Anna E. Marshall MSN Portfolio



Washburn UniversitySchool of NursingNU 607 Health Care Practicum II- Specialty (Family) Clinical Performance Tool(Completed by Student and Faculty)Student__Anna Marshall_____________________Semester__Spring 2012_____Agency___Heartland Community Health Center___Instructor__Dr. Jane Brown___Clinical performance is based on Universal Outcomes, End of Program Outcomes and National Organization of Nurse Practitioner Faculty Core Competencies of Nurse Practitioner Practice (2011). Nurse Practitioners must demonstrate care that is effective, patient-centered, efficient, timely, and equitable for the treatment of health problems and promotion of wellness. Universal Outcomes: Evaluating BehaviorUniversal Outcomes must be met in order to pass the course. Failure to meet any of the three Universal Outcomes will result in a grade of F. If an F is earned, the Core Competencies will not be consideredUniversal OutcomesDemonstrates honesty and integrity by submitting original work MetNot meton assignments and accepting responsibility for own actions taken/omittedPrioritizes patient safety as the primary consideration in all careMetNot metMaintains professional boundaries with patients, family and Met Not metstaff. Maintains confidentiality at all timesNurse Practitioner Core CompetenciesStudents must achieve an 75% on the final clinical evaluation tool to be successful in the course. These outcomes are only evaluated if the three Universal Outcomes are met. Students who do not meet the competencies within the required practicum hours may be required to successfully complete additional hours before a final grade will be awarded. Points are assigned as follows: Please rate your own performance using the descriptors listed below:0 = no opportunity to experience1 = defined as not meeting expectations; failing to initiate learning experiences; arriving late and unprepared; failure to effectively communicate with the patient, family, preceptor, staff and faculty2 = defined as inconsistently meeting expectations; requires much faculty/preceptor guidance in learning experience/support3 = defined as routinely meeting expectations yet requires more faculty/preceptor direction in learning experiences4 = defined as routinely meeting expectations with minimal support from faculty/preceptor5 = defined as consistently meeting expectations with little guidance; proficient; can perform independently; initiates learning experiences; is well prepared for learning experiencesGradingThe Clinical Performance Tool is completed and submitted by the student at the completion of 60 clinical hours, 120 clinical hours, and all clinical hours for a total of three submissions. The first submission must address items 1-13. The second submission must address items 1-28. The final submission must address all competencies. The final submission is graded.first submission (9 March)first or second submission (18 April)second or third submission (4 May)NONPF competencies addressed in this course include Independent Practice, Leadership, Quality, Technology/Information Literacy, and Ethics. Competencies are founded on an understanding of pathophysiology, patient presentation, differential diagnosis, patient management, surgical principles, health promotion, and disease prevention. Utilization of communication strategies, principles of quality care, information technology/literacy and ethical principles are expected. NP students are expected to demonstrate an investigatory and analytic thinking approach to clinical situations, professional behavior, effective communication, and a sensitivity and responsiveness to patient culture, age, gender, sexual orientation and ability.NP students are expected to: 0 1 2 3 4 51.Develop individualized health promotion, disease □ □ □ □ □ X □prevention and health protection services for patients acrossthe life span9 March (first submission) – I assess each patient to determine what age-specific screenings or other health protection services might be indicated. Still rely heavily on reference material for current evidence-based recommendations. I recommend age-appropriate immunizations usually based on CDC’s recommendations. I promoted the Medicare-approved screening for AAA in an individual between 65-75 years of age who met certain criteria for risk (ex. ≥100 cigs in lifetime)-based on a USPSTF recommendation.I have recommended a frequency of woman’s health screening, including mammography, routine pap, and bone density testing based on the American College of Obstetricians and Gynecologists' & ACS recommendations. (ex.Pap test q ≤3 years, in women of average risk, who are or have been sexually active and have a cervix).The clinic offers integrated mental and behavioral health services, clinical counseling on-site, and wellness programs, which I frequently refer patients to. The wellness program offers individualized nutrition education & weight loss support, as well as smoking cessation. The smoking cessation program offers ongoing support & education, and one-on-one assistance with developing an individualized quit plan. The clinic offers many different modalities to educate and support patients in the promotion & protection of health and prevention of disease. 18 April (second submission) – I have improved on this outcome, as I have become more familiar with recommended screenings for common diseases based on age, race, gender, and specific risk factors in support of disease prevention, and have become more knowledgeable of the resources available through the clinic and within the Lawrence (& surrounding) community for health promotion and protection services. For example…I have recommended the pneumococcal vaccine for older patients and especially those suffering from chronic respiratory problems, or other comorbidities. Also, patients counseled on alcohol and tobacco use, and given referral for help with cessation, as indicated. Whenever possible, patients provided with printed material to supplement verbal recommendations/educational points. In the future, I will strive to encourage health promotion and protection behaviors in all patient encounters, examining each individual for all obvious risk factors, and being diligent in search of learning opportunities.In the future as a nurse practitioner, I would like to be involved in the implementation of health promotion activities on a community level, and am interested in collective approaches to health as ways of helping individuals manage chronic diseases.4 May (third submission) - I have grown enormously in this competency during my time at HCHC. Mainly, in that it has become a much larger portion of my focus with every patient encounter, and I have gained fluency in applying the recommendations. I have a greater appreciation of every encounter as an opportunity to affect someone's quality of life over their lifespan. Through observation of how my preceptor strategically works it into every patient visit, I have learned strategies and new skills to incorporate into my future practice. I have had the opportunity to perform several pelvic exams, screening for cervical cancer, and have recommended colonoscopies for many patients, based on risk factors (family history of colon CA < 50 yrs old, rectal bleeding/blood in the stool, if indicated). I had one 63 year old female patient who, when asked about having a colonoscopy, respectfully refused, stating, "Of all things that could kill me, I don't think it would be that - it'll be this blood pressure. I am not worried about that". The woman was encouraged to consider a fecal occult blood test card to take home, at least, and she agreed, but made no promises about actually doing it. I documented such, along with the absence of risk factors, as told by history, and her decision to refuse my recommendations for colonoscopy. I have had the opportunity to perform CBEs on two separate women presenting to the clinic with breast lumps. Both women were sent for 'diagnostic' mammography, These were both 'no-brainers', because, in both cases, the masses were highly suspicious, being easily palpable, fixed, firm, and non-tender. In both cases, the women reported having first noticed the lump 2-3 months before, but had been waiting to see if it would change or go away on its own. One of the women even had visible enlargement of the one breast with dimpling and had been experiencing drainage from the nipple as well. Both women were diagnosed with breast cancer. Seeing young women diagnosed with such an aggressive disease gives good perspective on the importance of thorough screening services for all. I recognize the benefit of point-of-care access to recommendations for health promotion, disease prevention, and health protection services electronically. In the future, I will work to become more familiar with the apps available through various agencies, and will develop proficiency in accessing/applying them. 2. Develop individualized anticipatory guidance and □ □ □ □ □ X □health counseling for patients across the life span9 March (first submission) – recommend routine screening (colonoscopy) for adults every 10 years, beginning at 50 yrs. old for those with average risk; sooner, if indicated.Individualized health counseling about smoking cessation, healthful nutrition choices, exercise, weight management, and other self-care practices provided to patients and families within the setting of provider visits; references made for additional support available through programs run by Americorp volunteers (in-house & free). Often, anticipatory guidance and health counseling are based off of information gained during the intake interview. My provider is good to help me identify potential areas of need, and I always take note of a person’s response to questions related to smoking, alcohol/other drug use, depression screening, and notable trends in weight change. 18 April (second submission)-This is one competency that improves over time, growing with experience. The simultaneous experience of doing more clinical hours, and progressing through the adult health coursework has been as helpful as anything at development within this competency. An example of a time I used individualized anticipatory guidance was in the counseling of a patient with a pertinent medical history of asthma, (even though the patient was in for another complaint) about the importance of smoking cessation, and resources available to help them quit. I have continued to compile a 'clinical brain book' of helpful clinical tools and reference materials for use in providing guidance and health counseling for patients. I will continue to compile a library of resources and references, and into the future, will use it to provide anticipatory guidance and health counseling for adults and children. 