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NURS 3021H Clinical Practice Focused on Chronic Disease Management

Final Evaluation

Student: Anya Cheremeteff

Clinical Instructor: Pamela Caldwell

Clinical Placement Hospital: PRHC Unit: D2

Date: April 2nd, 2018

Missed Clinical Hours: 0 Missed CLC Lab Hours: 0


NURS 3021H Clinical Practice Evaluation

Progress
Course Objective Evidence/Indicators SP/S ND UP/U
1. Demonstrate accountability and responsibility in MIDTERM
the teaching-learning relationship.  I demonstrate responsibility by handing in all pre-
clinical’s, post-clinical’s, reflections and other
assignments on time. I arrive to clinical on-time, 10-
15 minutes before the shift starts. I wear a clean
and appropriate uniform, and always ensure I have
my I.D. badge visible. I attend all labs/sims.
 I demonstrate accountability by ensuring I
understand my patient’s diagnosis, and priority
assessments. I have my medications researched
before arriving to clinical to ensure I am familiar
with what I am administering. Whenever a peer
needs help with a task, I help in any way I can – for
example by assisting with repositioning or a bed
bath.
 I also show accountability and responsibility by
answering call bells and assisting patients. I be sure
to take a look at the board in the patient’s room, or
address the kardex if I need any more information
about a patient’s before assisting them to the
bathroom, for example. I report to the nurse and
my peers before going to break or leaving the floor.
FINAL
 I have continued to demonstrate responsibility by
handing in pre-clinical’s and post-clinical’s as well as
reflections on time. I still continue to arrive to
clinical 15 to 20 minutes before the shift starts so as
to get report from the nurse and check the kardex
so I am familiar with my patients needs.
 I have completed all necessary preparation before
attending’s labs and simulations. This includes doing
a pre-clinical assignment on the simulated patient,
as well as creating thorough drug cards for all of
their medications. I watch videos and read
information to ensure I am knowledgeable on all of
the skills I may be asked to perform during
simulation.
 Within my clinical shift, I always ask my instructor
any questions I may have before proceeding with
any task. This ensures that I am safe when assisting
my patients and comfortable performing these
tasks. For example, even though I had performed a
subcutaneous line insertion before, I asked my
instructor to go through the steps with me before
entering the patients room so that I would be safe
and comfortable performing the task.
2. Explain the experience of chronic illness in MIDTERM
individuals receiving care in chronic care  I have developed an understand of the experience
settings of chronic illness through caring for my patients. For
example, I had a patient who had just had a
procedure which left them with three ostomy
bags/fistula’s. When draining the bags, I could see
the emotional distress that this lifestyle
modification caused for the patient. I now have a
better understanding of how emotionally upsetting
it can be to have such a major change to your
everyday routine and how a patient needs support
to cope with the adaptations that come with
chronic illness.
 I have also seen how patient’s talk about their life
before their chronic illness caused them to have to
permanently require full care. For example, a
patient explained how frustrating it is for them to
rely on sometime to simply get to the bathroom.
 For the NURS3001 course, I completed a simulated
lifestyle modification exercise in which I adapted to
changes such as diet, exercise and complex
medication regimens. Completing this exercise for a
week allowed me to develop an understanding of
how difficult it can be to adapt to the lifestyle
changes that accompany chronic illness.
FINAL
 I have many opportunities to understand how
different individuals experience their chronic
illnesses. The conversations that take place
allowing me to develop this understanding have
also allowed me to practice the use of
therapeutic communication with both patients
and family. For example, I was able to help a
family member feel okay about leaving her
mother and going home to take a shower by
assuring her that she had been doing a great job
and promising I would stay with her daughter as
much as possible until she got back. I was able
to help the daughter to feel comfortable leaving
by using therapeutic communication techniques
when discussing this with her.
 During this placement I was able to help provide
care for a patient experiencing ALS. I was able to
