Reflection

At this point now, I feel more prepared to practice as a Family Nurse Practitioner (FNP). Backed up with the knowledge I gained during the two years of studying for this program, I could say that it helped me to be a powerful NP who can treat the patient safely with high quality using critical thinking skills.

Though I have not mastered all of the common diagnoses yet, I feel that I need to research further on sports medicine-related topics. I am confident about assessing for musculoskeletal problems but I believe that I have to learn more to better diagnose sports medicine-related diagnoses.

Reflecting on the goals that I set for the week 1 of the course, I am proud to say that I met all of it. The goals include being more familiarized with the differential diagnoses pertaining to the chief complaint to better diagnose a disease. In addition, it also includes filling in gaps in learning with regards to assessing, diagnosing, planning, intervening, and evaluating. This is as evidenced by exposing myself to all evidence-based knowledge that I came across throughout this learning experience. As we know, nursing and medicine are two evolving aspects of healthcare, and that paired with a non-ending commitment for excellence by voluntarily updating myself to things that are new and modernized. In the future, as I apply all these learning into practice, I will make sure to go back and be mindful to apply all the education I gained when seeing patients.

Presently, the goals that I have placed for myself is to review and prepare for the boards. I will make sure to pass the boards to be able for me to fully apply all the learning that I received to the practice. From there, I will look for a job in a setting which I really like. Though I know that I am almost done with this program, I will not stop learning. In order for me to do that, I will expose myself to people, events, conferences out there that relate to family practice as a FNP.

Delivering Difficult News

This week, we are asked to execute ways on delivering difficult news to the patient using three different cases. One of the three cases I chose is a 33-year-old female who is 11 weeks pregnant who has been having pelvic cramping and vaginal bleeding since three days ago. Her quantitative hCG today has decreased since it was checked a couple of days ago. Based on the signs and symptoms, she is having a spontaneous abortion. The second case that I chose is a 52-year-old female patient who had a mammography and found some abnormalities in the test. She was then sent for a biopsy and was diagnosed to have stage II breast cancer. Lastly, the third patient that I chose is a 17-year-old female who is in the clinic for painful vaginal sores. She was diagnosed with genital herpes.

The questions for these cases are: What do I tell them? What are the next steps in their treatment? To answer the first question, I will tell them their diagnoses. However, I will inform them their diagnoses in a sequential and more therapeutic way by the use of SPIKES protocol (Setting, Patient perspectives, Invitation for information, Knowledge, Explore emotion, Summarize) (Clinical Advisor, 2015). I will first make sure that the setting of where I am going to talk to the patient is in a quiet environment in which there are no detractions. When I talk to the patient, I will make sure that there is proper eye level and that he/she is comfortable. Second, I will make sure to ask patient’s perspectives. By doing this, I am aware of the reason the patient is in the clinic and what he/she is thinking about the symptoms that were presented in the clinic. Thirdly, I will ask if he/she is ready to hear more about the diagnosis. This is the stage in which patient is starting to get a hint of what the diagnosis is about. The more therapeutic way to handle the situation is to at least ask the patient if he/she is prepared to hear further details of the problems. From there, the fourth important aspect is to talk to them at their level of knowledge. I would refrain from using medical terms that they cannot understand. Rather, I will use layman’s term for them to easily understand the message I am trying to convey. By now, they have the information that they want to know. This is the perfect time to explore their emotion and empathize. I can do that by directly asking the patient about what they feel about the news while being empathetic to the situation. Finally, after relaying the news, I will summarize everything that the patient and I have talked about. This will facilitate confirmation that the patient gets the right information.

The next step in the treatment of the 33-year-old female patient who is having a spontaneous abortion is to do a transvaginal ultrasound, to prepare her for a dilation and curettage (D&C) and to monitor the decreasing number HCG. Our goal for her HCG is to completely decrease down to pre-pregnancy level. She should be advised not to try to get pregnant until after three menstrual periods after the D&C.

