MSU College of Nursing

NUR807: Clinical Decision Making Summer 2019

Documentation of CNS Clinical Competencies, Activities, and Hours

Student Name: Megan Johnson

Date of First Clinical Day: 5/29/19 Date of Last Clinical Day: 7/31/19
Preceptor: Regi Freeman
Agency: Michigan Medicine
Clinical Faculty: Dr. Pfander Clinical Faculty Email:
Total Cumulative Internship hours (at time of submission): 93 (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.
Signature (electronic/typed): Regi Freeman, MSN, RN, ACNS-BC
Date: 8/2/19
Comments:

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.

1 Clinical competency and hours NUR807 | 2019

Provide 2 - 3 personal objectives for achieving course objectives:
Personal Objective with Planned Learning Activities / Required Resources & Evidence of Achievement:
1. Compare and contrast different diagnostic tools during case study presentation
Talking with staff nurses and preceptor about diagnostic tools used with case study patient
Textbook
Educate other students during case study presentation
Evidence of Achievement (including date):
 6/12/19 Educated peers on different diagnostic tools used during TEVAR surgery as
evidenced by case study

Personal Objective with Planned Learning Activities / Required Resources:

2. Integrate cultural values into patients plan of care during focused assessment
Talking with patients about their cultural values
Textbook
Educate staff about patients preferences
Evidence of Achievement (including date):
 6/5/19 Educated staff nurses about interpreter services for Vietnamese speaking
patient to improve quality of care for the patient as evidenced by reflective journal 1
and case study presentation

Personal Objective with Planned Learning Activities / Required Resources:

3.
Evidence of Achievement (including date):


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):
 6/5/19 Focused assessment of the oldest-old adult using FLACC scale for pain AEB focused assessment 2
(Patient)

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).
Evidence of Achievement (date):
 6/5/19 Focused assessment of the oldest-old adult AEB case study presentation (Patient)

2 Clinical competency and hours NUR807 | 2019

Employs evidence-based clinical practice guidelines to guide screening and diagnosis for age-specific
and genetic risk factors.
Evidence of Achievement (date):
 6/5/19 Focused assessment of the oldest-old adult using RASS scale for ICU delirium AEB case study
presentation and focused assessment 2 (patient)

Assesses the effects of interactions among the individual, family, community, and social systems on
health and illness.
Evidence of Achievement (date):
 6/19/19 Educated staff nurses on the psych CNS and NP resource available to work with difficult family
members to improve the quality of care for a patient; assisted staff in consulting this resource (Nursing)

Assesses the interaction between acute and chronic physical and mental health problems.
Evidence of Achievement (date):
 5/29/19 Created nursing diagnosis and differential diagnosis for the acute and chronic health issues of a
lung transplant pt as evidenced by focused assessment 1 (Patient)

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.
Evidence of Achievement (date):
 6/19/19 Identified risk factors for young patient with multiple co-morbidities as evidenced by focused
assessment 3 (Patient)

Assesses the impact of environmental/system factors on care

Evidence of Achievement (date):
 6/19/19 Educated staff nurses about new lumbar drains since vendor was unable to come and present
education (Nursing)

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.
Evidence of Achievement (date):
 5/29/19 Assessed orientation and delirium status of a pt with known post-anesthesia delirium as
evidenced by focused assessment 1 (Patient)

3 Clinical competency and hours NUR807 | 2019

Assess for manifestations of health disorder or health disruptions, e.g. infection, adverse drug effect,
dehydration, ischemia, and geriatric syndromes.
Evidence of Achievement (date):
 6/11/19 Assisted nursing staff with staging, care for and charting of pressure ulcers AEB reflective journal
2 entry June 11, 2019 (Nursing and Patient)

Evaluates for common mental health disorders such as depression, dementia, anxiety, or substance-
related disorders.
Evidence of Achievement (date):
 5/29/19 Assessed patient for depression as evidenced by focused assessment 1 (Patient)

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.
Evidence of Achievement (date):
 6/5/19 Conducted medication review for 83 year old with multiple medications, assessed for
polypharmacy and drug interactions AEB case study assignment (Patient)

Assesses patient, caregiver, and family’s preferences in relation to cultural, spiritual, quality of life,
and lifestyle choices.
Evidence of Achievement (date):
 6/19/19 Collaborated with patient’s mother, nursing and multidisciplinary team to create an agreed upon
plan of care. Mother was impeding care and distrusting of medical staff. Mother and I met in a quiet area
to discuss her concerns with her daughter’s care. She was tearful as she explained that she is worried
about losing her daughter. After our conversation, mother said she felt better and was willing to talk with
medical team about her daughter’s plan of care. During collaboration with team, mother was more
receptive to the medical staff and grateful towards nursing staff. Mother was able to make difficult
decisions during this meeting about daughter’s plan of care. (Nursing and Systems)

Interprets values/results of laboratory and diagnostic tests with consideration of age, ethnicity and
health status.
Evidence of Achievement (date):
 6/5/19 Interpreted lab results pre-transplant and post-transplant of a pt that came in with hypoxia for
completion of focused assessment assignment 1. Used labs to determine if lung transplant was
successful so far, if pt was hemodynamically stable and to assess if pt had an infection. (patient)

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

4 Clinical competency and hours NUR807 | 2019

 Evidence of Achievement (date):
 6/19/19 Determined need for CNS intervention for multiple patients: one with skin care issues and
charting confusion, and another with family dynamics impeding care; assisted with providing resources
and education to staff to improve quality of care as evidenced by reflective journal 2 entry June 19, 2019
(Nursing and Systems)

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):
 6/5/19 Assessment of co-morbidities, life events and pharmacologic history of patient as evidenced by
case study (Patient)

Prioritizes differential diagnoses to reflect those conditions most relevant to signs, symptoms and
patterns amenable to CNS interventions.
Evidence of Achievement (date):
 6/5/19 Prioritizing differential diagnosis and nursing diagnosis for patient with cultural care needs as
evidenced by case study presentation (Patient)

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.
Evidence of Achievement (date):
 7/24/19 Assessed pay for performance measures and audited charts for evidence of sequential
compression devices on within 24 hours of surgery. Audited the charts of all patients that were 24 hours
post-op that day, a total of 7 charts. All 7 patients had sequential compression devices on within 24hours
of surgery, meaning that the hospital had met this standard of care for DVT prophylaxis post-surgery.
(Systems)

Balances patient and family preferences, threats to patient safety, and risk/benefit analysis of
interventions such as fall prevention, pain management, and treatment choices.
Evidence of Achievement (date):
7/30/19 Reviewed risk and benefits of using a patient attendant versus a family member for impulsive
patients; reviewed allotted amount of pt attendant hours for unit. There is a yearly budget allotted for
patient attendants and it is a minimal amount for an ICU because the nurse to pt ratio is smaller than on a
general care floor. Although pt attendants can be expensive for a unit, when looking at the falls of the unit
over the last 6 months, more pt’s fell when a patient attendant wasn’t there, and many even fell when family

5 Clinical competency and hours NUR807 | 2019

 was present. Family members tend to be more lenient with their loved one or they think that their loved one
is more stable than they are. Nursing staff are more likely to give a formal report to an attendant, which also
is an important factor when trying to prevent a fall. Lastly, I explained at the daily management system that
attendants are important to use because although many family members like to help, many times being a
loving family member is more important for the patient than having another caregiver. (Systems)

Identifies ethical implications of complex care situations.

Evidence of Achievement (date):
 6/5/19 Identified the need for ethical consideration of pt with known orientation x1 prior to aneurysm
rupture, now on a ventilator with family wanting to have peg placement and keep pt full code; educated
staff about escalation to ethics committee if needed (Nursing)

Considers the impact of scientific advances, cost, clinical effectiveness, patient and family values and
preferences, and other external influences.
Evidence of Achievement (date):
 7/24/19 Reviewed gap analysis for falls and pressure injuries
 For falls: looked for evidence for chair alarm. There is not enough data to support chair alarm’s, so they
are not listed as a technique in our gap analysis. Began using the NACNS listserv to see if other
institutions were having success with chair alarms. Reviewed different types of chair alarms, including
vocal ones that can talk to the patient in multiple different languages. Reviewed pricing and then began
writing a proposal for a grant to trial chair alarms on the neuro unit. (Systems and Nursing)

Engages in a formal self-evaluation process, seeking feedback regarding own practice, from patients,
peers, professional colleagues and others.
Evidence of Achievement (date):
 7/31/19 Formal self-evaluation completed and feedback received from preceptor as evidenced by
midterm evaluation (Nursing)

Fosters professional accountability in self or others.

