NURS 3021H Clinical Course Evaluation

NURS 3021H Clinical Course Evaluation

Evaluation

Student: Lara Robertson 0536019

Clinical Instructor: John Corso

Missed Clinical Hours: 0 Missed Lab Hours: 0

NURS 3020H Clinical Course Mid-Term Evaluation

Progress
Course Objective / Evidence/Indicators / Satisfactory / Unsatisfactory

Explain the experience of chronic illness in individuals in chronic care settings

Week 1: Cared for an elderly man with end stage CHF, and a hx of CAD, HTN, COPD, and emphysema. He suffered from severe edema and was frustrated by his loss of independence and ability to care for himself. I helped him with ADLs, personal care, his pressure stockings, and talked to him about his life and how he was coping with the changes he was going through. I also monitored his inputs and outputs as part of his CHF care protocol. Other skills performed included placing a subQ lock and medication administration.
Week 2: Care for a late-middle aged woman with glioblastoma multiforme. The patient had decreased LOC the majority of the time. Maintaining skin integrity through peri-care and repositioning, ensuring a sufficient diet when possible, and promoting rest were important parts of her care which I performed. I also talked to her husband about their situation and how he was coping, and their goals. Other skills practiced on the unit include subQ lock placement and medication administration, post mortem care, repositioning, showering and bathing (bed and tub) patients, advocated for medications for pain and anxiety control for patients, and ADL support.

Lara – has used her time on D2 to her advantage. She has adapted to the different role of nursing advocate on a palliative care unit. She has ensured she is aware of her patient’s diagnosis and how this affects her care for them. She has shown this knowledge in her pre and post clinicals and during her care of her patients.

Week 3: Care for elderly male with squamous cell carcinoma, admission of woman with metastatic lung cancer and a collapsed lung, and an elderly man with pancreatic cancer. My first patient on this shift passed within an hour of shift change, and so care before that involved supporting the family, ensuring the patient was not in pain and was repositioned regularly. After he passed, care involved supporting the family and beginning post mortem arrangements. I performed the admission for two new patients. Care for the women involved comfort, monitoring pain and dyspea, as well as Jackson pratt drain output, support to her and her family with her new diagnosis, pain control and placement of a subQ lock, and discussing plans and goals with the family and patient. Care for the second admission after admission was also comfort, family support, goal setting and education, pain control, and emesis care and control.
Week 4:Care of elderly male with renal cell cancer. Care for this patient included monitoring inputs and outputs, helping the patient manage his cochlear implant, support for the patient and family, education around treatments, subQ injections, fleet enema administration, help with ADLs, requesting and organizing a pain pump and education for the patient and his wife around the use and purpose of that. Monitoring for pain, mobility, fluid balance, personal care, and discussing goals and plans with the patient were also part of his care.
Week 5: Care of male with end stage renal failure and an elderly male with hx of CVA, CHF, renal failure, and falls. Care for the first patient occurred until he passed, and so it focused on pain control, comfort, oral care, good pericare, suctioning to remove excess fluid in his mouth, and supporting the family. Care for the elderly patient with hx of CVA, CHF, renal failure, and falls included frequent repositioning, especially off of weak side, administration of microlax enema, encouraging safe ambulation, monitoring pain and wounds, discussing goals, monitoring for dyspnea and shortness of breath, personal care, and help with ADLs.

Final – Lara has continued to excel at working with palliative care patients. She works diligently at ensuring her patients receive the best care possible. She makes sure that she has as much background on the illnesses that her patients have and comorbidities that may affect them

Interpret critical aspects of the person’s experience of chronic illness in relation to common signs and symptoms, responses to treatment, patterns of coping, and impact on individual and family relationships.

Each night before clinical I made sure I understood my patients Dx, Hx, Tx, and Rx. This can be seen in my pre-clinical assignments.
My understanding of the pathophysiology of my patients’ conditions allowed me to focus on the important assessments and interventions for each. This included monitoring inputs and outputs, edema, pain, dyspnea, coping, and skin integrity on my patient with CHF, and LOC, mentation, pain, comfort, goals, skin integrity, seizure activity, hallucinations, and family coping in my patient with glioblastoma.

