsened by reaching overhead. We ordered an X-ray of her cervical spine to evaluate for narrowing of the vertebrae, etc… and discussed ordering a MRI or EMG depending on the results of the X-ray.(5/3/13): On 4/16/13 I cared for a 65 year old female patient that came to the clinic for complaints of a raised, red, burning painful rash on her right shoulder and up the side of her neck into her hairline. Prior to seeing the patient, I suspected that she could have shingles due to the nature of her complaint. However, when I did her physical exam there was no rash visible. Her skin was very sensitive to touch and even her hair touching her neck caused her severe discomfort. The patient had a history of degenerative arthritis in her lower back which made me wonder if she couldn’t have some degenerative changes in her neck as well. We ordered an X-ray of her c-spine to evaluate for narrowing of the vertebrae, etc. which, if compressing a nerve, could cause the burning pain she was suffering from. We got a phone call from the radiologist later that afternoon confirming that she had degenerative changes in her neck and would need an MRI. On 4/26/13 I cared for a 56 year old Hispanic female that came to the clinic for c/o back and lower abdominal pain that had started in March and occurred intermittently since then. Her physical exam revealed LLQ and LUQ abdominal tenderness, no palpable masses, liver and spleen WNL, and no CVA tenderness. I ordered a UA to rule out UTI and it came back normal. Her last PAP was in May 2011 and was normal. My preceptor and I debated whether to order an abdominal sonogram or a CT of her abdomen and pelvis. Because we were suspicious that she had diverticulitis, we decided to order the CT scan, as it is the procedure of choice when assessing for diverticulitis. C: (2/24/13): I will continue to recommend diagnostic strategies based on patent presentation and will continue to refer to treatment guidelines for specific diagnostic strategies. D: (2/24/13): For the most part, I have used the Ferry and Dunphy textbooks as references. I have a lab work app on my phone that tells me what each lab test is used for and normal ranges, etc. Occasionally I use Google if I run across a test I am completely unfamiliar with. 9. Develop a plan of care utilizing evidence-based practice □ □ □ □ X/X/X □First Submission (2/24/13): A: Evidence-based treatment is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. B: (2/24/13): On 2/12/13 I helped care for a 60 year old female patient who came to the clinic for a lab review and follow-up on her hypertension. She had a lipid panel drawn about 2 weeks earlier and had been found to have an elevated LDL level (176) and a low HDL level (31). Her weight was 168 lbs and her blood pressure was154/80. After consulting the EB guidelines for treatment of hyperlipidemia and discussing her treatment options, my preceptor and I started her on Simvastatin 10 mg daily at night and encouraged her to eat a diet low in saturated fat & cholesterol. We scheduled a follow up appointment and labs for 3 months later to assess her progress.On 2/18/12 I saw a 56 year old male patient with hypertension, type II Diabetes, and morbid obesity. We discussed ways to increase physical activity and maximize glycemic control. In discussing this with him, I encourage him to set small goals in the process of attempting to reach the larger goals of losing weight and gaining control of his blood pressure. For this patient, we discussed how with exercise and diet he might be able to decrease his blood pressure, and maintain a lower HgA1c. I additionally discussed with the patient the JNC VII recommendations for the non-pharmacological treatment of hypertension, including weight loss as the best way to decrease blood pressure.(3/29/13): On 3/26/13 I helped care for a 40 year old female patient that came to the clinic for follow up on her ER visit on 3/24. In the ER, she was diagnosed with gastroenteritis and was given prescriptions for Prilosec and Ultram. When we saw her in the clinic, she was continuing to have moderate to severe abdominal pain, as well as gas, bloating, and constipation. Her exam revealed LLQ tenderness. My preceptor and I suspected that she may have diverticulitis due to the location of her pain and her symptoms. Since the patient had a CT scan done in the ER two days earlier, and she already had an appointment scheduled with GI for a colonoscopy on 3/29, we opted not to send her for a repeat CT scan of her abdomen at this time. Her UA was positive for keytones, but negative for UTI. We got on Up to Date to find evidence-based treatment guidelines for diverticulitis. Keeping in mind that the patient has a Sulfa allergy, we prescribed Ciprofloxacin and Flagyl and treated her for diverticulitis.(5/3/13): On 4/3/13 I cared for a 42 year old white female who was seen in the clinic for review of lab results. Her glucose on the Comp was elevated, so I asked the nurse to check a finger stick BS and AIC before I went in to see the patient. Her BS=106 and her A1c was 6.6. According to evidence based guidelines, an A1c >/=6.5% on two occasion is diagnostic of diabetes. Even though I didn’t have a second A1c to confirm the diagnosis of diabetes, I still initiated a plan of care based on the treatment recommendations for diabetes. (My preceptor has really encouraged me to treat pre-diabetes and diabetes aggressively so that the pancreas function is preserved and the blood sugars are better controlled.) I discussed diet, exercise, and weight loss with her and gave her printed information to take home and read. The patient did not appear to be very receptive to the lifestyle modifications that I suggested, so we also prescribed metformin XR 500mg daily and asked her to follow up with us in one month. C: (2/24/13): Healthcare is continuously changing, and so, to continue to improve in this area I will continue to refer to the treatment guidelines periodically to make sure that my practice stays current.D: (2/24/13): National Guideline Clearinghouse, as well as other reliable websites such as CDC, American Diabetes Association, American Heart Association, and Up to Date have been helpful in meeting this competency.10. Prescribe medications based on cost, diagnoses, □ □ □ X X/X □efficacy, safety, and individual patient needsFirst Submission (2/24/13): A: For health care providers, the major principles in the management of illnesses with drug therapy are to elicit a remission or cure and to prevent untoward effects in patients resulting from prescribed medications. When prescribing medications, providers must not only take into consideration the patient’s diagnosis, but the patients co-morbidities, allergies, and ability to comply with the treatment as well. All treatment decisions should be based on assessment of patient data and must be properly documented. B: (2/24/13): On 2/18/13, I helped care for a 52 year old female who came to the clinic for follow up on her diabetes. Her insurance was KanCare. At that visit, I discovered that her moderate COPD was not well controlled. She was using her albuterol twice daily and she was using 3 puffs each time. She was coughing throughout the day and was only able to walk about ? block before having to rest. Since we had Symbicort samples, we started her on that twice daily. We also ordered Spiriva for her on PPAP (patient prescription assistance program), but that can take several weeks to come in. On 2/19/13, I helped care for a 42 year old female patient with GERD. Her health insurance was Health Access. We wanted to start her on Dexilant, however her insurance would not cover it. We ended up giving her enough samples of Dexilant to last her a month and then gave her a prescription for ranitidine, which her insurance did cover, that she could start on after she used all of the Dexilant. (3/29/13): On 3/7/13 I cared for a 39 year old white female who was seen in the clinic for follow up on her blood pressure. Her blood pressure had been elevated at the previous visit 3 months before and she had instructed on lifestyle modifications at that time. At this visit her BP was 145/100, so I decided that we should start her on medication. She did not have health insurance, but was on Health Access and eligible for PPAP. I debated about whether to start with HCTZ or lisinopril, since they are both cheap medications. My preceptor (and another provider in the office) told me how much she likes Bystolic, (especially in younger patients that don’t tend to get dizzy and fall down). We ended up giving her 7 weeks of Bystolic 5mg samples and asking her to come in for follow up in 6 weeks. At that time we will reassess her BP, adjust the dose if necessary, and order the medication through the PPAP program once we find the dose necessary to control her BP.