As for the second patient, a 52-year-old woman who was diagnosed with breast cancer, she will be referred to an oncologist to manage the breast cancer.

Lastly, the 17-year-old female will be counseled about the mode of transmission of genital herpes, prevention, and treatment about the problem. She will be started on an antiviral medication. Her partner should also be treated.

Reference

Clinical Advisor (2015). The spikes protocol for telling patients bad news. Retrieved from https://www.youtube.com/watch?v=Kh67JV3W0Zk&feature=youtu.be

 

 

Ethical Decision Making

In the case study for this week, I chose Otto’s family’s viewpoint. With that viewpoint, I paired it by using beneficence, the “do good” ethical principle. Beneficence is a normative statement of a moral obligation to act for the others’ benefit by preventing or removing possible harms (Stanford Encyclopedia of Philosophy, 2013). Since Otto has been recently diagnosed with HIV encephalopathy in which he is manifesting unstable behavior to others and some confusion, he is not in the right situation to know the truth about his diagnosis. In the past, he was aggravated and became uncontrollably angry when the doctors told him his medical problem. At this point, I am more concern of Otto’s safety and his emotional stability. By not telling him the truth facilitates an ethical responsibility of his family to act for his benefit of being in a harmless situation. Using beneficence promotes important and legitimate interest by preventing or removing possible harms to Otto, his wife, and their kids.

On the other hand, the opposing view, which is the provider’s viewpoint, promotes an ethical principle of autonomy. Autonomy is the acknowledgment of Otto’s right to make decisions and choices, to hold views, and to take actions based on personal values and beliefs. Because he was diagnosed with HIV encephalopathy, a medical problem that affected his brain that disturbed his ability to think right, autonomy should not be utilized at this point. He does not show evidence of complete sound mind because of his medical diagnosis.

The resource that I may use at this point is to give Otto’s wife some education of the disease process about HIV encephalopathy. I will tell her about the disease, its pathophysiology, and the epidemiology. That way, she would appreciate the education regarding treatments, will be knowledgeable of the proper way to treat Otto and be empathetic of her husband’s condition. In addition, the other focus in the situation is for Otto to not feel distressed of his current situation. Educating Otto’s wife of the disease may facilitate more considerate outlook of Otto’s family to him and his medical problem. Finally, I will continue to provide medical care to Otto as a whole person. I will address what medical needs he has and answer all his questions while being a professional and ethical medical provider to him.

References

Stanford Encyclopedia of Philosophy. (2013). The principle of beneficence in applied ethics. Retrieved from https://plato.stanford.edu/entries/principle-beneficence/

Cultural Differences

One of the clinical facilities I am doing my internship at caters 80% of patients who speak Spanish, 20% are fluent in English. The language needs of the patients who speak Spanish are significantly high. Care can be more effective if the practitioner who takes care of them also speak or understand the language they are using to communicate. Fortunately speaking, the clinic I am interning at has staffs who speak and understand the Spanish language. These Spanish-speaking staffs can be so valuable to the patient who they serve. Though they also have providers who do not speak Spanish, they can make up and utilize the Spanish speaking staffs in translating for the patient, giving attention not to be biased or to change patient’s statements while doing the translation. In addition, each of the providers who are not 100% fluent in speaking Spanish has their own apps on their phone that they can utilize if the translator is not readily available. I can say that the resources available and system in placed, such as the Spanish-speaking staffs or using the app for translation, allow patients with language barriers to experience the same level and continuity of care as English-speaking patients. The benefit of the system in placed facilitates increased delivery of health care to patients. On the contrary, utilizing one of the staffs in the clinic as a translator not only produces waste of time on the part of the staff (who supposed to be doing his/her assigned job responsibilities than translating for the patient) but also may result in a “biased” translation of words from the patient to the medical provider. This will cause ineffective communication or worse, ineffective treatment and management of the medical problem of the patient. The recommended ways to better serve the patients who are not English proficient is to provide interpreter services to the patient in the clinic. Though it may cost them few more bucks in their expenses, interpreter services will provide an unbiased translation of words. I would say that though it is another expense in their budget, interpreter service is a financially feasible method that will benefit 80% of the clinic’s non-English speaking patients.

