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Washburn UniversitySchool of NursingNU 607 Health Care Practicum II- Specialty (Adult) Clinical Performance Tool(Completed by Student and Faculty)Student: Louisa GolaySemester: Spring 2012Agency: Lawrence Memorial Hospital & First Med, Lawrence KSInstructor: Karen FernengelClinical performance is based on Universal Outcomes, End of Program Outcomes and National Organization of Nurse Practitioner Faculty Core Competencies of Nurse Practitioner Practice (2011). Nurse Practitioners must demonstrate care that is effective, patient-centered, efficient, timely, and equitable for the treatment of health problems and promotion of wellness. Universal Outcomes: Evaluating BehaviorUniversal Outcomes must be met in order to pass the course. Failure to meet any of the three Universal Outcomes will result in a grade of F. If an F is earned, the Core Competencies will not be consideredUniversal OutcomesDemonstrates honesty and integrity by submitting original work MetNot meton assignments and accepting responsibility for own actions taken/omittedPrioritizes patient safety as the primary consideration in all careMetNot metMaintains professional boundaries with patients, family and Met Not metstaff. Maintains confidentiality at all timesNurse Practitioner Core CompetenciesStudents must achieve an 75% on the final clinical evaluation tool to be successful in the course. These outcomes are only evaluated if the three Universal Outcomes are met. Students who do not meet the competencies within the required practicum hours may be required to successfully complete additional hours before a final grade will be awarded. Points are assigned as follows: Please rate your own performance using the descriptors listed below:0 = no opportunity to experience1 = defined as not meeting expectations; failing to initiate learning experiences; arriving late and unprepared; failure to effectively communicate with the patient, family, preceptor, staff and faculty2 = defined as inconsistently meeting expectations; requires much faculty/preceptor guidance in learning experience/support3 = defined as routinely meeting expectations yet requires more faculty/preceptor direction in learning experiences4 = defined as routinely meeting expectations with minimal support from faculty/preceptor5 = defined as consistently meeting expectations with little guidance; proficient; can perform independently; initiates learning experiences; is well prepared for learning experiencesGradingThe Clinical Performance Tool is completed and submitted by the student at the completion of 60 clinical hours, 120 clinical hours, and all clinical hours for a total of three submissions. The first submission must address items 1-13. The second submission must address items 1-22. 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.Develop individualized health promotion, disease □ □ □ □ □ □prevention and health protection services for adults2/24/12 Score 5: I feel I am meeting this competency in my current practicum in the primary care setting. I am able to discuss health promotion, disease prevention and services for nearly every patient I see in the clinic. A few examples of primary interventions I feel comfortable discussing with females is the importance of monthly SBE (able to demonstrate), STD prevention, annual well-woman exam and mammograms if age appropriate. Additionally, I discuss the importance of colonoscopies (to both men and women > 50 y/o), bone density screenings ( > 60 y/o), and annual eye exams and labwork. I routinely provide patient education on disease prevention such as: hyperlipidemia and diabetes. I am able to discuss lab values with patients and provide ways to help patients make life style changes to avoid having to take medications. For example, limiting carbohydrate, starch, sodium, and processed food intake to help aide in lowering triglycerides and blood glucose. I too have had the opportunity to discuss smoking and ETOH cessation with 2-3 patients. I continue to learn about the different medications used to aide in smoking cessation (Chantix and Nicotrol) and ETOH cravings (Depade). 3/28/12 Score 5: I continue to provide age appropriate health promotion, disease prevention, and health protection services as stated above; many of which are identified by patient risk factors, age, gender, history, and life style. I discuss disease prevention, overall health and mental promotion at nearly every patient visit, but consistently during annual physical visits with patients. Topics include weight loss, exercise, diet modifications, screening procedures, stress management, mental health threats, and tobacco/alcohol abuse. 