(5/3/13): On 4/2/13, I cared for a 46 year old white male that was seen in the clinic for lab review and hypertension. His labs were as follows: Trig 236, Chol 215, HDL 34, and LDL 134. I wanted to get him started on medication to lower his cholesterol, and felt that he was a good candidate for a statin. The patient had no insurance, so I went to the sample cabinets and got him 7 weeks worth of Crestor 5 mg. I asked him to follow up in 6 weeks to see how the medication was affecting his lipids. I told him that we may need to increase the dose at the next visit. I also told him that once we figure out the dose of medication that is needed to get his lipids down to normal (or as close to normal as possible), we will get the medication through the PPAP program for him. He was agreeable to that plan.On 4/24/13, I helped care for a 20 year old patient that was interested in starting birth control. She did not have insurance, so cost was definitely a factor for this patient. My preceptor and I reviewed some of the different options available to her, including the pills, the Depo-Provera injection, the NuvaRing, and IUDs. After discussing the pro’s and con’s of the different methods, the patient chose to try the NuvaRing. Through the Health Department, she was able to get the NuvaRings at a reasonable cost and the patient felt like it was the best option for her lifestyle right now.C: (2/24/13): This has been a very challenging competency to meet due to the setting that I’m in this semester. Cost and individual patient needs play a huge role in the medications that are prescribed at the Shawnee County Health Agency. Frequently, the medication that is prescribed depends on the samples that are available that day. You can’t always prescribe the medication that you would prefer the patient to be on due to the high cost. This has shown me that I need to practice being flexible and work to find alternatives that the patient will be able to obtain.D: (2/24/13): The references/clinical guidelines that I have been using to achieve this competency have been Epocrates, the National Guideline Clearinghouse, the Walmart $4 prescription list, the formulary(?) list of drugs that KanCare covers, and JNC 7 recommendations. 11. Perform medical and surgical procedures as appropriate X/X □ □ □ X □First Submission (2/24/13): A: Medical and surgical procedures are an important part of family medicine, since they may account for a significant portion of the providers’ office visits. Some commonly performed procedures done in the office setting might include skin biopsies, laceration suturing, wound care, joint aspiration/injection, and short arm or leg casts. B: (2/24/13): I have performed three diabetic foot exams so far this semester. Unfortunately, the Shawnee County Health Dept does not seem to be a setting in which very many procedures are performed. We saw one patient with carpal tunnel that was probably an appropriate candidate for steroid injection, however my preceptor stated that she does not do joint injections. I have not participated in any other procedures this semester.(3/29/13): I have performed several diabetic foot exams since my last submission. Unfortunately, this is not a setting where many procedures are performed. Most procedures are scheduled during a procedure clinic, which the Shawnee County Health Department has monthly.(5/3/13): On 4/24/13, I spent the day with April at the Women’s Health Clinic. During the morning, I observed April perform clinical breast exams and PAPs during the first two visits. Later that morning and afternoon, I performed four clinical breast exams and four PAPs. On 4/26/13, I spent the afternoon with Leslie during her procedure clinic. We had a couple of patient that didn’t come, but I still got the opportunity to use liquid nitrogen on two patients with plantar warts and did nail care on three diabetic patients. C: (2/24/13): I am planning on spending some time with April from Women’s Health, and I hope to get some more experience with procedures at that time. (3/29/13): I am scheduled to spend an afternoon with Leslie (another APRN that works with my preceptor) in the procedure clinic in April. I will hopefully get to spend some time in the Women’s Health Clinic with April as well.(5/3/13): To move towards meeting this goal in the future, I will seek out opportunities within the office to assist in medical/surgical procedures. For this evaluation, I had limited opportunity to perform or assist, as my primary preceptor did not perform procedures in her office. I did seek out opportunities in the Women’s Health Clinic and got to follow for one afternoon during a procedure clinic. D: (2/24/13): So far this semester I have not needed any resources to complete this competency. In the past I have used the AAFP website (for procedures commonly performed in the office, such as regional anesthesia, punch biopsy of the skin, etc.), MedlinePlus (for the procedure for ear irrigation), and also YouTube (you just have to make sure the source is reliable). 12.Interpret patient responses to treatment and recommend □ □ □ X/X □ Xchanges to the treatment plan as indicatedFirst Submission (2/24/12): A: With any medical problem, follow-up is essential after the initial intervention. We need to know if the intervention is working. Some individuals with a given problem may respond better to certain treatments than to others, whereas a different patient with the same problem may show a different pattern of response. By following up with the patient, the provider is able to evaluate the patient’s response to treatment. Follow up can be as simple as a phone call made by a health-care worker. For more complex patients, an office visit follow-up with the clinician may be necessary to evaluate response to treatment. B: (2/24/13): On 2/12/13, I was able to follow up with an 11 year old male patient who was being treated with Pulmicort for his asthma. His mother reported that he had not had any nighttime symptoms and that he had not had to use his albuterol inhaler at all. Since he was doing so well, we decided to have him stop the Pulmicort inhaler to see if he would do okay without it. His mother was instructed to have him resume the Pulmicort if he started needing his albuterol inhaler more than twice per week. We also scheduled him for a follow up appointment to reassess his progress in 3 months. On 2/18/13, I was able to follow up with a 22 year old female patient who was being treated with oral medications for her diabetes. Her Hgb A1c at this visit was 8.5 and her FSBS was 304 (both higher than they had been the previous visit). Since the oral medications she was taking were not controlling her blood sugars well enough, we decided that she needed to be started on insulin. We provided education about insulin therapy and instructed her to check her blood sugars at least every morning. We also scheduled her for a follow up visit in 2 weeks to see how she was doing with the insulin and to make adjustments to the insulin dosage. (3/29/13): On 3/11/13, I cared for a 41 year old Hispanic female patient who was seen in the clinic for follow up on her diabetes. According to the evidence based guidelines, the goal A1c for most diabetic patients is <7.0%. In December, the patients A1c=7.2. Her diabetic medications were not changed at that time, but she was instructed to watch her diet more closely. At the visit on 3/11, her A1c=6.7. I could tell that she had been monitoring her carbohydrate intake more closely, since her A1c had come down 0.5%. We continued her current diabetic medications (glipizide 5mg BID, Actos 15mg daily, and metformin 1000mg BID), encouraged her to continue paying close attention to her diet, and asked her to try to incorporate 20-30 minutes of exercise daily. We asked her to follow up again in 3 months so we can recheck her A1c.On 3/26/13, I cared for a 21 year old female that was being seen in the clinic for follow-up on her asthma. I had seen her in February for asthma and her peak flow that day was 220. She had inspiratory and expiratory wheezes at the