msu college of nursing documentation of cns clinical ... · preceptor align with the patient’s...

1 Clinical competency and hours 807 2017

MSU College of Nursing NUR807: Clinical Decision Making Summer 2017

Documentation of CNS Clinical Competencies, Activities, and Hours

Student Name: Kelly Ashcraft

Date (range for submission) Start: 5/22/2017 End: 7/30/2017

Preceptor: Melanie Miller MSN, RN ACNS-BC

Agency: Harper University Hospital

Clinical Faculty: Linda Hansen MSN, RN, ACNS-BC-AG

Clinical Faculty Email: [email protected]

Total Cumulative Internship hours (at time of submission): 100.5 (to be entered by

student)

This Section for Preceptor Use Only

Preceptor Validation of student competency documentation, activities and clinical hours as noted

on this document. Your typed/electronic signature indicates you have reviewed and agree with

the student’s documentation of competency achievement and clinical hours as written.

Preceptors, once validated, please email directly to the clinical faculty named above.

This Section for Student Documentation

Students are to document how each competency listed below was achieved, label with the

corresponding sphere of influence (patient/patient care, nurse/nursing personnel,

organization/systems) and the date of entry. Statements are to be brief, outcome statements,

providing evidence of completion and associated dates. When the evidence of competency

achievement is the completion of a course assignment (example: history and physical) it is

appropriate to document that as part of the outcome statement.

Course Objectives:

At the end of this course, students will: 1) Apply decision theory to formulate differential diagnoses.

2) Formulate differential diagnosis based on evidence for nursing and medical diagnoses of common problems.

3) Develop mutually agreed upon diagnostic strategies for working diagnosis based on evidence, knowledge of the individual’s age, gender and cultural values.

4) Analyze the implications of diagnostic decisions relative to cost and efficacy within the health care system.

5) Compose a researchable clinical question and synthesize the literature related to this topic in the Problem/Intervention/Comparison/Outcome/Time (PICOT) format.


Provide 2-3 personal objectives for achieving course objectives:

Personal Objective with Planned Learning Activities / Required Resources:

Integrate advanced nursing knowledge and

clinical assessment skills to create a plan of

care and differential diagnoses for a complex

patient population.

Planned Learning Activities and Required

Resources

• Collaborate with preceptor while

completing patient assessments

• Participate in multidisciplinary rounding

of patients

• Review patient outcomes from previous

weeks to determine if my plan of care or

differential diagnosis was accurate for

successful patient outcomes

• Utilize course information to improve

skills

• Complete Shadow Health assignments

Evidence of Achievement (including date): 5/15/17: Successfully completed shadow

health assignments.

6/26/17: Patient Sphere

I have consistently displayed improvement

in my assessment skills of complex patients.

The differential diagnoses presented to my

preceptor align with the patient’s plan of

care.

7/6/17: Patient Sphere

Conducted an assessment of a returning

patient from previous clinical weeks, who

was transitioning to palliative care.

Advocated for patient and family needs

during multidisciplinary rounding with case

management, social work, nursing, and

medical staff.

Personal Objective with Planned Learning Activities / Required Resources:

Summarize the use of diagnostic testing and

plans of care and the financial implications to

the intercity patient population.

Planned Learning Activities and Required

Resources

• Discuss with preceptor the considerations

included while devising a plan of care

• Collaborate with social work regarding

the Medicare Medicaid patient population

• Utilize journal searches to review

evidence based processes while

developing a plan of care

• Identify cost effective strategies for a

patient hospitalization

• Familiarize self with the cost of studies

ordered for my patients

Evidence of Achievement (including date): 7/6/17 – Patient & Systems Sphere

I have become more active and engaged in

progressive discharge planning with nursing

staff, physicians, and case managers on the

unit. I collaborated with the case manager to

learn more about the Medicare discharge

appeal process and the implications on the

patient and hospital. Patients who appeal the

discharge are not comfortable with the

discharge plan, in turn contacting Medicare.

Medicare reviews the plan of care and

determines if discharge is appropriate. If

discharge is deemed appropriate the patient

must consent to discharge by noon or will be

responsible for the cost of hospitalization.

Collaborated with pharmacy and case

management on cost effective home

antibiotic therapy for a patient discharge.


Required Clinical Competencies and tasks for NUR807

Direct Care Competencies:

Conducts comprehensive, holistic wellness and illness assessments using known or innovative evidence-based techniques, tools, and direct and indirect methods. Includes those who are non-verbal, developmentally, functionally, and/or cognitively impaired.

Evidence of Achievement (date):

• 6/23/17 – Patient Sphere

Conducted a comprehensive history and assessment on a patient with progressive multiple

sclerosis, extensive pressure injuries, and moderate dysphagia with aspiration pneumonia.