2. Develop individualized anticipatory guidance and □ □ □ □ □ □health counseling for adults2/24/12: Score 4: I feel fairly confident in counseling patients with minimal support from my preceptor. I believe that reiterating the importance of screening for certain diseases, taking medications as prescribed, lifestyle modifications and/or weight management specifically should be mentioned at every office visit regardless of chief complaint and when appropriate (obese, hx of HTN, etc). Additionally, tobacco cessation along with ETOH abuse (if applicable) and depression screening should be discussed at every office visit as well. If their history reveals any psychiatric diagnosis, such as depression, I routinely ask if the patient is taking medications as prescribed and/or having suicidal/homicidal thoughts or any issues with their depression. I also recommend receiving flu vaccination (seasonal) to all patients and/or Tetanus (patient presents with laceration, animal bite, etc.). When discussing PMH and medication regimen, I routinely ask the patient for pertinent FH and SH.3/28/12 Score 5: I continue to provide anticipatory guidance and health counseling in the clinic setting as stated above, mostly during annual physicals. During these visits I educate patients on the importance of age or risk appropriate screenings such as: annual mammograms for female > 40 y/o or risk factor, annual pap smear, colonoscopies every 10 years for adults > 50 y/o or risk factor, annual lipid profiles, and appropriate vaccinations (flu shots, TDaP, pneumonia shot, zostavax, etc). Additionally, I have counseled patients regarding lifestyle modifications such as weight loss, diet modifications, exercise, and tobacco/ETOH cessation. I rate myself a 5 at this point, as I rarely rely on support from my preceptor in providing anticipatory guidance and counseling. My plan for continued development will be to practice these skills independently in future clinical rotations.3.Prioritize differential diagnoses based on etiologies, □ □ □ □ □ □ risk factors, underlying pathologic processes and epidemiology for medical conditions including acuteand chronic dermatologic conditions, anxiety, depressionbipolar disorder, fractures/sprains/stains, back pain, connectivetissue disease, sexually transmitted infections, incontinence,and men’s health issues.2/24/12 Score 4: I feel like I am meeting this expectation, but still needing some assistance from my preceptor. I am able to identify several etiologies, risk factors and underlying pathologic processes for medical conditions such as HTN, hyperlipidemia, diabetes, psychiatric diagnoses (anxiety, depression, bipolar), STD, and musculoskeletal pain. I too am able to provide patient education on disease prevention and provide referrals when necessary to other health care professionals (PT, psychiatrist, counselor, etc.) Likewise, I am able to recognize risk factors for a variety of respiratory disorders including seasonal allergies, asthma, signs/symptoms associated with an URI, and COPD. I feel that I still need assistance from my preceptor in recognizing risk factors for thyroid disorders, dermatologic conditions, men’s health issues and being able to differentiate and develop differential diagnoses based on x-rays for fractures/sprains/strains.3/28/12 Score 5: I continue to be able to identify the above information when discussing conditions listed above. Since my last submission, I have had additional exposure to respiratory related conditions such as treating influenza, hypothyroidism, and made a few dermatology diagnoses (impetigo, contact dermatitis, and tinea corporis). I continue to rate myself as a 4 at this point in my education, as I feel I need additional exposure in various areas such as: fractures/sprain/strains and dermatological complaints.________________________________________________________________________4. Perform comprehensive health history and physical exam □ □ □ □ □ □ 2/24/12: Score 4: The clinical site that I am at does allow students to document on their paper charts. Often times, I do not always have the opportunity to obtain a comprehensive health history because the patient is an established patient to the clinic and this part of the exam has already been conducted. In this situation, I briefly discuss PMH, SH, and FH to ensure the correct information is provided in the patient’s chart. I perform the initial interviewing of all new patients and am able to perform a comprehensive health history with minimal help from my preceptor (he may ask additional questions that I didn’t originally ask). I also independently perform the initial physical exam and discuss findings (health history, review physical exam, and discuss my plan) with my preceptor prior to him seeing each patient. 3/28/12 Score 5: I continue to be able to independently conduct a comprehensive health history, physical examinations, and formulate basic differential diagnoses. I require minimal assistance from my preceptor in refining assessment skills and differential diagnoses. I will continue to practice these skills to refine my overall exam.________________________________________________________________________5.Perform problem focused health history and physical exam □ □ □ □ □ □2/24/12 Score 4: I have had the opportunity to perform several problem-focused health histories. I perform this task independently most of the time with minimal support from my preceptor. Since beginning this rotation, I have adopted a systematic routine for asking initial questions prior to beginning my physical examination – FH, SH, subjective assessment, and medication regimen. While performing a brief head to toe and neurological exam (followed by problem focused exam), I discuss health promotion such as: healthy eating habits, exercise, while asking pertinent questions regarding sign/symptoms and alleviating/aggravating factors r/t patient’s chief complaint.3/28/12 Score 5: I continue to independently perform a problem-focused health history and physical examination as stated above. I focus on problem-focused history collection and physical examination to assist with narrowing my differential diagnoses for a final diagnosis. I continue to use the same systematic routine as stated above to collect patient information. Additionally, I am able to present each case to my preceptor in an organized and professional manner utilizing the SOAP method. ________________________6.Demonstrate diagnostic reasoning and critical thinking □ □ □ □ □ □in the development of a treatment plan2/24/12 Score 4: When it comes to basic disease processes, I am able formulate a treatment plan with minimal assistance for HTN, hyperlipidemia, NIDDM, URI, UTI, muscle sprains, etc. I too am also able to order and interpret lab values and prescribe medications for the above diagnoses. However, for more complex diseases such as dermatologic, abdominal pain, and thyroid disorders, I find myself doing more research by utilizing electronic references such as Epocrates and Lexicomp to correctly identify which labs/appropriate diagnostic testing is necessary and to also determine a medication regimen. I still need some assistance with clinical decision making – such as: interpreting some lab results, reading x-rays, and when to prescribe certain medications (ex: when and what dosage to start a patient on Synthroid).3/28/12 Score 4: I continue to be actively engaged in diagnostic reasoning, clinical decision making, and development of treatment plans as stated above. I am feeling more comfortable in utilizing electronic resources and am becoming quicker at finding the information needed. I continue to interpret diagnostic testing with my preceptor and make medication recommendations with minimal guidance from him. I continue to rate myself a 4 at this time, as I need assistance with reading films and frequently refer to online resources for guidance in treatment plans. Ex: prescribing appropriate antibiotic and dosing for a 4 y/o with AOM and allergy to PCN – gave pt Rx for cefdinir 300 mg PO BID for 7 days. 7.Initiate screenings appropriate to differential diagnoses □ □ □ □ □ □2/24/12: Score 4: I feel fairly confident of when to initiate screenings appropriate for differential diagnoses. Some examples include:Annual lipid check for patients with family history, diabetes, or age appropriateColonoscopy for patients > 50 y/o, history of colon or rectal cancer, rectal bleedingMammogram Females > 40 y/o, history of breast cancer, or any lumps/nodules felt on SBEAST/ALT for patients on medications that are filtered through the liver: ex statinsAlk phos and Total Bili to aide in r/o gall stone or cholecystitisUric acid to r/t goutDepression screenings to differentiate between moderate to severe depression, which has guided me in determining the appropriate anti-depressant to prescribe3/28/12: Score 5: In addition to the above screening examples for development of differential diagnoses:TSH and FT4 if necessary for chief complaint of fatigue, hair loss, brittle nails, family history, taking thyroid medicationHemoglobin A1c for history of diabetes of new onset – check fasting lipids in 1-2 mon. after blood sugars are in better controlRA panel to r/o RA and lupus – would also include sed rate and CRPAmylase/lipase to r/o pancreatitisBlood pressure checks at all appointmentsThorough skin assessment to screen for skin cancer – asking the patient if he/she has any spots they have noticed, changed, become bothersome to them, etc. that they would like me to take a look atDepression screenings – ensuring patient is not having depressive, suicidal, or homicidal thoughts; if so, treating and referring appropriately_____8.Initiate diagnostic strategies appropriate to differential □ □ □ □ □ □Diagnoses2/24/12 Score 4: I feel fairly confident when to initiate diagnostic strategies appropriate to determine differential diagnoses: Some examples include:Ordering appropriate labs when patient c/o increased fatigue/stress, brittle nails, hair loss, weight loss, and heavy vaginal bleeding. Labs ordered: CBC, CMP, TSH, Vit. D to r/o Vit D. deficiency, anemia, hypo/hyperthyroidism, electrolyte imbalanceOrdering extremity x-rays to r/o fractures vs. sprain, identify inflammation, and fused growth platesOrdering appropriate diagnostics when patient c/o generalized abdominal pain with int. n/v: CBC, CMP, lipase/amylase, total bili., and alk phos. If necessary based on s/s and lab results – ordering ultrasound of gallbladder or CT to r/o diverticulitis, appendicitis, bowel obstruction, etc. Ordering EKG when patient c/o CP, SOB, syncope, dizziness, etc.3/28/12 Score 5: In addition to the above diagnostic strategies for development of differential diagnoses: UA to r/o UTI, identify hematuria for possible dx of kidney stone, pregnancyEGD and or colonoscopy for possible GI bleeding, cancer screening, diverticulosis, polyps Stress ECHO: patients with family history of CAD, hyperlipidemia, MI or complaints of CP or SOB______________________________________________________________________________9. Develop a plan of care utilizing evidence-based practice □ □ □ □ □ □2/24/12 Score 4: I feel I am able to develop a plan of care utilizing evidence-based treatment practice information. For example, I have discussed the over-use of antibiotic prescription on several occasions with patients who may not need an antibiotic, but simply want a “quick fix” versus waiting for the virus to run its course. Even though 9 times out of 10 I go ahead and write a script for an antibiotic; I am able to provide adequate patient education based on evidence-based practice (viruses need adequate time to run their course – taking abx for viral infection can not only kill off good bacteria, but may not work when you truly need an abx for bacterial infection). I ensure the patient understands how to manage s/s appropriate and is properly educated on s/s to watch for to indicative worsening infection (fever, worsening s/s – not resolving within 7-10 days, increased fatigue, etc.) Additionally, I recommend OTC medications for symptom management or may prescribe an inhaler (if wheezing present) along with prednisone if I feel inflammation is apparent. 