February visit as well. We had given her a sample Pulmicort inhaler and asked her to follow up in 6 weeks. At the visit on 3/26, her peak flow was 325. She also said that she feels better, is using her albuterol less often, and is having less night time symptoms. We gave her a prescription for the Pulmicort, since it seemed to be working so well for her. (5/3/13): On 4/2/13, I cared for a 44 year old female patient that had come to the clinic for follow-up on her blood pressure. I had seen her on 2/19/13 for a hospital follow up visit (for a CVA). At that visit, I recognized that her high blood pressure was not well controlled on her current medications. She was on Labetalol 200mg BID and Hydralazine 50 mg TID. At the February visit, my preceptor and I decided not to change her blood pressure medications, since she had just gotten out of the hospital and had been off some of them. We asked her to follow up with us again in 6 weeks so that we could check her blood pressure. At this visit (4/2/13), her BP was 183/114. We were still not able to get an accurate picture of how her medications were controlling her blood pressure because she had run out of her labetalol and could not afford to pick up a refill. After some discussion with my preceptor, I decided to add lisinopril 40mg daily to try to get her blood pressure down (because it is cheap and she was such a high risk for a stroke). The patient said that she would be able to pay for the prescriptions that day, and so we made a plan for her to come back in 1 month for a recheck of her BP. She also agreed to get her blood pressure checked in the next 2 weeks and call us with it. On 4/16/13 I followed up with a 39 year old patient that I had seen in March for HTN. At that time I had started her on Bystolic. Her BP on 4/16/13 was 130/93. Her blood pressure had improved from the first visit, but I told her that if she’s going to be on medication, why not have it well controlled instead of borderline. I increased her dose of Bystolic to 10 mg daily. I gave her 7 weeks of samples and made arrangements for her to follow up in 6 weeks.C: (2/24/13): I still struggle with what the timeframe should be for certain illnesses. For example, when adjusting diabetic medications, do you bring someone back in 2 weeks or 1 month? I have looked for guidelines, but for the most part it seems to be provider discretion. I will probably become more comfortable as I see how other providers manage follow-up care for their patients.(5/3/13): At the conclusion of this clinical experience, I feel that I am able to consistently perform the objectives of this competency independently and proficiently with little guidance from my preceptor. I really enjoy following up with a patient for a second or third time and being able to monitor their progress. I feel much more comfortable gauging how soon to bring a patient back for follow-up than I did at the beginning of the semester. I will continue to seek out learning opportunities to improve my interpretation of patient responses to treatment and the recommendations I offer in response.D: (2/24/13): National Guideline Clearinghouse for treatment guidelines on diabetes and asthma. 13.Document using professional terminology, □ □ □ □ X X/Xformat and technology (ie: ICD9, E/M coding, CPT)First Submission (2/24/13): A: Clinical documentation should reflect safe, ethical, competent care. One of the most important responsibilities an APRN has is to ensure that our patients’ health records provide clear evidence of the care planned, the decisions made, the care delivered, and the patient’s response to that care. By recording clinically meaningful data using professional terminology and standardized formatting/technology (ICD 9, E/M coding, CPT) other members of the care team will have sufficient information to maintain continuity of care/services for that patient. Using proper terminology and standardized formatting also helps communicate the complexity of the patient’s presenting health problem and acuity of their condition for purposes of proper billing. B: (2/24/13): The Shawnee County Health Agency uses Medcin EMR for documenting the patient visit. On 2/12/13, I cared for a 43 year old male patient with DM II. I documented the HPI, ROS, physical exam, and plan (including education) in the EMR. On 2/13/13, I cared for a 51 year old patient who came to the clinic for follow up on her hypertension. I charted the HPI, ROS, physical exam, and plan (including education) in the EMR. (3/29/13): I document the HPI, ROS, physical exam, plan, and education for every patient that I see. The only parts of the documentation that I’m not doing are entering the ICD-9 codes and the medications. (5/3/13): I have continued to document the HPI, ROS, physical exam, plan, and education for each patient that I see. My preceptor continues to enter the medications and ICD codes for each visit, but I write the codes down in my notes for practice. Over the course of the semester, I have become faster at documenting as my comfort with their EMR has increased. C: (2/24/13): My preceptor reads over my notes with me at the end of the day to make sure I haven’t omitted something important. She offers her suggestions as we go through them. She does the coding for each visit, so I haven’t been able to practice entering the ICD codes into the official Superbill, but I do write down the codes in my notes for practice. (5/3/13): My preceptor continues to read over my notes to make sure that my documentation is accurate and includes all the necessary information. She rarely has me add or change information and has commented that I do a very nice job documenting. There have also been a few times that I have looked at the ICD codes after she has entered them and reminded her to add something. D: (2/24/13): I have been using the electronic medical record at the clinic which has a programmed format to follow. I also have an ICD-9 app on my phone that I have used a few times. 14. Recognize need for referrals by collaborating □ □ □ X X □and consulting with members of the health care teamSecond Submission (3/29/13): A: At the Shawnee County Health Agency, in addition to family practice services, there is a Social Worker available and there is a Women’s Health Clinic that we refer patients to frequently. There are no other specialty services available through the SCHA that I’m aware of. In the time that I have been at this site, we have referred patients to pulmonology, orthopedics, urology, gastroenterology, dermatology, and endocrinology. Most of the time, we refer patients because the treatments we have tried have not successfully controlled the patient’s problem. When we are considering referring a patient to a specialist, we consider what services/treatments they may be able to offer that we can’t, what the patient’s insurance is going to cover, or if the patient doesn’t have insurance, will they be able to pay to see a specialist and for the treatment they may recommend. (5/3/13): Referral to a specialist depends on the resources that are available in the area. In Topeka, we have lots of specialties available that are easily accessible to patients versus the options that might or might not be available in a small rural community in western Kansas. It can also depend on the comfort level of the provider treating the disease. For example, the provider I’m with this semester is comfortable treating hypothyroidism, but prefers to send patients with hyperthyroidism to endocrinology since they would need to go to them anyway if they required radioactive iodine treatment, etc. B: (3/29/13): On 3/19/13, I helped care for a 39 year old male who came to the clinic for follow up on his diabetes and hypertension. During the ROS, he told me that he often has to get up 4 times during the night to urinate. After some discussion, he remembered that he had seen urology in the past and had to have his “bladder stretched”. We checked his PSA and gave him a referral to urology.