Tracy Hill MSN Portfolio



December 7, 2011Washburn UniversitySchool of NursingNU 602 Clinical Performance ToolStudent___Tracy Hill_____________________Semester___Fall 2011_____Agency__Karen Evans, DO; Mt. Oread Family Practice, Lawrence, KSInstructor_Dr. Shirley DinkelClinical 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 70% 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 donot meet the competencies within the required practicum hours may be required to successfully complete additional hours before a final grade will be awarded. Points are assigned as follows: Please rate your own performance using the descriptors listed below:0 = no opportunity to experience1 = defined as not meeting expectations; failing to initiate learning experiences; arriving late and unprepared; failure to effectively communicate with the patient, family, preceptor, staff and faculty2 = defined as inconsistently meeting expectations; requires much faculty/preceptor guidance in learning experience/support3 = defined as routinely meeting expectations yet requires more faculty/preceptor direction in learning experiences4 = defined as routinely meeting expectations with minimal support from faculty/preceptor5 = defined as consistently meeting expectations with little guidance; proficient; can perform independently; initiates learning experiences; is well prepared for learning experiencesGradingThe Clinical Performance Tool is completed and submitted by the student at the completion of 80 clinical hours, 160 clinical hours, and all clinical hours for a total of three submissions. The first submission must address items 1-18, The second submission must address items 1-22. The final submission must address all competencies. The final submission is graded.NONPF competencies addressed in this course include Independent Practice, Leadership, Quality, Technology/Information Literacy, and Ethics. Competencies are founded on an understanding of pathophysiology, patient presentation, differential diagnosis, patient management, surgical principles, health promotion, and disease prevention. Utilization of communication strategies, principles of quality care, information technology/literacy and ethical principles are expected. NP students are expected to demonstrate an investigatory and analytic thinking approach to clinical situations, professional behavior, effective communication, and a sensitivity and responsiveness to patient culture, age, gender, sexual orientation and ability.NP students are expected to: 0 1 2 3 4 51.Provide age appropriate health promotion, disease □ □ □ □ □ xprevention and health protection services. 10/18/11Influenza vaccine promotion, breast exams and PAP exams are just a few ways that I meet this expectation and will continue to promote vaccines, seatbelt use, contraception management and other screenings as appropriate.11/29/11- I believe I have demonstrated this outcome effectively. I continued to provide education on and encourage influenza vaccinations/ pneumonia vaccinations, shingles vaccinations, dTap and Gardasil vaccinations; performed clinical breast exams and recommend monthly breast self-exams, and perform pelvic exams and PAPs. In our clinical practice site, we continued to promote the new guidelines and recommendations for PAPs were discussed with age appropriate individuals according to the ACOG (American College of Gynecologists), including information regarding which vaccinations are recommended, by age and risk group, including the flu shot, Hepatitis A and B, human papillomavirus (HPV), and measles. Annual testing for chlamydia and gonorrhea is recommended for all sexually active adolescents and young women up to age 25. Routine HIV testing is recommended for all sexually active adolescents and women beginning at age 19 until age 64 ( recommendations). Information discussed with patients include that The American College of Obstetricians and Gynecologists now recommends that cervical cytology screening begin at age 21 years, regardless of the age of onset of sexual activity. The few rare cases of cervical cancer in this population do not appear to have been preventable by screening (). Also, the recommendation is that if you have had 2 consecutive normal Paps, you can wait 2-3 years before another one, if you don’t change sexual practices/partners, or have any further increased risk factors; this does not take the place of having an annual “comprehensive exam” to discuss the well woman exam and do a pelvic or STI testing and even a PAP if necessary. These are just some of the topics discussed regularly during comprehensive exams when appropriate. I also discussed the need for other screenings, including colorectal screenings for patients over 50 – I had a patient who had come in after several years, and wanted a female pelvic exam and lab work – I recommended a colorectal screenings and colonoscopy because the patient was >50 years old – the patient declined, stating she didn’t want to have one and probably wouldn’t ever have one “because I have heard stories about those and I won’t have one unless I need it”; I discussed that this was a screening test and that a patient probably wouldn’t be symptomatic unless it was an advanced disease process. She continued to decline the screening, and we left it at that. Also, I became more fluent in the scripting and ability to discuss this and other topics with correct educational information during this clinical rotation, and I plan to continue to update my knowledge base and comfort level in discussing such topics. In the United States, there are two types of intrauterine contraceptive available: the copper Paragard and the hormonal Mirena. There have been several patients inquire about these IUD’s in the office. We have contraceptive management appointments, and these devices are inserted in this practice by my preceptor. In addition to verbal education regarding these devices, many patients want to go home and think about their choices prior to making a decision; one thing I did not see was a handout about these devices, which I think would facilitate education for this patient population and give the patient something to share with their partners. With so many pharmaceutical reps out there, I’m surprised I didn’t see anything about these devices in the office. As far as common websites that were used or resources that were utilized in this practice setting, resources included the CDC website, Epocrates app on my iPhone, ASOG website, AHRQ and several medical reference books that Dr. Evans had in her office that we used together to look up information. The American Cancer Society is referenced frequently and I also used my Tarascon reference book and the Sanford guide when appropriate. I plan to continue to update my knowledge base and work on my fluency with presentation and confidence as I continue each clinical rotation. I learned efficient scripting techniques and ice breaking techniques from Dr. Evans when discussing sometimes “difficult or awkward” topics. For further health protection services, there were at least 2 occasions where a rapid mental health assessment was done to decide and discuss whether or not a patient was currently suicidal. There were at least 2 similar patient presentations where a patient came in to discuss depression and follow-up and possible anti-depressants. I asked if they were currently suicidal and when they said no, we discussed local resources and crisis intervention in case of emergent or urgent needs or thoughts of suicide. We also had to determine if these patients needed more immediate evaluation by the local mental health center or in the emergency department. Both patients were not actively suicidal, but had previous thoughts of harming themselves, one even a past history of self-mutilating behavior. The appropriate screenings were conducted and current and future patient safety was discussed. Resources were provided and information was well documented. I plan to continue to improve in this area, with current knowledge and anticipation for future needs. My current job as an ER nurse helps in this area, as we do mental health screens on patients daily. I’m just learning more aspects of liability and available resources. When I evaluate my progress with this outcome from beginning to end, I realize I have made significant improvement in my approach to meeting this outcome. Encouraging health promotion is a part of every patient encounter; whether encouraging vaccinations, or smoking cessation or weight loss or addressing other individual health concerns. The examples above reflect providing age appropriate health promotion, disease prevention and health protection services. At the end of this clinical experience I was approaching each patient with the idea of helping to ensure a better state of overall health and well-being.2. Provide anticipatory guidance and health counseling □ □ □ □ □ x(Eg: lifestyle, tobacco/ETOH/ use, weight management, safety, immunizations)10/18/11 I regularly remind staff and encourage eligible patients to get influenza vaccines. I have even asked the nurse “How many flu vaccines are we going to give today?” I also encourage other “due” vaccines, such as tetanus, shingles, pneumonia, etc. I had a patient the week of 1012/11 that was inquiring about the shingles vaccine; it was age appropriate for her and she had several questions, so while we were discussing it, I went online to the manufacturers website and printed off a patient information fact sheet for her before she left to answer any other questions she might have before deciding whether or not to get it. We use computerized documentation in the exam rooms, so it was easy for me to do that while we were discussing it. I regularly offer smoking cessation information to those patients who smoke, if they are interested, and to those who expose their young ones to second hand smoke, emphasizing the long term effects of exposure to second hand smoke. I don’t shove it down their throat, but offer in a nice, educational manner. 