Look back: During my third week clinical experience, I did both computer charting and paper charting (for maternal assessment) with nursing care plan. Besides charting, I reported my significant findings of the mother verbally to the primary nurse.
Elaborate: It was my first time to complete documentation on my own. When I went on the computer, I felt anxious and had no confidence. While opening my patient’s file, I recalled the story about how a nurse got laid off because she checked on the patient from another unit. Before clicking on the patient, I checked the unit and the name twice. My patient had a Caesarian section, so I remembered I had to chart vital signs, daily activity, maternal assessment and acute pain (due to the use of Epimorph). After charting each section, I checked the data over and over since I was afraid of making a mistake. As I expected, there were still some parts I forgot to fill and made wrong judgments for some but I have become more familiar with the charting system.
I reported the significant findings to the primary nurse verbally. I was not quite prepared for this. When the nurse looked up at me, my brain blanked out. The significant finding was “a small hemorrhoid”. At the moment, I forgot the word and kept saying “hemo” only. The nurse finished my word and gave me a smile that seemed to be encouraging. I soon recovered from the mental block and further reported about the size of the hemorrhoid and the pain level the patient was experiencing.
After the report, I started working on my own charting on maternal assessment. For the mother’s basic information such as Rubella immunity, I only completed partially. I wrote about hemorrhoid for my care plan, in which I wrote “a small hemorrhoid” as my dia...
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... basic information of the patient. Professional and precise language should be used when documenting. For the care plan, I have learned to correctly write a nursing diagnosis and writing interventions that are within nurses’ capability and suits the patient’s personal status. From now on, I will remember to distinguish medical diagnosis from nursing diagnosis. For each diagnosis, I will write about the patient’s (potential) response to the health problem and state why this might be the concern.
New Perspective: In my future learning experiences, I believe what I have learned at Southlake will help me quickly adapt to the new charting system at other health care facilities. In addition, I have learned how nurses play a different role from doctors. As nurses, we focus on caring the patients while doctors aim to treat the health problems that the patients suffer from.
Patient A.B. was a 26 year old female who had delivered her baby girl at 0502, approximately two hours before I assumed care of the patient with my preceptor. This was her third pregnancy and all were a cesarean delivery. Gestational age at time of delivery was forty weeks and one day. Mom was group B strep negative and required no antibiotics, blood loss was approximately 400ml and baby had Apgar score of eight and nine. The patient had a very detailed birth plan which included some details such as; staying with her baby, breastfeeding, and providing
Bethanie is a 32yo, G2 P0100, who is currently 11 weeks 3 days as dated by LMP consistent with a 6-week scan. She is known to our office from her prior pregnancy early in 2016. She was followed in our office for diabetes and had had a normal anatomic survey. About one week later she presented with cramping for a couple of days and on arrival she was noted to be 1 cm dilated and 90% effaced. The bag of os was noted to be at the external os. Because of her cramping an amniocentesis was performed which was negative for overt infection and a rescue cerclage was placed. Unfortunately, about one week later her water broke and she ultimately delivered a nonviable fetus. She did have chorio on placental pathology by the time of delivery. She does report that despite this history of possible type 2 diabetes that she has not required any medication and she had an early 1-hr glucose this pregnancy that was negative. She also has some fairly significant social issues as she is currently in the middle of separating from her husband due to domestic violence. She is here today to discuss her history in her prior pregnancy as well as possible FTS.
At birth the neonate goes through many physical changes (Fraser & Cooper, 2009). The most dramatic and difficult being when the newborn takes its first breath (Meeks & Hallsworth, 2010). This breathing triggers change within the heart, lungs, blood flow and every other system of the neonate (Coad & Dunstall, 2009). During the first few minute until 6 hours of life, the neonate is considered to be transitioning from intrauterine to extra-uterine life (Sinha, Miall, & Jardine, 2012). It is within this time that the neonate needs close observations to evaluate their progress into their new life, thus showing the importance of newborn examinations within neonatal care (Fraser & Cooper, 2009).
In my previous role as a Licensed vocational nurse, I worked in the outpatient setting, Perinatology, where there are high-risk pregnant patients. The patient I helped take care of, was early in her pregnancy, approximately 29 weeks, and was a patient who had been seen in this clinical office
As a nurse you must know how to write legible so that other nurses can understand your writing to follow out care plans. If a nurse can’t understand the writing they may give wrong medications to patients, which could cause several medical issues. A simple mistake like this can cause a nurse their licenses and serious federal charges (Purdue). Several times information written on medical charts can turn into legal documents in the results of death of the patients (Purdue). Therefore the information must be accurate and correct at all times. Many nurses go by the motto “If its not charted, then its not done”.