(5/3/13): On 4/3/13, I helped care for a 43 year old female who had come to the clinic for review of lab results. The patient had previously been seen in the clinic for hyperlipidemia and joint pain in her lower back, knees, and feet. My preceptor had ordered a lipid panel, an ANA, RF, Vitamin D, and TSH level at that time. The patient’s ANA was positive, RF was normal, Vitamin D level was low, and her TSH was normal. After reviewing the lab results with the patient and finding out that she was continuing to have joint pain, we decided to refer her to rheumatology for further work-up. Also on 4/3/13, I helped care for a 42 year old white female that had come to the clinic for lab review. She had recently had her yearly routine labs drawn (CBC, Comp, lipids, TSH) and her TSH was 0.019. I discussed the result with the patient and told her that this meant she has hyperthyroidism. We referred her to endocrinology for further work-up and treatment.C: (3/29/13): I am continuing to familiarize myself with the services available and not available at the SCHA. For example, I was going to schedule a patient to have a lesion removed from his cheek at the monthly procedure clinic offered at the SCHA when I found out that they do not remove lesions from faces. Obviously, every agency has different services that they are able to offer and it takes time to become familiar with what those are. (5/3/13): At the conclusion of this clinical experience, I feel that I am able to routinely meet the expectations of this objective with minimal support from my preceptor. I am able to recognize the need for referrals in the majority cases and do not hesitate to consult with my preceptor and other members of the health care team when I have questions about the services this facility is able to provide. I will continue to strive to find ways to improve during my next clinical rotation by becoming familiar with services available at that site and by discussing with my next preceptor how they determine if a referral is warranted. I will also use medical literature to help guide my decisions. D: (3/29/13): I have used my preceptor as my source of information this semester. 15. Discuss access, cost, efficacy and quality when □ □ □ X X □making care decisionsSecond Submission (3/29/13): A: Access, cost, efficacy, and quality are issues I run into during every encounter at the SCHA. I’m unsure of the exact demographics, but I would guess that the majority of patients seen there do not have health insurance. I have only cared for 2 or 3 patients with private insurance during the 2 months that I have been at this site. With this population of patients, providers must always have cost in mind B: (3/29/13): On 3/26/13, I cared for a 57 year old female patient that was continuing to have shortness of breath after being treated for bronchitis. During her exam, I heard a soft, systolic murmur. After discussing the patient’s symptoms and exam findings with my preceptor, I felt that an echocardiogram was warranted. Before I ordered the test, I had to make sure that Health Access would cover the cost of the test since the patient would not be able to afford to have it done otherwise.On 3/28/13 I cared for a 48 year old female who hadn’t had a PAP or a mammogram for several years. She had no insurance to pay for these tests. I referred her to the Women’s Health Clinic so that they could get her set up with Race Against Breast Cancer and get her a mammogram.(5/3/13): On 4/8/13, I cared for a 50 year old Hispanic female with no health insurance. She was being seen in the clinic that day for follow up on her diabetes and her last A1c was 7.4. She told me that the Januvia she was taking was hurting her stomach and she wanted a different medication. She had previously been on metformin, but said that it caused her to have nausea and diarrhea. She had also been on Onglyza, but didn’t like that it caused her to gain weight. The patient, my instructor, and I had a long conversation about the efficacy, side effects, and cost of each of the medications. We laid out the options for the patient and let her decide which of the three medications was going to be the best choice for her. She decided to try the Metformin XR again because of cost and the most tolerable side effects. We asked her to follow up in 6 weeks to see how she was tolerating the medication. **I also referred her to the Women’s Health Clinic for her annual exam and so they could get her set up with either Early Detection or Race Against Breast Cancer for her mammogram.I cared for a patient this semester that had been getting her Actos through the PPAP program. Since Actos is going generic soon, it will no longer be covered under that program. For this patient, I had to consider what alternative medication we should use since there is no way for her to pay for it out of pocket. We decided to keep her on the Actos as long as possible, and then possibly switch her to Victoza or another similar medication depending on PPAP (prescription assistance program) and samples that are available at the time. C: (3/29/13): I need to continue to familiarize myself with the various programs that are available to help pay for services for needy clients. I will continue to ask my preceptor questions as I encounter situations that I’m unsure about.D: (3/29/13): I have used my preceptor as well as handout information found around the clinic on various programs.16. Perform care in a timely manner □ □ □ X X □Second Submission (3/29/13): A: Performing care in a timely manner means carrying out my clinical duties in a way that reduces delays and waiting time for patients. It also means discussing my patients with my preceptor in a thorough, efficient manner that doesn’t slow her either. B: (3/29/13): Over the course of the semester, I have been able to increase the number of patients I see in a day by becoming more familiar with how patient flow and documentation in this office work. Each office has a little different flow, and it takes a little while to adjust to each new setting. As the semester has gone by, I make revisions to my “cheat sheet” so that I am more organized with the questions I ask the patient. It also helped me remember to ask important things so that I don’t have to go back into the room again to ask the patient the questions I forgot earlier. I have tried to develop a “routine” when I would go in to see a patient which helped me be more efficient. I also didn’t need to look things up quite as often as I did when I first started which made me a little faster I think.(5/3/13): Toward the middle/end of the semester, I felt that I had found a “routine” that worked well for me in this setting. As the patient was being put in the room, I would review their electronic medical record for past medical history, health maintenance (PAPs, bone density studies, etc..). Once I received their paper chart from the nurse, I would review it and discuss my preliminary plan with my preceptor. After seeing the patient, I would discuss anything unexpected that had come up and verify the plan for follow up with my preceptor. After sending the patient on their way, I would document the visit in the EMR before moving on to the next patient. While I was documenting, Karen would see the next patient and we would alternate like this throughout the day. This routine allowed me the luxury of focusing on one patient at a time and our patients were seen in a timely fashion. C: (3/29/13): Repetition is the way that I’m going to improve in this area. I do feel like I am making some improvements and getting a little faster each week. When I started, it would take me about 60 min to see a patient and document a note. I think I’m down to an average of about 30-45 min now. (5/3/13): By the middle of my clinical experience this semester, my preceptor and I had a nice workflow figured out that allowed me to see about every other patient and document immediately following each visit. That was a strong contrast to the prior semester, where I saw one patient after another and then documented during lunch or at the end of the day. I think that seeing both ways of handling patient care has been beneficial and each has their good/bad sides. To move towards meeting this goal in the future, I will seek out opportunities in my next clinical experience to push my pace a little bit more. In the future, I know that it is unlikely that I will get the chance to document after each encounter, so I will work on finding a good way to balance patient care with documentation. D: (3/29/13): I used a “cheat sheet” that has ROS questions, health promotion questions, etc… to meet this competency.17. Maintain confidentiality and privacy □ □ □ □ □ X/XSecond Submission (3/29/13): A: Privacy is the right of an individual to keep information about him- or herself from being disclosed. Patients decide who, when, and where to share their health