Using diagnostics in the clinical blog

  • Identify up to five diagnostic tools used in acute or episodic care that you have used or seen used in your clinical practice.
  • Can you give examples of pros and cons to using or not using diagnostics? For example, the pros and cons of ordering a rapid strep test.

The diagnostic tools that I have seen in my clinical rotation are EKG, rapid strep test, pap smear, Hgb testing, urinalysis, and colposcopy. EKG provides basic information regarding the heart rhythm when a patient comes with chest pain, palpitations or irregular or skipped heart beats. Rapid Strep test used to rule out streptococcal infection to provide antibiotics needed for the patient. Pap smear is diagnostic screening procedure for cervical cancer. It tests for the presence of precancerous or cancerous cells on the cervix, the opening of the uterus. When the pap smear results show abnormalities than colposcopy test performed to get a biopsy from the cervix to detect cervical cancer. Hgb testing is done to check the level of Hemoglobin level in patients with anemia, recent heavy bleeding. Urinalysis is screening test to detect problems related to urine such as urinary tract infections.

The pros of these diagnostic tools help to make accurate and early diagnosis to initiate treatment as needed. It helps to detect contagious infections early. The cons of using diagnosis are that they are not always correct if the sample is not taken the correct way it is supposed to it gives false results. It is difficult to estimate the impact the various measurement tools identified in this review would have in improving patient safety. Tools in primary care environments have the potential to contribute to a serious error that can cause both morbidity and mortality; which has been demonstrated in the field of prescribing.

Reference:

Tools for primary care patient safety. (n.d.). Retrieved October 06, 2016, from http://www.medscape.com/viewarticle/834550_2

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Using the evidence in practice

I choose urinary Tract Infection as an acute and episodic condition.

Recently there is a new FDA warning regarding the use of Fluoroquinolone Antibacterial Drug. FDA recommends that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with sinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options. My preceptor made a decision to follow this guideline regarding the prescription of ATB for uncomplicated urinary tract infection.

According to the recommendation, treatment of choice for uncomplicated UTI is as:

First line treatment – 3 days of Sulfa or 5 to 7 days of Nitrofurantoin.

Second line treatment – 3 days of Quinolone (contraindicated in pregnancy) or 7 days of Amoxicillin.

I accessed the website by using word urinary tract infection in search and found this FDA recommendation/warning which I was already made aware last week during the encounter with a patient who diagnosed with urinary tract infection. This website is really a good source to learn about FDA approved recommendations regarding different diagnosis and treatments associated with them. I have seen some other recommendations which are currently used by my workplace but I was not sure why we do the things like this, my thinking was it’s a way to do things. It is a good source to enhance knowledge and to keep up to date with recent information. This guideline is going to be followed in my clinical setting.

Reference:

Specialty, B. C. (n.d.). Urinary tract infection. Retrieved September 25, 2016, from http://www.guideline.gov/summary/34419/urinary-tract-infection

Getting started blog

New skills learned during the first semester are:

·     Detailed history taking, physical examination, making a diagnosis, and prescription of drugs in certain conditions.

·     Assessment of adults throughout the stages of chronic illness.

·     Distinguishes between normal and abnormal change with aging and diagnoses commonly occurring complications of chronic health problems.

·     Exposed to common mental health and substance abuse problems such as anxiety, depression, obesity, alcohol, and drug abuse.

·     Learned to use the latest technological innovations to enhance access to the programs clinical site is using.

Learning goals for N679L – 

·     Synthesize assessment data to diagnose and manage patient health and illness needs

·     Focus more on making a differential diagnosis so that it help to provide more safe, evidence-based, patient-centered care that reflects ethical clinical judgment and inter-professional collaboration.

·     Integratively assesses, diagnose, plan, implement, and evaluate cost-effective healthcare strategies.

·     Evaluate health needs of populations I’m dealing with in clinical site for necessary teaching and education to promote health and prevent illness/injury.

·     Continue professional growth through continuing education of current semester course material and engage in lifelong learning and the professional development of self and others.

·     How to make appropriate referrals to other health care professionals and community resources for individuals and families.

I get to know numerous diagnosis, procedures, and medications in my journey of FNP; some from those are Pap smear, colposcopy, correct prescription of narcotics.

The first week in woman’s health specialty was full of excitement to learn about new procedures as well as nervousness to talk about questions related to sexual health of patients. It was not too bad with the guidance of a proficient and experienced preceptor.