gain an understanding of how this chronic illness
can impact a person’s life. I can begin
understand how frustrating it can be for a
person experiencing this illness, having their full
mind unaffected, but not being able to use their
body in the physical way that they used to. I
have been able to see how the person is able to
find new ways to communicate with their family
and care providers. For example, this particular
patient was able to communicate what they
needed to the care provider by using an I-pad.
3. Interpret critical aspects of the person’s MIDTERM
experience of chronic illness in relation to the  Through completing pre-clinical’s and post-clinical’s
nursing process such as common signs and I have been able to identify critical aspects by
symptoms, responses to treatment, patterns of understanding the diagnosis, symptoms, diagnostic
coping, and impact on individual and family tests, priority assessments and special care needs.
relationships.  Through caring for patients I have been able to
identify the impact of chronic illness on individual
and family relationships. For example, I had a
patient whose daughter was having a hard time
coming to terms with the fact that her mother
would not be cured of her illness, and wouldn’t be
able to carry on with her normal lifestyle. I can
understand and see how hard it could be to realize
that your parent wont be able to continue living the
way that they are used to.
 I have also seen how relationships change when
someone has to become a caregiver. I have had
many patients whose family members have helped
them with personal care, and how this has made
them feel powerless and upset. For example, one
patient explained how they felt that there was
nothing they could do to help themselves, but that
they were glad they were in hospital so that their
wife no longer had to provide personal care for
them.
FINAL
 I have continued to complete pre-clinical’s and post-
clinical’s, which have allowed me to identify critical
aspects of the person’s experience of chronic illness
through understanding the diagnosis, symptoms,
diagnostic tests, priority assessments and special
care needs.
 During the last week of this placement I had a
patient whose daughter was hesitant to leave her
mother even though she needed to run errands at
home and take care of her own self. This showed
me how chronic illness can impact family by making
them feel a sense of guilt when engaging in self-
care, even though it is so important for the family to
stay mentally and physically healthy themselves. I
can see that taking care of your own self can be
hard for family members as they do not want to
leave their loved ones alone.
4. Identify symptoms and common medical MIDTERM
treatments of selected chronic illness.  I have identified that a common symptom that
cancer patient’s experience is nausea and vomiting.
When it is identified that a patient is experiencing
this, I administer an antiemetic such as Zofran with
my clinical instructor present. Along with this, I
provide a cool cloth if it is wanted to help comfort
the patient during this time.
 Another common symptom associated with chronic
illness is pain. I assess for pain every time I go into a
patient’s room, and treat the pain in various ways. A
common medical treatment is administering
dilaudid along with my clinical instructor.
Repositioning also helps, especially when the pain is
associated with one side of the body.
FINAL
 A common symptom that is seen with many of the
patients on the palliative floor regardless of their
specific chronic disease is pressure injuries. Many
patients are confined to their bed because of their
chronic illness leaving them at risk for developing
these pressure injuries. For example, I had a patient
who started out with a red spot on his coccyx. I used
no-sting and barrier cream to treat this spot. A few
weeks later when helping the patient again I noticed
the the spot had become much larger and purple
with a small area where the skin began to tear. In
order to treat this, I placed a coccyx mepilex over
barrier cream in order to try and prevent the wound
from getting worse and promote healing.
 As many patients with chronic illness experience
pain, they take medications (e.g. morphine) that
help to decrease their pain but have side effects
such as constipation. For this reason, a common
symptom seen on the floor is constipation. I had a
patient who had not had a bowel movement in 5
days and therefore I administered a suppository
laxative with my clinical instructor present in
attempt to help alleviate the constipation.
5. Demonstrate select nursing and collaborative MIDTERM