4 May (third submission) - I have had opportunity to provide anticipatory guidance and health counseling at most patient visits on a variety of subjects. I have continued to become more efficient at picking up risk factors from the family and social histories, anticipating the topics and opportunities for guidance and counseling embedded in patient encounters. I have had ample opportunity to counsel patients with diabetes, hypertension, hyperlipidemia, obesity, and chronic joint pain on the benefits of exercise and nutrition therapeutics. When planning care for a 24 year old female with asthma, who was complaining of a two week history of moderate-persistent daily symptoms and frequent nocturnal symptoms, I included counseling on the synergistic effects of seasonal, allergic triggers for many asthma sufferers. I recommended Singulair in addition to oral prednisone to her regimen of pharmaceutical agents, and recommended that she consider the pneumococcal vaccination in the near future, for additional protection. I also learned the importance of the pneumococcal vaccination in all asplenic patients after one woman was hospitalized and almost died from an infection. I have counseled patients on age, risk, and gender appropriate screenings, such as mammograms, pap smears, colonoscopies, fecal occult blood testing, lipid testing, BP and weight screening, and immunizations. In future clinicals, I will need to have more pediatric experiences to ensure my ability to develop individualized anticipatory guidance and health counseling for this unique population. 3.Prioritize differential diagnoses based on etiologies, □ □ □ □ X□ □ risk factors, underlying pathologic processes and epidemiology for medical conditions including acuteand chronic dermatologic conditions, anxiety, depressionbipolar disorder, fractures/sprains/stains, back pain, connectivetissue disease, sexually transmitted infections, incontinence,and men’s health issues.9 March (first submission) – Continue to require a fair amount of assistance from my preceptor in this. Most comfortable with cardiovascular disease, thyroid disorder, and diabetes. I assisted preceptor in considering & prioritizing differential diagnoses for a middle-aged male with abdominal pain, based on past medical & surgical history, symptom characteristics, & etiologies of various pathological processes. Differential diagnoses considered for 38-year-old female patient presenting with c/c of symptoms of depression and anxiety include: anemia, uterine problems, thyroid dysfunction, alcohol or other substance abuse. Baseline CBC and TSH done to rule out underlying pathological processes, thorough history obtained. Diagnosis of depression reached, based on results of PHQ-9 screening test plus severity and duration of symptoms. 26 April (second submission) - I have made consistent improvement and gained independence in reaching this competency, although I do still require assistance from my preceptor, from time to time. One example of this competency involves a patient who was in to be evaluated for depression. In order to make the diagnosis of depression, the assessment involved review of the specific screening for depression (PHQ-9), and consideration for other differential diagnoses, such as thyroid dysfunction, substance abuse, bipolar disorder, anxiety disorders, or other general medical illnesses (cardiac disease, cancer) as contributing factors. The patient was then referred to talk with the clinic's LCSW, and her assessment of the patient's condition was considered before making the diagnosis of depression. Understanding for the causes of and risk factors for many acute and chronic conditions is incorporated into patient teaching and Another example involved prioritization of differential diagnoses made when assessing a patient's back pain. In order to differentiate between an exacerbation of chronic back pain and an acute process, the patient was assessed for any recent trauma, fall or injury, inflammatory symptoms, neurologic deficits associated with the back pain, or other possible viscerogenic causes. I often use Ferri's Clinical Advisor in the clinical setting to help formulate my list of differential diagnoses. 4 May (third submission) - I continued to gain skills and competency throughout this clinical in prioritizing differential diagnoses based on individual patient factors and underlying pathological processes and epidemiology. Now that we have covered all units in lecture, I feel more confident in all of the medical conditions listed. The majority of patients have been in the 22-55 age range, with chronic conditions. Just after the lecture on sexually transmitted infections (STI), I had the opportunity to care for a young man in the ED with a probable STI, and, from the lecture, I remembered that there are two types of STI: 1) drips and 2) sores. This differentiation along with a thorough history and focused physical exam, made it easy to prioritize. The diagnosis was urethritis and treatment based on the most likely cause (gonorrhea/chlamydia). One man in the clinic expressed concern related to sexual dysfunction that he related to his BP medication. I checked his testosterone level to help in prioritizing differential diagnoses. In another example, a 63 year old woman was establishing as a new patient, and reported severe anxiety and depression, with symptoms that bordered on agoraphobia, since she moved from Florida to Kansas less than a year ago to be closer to her daughters and grandchildren. She was screened for depression, anemia, thyroid dysfunction, assessed for hormonal factors, and then set up for an appointment to talk with the clinic's LCSW in order to further explore underlying issues and stressors. When all variables were known, the patient was diagnosed with anxiety disorder NOS, started on a small dose of Clonazepam, and scheduled for follow-up with the LCSW, which helped tremendously. ________________________________________________________________________4. Perform comprehensive health history and physical exam □ □ □ □ □ X □on patients across the life span 9 March (first submission) – Independently perform comprehensive health history and physical exam on many new and established patients. RN performs extensive ‘intake interview’ with all new patients prior to first appointment to gather & document a thorough, detailed health history.Numerous opportunities to perform annual (comprehensive) physical exams on male and female patients, with special attention paid to health screenings & other maintenance behaviors.Additional opportunities to perform comprehensive sports health history and physical exams for adolescents requiring a sports pre-physical exam. 26 April (second submission) - As I continue to gain more experience, I have gotten more competent at performing a comprehensive health history and physical exam. Each opportunity to practice makes it easier to adhere to an organized, systematic approach. I had the opportunity to perform a 'Welcome to Medicare' exam on a woman, which included a thorough and comprehensive health history and physical exam. I used a form published by Family Practice Management, that guided the encounter so that I would be sure to cover: medical/social history, depression screen (PHQ-2), functional ability/safety screen, physical exam (height, weight, BP, BMI, & visual acuity), ECG, discussion of advanced directive, and referrals based on history, exam, and screening. Counseling and referral of other preventive services was based on the relative need for the following services: vaccines, mammogram, PAP/pelvic exams, colorectal cancer screening, bone mass measurements, glaucoma screening, cardiovascular screening blood tests, and diabetes screening tests. I have had additional opportunities to perform the 'Pre-participation physical examination' on high school-aged athletes using the PPE form published by the Kansas State High School Activity Association. In addition to a thorough and comprehensive medical history that asks about previous chronic or severe illnesses, previous injuries, previous head injury or concussion (when & how many?), and overall activity tolerance, among other things. The physical examination involves a comprehensive general medical examination with special attention to the musculoskeletal system. 4 May (third submission) - Comprehensive health histories are taken on all new patients, and I continue to perform comprehensive physical exams on all new patients, male and female. I had the opportunity to perform a pre-kindergarten head-to-toe physical exam on a 4 year old girl using the school district's form. I also got to complete the comprehensive physicals for two brothers, ages 9 and 11, using international forms, providing medical clearance them for return to their native country in Africa. In this case, the 11 year old was referred to an opthamologist to follow-up on the finding of decreased visual acuity in his right eye, identified during the exam. I will continue to practice proceeding in an organized routine when doing comprehensive health history and physical examinations in my future practice. I would be afraid of missing things, if I did not. ________________________________________________________________________5.Perform problem focused health history and physical exam □ □ □ □ □ X □ on patients across the life span 9 March (first submission) – Independently perform focused health history and physical exam on patients and present to preceptor. Examples of visit complaints that have provided the opportunity to perform problem-focused health history and physical exam include: acute problems, such as URI, UTI, shortness of breath, abdominal pain, and ear pain, as well as routine diabetes checks, and blood pressure checks. Ability to perform problem-focused history and exam has improved since adopting the routine of examining patient’s chart prior to entering the room, noting: chief complaint (as stated by the patient), previous medical history, current medications, and vital signs. Then, thinking of my top 3 differential diagnoses, I enter the exam room and proceed from there. Continue to refine assessment skills and learn new skills from my preceptor. 