information. On the other hand, confidentiality is how we, as providers, treat private information once it has been disclosed to others or ourselves. Patient confidentiality means that personal and/or medical information given to a health care provider will not be disclosed to others unless the patient has given informed consent.B: (3/29/13): When I am in the clinic, I am careful not to discuss patient information in areas where other patients might hear it. I do not use any identifying information on my patient logs. When my preceptor and I discuss patients, I try to do it in her office so that the information is not overheard by other patients or office staff that is not directly involved in the care of the patient. (5/3/13): This semester I encountered a privacy issue that I had never thought of before. When we give out samples of medications in the clinic, we try to always put them into a brown paper bag. Not only are the paper bags useful for carrying the medications, they also help protect the patient’s privacy as they leave the clinic through the waiting room. C: (3/29/13): I feel that there is always room for improvement in everything that I do, but because of my background in nursing, I feel that confidentiality and privacy have been so ingrained into my practice that I am aware of privacy/confidentiality during any interaction that I have. (5/3/13): At the conclusion of this clinical experience, I feel that I am able to consistently perform the objectives of this competency independently and proficiently. I will continue to challenge myself to improve in this area by discovering the privacy/confidentiality challenges that are unique to each area of health care (ex: I had never been in an area that gave out medication samples and didn’t think about it being an area that patient privacy could be jeopardized) and incorporating those things into my daily practice as possible. D: (3/29/13): I used my knowledge of HIPPA to meet this competency.18.Demonstrate professional behavior □ □ □ □ □ X/XSecond Submission (3/29/13): A: As a student in a clinical setting, it is important to remember that you not only represent yourself, but your school and your profession as well. Demonstrating professional behavior indicates that you take your work and your clients seriously. Professional behaviors may include dressing appropriately for the setting you’re in, being courteous and mindful of others in conversation, assuming responsibility and accountability for your actions, and being respectful of personal boundaries.B: (3/29/13): I demonstrate professional behavior by wearing my Washburn name badge when I’m in the clinic. We do not wear white lab coats in this clinic setting, but we are expected to dress in slacks (business causal). I consistently meet the expected dress requirements. I also demonstrate professional behavior by arriving on time, being prepared, having all my necessary “tools”, and being ready to get to work on the scheduled days that I have agreed to be there.Another example of professionalism occurred when a patient expressed their wish to not have a student participate in their visit that day. I was able to professionally exit the situation without causing the patient distress or feeling resentful towards the patient’s decision.(5/3/13): One experience that I had this semester was with a patient we were seeing in the clinic for diabetes. I had taken her shoe off to do a diabetic foot exam. When I picked her shoe up to help her put it back on, three roaches crawled out of it. I could tell the patient was embarrassed by the incident, so I did my best to reassure her and move along with the visit. Even though I really was kind of “creeped out” by the incident, I continued to maintain a professional demeanor throughout the remainder of the visit. C: (3/29/13): Although there is always room for improvement, I feel that I have a really good understanding of what it means to demonstrate professional behavior. This semester, I have consistently demonstrated professional behavior in my interactions with my preceptor, the clinic patients, and the office staff.(5/3/13): At the conclusion of this clinical experience, I feel that I am able to consistently perform the objectives of this competency independently and proficiently. I will continue to challenge myself to improve in this area by observing those around me that I feel exemplify professional behavior, and do my best to incorporate their behaviors into my own style. D: (3/29/13): I used my knowledge of Washburn’s Code of Conduct and the ANA Code for Nurses to meet this competency.20. Employ effective communication methods with patients, □ □ □ □ X/X □families, preceptor, and staffSecond Submission (3/29/13): A: Good patient/provider communication is important and has multiple impacts on various aspects of health outcomes. Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety. The impacts of effective communication include better health outcomes, higher compliance to therapeutic regimens in patients, higher patient and clinician satisfaction.APRNs are both interviewers and teachers. As the interviewer, we must listen closely, ask the appropriate questions and have the ability to accurately understand and respond to the answers. As the teacher, we need to communicate vital information and ensure that the patient understands. B: (3/29/13): There are several things that I try to incorporate into my interactions with patients to improve communication during our encounters. These include making eye contact, sitting down during patient, listening attentively, showing empathy and respect, and answering questions honestly. When I discuss patients with my preceptor, I try to be clear and concise while making sure I am giving her all of the necessary information. When communicating through an interpreter, I try to repeat back what the patient has told me, to make sure that I am understanding them correctly.(5/3/13): When I review labs with patients, I try to explain in simple terms what each lab means (HDL is your good cholesterol, LDL is your bad cholesterol, etc) so they have a better understanding of what were looking at and why. When I give handout or printed information to a patient about diabetes or hyperlipidemia, I like to write their lab values next to the lab values on the handout so they can get a visual picture of where their numbers should be. When communicating with the staff in the clinic, I try to be clear, polite, and respectful when I ask questions or need them to do something for a patient I’m seeing. C: (3/29/13): I will continue practicing my ‘Bullet Presentations’ with my preceptor. I feel that I present all the necessary information, but I can be a bit unorganized in my presentation of the information. I have worked on improving my communication with faculty this semester and have been checking my Washburn e-mail more frequently.(5/3/13): To move towards meeting this goal in the future, I will seek out opportunities in my next clinical experience to practice explaining thing to patients in a way that they can understand. I will also continue my to refine my “Bullet Presentations” with my next preceptor.D: (3/29/13): I have used my preceptor, as well as other providers I have been in contact with this semester, as my main source of information.21. Provide culturally competent care to patients □ □ □ □ X/X □and families and negotiates a mutually acceptableplan of careSecond Submission (3/29/13): A: Culturally sensitive care is a set of behaviors, attitudes, and skills that enables nurses to work effectively in cross-cultural situations. To deliver truly culturally competent care, APRNs have to look at where our patients are coming from and what their ideas of wellness and illness are. This requires us to use critical reflection and self-awareness of our own values and beliefs. Providing effective, sensitive healthcare for patients of other cultures requires empathy, flexibility and a commitment to continuous learning.B: (3/29/13): On 3/28/13, I performed a KBH exam on a 16 year old Hispanic girl. The patient spoke English, however she was accompanied by her mother who did not. In order to make sure any concerns the patient’s mother had were addressed and to make sure she received the same information that the daughter did, we brought an interpreter into the room to translate for us.On 3/28/13, I cared for a 39 year old Hispanic female who came to the clinic for