3/28/12 Score 4: As stated above, evidence-based treatment continues to occur frequently between conversations with my preceptor and I as well as with patients and myself. Throughout my time in this clinical setting I have increased my knowledge of evidence-based treatment information in patient care; however, this will forever be an area of knowledge I will be able to expand on. In order to achieve a higher rating in this category in the future, I feel that I need additional practice and independence in the clinical setting to really apply my skills with limited guidance from a preceptor. One example of utilizing EBP in developing a plan of care is prescribing antibiotics. The literature or references recommend antibiotics for common illnesses such as otitis media, acute pharyngitis, or empiric treatment of acute bronchitis. My preceptor will often prescribe a medication based on what samples he has in the office, based on his experience with certain medications, or what has worked well in the past for each particular patient. For example, Zithromax might be a primary option that I would select for acute bacterial sinusitis, whereas my preceptor recommends secondary options such as Augmentin (his experience: Augmentin is stronger, works faster, has seen better results and less resistance) or Avelox (has samples in the clinic, but is expensive at the pharmacy).__________________10. Prescribe medications based on cost, diagnoses, □ □ □ □ □ □efficacy, safety, and individual patient needs2/24/12 Score 4: I feel very comfortable recommending medications for basic diagnoses such as: sinus infections, strep throat, URI, UTIs, AOM, and musculoskeletal pain. Likewise, I am feeling more and more confident and comfortable recommending different classes of medications for: HTN, diabetes, hyperlipidemia, depression, anxiety, etc. I continue to refer to Medscape, Epocrates, Sanford guidelines, Ferri’s text, and/or my preceptor for guidance. Some examples include: treating acute pharyngitis with a z-pack – azithromycin is a wide spectrum antibiotic, which will more than likely treat most bacterial organisms causing acute bacterial infection. Treating a AOM with amoxicillin – amoxicillin typically will treat AOM and is affordable, utilizing the $4 list when available. Starting a patient on Prozac instead of Lexapro (even though Lexapro is metabolized quicker and results are seen faster) d/t cost.3/28/12 Score 4: I continue to see the same conditions as stated above and continue to identify and recommend appropriate classes of medications for given conditions. I believe I am becoming more proficient with recommending the correct medication based on diagnosis without having to refer to external resources each time. Safety, cost and individual patient needs are certainly areas for consideration with the patient population served in each clinical setting. I also consider how many times per day a patient may have to take a medication; always question whether it is feasible to take 4 times a day and if the patient will be compliant and take as prescribed, or would it be easiest for the patient to take BID for a longer period of time. The affordability of medications is an issue as well – I readily use the $4 list, especially with patients who are uninsured, on multiple medications, have Medicare or Medicaid, etc. If available, I try to provide samples to save the patient money. In order to achieve a higher ranking, I believe repeated exposure and education will assist in development of my knowledge base. Additionally, gaining proficiency will help me to practice more independently. ______________________________________________________________________________11. Perform medical and surgical procedures as appropriate □ □ □ □ □ □2/24/12 Score 4: I have performed several procedures thus fair in my current practicum. I am starting to feel more confident each in being able to do them on my own without assistance. I feel fairly confident in performing digital blocks, simple sutures, and I & Ds on my own without assistance. I am continuing to perform pelvic with minimal assistance, but feel I need much more guidance when determining what type of splint to apply to different fractures.3/28/12: Score 4: Since my last submission I have not had any additional opportunities to perform surgical procedures, but have observed removal of a skin tag and a sebaceous cyst on the scalp. Additionally, I have performed 2 pelvic exams independently since my last submission.