Completed wound assessment and care and participated in the consultation documentation in

the electronic medical record. Provided nutritional counseling when assisting the patient eat

lunch.

Assess physiological and functional changes associated with aging and development across the adult continuum necessary to formulate differential diagnosis (include both non-disease and disease related factors).


• 6/12/17 – Patient Sphere Completed a comprehensive physical exam for an 85 year-old patient with severe dementia.

Utilized different communications techniques such as empathy, asking permission, and

keeping questions simple, to engage her in conversation to determine differential diagnoses.

Differential diagnoses included advanced dementia with possible depression upon

completion of the assessment.

Employs evidence-based clinical practice guidelines to guide screening and diagnosis for age-specific and genetic risk factors.


• 7/10/17 – Patient Sphere Researched the indications for Unna Boot application for patients with venous insufficiency

as requested by my preceptor prior to clinical in the vascular clinic. Preformed assessments

for vascular clinic patients including the effectiveness of Unna Boot therapy. Managed the

application of Unna Boot for several patients during clinical.


Assesses the effects of interactions among the individual, family, community, and social systems on health and illness.



Effectively communicated with a patient experiencing an acute phase of schizophrenia. I

was successful in gaining trust which allowed for the medical team to give care which was

previously refused by the patient. This positive interaction resulted in the patient receiving

care appropriate to her needs.

Assesses the interaction between acute and chronic physical and mental health problems.


• 6/23/17 – Patient Sphere Participated in the care of a patient who’s differential diagnoses included hepatic

encephalopathy or acute schizophrenia. Both diagnoses could impact the patient’s

presentation of agitation and altered decision making capabilities.

Identifies potential risks to patient safety, autonomy and quality of care based presence of co-morbidities and psychological issues that may impact optimal level of health.


• 6/23/17 – Patient Sphere Provided a comprehensive assessment of an uncooperative, threatening patient who was at

risk for personal safety as well as staff safety. Recognized the potential causes of

presentation including psychiatric history and acute health status changes.

Assesses the impact of environmental/system factors on care


• 6/12/17 – Systems Sphere, Nursing Sphere Provided assistance and guidance to staff during a busy shift. Noted the change in the

environment and relaxation of the nursing staff when they felt they had support throughout

the shift.

Uses reliable and valid age-appropriate assessment instruments to assess acute and chronic health concerns, including but not limited to mental status, delirium, dementia and pain.


• 6/12/17 – Patient Sphere Utilized the Geriatric Depression Scale Short Form to assess for possible depression in an

elderly patient with a history of dementia. Frequently utilize the Nonverbal Pain Scale

(NVPS) when assessing patients.


Assess for manifestations of health disorder or health disruptions, e.g. infection, adverse drug effect, dehydration, ischemia, and geriatric syndromes.


• 6/12/17 - Patient Sphere Completed a physical assessment for an 85 year-old patient for signs of infection. Assessed

fluid volume status since she was not eating or drinking adequately.

Evaluates for common mental health disorders such as depression, dementia, anxiety, or substance-related disorders.


• Patient Sphere Utilize the Geriatric Depression Scale Short Form when monitoring the geriatric population

for depression.

Recognizes signs and symptoms of anxiety such as anger, uncooperative behavior, and

crying related to stress of illness or hospitalization. Provide therapeutic techniques such as

active listening, asking permission, and including the patient in the plan of care to assist in

alleviating anxiety symptoms.

Conducts a pharmacologic assessment including polypharmacy, drug interactions, over-the-counter and herbal product use, and the ability to safely and correctly store and self-administer medications.


• 7/28/17 - Patient Sphere Evaluated a patient admitted for pericarditis and non compliant with antibiotic treatment

plan. Evaluated a history of poly opioid use including heroin, and prescription. Considered

the patients ability to maintain medication compliance as she is homeless.

Assesses patient, caregiver, and family’s preferences in relation to cultural, spiritual, quality of life, and lifestyle choices.


• 7/6/2017 - Patient Sphere Provided patient and family support when making decisions for end of life care. Discussed

hospice and palliative care options per the patient and family request and collaborated with

the multidisciplinary team to obtain information.


Interprets values/results of laboratory and diagnostic tests with consideration of age, ethnicity and health status.


• 7/3/2017 – Patient Sphere, Systems Sphere Interpreted laboratory and diagnostic imaging studies for a patient presenting with a

generalized complaint of abdominal pain. Through the diagnostic results I was able to

determine a diagnosis of cholecystitis and pancreatitis.

Synthesizes assessment data, advanced knowledge, and experience, using critical thinking and clinical judgment to formulate differential diagnoses for clinical problems amenable to CNS intervention.