11/29/11- Providing anticipatory guidance to patients has continued to be an outcome that I have effectively met. In addition to the above guidance and counseling, I recently was able to offer information to a patient about the safety of immunizations during pregnancy. On 11/22/11, an established 30 y.o female patient presented with s/s of pregnancy and had been trying to conceive. She had a positive home pregnancy test and presented with her spouse to confirm pregnancy and get a referral to an OB for pregnancy. She had questions about the safety of vaccinations in pregnancy, as her and her spouse, who was in the military, were soon to be deployed to Thailand in January 2012, and they would be delivering their child there and living there for about 3 years. They had received a list of recommended vaccinations from the military but were wondering which ones she should receive in pregnancy. Of particular interest was the Hepatitis A vaccine, which ironically we had just discussed in class. I informed her that the Hepatitis A vaccine, inactivated, was pregnancy category C: showing adverse fetal affects and is not recommended in pregnancy. I referenced Epocrates, and the CDC website, right from the room, so she could see this info, and I printed off info for her from the CDC website. This was the only vaccination that I (and Dr. Evans) did not know the safety information on right away, but were able to look up quickly and report to the patient. We also had previously discussed the importance of prenatal vitamins with this patient at a previous visit since we had discussed that she was trying to conceive. Another example of providing guidance and health counseling occurred on the same date, when another patient came in to confirm pregnancy. She was 19 y.o, and this was first pregnancy; in obtaining health history and discussing risk factors and habits, the patient admitted that she was a 1 ppd smoker and at least on a weekly basis smoked marijuana and had continued those habits since she found out she was pregnant. She presented with “baby daddy”, who had been trying to convince the patient that she needed to stop smoking and quit using marijuana as well. I educated the patient about the dangers of smoking cigarettes and using marijuana during pregnancy (low birth weight, prematurity, respiratory problems, stillbirth, birth defects, etc). Resources included CDC website, Epocrates, March of Dimes website, and ACS as well; I also discussed importance of prenatal vitamins and baby development. The information was provided in a timely and professional manner. I also continued to discuss safety in wearing seatbelts, eating healthy, promoting other vaccines (tetanus/diphtheria/pertussis, MMR, Hep. B, influenza, shingles, pneumonia, HPV) to name a few. Contraception management was also a regular topic during several visits. Probably weekly, if not daily, a woman came in to discuss contraception and whether or not they were happy with their current form of contraception or desired a new type, such as a switch from the oral contraceptive, to an IUD or the patch or the NuvaRing or the Depo shot or Implanon – we discussed each and I became more knowledgeable about each type of contraceptive, including risks, benefits, side effects and preferences. I observed at least 2 IUD insertions. These are just a couple of examples of the ongoing anticipatory guidance and health counseling that was provided during my clinical rotation. Other examples of providing health counseling have been with the female comprehensive exams I have performed. With each exam I discussed doing self-breast exams monthly, mammograms and depending on their age, anticipatory guidance for menopausal symptom management. 3. Identify etiologies, risk factors, underlying pathologic □ □ □ □ x □processes and epidemiology for medical conditions including hypertension, lipid disorders, chronic and acute respiratory conditions, diabetes and thyroid disorders10/18/11Each patient is asked about family history, it is documented and reviewed at each visit; personal social, medical and surgical histories are also obtained. With family hx of CAD, HTN, DM, hyperlipidemia, patients are screened at an earlier age for such disorders since they have + family hx – such as fasting blood glucose studies or fasting lipid profiles; close attention to ongoing BP readings. TSH and breast ca screenings such as mammograms or ultrasounds are closely followed and ordered at earlier ages in those patients with + family hx as well.11/29/11 – I have a better understanding of pathophysiology for the more common medical conditions such as HTN, DM, CHF, etc. I am able to identify causes and risk factors and have incorporated this in teaching patients about their disease. Describing the pathophysiologic process to the patient in terms they can understand is crucial and I have worked hard and improved upon my approach to teaching to make it more fluent and efficient and easier for the patient to understand in lay terms. In addition to continuing to identify risk factors for diseases and medical conditions such as family, personal, social, medical and surgical histories as described above, underlying pathologic processes and epidemiology for medical conditions were also identified and discussed. Essential benign hypertension and type II (non-insulin dependent type) or unspecified type diabetes mellitus without mention of complications have been the two common medical conditions I have participated caring for in my practicum experience. Other prevalent conditions in our practice for this clinical rotation included thyroid disorders, lipid disorders, and chronic and acute respiratory disorders, to name just a few. Etiologies and risk factors for HTN include family history of HTN, stroke, and cardiovascular disease, as well as personal history of obesity, diabetes, hypercholesterolemia, and smoking. Etiologies of these other conditions in our practice included family history, obesity, high-fat/ low-fiber diets, and sedentary lifestyles, in addition to age, gender, race and socio-economic status, and include work-related risk factors including prolonged sitting or standing, and construction work. These etiologic factors are similar to those found nationwide. Multiple strategies for increasing proficiency in this area must be included in patient care – for example, a patient presents and is dx with acid reflux – we don’t just give them an H2 blocker or a PPI and say “see ya later – hope this works for you”; we discuss other strategies as well, including types of foods to eat and those to avoid, keeping HOB elevated, not eating 3 hours before bed, is it something else like an ulcer?, is it H. Pylori?, do we need to do an EGD, etc. Multiple strategies are necessary to improve the overall health and well-being for the patient and it is important to educate them and include them in their care. DM is another example of using multiple strategies to treat medical conditions: we don’t just put them on Metformin and say “See you in 3 months”; we discuss diet and exercise changes, pertinent labs, side effects of medications and what further treatment might be necessary; we also include education on teaching patients to properly check their finger stick blood sugars, and when to do them. We have them report their reading over 2 weeks, sooner if drastic changes noted; refer to diabetes educator if they are willing; discuss future medication treatment, including other diabetes meds and insulin. Give patients time for questions and feedback, and let them be the decision makers in their care. It’s important to give them all their options so they can look at the big picture and have as much knowledge and education as they need to make informed decisions about their health. I have also made consistent improvement and become more independent in meeting this outcome over the last couple of months due to additional information and learning in class as well as experience gained in the clinical setting. Between caring for the patients in the practicum and receiving informative lessons in NU 600 Adult Health I, I have increased my exposure to common internal medicine conditions such as lipid disorders, chronic and acute respiratory conditions, and thyroid disorders and as such, I believe I have a more solid understanding of the etiology, risk factors and pathophysiological processes of respiratory illnesses, DM, HTN, lipid and thyroid disorders. 