Pet Week 5

Carroll Community College
NURS 242 – Nursing Concepts 4

Practicum Evaluation Tool (PET)
Purpose: By completion of the practicum learning experience, the student will provide written documentation of Evidence (see below) of how
each of the four course outcomes were met.
Directions: Step One to be completed by student and preceptor. Step two to be completed by student and submitted to Bb by end of each week.
Course Outcomes Step One - Planning At the beginning of each practicum week, develop Step Two – Evidence Document (students) how the plan
a simple but specific plan (one for each of the 5 outcomes). (for each outcome) was put into practice.
1. Apply the nursing Example: “I plan to provide nursing care for a patient diagnosed with Example: Document how care was provided using each
process (weekly) to _____.” step of nursing process.
optimize patient Week #1: I plan to provide nursing care for a patient diagnosed with After morning handoff report and prioritization of patient
health care congestive heart failure. care, we determined the patient who had higher acuity
and needed to be seen first. I went into the room to do
my morning assessment. I did a full head to toe
assessment, however my focus was the cardiovascular
system. This patient has a significant cardiac history and is
awaiting a heart transplant. The patient has a left
ventricular assist device (LVAD). I was sure to auscultate
heart sounds, palpate peripheral pulses, assess the
extremities for warmth and color, assess for swelling and
any abnormalities in the extremities such as dry, flaking
skin. The patient had a nursing diagnosis of being at risk
for decreased perfusion due to the condition and the
ability of the heart to do its job. After rounds with the
physicians and talking with the patient we determined the
plan and interventions for the day was going to be
continuing with the current medications for blood
pressure and heart rate, such as Lasix to for diuresis to
help with HTN, administer Heparin to prevent blood clots,
perform 12 lead EKGs, draw labs to monitor electrolyte
levels before and after administering the diuretic, replace
electrolytes (especially potassium (if needed). Towards
the end of the shift, another set of labs was drawn to
determine the need for electrolyte replacement,
replacement was not needed. The patient remained
stable throughout the shift with blood pressures and
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heart rate within the normal limits for the patient based
off their baseline.
Week #2: I plan to provide care for a patient post major cardiac event. Patient R.S. was transferred to Hopkins from Howard
County General Hospital following a cardiac arrest. Patient
was sent to the cath lab at HCGH for stent placement
after stabilization. Once he arrived to Hopkins, a head to
toe assessment was performed, with extra focus on the
cardiovascular assessments. Assessment included heart
sounds, palpating pulses, palpating the skin for
temperature, looking for presence of edema, cap refill,
and assessing the rhythm with the assistance of the
primary nurse. Patient assessment findings were: normal
sinus rhythm, BP stable in the 120s/70s, HR 80-90s,
palpable radial and pedal pulses, cap refill less than 3
seconds in bilateral upper and lower extremities, skin was
warm, dry and intact, no edema was noted. Patient had
blood shot eyes, doctors noted this to be from performing
chest compressions. Patient’s neuro assessment revealed
A&Ox4 with slightly withdrawn presentation from coping
with course of occurring events. Nursing diagnosis for this
patient was risk for decreased cardiac output and risk for
ineffective tissue perfusion related to injury to the heart
muscle during arrest. The plan/outcome for this patient
was to ensure the patient remained hemodynamically
stable after the arrest and placement of the stents. The
plan was also to have PT/OT follow the patient
throughout stay at Hopkins to increase his activity
tolerance. Patient was to remain at Hopkins for a few days
to be further monitored closely and then plan for
discharge home if hospital stay remained uneventful.
Implementation of interventions, patients on this floor
have their vitals taken every 4 hours, but for this patient
we were taking them more frequently (every hour) to
ensure he remained hemodynamically stable. This
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included close monitoring of BP and MAP, the patient had
a MAP goal of greater than 65, continuous telemetry
monitoring was initiated to reveal normal sinus rhythm,
consult with PT/OT to determine patient progress and
discuss exercise plan for after discharge, and initiate and
provide patient with a heart healthy diet. During the time
I cared for this patient, he was not on any drips, however,
we ensured he had multiple IV access sites that were
ready to use in the event of an emergency requiring life
saving medications. Labs were drawn to include
electrolytes, especially potassium and magnesium.
Patients magnesium remained on the low side of within
normal limits while the potassium was trending down
(result was 3.2). Potassium replacement, PO, was given
and repeat labs were drawn later in the shift which
resulted in an increase in potassium to the normal range.
Evaluation included evidence from lab draws that
electrolytes were stable after administration of the PO
potassium, patient remained hemodynamically stable
evidenced by MAPs between 65-70, BP 120/70s, HR 80-
90s in normal sinus rhythm. Patient tolerated first visit
from PT/OT. At the end of my shift, no alterations in plan
of care was needed.
Week #3: I plan to provide nursing care for a patient post cardiac This week I had the opportunity to care for a patient who
procedure. recently had a pacemaker inserted. She was post
procedure day 3 and was waiting for the decision to be
made if discharge home or to a rehab center was more
appropriate for her. The assessments for this patient was
a focused cardiac assessment to include HR, BP, heart
sounds, pulses in all 4 extremities, presence of edema,
assessing rhythm with the primary nurse. The findings of
the assessment included presence of trace edema in all 4
extremities, HR in the 70s, BP was normotensive
(120/80s), S1 and S2 heart sounds were present with no
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presence of murmurs, pulses in all extremities were
palpable (radial and pedal), and patient was in normal
sinus rhythm with pacemaker V-paced. Neuro assessment
revealed patient was A&O x4. Lung sounds were clear and
diminished in all lobes with no abnormal sounds noted.
Pacemaker site was also assessed to determine if there
were any signs of infection present. Signs that could
indicate infection would be redness and swelling at the
site, warmth, pain to touch, fever, and any changes in
drainage. Assessment findings revealed no signs of
infection through shift. A nursing diagnosis for this
patient would be at risk for infection. This patient is at risk
for infection due to the procedure of placing the
pacemaker. The patient had a small incision with a
transparent dressing with gauze underneath. The
plan/outcome for this patient was to communicate with
physicians, PT/OT, social work, and the patient’s daughter
to determine the best discharge plan. In conversation
with the team, it was being discussed whether the patient
was to be discharged to a rehab facility or to home with a
home health aide. PT/OT worked with the patient
throughout her stay to increase her strength and try to
get her to a stability where she could be discharged home.
Implementation of interventions included monitoring
vitals every 4 hours, administering ordered medications,
assisting out of bed when needed, continue with diuresis
overnight, and draw ordered labs. This patient was
brought into the ER with bradycardia (30-40s) and BP
readings that were fluctuating from the high to low range.
It was important for this patient to have continuous
cardiac monitoring to monitor the HR closely and ensure
the pacemaker was pacing as it should (v-paced). During
the 4-hour vital checks, BP was a top priority for us
because she has a history of HTN, was on Hydralazine for
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BP control, was on two diuretics, and had fluctuating
readings in the ER. If a reading was not in the parameters
the doctor ordered (goal: systolic >110, MAP >60, HR>50)
we made sure to notify him of the patient’s vitals. The
ordered medications that were administered throughout
the shift were Hydralazine and Nifedipine for BP control,
Spironolactone and Furosemide for diuresis, Melatonin to
help with sleep, and Isosorbide to assist with vasodilation
of the vessels to lessen the workload on the heart. When
the patient called to get out of bed, she was mostly
independent. She only needed a standby to assist to help
get the walker ready and standby her side in case she
needed some extra help/guidance. This patient had
gained 12 pounds in a week due to fluid volume overload.
Diuresis was important to lessen the workload of the
heart by removing some of that fluid. The ordered labs
that were drawn were BMP, CBC, and add on magnesium.
It was important for this patient to have these labs drawn
to monitor her electrolytes due to the heavy diuresis that
was taking place throughout her hospital stay. With this,
close eye was kept on her potassium and magnesium
levels. The provider ordered this patient to be on the
“Mag and K” protocol for repletion if necessary.
Evaluation of interventions proved to be successful. Vitals
had remained stable and within the providers ordered
parameters throughout the night. The provider was
notified two times throughout the night for BP readings
that fell below the systolic goal of >110. Those readings
were 102/62 and 104/68. The provider had ordered us to
recheck the BP is 30 mins and notify him if BP goal was
not met. No action was needed to bring the BP up, the
pressure increased to the goal when rechecked at the 30
min mark. The patient had not worked with PT/OT during
my shift as it was overnight, however when ambulating
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with walker in the room, the patient tolerated this very
well and needed minimal assistance. Her electrolytes and
CBC remained within normal limits; no repletion was
needed. Diuresis overnight was successful; total urine
output overnight was 1.7 liters. At the end of my shift, no
change in the plan of care was needed.
Week #4: I plan to provide nursing care for a patient post cardiac Patient A.H. was transferred to John’s Hopkins from an
transplant. outside hospital for a near syncopal episode. She was
transferred here for further workup of this episode as she
is in the process of transferring all care to Hopkins. On
admission, report from EMS was obtained and an
admission assessment was performed. Cardiac and neuro
assessments were the focus for this patient. The priority
assessments for cardiac was obtaining vital signs
especially blood pressure and heart rate, hooking up to
cardiac monitor to assess rhythm, palpate peripheral
pulses, assess skin for temperature and any breakdown,
and presence of edema. Findings showed BP of 84/52,
tachycardia in the 110-120s, rhythm showed normal sinus
rhythm with occasional PVCs, +3 palpable radial and pedal
pulses, warm, dry and intact skin, and presence of trace,
non-pitting edema in the bilateral lower extremities. The
priority assessments to obtain neuro status was asking
questions to determine alert and orientation status,
assessing reactivity and size of pupils, sensation in all
extremities, and presence of any headaches or light-
headedness. Findings from a neuro assessment included
A&O x4, pupils met PERRLA, sensation in extremities was
WNL and equal in all extremities, and no presence of
headache or light-headedness. A respiratory assessment
was done to include lung sounds, work of breathing, and
pulse ox. Lung sounds were diminished in all lobes with
slight dyspnea on exertion and pulse ox 99% on RA. A
nursing diagnosis for this patient would be at risk for
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impaired cardiac output. A.H. is at risk for impaired
cardiac output because an ECHO showed heart failure
with reduced ejection fraction of 35-40%. The
plan/outcome for A.H is to do a full workup and
determine if patient is rejecting transplanted heart. It was
determined the patient was rejecting the heart.
Throughout the course of her hospital stay, an extensive
cardiac workup is to be completed to determine the
eligibility for another heart transplant. Once workup
completed, plan for discharge and continue IVIG (IV
immunoglobulin) treatments outpatient and prepare for
another transplant if needed. Implementation of
interventions included assisting the physicians involved
with the plan of care for the transplant workup. Part of
the workup consisted of cardiac MRI, placement of
tunneled pheresis catheter, close monitoring of
Tacrolimus levels, diuresis, IVIG treatments, administering
medications to prevent further worsening of rejection and
pain control, and monitoring of electrolytes. After
placement of the pheresis catheter, the site was steadily
oozing for multiple hours. Multiple dressing changes were
performed, as the dressings were completely saturated
within an hour. It was important during this time to
closely monitor the patient’s heart rate and blood
pressure to ensure she wasn’t losing too much blood.
Patient remained stable. The doctors had ordered for
morning labs to monitor the Tacro levels. The stated goal
was for her to fall within the range of 10-12. It was
important to draw these labs in the morning so they could
result in time before administering her afternoon dose.
Diuresis was implemented in the plan to remove some of
the fluid she was retaining from worsening rejection.
Diuresis was established through administration of
Furosemide, however medication was held once due to
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low blood pressure. Other medications administered
throughout the hospital course was Aspirin, Plavix,
Magnesium Oxide, Prednisone, Tacrolimus, Tylenol,
Tramadol, and Myfortic. Myfortic, Tacrolimus, and
Prednisone were all administered to help with the
rejection. Tylenol and Tramadol were used for pain
control. Magnesium Oxide was used to keep magnesium
levels within the normal ranges. Lastly, Aspirin and Plavix
were administered as blood thinners. Electrolytes were
monitored through morning labs. All results came back
within the normal limits but once throughout the course I
cared for her. PO potassium was given to replace a value
of 3.2. Evaluation of interventions, cardiac MRI showed
no major changes since last cardiac MRI at the beginning
of 2021. Patient tolerated insertion of tunneled pheresis
catheter and oozing at insertion site was controlled after
many dressing changes with stat seal powder. Tacro levels
remained within the ordered parameters of 10-12, no
afternoon doses needed to be held. Patient tolerated
diuresis with Furosemide well and had an output greater
than intake. The insurance company was called to ensure
the patient’s IVIG outpatient treatments after discharge
would be covered, this decision was still pending upon the
end of my shift. Patient tolerated medication
administration and had no questions about medications
as most orders were her home medications or she had
received them during previous hospitalizations.
Electrolytes remained stable throughout, only requiring
one dose of PO potassium.
Week #5: I plan to provide nursing care for a patient undergoing a A patient I cared for this week is in the process of a heart
heart transplant workup. transplant workup. Patient D.G. has been admitted
several times throughout my practicum time for recurring
shortness of breath, a-fib with RVR, and HTN. This patient
has a history of HTN, a-fib with RVR, congenital heart
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defect of ventral septal defect, tricuspid and pulmonary
regurgitation, bicuspid aortic valve replacement, and right
heart failure with subaortic stenosis. As a child he
underwent many surgeries to correct the congenital heart
defects. Patient presented to Hopkins on 3-24 with left
sided chest pain radiating to shoulder and down his side
as well as shortness of breath and tachycardia.
Assessment for this patient was a focused cardiac and
respiratory assessment. Cardiac assessment included
auscultating heart sounds, palpating peripheral pulses,
visualizing extremities for presence of swelling and overall
condition of skin (dry, flaking, etc) as well as feeling for
temperature, and heart rate and blood pressure. Intake
and output was also monitored closely to ensure the
kidney’s were being properly perfused. Cardiac
assessment findings revealed normal S1 and S2 heart
sounds, strong palpable radial pulses and weak palpable
pedal pulses, presence of +2, pitting edema in the lower
extremities and no edema in the upper extremities, skin
condition was warm, dry, and intact, with no skin flaking
or dryness. Heart rate showed intermittent tachycardia as
high as 120 BPM and mild hypertension of 150/90s which
was later normalized with medication. Output showed a
close correlation with the output revealing proper kidney
perfusion and function. Respiratory assessment included
auscultating lung sounds, monitoring pulse ox, and
respiratory rate. Patient was at 98-100% on RA, lung
sounds were clear but slightly diminished in the bases,
and respiratory rate was between 20 and 30 breaths per
minute. Nursing diagnosis for this patient would be at risk
for decreased cardiac output. While this patient had a
slightly below normal ejection fraction, of 50%, he has an
extensive cardiac history (regurgitation, valve
replacements, a-fib with RVR, subaortic stenosis) that puts
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him at risk for decreased cardiac output. The
plan/outcome for this patient is to undergo diagnostic
testing to determine if the patient is eligible for a heart
transplant and to determine if there is something else
going on non-cardiac related. Patient was to undergo right
heart catheterization, chest and abdomen CT, head and
brain CT, and have multiple labs drawn. Interventions for
D.G. was controlling pain, diuresis, diagnostic tests, and
consulting with the health care provider to determine a
plan for the future. Pain medications (Tylenol and
Oxycodone) were administered to control the patient’s
7/10 pain. Patient received Spironolactone and a high
dose of Lasix (160mg) to achieve removal of the extra
fluid. Diagnostic tests such as lab draws, and urinalysis
were done. A paracentesis was also done at the bed side
to remove fluid in the pericardial sac; however, providers
did not find enough fluid to remove. Future scans such as
CTs and heart catheterizations were to be done, as well as
more blood work. Consent was received and witnessed
for the future procedures. After consultation with the
health care providers, they determined the plan would be
to perform and extensive workup to determine the
eligibility of a heart transplant and see if there is any
noncardiac issues going on. Blood pressure medications
such as Lisinopril and the above stated diuretics were
administered to bring patient’s blood pressure into the
normal range. Magnesium Oxide and Potassium were
replaced for lab values of mag: 1.4 and potassium 3.2.
Amiodarone was administered to control the tachycardia,
Heparin drip was started to prevent blood clots, and
Ceftriaxone was administered as a prophylactic antibiotic.
Evaluation of interventions included pain level reduced to
4-5 out of 10 after pain medication administration. Urine
output was 1 liter after administration of diuretics
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resulting in lower HR and BP. Lab results were
unremarkable which is why further diagnostic tests were
to be done in the future. Paracentesis was unsuccessful as
providers did not find enough fluid to remove from the
pericardial sac. After administration of diuretics and BP
medications, the BP returned to a normal range, 128/72.
Magnesium and Potassium lab values were within normal
range after administering the PO replacement (Mag: 1.8,
K: 3.7). Heart rate had returned to normal ranging from
70-80s, with mild tachycardia (110s) with activity. After
initiation of Heparin and Ceftriaxone, the patient showed
no signs of blood clots or infections.
Assessment - baseline and ongoing; identify & report changes in patient condition Diagnosis - prioritize patient care Patient outcome - work with patient to
establish measureable goals Interventions - evidence-based Evaluation - determine if patient outcome was met; alter plan of care as needed.
3. Assimilate into the Example: I plan to focus on establishing priorities this week. Example: What, when, where, why, how I established
profession of priorities
nursing (see Week #1: I plan to focus on establishing professional appearance and Sunday, February 7th was my first shift on the unit. I
examples below) behaviors. wanted to present to the unit in a professional manner to
provide a good reputation for not only myself but for my
school as well. I did this by wearing my proper school
uniform, maintained a professional demeanor when
interacting with staff and patients, utilizing the proper
PPE, and arrived on time to meet preceptor prior to the
start of my shift.
Week #2: I plan to focus on establishing collaboration with multiple This week I had my first night shift. During this shift, a
members of the health care team at Hopkins. nurse was admitting an unstable patient from the ER. My
preceptor and myself helped her admit this patient. We
did this by being the “runner” and getting whatever
materials she needed that was not in the room. Not long
after the patient was settled on the unit, a rapid response
was called for him. He was presenting with multiple
bloody stools (x5), changes to skin color (pale) and
temperature (cool), tachycardic and the lowest BP of
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55/38. Once the rapid response team arrived, clear roles
were established to make the emergency situation more
organized. Tasks that were divided among the team of
professionals were documenting, obtaining more IV
access sites, medication preparation, medication
administration, acting as a “runner” to get supplies on the
unit, and obtaining blood from the blood bank to prepare
for mass transfusion. My role in the situation was to go
with a nurse to obtain the blood. The patient was
stabilized and sent to the ICU after blood and Levophed
administration was initiated. When the rapid response
was over, we sat down as a team to discuss the event. We
collaborated among nurses and the responding doctors
about what we could have done to prevent the situation,
what we did well, and what could have been done better.
Week #3: I plan to focus on establishing priorities. This week I cared for the same patient twice. I cared for
her on 3/1/21 and 3/6/21. Patient, IP, had fallen a week
prior and was found to have an intracranial hemorrhage.
Before I had cared for her the first time, her hemorrhage
was managed on a different unit and was transferred to
the Progressive Cardiac Care Unit (PCCU) for further
hemodynamic monitoring. Caring for her on 3/1, she was
having multiple cardiac pauses throughout the night. (the
longest pause was 8 seconds). We notified the provider of
the patient’s pauses, the provider was not concerned at
the time as she was not symptomatic, no intervention was
ordered, except for continuing with continuous cardiac
monitoring. Patient’s HR was in the 80s-90s, with the
highest rate in the low 100s. A history of HTN was noted,
she was on Hydralazine to control the HTN, which was
resolved with BPs within normal, 110/80s throughout
shift. This patient continued to remain stable throughout
my shift on 3/1/21. When caring for her on 3/6, report
was given to include she received a pacemaker on 3/5 to
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control the cardiac pauses. It was also noted on 3/7 she
will be starting on Heparin drip until two therapeutic
doses are met. After the therapeutic doses are met, the
patient will be sent for a repeat head CT to determine the
status of the intracranial hemorrhage. If the head CT
showed no changes, the patient will be discharged mid-
week. JM was the other patient I was caring for on 3/6. He
was admitted for rule out TB. Patient has been declining in
health since February 2020. Multiple tests were done to
determine the cause of his decline in health and all results
have come back negative. Patient was sent to Hopkins for
an extensive workup involving infectious disease,
oncology, and rheumatology. Infectious disease is
involved to rule out TB, Brucellosis (Mediterranean fever)
and Whipple’s Disease (rare bacterial infection involving
joints and digestive system). After communicating with
my preceptor about the status of the patient’s, we
prioritized the need to see patient JM first. We had
decided this patient was the priority to see, as he needed
pain medications for 10/10 pain, he was presenting with
severe shortness of breath on 3 liters NC with saturations
90-92%, pericardial drain present (post procedure day 1),
had a thoracentesis in February 2021, unexplained weight
loss of 30 pounds, and was a new patient for the both of
us. This patient needed Dilaudid to be administered to
control his 10/10 chest pain and Tylenol to control a fever
of 38.6. Patient IP, we determined was stable and did not
need to be seen first. Her vitals were within normal limits
with HR in the 80s with pacemaker v-paced and BP was
120/70s. This patient had also met all her goals in her care
plan of achieve stable neuro status, maintain optimal
cardiac output and hemodynamic stability, achieve
optimal oxygenation, and pain control. The only
medications that needed to be administered for her was
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Hydralazine to maintain her BP within normal limits,
Atorvastatin, and stool softeners.
Week #4: I plan to focus on improving upon areas of weakness. During the past few shifts, I have been practicing giving
report to the oncoming nurse. This has always been an
area of weakness for me as I am not always sure what
information is pertinent to relay to the next nurse. On
recent shifts, I have been practicing giving report to my
preceptor, during down time, on our patients. We are
doing this together so she can explain to me what I did
well and what I should change or include in the report. I
have found this to be very helpful to know what
information I should include when reporting off to the
patient’s next nurse. After practicing a few times together,
my preceptor has been allowing me to give report to the
oncoming nurse. The first information we relay is patient’s
name, DOB, allergies, and code status. We then proceed
into PMH and their present illness that brought them to
the hospital. Next, is any abnormal findings that were
noted during the assessments and any abnormal lab
results, with focus on sodium, potassium, magnesium,
creatinine, and CBC. Lastly, we inform the nurse of the
patient’s cardiac monitoring orders (continuous or
intermittent), diet orders, when blood sugars need to be
checked (Q1, Q4, Q6, or ACHS), and any other special
things to make note of regarding the patient (major
events through shift, new orders, planned procedures,
etc).
Week #5: I plan to focus on participate in meetings that contribute to Each afternoon the nursing team has a meeting with the
professional growth. fellow of the medicine team to discuss the plan of care
and mobility level of each patient on the unit. These
meetings are called multidisciplinary rounds (MDRs). The
meetings consist of the fellow and resident, nurses,
charge nurse, social work, PT/OT, and sometimes
palliative care is involved. The purpose of these meetings
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is to establish a plan for the patient to inform all members
of the health care team such as those stated above.
Hopkins utilizes a process called highest level of mobility
(HLM) to set a goal and encourage the highest level of
mobility the patient should achieve. The highest score a
patient can be is an 8, which would be if they are walking
laps independently around the unit. The lowest a patient
can be is a 2, which is slight bed activity such as rolling in
bed. The team utilizes the HLM to assist them in making a
plan of care as well as with a discharge plan (going home,
to rehab, etc). Throughout the shift, we encourage our
patients to walk the unit if possible, or to utilize the
bedside commode or walking to the bathroom rather
than using the bedpan to promote mobility. These
meetings contributed to my professional growth as it
better helped be understand how important mobility is
and communicating with not only providers but other
members of the health care team who you may not
interact with each day on the unit. Encouraging mobility
not only prevents ulcers, but it improves the patients
healing process and shows their level of motivation and
dedication to their health.
Select one/week: Professional appearance/behavior; collaborate with member(s) of team; improve upon area of weakness; participate in meeting that contributes
to professional growth; use of info technology; establish priorities; delegation activity; recognize & seek assistance with unfamiliar task/patient care; report an
error
5. Provide patient- Week #1: I plan to focus on therapeutic relationship and I had a patient who previously had a heart transplant and
centered care (see communication skills. came in because he hadn’t been feeling like himself for a
examples below) couple of days. Doctors were trying to rule out an
infection or rejection of the transplanted heart. After
updating the patient in the morning about the plan for the
day of an echocardiogram, lung scan, and nuclear
medicine treatments he became emotional. He
mentioned to the team that he became depressed when
his wife fell a few months ago and needed knee surgery.
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He stated he was overwhelmed with taking care of his
wife, caring for the house, working, and taking care of
himself as well. At this point in the conversation the
patient became very emotional. He was crying and would
not make eye contact. The team (transplant team, nurse,
and myself) reminded him we were going to take very
good care of him so he could get home to his wife,
acknowledged he was upset, maintained an open posture,
sat down to be at the same level as him, lent a hand for
him to hold, and asked him of anything we could do to
make him more comfortable while he was in the hospital
away from home. After this conversation with the patient,
he remained sad for a short amount of time and his mood
drastically changed, he mentioned that he was in a much
better state physically and mentally, he continued to
express his appreciation for all staff throughout the shift.
Week #2: I plan to focus on infection control. This week I cared for a patient who was on contact
isolation for multidrug resistant organisms (MDR) and
latent stage syphilis. Prior to entering the patient’s room, I
used hand sanitizer to prevent bringing any organisms on
my hands into the patient’s room. I also utilized the
proper PPE for contact isolation, as well as continuing to
wear the proper PPE for COVID. I wore a gown, gloves,
mask, and face shield when in the patient’s room. Instead
of using my own stethoscope when assessing the patient,
a yellow isolation stethoscope, that remained in the
patient’s room was used. Prior to entering the patient’s
room, I gathered any needed materials while
remembering not to bring in too many items as those
items could not be taken out of the room and used for
other patients. When it was time to take the patient’s
morning weight, the scale was brought into the room and
cleaned thoroughly with wipes when we were done. Upon
exiting the patient’s room, PPE was doffed in the proper
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manner, hand hygiene was done, new gloves were
donned, face shield was cleaned, and hand hygiene
repeated.
Week #3: I plan to focus on patient and family education. This week was the first week I have attended practicum
when visitors were allowed. Upon entering the patient’s
room during change of shift, we informed the patient and
the family member that we would be caring for them
throughout the night and updated the patient and
daughter on the plan of care overnight. When we
administered medications, we told the patient and family
member what the medication was, what it will do for
them, and some potential side effects that may occur. It
was also important to continue to educate the patient
about falls risk. Each patient on this floor is considered a
high fall risk. Most patients on this floor are on multiple
medications that can alter their awareness and are
hooked up to cardiac monitors, oxygen and IVs. It is
important to ensure the patient and family knows the
importance of calling for staff when the patient needs to
get out of bed. Each time we left the room we were sure
the patient had the call bell and phone within reach, bed
was in the low position, reminded them to call for help
when needing to get up, ensure there was no clutter
around the room, and reorient them to their surroundings
when needed.
Last week I wrote about infection control, but I wanted to

add it in for this week again as infection control was a big
focus for my shift on 3/6. One of my patient’s was on
isolation for rule out Tuberculosis. He was on contact and
airborne precaution and placed in a negative pressure
room. Before entering the room, we ensured we had all
the needed supplies before entering to reduce the need
to leave the room. The proper PPE of N-95, surgical mask
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over N-95, gown, gloves, and face shield was worn in the
room. Proper hand hygiene was done before entering the
room as well as upon exiting the room. I had cleaned my
face shield each time I left the room because I knew I
would be wearing it in other patient rooms and did not
want to risk the spread of any organisms to other
patients.
Week #4: I plan to focus on patient advocacy. One patient was scheduled to have a transaortic valve
replacement (TAVR) procedure the next day. This
procedure was cancelled after a GI consult for mild
amounts of blood after a bowel movement. We believed
this was occurring from straining due to constipation. The
patient’s daughter was there and informed us that this
was not a new problem for their father. She had
mentioned this was an off and on issue for about 20 years.
The daughter said the patient has had multiple
unremarkable colonoscopy procedures in the past. The GI
doctors were concerned about the patient undergoing
this procedure if bleeding was occurring and informed the
cardiologist, they did not want the procedure done as
scheduled. The daughter was trying to find old medical
records from previous colonoscopies and visits with his
primary care doctor to prove this was an off and on issue
for years. We communicated the information the
daughter provided to us with the cardiologist. The amount
of blood in the patient’s stool did not concern the
cardiologist. He as well as my preceptor and I advocated
to have the procedure performed on schedule rather than
pushing it back to the end of the week. By the end of my
shift, there was no answer on when the procedure was
going to be performed.
Week #5: I plan to focus on discharge planning. This week we had multiple patients who were planning
for discharge during my shift. One patient did not get
discharged until three days after the expected discharge
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day due to lack of communication with her insurance
company. This patient was not able to be discharged on
time because the insurance company did not have the
needed information from the hospital stating her
outpatient procedures were life necessary. The insurance
company would not cover the outpatient treatments
without notice from the hospital stating the patient
needed these treatments until her heart transplant. The
patient needed to stay in the hospital an additional three
days so she could have the procedure done in house
rather than outpatient. This shows how important
communication is between the providers and outside
companies to ensure everything is set up for discharge.
Yesterday we had four patients, one of which was to be

discharged. We planned to see her first to administer her
few morning medications and to let her know the plan for
the day so she could let her ride know when to plan to be
at the hospital for pickup. We saw out other patients for
morning assessments and medications. After we laid eyes
on our all patients, we began the discharge process. The
patient called her husband to tell him to come pick her
up. The discharge process consisted of going over
discharge instructions, removing patient from monitors,
assisting with getting dressed, removing the IV, and
wheeling her to the main entrance. Communication was
important in this discharge as the patient needed to
communicate with her husband when to plan to be at the
hospital as well as communicating with the transporters
to plan to discharge the patient in the stated time frame
the husband would arrive.
Select one/week: Infection control; therapeutic relationship and communication skills; cultural competency (e.g., language, values, beliefs, sexual orientation,
age, physical and mental disability, etc.); patient advocacy; legal/ethical patient issue; discharge planning; and, patient/family education
6. Engage in evidence- Week #1: I plan to identify unit of facility policy/procedure that I was able to identify the importance of the Lifeline
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based practice (see directed specific nursing care. Transport Team throughout the John’s Hopkins system.
examples below) This transport team consists of a ACLS certified nurse, a
paramedic, and an EMT. This team is utilized to transport
critical and unstable patients throughout the hospital to
different rooms or any scheduled procedures. They do
this so the primary nurse caring for the patient does not
need to leave the unit and remain with the patient for the
unknown amount of time they will be off the unit. This
also enhances the safety and quality of care for the other
patients on the unit as their nurse will not have to
delegate jobs to other nurses while they are gone and
leave the patients unattended to. Patients who are
transported via the Lifeline team are transported on the
transport monitor and with any other necessary items
such as oxygen, ventilator, IV pumps, etc.
Week #2: I plan to use HIPAA when caring for patients. HIPAA was utilized throughout my shifts by logging out
when not at the computer, discarding all papers/labels
with patient information in the designated shred bins,
only communicating with people involved in my patient’s
care about their status, and not looking through patient’s
charts who were not assigned to me. Evidence shows that
many healthcare providers have become insensitive to
the high importance of complying with HIPAA (Borten,
2016). Research has shown that patient data is more
accessible to people with the use of EHR. Providers not
logging off the computer when stepping away poses a
risk. Using multiple devices to access EHRs rather than
only having a paper chart at the nurse’s station, also
increases the risk for HIPAA violation. Healthcare
professionals should recognize the importance of
maintaining patient privacy. HIPAA awareness can be
increased by stressing the importance of not accessing
information you are not supposed to, having more access
and utilizing the shred bins, logging off when leaving
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computer, being aware of surroundings and not
discussing patient care in public areas.
Kate Borten of The Marblehead Group. (2016, August 19).

The Role of Nurses in HIPAA Compliance,
Healthcare Security. Retrieved February 21, 2021,
from https://healthitsecurity.com/news/the-role-
of-nurses-in-hipaa-compliance-healthcare-
security
Week #3: I plan to research scientific rationale for specific nursing This week a nurse on the unit had a patient who had a
interventions. Swan-Ganz catheter. She showed me the set up in the
team room and then we went into the patient room to
see what it looked like in the patient and how the
numbers presented on the monitor. The numbers that
continuously present on the monitor were the pulmonary
artery pressure and the central venous pressure. The
normal for the pulmonary artery pressure is between 20
and 30mmHg. The normal for the central venous pressure
is between 2 and 6mmHg. Around 5am, she showed me
how the numbers are ran on the catheter. The other
numbers they look at when they do this are cardiac
output, pulmonary catheter wedge pressure, cardiac
index, systemic vascular resistance, systemic vascular
resistance index, pulmonary vascular resistance,
pulmonary vascular resistance index, left ventricular
stroke work, and right ventricular stroke work. The
scientific rationale for nurses obtaining these numbers in
the morning is to assist the providers in determining the
plan the care for the day. These numbers are also
important in determining the patient’s need for a left
ventricular assistive device (LVAD) or a heart transplant.
Swan-Ganz - right heart catheterization: MedlinePlus