Lara is a well rounded nurse – she is caring and knowledgeable about how to care for her patients and adapted to the very different role on D2. She was concerned about her ability to care for her patients and has worked hard to prove herself wrong! She has done it during the first half of the term.

I have continued to make sure that I am prepared for my patients in my pre-clinical assignments.
As in the first half of the term I used my pathophysiology knowledge to focus my monitoring and assessments to those most pertinent, such as monitoring for pain in all my patients, monitoring for dyspnea and shortness of breath in my patients with CHF and lung cancer, monitoring inputs and outputs in patients with renal problems, encouraging safe ambulation and compensating appropriately for weakness or mobility problems, and monitoring skin integrity for at risk patients.

Final – Lara has continued to demonstrate her ability to be prepared in as many ways as she can. She helps her patients by being an active listener and helps the unit operate well by being thorough with her patient and the other patients on the floor.

Identify common medical treatments of selected chronic illnesses

Week 1: Common medical treatments for CHF/HTN/CAD/COPD include symptoms control through medications, such as bronchodilators, oxygen, steroids, diuretics, anti-hypertensives, and pain medication, such as opioids or NSAIDs. Diet may also be important, but as the patient is end stage that becomes less of a medical imperative and more of a discussion.
Week 2: Common medical treatments of glioblastoma multiforme include surgery to remove the tumour if possible, radiation, and chemotherapy. Other treatments surround symptoms control.
Week 3: Common medical treatments for squamous cell carcinoma, metastatic lung cancer and pancreatic cancer are chemotherapy and radiation. Pain control and symptom management through use of anti-emetics, oxygen therapy, chest drains for collapsed lungs (due to lung cancer), and effective wound care for tumour removal sites and grafts for squamous cell carcinoma are all important treatment and management strategies as well.
Week 4:Common medical treatments for renal cell cancer are also chemotherapy, radiation, and potentially surgical removal of the tumour. Pain management and symptoms control through medications similar to those in Week 3 are also important. Treatment of constipation is often done with laxatives and/or bowel preps such as enemas.
Week 5:Common medical treatments for end stage renal failure include renal replacement therapy, and diet and fluid intake control (low sodium, volume restriction, etc). CVA can be treated with fibrinolytic therapy immediately after it occurs if it is ischemic, otherwise treatment involves PT and OT rehabilitation and supportive care. CHF treatment involves symptoms control, described in Week 1. Falls aren’t treated per se. They can be prevented through safe ambulation strategies and the effects of falls can be treated through good wound care and supportive care, or even setting bones depending on the extent of the injury.

Final – As said above Lara is very thorough in preparing herself for clinical and understanding all the pressures a patient may be under from staff, doctors, families and their illness. She helps in any way that she can whether it is to toilet another nurse’s patient or walking another. She is a valued member of the team, staff have given positive comments on the fact that she is always busy helping and knows what she is doing with their patients. In fact, today a nurse said she had a patient prepared as good as she could.

Demonstrate selected nursing and collaborative interventions related to caring for the person with chronic illness, such as medication administration, physical and chemical restraints, enteral feedings, residual volumes, NG tube insertion, wound care, colorectal screening, patient-controlled administration pumps, neurological assessment

Week 1: Nursing interventions for my patient with end stage CHF included administration of medications to control symptoms (see 3.), monitoring the patient’s subQ locks, catheter, and nasal prongs. Also monitoring symptoms of dyspnea and signs of sufficient oxygenation (proper skin colour, unlaboured breathing, no decreased LOC or altered mentation), encouraging ambulation when possible and rest when not possible, monitoring skin integrity in perineum and legs, monitoring edema, recording inputs and outputs and advocating for appropriate medication administration.
Week 2: Nursing interventions for my patient with glioblastoma included monitoring LOC, seizure activity, and altered mentation, advocating for appropriate medication administration for symptom control and comfort. This patient was not being treated with chemotherapy, surgery, or radiation, but was on medications to control symptoms such as seizures and edema. Other interventions related to comfort care, including ensuring adequate nutrition as much as the patient desired, repositioning to prevent skin breakdown, pain control if necessary, and assisting with ADLs.
Week 3: Nursing interventions associated with squamous cell carcinoma, lung cancer, or pancreatic cancer during the time immediately preceding death include comfort care, pain control, symptoms control (see 3.), personal care, repositioning frequently, monitoring skin integrity, monitoring output from the Jackson pratt chest drain for the patient with lung cancer, and providing support for family and patient.
Week 4:Nursing interventions for renal cancer include monitoring fluids, symptom control including pain pumps (see 3.), monitoring inputs and outputs, support and education for family.
Week 5: Nursing interventions for these patients included repositioning frequently, monitoring skin integrity, suctioning to prevent aspiration, use of aids to help ambulate safely, such as a Sara-lift, and symptom management through medication (see 3.).