interventions related to caring for the person  With medication administration, I always perform
with chronic illness such as specific the three checks to ensure I am giving the right
assessments, medication administration, order, while always going through the 10 rights of
physical and chemical restraints, enteral medication administration as I go. This includes
feeding & residual volumes, NG tube insertions, checking the I.D. band for name, DOB, and K
wound care, patient controlled medication
number, while also asking the patient for the same
administration pumps.
information. Along with this, I have also had the
opportunity to observe the initiation of a CAD
pump.
 An example related to wound care would be
changing dressings for patients with pressure
injuries when they are coming off or soiled. I
remove the old dressing, clean the wound with 4x4
gauze and NS, and apply a new dressing. Along with
this I apply “no-sting” to any reddened area to
prevent the formation of a pressure injury.
 Upon identifying that a patient was unable to
urinate recently, I performed a bladder scan with
the assistance of my clinical instructor. This nursing
intervention allowed me to know whether or not
catheter insertion was necessary for the patient.
FINAL
 This semester I have been able to observe how
other healthcare professionals contribute to patient
care. For example, I had a patient who I was getting
ready to provide morning care to when the
physiotherapist walked in to help the patient
exercise. I scheduled the bath for a later time and
observed how the physiotherapist helps the patient.
The physiotherapist observed the patient walk
around the unit with their walker, and gave the
patient tips such as standing up taller to help with
their gait. The physiotherapist also noticed that the
walker was too short and adjusted it to the correct
height. This experience allowed me to understand
how collaboration between all healthcare
professionals is important for the patient with
chronic illness.
 During this placement I had a patient who was
constantly trying to get out of her bed alone even
though she was a high risk for falls. The patients
nurse put the bed alarms on but the patient was still
trying to get out of bed regardless of the bed
alarms. To prevent harm, I spoke with the nurse
about putting a third bed rail up and the nurse
agreed that this was a good idea. The bed alarms
and bed rails are an example of using minimal
restraints to prevent harm from falls in a high risk
patient.
6. Identify potential consequences/complications MIDTERM
of select chronic illnesses and related  I understand that chronic illnesses and their related
interventions. interventions have certain consequences and
complications. For example, I know for patients who
are taking morphine to control the pain associated
with their illness are at risk for constipation as it is a
common side effect of the drug. Knowing this, I am
sure to document all bowel movements and
administer laxatives as ordered, while ensuring that
my patients are staying adequately hydrated.
 Another complication I have observed was the
development of weakness, pain, and eventual
immobility in a patient’s arm. Over the course of a
week I could see the patient begin to have pain in
her arm with weakness, and then eventually fully
lose the use of her arm. This was due to nerve
irritability and caused a lot of discomfort and
frustration for the patient.
FINAL
 I have identified that a potential complication of
chronic illness is a decrease in the ability for a
patient to communicate. For example, I had a
patient that did not have enough energy and their
speech was very soft and very difficult to
understand. The intervention I used was trying to
communicate by using hand signals such as thumbs
up for yes and thumbs down for no. As well as this I
provided the patient with a pen and paper when
more elaborate communication was needed and
this allowed the patient to relay what they were
trying to say.
 Another complication of chronic illness is the
gradual decrease in physical mobility and increase in
weakness. This is seen in almost all patients I have
had on the palliative unit. For example, I have
watched as I’ve seen a patient start out
independently caring for themselves and walking
around the unit, and then a week or two later are
unable to care for themselves any further than
washing their face. As a nurse I intervened by
ensuring I provided thorough personal care so that
the patient feels clean when they are unable to
wash themselves, and promptly bring them
whatever they need such as a snack or water.

