Sample Pre and Post Clinical Assignments – NURS3020 Papers

What is the patient’s diagnosis?- Total Rt Hip Replacement- Jan 15th Define the diagnosis– A total hip replacement is when the damaged bone and cartilage is removed and replaced with prosthetic components. The damaged femoral head is removed and replaced with  metal stem that is placed in the hollow center of the femur. A metal or ceramic ball is placed in the upper part of the stem (replacing the femoral head). The damaged cartilage of the socket is removed and replaced with a metal socket. A plastic, ceramic, or metal spacer is inserted between the new ball and socket to allow for smooth gliding. What may the patient display with this diagnosis? Pain (in area of right hip), potentially radiating. Altered gait (due to replaced hip). Fall risk (due to unstable gait). Pain associated with stitches or staples, loss of appetite (make sure they have plenty of iron and fluids). Potential adverse post-surgery effects: infection of incision, blood clots, leg-length inequality, dislocation of the new hip, nerve and vessel damage, or stiffness. How may it be treated? Pt is on IV fluids, dressing changes needed for Day 2 post surgery. Pain management and physiotherapy may also be needed.

What other co-morbidities does the patient have? Rhematoid arthritis, osteoarthritis, angina, parkinsons disease, IBS, dysphagia, GERD, chronic back pain Relate how their past medical history may be effecting their current diagnosis and admission to hospital or vice versa how does this current diagnosis/admission effect their past medical history?

The rheumatoid arthritis and osteoarthritis may have caused the patient to need a hip replacement in the first place, and is probably still affecting the other joints of their body- need to look at pain management for this and for the hip surgery to ensure we are not over-medicating the patient. A hallmark of Parkinson’s disease is unsteady or shuffling gait- this may be further compromised due to this surgery, putting the patient at a greater fall risk.

IBS may lead to the patient needing to use the washroom more frequently, again complicated by their compromised gait due to the surgery- need to monitor bathroom trips for fall risk. The dysphagia means that they will need to be monitored when they eat, and along with the GERD, may affect the diet of the patient. The patient may also be on antacids to treat their GERD, which reduce the absorption of acidic drugs, but increase the absorption of drugs such as levodopa (which is a common medication for Parkinson’s). Chronic back pain may lead to the patient being unwilling or not wanting to move (also will need to treat for pain). The angina may also lead to the patient not wanting to do too much physical activity, as angina pain can increase with activity.

Pain Scale (0-10) throughout the day- Since the patient is post-surgery, and also has other conditions (rheumatoid/osteoarthritis, chronic back pain), keeping this patient’s pain to the minimum is crucial for compliance for mobilization and recovery. 

Head-To-Toe Assessment: scan the patient throughout the shift- perform vitals every 4 hours. Note changes in mental status, skin condition, and vitals. Perform respiratory, cardiac, bowel, and skin assessment (look for pressure ulcer formation). Note ambulation status of the right leg and hip. Wound Assessment: note the size, appearance and condition (good condition, infected, poor healing), smell, amount of exudate, exudate type and consistency, pain at wound site, temperature of surrounding skin, and wound bed. Sample Pre and Post Clinical Assignments – NURS3020.

Cardiac Assessment: take heart rate, O2 saturation, and BP of patient- since patient has angina, perform cardiac assessment using Z pattern- note rate and rhythm of heart, and any pain noted from the patient. 12 hour fluid balance- monitor and measure intake and output of the patient during shift (PRN). GI/ Dietary Assessment- since the patient has dysphagia, they will probably be on a special diet. Also, their GERD may lead to them not wanting to eat, due to discomfort. I need to assess how much the patient is eating, to ensure adequate nutrition- I also need to monitor my patient at meal times, since they are a choking risk.

Education regarding fall risk- patient should understand their risk for falls, and the importance of using a walker for help to ambulate. The patient should also have two people lifting them and moving them to ensure safety. Sample Pre and Post Clinical Assignments – NURS3020.