4.Perform comprehensive health history and □ □ □ □ x □physical examination to formulate basic differential diagnoses10/18/11- In a recent meeting with my preceptor about my performance, she stated that I was “doing a great job with obtaining health histories, doing physical exams, documenting and explaining care to and educating patients about their diagnoses”. 11/29/11- My preceptor, as well as myself, continue to believe I am doing well in this area. I also think that obtaining comprehensive health histories and doing physical exams is one of my strengths. Often times my exams were more thorough than those of my preceptor, and she complimented me for this – as an area in which she felt she should also sometimes be more comprehensive. It has not been difficult for me to formulate basic differential diagnoses, and most often I have been able to determine the correct diagnoses from a list of formulated basic differentials. It is when there are more problem-focused differential diagnoses that I struggle a little bit. I have become more organized and systematic and have gained more confidence in my approach to completing a comprehensive health history and physical exam and formulating differential diagnoses since the beginning of this clinical experience. As a result of the feedback of my preceptor and instructor during this clinical rotation, I was able to improve my assessment techniques, from being more culturally sensitive and more softly spoken, to having a “lighter touch” when performing pelvic and bimanual exams and during thyroid palpation. I have watched my preceptor’s systematic assessment and have taken aspects of it and developed my own systematic approach to assessing patients in a thorough and efficient fashion. To become more proficient in meeting this outcome, I need continued practice with patients of all age groups, gender, cultural and ethnic backgrounds. I have had the opportunity to assess many challenging patients with multiple co-morbidities and I believe my future practicum will offer similar challenging patients and experiences. This is an area that can always use more improvement and finesse. I will continue to work on this process to verbalize more differential diagnoses and to be more confident in my formulation of more potential differentials and always consider the “worst-case” and “most probable” diagnoses first as I consider my plan of action. Proficiency will be gained with continued practice and experience that enables me to refine and improve all aspects of my care.5.Perform problem-focused health history and □ □ □ □ x □physical examination to formulate basic differential diagnoses10/18/11 Some examples of problem-focused health hx and physical exams with DiffDx. I have done include, but are not limited to: annual pelvic and PAP exams with Breast Exam for well-woman check-ups; ingrown toenail with removal; cough/wheezing/sob/- asthma exacerbation, bronchitis, pneumonia. COPD; eye redness and pain – conjunctivitis, corneal abrasion, foreign body; sore throat – pharyngitis, allergic rhinitis, bronchitis; contraception management; diaper rash – candidiasis; runny nose, ear pain and cough – allergic rhinitis; My preceptor stated that I was doing a good job with differential diagnoses, and just needed to work on “finesse”, and needed to” tweak” diagnostic test selection based on common/likely DD and severity of illness/disease. 11/29/11- Comprehensive physicals and health histories were completed on both women and men. Thorough head to toe assessments were completed. Obtaining thorough health histories and performing comprehensive physical assessments is strength of mine. Also, it has not been difficult for me to formulate basic differential diagnoses, and most often I have been able to determine the correct diagnoses from a list of formulated basic differentials. Each day I become more organized and detailed in performing a problem-focused history and physical exam and have improved in my ability to think in terms of differential diagnoses. Before seeing each pt, I review their past medical hx, VS and CC and then think of at least three differential dx for this pt. It is when there are more problem-focused differential diagnoses that I still struggle a little bit. It is sometimes more difficult to consider the worse-case scenario when a patient presents looking pretty good from a physical assessment perspective, so I don’t always verbalize the worst case scenario differential diagnoses. I think part of that comes from working in an emergency department setting for so many years and actually seeing worst-case scenarios, so I know when someone is usually very ill. I will continue to work on this process to verbalize more differential diagnoses and to be more confident in my formulation of more potential differentials. Often I bypassed some potential differentials because I was sure of the final diagnosis, but need to continue to think about the worst case scenario diagnosis and the most probable diagnosis when devising a plan of care and treatment options. An example of this is a 35 y.o female patient that came in for chronic constipation issues, reporting she only had a bowel movement every 2-3 weeks, and it was hard and with small pellets, and she had to take daily laxatives to have a BM; she reported that she had taken stool softeners, increased fiber in her diet, drank plenty of water and got regular exercise; she denies diarrhea, no n/v, no blood in stools; her worse-case scenario dx was partial bowel obstruction, with Crohn’s and colitis as options, and with constipation as probable. I hadn’t thought about constipation IBS as a potential diagnosis because she didn’t ever have diarrhea and didn’t seem to have any pain except when having a BM; she was a/o, in no acute distress; we ordered abdominal x-rays to make sure it wasn’t a bowel obstruction. It is easier when there is another experienced provider to bounce ideas off of, but I need to be more confident in my decisions and stick with my plan as if I am the provider. This clinical experience provided a challenging, diverse patient population and was fundamental in becoming proficient, which was more reflective at the end of the rotation much more than at the beginning. These are many examples to illustrate my ability to perform a problem-focused health history and physical exam to formulate differential diagnosis, which I will continue to improve upon as time goes on and I gain more experiences.6.Participate in diagnostic reasoning in clinical decision □ □ □ □ x □making and development of a treatment plan.10/18/11Each patient that I see is discussed with my preceptor. We participate together in diagnostic reasoning and clinical decision making and develop a treatment plan together. Usually, I see each patient individually, then present my patient to my preceptor, giving her a brief report/SOAP presentation, she will give her feedback and make any further recommendations or suggestions, then we go together to see the patient briefly and will discuss the plan of care with the patient based on our team approach to treatment. We have a dialogue between patients and at the end of the day when reviewing documentation on each patient about “what is good and what needs some work”; therefore, I have daily and up to date feedback on patient care, treatment plans and suggestions.11/29/11- I participate in diagnostic reasoning and clinical decision making and develop a treatment plan with each patient I see in the clinic. I feel like this is an area in which I continue to grow and develop. Diagnostic reasoning is a critically important skill that involves instinctive and methodical processes used to make a clinical decision in regard to a developing a patient’s diagnosis and treatment plan. I have had the opportunity to develop the skill of diagnostic