26 April (second submission) - A systematic approach of reviewing each patient's past medical history, current stated complaint, and vital signs to come up with three differential diagnoses prior to ever seeing the patient has helped me become more organized in performing problem-focused health histories and physical exams. To practice time management skills, I have conscientiously become more consistent at keeping the focus of the visit on the stated problem, guiding the interaction, and limiting tangential conversation. An example of a patient that provided the opportunity to perform a problem-focused health history and physical exam was a middle-aged man that came in for upper respiratory symptoms of sore throat, cough and congestion with increased shortness of breath and a moderate amount of sputum production for the past 4-5 days, which 'just wasn't getting any better'. His respiratory rate was 22 breaths per minute and his Sa02 was only 87% on room air and 90% after a nebulizer treatment. On assessment, his skin was pink and warm, he was tachycardic, and he had crackles, diminished breath sounds, and dullness to percussion over the left lower lobe of his lung. After consultation with my preceptor, I recommended that he go promptly to the Emergency Department for further evaluation of what I believed to be pneumonia. We were able to check on it later, and learned that he had been admitted to the hospital for left lower lobe pneumonia.4 May (third submission) - Problem focused health history and physical exams have been performed in a number of different conditions including pain and swelling of an extremity, joint pain, toe pain, ear pain, throat pain, depression, anxiety, bladder prolapse, sores in mouth, cough and shortness of breath, to name a few. I have consistently been able to identify the correct problem-focused examination to perform and appropriate assessment techniques, with minimal prompting from my preceptor. One example of a problem focused history and physical, was in the Emergency Department (ED) with a young man who complained of a constant, 'achy' pain in his penis, burning with urination, and a white/yellow discharge that all began after a female acquaintance performed (unprotected)oral sex on him. He adamantly denied any other sexual contact (with her, that night), but did admit to having more than one partner within the past month. He also denied any other unprotected contacts of any kind. As he had admitted to some high risk behaviors, I counseled him on the importance of safe sex practices in order to avoid unpleasant infections, like the one he was currently experiencing, or worse. I have gotten better at keeping the problem in focus in my collection of pertinent history, and in the physical exam to help narrow differential diagnoses for a making a final diagnosis. I also learned to limit the number of problems being addressed in a single visit. This is for those patients who will save up a number of problems, bringing 5 or 6 problems to a single visit. ________________________6.Demonstrate diagnostic reasoning and critical thinking □ □ □ □ X□ □in the development of a treatment plan9 March (first submission) – In all cases, I am actively engaged in diagnostic reasoning and critical thinking with my preceptor in the development of an appropriate treatment plan. In most cases, I go in and see the patient independently at first, and then go report my history and PE findings to my preceptor. The discussion includes my opinion and diagnostic reasoning for the diagnosis based on clinical findings. In some cases, we go in together and actively participate in diagnostic reasoning and critical thinking at the point of care, as appropriate. I continue to require a fair amount of assistance with clinical decision making.In trying to change the anticonvulsant medication of a 27-year-old female, I was unable to find a documented recommendation for downward titration of her medication, and neither was my preceptor. The patient was sent home with a prescription for a starter pack of the new medication, starting with a low dose and the instruction that we would call later that day or the next with the information on how to titrate the other medication down. Much diagnostic reasoning and critical thinking went into the development of the treatment plan. 26 April (second submission) - I continue to engage in diagnostic reasoning and critical thinking with every patient I see in the clinic, and am now doing it more independently than ever. I will be the first to admit that I am not always 100% correct or inclusive with my thoughts about what is going on, but I do try to be thorough and conscientious in my reasoning and clinical decision-making and my preceptor is good to guide me. She has helped me in the ongoing development of this competency. Using knowledge of evidence-based practice as well as information from a patient's history and physical exam, I developed a plan of treatment to adjust the basal insulin for a brittle, type1 diabetic patient who reported that her morning (fasting) blood sugars had been in the 200-300s for the past couple of months. The plan included reinforcement teaching about the signs and symptoms of hypoglycemia, and a point of phone contact about a week after initiating the insulin adjustment to check to see how the patient was tolerating it and how blood sugars had been. Another example of this was a in the diagnosis and treatment of a patient with foot pain. Because of the nature of her complaints, her history and current presentation, I was able to diagnose her with plantar fasciitis, and provided her with printed materials on the different stretches, exercises and home treatments that were most helpful for the condition. My preceptor was in agreement with the plan. I believe that the development of reasoning and decision-making skills is ongoing, and will continue to grow and improve throughout my time in practice.4 May (third submission) - During this clinical, I have actively engaged in diagnostic reasoning and critical thinking with all patients seen, and have exhibited growth in my ability to apply these to the development of treatment plans for patients. It is very helpful to practice doing this independently, and then getting confirmation from my preceptor that the reasoning, decision-making, and treatment plan development was on-target and appropriate. One example of that is in my assessment and treatment of an overweight young female (64 in, 334 lbs.) complaining of foot pain. Using diagnostic reasoning, I was able confidently assign a diagnosis of plantar fasciitis without the use of xray. The pain had begun a week and a half prior, and was worst on the plantar surface of her foot (medial>lateral), worse with weight-bearing and palpation, and was not the result of an injury that she could recall. She also reported working at a job in which she had to stand for 6-8 hours, and admitted to often wearing unsupportive shoes. The treatment plan included counselling on prevention factors, such as wearing high-quality shoes with good arch support, losing weight, and avoiding long periods of standing, if possible. She was given a print-out to take home outlining some stretches and exercises she could do to help, and given some additional tips on the use of a cold steel can, as an aid for stretching the foot. Numerous patients with multiple chronic, comorbid conditions were treated in this primary care setting and the degree of diagnostic reasoning and critical thinking was complex at times in trying to manage the care of these complicated patients. The clinic currently serves 108 diabetic patients (approx. 10% of the total clinic clientele), and many of these individual also have hypertension and/or hyperlipidemia. I have seen, in both of my clinical rotations, the importance of being well-versed in these conditions. The treatment plans are often complex, requiring a high degree of diagnostic reasoning and clinical decision-making to manage. An example of this, titrations of oral medications and/or insulin in diabetic patients are considered/made every three months in response to patient reports about what fasting and post-prandial blood sugars have been since last visit, and hemoglobin A1c values in effort to achieve adequate glycemic control without causing hypoglycemia. Blood pressures and cholesterol levels are monitored and adjustments to the plan of treatment made, as indicated. This competency will increase over time with years of practice.7.Initiate screenings appropriate to differential diagnoses □ □ □ □ X □ □for medical conditions including acuteand chronic dermatologic conditions, anxiety, depressionbipolar disorder, fractures/sprains/stains, back pain, connectivetissue disease, sexually transmitted infections, incontinence,and men’s health issues.9 March (first submission) - Able to recommend screenings for common diagnoses based on a variety of factors. Still rely heavily on reference materials. On middle-aged, overweight female, who reported that she ‘hadn’t been to the doctor in a number of years, and had no medical conditions that she knew of’, recommended a lipid panel as part of her initial screening as a new patient, and based on her age and diagnosis of obesity. 