Reference:

Sales, A., Smith, J., Curran, G., & Kochevar, L. (2006). Models, Strategies, and Tools: Theory in Implementing Evidence-Based Findings into Health Care Practice. Journal of General Internal Medicine, 21(Suppl 2), S43–S49. http://doi.org/10.1111/j.1525-1497.2006.00362.x

Teamwork and Interprofessional Collaboration Blog

Definition of teamwork: A team consists of two or more individuals, who have specific roles, perform independent tasks, are adaptable, and share a common goal (Baker et al., 2006).
My clinical setting is a primary care clinic in which there is 2 MDs, 1 NP (my preceptor), 3 medical assistants and 1 registration clerk. NP is very experienced and she is in this field from more than 15 years. The clinic is doing an excellent job in providing services to the local residents and served a large number of population as there are not many primary care clinics in this area. In clinic from 2 MDs, one is eye doctor who barely talk to staff besides his own medical assistants. NP communicates with physician and medical staff very often and they all work as a team and it helps to run clinic smoothly. Chief medical officer of the clinic makes rounds once in every few days and talk to everyone but otherwise, most of the communication with her is through email, unless if anything urgent then they call her. As I believe in: Teamwork as an Essential Component of High-Reliability Organizations. This clinic is small, without enough support for employees but still they work together to run it smoothly. In my future, I’m looking a place which has more opportunities.

Reference:

Baker, D. P., Day, R., & Salas, E. (2006). Teamwork as an Essential Component of High-Reliability Organizations. Health Services Research41(4 Pt 2), 1576–1598. http://doi.org/10.1111/j.1475-6773.2006.00566.x

Ethical Practice Blog

The Principal of Beneficence

Definition:  Compassion; taking positive action to help others; desire to do good; core principle of our patient advocacy. It is a heart of everyday health care practice.

A clinical visit in which I participated with my preceptor, we used the principal of Beneficence for Hispanic  48 years female presents to the clinic with breast pain on her right side. On assessment, I asked her to describe the nature and exact location of pain. She had constant pain in her upper right abdomen that radiates to the back. On palpation, she had tenderness over abdomen with nausea and vomiting, all these symptoms give us the red flag of possible inflammation of gall bladder (Cholecystitis). The patient has explained it is not a breast pain, she needs immediate care by doing an ultrasound or CT scan. The patient was transferred to the emergency department.Sometimes patient’s are not able to decide what is good for them and they fail to recognise what is going on with their body and on that time it is the responsibility of healthcare providers to do good for them. “The process of applying principles to the particular situation should be carried out objectively, with the subject deciding in a calm and detached manner the relative importance of each theoretical principle” (Limentani, 1999).

Reference:

Limentani, A. E. (1999). The role of ethical principles in health care and the implications for ethical codes. Journal of Medical Ethics, 25(5), 394–398.

Theoretical Framework and EBP Blog

Health belief theory 

The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Public Health Services.

Case # 1- Mrs. M.K. is 56-year-old white female came to the clinic with hypertension. She has a history of non-compliance related to her medications. She has a family history of heart diseases. On this visit, she mentioned her concern regarding getting heart disease as her husband is asking her to change behavior related to non-compliance, her blood pressure is on the higher side and the patient is asking for help.

According to the Health belief model:

  1. Perceived susceptibility- It is one’s opinion of chances of getting a condition. Mrs. M.K. is on stage where she is thinking she can get heart diseases based on her hypertension and family history.
  2. Perceived severity- One’s opinion of how serious a condition and its consequences are, Mrs. M.K. understand the severity of her hypertension and its effects on the body.
  3. Perceived benefits- One’s belief in the efficacy of the advised action to reduce risk or seriousness of impact. Mrs. M.K. understand the benefits of taking blood pressure medicine.
  4. Perceived barriers- One’s opinion of the tangible and psychological costs of the advised action. She has a blue cross medical insurance that can cover the cost of her medicines.
  5. Motivation: Patient is really motivated to change non- compliance behavior.
  6. Modifying factors: She has some positive modifying factors such as family support, patient satisfaction related to her provider guidance. 

    Reference:

    Health Belief Model. (n.d.). Retrieved May 30, 2016, from http://currentnursing.com/nursing_theory/health_belief_model.html

     

Safety in practice

Two common areas where errors occur in the clinical setting are related to:

  • giving immunizations with the correct documentation

Giving proper vaccination is as important as giving correct medicine to patients. Most common errors occurred when prescribers failed to recognize the correct age of patient for vaccination and staff is not updated regarding the new recommendations for the vaccines. To avoid these type of mistakes staff should receive ongoing education, such as whenever vaccine administration recommendations are updated, or when new vaccines are added to the facility’s inventory, to maintain staff competency.

Some other examples of immunization errors are:

Drug administered at inappropriate site

Drug administration error

Incorrect drug dosage form administered

Incorrect drug administration duration

Incorrect route of drug administration

Multiple uses of a single-use product

Wrong technique in drug usage process

  • writing prescriptions

Prescription errors are a major problem among medication errors. Errors often arise from a lack of knowledge about drugs, including indications and contraindications, appropriate doses, maximum dosages, routes and drug interactions. At my clinical site prescribers always attend seminars and meetings related to new research in medicine field. If they are doubtful regarding doses they always confirm with recommended doses through medicine sites or books.

Communication failure: When communication failed between prescriber, assistants and pharmacies errors occurred such as poor handwriting, misinterpreted verbal orders, use of abbreviations and missing decimals are some sources or errors. Read back the orders can help to prevent these errors.

