clinical assignment
1. Identify specific situations (more than one) encountered during this clinical experience where nursing care made a difference in a client’s outcome. Be specific without using any identifying information.
My clinical experience took place in the ICU in OU Edmond. Nursing care in this ICU unit makes a significant difference in transitioning and saving patients life. Patients that comes to this unit are mostly hemodynamically unstable and usually comes to this unit after being stabilized from ER and surgery for further closeup monitoring needs. During my clinicals experience, I encountered two patients when having cardiac arrest and being saved their lives by nurses. The nurses saved their patient life by calling code right away, performing CPR, administering medication, managing airway, documenting, and later by closely monitoring the treatment effectiveness which makes difference in patients life. I believe nurses made difference in patients’ life by giving patient daily care and providing intervention immediately when their health deteriorates. Moreover, I saw when nurses made difference in patients life by administering Atropine medication on times when patient heart rate drops below 60, Amiodarone to decrease heart rate, titrate Levophed to increase blood pressure, and constantly reminding patients the importance of being NPO before surgery or procedure to decrease aspiration complication. Also, the nurses improved or made difference in their patients’ outcome by being trust worthy in providing care and offer hope during patient difficult time.
2. Identify specific examples of how nursing prioritization impacted care, either positively or negatively and identify how care could have been different had the nurse/student prioritized differently.
Nursing prioritization impacted care in a positive way when saving one patient life by performing CPR after she had cardiac arrest. However, during this coding event my preceptor and all other three nurses in the unit gather to the coding patient room and got busy for almost an hour with assisting CPR, giving medication push, documentation, and leaving their others patient care on the side which can cause negative effect. Thus, I shifted my prioritization to care for one of my patient who she has been admitted for DKA and was on insulin drip who we haven’t check her glucose level for more than an hour. After assessing her glucose, I found out that it was 57. I rushed and reported this finding to my preceptor nurse who later I assisted her stopping the insulin drip first and gave patient Dextrose or D50 shot to correct the glucose level. I believe, if I haven’t think about my patient situation and intervene quickly by reporting my nurse, it would have cause the patient life.
3. Describe any non-care delivery situations that, in your opinion, could have been handled differently. Do not address a patient care issue. Think in terms of interpersonal interactions, management issues, or institutional issues.
An institutional issue that can be handled differently is that when patients come from surgery at nights, they healthcare providers are sometimes not available for the nurses. If the nurses needed to double check on order on a patient, contacting HCP at nights is difficult. And if the HCP thinks the reason for the nurses calling is not important, they get angry at the nurse for calling. Having HCP that are available for nurses at could fix this issue and HCP should be more understanding that nurses are calling them to double check during night time.
4. Make suggestions that could change the outcome, either in client care or in floor management, that reflect the observations in 2-4 from the criteria above.
During night shift in the ICU, I observed that there wasn’t rapid response team available during coding. Thus, all the nurses in that unit and nurse manager or nurse leader had to help each other during code which creates temporarily abandonment from their other patients because all their attention and energy is shifted on saving one patient. Thus, I would suggest either to make rapid response team available in the hospital in any shift or hire more nurses. Side from this issue secondly, I would suggest other healthcare team members to should notify nurses when they bring patient back from surgery and procedure to the ICU unit to limit number of falls. Moreover, since all the patient in the ICU are in continuous telemetry, O2 pulse, and blood pressure monitors, it would be important the nurses to know that their patients are back to the unit so that they can properly hook them up to the machines to avoid any errors.
5. Identify the system used for report. How effective is the report as given? Do you receive sufficient data to plan nursing care? What organizational methods will you use to be sure you administer an effective report?
The ICU uses the SBAR method is used to give report. I saw SBAR report given when the patient is newly admitted. Also, I saw SBAR report given to the healthcare provider over the phone when patient health worsens or if abnormal lab finding is present. The report is effective because it addressed patient background, report abnormal finding, important medications list that is taken currently that supposed improve their abnormal finding or one time given, and received recommendation from the healthcare provider to intervene quickly. Nurses give focused report to each other that help gather important data to planning nursing care like reporting abnormal finding, medication given one time, abnormal labs, if they going to procedure, and patients or families concern. I would use SBAR format and write down all the important information before calling the doctor so that I don’t miss out essential information or being disorganized when giving report.
6. Observe and ask questions about how staff assignments are made on the unit. Are assignments made based on geography, acuity, staff skill sets? How effective is this system?
The ICU has 12 beds, four nurses every 12 hours shift. Nurse to patient ratio is usually 1:3. If the Unit becomes slow by discharging lots of people, or transfer to another unit, the nurses would have 1:2 ratio. For this instance, the nurses help other nurses that has 3 patients. Most of the nurses have 5 or more years of ICU experience. The ICU unit rarely hire unexperienced nurses because most patients are hemodynamically unstable thus, they require more critical thinking and care to be given. If they hired new graduate nurses, the unit will train the his or her for minimum of six months. I believe the unit system is very effective because they give new nurses opportunity by hiring them and by taking time to train them adequality. All nurses that I interviewed regarding staff assignments, stated the mangers do good job on being fairness on dividing tasks equally and scheduling them properly in putting seniority into consideration.
7. Identify the usual staffing mix of the unit. How many RNs, LPNs, Nursing Assistants, etc? In your opinion, describe the effectiveness of this method of staffing. What changes would you like to suggest to the Nurse Manager regarding staffing? What is the rationale for the changes?