Education regarding pain management- patient should be aware of the pain scale, and the 0-10 rating. The patient should be made aware of common side effects of pain medications (often drowsiness) which could lead to an increased risk of falls. Education regarding returning home- patient should be educated on the importance of being able to ambulate safely before returning home, and how to make the adjustment to home easier by getting certain things in place (family or homecare aid to help the patient throughout their day). Patient should be aware of acceptable and unacceptable ambulation and other activities for their return home- review “On the Path to Recovery” booklet.

Ambulation- getting the patient up and safely ambulating will help them recover faster, and will help them to build strength. It will also help prevent DVTs from forming- look at weight bearing status, exercises, and mobility precautions. Anticoagulant therapy and signs of DVT and PE- note the patient’s risk for developing a DVT and PE and explain warning signs of both DVT (heat, swelling in affected leg, pain in leg) and PE (unexplained sudden onset of shortness of breath, chest pain or discomfort, lightheadedness, rapid pulse, coughing up blood). Sample Pre and Post Clinical Assignments – NURS3020.

Think about medications or procedures that may have been done with patient that may affect these levels. Lab values provided were: sodium (133) and chloride (94). Normal levels for chloride are: 110-250mmol/d, and normal levels for sodium are: 134-145mmol/L. The patient’s sodium value was slightly below normal, however her chloride levels were well below normal.  Sodium and Chloride are often ordered as part of the basic “blood electrolyte” test, which is performed when monitoring treatment involving IV fluids, or when there is a possibility of developing dehydration. A blood sodium test specifically could have been ordered, since weakness, confusion, and lethargy are symptoms of hyponatremia that were being displayed by the patient. My patient’s values could have been below normal since she was having difficulties with her nutritional status (was not eating to maintain electrolyte levels). She was also dehydrated, which would cause low electrolyte levels. Low chloride is also caused by respiratory acidosis, which my patient could have had, since she was on oxygen since she was having difficulties keeping her O2 sats up.

Only need to discuss one intervention. Some interventions that I provided to my patient during clinical were basic am care, IV removal, and head-to-toe assessments. Although these things aren’t really “interventions” per say, my patient was pretty drowsy throughout the shift, so I was unable to provide other interventions such as patient education or wound care. I believe these small tasks were beneficial, to help to promote patient well-being, with good hygiene and barrier protection for pressure ulcer prevention. I also think that the IV removal was beneficial since the IV was deemed interstitial. Finally, the head-to-toe assessments were beneficial to assess the patient’s breathing and to find out that she was having crackles, which is a warning sign of pneumonia. In my future practice, I will respond to more call bells, since I found myself often allowing other students to do that, and I would like to be able to do more my next clinical shifts.

Link one nursing theory to your practice or experience this week in clinical. Newman’s Systems Model

This model consists of energy resources (normal temperature range, genetic structure, response pattern, organ strength or weakness, ego structure, and knowns or commonalities) that are surrounded by several lines of resistance, the normal line of defense, and the flexible line of defense. This week in clinical I worked with my patient on her tertiary line of defense, which was helping her readapt and stabilize to return to wellness following treatment. I did this by pushing fluids to promote hydration and try to prevent dehydration, by performing am care to promote hygiene and prevent pressure ulcers, and by performing care such as encouraging ambulation and voiding, to help her return to a state of well-being.

I thoroughly enjoyed just being in a hospital setting, being able to work on some of my skills. This is my first placement in the hospital setting (other than mental health at Lakeridge), and I am so excited to really sink my teeth into this and get going and practising my skills. I am a quick learner, but am not confident in myself, so I need to work on improving those things, and having confidence in my ability as a student nurse.

