Daily Goals The Differentiated Essential Competencies (DECs) made by

Daily Goals

The Differentiated Essential Competencies
(DECs) made by the Texas Board of Nursing (BON) were initiated throughout the
clinical rotation at Las Palmas Medical Center Intensive Care Unit. On November
20, 2017 the seventh goal was to assume accountability for individual nursing
practice (Competency I Member of the Profession B5A. pg.24). This goal was met
AEB the documentation after any intervention was completed by explaining what
was done and the patient’s response. An example would be the student nurse
administering morphine and checking back to see if any respiratory depression
occurs. A modification could be to stay with the patient for five to ten
minutes after so that the student nurse can intervene more quickly for a
reaction.

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The eighth goal took place on November 21,
2017 and it was to comply with professional appearance requirements according
to organizational standards and policies (Competency I Member of the Profession
B8. pg. 25). This goal was reached AEB the student nurse’s appearance wearing
scrubs that were properly fitted, white shoes, no nail polish, and name tags
showing. Something that can be different is to have the hair up in a high bun
instead of one that is loosely done at the bottom of the neck to avoid it
getting exposed to bodily fluids. 

November 22, 2017 the ninth was done by
following confidentiality regulations (Competency IV Member of the Health Care
Team 4A. pg.78). This goal was completed AEB patient’s charts being placed
inside a drawer that contains a lock. Another example is logging off the
computer anytime the student nurse needed to step away so that no one can
access the files unless they had the password. Something that can be improved
is to not just turn the computer screen off but to completely log off because
anyone can turn it back on and see information that should be kept private.

Goal ten was on November 29, 2017 on
manager observation day dealing with time management (Competency IV Member of
the Health Care Team F3. pg. 87). This goal was illustrated by the
administrator on duty by her doing certain tasks before having to attend
meetings. She did everything by schedule and completed each task as expected.
The AOD demonstrated how time management played a huge role because the tasks
assigned needed to be addressed as soon as received in case there was a code or
MRT that she must attend. The way she scheduled herself was successful AEB her
completing everything needed, and I felt there was no modifications to be made.

November 30, 2017 goal eleven was to
recognize and manage conflict through the chain of command. (Competency IV
Member of the Health Care Team D5. pg. 83). On this day the goal was achieved
AEB the student nurse seeking out their preceptor to ask a question over
documentation that two other staff nurses disagreed on. The problem was whether
to document a patient as alert and oriented or not because there were times the
patient was involved and other times he would act as if no one was there
ignoring all questions. The preceptor sided with one nurse but ultimately the
charge nurse was brought into the situation in order to see what he would
choose. The director of the ICU was also involved because he found
discrepancies in the documentation and wanted to clarify the status of the
patient. In this situation I feel the chain of command was reached
appropriately but upon speaking to them the student nurse should have been more
prepared for the questions asked about the interactions with the patient.

The last goal took place on the last
clinical day December 1, 2017 and it was a self-evaluation, staff evaluation,
and peer evaluation process (Competency I Member of the Profession B5A. pg.22).
This goal was met AEB receiving my evaluation that had my personal critiques
that I felt I can work on and what my preceptor felt I lacked in. I also gave an
evaluation on the hospital staff which included my peers in my overall clinical
experience and what a significant impact they each made on me. I feel the
evaluation sheets were thorough in the questions asked to get a good
understanding of my experience. Possible modifications can include more
in-depth questions concerning the clinical process with more surveys to fill at
the end.