Evidence of Achievement (date):
 7/24/19 Collaboration with staff to ensure skin prevention techniques are being maintained; while
rounding on the unit I asked the nurse of each pt we visited if they needed help and how they would be
preventing new or worsening skin breakdown. I offered suggestions when appropriate including how to
use the pillow wedge correctly. Encouraging the staff to think about the patient’s skin earlier in the shift
motivated them to pay more attention to prevention techniques for the remainder of their shift.
(Nursing)

Promotes a practice climate conducive to providing ethical care.

Evidence of Achievement (date):
 6/5/19 Talked with charge nurse and the nurse caring for a Vietnamese speaking patient and began

6 Clinical competency and hours NUR807 | 2019

 walking them through the steps of contacting interpreter services for help when talking with the patient.
Educated charge and staff nurse on ethical issues involved with using family as translators. Reviewed
PowerPoint with them used by interpreter services and obtained a translator phone. (Nursing)

Coaching Competencies:

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

Evidence of Achievement (date):
 6/5/19 Assisted staff in using interpreter services for Vietnamese patient and educated them on the
increased risk of errors when using family as translators as evidenced by case study (Nursing)

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.
Evidence of Achievement (date):
 7/24/19 Reviewed gap analysis for falls and pressure injuries to assess where staff education is needed
(Systems and Nursing)

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

Evidence of Achievement (date):
 7/24/19 Used NACNS “listserv” to review the use of chair alarms at other facilities in preparation for a
proposal to start them here. There were 19 responses under the title chair alarms and many reported
positive results with them. One hospital shared their current guidelines on the use of chair alarms. There
was one brand of chair alarms that was commented on by two different hospitals as not being loud
enough for staff to hear. However, there is another chair alarm that multiple hospitals reported using
that talked to the patient and could be programmed to speak in another language. (Systems)

Provides leadership in identifying gaps in data and analyses specific to age-related outcomes of care.
Evidence of Achievement (date):
7/24/19 Used NACNS listserv to review the use of chair alarms (for patients with dementia) at other facilities
in preparation for a proposal to start them here. Contacted manager of the nursing quality indicators to
discuss how to determine acceptable evidence when looking at evidence-based interventions. Reviewed
proposal with the nursing quality indicator manager and unit manager. Submitted proposal for grant money
to trial chair alarms. (Systems)

Participates in establishing quality improvement agenda for unit, department, program, system, or
population.
Evidence of Achievement (date):

7 Clinical competency and hours NUR807 | 2019

  6/5/19 Committed to participation in project to improve quality of care for patients with dark skin tones
as evidenced by reflective journal 2 entry June 5, 2019 (Systems)

Fosters an interdisciplinary approach to quality improvement, evidence-based practice, research, and

translation of research into practice.
Evidence of Achievement (date):
 6/19/19 Shared information with staff at the Daily Management System about the use of new products,
specifically lumbar drains and male condom catheters. The information was shared with nursing staff,
service providers and therapists. Policy was reviewed with all, including the need for service to specify in
the orders the drainage amount expected from a lumbar drain and the use of an externalized
incontinence device. Most staff appeared to be excited about the new condom catheter as it seemed
easier to apply and more durable, however service was not happy about having to write an order for its
use. (Nursing)

Research Competencies: Interpretation, Translation and Use of Evidence

Analyzes research findings and other evidence for their potential application to clinical practice.
Evidence of Achievement (date):
 7/24/19 Used NACNS “listserv” to review the use of chair alarms at other facilities in preparation for a
proposal to start them here. Used PubMed to see what research exists for the use of chair alarms to
prevent falls, specifically in the neuro population. Although there were multiple peer reviewed articles in
support of chair alarms, there was also three that argued against them for different reasons. There was
no systematic review for the use of chair alarms and there was no data found on the use of chair alarms
specifically in the neuro population. (Systems)

Facilitates the incorporation of evidence-based practices, products, and technology that are specific
to adult-older adult populations, into clinical practice and policies.
Evidence of Achievement (date):
 7/24/19 Used NACNS “litserv” to review the use of chair alarms at other facilities, reviewed falls gap
analysis to see if chair alarms were a current option and used PubMed to see what research exists for the
use of chair alarms to prevent falls to apply to for a research grant (Systems)