______________________________________________________________________________________________________________________________________________Nursing 3020 Reflection Identification

One clinical experience that stands out as significant for me, albeit kind of unprofessional, was on week 2 of clinical when another student and myself responded to a call bell for someone needing to use the washroom. The room was full isolation, as it was believed that the patient was at risk for C. difficile, so we gowned up and went in. The patient needed to use the washroom, so we walked with him over to the washroom, and got him situated on the commode. When we were told he was finished, we walked back to the washroom, to find that we had left the seat lid down on the toilet (under the commode), and that there was loose fecal matter everywhere. Initially, we were shocked, so we just looked at each other, and went to work finding some barrier cream wipes, and toilet paper.

The patient had no idea that this had happened, and we got him up and facing forward on his walker while we provided peri-care and applied a new brief. The other student walked him back to bed (where his wife was waiting), while I used the bleach wipes to clean up the mess (the other student came back in and helped). We held ourselves together emotionally, and I think we handled the situation quite well overall, by acting professional and not giggling or acting disgusted by the mess. We tried to maintain the dignity of the patient, since he was fully alert, and we knew he would’ve been embarrassed with the mess. This situation could also be viewed from the patient’s perspective, and from a health-and-safety perspective.

From the patient’s perspective, I hope that they viewed the other student and myself as competent nursing students, in the care we performed. Also, if they had have noticed the mess, I hope they would have viewed our actions as professional, in the manner that we dealt with it. From a health-and-safety perspective, I’m sure that this wasn’t an ideal situation- however I think we dealt with it well, all things considered. We used bleach wipes to disinfect the areas where the mess occurred, then called housekeeping once we were out of the room, to come and use their disinfectant products on the bathroom. Sample Pre and Post Clinical Assignments – NURS3020.

I had many different thoughts and feelings regarding this situation. Initially, I thought, “oh my God, what have we done?”, followed by thinking how unprofessional it would be to laugh at the situation, followed by, “how can we fix this, without the patient noticing- to maintain dignity?”. I felt incompetent as a student nurse, and felt as though I let my patient down, in the sense that they were left in a situation that could have been uncomfortable if they had noticed the mess. Ethically, I knew that we needed to preserve the dignity of the patient, so we made the choice to handle the situation as we did, to preserve it. My personal beliefs of treating people how I would want to be treated impacted this action, because I know if I was the patient, I would not want to feel humiliated for a mistake that the staff had made, especially since it involved a very personal matter. Literature that could have supported my response to this situation would have been literature supporting ethical action, such as the RNAO Code of Ethics for Nurses (2008), to ensure that I was supporting the client, performing client-centered care, and maintaining the dignity of the client. Keeping these values in mind, I performed the care that I could, to the best of my abilities, to handle the situation at hand.

Prior to this event, we learned all about maintaining patient dignity, and client-centered care in NURS 1000, in our first year. We learned about the phenomenological lens (putting yourself in the client’s shoes, or the lived experience of the client), in NURS 2001, and learned the nursing skills related to basic care, also in NURS 1000. Using these things that I had previously learned, I believe that my nursing partner and I were able to handle the situation with grace, and professionalism. We put ourselves in the patient’s shoes, and maintained his dignity, while performing the basic care that we needed to perform, to ensure that the patient was cared for, and that the environment was left clean and sanitary. I could have applied evidence from nursing literature regarding hygiene precautions to this situation (i.e. what to do in this situation to ensure that the environment after is up to health and safety regulations for cleanliness). I also could have looked at theorists like Nightingale, to tie in her views on cleanliness of the environment (such as allowing for fresh air and natural light into the room).

This experience made a difference in my practice by reminding me that I am indeed still new to this profession, and by providing some humility. I am usually a humble person, and this was just another reason to remember why I am still a student, and a reminder that I still have far to go in my learning experiences. This made a difference in my practice by allowing me to use a phenomenological lens, to handle the situation, something that I really should be doing more. It allowed for introspection to be done, examining how I would’ve felt as the client. Sample Pre and Post Clinical Assignments – NURS3020.