7. Under the supervision of a Registered Nurse, MIDTERM


demonstrate safe, competent, evidence-  An example of patient advocacy would be finding
informed, holistic nursing practice with clients the patients nurse and asking them to administer
with chronic illness pain medication or antiemetic’s when a patient
a. Use a wide range of effective state’s that they are in pain or are nauseas. The
communication strategies and nurses are very busy and can’t always get to the
interpersonal skills to appropriately
call-bell right away, so by answering the bell and
establish, maintain, re-establish and
terminate the nurse-client relationship finding the patients nurse I am advocating for the
b. Demonstrate accountable, responsible patient’s comfort.
and ethical practice  I demonstrate the use of nursing models and
c. Engage in respectful, collaborative, theories in my post-clinical assignments when I
therapeutic and professional apply various nursing theories to practice. For
relationships example, I commonly apply Nightingales
i. Demonstrate therapeutic use of
Environmental theory in that I aim to keep my
self
patients comfortable with a warm blanket, clean
ii. Create a culturally safe
environment and tidy surroundings, personal care, etc.
d. Apply nursing models and theories  In terms of effective communication strategies, I
e. Demonstrate health promotion and introduce myself as a nursing student with my name
illness prevention practices every time I enter a patient’s room so they know
f. Demonstrate patient advocacy who I am. I then proceed to ask about pain and
g. Predict outcomes of nursing care comfort if the patient has no immediate concerns.
h. Evaluate client response to nursing In terms of safety, I always check patient identifiers
care to ensure I am assisting the correct patient.
i. Critically appraise own practice in FINAL
relation to nurse-client/family  For health promotion and illness prevention, I
interactions and as a member of the always apply no-sting to an area that looks red in
health care team order to prevent the formation of a pressure injury.
This promotes health for the patient as it prevents
unnecessary pain and and discomfort.
 I have applied the theory of person-centered care
by always doing my best to ensure the patient gets
their care however they seem fit. For example, I had
a patient who continuously denied having their am
care and asked if they could have it after lunch.
Even though I knew that after lunch I would have
medications and documentation to do, I ensured
that I organized my day so that I could fit that
patients am care after lunch as that is what they
wanted.
 In terms of communication strategies, I always try
to comfort my patient and allow them to be heard.
Sometimes this means active listening rather than
talking to ensure the patient knows that their
feelings are being acknowledged and that their
feelings are valid. I have seen this bring ease and
comfort to my patients.
8. Critically appraise own practice in relation to MIDTERM
nurse-client/family interactions and as a  In this clinical placement along with all my clinical
member of the health care team placements, I am constantly critically appraising my
interactions with patients and family. For one of my
reflections this semester, I analyzed an interaction
with a patient who was verbally harassing myself
and another nurse. I felt as though I did not handle
the situation as well as I could have and researched
methods to handle a similar situation more
successfully in the future.
 Another example of critically appraising my
interactions with clients and family is when I
identified that I needed to improve my emotional
support skills while a patient was visibly upset due
to her new ostomy. I felt as though I did not know
what to say to make them feel better in that
situation. From this experience I researched and
studied therapeutic communication techniques in
order to improve my practice.
FINAL
 In terms of nurse/client interactions, I always
answer call bells to ensure that the patients know
that their needs will be met promptly. This helps to
build trust with the patient and begin a therapeutic
relationship. Along with this I always follow through
with any promises I make to the patient. For
example, if I say I’ll be back in five minutes with a
glass of water, I ensure I am back within five
minutes so as not to break the trust my patient has
with me.
 In terms of family interactions, I have been able to
use relational practice as well as therapeutic
communication by helping to answer their
questions. For example, towards end of life the
patient’s extremities were cold and the family was
very anxious about this. In order to alleviate some
of their worry, I explained to them that this was a
normal sign towards end of life and did not mean
that the patient was uncomfortable.
9. Participate in professional development based MIDTERM
on reflective practice and critical inquiry  I participate in professional development by
completing “LEARN” based reflections, where I
identify a situation and use research to find ways to
improve my practice in the future.
 An example of reflective practice is when I
participate in post-clinical, discussing how the
previous shift went. I also participate in this practice
along with critical inquiry by completing my post-
clinical assignments, where I discover more about
my patient’s diagnostic tests, medications and
reflect on nursing theories that I used that day in
clinical.
 I participate in professional development when
participating in SIM labs. After the SIM is complete,
as a group and individually I reflect on where my
strengths were for that SIM, and where I could use
practice and improvement. I am also able to
participate in professional development through
attending labs every week where I get to practice
and learn new skills.
FINAL
 Throughout the past semester I was given the
opportunity to complete two thorough reflections. I
successfully used scholarly research and critical
thinking to participate in professional development
by identifying a difficult situation, analyzing how I
dealt with it, and finding scholarly articles that gave
me new and improved ways to deal with a similar
situation in the future.
 I have completed four difficult simulations
throughout the semester. After I complete my
participation I engage with my clinical group and
simulation instructor and reflect on my strengths
and areas for development and listen to what other
members have to say about my participation as
well. This allows to me to know where I am strong
and where I could use extra practice for the future.

Areas of Strength Identified by Student

1. Organization of time and prioritization to ensure all tasks are completed for both patients

2. Assessing for patient pain and comfort and timely intervention

3. Providing thorough personal care

Areas for Future Development Identified by Student

1. Emotional Support/Therapeutic Communication

2. Inserting subcutaneous lines

3. Catheter insertion

Clinical Instructor Comments (All areas marked as unsatisfactory must have a comment)
Clinical Practice Attendance (8 Hours Per Shift)

Thurs Fri Thurs Fri


Week 1 8 8 Week 6 8 8
Week 2 8 3.5 Week 7 8 3.5
(sim)
Week 3 8 8 Week 8 8 8
Week 4 8 8 Week 9 8 8
Week 5 8 3.5 Week 10 3.5 8
(sim)

Total number of clinical practice hours completed: 128/128 Hours

Clinical Practice Outcome (completed by Clinical Instructor): Satisfactory Unsatisfactory

Clinical Learning Centre

Total number of clinical simulation hours completed 14 / 14 Hours


Total number of lab hours completed 22/22 Hours

Clinical Learning Centre Outcome (completed by Course Lead): Satisfactory Unsatisfactory

Signature of Course Lead: Date:

Signature of Clinical Instructor: Date:

Signature of Student: Date: