Exam (elaborations) NURS 6531 EXAMPLE Journal Entries

Exam (elaborations) NURS 6531 EXAMPLE Journal Entries I have spent my 20 plus years career in one facility as an RN. This has allowed me to create a comfort zone that has a positive and negative effect on me. The positive influence was that it has allowed me to learn advanced physical assessment while working with physicians in an emergency department and has allowed me to establish professional relationships with many knowledgeable providers who agreed to allow me to learn from them during my practicums. The negative influence is that the comfort zone of emergency nursing created anxiety in stepping into the family practice world. Prior to starting the practicum I went to The Glasser Clinic and met the staff and learned the layout of the facility. I also contacted the information technology department and requested access to their medical records during my time as a student to allow me to use all my clinical hours to my greatest benefit. Transitioning to another role creates anxiety because I have spent many years augmenting my basic nursing education to enable me to better at emergency nursing. I did not stop with the basics, and continued to acquire greater knowledge by becoming an instructor in three courses, ACLS, PALS, and TNCC. Now, after all my time and effort in emergency nursing I am going to be the person with the least amount of knowledge in the patient care environment. I feel like a new graduate nurse NURS 6531 EXAMPLE Journal Entries again, but I have one advantage I did not have when I started my nursing career. I know more than I did then, and I know a lot more than when I started this program. Clinical hours will be accomplished with one or two nine hour shifts per week with Dr. Douglas. This will not be on a set schedule, but will be coordinated with my work hours and Dr. Douglas’ days in the office. I will use my clinical time trying to learn everything possible from the two physicians who have given me this opportunity to expand from my present role into one as an APRN. Week One Nursing Theory into Practice, September 3, 20XX The assigned task is to choose a nursing theory to guide us throughout the practicum experience, determine objectives for the clinical setting, and establish goals to accomplish throughout the quarter. This required reading again about nursing theory and trying to identify what my goals as a family nurse practitioner student are now and trying to determine what my goals as a family nurse practitioner will be upon starting practice. Introspection and comparing the various nursing theories showed me that the Theory of Caring most closely identifies my beliefs. The Theory of Caring conceptualizes that an individual’s health is a combination of mind, body, and soul (Polit and Beck, 2012). Nursing practice expands that theory into caring for the whole patient, while other theories reduce care based on physical health. My belief is that an individual needs to utilize his mind and soul for engagement in caring for the physical body, and that nursing practice entails all of a patient’s being to sufficiently provide care. Each encounter might have a different focus, but throughout a patient’s life their needs will vary between mind, body, and soul. Watson (2012) explained that applying conscious caring into patient interaction with knowledge creates a caring-healing modality. The Professional Practice Model expands the Theory of Caring to recognize that the patient, the team, the clinical setting, the community, and the profession are significant in healthcare provision and interaction, and modeling my practice in the established prioritization of the essential elements will be my goal throughout the clinical practicum (Tonges and Ray, 2011). I will further strive to incorporate the weekly learning objectives from the classroom into the clinical environment while utilizing the Theory of Caring. Goals for this practicum are incorporating classroom education into practice, utilizing clinical guidelines, identifying correct pharmacological indications and usage, and improving my ability as a diagnostician. The application of the critical thinking to patient care, learning the standards of care as a nurse practitioner, and using established objectives that have been determined to be fundamental for the FNP education will assure my goals to be comprehensive. Goals and Timeline for Goal Completion I will learn to provide patient-centered care by establishing professional relationships with patients that includes respect to their cultural values, spiritual preferences, and medical decisions by formulating treatment plans that includes patients in the decision process with the assistance of my preceptor during the clinical practicum. I will utilize advanced assessment skills and critical thinking to evaluate patients for normal and abnormal findings to formulate differential diagnoses, identify appropriate screening diagnostics, and formulate treatment plans for disease processes under the guidance of my preceptor during the clinical practicum. I will perform targeted physical exam as indicated by the patient’s presenting complaint and correctly perform those assessments while being observed by the preceptor during the clinical practicum. I will learn to utilize patient assessments to formulate differential diagnoses and determine appropriate treatment plans for viral and bacterial infections in presenting patient conditions and apply evidence based practice guidelines