From this experience, I believe I have grown as  person, because I know that I will never make that mistake again (I hope). I also know now that I can handle situations professionally, and with dignity preserved for the patient.  In similar situations, I don’t think I would react any differently, as I believe my nursing partner and I did a good job at handling the situation professionally, and respectfully. Overall, I think this was a great learning experience, and something I will not forget as I move forward in my journey to becoming a RN.

______________________________________________________________________________________________________________________________________________Clinical Evaluation Process Nursing 3020 Midterm (Check one) Midterm _____X_____ Final ____________ Student Name: __Emma Cumming__ Clinical Instructor: _Ashley Finnegan_ Missed Clinical Hours: ___0___        Missed Lab Hours: ___0___

Graduates are generalists entering a self-regulating profession in situations of health and illness. Graduates are prepared to work with people of all ages and genders (individuals, families, groups, communities and populations) in a variety of settings. Graduates continuously use critical and scientific inquiry and other ways of knowing to develop and apply nursing knowledge in their practice. Graduates will demonstrate leadership in professional nursing practice in diverse health care contexts. Graduates will contribute to a culture of safety by demonstrating safety in their own practice, and by identifying, and mitigating risk for patients and other health care providers. Graduates will establish and maintain therapeutic, caring and culturally safe relationships with clients and health care team members based upon relational boundaries and respect. Graduates will be able to enact advocacy in their work based on the philosophy of social justice. Graduates will effectively utilize communications and informational technologies to improve client outcomes. Graduates will be prepared to provide nursing care that includes comprehensive, collaborative assessment, evidence-informed interventions and outcome measures. Sample Pre and Post Clinical Assignments – NURS3020.

1. Explain the experience of acute illness in individuals receiving care in acute setting One of the most important things I found through the clinical experience thus far, is how different the hospital experience is for many patients compared to living and dealing with illness at home. The experience of acute illness is almost compounded by the fact that the individual is missing out on so many normal daily routines of their lives, that adjusting to acute illness is just another added stress to that. Many of my patients simply want to return home to comfortable surroundings, where they can be with loved ones, and have the comforts of home easily accessible, such as their own bed, showers, soaps and hygiene products, and to simply just be in familiar surroundings.

The patient needs to adjust to the new hospital environment (smells, sounds, sights), while also adjusting to their post-surgery pain, mobility, and lifestyle. This can be overwhelming for some patients, especially those who have less-developed coping mechanisms, or who are confused since they have dementia-related cognitive impairment. If a patient is unable to adjust successfully to their environment, or has a failure to thrive, they will be at risk of developing more infections and serious complications associated post-surgery, running the risk of them never being able to return home. Ultimately, as a nursing student, I provide care to patients to enhance comfort, to allow them to focus more on their recovery process. I also try to relieve the stress and anxiety around being in a new environment, by explaining procedures, or sounds, and ensuring my patients that they will be ok, and that they are in good hands with the staff at the hospital. Sample Pre and Post Clinical Assignments – NURS3020.

2. Interpret critical aspects of the person’s experience of acute illness in relation to common signs and symptoms, responses to treatment, patterns of coping, and impact on individual and family relationships There are many aspects of the experience of acute illness in different patients. However, common signs and symptoms associated with acute illness include: pain, swelling, inflammation, immobility due to injury, confusion and disorientation due to medication, irregular vital signs, edema, fever, and the onset of secondary conditions (such as hospital-born issues like C. difficile and pneumonia). Lab tests, vital sign checks, and head-to-toe assessments are common aspects of care for these patients, along with basic care, such as feeding, helping to ambulate, and am/hs care. I have found that patients generally respond well to treatment, if given an explanation as to why the treatment is being done, and why it will help them get better (why it is important).

For example, many patients are in pain and do not want to ambulate, but if you explain to them that turning and ambulation will help prevent DVT, and will help them to use their newly constructed limb sooner to gain function, they usually respond well to the treatment intervention. Patients usually cope by using medications to relieve pain, both pharmacological (narcotics), or other mechanisms (heating blankets, ice). Patients seem to cope well when their family is supportive, and when they have supportive, caring nurses looking after them. The acute experience has an impact on the individual themselves, through the pain/discomfort/loss of independence they experience, and their family relationship, as they may depend on family more than ever to help with their basic needs (mobility, hygiene, daily tasks).

