Taylor Hughes

N611C
Journal 1
9/13/2013

Description
Today at clinical I took care of an 85 yo Male who presented to the ED with
episodes of vertigo. On arrival he had blood work taken to rule out an MI, exacerbation
of heart failure, and/or an infection. His blood worked reveled all of the above. He had
elevated tropnin so he was started on ASA, an ACE inhibitor and a beta blocker. He has a
chronic foley, which had caused him to get an UTI. He was also having an exacerbation
of his heart failure with blood work showing his proBNP to be 24,000. On top of all of
this a CXR showed that he has bilateral plural effusions in the bases along with
atelectasis in the left lower lobe.
When I first got report on him the nurse just said he had a UTI with pneumonia so
I was not expecting for him to have all of these issues. After reading over his chart
though I was amazed to see all that he had going on. When talking to him you would
never suspect so much to be going on. During my assessment I could tell that something
was going on with his lungs because they were very diminished in the bases but that is
the only part of my assessment that gave anything away. He was very alert and oriented
and didnt present with any signs you would normally suspect, no edema or chest pain at
all.
Through out the day all I got done was a head to toe assessment because he was
being pulled in every direction. First thing in the morning he was with respiratory therapy
and after that he was rushed down to x-ray. When he got back his nurse was with him for
a while doing her assessment and giving meds and when I finally went back in to finish
bathing and asking questions PT/OT was there working with him. By the time he was
done with them it was 10 am and he just wanted to eat breakfast, not to be bothered
anymore. About the time we left for post conference is when he was finishing up
breakfast so I did not finish up everything I planned on doing.
Feelings
When I first went in to meet my patient I was a little thrown off track because I
did not get a full report on why he was there, the previous LNA just told me he was here
for a UTI. Knowing only this I did not really know what my main focus should have
been. The LNA told to get orthostatic vital signs on him and when I started to do them
the patient informed me that he was still experiencing vertigo and that I needed to be
quick because he was very dizzy. When he told me this I was a little confused because no
one had mentioned this to me. I sat him down to relieve the dizziness he was feeling and I
figured this would be a good opportunity to listen to his lungs and heart while he was
sitting up. Starting there though threw me off my normal head to toe assessment that we
practiced in lab.
After heart and lungs I thought it would be a good time to test his strength in his
legs and hands since he was sitting. This really threw me off because thats normally the
last thing I do in my assessment. Once I completed that I lied him down and finished my
assessment but I had to jump around and go back to mental status, which is normally the
first thing I do. I got everything done but I felt a little flustered because I did it all so
jumbled up and not in any organized fashion, which is so unlike me. Besides this initial
visit the overall day went well and I felt confident in what I was doing LNA wise.
Evaluation
The good parts about the day were that I understood what was going on after
reading up everything. We learn all these lab results and diseases in class but we have
never really had any experiences with them. Being able to read my patients chart and
figuring out, for the most part, what things meant and piecing together what was going on
felt good. It was a good confident booster to know that what we are learning isnt just
going in to ear and out the other, say to speak.
The bad part of the day was getting used to the flow of the floor and how to
multitask/think. I know how the flow goes for being a LNA but I need to get used to how
to get in the flow of being a nurse. I felt like I was very choppy in getting my report,
piecing it together, and doing my assessment. I need to gain more confidences being
around patients in the nursing roles. I feel like we go through doing all this nursing stuff
in lab but it is nothing like clinical and I was thrown off guard being around a real
patient.
Analysis
I knew I was not going to be perfect going in to see my first real patient but I was
not prepared mental what to do in those situations. There is no way though to mentally
prepare for that, the only was to prepare is to actually do it. I know that with practice
though I will get down the flow of what to do and how to calm myself when things dont
go exactly how we practice them. I also need to take time and figure out everything
before I go into a patient room; look over labs and admitting diagnosis plus past medical
history, that way I can figure out everything that is going on before I throw myself into
the situation half blind. Also I learned that it is important to get a good report from the
nurse not just the LNA. Being an LNA, I am used to having the previous LNAs report be
good enough because for the most part as an LNA you dont need to know his history and
lab results. As the nurse though all of that matters and I need to be prepared before I go
into the room and start doing an assessment. I cant really do an assessment with out
knowing what I should be assessing and that is what I did at this clinical.
Conclusion
If we had had more time I would have gone back and redone my assessment.
Knowing everything I figured out after I assessed him I would have done my assessment
differently. I would have listened to lungs more closely and tried to hear the difference
between the bases on the lungs and the top to see if I could hear it. I also would have
asked questions about his foley to see if it was painful due to the UTI. Another thing I did
not ask and would have is about his breathing, was he having difficulties because of the
pleural effusion and atelectasis? I could have also asked questions about his heart failure
and maybe questions about his lifestyle and diet that may have lead to his exacerbation.
There were a lot of things I forgot, or did not think to do because I went in there without
knowing the whole story. I just did a simple basic head to toe like I practice in lab. When
in reality you need to individualize each assessment to match what is going on with the
patient at that time.
Action Plan
Next clinical I am going to get a full report from the previous nurse about
everything. Then before going in there I am going to look up lab results and figure out if
there are any tests that need to be done, such as a x-ray. After all that I am going to take a
minute and piece it all together, what is going on with this patient and what is the most
important thing for me to focus on. Once I get my head around everything I am going to
write down all the systems I need to hit and make check boxes next to them so I check it
off when theyre done. I like to do that to remind myself what is left and what is done.
Once I feel confident that I know what is happening and what needs to be done then I will
see my patient. I think that using this approach will allow me to feel more calm and
relaxed going into the situation because I will be prepared for most of what will happen
as opposed to this clinical where I was learning what was going on while it was
happening and at this stage in my career I am not the best on my toes thinker. I hope that
with practice and experience I will become quicker and will be able to handle unforeseen
situations much easier.