26 April (second submission) - Many of the patients using this clinic have complex medical conditions, and numerous comorbidities to consider. Screenings are emphasized for all, and valued as an important part of holistic primary care. I have had multiple opportunities to initiate screenings for obese, middle-aged patients with risk factors for diabetes and cardiovascular disease, such as smoking, family history, poor diet, and sedentary lifestyle. Another patient presented with a 2 month history of RUQ abdominal pain with anorexia and 'just not feeling well'. Based on his known health history and clinical presentation, which included alcoholism, past IV drug use, and the abdominal symptoms, I wanted to screen him for hepatitis. At this point he said, "oh yeah, I did have hepatitis one time". He was unsure of which kind, but a release of old hospital records did subsequently reveal a diagnosis of Hepatitis C several years before. In the future, I will learn more about the different recommendations behind the various screenings implicated for people seeking primary care. 4 May (third submission) - I continue to use the PHQ-2/9 tool to screen patients for depression. Ideally, the PHQ-2 screen should be given to every patient as part of the intake process, indicated as part of a thorough assessment, and in support of providing truly patient-centered and holistic care. It is followed up by the PHQ-9 tool, as indicated by responses and/or differential diagnoses. I have initiated numerous screenings for possible thyroid problems in patients with a range of complaints from hair falling out, and inability to lose weight, to depressive symptoms. A 19 year old female was brought to the clinic by her mother because, according to the mother, 'she had no interest in anything, and when she came home from college on the weekends, all she would do was lay around on the couch and watch T.V.' While the mother was concerned that something was terribly wrong, the patient did not feel like anything was wrong. The patient was screened for several things, including anemia, thyroid dysfunction, depression, and domestic concerns or issues contributing to her relationship with her mother. Prioritization of the differential diagnoses was begun as the results of each of these screens was processed and thoughtfully applied to the situation. Screening by colonoscopy or fecal occult blood testing initiated for every patient with report of blood in stool (cause not identified). Prioritization based on risk factors as well as results of history and physical exam. In the future, staying abreast of changing recommendations and new technologies and procedures for screening patients will be part of the challenge. As I become more skilled in the prioritization of differential diagnoses, I anticipate that the appropriate use of screenings will also improve. ____________8.Initiate diagnostic strategies appropriate to differential □ □ □ □ X□ □diagnoses9 March (first submission) – In this majorly uninsured population, diagnostic strategies are carefully considered for what information they will yield, and how plan of treatment will be affected. I assisted the practitioner in initiating a CT scan for an uninsured patient with a significant smoking history, unintentional weight loss, and complaints of acute back pain. The CT scan did reveal a lung mass and a nodule on the spinal column, which was later confirmed to be adenocarcinoma lung cancer. Spirometry ordered to differentiate between asthma and COPD as the primary cause of 60-year-old male’s respiratory symptoms. Results to help distinguish among differential diagnoses, and guide subsequent treatment choices. Assisted the practitioner initiating a cortisol-challenge test to rule out Cushing’s disease in patient with bilateral adrenal enlargement.26 April (second submission) - This experience of caring for mostly uninsured and underinsured patients in a primary care/safety net clinic is vastly different from my experience of working in the emergency department in regard to what diagnostic strategies are used to rule in or out different diagnoses. For patients with exacerbated or worsening symptoms of asthma or COPD, I routinely utilize peak flow meter to assess pulmonary function, and recommend spirometry, as indicated and economically feasible. In a female 30-year-old established patient with complaints of anxiety and rapid heart rate(120s) an EKG was done along with an assessment of her anxiety. Since EKG was normal, she was given a small dose of anti-anxiety medication to help with her symptoms and told to monitor for future occurrences. She began using the anti-anxiety medication, 'which helped some', but returned to the clinic because she continued to have breakthrough episodes of anxiety/panic attack with tachycardia not brought on by exertion. The patient denied chest pain, and so a Holter monitor was recommended as a way to capture what was going on when she had an episode. The patient agreed to this diagnostic strategy. I will continue to work on sharpening my assessment skills in order to become the best diagnostician that I can be, and will strive to use diagnostic technology appropriately. 4 May (third submission) - I have continued to develop my skills in recommending diagnostic studies for patients, becoming more proficient in recognizing what is appropriate to differential diagnoses. After the assessment, I ordered an xray for a patient with ankle pain, mostly due to her response to the Ottawa criteria for ankle pain, and the nature of the injury (rolled out, off of a sidewalk). As appropriate to differential diagnoses, I have referred several patients to the health department for STI testing based on the nature of symptoms, and reported history of unprotected sexual contact. Diagnostic strategies (Echocardiogram) recommended for an adult patient with an audible, Grade II heart murmur. However, being uninsured and unable to pay out of pocket, the patient did not think she would be able to have it done. Her name was added to a list of persons for whom it would be nice to have, if the assistance or resources for obtaining ever became available. I have learned several valuable lessons in the development of this competency during my time at this clinic. I learned that sometimes, you have to come up with a plan B, if it is not possible to order the diagnostic test you would like, and important considerations for the prioritization of differential diagnoses, if the first choice of diagnostic is not available. Also, I learned that even diagnostic tests are not always accurate or totally telling, and must be considered in the context of the situation. ______________________________________________________________________________9. Develop a plan of care utilizing evidence-based practice □ □ □ □ X□ □ 0 1 2 3 4 59 March (first submission) – Able to apply concepts of evidence-based practice to the development of the care plan for diabetic, cardiovascular, and respiratory patients, but less proficient in other areas of practice. Recommended diabetes care includes, every 3 month visits with tracking of blood sugar trends, Hgb A1c, weight, regular medication reconciliation and foot exams. Resources for the ongoing utilization EBP in the development of plans of care include: Ferri’s Clinical Advisor, Sanford’s guide to Antimicrobial therapy, CDC, ADA, AHRQ, UpToDate,the Cochrane Library, and others. Because high percentage of the population using this clinic is uninsured, EBP guidelines are definitely considered, but always within the context of an individual’s circumstances, and the constraints of what is feasible. 26 April (second submission) - I continue to use a variety of resources to help me utilize evidence-based practice in practice. I find that my preceptor, being a relatively recent graduate, is quite attentive to evidence-based practice guidelines, and often uses them to establish a standard of care to help guide the management of complex patients. The program for diabetes management is structured around evidence-based practice guidelines, and certain measures, such as frequency of having Hgb A1c checked, level of Hgb A1c, and lipid profile, are tracked. Guidelines are readily available through multiple online and printed resources for review of evidence-based recommendations, but the actual application of evidence-based findings into real life situations typically requires more than accessing guidelines and following algorithms. In other words, evidence-based practice guidelines are considered, but always within the context of the individual situation. 4 May (third submission) - Guidelines and recommendations for the utilization of evidence-based practice are readily available, and were used regularly in the development of a plan of care. I utilized numerous resources, including UpToDate, AHRQ, and others. For patients presenting with mental health-related issues, consultation is made with the clinic's LCSW to assess the situation and make recommendations to help guide the plan of treatment. This collaboration with a social work professional ensures a more thorough assessment of the situation, and better utilization of evidence-based practice, as this is her area of expertise. This arrangement was not only helpful to me, helping me better understand the rationale for various mental health treatment options and what, in her experiences, was most helpful for patients, but also benefited the patients by providing additional time, attention, talk therapy, and professional insight into their situation. I also used evidence-based practice to guide the discussion when I was explaining to a patient that CPAP was for more than just 'problem snoring'. In discussing the research in support of using a CPAP machine for sleep apnea, I explained the long-term benefits related to decreasing the risk of cardiovascular and cerebrovascular events. Ongoing competency in this measure will require ongoing attention to the ever-changing realm of evidence-based practice.__________________10. Prescribe medications based on cost, diagnoses, □ □ □ □ □X □efficacy, safety, and individual patient needs9 March (first submission) – I am recommending medications for many common conditions and pay attention to individual patient factors(age, history, other meds/comorbidities, tolerance, etc.) when prescribing, with extra-special attention to the factor of cost and affordability. Use Epocrates on my I phone as a clinical reference. Example: a 68-year-old male with a medical history of hypertension, hyperlipidemia, and tobacco abuse is in for a routine check-up/medication refill. His blood pressure is well-controlled on 360 mg Verapamil & 10 mg Lisinopril, but he complains of a unilateral hand tremor that has become so severe, that he has recently had trouble writing. Medication change prescribed, changing from verapamil to propranolol, in hopes of controlling BP and calming the tremor as well. 27-year-old, uninsured epileptic patient expresses the desire to change anticonvulsant medications because of frequent migraine headaches as a side effect of med. She stated that she had been on many other anticonvulsant medications in the past, and had reasons for not liking various ones, in addition to the desire to become pregnant and limited financial resources. I considered her diagnoses, her individualized needs and pregnancy class, involving both her & her husband in the choice of an anticonvulsant that would work for her and was covered by the medication assistance program. Also, together with social work, we got her enrolled in the medication assistance program (MAP) at this visit, and she was able to start working on the transition that day. 26 April (second submission) - I continue to prescribe and recommend medications based on individual patient needs and diagnoses, safety factors, efficacy factors, and cost. The factors related to prescribing medications are so many and so complex that I probably learn something new every day that I work in the clinical setting. Mostly I use the Sanford's Guide, and Epocrates for reference, and have become increasingly familiar with the workings of the medication assistance program (MAP) during my time at the clinic. I am appreciative of the social work staff, their availability and the collaboration that takes place to help patients navigate the process of applying for eligibility for assistance programs and accessing resources. When working with these programs. I have learned certain questions that may help: what medications have you taken for this condition before? what has worked/not worked for you in the past - and why? have you ever been enrolled in a MAP before? when? Also, I frequently order lab work to monitor organ function and critical levels of various electrolytes and metabolic indicators in patients taking certain medications. Examples include the periodic monitoring of liver function in patients taking Terbinafine, monitoring of potassium levels in a patients taking Lisinopril, and monitoring of hemoglobin A1c and microalbumin in patients taking diabetic medications. 4 May (third submission) - I continue to perform this competency, as above, adding new knowledge and experience daily. I am able to identify appropriate families of medications for given conditions, and have become more familiar with specific medications during my time in this clinical. This is demonstrated by a patient, during my time in the ED, who was being treated for urethritis , suspected organism N. gonorrhea &/or Chlamydia. I was able to accurately recommend one time doses of Rocephin 250 mg IM and azithromycin 1 gram po, given now after covering this in lecture. One of the mid-level practitioners in the ED showed me a list put together by the hospitalists that had I continue to use Sanford's, Epocrates for up-to-date information, and also look things up in my Pharmacology for the PCP book. Eighty percent of the clinic's clientele are uninsured, and 67% are living at or below the Federal Poverty Level, so I have also had to become more familiar with programs and resources available to help patients be able to afford the medications they need. I had the opportunity to work in conjunction with the HCHC social work department, and have learned so much from their expertise, and appreciated their work in helping to coordinate services. I wish there was a rule requiring pharmaceutical companies to even out the distribution of reps dispersing samples and other benefits to cover a certain percentage of safety net clinics and clinics serving the underserved, to balance their other attention on more lucrative and for-profit practices. The clinic receives very few samples, and visits from reps were virtually non-existent. ______________________________________________________________________________11. Perform medical and surgical procedures as appropriate □ □ □ □ □X □9 March (first submission) – no opportunity to perform medical and surgical procedures at this clinic. With a majority of the patients presenting as ‘self-pay’ patients, most cannot afford procedures.26 April (second submission) - Labs are ordered and collected for both 'send off' and 'in-house' testing. Some point of care testing is done, including urinalysis, strep screening and mono spot, as well as EKG, and peak flow meter. I have gotten to remove sutures twice, but have had no opportunity to place sutures or participate in any other surgical-type procedures at this clinic. I hope to have more opportunity to perform medical and surgical procedures in my future clinical experiences, as more practice is needed. 4 May (third submission) - I have performed both CBEs and pelvic and PAP smears independently, have removed (but not placed) sutures, and participated in a wound debridement of an infected post-cyst removal site. I have continued to order urine tests, blood work, collected specimens for culture, and other point of care tests, such as capillary blood glucose tests, strep screen, and mono spot. In the ED, I was able to assess for foreign object of a 5 year old using the Wood's lamp, and observe as the APRN placed 5 sutures in an 1.5 cm laceration on the ring finger of one patient after injecting the with 1% lidocaine. 12.Interpret patient responses to treatment and recommend □ □ □ □ X □ □changes to the treatment plan as indicated9 March (first submission) – Able to interpret patient responses to treatment and recommend changes to treatment plan for some common and routine disorders, including diabetes, cardiovascular, thyroid and some respiratory disorders. Still need considerable assistance with other conditions and more complex cases in both the interpretation of results and recommendations for change. 26 April (second submission) - I have had the opportunity to evaluate patients and interpret their response to treatment both when I had been the one to see and treat the patient at the previous visit, and when they were seen at treated by others previously, and referred for follow-up care. One example of this tracking, involved a man who was complaining of intermittent wheezing, and shortness of breath, worse with exertion, but denied cough, congestion, sputum production or other infectious symptoms. Pulmonary function testing was done, and he was started on an albuterol inhaler, to be used as needed. When he followed up a few weeks later, he reported that he had been needing to use the inhaler four times per day, on average. Based on his report of poor control, a change was recommended to the treatment plan that included the addition of Symbicort and Singulair, to reduce his dependency on the rescue inhaler. At a follow-up a short time later, the patient reported 'doing much better' with those changes to the treatment, and reported much less frequent use of the albuterol inhaler (1-2 x/week). Another example involves diabetic patients who are asked to come in every three months for a routine check-up. Changes to the treatment plan are made (or not made) based on the patient's hemoglobin A1c, as well as the assessment of the patient. In the future, I hope to become more independent with this competency.4 May (third submission) - I have conducted many follow up exams to evaluate patients' response to treatments such as diabetes medications, blood pressure medications, depression medications, thyroid medications, iron replacement, potassium supplements, making changes, as indicated, and to discuss other abnormal diagnostic findings with patients and plan future treatments. One way I interpret patient responses to treatment is by looking back to review the patient's history and previous visit notes to get a context for what is currently being considered. A patient had sutures placed and came to the clinic 5 days later to have them removed. I looked at the site and did not think it was ready for them to come out. My preceptor agreed, and we instructed the patient to come back in 5 more days to have the sutures removed. When he came back day 10, the site looked terrible: the sutures were loose, and purulent drainage was noted coming from the gaping incision. At this point, the sutures were removed (they were doing nothing), the wound debrided, and left open for inside-out healing, wound care instruction given, the patient was started on oral antibiotics and scheduled for follow-up. Of course, this was not the goal when we started out, but despite changes made to the original plan, the wound ended up healing alright with no further signs of infection. There will be a scar, but luckily it is in a place that will not matter. It is important to know and screen for the most serious and potentially problematic complications associated with the patient's condition as well as prescribed treatments. Also important to document the absence (or presence) of these things.____________________________________13.Document using professional terminology, □ □ □ □ □ X □format and technology (ie: ICD9, E/M coding, CPT)9 March (first submission) – I document independently on the clinic’s electronic documentation system, and the computerized system assists in the task of using appropriate professional terminology. I use various resources to determine the appropriate ICD9 code (FPM short list, I phone app, Ferri’s text, etc) choose the correct E/M code, and other CPT codes, entering them as indicated. My preceptor uses her logon and password to log me in, then I am able to document assessments, order tests, and prescribe using the clinic’s ‘EClinicalWorks’ program. Preceptor assists with refining the documentation. (FYI: The clinic began using the electronic system in January of this year, so it is new for all of us. )26 April (second submission) - I continue to document using professional terminology, format, and technology, and have been able to continue documenting in the electronic record, under my preceptor's supervision. The template in the electronic medical record guides the format and supplies some prepared terminology from which to choose, but also allows for free-texting to best describe my assessment. Since coding and documentation are interconnected, careful attention is paid to documentation to ensure that it supports what is being coded and billed for.4 May (third submission) - I continue to be able to document using the clinic's E-documentation system, and am able to navigate a patient's chart pretty well now, entering data, sending E-prescriptions successfully, and generating patient discharge instructions to print. My preceptor has been consistently satisfied with my use of professional terminology and format, as she checks over all of my documentation, prior to 'locking' the chart. I love learning new professional terminology, and definitely think that my prior study of Latin has definitely helped, often allowing me to breaking the word into smaller root words, and figure it out. _____________________________________________________________________________14. Recognize need for referrals by collaborating □ □ □ □ X□ □and consulting with members of the health care team26 April (first submission) - Working as a member of the health care team at this clinic, I have become better at recognizing the need for referrals, and have built a better understanding the opportunities and constraints related to making referrals. Still, in some cases, I had not thought of referral as an option for managing a patient until my preceptor mentions it, and then I can see that it would be a good idea. For example, in a patient complaining about the inability to gain weight, among other symptoms, I was thinking of a possible thyroid process or eating disorder, so my preceptor suggested that she meet once with the clinic's wellness coach to talk about her diet, and assess the adequacy of her caloric intake to give us a better picture of the problem. I have worked in close collaboration with the clinical social worker, and, in addition to making numerous referrals for patients to meet with her, have consulted with her for her assessment and recommendations on the management of care for patients with mental health needs. In the future, wherever I practice, I will make it a point to become knowledgeable of the resources available to my patients for referrals, and certainly hope to be surrounded by a team of health care workers with which to work in collaboration. 