___________________________________12.Interpret patient responses to treatment and recommend □ □ □ □ □ □changes to the treatment plan as indicated2/24/12 Score 3: I rate myself a 3 at this point in my clinical experience d/t the fact I have only been able to interpret a few patient responses to treatment. More often than not, patients are told to call if s/s are not improving and/or if experiencing unwanted side effects from medications. Otherwise, it is to be expected that patients are having a positive response to treatment, condition is improving, and adequate follow-up is scheduled when appropriate. I continue to strengthen my knowledge in lab interpretation and learning to analyze which antibiotics are susceptible to different bacterial organisms, since I prescribe antibiotics on a routine basis. I am able to recommend families or classes of medications appropriately and can offer specific information on pharmacologic agents I recommend. For example, treating an acute sinusitis with a cefdinir, treating a UTI with Cipro – Cipro is susceptible to several bacterial organisms; however a urine specimen is always cultured to ensure the patient is on the appropriate antibiotic. Lastly, starting a patient on Prozac or Lexapro for severe depression and ensuring their moods remain stable on initial dosage, increased energy, interested in normal activities/hobbies, minimal side effects, taking medication as prescribed, etc. – also important to monitor lab values.3/28/12 Score 4: I have been working with the hospitalist team the last 60 hours since my previous submission, so I have been able to evaluate patient’s response to several treatment plans and modify accordingly. Some examples include: anti-hypertensive, anti-emetics, pain management, and antibiotics. I feel that I can successfully evaluate a patient’s response to the above medications with minimal assistance from my preceptor yet require some assistance with uncommonly seen treatments. To continue improving my knowledge base, I plan to utilize electronic resources/textbooks when necessary (UptoDate, Ferris, Buttaro Epocrates, Medscape, etc.) and also will continue to learn from my preceptor’s examples. ____________________________________13.Document using professional terminology, □ □ □ □ □ □format and technology (ie: ICD9, E/M coding, CPT)2/24/12 Score 4: I am able to correctly document using professional terminology, format, and technology when using the E-logs patient tracking system. I have become very familiar with looking up appropriate ICD-9 codes as well understanding the various levels of CPT coding. Likewise, my documentation at my clinical site reflects my ability to use professional terminology (specifically in the objective section), format (correctly filling out ROS assessment portion of the chart), and technology (ability to provide proper documentation for procedures and diagnostic testing). I rate myself a 4 at this time, b/c I feel I still need practice charting as a provider versus as a nurse. The initial assessment charting is quite similar, but knowing how to properly document abnormal findings is an area for improvement (especially skin assessment). Completing my e-logs has helped me feel more confident in documentation and coding as well. 3/28/12 Score 4: While with the hospitalist team, I have been able to independently document several electronic versions of SOAP notes as well as a conduct several comprehensive health histories with minimal assistance from my preceptor. I feel very confident with ICD9 and CPT coding from documenting in the e-logs database. Since my previous submission, my documentation of various SOAP notes and continuation of coding has helped me feel more confident in charting.______________________________________________________________________________14. Recognize need for referrals by collaborating □ □ □ □ □ □and consulting with members of the health care team3/28/12 Score 5: I feel very confident in recognizing the need for referrals and consulting with members of the healthcare team. In the Primary Care setting, I have referred multiple patients to the ER for further evaluation. Examples include: 51 y/o male who presented with acute onset of CP who had an abnormal EKG (right bundle branch block), history of hyperlipidemia, HTN, NIDDM, and obesity with significant family history of MI and CAD23 y/o female with history of forceful trauma to the LUQ (punched in the abdominal) who presented with moderate splenomegaly65 y/o male who presented with 3 day history of confusion, diarrhea, 5 lb weight loss and decreased appetite. Stat labs obtained with critical Na (118) and K (2.5) levels.Additionally, I have referred patients to physical therapy, neurology, oncology, cardiology, diabetes education, nuclear medicine, and general surgery. A few examples include:Diabetes Education: 44 y/o male new onset of NIDDM admitted to LMH for observation, IVF hydration and blood glucose control. Discharged with Rx for Levemir and MetforminGeneral Surgery: 31 y/o female presented with inguinal hernia (history revealed occupation as a personal trainer who lifts weights on a daily basis)Cardiology consults: multiple patients sent for stress ECHOs, Holter monitor applications, and abnormal and/or questionable EKGs______________________________________________________________________________15. Discuss access, cost, efficacy and quality when □ □ □ □ □ □making care decisions3/28/12 Score 4: Access to healthcare and cost are two areas I feel I have not gained a lot of experience in