3. Identify common medical treatments and potential consequences/complications of selected acute illnesses Lab tests are usually conducted to assess the patient, and how their body is responding to the acute trauma, such as testing for CPK and Troponin levels, to see if they have damaged cardiac or other cellular tissue. Other lab tests include electrolyte levels, to see how the body is responding to the fluid (if the person needs more fluids via IV or oral consumption), and tests such as blood tests (to see if their white blood cell level is elevated, indicating infection; or to see if they have thrombocytopenia or other blood clotting issues before giving blood thinning medications). Common medical treatments given to patients post-surgery include: PCAs, IV fluids, hemovac drainage, catheter insertion/ removal, oral medications for pain once the PCA is discontinued, wound care, and physiotherapy.

All of these treatments and interventions help the patient to recover as quickly and comfortably as possible. Some complications or consequences associated with post-surgery patients include: infection, pneumonia (associated with fluid accumulation in the lungs, because of immobility), DVT, PE, loss of range of motion of newly operated on limb, hospital acquired infections and diseases such as C. difficile, and a failure to thrive. These all might cause the patient to have a longer hospital visit, associated with increased complications, or might cause the patient to have to go somewhere other than home (long term care, retirement care), after their hospital stay, because they would be unable to care or have the care needed at home. Sample Pre and Post Clinical Assignments – NURS3020. 4. Demonstrate selected nursing and collaborative interventions related to clinical pathways, peri-operative care, IV medication administration, cardiac assessment and rhythm strips, neurological  assessment, wound care, blood component therapy, TPN and central lines, pulmonary care including chest tubes and tracheotomy, initiating IVs, rapidly changing conditions, and resuscitation Throughout the clinical placement thus far, I have helped numerous patients through their “Pathway to Recovery” booklets, outlining how to recover from hip and knee surgeries. I have worked with patients, educating them on the importance of doing weight bearing as tolerated movements through a big range of motion, having adequate nutrition, being aware of signs and symptoms of DVT/PE, and the risk of falls associated with medications and instability.

Throughout this placement I have also had the opportunity to perform peri-operative care, spike and hang IV bags, flush IVs that were deemed interstitial, and remove IVs. I was able to give PRN medications, and give a subcutaneous injection. I have also performed numerous head-to-toe detailed assessments (on average 3-4 per shift), and have learned about the components of blood by evaluating lab values, such as CPK and Troponin. I have performed wound care on different types of wounds (hip, knee, tibia), and was fortunate to witness a wound packing (something I would like to do). I have not seen any resuscitations thus far, nor have I practised more complex skills such as performing pulmonary care (since I haven’t been exposed to it on the floor yet). Sample Pre and Post Clinical Assignments – NURS3020. 5. Under the supervision of a Registered Nurse, demonstrate safe, competent, evidence-based, holistic nursing practice with clients with acute illness

1. Apply relevant nursing models, philosophical frameworks, theories and evidence
2. Demonstrate therapeutic use of self
3. Engage with patients in an ethical and culturally safe manner
4. Understand and anticipate emerging bio-psycho-social needs of persons with acute illness and apply this knowledge to care:
   1. Plan appropriate nursing care
   2. Predict outcomes of nursing care
   3. Evaluate client response to nursing care
5. Demonstrate health promotion and illness prevention practices
   1. Engage with patients and families to identify health-related situational challenges
   2.  Work with patients and families to create reasonable and effective solutions
6. Demonstrate patient advocacy
7. Demonstrate accountability
8. Demonstrate reliability

I believe that I have demonstrated safe and competent, evidence-based, holistic nursing practice with clients with acute illness throughout this clinical placement thus far. I believe I have provided safe and competent care by performing care for my patients, without injury or hard (emotional or physical) to my patients during this placement. I believe that I have engaged with my clients in an ethically and culturally safe manner by using respectful language and avoiding medical jargon when conversing with them, and by respectfully asking to perform care that might be ethically or culturally sensitive (such as peri-care).