of antibiotic therapy under the direction of my preceptor during the clinical practicum. I will learn to use pharmacological resources and evidence based guidelines for recommendations on prescribing practices for indicated illnesses during the clinical practicum under the guidance of my preceptor. I will learn the requirements required by Kentucky All Schedule Prescription Electronic Reporting system that monitors and controls narcotics and stimulants prescriptions prescribing practices by providers in Kentucky during the clinical practicum (Kentucky, 2013). I will learn to facilitate treatment compliance by considering economical impact of prescription medication with cost evaluation of indicated medications and choose lower cost medications when possible, utilize medication samples when possible, and provide pharmaceutical program assistance information when indicated under the guidance of my preceptor during the clinical practicum. Conclusion The opportunity to use this period wisely in an effort to learn from every patient interaction, learning the role of a primary care provider, and identifying my own knowledge gaps while under the direction of an experienced physician is recognized as invaluable. Expanding my knowledge while on a path to extend my career to a greater role of responsibility will be taken seriously during the practicum. My future ability in the role as an APRN will be built on the classroom foundation and extending my knowledge in a family practice setting while utilizing the Theory of Caring . References Kentucky: Cabinet for Health and Family Services - KASPER. (2013, June 24). Kentucky: Cabinet for Health and Family Services - CHFS. Retrieved from Peterson, M., and Potter, R. L. (2004). A proposal for a code of ethics for nursepractitioners. Journal of the American Academy of Nurse Practitioners, 16(3), 116- 124. Polit, D. F., and Beck, C. T. (2012). Nursing research: generating and assessing evidence for nursing practice (Ninth ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams and Wilkins. Tonges, M., and Ray, J. (2011). Translating Caring Theory Into Practice: The Carolina Care Model. Journal of Nursing Administration, 41(9), 374-381. Caring to practice (Tonges and Ray, 2011). Watson, I. (2012). The theory of human caring: retrospective and prospective. Caring in Nursing Classics: An Essential Resource, 237. Week Two, Pattern Recognition This week I spent two nine plus clinical hour days with Dr. Douglas. The clinic is now a comfortable area for me and I have been welcomed by the staff. The variety of patient presentations is as unique in the clinical setting as in the emergency department (ED). Patients with complaint of chronic back pain, hypertensive follow-ups, headaches, upper abdominal pain, upper respiratory infections, sore throats, wellness physicals, and many others were seen by Dr. Douglas and I. The established pattern of reviewing the previous health history to identify any changes is done first, followed by a comprehensive review of their current medications. The patient’s presenting complaint is then explored with onset of illness, duration, and mitigating factors. Physical exam in the clinical setting always includes breath sounds and heart sounds with a focused physical exam based on complaint. Dr. Douglas has the provider-patient trust relationship established. His patient’s appear comfortable in his presence, and he generally asks about their activities, their families, and their interests in the course of the exam. His patients listen to him, ask his advice, and report progress from previous treatment. Buttaro et al. (2013) advised that patients provide the most accurate information in the presence of a trust relationship, and Dr. Douglas exhibits kindness with his knowledge. He listens to what the patients say, but does not anchor his diagnosis based on the patient’s opinion (Connor, 2011). The application of the Theory of Caring into practice is being demonstrated by Dr. Douglas, and this physician is an eager teacher with his knowledge, but also a great example as a preceptor who has genuine concern for his patients. Pattern recognition was seen when multiple patient’s requested evaluation of discolored areas for evaluation of melanoma by utilizing a brighter light source for illumination for examination and discussion about the previous appearance of the areas. Each area of concern was evaluated for change in color, change in characteristics of the border, and changes in surface characteristics (Buttaro et al., 2013). Few of the skin conditions evaluated were positive for the changes that have high suspicion for malignancy and seborrheic keratoses was the most common diagnosis for discolored areas. Areas that had recent color change had higher suspicion and greater concern for the patient were removed with a derm blade and superficial excision after an injection of local anesthetic (1% Xylocaine with Epinephrine) and sent for pathologist’s examination. Pattern recognition allows us to identify that certain illnesses often have predictable characteristics. Pattern recognition is done to establish Centor scores with patients complaining of sore throats, to determine risk of pulmonary emboli using a Wells score, and to determine risk of heart disease with a Farmingham score (Buttaro et al., 2013; Mamede et al., 2010). The patient with appendicitis often has right lower quadrant pain, the patient with streptococcal pharyngitis usually complains of a sore throat, and the patient with an acute