this semester. Most of the patient population my clinical site serves has private insurance. In regards to prescriptions, I am still conscience of the out of pocket cost to my patients. For example, prescribing amoxicillin instead of Omnicef for acute sinusitis. I of course educate the patient to call if the antibiotic is not treating the infection and/or their symptoms become worse. I also explain to them that there is always a possibility of having to switch to a more expensive antibiotic if the cheaper choice is ineffective. I rate myself a 4 at this point in my clinical hours due to lack of exposure. To gain a higher rating, I feel it is important to gain additional exposure to access, cost, efficacy and quality when making care decisions. Likewise, I will continue to improve this competency as I become more proficient and care for a diverse patient population.______________________________________________________________________________16. Perform care in a timely manner □ □ □ □ □ □3/28/12 Score 5: Time management is one area I feel confident in at my current clinical site due to the patient presenting with a more focused chief complaint. When charts start stacking up, I feel more rushed and that I need to speed up my assessments, but for the most part I’m able to appropriately assess, diagnosis, and treat in a timely fashion. I am able to complete a focused assessment while discussing the patient’s health history and medication regimen while assessing their mental status, etc. I feel this saves a great deal of time. I also sit while conversing with the patient – I am a firm believer that this makes patients feel as though I am spending more time with them and not making them feel rushed. One challenge I have found is discussing health promotion and prevention while performing a focused assessment. Of course if the patient is scheduled for their annual physical or medication refill, discussing either of these seems easier due to increased time allotted for this type of appointment. At future clinical sites, I plan to spend a few more minutes with each patient and discuss these topics while performing care in a timely matter. _____________________________________________________________________________17. Maintain confidentiality and privacy □ □ □ □ □ □3/28/12 Score 5: I feel that I am fully able to maintain confidentiality and privacy while in the clinical setting. Whenever assessing the patient, discussing diagnostics, test results, etc., I ensure we converse in the patient’s room with the door closed versus at the nurse’s station or in a common area. If friends or family members are present in the room, I always ask the patient if it is okay to discuss their care in front of them. Additionally, I step out of the room and allow the patient to change into a gown (if appropriate). ______________________________________________________________________________18.Demonstrate professional behavior □ □ □ □ □ □3/28/12 Score 5: I feel that I am fully capable of demonstrating professional behavior during clinical by dressing in professional attire, respectful to patients and staff, maintaining patient and staff confidentiality, and arriving to clinical 15 minutes early. Additionally, I feel that I meet this competency through demonstrating professional behavior through effective communication with patients and co-workers. For example, patients and co-workers provide feedback by responding to delegation (doing the tasks I ask them to do) and respecting my advice while conversing on an adult level (discussing diagnoses and treatment options).______________________________________________________________________________20. Employ effective communication methods with patients, □ □ □ □ □ □families, preceptor, and staff3/28/12 Score 4: I employ effective communication methods with patients, families, preceptor, and staff on a daily basis. When communicating with patients and families, I use common terminology to explain complex medical concepts to ensure they understand their medical condition and how to treat it. I discuss treatment options and diagnoses with patients/families to confirm they understand each prior to implementing any interventions. I double check that any additional questions are answered prior to discharge while making it a point to re-iterate the patients discharge instructions despite giving them discharge paperwork with this information included on it. Additionally, I ask that patients and/or family members repeat instructions, sign/symptom management, need to f/u, medication regimen etc. back to me to ensure they understand. In having the patient and/or family member repeat this information, I am able to obtain clues to confirm information given was understood and comprehended.When communicating with my preceptor and other staff members, I utilize professional terminology. In doing so, I am feeling more and more confident in developing my skills in becoming more assertive, confident and practicing independently. At this point in my clinical hours, I rate myself a 4. I feel my communication skills will continue to improve as I become more proficient and gain additional clinical exposure. __________________________________________________________________21. Provide culturally competent care to patients □ □ □ □ □ □and families and negotiates a mutually acceptableplan of care3/28/12 Score 4: I feel that