follow up on hyperlipidemia and lab review. During the visit, we communicated through a translator. During the ROS, she stated that she was having some dizzy spells. In trying to decide the most likely cause of her dizziness, I asked her about any other symptoms she was having. It was challenging because the translation/phrasing of things are different when communicated through a translator. She said something like “There are things in my eyes” when what she was trying to communicate would be phrased “My vision gets blurry/changes during these episodes” in English. It forced me to be creative and very specific in the questions that I asked. (5/3/13): On 4/16/13, I cared for a 49 year old Hispanic patient that was a new patient to the clinic. She was Spanish-speaking, so I used a translator to facilitate communication during the visit. She had a history of diabetes and had been receiving healthcare in Mexico. The pill bottles that she had with her had Spanish on the labels. The translator wasn’t familiar with the medications, so we had to look them up on the computer to figure out what she was on. We were finally able to figure out that she was on Metformin 850mg BID and Glipizide 5 mg BID. We checked her blood sugar and A1c (215, 10%) and knew that her medications needed to be adjusted. We explained through the translator that we would like her A1c to be less than 7% and that we were going to have to adjust her medications to get it there. When we sent the medications to the pharmacy, we asked that the labels be printed in Spanish so that she would have an easier time taking her medication. She agreed to the adjustment of her medications and was willing to come back for follow up in one month. C: (3/29/13): In my practicum experience this semester, I would say that I have had a wider range of culturally diverse situations compared to my clinical experience last semester in Netawaka, KS. I have encountered both men and women, diversity in age ranging from 5-70’s, people from Caucasian, African American, Hispanic, and Arab ethnic backgrounds, and people from different socioeconomic backgrounds. At first, trying to get through an office visit using a translator was very difficult. I am now becoming more comfortable communicating through a translator and understanding the subtle variations in how different groups describe things, such as dizziness. I will continue to try to improve in this area by establishing trusting relationships with the patients I see through open and sensitive communication. I will try to be mindful of cultural preferences and do my best to negotiate and implement culturally congruent interventions in order to produce the best possible health outcomes for that patient.D: (3/29/13): AACN Tool Kit for Graduate Cultural Competence provides resources to assist in preparing culturally competent graduate students for practice and research. The Tool Kit includes numerous resources and examples of references as well as classic work that are useful. (5/3/13): The translators at the SCHA have been a wonderful resource and I don’t know that I would have survived the semester without their help!22. Communicate practice knowledge effectively both □ □ □ □ X Xorally and in writingSecond Submission (3/29/13): A: Communication is the process of sharing information between two or more people. It is necessary that every member of the healthcare team communicates with one another for better coordination of care, maintaining good working relations, and keeping everyone on the same page as far as the patient’s treatment goals are concerned. Effective communication skills require knowledge, practice and effort.B: (3/29/13): I have been able to see patients and give a short report to my preceptor of the CC and findings associated with the patient. I actively discuss each clinical case with my clinical preceptor in terms of reason for diagnosis, differential diagnoses, and possible treatment plans based on diagnosis. I document progress notes in an effective manner that will hopefully allow for future providers to easily track what has been done/needs to be done in follow up with patients.I was able to write a reflective case presentation on my practice in the clinical setting and present that information orally in a grand rounds format. (5/3/13): I have continued to refine my written documentation throughout the semester. My progress notes are thorough and rarely need to be edited or added to by my preceptor. I am able to communicate pertinent patient information to the staff at the agency so that they are able to better meet the patient’s needs (ex: I communicate with the PPAP coordinator re: patients in need of that program so that the patient can begin receiving medications as soon as possible).I have maintained communication regarding my clinical experience (in person and through e-mail) with the faculty at WU as expected. C: (3/29/13): I will continue to try to consistently communicate pertinent information both orally in reporting to my preceptor and graduate faculty and in clinical documentation. D: (3/29/13): I will continue to document on this tool so that I can reflect on my experiences. In the clinical setting, I have used the electronic medical record cues to help me chart as accurately and completely as possible. 23. Apply available evidence to continuously □ □ □ □ X/X □improve quality clinical practiceSecond Submission (3/29/13): A: Quality care can be defined as the degree to which health services to individuals and populations increase the desired health outcomes consistent with professional knowledge and standards. Quality care also means avoiding underuse, overuse, and misuse of health care services. Improving the quality of clinical practice involves using current best evidence in making decisions about the care of individual patients, and requires the active integration of clinical knowledge, external clinical evidence from the literature, and individual patient needs and wishes.B: (3/29/13): On 3/20/13, I cared for a 46 year old female patient with c/o lower back pain. Prior to talking with the patient, I quickly reviewed the recommendations on the management of back pain. The recommendations state that providers should not order x-rays, CT scans, MRIs or other tests unless they suspect nerve damage or a specific cause of the low back pain that would show up on the test. When patients have signs of nerve damage that might be treated with surgery or spinal injections, an MRI is the best test to order. After speaking with the patient and performing the physical exam, I felt that her pain was not nerve pain, she showed no signs of muscle weakness, and that x-rays were probably not necessary at this time. I encouraged her to use a heating pad, ibuprofen or Tylenol, and to continue to exercise to help with pain. We also sent a referral for her to physical therapy to teach her stretching and strengthening exercises for her lower back.(5/3/13): On 4/15/13, I cared for a 35 year old male patient with c/o a rash that wasn’t improving with current treatment. He had been treated for tinea corporis twice over the last few months, once with topical cream and once with oral fluconazole. He continued to have a 2-3 cm lesion in his right axilla and a 4-5 cm lesion in his left axilla. Because his lesions were not improving, I looked up the treatment guidelines to make sure that we were treating appropriately. I discovered that it was probably not responding well to treatment because of the moist, warm environment of the axilla area. Per the recommendations of the AAFP, cultures can be obtained in cases that seem to be resistant or if the diagnosis is in doubt. Based on those recommendations, we decided to culture the lesions before prescribing any more medications.C: (3/29/13): Healthcare is continuously changing, and so, to continue to improve in this area I will continue to refer to the treatment guidelines periodically to make sure that my practice stays current.D: (3/29/13): The Up to Date website and National Guideline Clearinghouse website have been helpful in meeting this outcome.24. Utilize appropriate agency educational tools □ □ □ □ □ X/Xto provide effective, personalized health care topatients and caregiversSecond Submission (3/29/13): A: Educational tools are used to supplement the verbal information a healthcare provider gives their patient. Examples of educational tools might include handouts, diagrams, models, or