Medical Encyclopedia. (2018, July 25). Retrieved
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March 6, 2021, from
https://medlineplus.gov/ency/article/003870.htm
Week #4: I plan to show how the six rights of medication This week I administered a variety of medications.
administration prevented an error. Utilizing the six rights of medication administration has
prevented me in performing medication errors. The six
rights of medication administration are right patient,
route, drug, dose, time, and documentation. It is very
important to check all of these before administering
medications. This prevents administering the wrong
medications to the wrong patients or giving too much or
too little of a medication. Utilizing the six rights of
medication helped me to prevent administering the
wrong dose of insulin. One of my patients was a type 2
diabetic. She required correctional insulin before meals as
well as sliding scale insulin. I was able to determine the
proper dose that needed to be given by checking the
orders with the administration time as well as the result
of the blood sugar. The patient had a schedule to when
they ate their meals, therefore the times the correctional
insulin needed to be given matched with mealtime. The
set dose for this was 1 unit before every meal. The sliding
scale insulin was a set order for every 4 hours after a
blood sugar was checked and a certain number of units
was to be given based on the result of the blood sugar.
Ensuring the 6 rights of medication ensured that I was
administering the correct dose of insulin at the right time,
to the right patient, via the subcutaneous route, and
documented whether insulin was given or held.
HCPro, I. (2019, August 12). Practice the six rights of