Final – Lara has given good examples of her interventions that she has offered to her patients.

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.

Week 1:My patient that week was on the palliative unit for symptoms management, and so was not undergoing frequent treatments or assessments. The main goal was pain and edema control, and maintaining skin integrity and dignity of the patient. To this end, careful skin care was important. This involved monitoring skin integrity, repositioning as much as possible, applying antifungal creams to yeast infections, and barrier creams to perineum to prevent breakdown. Edema control was being done medically through catheterization and diuretic administration.
Week 2: This patient was also on comfort care until she could attempt to return home, and so rest, assistance with ADLs, and maintaining skin integrity while on bed rest were the major interventions performed. Discharge planning and home support were also important collaborative interventions.
Week 3: All three of these patients were on the palliative unit for symptom management and comfort care.
Week 4:This patient’s goal was to determine if he was a surgical candidate (which he was not) and get his pain levels under control so he could return home, and so getting a pain pump for him, and teaching him and his wife how to use it, were priorities. Symptom control, personal care, and monitoring made up the majority of the remaining interventions for this patient.
Week 5:The patient with end stage renal failure was on the palliative unit for comfort care, and so no diagnostic or treatment procedures were being done. Symptom management and support for the family were the goals. The CHF/CVA/Renal failure patient had a wound on his head and was being monitored for fluid on his lungs, so dressing changes and chestx-rays were part of his care. Encouraging and helping the patient use safe methods of ambulation were also important.

Final – Lara has worked hard to ensure she is willing to do any task to gain experience. She asks nurses if she can help, she volunteers for any task, even if simple or menial. She gains the trust of the nurses by doing all tasks well and in a timely manner. Thus the nurses look for her with new opportunities and learning chances, which Lara does willingly. She does however think of her peers and offers anything that she has already done to them, but if no one is able she goes ahead and does the experience.

Identify potential consequences/complications of chronic illness

Week 1:Potential complications of CHF/HTN/CAD/COPD are impaired oxygenation and hypoxia, severe and painful edema, skin breakdown, insufficient circulation leading to limb hypoxia and damage, and cardiac complications/events such as MI.
Week 2:Potential complications of glioblastoma are decreased/altered LOC, altered mentation, loss of function of the part of the brain that is being compressed or damaged by the tumour. This can result in stroke like symptoms, such as unilateral paralysis or weakness, speech deficits, swallowing problems, incontinence, and altered personality.
Week 3: Potential complications of squamous cell carcinoma include skin damage, and bone damage from the cancer, and pain. This patient had had portions of the bones in his face removed or damaged, his eye was damaged, and one of his ears was gone. Potential complications of lung cancer include metastasis, pneumothorax, dyspnea, infection, hypoxia, and pain. Potential complications of pancreatic cancer include pain, nausea, vomiting, post-hepatic jaundice from blockage of the bile duct, obstruction or malfunction of the GI tract, and metastasis.
Week 4:Potential complications of renal cancer are metastasis, mobility problems and pain if the cancer spreads locally to the spine, renal failure, electrolyte imbalances, problems with regulating blood pressure, adrenal secretions, blood volume, calcium balance, and problems synthesizing vitamin D.
Week 5:Potential complications of a CVA include unilateral weakness, problems talking, reading, swallowing, incontinence, and personality changes. Potential complications of CHF include pulmonary edema, insufficient circulation to extremities, hypoxia, shortness of breath/dyspnea, and heart failure. Potential complications of renal failure are similar to those for Week 4 minus the metastasis.