videos. Health education materials are effective only when used as a part of an overall patient education strategy. Simply handing your patient a pamphlet is not enough to promote understanding or behavior change. Patients have various levels of literacy and speak different languages. Your selection of well-designed educational materials and how you use them when educating your patients will determine how effective you are at helping them manage their health care.B: (3/29/13): On 3/7/13, I provided printed information about high blood pressure to a 39 year old female patient diagnosed with hypertension during her office visit. I supplemented the handout by explaining what high blood pressure is, why it is harmful, what her goal blood pressure is, and ways to decrease her blood pressure to reach her goal BP.On 3/28/13, I cared for a 39 year old Hispanic patient who was seen in the clinic for review of lab results. Her triglycerides and her LDL were elevated, so my plan was to have her try dietary changes before starting her on oral medication. I explained the diet changes she needed to make and used a handout printed from Up to Date on high cholesterol to supplement my verbal information. I also gave her a booklet on Living with Diabetes for the diet information, since she was pre-diabetic as well, to reinforce information that she had received during a previous visit. (5/3/13): On 4/15/13 I cared for a 47 year old female patient that was seen for follow up on lipids. During her visit we discussed smoking cessation and I gave her a KanQuit card to take with her after the visit. The KanQuit program offers tobacco cessation resources free of charge. I have continued to use the Living with Diabetes pamphlets regularly. There is also a handout that gives information of symptoms of hypo- and hyperglycemia that comes in English and Spanish that I have used several times. I have also discovered that the Up to Date patient information (on almost any topic you could ever want) can be printed in Spanish for our Spanish-speaking patients. C: (3/29/13): To improve my skills in this area, I am starting a collection of handouts that I have found particularly useful or that I wish I had available during a previous visit with a patient. I would like to add some non-handout visual aides to my collection, such as a dermatome diagram, to use when explaining neuropathy, etc… I would also like to find some information on low impact exercise, since that information is not readily available at this site. D: (3/29/13): Many of the drug reps that visit the Shawnee County Health Agency leave printed material for the providers to give their patients. My favorite so far is a booklet on living with diabetes that is printed in Spanish. I have also used the Journey for Control website because it has printable patient information on Type 2 Diabetes and A1C testing. The CDC website and Up To Date website have printable patient information handouts on many different subjects, such as hypertension, high cholesterol, etc…that have been helpful in meeting this outcome. 25. Coach the patient and caregiver for positive □ □ □ □ X Xbehavioral changeSecond Submission (3/29/13): A: The negative health effects of behaviors such as smoking, drinking, excessive caloric intake, and lack of physical activity have been demonstrated over and over again. These behaviors have implications for a variety of health outcomes including cancer, diabetes, heart disease, arthritis, depression, obesity, and kidney diseases, as well as related outcomes, such as functional impairment and disability, poor quality of life, and increased health care utilization. Behavior change, therefore, is critical to the prevention, management, and treatment of many important health conditions. The initiation and maintenance of behavior change can be very difficult. Even the most successful behavior change interventions are limited in their ability to induce significant, long-term behavioral changes in the majority of adults. For example, most smoking studies show a pattern of relapse and cessation that may continue for years. The heart of the coaching interaction is to provide feedback that will help the patient develop an awareness of what they are doing by continuing to choose negative behaviors. A coach may guide, explain, demonstrate, focus, encourage, and show new possibilities. The ideal coach acts as a clear, non-judgmental mirror that reflects what really happens in the patient’s efforts. Rather than teaching or advising, which suggests that the coach shows the patient something they didn’t know, he or she coaches the patient to help bring out and strengthen the knowledge that the patient already has.B: (3/29/13): I recently cared for a 48 year old African American female who came to the clinic for follow up on her HTN. She told me that she had been trying to decrease her portion sizes and increase her intake of green vegetables in an effort to lose weight. She also said that she is trying to stay active and is looking forward to the spring when she can get outside more. I encouraged her to keep up her efforts and that making these positive changes was going to help her blood pressure, lower her risk for diabetes, and help her depression. I encouraged her to keep up the good work.(5/3/13): On 4/8/13, I cared for a 46 year old male patient that was being seen in the clinic for blood pressure monitoring. His blood pressure that day was 130/81. The patient was interested in starting an exercise program and wanted some suggestions on how to get started. Because the patient had a history of CHF, I encouraged him to start slowly with 5-10 minutes of walking 3x/week. I encouraged him to listen to his body and not over-do at first. I told him to slowly work up to a goal of 30 minutes 5x/week. I tried to reinforce that he should find an activity that he enjoys, so that it is a fun experience. During the visit, I tried to cheer him on and reinforce the benefits that he is going to get from starting to exercise, such as weight loss, lower blood pressure, more energy, etc…C: (3/29/13): Repetition and self-reflection are probably the best ways for me to improve in this competency area. I would also benefit by continuing to observe how my preceptor approaches sensitive subjects with patients and family members.(5/3/13): At the conclusion of this clinical experience, I feel that I am able to routinely meet the expectations of this objective with minimal support from my preceptor. I have found that, even with people who don’t seem to want to make any kind of lifestyle change, you can usually find one positive thing that they are doing and try to build on that. D: (3/29/13): I have used several websites including Sparkpeople, , and the ADA website to complete this competency.26. Demonstrate information literacy skills in complex □ □ □ □ □ X/X decision making0 1 2 3 4 5Second Submission (3/29/13): A: "To be information literate, a person must be able to recognize when information is needed and have the ability to locate, evaluate and use effectively the needed information" (American Library Association, 1989). In order to demonstrate information literacy skills in complex decision-making, the provider needs to be able to define the problem, use information seeking strategies to locate and access the information, and then use the information to synthesize a solution to the problem.B: (3/29/13): On 3/28/13, I saw a 48 year old female patient with Type II Diabetes, morbid obesity (BMI 42.4 kg/m^2), and HTN. I discussed ways to increase physical activity and maximize glycemic control. In discussing this with her, I encouraged her to aim for small goals in the process of attempting to reach a large goal. For this patient, we discussed how with exercise and diet she might be able to decrease her blood pressure, and maintain a lower HgA1c. I additionally discussed with the patient the JNC VII recommendations for the non-pharmacological treatment of hypertension, including weight loss as the best way to decrease blood pressure.