Interpretation, translation and use of appropriate best evidence to analysis of research findings and
other evidence for their potential application.
Evidence of Achievement (date):
 7/24/19 Used PubMed to see what research exists for the use of chair alarms to prevent falls to apply to
for a research grant. There was no evidence available for the use of chair alarms in the neuro population
specifically. After identifying this knowledge gap, the grant was written as a proposal to fund trialing
chair alarms to see if using them would decrease the units fall rate. (Systems)

8 Clinical competency and hours NUR807 | 2019

Interpretation, translation and use of appropriate best evidence to disseminate expert knowledge.
Evidence of Achievement (date):
7/31/19 Reviewed current evidence on PubMed regarding prevention of pressure injuries in dark skin
tones. Worked with staff on the unit on skin day to help with assessing for pressure injuries in dark
skin tones. Current research suggests using more than just visualization because lighting can be poor.
Feeling for warmth or hardened areas is suggested as one technique to help locate potential sores.
(Systems)

Interpretation, translation and use of appropriate best evidence to evaluation of clinical practice.
Evidence of Achievement (date):
 7/24/19 Reviewed gap analysis for pressure injuries to assess where staff education is needed. The gap
analysis for pressure injuries suggests using a barrier cream on all incontinent patients. During skin day, I
noted that this was not being done on a regular basis. Most staff wait to implement barrier cream until
breakdown or dermatitis has already started. I supplied all rooms with barrier cream and shared this
information with all nursing staff during the Daily Management System meeting. (Systems and Nursing)

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

Evidence of Achievement (date):
 7/24 During an NDNQI meeting earlier in the semester, the neuro CNS asked if we could trial chair alarms
because where she came from used them successfully. It was reported by the NDNQI manager that chair
alarms to prevent falls was not evidence based and so would not be funded. As a staff nurse on the
neuro floor, I have witnessed the bed alarms prevent multiple falls and I have also witnessed many falls
from our patients getting out of the chair by themselves. I found it interesting that chair alarms were not
evidence based and wanted to do some more research on this. Also, since many patients who fall from
chairs on our unit are impulsive, I was interested in knowing whether there was any evidence specific to
the neuro population on fall prevention. I used the NACNS listserv to see what other facilities thought
about chair alarms. (Systems)

Identification of questions for clinical inquiry.

Evidence of Achievement (date):
 7/24 When meeting with the neuro floor CNS, unit manager and the nursing quality indicator manager
about trialing chair alarms, multiple questions were identified that would help us to identify ways to keep
our neuro population safe and free from falls. When reviewing the gap analysis for falls, delirium
prevention was noted as one way to prevent a fall. However, in our confused patients it may be hard to
tell whether the patient is confused vs when they are affected by delirium. One question that was
identified is how do health care providers assess for delirium in a neurologically impaired patient?
(Systems)

Conduct of literature reviews.

Evidence of Achievement (date):
 7/24/19 Used PubMed to see what research exists for the use of chair alarms to prevent falls to apply to
for a research grant. There was only 8 articles that talked about chair alarms and 3 of them did not

9 Clinical competency and hours NUR807 | 2019

 support the use of chair alarms. However, there was no present information available on the use of chair
alarms to prevent falls in the neuro-impulsive population. Evidence gap identified. I used this information
to ask for funding to trial the chair alarms to see if we could gather information on the efficacy of chair
alarms. (Systems)

Systems Leadership Competencies:

Participates in development, implementation, and evaluation of clinical practice guidelines that

address patient needs across the adult age spectrum.
Evidence of Achievement (date):
 7/24/19 With this unit having the highest rates of pressure injuries in the institution, we identified that
most unit acquired pressure injuries were on the heels and coccyx in immobile patients after surgery.
Using best practice from two other ICU’s, we created a standardized practice guideline for all adult ICU’s.
The pressure injury prevention guideline/bundle included Mepilex to bilateral heels and coccyx, q2
repositioning and ear padding for nasal cannula (if present) to all immobile patients within 72 hours post-
op. Submitted this guideline for approval by systems committee and discussed with all ICU CNS the plan
to monitor the number of unit acquired pressure injuries after guideline implementation (System)

10 Clinical competency and hours NUR807 | 2019

11 Clinical competency and hours NUR807 | 2019