reasoning to assist me in making clinical decisions about the diagnosis and treatment plan for over 180 patients over the course of this practicum. Within the first month of this rotation, I began to see patients individually and give a SOAP report to my preceptor and provide my opinion and diagnostic reasoning for the diagnosis based on clinical findings. We discussed the plan and then she would go into the room to “clarify and close” so to speak. As time has progressed, my preceptor has to spend less time in the room based on my assessment and plan and the ability to answer questions confidently to the patient and to give a better “big picture” to my preceptor before she goes into the room. I have developed an increased sense of confidence in my assessment skills as well as just having more experience in this particular setting. Diagnostic reasoning is practicing and having the ability to connect a diagnosis to a problem and recommend appropriate therapies and clinical decisions are applied when deciding what treatment to use or plan to make – for example, if doing a cxr on a patient with a cough going to change the plan of care – will I prescribe antibiotics anyway??. Clinical decision making is being able to sift through the data and determine the appropriate processes for or against differential diagnoses, and working together with the patient based on available resources – for example, a patient won’t take a medication they can’t afford, so why not give a medication sample if available? Sometimes you might be forced to use the “$4 list” to increase the ability of a patient to obtain a medication, or you might need to prescribe a medication that is a 3 day course instead of a 10 day cheaper course to increase adherence to taking a finishing a medication. 7.Recommend screenings for common diagnoses of □ □ □ □ x □hypertension, lipid disorders, chronic respiratory conditions, diabetes and thyroid disorders10/18/11On an ongoing, daily basis, we screen new and established patients for HTN, DM, lipid disorders, asthma, COPD, and thyroid disorders. All patients have a complete set of VS on arrival, so BP is always included. New and established patients frequently do BP readings daily for 2 weeks and bring in results on a 2week follow-up – either when first dx with HTN, if changing meds, or starting meds; TSH levels are frequently checked on patients– we had a 39 year old female patient that was c/o hot flashes, hair loss, irritability, dry skin, fatigue, irregular menstrual cycles last 3-4 months; dx was Hashimoto’s after checking thyroid levels. After med changes for HTN and before initiating antihypertensive drug therapy, we monitor kidney function tests (BUN/Creatinine) and serum potassium levels. If patients are on lipid lowering agents, we monitor lipid levels every 6 months and check LFT’s prior to initiation of therapy; We also educate patients on fasting prior to labs for accuracy. There is a lab in the office, and before lab draws we ask patients when the last PO intake was so we can determine when to draw labs. DM patients usually bring in 2 weeks of fingerstick blood glucose levels prior to initiating therapy with either Metformin or before initiating insulins – most commonly seen initiation of a new glucose lowering agent is Levemir or Lantus; in the clinic I am working in we usually prescribe Levemir and start low at 10u qhs and see pt in 2 weeks. We have an established pt with hx of myeloma and are newly dx DM – initially started on Actos and Metformin; we see him every 2 weeks, have increased his dose of Actos and added Levemir and have changed his dose from 10u qhs, to 20u qhs, to 30u qhs and have seen incremental changes, but are moving slowly. Pt is adherent to therapy and is actively involved in improving his health. He had a visit where his blood sugars were in the low 300’s at home and a spot check in the office was in the low 200’s; so we had him go home and check his monitor and make sure he did the controls on it, and found his monitor to be 100 points different than ours, so we got him a new monitor. 11/29/11- Most of the patients in this clinic already have at least two or three co-morbidities, and as a result, I have certainly had the opportunity to recommend screening for these common diagnoses. I have had several visits with an established 47 yr. old male patient who records his BP at home over 2 weeks prior to his office visits, as his office readings continue to be elevated above the 150/90 range. This same patient also checks his blood sugar levels at home and reports those over a 2 week period so we can make insulin adjustments since he just started on Levemir. Screenings for lipid disorders, diabetes and thyroid disorders have routinely been performed on patients who come in for comprehensive exams in addition to some patients who present with acute conditions that may indicate the need to screen for these diagnoses. I have become more proficient at recommending lab and diagnostic screening during this clinical experience – the computerized documentation system/EMAR makes it easier to view when a patient last had diagnostic tests or labs as well, even if their last visit was with a different provider. Knowing normal lab values and when other co-morbidities should be screened for based on previous illnesses or dx also helps to trigger the plan to recommend screenings. Class discussions have helped with becoming more familiar with the recommended guidelines for screenings and examinations for DM and HTN especially. Even my preceptor admitted to being less than diligent about not doing a foot screening on patients with diabetes at each visit when I discussed this recommendation with her. I have developed a good habit that I intend to keep, by checking a patient with diabetes feet at each visit and making sure I am reminding them about an annual eye exam if they haven’t had one._____8.Recommend diagnostic strategies (i.e.: Holter monitor □ □ □ □ x □EKG, spirometry)10/18/11No opportunity for Holter or spirometry testing, but have had several patients need EKG’s; Had a new pt with new dx of murmur, did EKG in clinic; also had pt with new carotid bruit – did EKG; both patients were also scheduled for echocardiograms. Had a pt with hx of sickle cell anemia; had several trips to ED for chest pain– found murmur in clinic that had not previously been worked up, so ordered echocardiogram. 11/29/11- I have had the opportunity to recommend spirometry testing on at least 2 patients since the last evaluation. One patient had an exacerbation of asthma and another was a COPD patient with wheezing and cough. These pt.’s needed Spo2 testing and peak flow testing in the office pre and post albuterol nebulizer treatments when determining the plan of care – did they improve or stay the same? Did their lung sounds change? Do they need a CXR? Both patients improved after the albuterol nebulizer treatments and did not require further diagnostic studies. I have continued to recommend EKG’s - one on a new patient to our practice who had HTN and worsening SOB and intermittent chest pain – currently resolved; the patient also had a previously undiagnosed carotid bruit. Other diagnostic testing was also performed, including an echocardiogram. I have become more knowledgeable about what testing is available in the clinic setting as well, especially with pulse oximetry, which isn’t done on every patient as I am used to seeing in the ED. So if a patient comes in with exacerbation of asthma or COPD, it is helpful to do a pulse oximetry reading, especially if an office intervention is being considered. In my next setting, I will have more of these options available to me, but I must first consider whether doing certain interventions or ordering certain diagnostic tests will change my plan of care. Will it be necessary if it isn’t going to change the plan? Patients will either have insurance or be self-pay patients at the clinic I am going to be at next semester. Are my recommendations going to be different based on insurance status? Sometimes, as it may be a highly recommended diagnostic test, but the patient may refuse based on expense if they are self-pay or have a higher deductible versus not batting an eye if they have insurance with small office co-pay and no deductible. I will make sure that my recommendations are based on practice guidelines first, and then discuss the options with my patient and determine the plan of care together. ____________________________________________________________________9. Discuss evidence-based treatment information □ □ □ □ □ xin patient care10/18/11 Discussion had with newly dx diabetic patient included the following information: Lifestyle changes plus metformin are initial antihyperglycemic therapy for most DM2 