• 7/6/2017 - Patient Sphere, Systems Sphere Collaborated with infectious disease, medicine, and surgery physician teams to assess a

patient with multiple wounds with purulent drainage. Assisted in determining a plan of care

including antibiotic treatment, the need for further surgical debridement, and discharge

planning.

Determines diagnoses in the complex patient and takes into consideration:

• Physiologic and pathophysiologic changes

• Morbidities and co-morbidities

• Events across the life span

• Patient’s pharmacologic history Evidence of Achievement (date):

• 6/23/17, 6/26/17, 7/6/2017 – Patient Sphere Completed assessments and provided guidance to staff for a patient during several hospital

stays. Considered the physiologic complications or advancing multiple sclerosis and the

events leading to each hospital admission. Reviewed the patient’s home pharmacologic

treatment plan and discussed possible medication treatment plans to improve the patient’s

outcome.

Prioritizes differential diagnoses to reflect those conditions most relevant to signs, symptoms and patterns amenable to CNS interventions.


• 6/23/17 – Patient Sphere Performed a complex patient assessment and presented differential diagnoses in order of

priority from aspiration pneumonia, to altered skin integrity.


Ethical Decision-making, Moral Agency and Advocacy Competencies:

Evaluating the impact of legislative and regulatory policies as they apply to nursing practice and patient/population health outcomes.


• 5/24/17 – Organization/Systems Sphere Examined current legislation introduced in the House regarding nurse to patient ratios.

Discussed the possible implications of this bill on a unit and system level with my preceptor

and nursing staff. As a result of this discussion I have agreed to follow up on the

progression of this bill and report to the unit leaders. The passing of this bill would require

changes in staffing and reporting to which leaders would have to prepare for.

Balances patient and family preferences, threats to patient safety, and risk/benefit analysis of interventions such as fall prevention, pain management, and treatment choices.


• 7/6/2017 - Patient Sphere Provided patient and family support when making decisions for end of life care. Discussed

the possible risks for the patient if discharged home and provided information for hospice

and palliative care for the patient and family to make choices regarding plan of care.

Identifies ethical implications of complex care situations.


• 5/24/17 – Patient Sphere Participated in a multidisciplinary meeting with a patient’s family regarding the continuation

of hospice/palliative care. Ethical implications of this conversation included the risk versus

benefit, and maleficence versus non-maleficence in continuing aggressive care.

Considers the impact of scientific advances, cost, clinical effectiveness, patient and family values and preferences, and other external influences.


• 5/24/17 – Patient & System Sphere Participated in a multidisciplinary conversation regarding the effectiveness of care for a

patient with a poor prognosis requiring frequent admissions. Family preferences and

financial implications were included during decision making.

Engages in a formal self-evaluation process, seeking feedback regarding own practice, from


patients, peers, professional colleagues and others.


• Patient Sphere, Nursing Sphere

Consistently seek feedback on delivery of care, communication style, and skills from my

preceptor, nursing staff, patients and family. I encourage feedback to continue to improve

my skills.

Fosters professional accountability in self or others.


• Patient Sphere, Nursing Sphere, Systems Sphere I maintain a professional appearance and professional relationships with patients and

hospital staff. I hold myself accountable for delivering safe, effective and compassionate

care. I assist with staff accountability by performing patient rounds and consulting with

nurses regarding patient plans of care.

Promotes a practice climate conducive to providing ethical care.


• Patient Sphere, Nursing Sphere I consistently provide ethical care by maintaining patient privacy. I respect the privacy of

the staff and ensure conversations about performance remains confidential.

Coaching Competencies: Mentor health professionals in applying the principles of evidence-based care.


• 7/10/17 Patient Sphere, Systems Sphere Provided evidence based research articles to medical students regarding Unna Boot

application while in the vascular clinic. Discussed what I had learned regarding Unna Boot

indications, assessment requirements, and application of, to medical students rounding in the

vascular clinic.

Research Competencies: Evaluation of Clinical Practice Facilitates the incorporation of evidence related to adults-older adults when formulating and reviewing age-specific policies, procedures, and protocols.


• 6/26/17 Patient Sphere, Systems Sphere Participated in a meeting regarding patient falls and the evaluation of current fall prevention

protocols and strategies. Took ownership to conduct research on fall prevention strategies

including the use of a mobility team to piolet on my clinical, geriatric floor.

Evaluates innovative approaches to delivering care to the adult-older adult populations.



• 7/6/17 – Patient Sphere, Systems Sphere Presented research findings for the use of mobility teams to aid in the ambulation of adult

inpatients. Benefits of such team include a reduction of fall rates, a decrease in hospital

acquired pressure injuries and infection, decrease in length of stay, and increased patient

satisfaction. Proposed a piolet study of said team for my clinical geriatric unit.

Provides leadership in identifying gaps in data and analyses specific to age-related outcomes of care.