I provide culturally sensitive care to patients and families with limited exposure to diversity in my current clinical setting. The majority of patients seen at First Med are Caucasian, Christian, English- speaking, and middle class patients with a minimum high school diploma (most higher education). I continue to rate myself at a 4 at this point in my clinical hours based on lack of exposure to diversity; thus, I don’t feel confident providing culturally competent care while maintaining cultural sensitivity. I feel it would be beneficial for me further my knowledge in the difficult culture groups in order to better care for patients and provide appropriate education for symptom and disease management. ______________________________________________________________________________22. Communicate practice knowledge effectively both □ □ □ □ □ □orally and in writing3/28/12 Score 4: I am able to communicate my practice knowledge effectively both orally and in writing with documentation tools such as: SOAP notes, H&Ps, and discussing patient presentations with my preceptor. I feel that my knowledge level is that of a beginner and that I need to continue increasing my depth and breadth of practice knowledge in order to improve on this competency. In order to do so, I plan to refine my writing by practicing my documentation skills in the clinical setting while independently seeing patients and completing SOAP notes. Areas of improvement for my oral communication of practice knowledge include increasing my use of professional terminology, medical diagnoses, and anatomy terminology. To improve in this area, I utilize electronic resources and textbooks. With continued development of my vocabulary and knowledge base as well as repetition and time, I feel I will be able to strengthen my ability to communicate practice knowledge effectively orally and in writing to other professionals and patients. ______________________________________________________________________________23. Apply available evidence to continuously □ □ □ □ □ □improve quality clinical practice3/28/12 Score 4: I have continued to practice evidence based treatment principles during my clinical rotation. Frequently seen opportunities have occurred during the treatment of lipid disorders, HTN, NIDDM, COPD, asthma, seasonal allergies, chronic pain management, ADHD, hypothyroidism, acute pharyngitis, URIs, and UTIs. I feel that I am able to utilize reference materials to find the coordinating evidence-based material that is needed for treatment of a particular condition. References I frequently use are Epocrates, the Stanford guide to antimicrobial therapy, UptoDate, Medscape, and our textbooks for NU 600. I rate myself a 4 due to my lack of proficiency. To improve in this category I will need additional practice, repetition, and utilization of references in order to increase my proficiency of evidence based knowledge to improve the quality of my clinical practice. Additionally, I recognize EBP guidelines will continue to change on a regular basis throughout my career. ______________________________________________________________________________24. Utilize appropriate agency educational tools □ □ □ □ □ □to provide effective, personalized health care topatients and caregivers3/28/12 Score 5: Assessing educational needs and providing education happens with all patient encounters. I have often found that you can assess educational needs by simply asking a patient how they think they are doing, or how they think their child is doing. By listening to what patients have to say, I am able to identify topics that need clarification and additional information. Additionally, I will print information out from UptoDate or WebMD and give to the patient regarding a certain medication they are taking or medical diagnosis they have to provide extra information. For patients with a musculoskeletal complaint, I will provide a handout with appropriate stretching exercises they can do to alleviate sprains/strains. To ensure patients have comprehended this education, I will ask them to repeat back to me any instructions I have given them. Ex: how to take their prescription, OTC relief, sign/symptom management, etc. I also can assess their education needs by asking if they have any additional questions prior to d/c, and if so, assess through their questions how well they understood the information I provided.______________________________________________________________________________25. Coach the patient and caregiver for positive □ □ □ □ □ □behavioral change3/28/12 Score 5: This outcome coincides with primary, secondary, and tertiary levels of prevention. Many items addressed under each level are encouraging the patient to maintain overall well-being, lifestyle modifications (diet and exercise), and/or improvements in health through behavior change – all of which consist of coaching that coincides with patient education. It is 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. For example, I took care of a patient who needed to start on BP medication, DM medication, and hyperlipidemia medication. Instead of starting the patient on all 3 medications, discussing the need to modify diet and start exercising, monitory blood sugars, etc., I simply started slow and went slow by introducing one BP medication initially (since this was the most critical). I also discussed the