Case Discussion

One patient came into the emergency room
with a chief complaint of shortness of breath and chest pain. It was an
84-year-old man with a history of hypertension, diabetes mellitus type II, and
hyperlipidemia. The patient was admitted with congestive heart failure and
pneumonia and transferred to the ICU for careful monitoring. The patient
presented with dyspnea, jugular vein distension, orthopnea, tachycardia, use of
accessory muscles and upon assessment crackles were heard, and pitting edema
was a 2+. The vital signs were BP 158/92, respirations 22, O2 saturation 82,
heart rate 110, temperature 36.7 and on a pain scale of 1/10 a 7 was noted at
admission. Throughout the day the patient had poor urinary output ranging in
the 20’s each hour. Three priority nursing diagnosis is ineffective airway clearance,
impaired gas exchange, and decreased cardiac output. Ineffective airway
clearance R/T mucous secretions and trapped fluids AEB crackles, dyspnea, and
orthopnea. For this diagnosis aspiration precautions were initiated to maintain
an open airway, the head of the bed was elevated at least 40 degrees in order
to open the lungs for greater breathing, and suctioning as needed to clear
mucous that the patient was unable to cough out independently. Impaired gas
exchange was R/T CHF and pneumonia AEB crackles, O2 saturation <90, dyspnea, and tachycardia. A few interventions were teaching and encouraging deep breathing to allow greater oxygen intake, and a smoking cessation program was offered to help decrease the damage being done to the lungs because the patient had a history of smoking 1 pack a week since age 21. Decreased cardiac output was R/T CHF and HTN AEB dyspnea, fatigue, JVD, and peripheral edema. Interventions done were to check the mental status q2hrs because it gives an idea if more oxygen may be needed, and record I&O's hourly to see if the patient may need a medication to help increase urine output. The preceptor reviewed the diagnoses and agreed that the order and interventions were appropriate and realistic. Member of the Profession             Having a health care team is very important when dealing with patients because each person has a specific role that increases the quality due to people specializing in certain areas. As nurses we have a general understanding of everything going on with our patients but when we have specialist on our team it brings a variety of techniques and different approaches that are overall beneficial. Nurses used evidenced based practice to provide the best care they are capable of and there is always new research and studies being done that it's important to continue education to stay relevant and provide a safe environment with the most optimal practices. For registered nurses they are offered certifications and courses to keep current and they are constantly evaluated by the chain of command daily. Being a member of the profession requires communication to reach a goal effectively and efficiently. An example of good communication is the Cath lab team will come and communicate to the patient and the assigned RN about the procedure that is going to take place. The Cath lab will communicate with the RN the needs for the transfer like if the patient will need an oxygen tank and to remove the leads before they arrived to make the transfer quicker. Speaking with one another allows the care to be continuous and it avoids problems in the future.   Core Measures             Core measures are created by the Joint Comission in order to provide standards of care with common issues that occur in the hospital setting. The core measures are evidenced based and it allows the staff to see what should be done under certain circumstances. One core measure commonly implemented on the ICU unit is for an acute myocardial infarction. The nurse's role with this core measure is to administer the medication and check the medications prescribed at discharge which include aspirin, a beta blocker and a statin. Financial Management             DRG is a Diagnosis-Related Group and it is a system based on statistics that show payment needed by an inpatient based on groups they are placed in. This system divides and subdivides to reach Medicare reimbursement. DRG's affect the hospitals reimbursement by making anything provided for the patient to be done in an appropriate time frame. The nurse's role dealing with the DRG is to provide documentation as accurately as possible to avoid any discrepancies. The information impacts patient care by decreasing their stay and doing only the interventions that are truly necessary. Nurses are impacted by causing them to be fast paced and to put an extra strain on being safe in avoiding a longer hospital stay. The manager style of the director was democratic because he would ask for opinions and take into consideration what the staff had to say for example dealing with discharges and how to make the process quicker with greater communication. Professional organizations             I surveyed five nurses that were available to ask about any organizations they were in and two of them were in the American Association of Critical-Care Nurses or (AACN). This organizations mission is to strive for excellence because many people rely on their expert knowledge at a very critical time. Some of the benefits of this membership include education courses, scholarships, education activities, clinical references, and databases. HCAHPS             Hospital Consumer Assessment of Healthcare Providers and Systems is also known as HCAHPS and it is a standardized satisfaction survey that ultimately advocates for the patients based on the care they received. This survey allows patients to voice how their stay at the hospital was and it gives the public an insight on how others felt with their treatment. These surveys can help the public choose which hospital they would prefer to be in and it provides the hospital an opportunity to get reimbursement if they have a good reputation, which overall increases the motivation of staff to do the best they possibly can. Las Palmas Medical Center uses HCAHPS to stay competitive with the other hospitals regarding the quality of care being given. The manager explained that benchmarking is important but that they compare their quality of care greatly with Del Sol Medical Center. A leadership role was taken by the manager when reminding people of protocols like to turn on bed alarms, respond quickly to calls, and to always leave the room as clean as possible. Reflection of the Week             There were many learning achievements made throughout the second half of clinical, because I felt more confident in my actions that I pursued more opportunities. The main achievement I felt I accomplished was to become more comfortable with treating the patient and not always the monitors. When first arriving in the ICU I would respond to any slight change in the numbers when that's not truly the case. One example is the patients would desaturate when sleeping and I immediately wanted to turn up the oxygen, but I realize that it's normal and it's important to not abuse the drug. A few situations that allowed me to learn was anytime another member of the healthcare profession came in to do an intervention on a patient I would stay in the room to understand their role. A few examples are respiratory doing oral care or closed inline suctioning, physical therapy doing ROM in unique ways, and the wound care team doing redressing's. Watching the members do the interventions allowed me to see new techniques so that I can do these skills effectively when the other staff members are unavailable. I also got to learn a lot on manager day because I followed the administrator on duty which allowed me to go to all codes and see every floor in the hospital. I feel my manager style would be a mix between laissez-faire and democratic. Laissez-faire I feel can be used with a lot of nursing staff in the ICU because these are individuals who are capable of working individually with many years of experience motivated by good patient care. With registered nurses in the ICU I would want staff who can critically think without me constantly telling them what to do. I feel this type of leadership would be effective from what I've experience on the floor because I see the nurses take charge and place orders if ever needed just based off of labs and vitals. I would also have a democratic style so that I can hear ideas in order to grow and learn as a team. There are many staff meetings that take place and with proper feedback the quality of care can be improved.                 References American Association of Critical-Care Nurses. (n.d.). Retrieved December 01, 2017, from             https://www.aacn.org/about-aacn Differentiated Essential Competencies of Graduates of Texas Nursing Programs. (2011).             Retrieved November 30, 2017, from https://www.bon.texas.gov/pdfs/differentiated_ essential_competencies-2010.pdf Lippincott? ?Advisor? ?for? ?Education.? ?(n.d.).? ?Retrieved? ?November 30,? ?2017,? ?from? http://advisor-            edu.lww.com/lna/home.do;jsessionid=EA69385A7CD9D570EC674FE4AA92E63D The Joint Commission. (2010). Acute Myocardial Infarction (AMI). Retrieved December 01,       2017, from https://manual.jointcommission.org/releases/archive/TJC2010B/Acute        MyocardialInfarction.html What are Diagnosis Related Groups (DRGs)? - Medicare FAQs. (n.d.). Retrieved December 01, 2017, from https://www.ehealthmedicare.com/faq-what-are-diagnosis-related-groups/