I believe that I have demonstrated holistic care, demonstrating health promotion and illness practices by following Nightingale’s philosophy of having a clean environment for the patient, with things like natural light (open blinds), fresh bedding, clean bodies (am/pm care), and by providing hope for patients. I have also biomedically performed wound care, and other interventions previously mentioned, to promote illness prevention. I have engaged with the patients and their families to identity challenges and create solutions through working through the “Pathway to Recovery” booklets, outlining barriers and facilitators to success along the way. I believe that I have demonstrated patient advocacy by asking nurses requests of my patients that I could not follow through on (such as administering pain medication), and advocating for help to perform care on my patients, such as lifting and repositioning patients. I believe that I demonstrate accountability by performing my charting accurately, and doing the proper corrections when necessary.

I also admit to being unable to do tasks out of my current scope of practice as a student, and admit to mistakes I make (such as forgetting to put the toilet seat up, causing a mess). I demonstrate reliability by always being on time and ready for clinical shifts, and by completing my pre and post clinical assignments on time. Overall, I believe that I follow the theory outlined by Orem, which basically states that all patients wish to care for themselves, and that they can recover more quickly and holistically if they are allowed to perform their own self-cares to the best of their ability. Through the use of this theory, I encourage my patients to try to be as independent as possible throughout their care (such as performing self-bathing and self-feeding, and getting up and ambulating with nurses and physiotherapists), for them to become advocates for themselves in their care.

I believe I have developed therapeutic relationships with my patients through having this theory guide my practice, where I advocate for the patient to advocate for them self, which ultimately forms a stronger bond between the patient and myself, working as equals towards them getting better. 6. Critically appraise own practice in relation to nurse-client/family interactions and as a member of the health care team Throughout this clinical experience thus far, I have learned many things from actively listening to my patient, their family members, and the staff around me. From my patients, I have been able to practice skills, and sometimes ask when I do a new skill, if it caused pain (such as giving an injection), and if the patient felt comfortable (like when I would lift and transfer them). I have also been fortunate to be able to educate my patients, as previously mentioned, throughout this clinical experience, and have educated them and their family members regarding topics such as fall risks, DVTs, and mobilization post-surgery. I have learned how to communicate effectively and respectfully with family members who are upset about the condition of their loved one (such as their loved one being “doped up” on pain medications).

I need to work on remembering family members of the patient, as I know that it would make them feel more comfortable if I remembered their name, or relation to the patient, day-to-day. I have learned so many things from the nursing staff on the floor, and have been able to help out with procedures such as IV administration of medications, wound care, and medication administration. I would like to develop more confidence to ask nursing staff to do more of their tasks for them, or to allow me to tag along while they do things. Hopefully this will come throughout the second half of this semester, as I don’t want to bug them. Sample Pre and Post Clinical Assignments – NURS3020. 7.

Participate in professional development based on reflective practice and critical inquiry Throughout the clinical placement thus far, I have provided pre and post clinical work to the best of my abilities, and have reflected on an experience that I had with a patient, for the reflection that was due. I contribute to post-clinical conversations with the group, discussing how the shift went, and what I would like to learn.

I try to support and provide honest, open communication and feedback with both my peers and my clinical instructor. I have performed critical inquiry through answering the post-clinical and pre-clinical questions regarding patient diagnoses, and lab values. I have participated in professional development by providing reflections, and doing research using the textbooks provided during “down time” on the shift. I have also researched different procedures and terms that I am not familiar with after clinical, and add to the professional development of my peers by advocating for them during clinical, and by providing advice and sharing knowledge that I have when asked.