medication administration. Retrieved March 22,
2021, from https://www.hcpro.com/NRS-201830-
4931/Practice-the-six-rights-of-medication-
administration.html
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Week #5: I plan to utilize the ANA Scope and Standards of Nursing This week I cared for a patient who was in the hospital for
Practice. exertional dyspnea, fatigue, and had a pacemaker
inserted. This patient was asking my preceptor and I to do
things that were out of the nursing scope of practice. Her
hemoglobin results were 7.2 with AM labs, she asked us
to put an order in to transfuse her. We informed her that
we would have to speak with the doctors and have them
decide the necessity of a transfusion and order it if
needed. The doctor spoke with the patient and ordered a
transfusion. We transfused this patient and ordered
repeat lab draws after the transfusion. The policy for
Hopkins states these lab draws are nurse managed orders
and can be ordered without consulting the provider prior
to ordering if the providers name is stated in the order to
refer to if the lab has questions. Later in the shift, the
patient had asked us to give her Lasix because she felt it
was appropriate to initiate diuresis. We informed her this
was not in the providers plan of care and again, not in our
scope of practice to give a medication without an order.
The provider was notified of this patient’s request and it
was not ordered to be given as there was no need for
diuresis. The ANA Scope of Practice for Nurses is a
resource that states the duties and responsibilities of
nurses that can be performed within our license. It states,
“Nursing is the protection, promotion, and optimization of
health and abilities; prevention of illness and injury;
facilitation of healing; alleviation of suffering through the
diagnosis and treatment of human response; and
advocacy in the care of individuals, families, groups,
communities, and populations.”
A. (n.d.). Nursing Scope of Practice: American
Nurses Association. Retrieved from
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https://www.nursingworld.org/practice-
policy/scope-of-practice/
One/week: Identify unit or facility policy/procedure that directed specific nursing care; research scientific rationale for specific nursing intervention(s); how six
rights of med admin prevented an error; Use of: HIPAA, Maryland Nurse Practice Act, ANA Scope and Standards of Nursing Practice, and/or OSHA regulations
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Step Three – Reflective Practice
Directions: Student to submit reflective comments at the end of each practicum week (with steps two and three of the PET).
 Give an example of how you and/or your preceptor applied critical thinking skills this past week.
 What were your strengths this week (based on the learning outcomes)? Discuss an area you’d like to improve. Consider adding the area to
improve in your PET (see Outcome #2) for the following week.
 Questions/concerns?
Week #1 Critical thinking skills that were applied this week were prioritization based off patient acuity and any scheduled procedures for the day,
determining whether it was safe to give a medication or if it needed to be held after obtaining a set of vital signs (example: holding blood
pressure or heart rate medications if the patient was below the ordered parameters, holding electrolyte replacement if lab values were
elevated), communicating with doctors about changing in patient status and the next steps to take, and utilizing the hospital’s online policies
regarding compatibility of IV medications and nomograms for titrating Heparin off aPTT lab results. Strengths this week were therapeutic
communication with patients, administration of PO medications, navigating through patient’s chart to gain pertinent information regarding the
plan of care, and obtaining finger sticks. Areas I would like to improve on is finding a process that better flows for me when hanging, priming,
and programming IV medications. There are no questions or concerns for this week. I feel as if I had a great week this past week and learned a
lot, I am excited to continue throughout the coming weeks.
Week #2 This week my preceptor and I were able to utilize critical thinking skills during the medication administration process. A patient I was caring for
was starting bowel prep during my shift to prepare for a colonoscopy the following day. During the shift, the patient was put on a clear liquid
diet for breakfast and later made NPO, except for the bowel prep. We checked his sugar around 1500, at this time the patient’s blood sugar was
99. After discussion with my preceptor, we decided it was best for the patient if we held his dose of insulin, knowing he was going to be NPO for
the rest of the day. Patient remained stable throughout the shift with no changes in presentation. His daughter had visitor exceptions due to her
father having dementia and needing reinforcement of the need to finish the bowel prep. Bedside handoff report was given to the night shift
nurse, patient was still presenting as he had throughout shift. A few minutes later, the daughter calls for help due to rapid change in patient
condition. He became diaphoretic, had muscle spasms, slurred speech, and was in and out of consciousness. We called a BAT and checked the
blood sugar; the result was 20. The patient had become severely hypoglycemic. D50 was administered via the IV, blood sugar was rechecked
with a result of 317. After the patient was stabilized, my preceptor and I had a conversation about the importance of checking vitals signs and
lab results before administering medications for reasons like this scenario. Had we given the patient his insulin for a blood sugar of 99, his sugar
would have dropped rapidly, and he could have gone into a coma and had much worse outcomes.
Week #3 On 3/6, we got a new admission from the ER. This patient was brought in as a Jane Doe from home via EMS. She has a history of CKD, alcohol
abuse, and polysubstance abuse. She was found on the floor in her home and EMS was called. Her labs revealed positive for Benzodiazepine’s
and Fentanyl. In report from the ER nurse, it was unclear whether this was in her system because the patient had taken it or if it was
administered in the field by EMS. Upon arriving to our floor, the patient had told us she was drunk and fell off her kitchen counter. An initial
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assessment was performed, the Clinical Opiate Withdrawal Scale (COWS) and the Brief Alcohol Withdrawal Scale (BAWS) was obtained to the
best of our ability. It was difficult to get accurate answers for these as the patient was very disoriented and speech was slurred. During the
assessment, multiple bruises and abrasions were noted on her body. It was clear the patient was withdrawing at the time she got to our floor
evidenced by tremors, agitation, restlessness, anxiety, nausea, disorientation, and increased HR. We asked if she had ever had seizures during
withdrawal, to which she answered yes. We utilized critical thinking skills to communicate with the doctor and inform her of this new
information. Seizure precautions was not initiated in the ER and no x-rays were ordered. With this information we called the doctor using the
SBAR format and recommended initiation of seizure precautions and x-rays to determine if any fractures were present. By the end of my shift,
seizure precautions and x-rays were ordered.
Week #4 Critical thinking skills that were used this week in practicum were related to communication. A patient we had was very hard of hearing. He had
hearing aids but were not working at the time. Family had taken them to be repaired. Communication was hard with this patient due to the lack
of hearing aids. We decided it was best to communicate with this patient via writing on the white board. We knew we needed to think of a way
to communicate to this patient because we needed to inform him of the plan of the day, medication education, how to use the call bell and do
not get up without staff as he was a high falls risk, and as a reminder to order meals. Critical thinking skills were also used when determining
what room to assign this patient to. He was assigned to a room close to the nurse’s station as he was a high falls risk and was admitted after
falling when trying to get out of bed at the assisted living facility. Strengths for this week was increased confidence in medication education and
administration. This week was a medication administration heavy week. I cared for three patients each shift, all of which had multiple PO
medications, IV medications (primary and secondary), as well as topical medications. After performing the needed assessments prior to
administration and the administration process multiple times throughout the shifts, I feel as if my confidence has gained, and I am more
comfortable with some of the medications that I hadn’t heard of until reviewing the MAR and speaking with my preceptor before
administration. While I have practiced giving report more in the past few shifts, it is still something I would like to continue to improve on to
have a better understanding of the pertinent information that needs to be passed along. I do not have any questions or concerns after this
week.
Week #5 Critical thinking skills that were used this week were related to prioritization. Our assignment consisted of four patients and one empty bed. We
knew prioritization was important in the morning regarding which patient we saw first. After obtaining report, we knew all patients were stable
and were stable throughout the night shift. We decided to see the patient who was to be discharged that day. After discussion with my
preceptor, we decided to see her first because she had the fewest morning medications to administer, did not feed a full head to toe
assessment because discharge was ahead, and we knew we could spend the least amount of time in her room. The other patients needed a full
assessment, had multiple medications to be given, and the night shift nurse informed us some of the patients had special requests. Two patients
were NPO so we knew it wasn’t important to get in those rooms to administer medications that needed to be taken on an empty stomach,
where as with the other patients, they had medications that needed to be administered before they began eating breakfast. I feel that my
strengths this week was knowing what I needed to assess for before giving a medication. Heart rate and blood pressure needed to be assessed
before giving medications that would decrease these values. I knew it was important to assess this because if the readings were low, I would
know to hold the medication to prevent dropping the HR or BP too low and causing harm to the patient. The primary nurse administered blood
to one patient, she asked me if I knew the process for blood administration. I knew it was important to check vital signs to include temperature,
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HR, and BP before the transfusion could begin. My role was to assess vitals while the primary nurse began the blood administration with
another nurse to include matching the product with the order, confirming the right patient, priming the tubing, and programming the pump.
Another assessment that is important before giving medications is to assess pain before giving a pain medication. If the pain level does not meet
the order parameters, then it is important to hold the medication and administer a different pain medication based on pain parameters or try
nonpharmacologic measures. I do not have any questions or concerns about my practicum week.
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Mid-term and Final Evaluation
A. Mid-term evaluation
Triad to discuss how the preceptorship experience has helped the student attain course objectives at this point. Discuss strengths,
areas for improvement, other concerns. Develop a plan to meet course outcomes. Specify responsibilities for each member of the triad.
Student signature and date Preceptor signature and date Faculty signature and date
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B. Final Evaluation
Reflect on how course outcomes were met (include strengths, weaknesses, areas for improvement). Discuss how this preceptorship
experience might impact the student’s practice of nursing in the future.
The undersigned preceptorship triad agree that the student has met all course, learning outcomes:
Student signature and date Preceptor signature and date Faculty signature and date
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Carroll Community College

NURS 242 – Nursing Concepts 4

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Last week I wrote about infection control, but I wanted to

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Yesterday we had four patients, one of which was to be

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Kate Borten of The Marblehead Group. (2016, August 19).

Swan-Ganz - right heart catheterization: MedlinePlus

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HCPro, I. (2019, August 12). Practice the six rights of

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Step Three – Reflective Practice

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Mid-term and Final Evaluation

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