Dougherty, L. & Lister, s. (2006) ‘The Royal Marsden Hospital manual of Clinical Nursing Procedures: Communication 6th Edition Oxford: Blackwell Publishing Ltd
For my particular self, I check to make sure each patient was alive after receiving the report from the night shift nurse, then I read each chart and the patients orders and wrote everything that needed to be done down. As I completed everything, I checked things off and as each patient received new orders I add to my list of things to do for each patient. Yes, I believe I was well organized and I would continue to use my organizational method that was taught to me by multiple different nurses on the
middle of paper ... ... The priority for this patient was to establish that she was fully aware of what the procedure involved and the possible risks and complications. I feel that the pre-assessment form used within the unit is far too fundamental, if elements of the roper et al activities of daily living were to be incorporated this would help in achieving a much more in-depth holistic nursing assessment enabling for the best quality and level of care to be given to all patients arriving in the unit. Whilst I feel a full nursing assessment is not fully necessary for a day case unit, as previously stated I feel that the communication element is an excellent way of ensuring a better holistic approach is achieved, it will also help to achieve better documentation and communication between all staff members.
This reflective essay will discuss three skills that I have leant and developed during my placement. The three skills that I will be discussing in this essay are bed-bath, observing a corpse being prepared for mortuary and putting canulla and taking it out. These skills will be discussed in this essay using (Gibb’s, 1988) model. I have chosen to use Gibb’s model because I find this model easier to use and understand to guide me through my reflection process. Moreover, this model will be useful in breaking the new skills that I have developed into a way that I can understand. This model will also enable me to turn my experiences into knowledge that I can refer to in the future when facing same or similar situations. Gibbs model seems to be straightforward compared to the other model which is why I have also chosen it. To abide by the code of conduct of Nursing and Midwifery Council (NMC) names of the real patients in this essay have been changed to respect the confidentiality.
For my first clinical observation, I was assigned to the trauma unit and it was not what I expected it to be. I thought the trauma unit would be fast pace and there would be nurses and doctors rushing everywhere, however, I did not see any of that. Instead, it was quite peaceful and this was probably because my clinical observation was from 10-12 p.m. When I met up with my senior nurse, she showed me a binder that contained all of her patients’ diagnoses, lab reports, treatments, and vital signs, which was a lot to take in because most of the terms she used, I had no idea what they were. After looking at the reports, she showed me a patient who had gunshot wounds on his back and abdomen. I could tell he was in a lot of pain by the tone of
I believe placing student nurses in the clinical setting is vital in becoming competent nurses. Every experience the student experiences during their placement has an educative nature therefore, it is important for the students to take some time to reflect on these experiences. A specific situation that stood out to me from my clinical experience was that; I didn’t realize I had ignored the patient’s pain until I was later asked by the nurse if the patient was in any pain.
Craig, S. & Lloyd, S. (2007). A guide to taking a patient’s history…clinical skills. Nursing Standard, 22(13), 42-48.
It is important as a nurse to assess your patient frequently checking for any variances in previous medical data or trends. Knowing the signs of complications stated in this article can help with recognition of a problem early enough prevent further damage or more serious complications. Communicating with other members on the healthcare team and knowing which specialty should be contacted is very important in maximizing the quality of care a patient receives during her treatment. Nurse practitioners can be a very important part of the mothers care and often can serve as coordinators throughout the process optimizing the results of care. The information in this article can help in assisting the nurse with recognition of medication errors and contacting doctors on possible contraindications with prescribed medications, understanding proper diagnostic studies and the rationale behind each, and the proper monitoring that should be provided to a mother with cardiac disease throughout the labor and delivery process. Postpartum care varies when a mother is at risk for cardiac complications. It is important that a nurse recognize changes in vital signs and understand when to contact a physician for further assessment. This article points out possible changes that may warrant further evaluation from a
This week I felt conflict prior to my clinical days. I have always looking forward to my clinical days because this is the opportunity for me to apply what I learned from our textbook and skill lab to the real situation. However, because we are having our first med-surgical exam on coming Monday, my thoughts is to complete my clinical day as soon as possible so I can go home study. Despite my feeling prior to the clinical day, my mood change as soon as I step into the hospital because I knew I would learn something new every day. I immediately change my feeling of thinking about study to can’t wait to see what is going to happen during my clinical practice and hopping to follow a good nurse that is willing to teach me things that I haven’t learn.
The nurse who I assisted to ambulate this patient was much more knowledgeable about the strategies developed to communicate with this patient than I was. When the nurse communicated with this patient, she spoke directly to the patient where the patient was able to ...