(5/3/13): On 4/2/13, I cared for a 38 year old with a UTI. I used the National Guideline Clearinghouse to find the recommended antibiotic for an uncomplicated UTI. While reviewing possible treatment options for this patient, I read that ciprofloxacin is a good choice, however it can cause seizures. Since the patient had a history of brain surgery and seizures, I decided that cipro was probably not a good choice for this patient. Instead, I opted to go with Bactrim DS for treatment of her UTI. On 4/15/13, I cared for a 53 year old female patient that had come to the clinic for follow up on her COPD. During her visit, she told me that she was expecting her first grandchild soon and she had heard that in order to be able to visit the baby in the hospital, you had to have proof of pertussis vaccination. I was unsure about the answer to her question, so I looked up Pertussis on the CDC website for their recommendations. I found that “Those around an infant are encouraged to get either the DTaP or Tdap at least two weeks before coming into close contact with the infant”. We went ahead a got her vaccinated and made sure that she had proof to take with her to the hospital. C: (3/29/13): I feel that I am proficient at finding the needed information. I feel that it sometimes slows me down, but I would rather be slow than wrong about something.D: (3/29/13): To meet this competency, I have mostly relied on knowledge and skills that I have gained throughout my graduate education. Because of my education, I am able to recognize when I need to look something up and I have the skill set to locate, evaluate, and effectively use the information I find. When there is a disease or condition that I’ve seen that day in the clinic that I’m unfamiliar with, I will use Google to find basic information on the topic. For more advanced information, I frequently use Epocrates or UpToDate depending on what information I’m trying to find. (5/3/13): I have also used the National Guideline Clearinghouse and the CDC website to meet this outcome.27. Integrate ethical principles in decision making□ □ □ □ □ X/XSecond Submission (3/29/13): A: Ethical decision making is the application of the processes and theories of moral philosophy to real situations. As a provider, situations will be encountered where you are faced with two alternative choices, neither of which seems a satisfactory solution. Conflict arises when there is a need to choose between two apparently equal courses of action, each of which would have significant consequences for the outcome of care. Autonomy, beneficence, non-maleficence, justice, veracity, and confidentiality are the six ethical principles that underpin moral philosophy. B: (3/29/13): On 3/20/13, I cared for a 71 year old patient that came to the clinic for a follow up visit on her HTN and lab review. During her visit, I reviewed her chart for health screenings for which she was due as well. I found that it had been several years since her last colonoscopy and bone density testing. My preceptor and I discussed this with her and she told us that she did not want to have any more colonoscopies. She told us that she had terrible experiences with her previous colonoscopies. She also felt that, at this time in her life, she would not want to go through treatment for any cancer that they might discover by doing the colonoscopy. She did agree to have the bone density test done, since she would be agreeable to being treated for osteoporosis.(5/3/13): On 4/22/13, I cared for a 57 year old female patient that was being seen in the clinic for follow up on HTN, lipids, and lab review. The patient was already on several medications for her blood pressure and a couple of medications for her triglycerides. After reviewing her lab results, my preceptor and I decided to add Cholestid to help lower her cholesterol. When I went in the patient’s room and reviewed the lab results with her, she was happy that her numbers had improved from what they had been several years before. When I told her that I would like to add another medication to lower them even more, she refused. She told me that she did not want to take any more medications and that she was genetically predisposed to having high lipids. She was adamant that she did not want to start another medication. I recognized that she had the right to refuse the treatment I offered, so I made sure that she was aware of the risks associated with high lipids and reinforced the importance of a low cholesterol diet. C: (3/29/13): I have been able to develop treatment plans which allow the patient to be active participants in their care by offering what is medically proven to be beneficial, but also taking quality of life and life circumstances into account. I also try to be mindful of my strengths and weaknesses, so that I may treat patients to the best of my ability, but also know when I need to send them elsewhere for services that I can’t provide. I can improve in the area by seeking input from my preceptors and instructors when I run into complex ethical situations that I’m not sure how to deal with.D: (3/29/13): The ANA Code of Ethics was helpful in achieving this competency.28. Demonstrate respect, compassion and integrity□ □ □ □ □ X/XSecond Submission (3/29/13): A: Respect is defined as a sense of the worth or excellence of a person, a personal quality or ability, or something considered as a manifestation of a personal quality or ability. Compassion is a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the suffering. Integrity is a concept of consistency of actions, values, methods, measures, principles, expectations, and outcomes. Threats to integrity may include a request to deceive a patient, to withhold information, falsify records, or acting in a way that is inconsistent with the values or ethics of the profession. B: (3/29/13): When I’m working with a patient, I try to treat them how I would want my parents or children treated. Everyone has problems that they are dealing with. I try to listen to what they are telling me and help them as much as I can.(5/3/13): My experience at the Shawnee County Health Department this semester has been one of the most difficult, but also maybe the most rewarding experience in my health care career so far. The patient population at this site struggles with so many challenges…poverty, drug addiction, violence…that it makes being respectful and compassionate challenging at times. I have struggled with how to show compassion to a person that is in obvious pain, but has had several “dirty” drug screens and is not allowed to receive prescription pain medications from this agency any longer. I have struggled with how to be respectful toward a patient that argues that they can’t pay for their medication or can’t afford to buy healthy foods, but somehow can manage to buy cigarettes every day. One of the best conversations I was able to be a part of this semester was when a provider told a patient very calmly “I can’t help you unless you help yourself”. That sentence stuck with me and has since become one of my favorite phrases. It made me realize that when you empower someone to take responsibility for their health, you are treating them with respect, compassion, and integrity even if you are not handing them the exact “cure” they’re asking for.C: (3/29/13): I can improve in this competency area by listening to my patients and being mindful of how I react to what they are telling me. I think that growth in this area is a lifelong process that requires reflection on past interactions. When a situation occurs where I’m not as respectful or compassionate as I could have been, I try think about what I can do to fix it now or how I will try do better the next time. D: (3/29/13): ANA’s Code of Nursing Ethics was helpful in meeting this competency. I also relied on knowledge and skills that I have gained throughout my education and nursing career.State Board of Nursing RequirementKSBN Requirements for Nurse PractitionersMetNot Metor N/ACommentsDemonstrates advanced practice roleDisplays ability to decide to order and/or perform diagnostic proceduresAble to interpret diagnostic and assessment findingsSelects and provides prescription of medications and other treatment modalities for clients?Submission #1 Student Signature______________________________________Date____________________Faculty Signature______________________________________Date____________________Submission #2 Student Signature_______Katie Hicks____________________Date_____03/29/13________Faculty Signature_____________________________________Date____________________Final SubmissionStudent Signature_________Katie Hicks_________________Date______05/03/13______Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade:November, 2011Revised 1/23/12Revised 1/13/13 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download