Practice Inquiry

Practice inquiry is conducted at two of my clinical facilities by bouncing each of the practitioner’s idea to one other. One example I can cite is a patient who came in the urgent care setting after coming back from a weekend snowboarding. The patient fell when he was snowboarding and hurt his left ankle. X-ray was done to rule out the problem from a very painful and swollen ankle. Initially, the physician assistant (PA) was the one seeing the patient, but the PA was uncertain of the right diagnosis to make based on the x-ray films that was obtained. The PA then called and asked for help from the medical director who has fair experience with sports medicine. In this example, practice inquiry was conducted in a way that each of the practitioners exchanged ideas to articulate a plan of care and to solve the problem. In my opinion, discussion of practice inquiry through exchanging ideas to another colleague is a way to be certain that the diagnosis given to the patient is precise. Precision will produce a provision of an appropriate management for the problem. Furthermore, before PA called the medical doctor, she stated that she used UpToDate application. Based on my personal experience, UpToDate is one of the most reliable apps I used when I am in the clinical setting especially if I have some reconsideration about patient’s health problems. I believe that the use of this kind of electronic resource can improve practice inquiry at the clinical site in a way that it does not only provide accessibility on the part of the practitioners but also provides evidence based and peer reviewed source that can be applied to the appropriate population group.

Tech Tool Review

As we know, chronic health conditions are paralleled to a continuous monitoring of patient’s condition to be able to reach the goal of a high quality of life of a patient. Electronic Health Records (EHRs) in the clinical site are used to offer primary care providers (PCPs) accurate and complete information about a patient’s health. It is a very effective tool in the continuity of providing treatment and care to the patients with chronic conditions. It allows PCPs to see what kind of treatment and management were given to address the condition. It also allows coordination and collaboration of care to all involved in the healthcare management team.

The performance of the EHRs used in my clinical site is superb in a way that it has the ability to quickly provide care. One example I can cite is that when treating a patient who is recently diagnosed with DM, a PCP can easily provide the care by documenting the trends in patient’s blood sugar and compare it from the one inputted from past visits. It also allows the PCP to instantly send the prescription to the pharmacy. This doesn’t only facilitate faster service but also enables an accurate documentation of the PCP on what is done on the face-to-face encounter with the patient.

In managing chronic conditions, the performance of the EHR can be improved by focusing more on its ability to coordinate care between healthcare providers, specialists, insurers, and patients. By doing so, all the patient’s vital information and data can come alive in a way that it displays trends, changes in the health data of the patient, and the effects of treatments prescribed. This will produce high patient outcomes by creating better medical decisions.

I am currently precepting at two different clinical sites. Both of them use a different type of EHR. What techniques that stand out to me in the way EHR swiftly sends the referral to the specialist to better manage the chronic ailments. In the past, there were no EHRs and everything was documented by writing everything on the paper. This technique provides a slower way and unsecured way of coordinating care to the specialist, pharmacy, and insurance. But now, through the use of EHR, the turn around time of referring and prescribing to patients are much faster.

Though both of my clinical sites use different EHR system, they have one commonality, and that is to provide a high quality of care and compliance with the health care laws, rules, and standards.

Getting Started

As I am thinking what to type for ‘Getting Started Blog’, I also started thinking how much work I have put into and how much knowledge I gained as I am finishing this journey of becoming a FNP. From the beginning of this journey and up until now, I learned a lot of new things about transforming the role of being an RN to a FNP. I learned to assess a patient by history taking, documenting, creating a plan of care, intervening, and evaluating at a higher level as a master’s prepared nurse. I also learned to recommend and prescribe a right treatment plan for a certain problem of age-specific patients. It sounded like a lot, but that would not stop me from there. I know for a fact that I need more practice and exposure to be able to prepare myself to be a better provider. Hence, 680L is here to better exercise what I have learned from the past four semesters. For this semester, my three learning goals are:

  • To be familiarized to some differential diagnoses pertaining to a chief complaint to facilitate correct diagnosing of a disease
  • To continue to engage in filling in gaps in learning that need to be improved in terms of clinical skills of assessing, diagnosing, and prescribing appropriate treatments and providing correct education to the patients
  • To be involved in clinical updates based on evidence-based practice to be able to provide skills that are timely and relevant.