4 May (second submission) - I recognized the need for referral when a patient presented with a lipoma, which he wanted to have removed. After assessing the location, on his neck, right smack over his cricoid process, I recommended that he go to a surgeon or plastic surgeon for removal, and that it was probably not something to be done in this office. My preceptor agreed that it would be too risky, considering the potential complications, and referral was appropriate. A referral to physical therapy (PT) was recommended for another patient for a problem with the thumb of her dominant hand. It kept 'locking up', and she was losing mobility. The patient expressed some hesitation, but agreed to go home and Skype her son in Virginia, who was a PT, show him the problem, and seek his opinion of what she should do. Later, we found out that he agreed and strongly urged her to have PT, which she did. I also learned that without EDW funding, it was more cost-effective to refer many patients to the health department for their women's health visits or checks related to STIs. In the future, I hope to be so fortunate to work in such close and effective collaboration with other health care team members (social work, esp), as what was demonstrated among the team members at this clinic. _____________________________________________________________________________15. Discuss access, cost, efficacy and quality when □ □ □ □ X□ □making care decisions26 April (first submission) - I feel that I do a relatively good job of discussing these factors, both with my preceptor, and with the patient, as appropriate, when making care decisions. Access and cost seem to be the factors that sway decision-making the most, among this population. Efficacy and quality are great, but only apply if the patient can get to the care in the first place. Again, referral to members of the social work team is an invaluable tool used in presenting patients with the detailed information about what it takes to enroll in the medication assistance program, or be eligible for other assistance, as indicated. The cost of various care options is something that I am attempting to gain a better understanding of. To be quite honest, I had not been as driven to gain that knowledge until I worked with a highly uninsured/underinsured population, for whom it was a huge factor. 4 May (second submission) - These are important factors to consider for all patients, but maybe even especially when dealing with such a high risk patient population. The factors listed above are discussed openly, and patients are assisted in weighing the pros and cons of various decisions related to the plan of care. Since, many times, patients face the prospect of paying out of pocket for the indicated tests and treatments, it is especially important for them to understand these factors. Without donations from specialty practices, physicians, and the hospital, many uninsured patients, unable to pay out of pocket, do not have access to certain expensive diagnostics and specialty treatments, because of cost. In one case, I had to explain to an uninsured woman that the local neurologists refused to see her for her 'new onset seizures' unless she would be able to pay $300 up front. Being unable to afford that, she was left without that option, and we had to discuss others. Quality and efficacy are considerations in all care decisions, regardless of other factors. _____________________________________________________________________________16. Perform care in a timely manner □ □ □ □ □X □26 April (first submission) - As I have gotten more organized in my approach to care, and gained more experience, my ability to perform care in a timely manner, has improved. In the beginning, the usual flow was, I would be seeing one patient, my preceptor would see the next, for the most part, alternating down the schedule. As I gained experience, I began to consciously pick up the pace and that allowed me to see consecutive patients. One strategy that has helped me improve in this competency is that if I start to fall behind, I will do what is necessary to get the patient on his or her way, and go back and do further documentation later from notes taken. Often, I will have 2 or 3 patients for which I will go back into the chart to finish charting on when I break for lunch or at the end of the day. I am always aware of the clinic's overall patient schedule for the day, and do my best to stick to the allotted time and stay on schedule, although I recognize much room for improvement in this competency. I feel that a lot of that will come with time and experience, and when I look at how busy my preceptor is on a day-in-day-out basis, with all of the other tasks associated with being a practitioner, I can see why it is necessary to consistently practice this skill and competency. 4 May (second submission) - I have definitely gotten a lot better and more consistent at performing care in a timely manner over the course of this experience. 'Focus' is what my preceptor would say, prior to me entering the room, if she recognized the patient as someone who frequently wanders off topic, likes to dominate the conversation or brings numerous concerns into every appointment, besides the chief complaint. I was able to utilize the clinic's staff in order to help stay on schedule if a patient visit ended up being more complex or taking longer than expected. For example, one patient, who was in for a general check up ended up needing to start several new medications because of problems identified by history and on exam. Since he would be unable to afford the Spiriva that was recommended, he enrolled in the medication assistance program (MAP) so that he could get the medication. If not for the clinical support, all of this would have put me terribly behind schedule. However, I was able to call in the help of the social work department for helping the patient with the paperwork and processing the request, allowing me to continue progressing through the patient schedule. Performing care in a timely manner is certainly a team effort. ____________________________________________________________________________17. Maintain confidentiality and privacy □ □ □ □ □ X□26 April (first submission) - In all interactions, I consistently maintain confidentiality and privacy, adhering to the standards of the law, our school, the agency, and my own moral code. I discuss patient information privately with my preceptor, close the door when visiting with or examining a patient, do not discuss patient information with anyone who does not need to know, and I do not remove any documentation with any type of patient identifier from the clinic. This is important in any health care arena - as a provider, I will always strive to give this competency a high level of priority in my practice.4 May (second submission) - Throughout the clinical, I maintained the highest degree of confidentiality and privacy in caring for patients, and outside of the clinical. Examples include protecting medical records from being viewed by others, discussing patients discretely with my preceptor and other health team members on a need to know basis, knocking on doors prior to entering rooms, and ensuring that patients are adequately draped for privacy when performing physical assessements. This has always been an important part of my nursing practice and I will continue to hold it in high priority as I move forward into advanced nursing practice.______________________________________________________________________________18.Demonstrate professional behavior □ □ □ □ □ X□_26 April (first submission) - I demonstrate professional behavior without difficulty, in the way I dress, act, and interact with others. I consistently adhere to the standards described by the clinic's guidelines, the school of nursing's guidelines, and my own personal standards of professionalism. In my interactions with others, including patients, my preceptor, and other clinical staff, I always strive to maintain professionalism, mostly through kindness, courtesy, honesty and respect. I always maintain professional boundaries with those I come in contact with. 4 May (second submission) - I consistently arrived to clinicals on time, was professionally dressed, wore my Washburn ID, respected patients, other staff and volunteers, and maintained patient confidentiality in all interactions. As always, I followed the ANA Code of Ethics for Nurses in my pratice. This competency is tied to credibility and ultimately, the ability of a practitioner to be successful and trusted in the provider role. _____________________________________________________________________________20. Employ effective communication methods with patients, □ □ □ □ □ X □families, preceptor, and staff26 April (first submission) - I believe that I am an effective communicator, and employ a variety of methods to communicate with patients and their families, my preceptor and the other clinical staff. Among the barriers to effective communication I have run into, language and cultural differences, low functional health literacy (FHL), and patient's baseline mental status, are among the most difficult. In general, barriers have been overcome by using family members or clinic staff to help interpret, respecting cultural bounds, and providing information in a simple, easy-to-understand format. Sometimes effective communication includes more frequent follow-up in the form of phone calls or returns to the clinic, especially when a patient seems to require more one-on-one contact or guidance. A patient with low FHL, was requiring adjustments to his insulin; despite what we thought was effective communication with the patient, he ended up in the emergency department with hypoglycemia, because he had gotten his basal and short-acting insulins confused. When he was dismissed and came in for follow-up, the same information was reiterated, reinforced, teach-back methods were used, in addition to a plan for weekly follow-up by phone contact with his diabetic coach to check in, record blood sugars, and answer questions. I try to use open-ended questions to elicit information from patients and families, and use statements of summary, such as "just so I'm clear, you said..", or "so what I am hearing is that.." when clarifying information. I have learned a little about motivational interviewing as a method of communication, and will continue to learn more about that skill and other tools and their use in future practice. 