importance of monitoring sodium intake, limiting processed food intake, and keeping a daily journal of BP readings. The patient agreed with and understood this plan of care and seemed encouraged to make these positive changes and even stated she appreciated being involved in the decision making process. I had her make a follow-up appointment in 2 weeks to discuss BP readings and the possibility of adding DM and hyperlipidemia medications. Lastly, I feel praising patients for achieving goals and continuous encouragement should be regularly incorporated in the ongoing care of my patients as part of the coaching and positive behavioral change method. In the Primary Care setting, I always encourage patients to stop using tobacco products, receive vaccinations/annual physicals, and educate on STD prevention if appropriate. I have also encouraged patients to have screenings (when indicated) such as: fasting lipids and glucose, mammograms, colonoscopies, bone scans, etc.______________________________________________________________________________26. Demonstrate information literacy skills in complex □ □ □ □ □ □ decision making3/28/12 Score 5: I feel I am independently able to synthesize information whether it is from my preceptor reviewing complex information with me, or researching on my own using the various guidelines mentioned above. For example, 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 continue to develop the ability to identify what information is needed, to understand how information is organized, and can identify and critically evaluate the best sources of information for a given need. I am improving my ability to research for the best evidence-based practice. Even when I do have experience with a disease, it is still imperative to have the latest research available. After understanding a concept, I make it applicable to various patient scenarios so I can explain the necessary information to the patient I am currently treating. Overall, I feel I have decent foundational skills and continue to need additional exposure and opportunities to practice these skills confidently.______________________________________________________________________________27. Integrate ethical principles in decision making □ □ □ □ □ □3/28/12 Score 5: Respect for patient autonomy, beneficence and non-maleficence are key ethical principles in providing patient care and being a respected provider. This competency is addressed on a daily basis in the medical profession. For example, it is not my position to push my views or opinions onto my patients, but to give them the necessary information to make informed choices that best fit the needs of their overall health and well-being. I have to respect their choices and decisions and can only guide them as I see appropriate based on my education and experience. Non-maleficence occurs with every patient interaction. My intentions are always to cause no harm and provide beneficence to my patient. Autonomy is given to patients that I see by providing them with education regarding their condition and treatment options; therefore allowing patients to be active participants in their own health care. I make concentrated efforts on an ongoing basis to integrate ethical principles in my decision making and believe in utilizing the ANA Code of Ethics. I plan to continue this practice as an ARNP student and upon graduation to the best of my abilities.______________________________________________________________________________28. Demonstrate respect, compassion and integrity □ □ □ □ □ □3/28/12 Score 5: I feel that I perform this competency on a daily basis. I ensure I demonstrate respect, compassion, dignity, and integrity whether it is with a patient, staff member, or family member; I feel this is the only way to effectively practice medicine. I feel these 4 traits are of utmost importance to the nursing core values, which I strive to demonstrate and implement myself with every patient encounter. Even with challenging patients, I focus on the needs of the patient and how to provide the best care to them versus focusing on whatever may be the reason they are a challenging patient. Examples include: respect – introduction myself to the patient/family members when entering the room and making good eye contact (if culturally appropriate) throughout the entire assessment, compassion – genuinely caring for the patient/families and offering support when indicated, integrity – being honesty and trustworthy while developing patient relationships. I too will continue to demonstrate respect, compassion, dignity, and integrity on a daily basis as a student ARNP and upon graduation.State Board of Nursing RequirementKSBN Requirements for Nurse PractitionersMetNot Metor N/ACommentsDemonstrates advanced practice roleXDisplays ability to decide to order and/or perform diagnostic proceduresXAble to interpret diagnostic and assessment findingsXSelects and provides prescription of medications and other treatment modalities for clientsX?Submission #1 after 60 hours of practicumStudent Signature: Louisa GolayDate: 2/29/12Faculty Signature______________________________________Date____________________Final SubmissionStudent Signature: Louisa GolayDate 4/29/12Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade:November, 2011Revised 1/23/12 ................
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