• 7/6/17 – Patient Sphere, Systems Sphere In response to an increase of inpatient falls I assisted with the research and proposed plan to

piolet a patient mobility team for my clinical unit where a geriatric population is the

majority.

Participates in establishing quality improvement agenda for unit, department, program, system, or population.


• 7/6/17 - Patient Sphere, Systems Sphere Participated in obtaining evidence based research and proposing a plan for a mobility team

trial.

Fosters an interdisciplinary approach to quality improvement, evidence-based practice, research, and translation of research into practice.


• 6/1/17 – Patient, Nurse, and System Sphere Joined staff in TEMPO board rounding with bedside nurses, charge nurse, social work,

CNS, leadership and physicians. During these rounds, recent evidence based practice or

research is discussed in relation to applicable patients. TEMPO board rounding has been

known to decreased patient length of stay and readmission rates.

Research Competencies: Interpretation, Translation and Use of Evidence

Analyzes research findings and other evidence for their potential application to clinical practice.


• 6/7/17 – Organization/System Sphere Participated in the critical appraisal of practice guidelines using the Agree II tool.

Facilitates the incorporation of evidence-based practices, products, and technology that are


specific to adult-older adult populations, into clinical practice and policies.


• 6/23/17 – Patient Sphere Utilized Aquacel Ag dressing to provide autolytic debridement of pressure related skin

injuries.

Interpretation, translation and use of appropriate best evidence to analysis of research findings and other evidence for their potential application.


• 7/6/17 – Patient Sphere, System Sphere Conducted research review and presented findings from peer reviewed journals regarding

the use of a mobility team and its potential implications for my clinical units population.

Interpretation, translation and use of appropriate best evidence to disseminate expert knowledge.



Provided staff nurse with rationale for obtaining lactate levels for septic patients. Provided

additional literature regarding the sepsis cascade per request.

Identifies areas of inquiry relevant to the adult-older adult population.


• 7/6/17 – Patient Sphere Conducted a literature review to inquire of possible interventions to decrease patient falls

and improve mobility for the admitted patient.

Identification of questions for clinical inquiry.


• 7/28/17 – Systems Sphere Participated in the Joint Commission survey process and attended the leadership debriefing

of findings. Areas of inquiry included positive findings and areas for improvement.

Conduct of literature reviews.


• 7/6/17 Systems Sphere Conducted a literature review regarding the use of mobility teams to decreased patient falls,

complications of pressure related injuries, and hospital acquired infections.


Systems Leadership Competencies:

Participates in development, implementation, and evaluation of clinical practice guidelines that address patient needs across the adult age spectrum.


• 6/7/17 – Organization/System Sphere Participated in the critical appraisal of practice guidelines using the Agree II tool.

Clinical Hours Tracking Calendar-draft


Document clinical internship hours per date (ex. 6a – 2p) and briefly list activities (ex. Unit rounds, QI meeting, …)

~ May 2017 ~ Weekly Clinical Hours Sun Mon Tue Wed Thur Fri Sat

NOTES:

1

2

3 4

5

6

7

8

9

10

11

12

13

14 15

16 Course Opens

17

2000-2115 Clinical Seminar

via Zoom

18

19 20

1.15

21 22

23 Can start clinical as long objectives approved by Clinical Faculty

24

Clinical 0700-1700

2000-2115

Clinical Seminar via Zoom

25

26

27

11.15

28

29 NO CLINICAL

HOURS THIS DAY University Closed

Holiday

30

31


Via Zoom

5 1.25

Total May Clinical Hours: 13.55




~ June 2017 ~ Weekly Clinical Hours Sun Mon Tue Wed Thur Fri Sat

NOTES: 1

Clinical 0700-1700

2

3

10

4

5

6

7


Via Zoom

8

9

10

1.45

11 12

Clinical 0700-1700

13

14


Via Zoom

15

16

17 11

11

18 19

20

21


Via Zoom

22

23

Clinical 0700-1700

24 11

12.25

25

26

Clinical 0700-1700

27

28


Via Zoom

29

30

11

12.20

Total June Clinical Hours: 46.9




~ July 2017 ~ Weekly Clinical Hours Sun Mon Tue Wed Thur Fri Sat

1

2

3

Clinical 0700-1700

4 NO CLINICAL

HOURS THIS DAY University Closed

Holiday

5 2000-2115

Clinical Seminar via Zoom

6

Clinical 0830-1700

7

8

19.45

9 10

Clinical 0730-1630

11

12


Via Zoom

13

14

15

10.15

16 17

18

19


Via Zoom

20

21

22

1

23

24

25

26


Via Zoom

27

28

Clinical 0700-1530

29

9.45

30

31 NOTES:

Total July Clinical Hours: 40.5

Clinical Hours Tracking Sheet


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