4 May (second submission) - I think this is one of the competencies in which I have experienced the most growth. As we all know, effective communication means much more than telling someone what you know. Above all, I strive to be a part of effective communication in all interactions. Directness, organization, and the ability to synthesize and clearly explain sometimes complex concepts are qualities of effective communication that apply to the role of the nurse practitioner. I pay careful attention to cues of nonverbal communication, being aware of my own nonverbal mannerisms when communicating with patients, families, my preceptor and the clinic staff, and strive to be culturally sensitive to the needs of others, especially in communication. I have become interested in the concept of health literacy, and plan to continue to explore the role of health literacy in the ability of patients and their practitioners to engage in effective interactions, making the most of each chance to communicate. The concept of health literacy has been the focus of some additional research during my time in this clinical, as I have also spent a huge amount of time searching the literature for related topics this semester, and I plan to carry that forward into my future clinical practice. _____________________________________________________________________________21. Provide culturally competent care to patients □ □ □ □ □X □and families and negotiates a mutually acceptableplan of care26 April (first submission) - This clinic serves a culturally diverse population and I have gained valuable experience in becoming more competent at providing culturally competent care to patients and families. Chinese, Hispanic, Native American, Caucasian, African, and African American are among the ethnic cultures represented, in addition to being largely an indigent, underserved population. I have had multiple opportunities to work with one Hispanic family in particular that illustrates this competency. The patients are an elderly Hispanic couple that do not speak English, and frequently schedule their appointments consecutively, so they can come in together, and bring their daughter (who is a nurse), as an interpreter. Per their request, they are always placed in the same exam room, and the appointments are conducted in a somewhat 'family-style' format. That way, the daughter is able to be involved in not only the interpretation, but also the negotiation of plans. Using this arrangement, getting the elderly father to come to the doctor has become much easier, (I am told by the daughter), because he is more comfortable and relaxed, and not as intimidated to come. Achieving cultural competence is a lifelong process, but luckily, many of the principles applied to the treatment of all patients, such as respect for dignity, help keep us from too much embarrassment along the way. 4 May (second submission) - I feel that I have been successful in providing culturally competent care to patients and families, and have numerous opportunities to practice the negotiation of (usually) mutually accepted plans of care. I achieve cultural competence by being culturally sensitive and recognizing that there is a lot that I don't know about cultural nuances, including things about individuals within my own culture. I have had the opportunity to practice providing culturally competent care while working in this clinic, as the population served represent diverse racial, ethnic, social and religious backgrounds. The majority of patients were white, English-speaking, and with a junior high to high school level education, but I also continued to encounter patients from a variety of other backgrounds, as stated above. Patients differed in racial, ethnic backgrounds, religious preferences, sexual orientation, primary languages, payer mix, and earning potential/income levels. Being a Kansas safety net clinic, approximately 96% of the clinic's population lives at or below 200% of the Federal Poverty Level. Poverty is a predominant factor that resonates throughout many attempts to negotiate culturally acceptable plans of care. A small percentage of the patients I saw were migrant, homeless, or lived in the community shelter. ______________________________________________________________________________22. Communicate practice knowledge effectively both □ □ □ □ □ X □orally and in writing26 April (first submission) - For the most part, I have demonstrated the ability to communicate practice knowledge effectively during this clinical experience, and confidence in myself in oral communication of practice knowledge has improved. This includes both my ability to communicate clearly, concisely, and effectively with patients, and my ability to present patients and recommendations to my preceptor in an organized and direct manner. Strategies to assess effectiveness have been used as well, including the teach-back strategy, and frequent assessment of appropriate plan implementation. Between the actual documentation that I do, the elogs, case study, and this tool, I have ample opportunity to practice written communications skills. Honestly, I believe that I have the capacity to be a very effective communicator, and that this skill, along with so many others, will only amplify with time and growth.4 May (second submission) - My ability to communicate practice knowledge effectively has been demonstrated throughout my time in this clinical, both through my oral and written communications. I am now better able to explain disease processes and rationale for recommended treatments, clarify concepts for patients, when needed, provide effective discharge instructions, and document appropriately. My ability to communicate information and counsel patients on the disease processes related to diabetes has definitely improved. I give credit to my preceptor, as I learned a great deal about this from observations of her in early patient interactions, and was then able to practice my own approach under her guidance. ______________________________________________________________________________23. Apply available evidence to continuously □ □ □ □ □X □improve quality clinical practice26 April (first submission) - I regularly access and apply available, up-to-date evidence to help guide me in providing the best possible quality of care to patients in clinical practice. Examples of resources I have used commonly, so far include: Epocrates, Up-to-Date, AHRQ National Clearinghouse guidelines, as well as the most up to date versions of various professional organizations' guidelines (ie. ADA, CDC), Ferri's, Butarro, and Sanford's Guide to Antimicrobials. The application of available evidence is one of the most effective ways to bolster confidence in self as a practitioner, because it provides substance to what is being recommended and statistical data to back up the rationale, which is usually sufficient to satisfy patients. 4 May (second submission) - As stated in the competency, this is a continuous process. Situations of clinical practice change daily, and evidence and recommendations for improving the quality of practice also change on a daily basis. I continue to use the resources available for the ongoing improvement of my clinical practice. I have appreciated and utilized the resources available to me as a Washburn student (UpToDate, DermNet, other databases), I receive frequent updates through Epocrates and also currently subscribe to two peer-reviewed, monthly publications, Consultant 360, and Prescriber's Letter. I intend to refine my list of favorite evidence-based resources, ones that and are most helpful in practice and consider what I would like to have access to as I move from my role as a student to a role as a APRN in the near future.______________________________________________________________________________24. Utilize appropriate agency educational tools □ □ □ □ □X □to provide effective, personalized health care topatients and caregivers26 April (first submission) - The reality is that, in most cases, the resources available to the patients served in this safety-net clinic are extremely limited, but despite that, I feel fortunate to have access to a depth of educational tools and services within the clinic. These services include additional education, tools, printed resources, and ongoing support from wellness coaches for help with smoking cessation, diet and weight management, and other lifestyle related wellness activities. Also, the availability of on-site mental health, and social services support is HUGE, and I definitely utilize those services for the counseling and educational benefits. Many times, patients report feeling 'really well taken care of' after their experiences at this clinic, despite the severe limitations we face in caring for patients and families. I have a passion for participation in health care that serves the critical needs faced by a relatively large portion of the population, and not only provides a service, but overall results in good outcomes for an underserved populations. This experience has been educational and inspirational in many ways, but particularly in the impact I have observed that is possible through the optimal utilization of the resources and tools available.4 May (second submission) - I have became progressively more proactive in my ability to recognize the need for, and initiate the utilization of agency educational tools, as appropriate, to provide effective, personalized health care. Examples include referral to the wellness program for patients who expressed the desire to lose weight or gain weight, and patients in need of nutrition education and counsel, and referrals to the smoking cessation program. I also utilized programs for medication assistance and programs to subsidize affordable quality supplies and low cost medications and insulin for diabetic patients in order to provide effective, personalized health care. I educated patients on the most affordable way to obtain WWEs and women's health services (through the Health Dept), since participation in the Early Detection Works program is on-hold due to lack of state