myocardial infarction most frequently experiences chest pain. Utilization of pattern recognition to illnesses allows us to be prepared to assess multiple conditions to establish differential diagnoses and the identification of inclusion and exclusion criteria from established patterns of illnesses leads to final diagnosis and treatment. Mamede et al. (2010) stated that the expert diagnostician will consciously use pattern recognition to make better decisions. References Buttaro, T. M., Trybulski, J., Polgar Bailey, P., and Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby. Connor, J. T. H. (2011). Understanding the cognitive restraints of physicians. Canadian Medical Association Journal, 183(2), E137-E138. D'Agostino Sr, R. B., Grundy, S., Sullivan, L. M., & Wilson, P. (2001). Validation of the Framingham coronary heart disease prediction scores. JAMA: the journal of the American Medical Association, 286(2), 180-187. Mamede, S., Schmidt, H. G., Rikers, R. M., Custers, E. J., Splinter, T. A., and Van Saase, J. L. (2010). Conscious thought beats deliberation without attention in diagnostic decisionmaking: at least when you are an expert. Psychological research, 74(6), 586-592. Tonges, M., and Ray, J. (2011). Translating Caring Theory Into Practice: The Carolina Care Model. Journal of Nursing Administration, 41(9), 374-381. Caring to practice (Tonges and Ray, 2011). Week Three Soap Note and Time Log Submitted Separately Week Four Cardiovascular Disorder, September 27, 20XX AF is a 66-year-old female with a history of atrial fibrillation. AF was hospitalized three years ago after experiencing presyncope and palpitations. She denied history of coronary heart disease, cardiomyopathy, and she has hypothyroidism (Buttaro et al., 2013). Her health history includes hypertension, obesity, and type II diabetes. Her heart rate in the clinic was 76 and regular. She is on propanalol and digoxin for rate control and warfarin for thromboembolism prophalaxis. One-third of patients with atrial fibrillation have strokes, and they are believed to be embolic, which is less likely with anticoagulation (Buttaro et al., 2013). Her warfarin dose is 5mg on Mondays, Wednesdays, and Fridays and 3mg the other four days of the week. She states she rarely feels like her heart is beating fast or irregular. She was in the clinic for routine evaluation of her PT/INR. The PT/INR was 2.9 and her dose of warfarin is to remain the same. The availability of a bedside monitor that does a PT/INR as rapidly as a bedside glucose was a clinical highlight and also made this ED nurse who has to wait an hour for this same test result envious. EKGs are done annually and follow up is planned in one month for routine monitoring of her anticoagulation therapy. Newer medications are now prescribed for atrial fibrillation that do not require monitoring of the PT/INR, dabigatran and rivoroxiban (Brokaw, 2012; Buttaro et al., 2013). The medications are reportedly as effective as warfarin without the time and expense of the continuous monitoring; however, there are not antidotes to the medication (Brokaw, 2012; Buttaro et al., 2013). The medications have the same risk of hemorrhage as warfarin, but the incidence of intracranial hemorrhage and death is reportedly lower (Brokaw, 2012; Buttaro et al., 2013). The cost of warfarin is to be $48 per year, but that does not include the cost of additional office visits and the PT/INR testing, and the cost of the newer dabigatran and rivoroxiban are reported to be in the $3000 range per year (Link, n.d.). The inability to evaluate the cost of the additional lab tests and office visits with warfarin makes its unclear which medication is most cost effective for the patient since both have similar patient outcomes, but the lower risk of death with dabigatran and rivoroxiban are offering improved patient outcomes (Browkaw, 2012). References Brokaw, D. K. (2012). New oral anticoagulants in the management of atrial fibrillation . (2012, June). Retrieved from Buttaro, T. M., Trybulski, J., Polgar Bailey, P., and Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby. Link, S. D. (n.d.) Atrial fibrillation: Which anticoagulant should I take to prevent stroke?. Retrieved from Week Five, Asthma Patient, October 5, 20XX CR is a 59-year-old patient with asthma and hypertension. CR was in the office for routine follow up after recently having an increase in his dyspnea and wheezing. Asthma causes localized edema and hypersecretion of mucus in an atypical response of the airways to stimuli (McPhee and Hammer, 2012). Environmental factors that increase asthma events are abrupt weather changes, exposure to allergens, infections, tobacco smoke exposure, and infections (Buttaro et al., 2013). CR denied any extra exposure to any known allergens or irritants; however, but he does work in the outside environment as a car salesman. He had faint wheezes in bilateral upper lobes, and he stated that he did not always use his metered dose inhaler twice a day due to his erratic work schedule and long work days. He said he always used it in the morning, but often omitted the evening dose. His medications included fluticasone/salmeterol two puffs every twelve hours, albuterol two puffs every four hours for increased wheezing and dyspnea, and losartan 50 mg once daily. He has not used his rescue inhaler of albuterol. CR is a caucasian male, which decreased race, gender, and ethnic factors that would have increased his genetic probability for asthma (Buttaro et al., 2013). CR was also atypical in