patients. If HGBA1C is above individual goal, pharmacotherapy is generally recommended to reduce the risk of microvascular complications (nephropathy, retinopathy, and neuropathy).. The ADA recommends that metformin be started concurrently with nonpharmacologic therapy when HBGA1C is above goal, because of the difficulty in achieving and maintaining lifestyle change. Metformin is the only glucose-lowering therapy that has been shown to possibly reduce cardiovascular mortality in type 2 DM. 11/29/11- My preceptor and I have had several discussions about prescribing antibiotics. The literature or references recommend antibiotics for common illnesses such as otitis media or community acquired pneumonia, or empiric treatment of acute bronchitis. My preceptor will often prescribe a medication based on what samples she has in the office or based on her experience with certain medications. For example, where Zithromax might be a primary option that I would select for acute bacterial sinusitis, she moves right into secondary options such as Augmentin (experience) or Avelox (has samples). This just comes with time and experience, everyone has personal preferences regardless of current EBP, and that must be taken into consideration as well. I plan to start by using EBP guidelines and then as I continue my practice, I’m sure I will develop preferences based on experience as well – experience is your own EBP investigation, it just isn’t published in a journal! EBP guidelines are just that, guidelines and will need to be adjusted based on my patient population. The most common resource I used in my rotation continued to be Epocrates via my iPhone, which I used to look up medication dosages as well as diseases. I also accessed practice guidelines from ARHQ or looked up diseases on the CDC website. Other sources of EBP used in this clinical setting included Buttaro and Sanford and the Tarascon guide. I also referred to my Mosby’s physical exam pocket handbook if I needed to. My preceptor and I diagnosed a patient with acute Lyme disease, so we researched Acute and Chronic Lyme disease on the CDC website. The National Guideline Clearinghouse (ARHQ) was used as well. I am glad to have had the exposure to these resources through our different courses and to know what people use the most is beneficial and time saving. Mostly I used Epocrates as well to research drug interactions and dosages. To be accurate with prescriptions, I used the Sanford Guide and Tarascon and Epocrates. An important key was the ability to evaluate the patient response, wither with a follow-up appointment in a couple of days if not improved, or to see them in a few weeks and to have improved or have their acute condition resolved. 10. Recommend medications based on diagnoses, □ □ □ □ x □efficacy, safety, cost, and individual patient needs10/18/11 In the practice that I am doing my practicum, patients with all forms of insurance are accepted, including Medicare, Medicaid, private pay, and commercial insurance. It is one of the few, if not the only practice in Lawrence that accepts Medicaid patients, so the “$4 list” is discussed frequently as cost of Rx’s is one of the primary concerns we hear from most patients. Samples of medications are also given when they are available and appropriate. 11/29/11- I believe I am getting more proficient with recommending the correct medication based on diagnosis without having to look it up every time. Safety, cost and individual patient needs are certainly areas for consideration with the patient population and the variety of forms of payment accepted. We also consider how many times per day a patient may have to take a medication and is it feasible to take 4 times a day when you are at school, or is a twice a day medication at a higher dose just as good or better. The affordability of medications is also always an issue - $4 list is popular with those patients on multiple medications, on Medicare or Medicaid, and many times they get samples if available. We have had to change meds a few times (Bystolic is one) because it isn’t covered on many insurance formularies. 11. Perform medical and surgical procedures as appropriate □ □ □ □ x □10/18/11Have had 2-3 opportunities to perform cryotherapy on a few actinic keratosis lesions; Have done about 6-8 PAP’s and breast exams; No opportunity yet for laceration repair. Have observed one punch biopsy; observed one toenail removal; Assisted with one KOH slide/wet prep; No opportunities yet for radiology interpretation or prenatal care.11/29/11- I have had several more opportunities to perform procedures. I have done cryotherapy several more times for actinic keratosis, assisted with toenail removal twice, sutured a biopsy excision, cauterized viral warts on multiple patients; used local anesthetic 3-4 times, done 2 solo punch biopsies, and another 10-15 pelvic exams/PAPs, with my preceptor stating she was “being the nurse”; Did not have the opportunity to view x-rays, but had multiple opportunities to discuss radiology interpretations with my preceptor on diagnostic tests ordered. For example, we discussed the findings on CXR or AAS or echocardiograms or MRI’s that we ordered on patients based on their physical exams, so that we could contact the patient with the results and further plan of care. There were at least 3 prenatal visits that we did, all on 1 day actually; they were early first trimester, so we confirmed pregnancy with a UA HCG, and discussed prenatal care in the first trimester and the importance of not smoking, and of taking prenatal vitamins, and the patients were subsequently referred on to an OB provider for their pregnancy care. This latter half of the clinical rotation provided more opportunities for performing procedures, especially when we went to Health Care Access – as they “saved a lot of procedures for us to do”; the first part of the clinical rotation was spent observing procedures I hadn’t done before, and the latter half I was able to perform with some assistance since I had seen the procedure and felt more comfortable, as did my preceptor in my ability to perform them. Practice makes perfect. My preceptor commented on how well I progressed with my PAPs and exams and assessment finesse, and I feel I progressed a great deal as well, with excellent guidance and teaching from my preceptor.12.Evaluate patient response to treatment □ □ □ □ □ x10/18/11Many of the patients seen in the clinic return for follow-up visits every 2 weeks, so I have had the opportunity to see many patients for follow-up on HTN, DM and med changes and how well they are working for the patient and what have BP measurements and blood glucose readings and do further changes or additions need to be made. 11/29/11- Subjective and objective assessments obtained during the history and physical exam, combined with findings from lab and diagnostic exams, most likely give the best indication of a patient’s response to treatment. In addition to the above ways that we evaluate patients’ response to treatment, the office nurse calls patients to follow-up on medications and tests results that we have reviewed. Each day before clinic starts and at lunch, we review lab and other diagnostic test results and email/instant message via the clinic system to the nurse what to do about tests/plans, etc. Also, we address patient phone calls and concerns at that time as well. We also review the “inbox of messages, results and critical values” as we have time between patients so we can keep patients informed of results and plan of care and response to treatment in a timely manner. There are often opportunities to evaluate a patient’s response to treatments during patient visits to the clinic such as performing an albuterol nebulizer tx on patients experiencing an asthma exacerbation and evaluating their response (discussed above in other outcome as well). Another way we evaluate the patient’s response to treatment is in having them check their BP daily and report it to us over a 1 or 2 week period of time – we can see if BP meds are working and if adjustments need to be made. These are often communicated by a phone call to the nurse and then a message to the provider, so we can determine a plan of action based on patient response. The same process is done with a patient who has diabetes. They are asked to check their blood sugar readings at certain intervals and report them to the clinic – this is especially helpful in determining response to medications or whether or not new medications need to be added or adjustments need to be made or if insulin needs to be added or adjusted, etc. We see patients on a daily basis who follow this type of plan on a regular basis. In my future practice, I plan to implement a similar strategy for monitoring HTN and DM