Final –Lara has shown that she understands the complications that may occur with her patients and ensures that she builds on each week to make her job on the floor easier. In this way she cares for many patients that are on the floor as long as she knows what the diagnosis is.

Under the supervision of a Registered Nurse, demonstrate safe, competent, evidence-based, holistic nursing practice with clients with chronic illness
Apply nursing models and theories
Demonstrate therapeutic use of self
Engage with patients in an ethical and culturally sensitive manner
Demonstrate health promotion and illness prevention practices
Demonstrate patient advocacy
Predict outcomes of nursing care
Evaluate client response to nursing care
Demonstrate accountability and reliability

/ a. I worked to keep in mind and use nursing models and theories when problem solving and analyzing situations on the unit.
b. I attempted to engage with all of the patients I interacted with, and discuss their worries, fears, and current emotional state in order to help them find resolution and peace in their condition.
c. I attempted to maintain the confidentiality of my patients, and to approach them with an open mind with respect to their personal preferences and habits.
d. I worked to promote the health of my patients through assisting with feeding when necessary, helping with bed and tub baths and showers, performing peri-care and repositioning patients, monitoring and implementing preventative measures for skin breakdown, and encouraging ambulation when possible.
e. I advocated for patients several times, usually regarding medication administration, be it for anti-anxiety medications for my patient’s roommate in week 2, or laxatives, or pain medication for my any of my patients.
f. I watched for signs that treatments were or were not working, by assessing things like anxiety after benzodiazepine administration, monitoring inputs and outputs of a patient on diuretics, and monitoring oxygenation of a patient on oxygen therapy.
g. I tried to keep an open line of communication between myself and my patients, and frequently asked how they were responding. i.e has your pain decreased, are you more comfortable in that position, do you feel like you can breathe better with that level of oxygen? I also monitored for responses to treatments, such as outlined in f.
h. I worked to be honest, reliable, and accountable to my patients, my preceptor, my peers, and the staff I worked with. I did this through charting to the best of my ability, and reporting actions and problems to whom the information concerned. I always wore my ID badge, identified myself and my status to patients, and tried to be professional in action and appearance on the unit.
Lara – you have worked hard to show your abilities both in nursing skills of hands on care – inserting a subq line and in the excitement you have for learning how to adapt to a new environment and style of nursing, Staff have noticed that you are always eager to help and do any task, you even helped with end of life care and post mortem care. Keep up the good work.

Critically appraise own practice in relation to nurse-client/family interactions and as a member of the health care team

I struggled with what to say to patients several times over my two weeks on the unit so far. One instance of this was when talking with my patient in Week 1 (CHF patient). He was frustrated, embarrassed, and distressed over his loss of independence and by the knowledge that he was never going to get better. He asked what keeps you going in a situation like that, and what you do. I tried to be supportive and help him take satisfaction in his previous achievements and the knowledge that there were still things he could do. He seemed a bit more satisfied at the end of the conversation, but this kind of interaction is one that I still need to work on.
In Week 2, I was faced with my patient’s husband being a bit unrealistic about his wife’s condition and what taking her home would be like. I tried to be honest but positive in describing her condition and the support that she would need in the home so that he would have a clearer picture of what might happen when she was discharged.
As a member of the health care team, I worked to maintain open and effective communication to my team members about my patients, be helpful, and take criticism well. I received good feedback from several members of the staff and patients/family about my work.

I continued to work at improving my communication and knowledge base in this setting, and at being more comfortable with being with the families. I feel that I improved at this as the weeks went on, and was thanked by several of the family members of my patient’s for my help and support. I also worked to continue being a team player and improve on my performance. I think that I was successful in being a productive, pleasant, and useful member of the team.

Final – Lara has worked hard to be an active listener for all her patients. She has sought out all manner of care for the end of life patient, from the dying patient to the dead one, she has cared compassionately and professionally for all aspects of their care. This speaks to her knowledge and diligent hard work with her patients best interests in mind.

Participate in professional development based on reflective practice and critical inquiry

I have attended all labs and clinical sessions in professional attire and have been on time.
I have completed all of my assignments.
I have worked to be pleasant, accountable and helpful to my peers, preceptor, patients, and the staff that I work with.

Clinical Instructor Comments (All areas marked as unsatisfactory must have a comment)