Reference:

Velo, G. P., & Minuz, P. (2009). Medication errors: prescribing faults and prescription errors. British Journal of Clinical Pharmacology67(6), 624–628. http://doi.org/10.1111/j.1365-2125.2009.03425.x

Vaccine Administration. (2015). Retrieved May 18, 2016 from http://www.cdc/gov/vaccines/pubs/pinkbook/vac-admin.html

Safety in practice

Two common areas where errors occur in the clinical setting are related to:

  • giving immunizations with the correct documentation

Giving proper vaccination is as important as giving correct medicine to patients. Most common errors occurred when prescribers failed to recognize the correct age of patient for vaccination and staff is not updated regarding the new recommendations for the vaccines. To avoid these type of mistakes staff should receive ongoing education, such as whenever vaccine administration recommendations are updated, or when new vaccines are added to the facility’s inventory, to maintain staff competency.

Some other examples of immunization errors are:

Drug administered at inappropriate site

Drug administration error

Incorrect drug dosage form administered

Incorrect drug administration duration

Incorrect route of drug administration

Multiple uses of a single-use product

Wrong technique in drug usage process

  • writing prescriptions

Prescription errors are a major problem among medication errors. Errors often arise from a lack of knowledge about drugs, including indications and contraindications, appropriate doses, maximum dosages, routes and drug interactions.

Communication failure: When communication failed between prescriber, assistants and pharmacies errors occurred such as poor handwriting, misinterpreted verbal orders, use of abbreviations and missing decimals are some sources or errors. Read back the orders can help to prevent these errors.

Reference:

Velo, G. P., & Minuz, P. (2009). Medication errors: prescribing faults and prescription errors. British Journal of Clinical Pharmacology67(6), 624–628. http://doi.org/10.1111/j.1365-2125.2009.03425.x

Vaccine Administration. (2015). Retrieved May 18, 2016, from http://www.cdc/gov/vaccines/pubs/pinkbook/vac-admin.html

 

Getting Started Blog

  • Preceptor’s expectations and concerns of working with an NP student

Direct questioning is the biggest thing on which my preceptor wants to focus. It helps to stimulate thinking and allow the student to share observations and interpretations with the preceptor.

Critical thinking needs to be applied while addressing each patient and feedback from preceptor will be given frequently.

Actively participate in making the assessment, plan and clear all doubts same time.

  • How your preceptor is applying the clinical thinking process to patient care.

critical thinking in nursing is an essential component of professional accountability and quality nursing care.

Applied research-based knowledge while addressing patient’s concerns.

Using decision-making skills and clinical judgement.

Focus on problem-solving skills and maintain the professional practice.

  • Drugs used in practice this week

Tramadol 50mg PO BID for pain management

Adderall 10mg PO once a day for ADHD

Claritin 10mg PO one time daily for allergy

Acyclovir 800mg PO every 4hrs for 7days for Shingles

My first week in clinical practice was awesome and I learned a lot of new things such as how to interact with patients in the clinic setting as I always worked in the hospital setting, the environment was a little bit different.

 

Interprofessional Education and Collaboration Blog

Transformational Leadership Theory

Transformational leadership, developed first by Burns (1978), is based on the concept of empowering all team members (including leaders) to work together to achieve a shared goal (Denisco and Barker,2016, p. 135). Advanced practice nurses are being called on and challenged to lead changes in the healthcare organizations to improve quality, decrease adverse events, reduce costs and enhance patient satisfaction. Transformational leadership is widely accepted in the healthcare industry and nursing is the preferred leadership style to accomplish this goal.

The Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, identifies Interprofessional collaboration among health care providers as an essential part of improving the accessibility, quality, and value of health care in the United States. Interprofessional practice include integrated care, team approach (through training and education), communication, and respect (Interprofessional Education Collaborative Expert Panel, 2011). Health professionals can improve the quality and coordination of healthcare by promoting a team-based approach to education and practice across all health disciplines.

Communication is needed in Interprofessional education and SBAR (Situation, Background, Assessment and Recommendation) is a best example as many facilities are paying attention on this to encourage their staff for effective communication. This method allows all participants to participate consistently in communication. Interdisciplinary team work is a complex process in which different types of staff work together to share expertise, knowledge, and skills to impact on patient care. It includes the interdisciplinary team of healthcare field. Everybody who is a part of team can lead it. Lack of communication creates situations where medical errors can occur. These errors have the potential to cause severe injury or unexpected patient death. Some other potential barriers are lack of training in interprofessional collaboration, lack of framework for problem discovery and resolution, lack of commitment of team members, and inadequate decision making.

Reference:

Clarke, P., & Hassmiller, S. (2013, October 26). Nursing leadership: Interprofessional education and practice. Retrieved from http://www-ncbi-nlm-nih-gov.samuelmerritt.idm.oclc.org/pubmed/24085670?dopt=Abstract

Denisco, S. M., & Barker, A. M. (2015). Advanced practice nursing. Burlington, MA: Jones & Bartlett Learning.