patients, to name a few strategies that I have found to be successful in monitoring the patients’ response to treatment. Another example is a 17 y.o female patient who we began seeing in September with back pain; she is a gymnast and has mild scoliosis, but had been unable to participate in her gymnastics or tumbling and was even sitting out of PE class. With continued stretching, muscle relaxers, NSAIDS, and PT, by the end of the rotation her back pain had improved significantly and the last time I evaluated her she was 90% better!13.Document using professional terminology, □ □ □ □ □ xformat and technology (i.e.: ICD9, E/M coding, CPT)10/18/11- I am the first student that has worked with this preceptor that has attempted to use the computerized documentation system. It takes a little longer initially, but you have to select the right diagnosis ( a drop down menu pops up for your dx and you have to select the proper one”; E/M coding, and CPT codes for each patient before completing their charts, so I have exposure to all the different codes and what works and doesn’t for each diagnosis and when to pull in working diagnoses and new dx, and what to charge for on visit coding, etc., as far as new patients and established patients and time spent on care, etc. and what you can charge based on the number of systems evaluated, etc. Dr. Evans has been helpful in explaining these criteria and in making suggestions and giving input in this area. It’s a real eye opener and will definitely help with future charting and selection of CPT and ICD-9/10 coding. I could say I started out pretty “green”, but now mostly I know what dx to choose and which templates to select based on the patients chief complaint. It gets better and more accurate daily. One of the benefits to using computerized documentation is it helps you find the right terminology and you select what you want with the option of adding additional notes or terms or free text writing, such as “consistent with yeast or candidiasis”, etc. 11/29/11- Documenting using professional terminology is something I consistently try to do. It has been extremely helpful to have a computerized charting/documentation system to facilitate learning medically appropriate terminology. The most challenging aspect in my opinion is documenting dermatology conditions. While I can pick a CPT code for a growth or lesion, and the coding/billing department is the checks and balances for this, properly describing dermatology conditions has been perplexing. Is it a macule or papule, or vesicle?!It is this area that accurately describing is important, especially for follow-up and referral. I think each office should be equipped with a camera that allows transferring of images right into a patient’s chart for accurate documentation! With all the technology available, this could be the next best interface! And since it isn’t quite readily available, I must continue to rely upon my documentation and assessment skills to “paint the picture”; Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology is a reference I’ve used to help me diagnose as well as accurately describe what I find. I have also noticed that every clinic seems to have a handy dermatology reference. I have also relied on the use of my iPhone applications such as Epocrates to look information up on diseases, medications or recommended treatment plans. My future practice will most certainly use online references and applications to provide the most up to date recommendations on treatments, dx and coding. ICD 10 is sure to bring about many interesting changes and challenges. It will be interesting to see how and if reimbursement changes initially based on incorrect ICD 10 coding by providers. A good coder will certainly be a key part of my future clinical practice, and with electronic medical records and documentation systems as safety nets for providers, maybe the change won’t be so noticeable. I believe that I have a leg up in this area by having had the opportunity to document in the electronic record. My preceptor did a good job explaining criteria for billing, such as how many systems have to be assessed before you can bill a 99214 vs. 99213 or how much time you have to spend with the patient before you can bill a higher level, even when you might just spend time talking with your patient and not doing much of an exam – it’s still time…She felt her partners under billed for their services, but she also had previously owned her own clinic with her father and was probably more in tune to that than other providers who have not had that opportunity. Overall, I believe I demonstrated significant improvement in meeting this outcome and was able to meet expectations with minimal support from my preceptor by the end of the practicum experience.14. Perform care in a timely manner □ □ □ □ x □10/18/11_Including documentation, it takes me 30-45 minutes on average to see and document on a patient; some acute urgent care type of patients are faster of course. My preceptor and I have discussed the “Timely manner” issue, and where I feel like I should be quicker at times, she feels like each patient that I see is helpful to her. Also, she has stated “I don’t care how many patients you see, as long as you are providing good care and are thorough and are doing it right – speed will come with time”. My goal is to cut about 5-10 minutes off time in room just to get more efficient by the end of the semester, but with keeping in mind to continue to do a thorough exam and to not cut corners or forget pertinent information.11/29/11- My preceptor has been satisfied with my time management. She continued to feel that it was important to provide good, thorough care, regardless of time spent with patients. This would be more efficient as well if I had a way to perform eLogs while in the clinic setting. It would be more realistic as well. My time management has also been potentiated by my desire to practice more independently- we are all looking for jobs when we finish school, and those preceptors/employers will have the chance to choose employees who they may have had experience with and those they feel can be efficient and make $$ for their practices. I continue to improve my SOAP reports to my preceptor. At this level, I feel it should take a little more time to assess and treat patients to ensure I am doing it correctly, without appearing rushed or like I’m not listening, while being thorough and accurate. As time has passed since the beginning of this clinical, I can say that I think I’ve improved greatly, and have cut about 5-10 minutes off the time in the room and time spent documenting, while continuing to be thorough. I do realize there’s still room for improvement, and feel that will come with each passing semester. 15. Maintain confidentiality and privacy □ □ □ □ □ x10/18/11_Patients are discussed in the office setting and privacy and confidentiality is maintained at all times. I always adhere to the WU policies, the MSN student handbook and “Student responsibilities” as outlined in the WU SON preceptor handbook. I also adhere to the clinical agency policies and procedures including HIPAA.____________________11/29/11- In addition to continuing the above practices, I continue to be conscientious in discussing patient information with my preceptor in a confidential manner and location. I have consistently maintained privacy and confidentiality of patients cared for in this practicum without guidance from my preceptor. Meeting this outcome is a priority in every health care environment and interaction. My preceptor and office nurse would also attest to this matter without reservation. As a provider, this will continue to be a priority in the care I give my patients. 16.Demonstrate professional behavior □ □ □ □ □ x10/18/11_I am consistently on-time, dressed professionally, courteous to patients, family, staff and preceptor. I am consistently prepared, and conduct myself in an appropriate, professional manner and adhere to the dress code as expected and addressed in the WU SON student handbook.11/29/11 – In addition to continuing the above stated practices, I continue to come to clinical promptly and appropriately dressed. I wear my lab coat with Washburn ID badge prominent. I am always polite, courteous and well-spoken, with the intent of always being professionally kind, courteous and respectful, no matter what the situation. I have remained calm under all circumstances and was never reactionary. I follow the ANA Code of Ethics in my practice. The medical profession demands providers are responsible, accountable, motivated, and self-directed. This includes a responsibility to maintain a sense of integrity, trust, safety, competence, and to continue to progress in personal and professional growth. I am confident that my preceptor and office nurse and other staff at my clinical site would attest to this matter without reservation. I have carried this into my personal life as well, even more so than in the past. For example, if I am out with friends, I am even more conscientious of my behavior, as there might be people around who are current or potential future patients, and if I am recognized, I want to be seen positively and professionally. Not that I get out much, but the one time I was out with friends I really thought about this – perception is everything! 