funds. In the future, I look forward to having more time to collect and develop appropriate and effective educational tools for patients and caregivers. ______________________________________________________________________________25. Coach the patient and caregiver for positive □ □ □ □ X□ □behavioral change26 April (first submission) - This probably one of the competencies that I feel least successful at. In its mission, this agency expresses its commitment to the supporting role of the health care workers in helping patients achieve and maintain positive behavioral and lifestyle change, and I certainly feel supported in my effort to do this effectively. However, while I do coach patients on the most basic things, such as the importance of screenings, smoking cessation, and good nutrition and exercise habits, I do not often proficient at my ability to take it beyond the basics to actually motivate behavioral change. While I do not deny the importance of healthcare professionals taking the time to coach patients on positive behavioral change, I doubt the current organization of the health care system as being supportive of this outcome. I have observed success in behavioral change for a few patients who work diligently and methodically with the wellness coaches, taking advantage of the availability of services and ongoing support. I have become fascinated with concept of behavioral change within the context of self-efficacy in chronic disease self-management, and have discovered that it is a complex, multi-factorial phenomenon. Evidence indicates that methods employed by most current systems of health care are geared more at treating acute illness, and less at the management of chronic conditions and the effectiveness of supporting patients in the types of behavioral, lifestyle changes that are associated with improved outcomes for so many different conditions.4 May (second submission) - I have had the opportunity to coach patients and caregivers for positive behavioral change related to a variety of topics ranging from hand washing and therapeutic nutritional choices to smoking cessation, prevention of STI, and moderate intake of sodium and alcohol. Influencing positive behavioral change is, perhaps one of the most difficult tasks with which health care providers are committed to. It is far easier to change the course of other things, such as altering a medication or treatment, and much harder to elicit behavioral change. However, health care professionals must be prepared to coach patients and be ready to take advantage of special circumstances in which patients and caregivers are open and ready for such coaching. I have had the luxury of working in close collaboration with a LCSW who is an expert at screening patients' behavioral health and also provides brief therapies and counseling services. I have learned a number of techniques from her, such as motivational interviewing and active listening techniques, and appreciate her skill in this. To be effective at coaching patients for behavioral change is truly an advanced skill. ______________________________________________________________________________26. Demonstrate information literacy skills in complex □ □ □ □ X□ □ decision making0 1 2 3 4 526 April (first submission) - Information literacy skills are demonstrated by my ability to organize, execute, and present a systematic health history and physical examination of a patient in the clinical setting, as well as my ability to translate clinical knowledge into patient teaching and interpret diagnostic test results, relaying the information to patients in a clear, easy-to-understand fashion. One example in which I did not feel literate, comes to mind that illustrates this (lack of) competency. In the interpretation of the information included in the results of a woman's mammogram and breast mass biopsy, I was unfamiliar with many of the things that the biopsy report was reporting on. If not for the interpretation and recommendations included within the report, I would have had no clue what to do with it. Luckily, through collaboration with the appropriate disciplines, we learned that she had a ductal carcinoma in-situ, and that treatment decisions would be determined by the oncology specialists. I am able to work with my preceptor to access hospital records electronically to look up old records that may help in interpreting results and aid in complex decision making. We have also utilized other information systems, such as KTRACs to gain information for use in complex decision making. 4May (second submission) - I have gained information literacy skills during my time in this clinical, and have gained skills in research and applying evidence to practice this semester, and throughout the graduate program. I do not claim to be an expert, but do claim to be literate, in that know how to look things up when I don't know. I continue to learn of and practice new ways of gaining information and have the literacy skills to sort through the information, extracting and organizing the pertinent information, and applying it to complex clinical situations. In a couple of instances, I made phone calls to colleagues with specialized training to gain knowledge and help me in complex decision making. One call was to a friend who worked in pediatrics with a question about a pediatric patient I had encountered. Another call was to a colleague who specialized in women's health, especially breast health, with a question about which diagnosis code to apply to a patient before sending her on for additional diagnostic testing. Reading, reading, and reading is the key to expanding on this competency and applying skills into the future. ______________________________________________________________________________27. Integrate ethical principles in decision making□ □ □ □ □ X□26 April (first submission) - At the root of all clinical decisions, are the principles of beneficence, honesty, compassion, and justice, and respect for patient confidentiality is maintained in all encounters. Presenting diagnostic strategies as options, is one way to integrate respect for patient autonomy in decision-making. In several instances, I have had to tell patients that we would not refill a controlled medication, such as a pain medication or muscle relaxer earlier than the agreed upon date. The clinic's stated policy stands, despite their reason for being out, and close adherence to it demonstrates justice, although the patient may not agree. Because of my upbringing, I will be able to consistently integrate ethical principles into decision-making, and rest easier with the inevitable uncertainties of practice, knowing that I have done so 4 May (second submission) - As always, I continued to exhibit competency in the integration of ethical principles into all aspects of practice, including decision making. Practicing in a community health center, and knowing the background and mission of community health centers, I was pleased to find that the standards of care were no different in this setting than any of the other settings in which I have worked. The ultimate goal is designing and providing the best possible, evidence-based, patient-centered care. Everyone deserves honesty and forthrightness, and I try to be very up front with patients when I know of alternate treatment of care options that might be in the patient's best interest. I counseled a man with apparent Hepatitis that he would be better off seeking care from HCA, since he qualified, had been there before, and would be in need of referral to an infectious disease doctor, a service we would not be able to provide as readily, if at all. I also counseled an 89-year-old man who came to our clinic wanting to transfer care from the primary care physician whom he had been with for 40-some years, because he was angry that she had told him to go to the Emergency Department the day before when he had fallen at home. While I provided some minor wound care, I explained to him some of the possible reasons that his PCP may have told him to go to the ED, and advised him to stick with her because he should really only have one PCP, and she was the one who knew him so well. In the end, he agreed, and agreed to follow up with her in a few days. _____________________________________________________________________________28. Demonstrate respect, compassion and integrity□ □ □ □ □ X□26 April (first submission) - I consistently demonstrate respect compassion and integrity in all clinical actions and interactions with patients and other staff members. One demonstration of compassion was in making an extra phone call to check on a patient after perceiving that she was upset by the outcome of her visit. She expressed gratitude for the call and I was able to feel better about the situation. This competency is crucial and I will continually strive to demonstrate respect, compassion and integrity in my future practice. 4 May (second submission) - I believe I was able to demonstrate respect, compassion, and integrity throughout the NU 607 clinical experience. This applied to my interactions with patients, their families, my preceptor and other clinic staff and volunteers. At times, I have come into contact with individuals that challenged my ability to demonstrate compassion or empathy, but never enough so that I was unable to fall back on my professional instincts, keep a level head and remember that my job is not to judge others, but to provide the best possible care and help others to the best of my ability. I will carry this forward into my future interactions and clinical practice experiences. State Board of Nursing RequirementKSBN Requirements for Nurse PractitionersMetNot Metor N/ACommentsDemonstrates advanced practice roleDisplays ability to decide to order and/or perform diagnostic proceduresAble to interpret diagnostic and assessment findingsSelects and provides prescription of medications and other treatment modalities for clients?Submission #1 after 60 hours of practicumStudent Signature___Anna Marshall_________________Date_9 March 2012_______Faculty Signature______________________________________Date____________________Submission #2 after 120 hours of practicumStudent Signature___Anna Marshall__________________Date__26 April 2012______Faculty Signature_____________________________________Date____________________Final SubmissionStudent Signature___Anna Marshall_________________Date__7 May 2012_______Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade:November, 2011Revised 1/23/12 ................
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