The staff in this ICU constitute only RNs. The ICU has 12 beds, four nurses every 12 hours shift. Nurse to patient ratio is usually 1:3. I think the shift works sometimes good when there is only 1:2 ratio; however, when there is 1:3 ratios, the nurses overwhelmed with care and charting requirements to be given since most of the patients are very sick thus requires frequent IV medication titration, oral care, Foley care, NG tube care, and bed bath. In my opinion hiring only RNs and not including LPNs in the unit is effective because working in the ICU unit requires continuous assessment, education, IV medication titration, manipulating ventilation machine system which is not the scope of LPNs practice. Moreover, I would suggest the nurse manger should hire more nurses to make nurse to patient ratio 1:2 because most of the patients are hemodynamically unstable thus they require more time to been take care of and should hire nursing assistance to help nurses with giving bed bath, and assist with toileting which the help can give them nurses an opportunity to focus other patient care .
8. Identify other members of the health care delivery team and actively collaborate with them to achieve coordinated care. What activities contribute to team cohesiveness and what activities are detrimental to team cohesiveness? Evaluate the effectiveness of the inter-professional collaboration on this unit. Evaluate the effectiveness of your collaborative activities and identify what you might do differently to be more effective in collaboration.
Other healthcare team are healthcare providers who followed up with their patients after doing surgery and ordering medication. The respiratory therapist who are present in the ICU unit always to give breathing treatment, assess and intervene when some patients fight the ventilators. Nurse manager or nurse practitioner who are always help with double checking protocols on times when the nurses are not familiar with the treatment and give medication order. Pharmacist who load patient medication on pyxis, double check side effects, and interaction. A laboratory stuffs who prepare blood products at all the time and do blood workers. Moreover, a housekeeping who disinfect all equipment on room and make it available to the next patient on timely manner.
All those healthcare members working in collaboration in ICU is to improve patient’s outcome. These all teams work together near to each other to provide immediate intervention on the times of emergency. The level of care that all these teams provides is effective because they communicate at all the time. For instance; in every morning the healthcare provider, nurses, pharmacist, nutritionist, respiratory therapist all gather together to do rounding checks to assess patient’s improvement, worsening, treatment effectiveness, and share recommendation. Activities that can detrimental to team cohesiveness can be not having team work and lack of communication which I didn’t observe to happen in this unit. I collaborate with nurses by helping them with patient reposition, administer medications, do Foley care, oral care, staring Iv, assist with feeding, bed bath, and reporting abnormal finding immediately. I would improve my communication skill to be effective in collaborating with the team because I am shy and not outspoken person which sometimes the healthcare team mistaken it lack confidence.
9. Identify problems on the unit. Are there any themes related to the problems, e.g personnel involved, recurring situations, etc? What suggestions do you have that might improve the problematic situation?
The problems that I have observed in this ICU unit is shortage of stuff. Moreover, I observed lots of nurses gossiping about their personal life, stuffs, and complains about patients loudly even in front of the patients because they think the patients will not hear them since most of the patients are in sedative medication. Also, I believe gossiping loudly in nursing unit is wrong because all ICU unit room doors are open, and the nurses voice can travel to the patient disturbing them. I would suggest nurses not to gossip in front of patients or talk loudly from the nursing unit because it is disrespectful to patient and nurses should respect their patient dignity by being professional at work.
10. List the four personal goals you had for this experience and describe how you met each one of them in this clinical rotation.
1. Develop effective communication with patients, family members, and health care members.
Since most of Patients are under sedation and intubated there is limited verbal communication. However, every time I interact with the patients, I greet them anyways even though they don’t answer me. In addition, despite patient response I always verbalized by assessment finding for example; before poking their finger to assess glucose level, I warn them and tell them afterwards what their glucose reading is. Moreover, for patients that are mildly sedated and intubated, I communicate with them yes or no technique by patients shaking their heads. I always have effective communication with families by answering their question and if not familiar with their question, I would ask my nurse to explain to them.
2. Prioritize interventions while maintaining patient safety when administering medication, performing skills, and in assisting patients in ambulation for a group of assigned patients.
I administer medication safely by first double-checking patients heart rate, blood pressure before administering hypertensive and respiratory rate before opioids medication. I promote safety by securing their intubation tube while I suction and restrain their hands for properly so that they dislodge their tube. I perform my nursing skills properly by first following standard preauction, perform skills adequately, and discharge needles in sharp containers. I personally, haven’t had chance to ambulate patients but if I have to first I would check their blood pressure level, oxygen level, and if they under sedation.
3. Collaborate with the health care team to provide appropriate education to the patient and family on health improvement measures with the goal of health promotion, disease prevention, and restoration of health.
Patient education was mainly based on safety and infection control before their discharge.
When patients are extubated and comes off from their sedation, I collaborate with my nurse on teaching patients by reoriented them to time, place, and situation so that they will decrease their anxiety and confusion level. We educated patient the usage of call light, the purpose of IV lines, bladder irrigation tube, central line, Foley catheter, Hemovac, TED hose, SCDs, and why staying on NPO. Moreover, we educated patients and families early signs and symptoms of infection and the importance of hand hygiene. In addition, We educated patients and families the importance of eating healthy food, exercise, and stress reduction techniques to promote better health outcome for the patients.
4. Prioritization in effective time management especially in regard to documentation.
I had a chance to do patient documentation in leadership class for the first time and I believe it is very important to document right away before forgetting something. It was time consuming for me at the beginning because I wasn’t familiar with the documentation technique. After, providing patient care, I prioritize documenting because not documenting patient care would shows that I haven’t provide the care and the hospital wouldn’t get reimbursement.