On my first week back in the clinical practice, I would say that it was a pleasant experience. I was able to do what I have been doing from the past clinical practicum such as assessing patients, taking history, giving recommendation and education to the patient, and documenting. I feel like that first week of clinical rotation is a breath of fresh air as I am currently exposed to a new setting: urgent care. I am also doing women’s health. I am optimistic that I will learn a lot of things in another exciting journey of becoming a FNP. I am looking forward to learning more on the management of common complex chronic conditions. At the end of the day, though a lot of hours need to be done for the internship, I take the experience as a win-win situation in which I don’t only learn but I also help patients in their journey to have a better health.

“Practice Inquiry, What is it?”

Twice a week, my clinical preceptor does her administrative duty as the medical director of the clinic. She does it not only to focus on the administrative aspect of the business but also for clinical works to ensure that high quality of care is provided to the patients. One practice inquiry that my preceptor shared with me is their weekly meeting of uncertain patient cases. These uncertainties are being presented with the rest of the doctors, NPs, and PAs to find more learning and solutions about the clinical ambiguities. Through this, they can talk about implementing clinical outcomes. Clinical outcomes in the clinic are implemented by first setting objectives. Their plan is to enlist the best interventions to meet the clinical outcomes while focusing on a better and safer care.

e-Portfolio

Nurse practitioners are one of the forefront people in the healthcare. Being a nurse practitioner in the future and being one of the people in the forefront of healthcare, I am responsible for updating myself with the current healthcare trends. The ways I can continue my education is by joining nurses and nurse practitioners association. Some examples of the association existing at this time are American Association of Nurse Practitioners and California Association for Nurse Practitioners. These associations will facilitate exposure to different conventions, seminars, and educational opportunities. These are frequently moderated by a more experienced nurse practitioners with a goal to further knowledge and to catch up with the unending progress in healthcare. Furthermore, joining an association will open more opportunities to connect to fellow nurse and nurse practitioners. This will result in a greater opportunity to learn from other nurse practitioners through their experiences and become well informed about the developments in healthcare.

Attending annual conventions, taking advantage of continued education activities, and inclining oneself in knowing more news about up-to-date healthcare topics are my processes in discovering modalities and developing resources in a continued nurse practitioner education.

Patient-Centered Care

The ways patient and provider compromise and or collaborate care is first by establishing an open, constant, and effective communication (Finn, 2012). Being open, constant and effective is a technique wherein two or more people are able to understand each other. That is without any language barriers that could hinder them to exchange an important piece of information. Another way is to show a sense of veracity. One patient-provider relationship would not be effective in collaborating plan of care that aims high standard of care if one of the persons in the relationship is not telling the truth. Honesty is very important in patient and provider collaboration.

Patient-centered care is rooted from care provider’s respect to the patient in which patients are listened to, informed, involved in their care, and their wishes are honored (Rickert, 2012). The benefits of patient-centered care are improved communications with patients. This facilitates a better understanding of patients’ needs that can result in better patient outcomes and can increase patient satisfaction. Additionally, high quality and safe care are another benefits of patient-centered care. Because it is a personalized care, it values a person as a whole focusing on her mind, body, and spirit.

References:

Finn, N. (2012). Collaboration, communication and connection: Fostering patient engagement in health care. Journal of Participatory Medicine. Retrieved from http://www.jopm.org/opinion/commentary/2012/09/05/collaboration-communication-and-connection-fostering-patient-engagement-in-health-care/

Rickert, J. (2012). Patient-centered care: What it means and how to get there. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/