17. Employ effective communication methods with patients, □ □ □ □ □ xfamilies, preceptor, staff, and faculty10/18/11_I introduce myself to each patient and their family upon entering the room, sit down next to them, discuss their CC and do their evaluation and exam, all while maintaining respect for them and their time. I always ask “Are there any other issues or questions I can answer for you today?” before I leave the room. I communicate well with my preceptor and the staff nurse and feel we have a good working relationship. I am appreciative and thankful of their time and patience, verbalize such and will continue to do so. Dr. Evans and I have a good working relationship and she knows she can give me feedback about anything at any time and I will be receptive, as I want to learn and do well and become a great NP. She feels like it is her role to be a good role model and teacher and know that individuals who will someday be working beside her have been properly trained. 11/29/11- In addition to continuing the above practices, I feel patients, families, staff and my preceptor have been very receptive and gracious to me. I continue to employ effective communication methods, and know that active listening, paired with summarizing and clarifying is the best method. I don’t want patients to feel I am not listening to their concerns. If I want to speak, I often remind myself to take a deep breath first, to make sure I am thinking before speaking, and that the patient doesn’t have anything further to add at the time – I don’t want to interrupt. Effective communication requires a variety of tools and techniques in an effort to gain trust, respect and participation with patients, families, staff, faculty and preceptors. I share my personal experiences when appropriate – it’s not about me and I don’t want patients to feel I have a similar experience for every one of theirs. Gaining knowledge and knowing the time and place to share personal experiences will improve with time. It would be appropriate to share my personal experiences if I see an opportunity for education and I might be able to relate my personal experience to put a patient or family member at ease. 18. Provide culturally sensitive care to patients and families □ □ □ □ □ x10/18/11_I continuously strive to treat all patients equally at all times and to be sensitive to their cultural differences and needs and will continue to do so. 11/29/11- In addition to continuing the above practices, I continue to be sensitive to other cultures. I try to listen to my patients and follow their cues. During my site visit, I had a patient who was elderly (86 y.o.) and did not speak very much English, she was a Hispanic female, who brought her daughter with her to interpret and assist with the patient and the plan of care. I looked at this patient when speaking, so the patient didn’t feel like she was being ignored or that she wasn’t part of the decision making process. I felt that I spoke louder than I would normally speak for 2 reasons: 10 my patient was 86 and I was talking to 2 people who were sitting on opposite sides of the room, and sometimes a different tone or a little increase in volume is necessary; 2) I felt a little nervous because of the site visit evaluation, so I probably added to the volume a little! I feel like I was in fact, maybe being a little more culturally sensitive and my nervousness contributed to me over-reacting with my tone and volume. However, point well taken and I am always open to constructive feedback. So I will continue to be sensitive to other cultures and to not answer questions for the patient, but give them choices and let them have the opportunity to answer for themselves. This is an area that can always be improved upon. I don’t want to be the provider whose patients feel like “they never listen to me or hear what I am saying”. I plan to continue to develop an understanding of the belief systems and preferences of the diverse populations served in our area are helpful in providing effective care. Being sensitive to patients with disabilities was demonstrated on multiple occasions by providing assistance in applying for disability, approving handicapped car tags, and recommending and approving adjunctive devices such as walkers, wheelchairs, canes, etc. to assist with mobility needs. municate practice knowledge effectively □ □ □ □ □ xBoth orally and in writing11/29/11- I am continually improving on my verbal SOAP reports, and improving on my documentation skills as well in the patient’s electronic record. I improve with each patient and each day, and my preceptor also felt I made great progress in orally presenting patient findings and in writing. I will continue to work on this area, as each facility has a different method for patient documentation and preference for presenting patients from a student and preceptor perspective. I am open to new ideas and ways to improve based on preceptor input and suggestions. I’ve had a lot of practice in communicating practice knowledge in written form after five reflection papers and a lengthy outcomes evaluation. Elogs for every patient seen was also completed.20.Use best available evidence to continuously □ □ □ □ □ ximprove quality of clinical practice11/29/11- I strive to use the best available evidence to continuously improve my quality of clinical practice. I receive “DocAlert message” notifications from Epocrates which I consistently read. I also receive email updates from Medscape Daily News, Medscape News Alert, and the NCCN. I referenced Ferri’s clinical advisor and Epocrates daily. I also utilized reference books available in my preceptors’ office; I reference online sites like Up to Date, and use my Tarascon and Sanford guides regularly as needed. My preceptor is supportive and encourages looking up information on a regular basis to stay up to date and to give patients the best available care based on current practice and guidelines. She mentioned to never be afraid to look up information and praised my abilities to utilize my iPhone or other readily available resources when I didn’t know the information off the top of my head. The feedback from my preceptor, both verbally on an ongoing basis, and in her written evaluation, is reflective of my demonstrating growth in the quality of my clinical practice. Other staff members, especially the staff nurse in the clinic, were also aware of my desire to improve my quality of care and my continuous desire to learn and have enthusiasm.21.Assess patient and caregiver educational needs to □ □ □ □ □ xprovide effective, personalized health care11/29/11- Assessing educational needs of patients and caregivers is an ongoing assessment, beginning with the initial patient contact and lasting at least through the initial visit and potentially follow-up visits and care across the continuum. I provided consultation, written materials, and resources and provided discharge instructions with plan of care and current and new medications. I provide effective, individualized health care to my patients and their caregivers after assessing their needs. Every patient has personal discharge instructions typed up and printed off for them which are a new practice for the clinic in which I was doing my practicum this semester. The new process of typing up discharge and follow-up information was implemented about midway through the semester. Although the clinic had previously been giving patients verbal instructions, writing them and providing them on discharge was new to the clinic although they were supposed to have been doing them for a while. This was not a new process to me, as we type discharge instructions and give them to every patient in my current role as an ED staff nurse, so that component was easy for me to adjust to and implement. I was actually able to help my preceptor navigate through the system a little and help her figure out where to find and include pertinent information. Demonstrative education is also provided – how to use a new med or stretching exercise demonstrated. Each set of DC instructions is personalized to the patients diagnosis and needs, including current and new medications, follow-up information and new plan of