Nursing Journal Entry
The second week of my preceptorship brought many new experiences for me, and I can honestly say that each day I spend with my preceptor is better than the last. This week I focused on time management of a full patient load with continued documentation practice as well as admission and discharge procedures. I’ve had brief experiences in my past rotations assisting with discharge teaching and admission assessments however I have never been able to fully take charge and complete the process from start to finish, so this was a great learning opportunity for me.
My first day with my preceptor this week (Wednesday October 26, 2011) was cut short due to a school obligation and personal situation. Although I only spent five hours on my unit, I did my best to make them count. I was particularly excited for my patient assignment today because I was caring for two infants which is truly my passion. My first patient was the same patient I had cared for the previous week, a now 21-day-old baby boy admitted with a positive urine culture and blood culture.
I was glad to have this patient again because I was able to further build on my relationship with the patient’s Mother and reinforce the education I had provided previously. While caring for this patient I think I demonstrated the clinical competency of evaluating the effectiveness of the patient’s plan of care utilizing critical thinking and the nursing process and revising the patient’s plan of care. For example, this patient was responding well to his antibiotic treatment every six hours, as well as consistently taking in adequate amounts of formula with each feeding.
While calculating the intake and output I noticed that the patient was urinating excessive amounts. After assessing the hydration status of the infant, I questioned the primary physician regarding the need for the client to be receiving maintenance fluid at a rate of 10ml/hr. The doctor agreed that this was excessive for such a small infant and requested the maintenance fluid be decreased to a rate of 5ml/hr. I felt really good about recognizing this issue and making sure the plan of care with this baby was as updated as possible.
Another important clinical competency I experienced while working with this patient was identifying the necessity of constructive feedback from my preceptor and others. Specifically when it came to feeding practices by this patient’s mother who I felt was over-feeding the baby. I realized that after explaining the situation I was sounding judgmental, and that I needed to disregard my personal feelings about the mom’s feeding style and instead find opportunities to advocate for the patient and educate the mom further.
With advice from my instructor and the help of Kathryn we then placed a phone call to the hospital lactation consultants and arranged a meeting for her to come and work with the mom to try and encourage breastfeeding and offer further education about proper feeding practices for her new baby. On my second day of clinical experience this week I focused a lot on time management and documentation for a full patient load, and also on the admission and discharge process.
After taking report on all three of our patients, I began my initial morning assessments. It was clear that our 8-year-old post-operative appendectomy was ready to be discharged. My priorities were assessing her incision sites and ensuring the presence of bowel sounds, as well as making sure she did not have a fever and was tolerating a general diet. After completing my assessment and documenting in the computer, we received the discharge orders from the surgeon.
In the past I have merely observed my preceptor and other assigned nurses complete all the discharge paper work, evaluate the medication reconciliation, and provide the teaching, but this time things were different. Instead, Kathryn wanted to observe me. I felt very excited that she trusted me with an important task, and although she was sitting next to me walking me through the entire process, it was still an amazing learning opportunity for me.
I was able to manage the needs of my other two patients (a 22-day-old baby, and a 56-year-old pneumonia patient) and successfully complete the entire discharge process that included entering orders, reconciling the medications, administering a final dose of pain medication, and providing instructions and teaching to both mom and the patient before calling the departure. For the future I need to be a little more organized and have everything pulled together before going in to the room, for example this patient needed a note for her school, and mom had also requested a flu shot for her daughter before leaving.
Kathryn told me I did well, but next time I will make it a goal to not have to run back and forth out of the room to obtain additional things. Almost as soon as we discharged our patient, we were notified by the charge nurse that we would be getting a new patient, a 41-year-old woman with a DVT and a heparin drip. When the patient arrived I was able to complete the entire health history and admission assessment. It was my first time having to interview the patient about every aspect of their health.
I really enjoyed it, I was able to pull a chair over next to the patient and bring in a portable computer and have a great conversation about her health and reason for visiting. I think I did a great job documenting everything specifically and performing a very thorough and detailed initial assessment. In my opinion this was a great example of the clinical competency of providing an example of learning and professional growth. For next week, my goals will continue to be time management and documentation, with the added goals of keeping an open mind about all patients and doing my best to not sound judgmental.