care, for example “check BP reading every day at same time, log in journal and report readings at follow-up appointment in 2 weeks”- given to patient with new BP med or adjustment in current meds, or if deciding on whether or not to put a patient on meds. Any referrals were written and provided, and any changes to meds were updated on a list for all involved to review and confirm. Any points of clarification for either the patient or caregiver were also included as necessary. Education is also an integral aspect of providing safe, effective, personalized care. In caring for each patient, it is imperative to consider education level, reading and writing ability learning styles, in addition to desire to learn or change behaviors, and which delivery methods are most effective. Most people learn by hearing, seeing, and doing (verbal, demonstration, written or a combination of all); many have disabilities and barriers that must be considered as well. For example, can a patient read their discharge instructions, do they need larger printed materials, do they need an interpreter, and do they need the information printed in another language? Is the information presented in an age/education level appropriate manner, etc? These are just a few examples of aspects to consider, not a comprehensive list by any means, however, it does provide an indication of special considerations. While many of these factors present an educational challenge, learning to utilize the most effective approach that is best for the patient is imperative. Time and experience will also contribute to the effectiveness of this process.22.Coach the patient and caregiver for positive behavioral □ □ □ □ □ xchange11/29/11- Coaching is the guidance provided the patient in an effort to assist them in improving their health status. Coaching has been integrated in my care during this practicum by encouraging smoking cessation, dietary changes for patients who are diabetic, low sodium intake for patients with hypertension, high fiber and low fat diet and implementing regular exercise for those patients with increased cardiovascular risk factors, to name a few. It is also important to emphasize what patients are doing effectively to improve their overall health, and to give feedback with small incremental changes that the patient can handle – make one change at a time so the patient and caregiver can manage and not be overwhelmed. A “start low and go slow” method was utilized, and we were careful not to implement too many changes at one time. For example, we had a patient who needed to start on BP medication, DM medication, and hyperlipidemia medication, but we started slow and just started with a BP medication initially, and would re-evaluate the patient in 2 weeks, and probably add another medication at that time – this would help if the patient were to experience any adverse side effects, and the SE profile might be difficult to distinguish if multiple meds were started at the same time. The patient agreed with and understood this plan of care and was positive about making these changes and being involved in the decision making process. Praising patients for achieving goals and continuous encouragement is regularly incorporated in the ongoing care of my patients. It remains essential in establishing trusting relationships and providing continuity of care to focus on successes and help patients establish and meet individual and team goals.23.Demonstrate information literacy skills in complex □ □ □ □ □ xdecision-making11/29/11- My ability to define patient problems and apply a systematic approach in obtaining detailed histories and performing comprehensive physical exams based on patient presentations demonstrates information literacy skills in complex decision-making. I am developing the ability to identify what information is needed, to understand how information is organized, to id the best sources of information for a given need, to locate those sources, to evaluate the sources critically, and to share that information. I am improving my ability to research for the best evidence-based practice. For example, we diagnosed a patient with Penicillinosis. It was necessary for me to look up the disease (found info on Epocrates, & Medscape) and then discussed with preceptor my findings. Neither of us was that familiar with disease process and how to treat, so after looking up information and reviewing Epocrates and Sanford guide and medical reference books together, we came up with a treatment plan and contacted the patient to discuss. Even when I do have experience with a disease, it is still imperative to have the latest research available. 24.Integrate ethical principles in decision making □ □ □ □ □ x11/29/11- Respect for patient autonomy, beneficence and justice are key ethical principles in providing patient care and being a respected provider. I make concentrated efforts on an ongoing basis to integrate ethical principles in my decision making and I believe in utilizing the ANA Code of Ethics. I planto continue this practice to the best of my abilities. For example, it is not my position to push my views or opinions on my patients, but to give them the information to make informed choices that best fit the needs of their health and overall well-being. I have to respect their choices and decisions – I can only guide them as I see appropriate based on my education and experience. We had a patient who was a 19 y.o female who just found out she was pregnant, and wanted to discuss having an abortion. Dr. Evans stated she could not discuss that with her, but could refer her to a more knowledgeable provider, an OB physician, who had more knowledge in that area and could better answer her questions. The patient was probably about 6-8 weeks pregnant, and we knew the timing of her discussion with an OB about her options was crucial, so we called over to the OB office and was able to schedule an appointment for the patient on the next day, so she could discuss her options with someone more educated on the topic. We did not try to sway her in any particular direction, but to provide the proper resources for her and answer any further questions she might have. This is only one example of how on a daily basis I integrate ethical principles in decision making. One the same day, we had a patient who had been trying to conceive and found out she was pregnant, and another 19 y.o. female who was pregnant and excited and scared at the same time, and was a smoker and regular marijuana user…so, it can be a lot all at once and can be difficult to keep personal opinions to yourself, and continue to provide necessary care to patients, as long as ethical principles are utilized and no harm is being done.25.Demonstrate respect, compassion, and integrity □ □ □ □ □ x11/29/11_ I always demonstrate respect, compassion, and integrity with my patients and coworkers. I do not feel there is any other way to practice. I also feel like my co-workers, preceptors and other staff, as well as patients would feel the same way about the way I practice, and I believe they would say so without reservation. Examples of respect include an introduction to the patient when entering the room, shaking hands when appropriate and making good eye contact when appropriate, and knowing in which situations/cultures eye contact and hand shaking is not appropriate. Compassion might include a hug and is genuinely caring for patients and their families the way you want your own family to be cared for. Integrity is being honest and trustworthy and developing life ling relationships with patients, their families, as well as establishing trusting relationships with other providers and caregivers with which work with and around. KSBN Requirements for Nurse PractitionersMetNot Metor N/ACommentsDemonstrates advanced practice rolexFor level of education to this point.Displays ability to decide to order and/or perform diagnostic proceduresxFor current level of educationAble to interpret diagnostic and assessment findingsxFor current level of educationSelects and provides prescription of medications and other treatment modalities for clientsxFor current level of educationSubmission #1 after 80 hours of practicumStudent Signature_____Tracy Hill____________Date___10/23/2011_________________Faculty Signature______________________________________Date____________________Submission #2 after 160 hours of practicumStudent Signature____Tracy Hill____________________Date_____12/7/11__Faculty Signature_____________________________________Date____________________Final SubmissionStudent Signature________Tracy Hill________________Date_______12/7/11_______Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade: ................
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