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Summary of Clinical Experience
Summary of Clinical Experience
I completed my first practicum at two different facilities: Governor's Family Practice and Atlantic Family Physicians. At each facility, I saw typically 10 to 15 patients per day. The age ranges in the practice were from 16 to 95 years old. We typically served medicare, medicaid, and HMO or PPO insurance beneficiaries. Typical disease processes that I have treated include anemia, diabetes, congestive heart failure, obesity, substance and alcohol abuse, and renal failure.
Governor's Family Practice
This practice was one of the few offices in the Dover area that treated patients for substance abuse. Typically we would see 3 to 5 patients a day for alcohol or opioid dependence and prescribe medications such as Vivitrol or Subutex to help encourage sobriety. While I was initially hesitant, I definitely valued this learning experience as I saw the progress that these patients made with their sobriety. My preceptor was also skilled in joint aspiration and corticosteroid injections and I was able to observe a few encounters for this issue and review proper technique with my preceptor.
Atlantic Family Phyisicans
This practice has a unique weight managment program known as healthy outcomes. Patients can be referred to this program to be started on medications such as GLP-1s and follow with a dietician and the provider for routine check in of medication compliance, counseling, nutrition management, and goal setting. I thoroughly enjoyed treating these patients and seeing them progress with their weight loss.
Throughout my time at these facilities, I have practiced applying evidence-based guidelines to each patient encounter and providing recommendations for health maintenance screenings and tests as recommended by the United States Preventative Task Force.
I have included the NOMPH competencies that I must exemplify during my clinical practice. I have the competency listed with two examples of my achievement throughout this semester. In addition, I have attached some assignments or other projects to showcase my skills.
Scientific Foundation and Practice Inquiry
Scientific Foundation and Practice Inquiry
Evidence of Achievement
Evidence of Achievement
I completed a sick visit for a 50 year old patient who presented with ear pain. By using my knowledge from health assessment and primary care, I was able to conduct a thorough history and phyiscal to develop three differential diagnoses. Based on my findings, I diagnosed the patient with otitis media because she recently had an upper respiratory infection that was treated with amoxicillin. Then, I used information from American Family Physician, a reputable medical journal, to prescribe the patient Augmentin instead of amoxicillin (Whelton et al., 2018).
SOAP Note 6 - HEENT
SOAP Note 6 HEENT.docx2. I completed a sick visit for a patient in an acute asthma exacerbation. The patient was using her rescue inhaler 4 times a day and was not getting any relief. I reviewed the step-wise approach from the new GINA 2024 guidelines (Global Initiative for Asthma [GINA], 2024). .The guidelines had changed, so I added on a combination SABA and ICS for this patient and scheduled a follow-up within 2 weeks to evaluate the effectiveness of her medication.
SOAP Note - Pulmonary
SOAP Note 3 Pulmonary.docxTechnology & Information Literacy
Technology & Information Literacy
Evidence of Achievement
Evidence of Achievement
I treated a patient for hypertension by reviewing her documented blood pressure logs over one month. She is part of a program that links her home blood pressure machine and logs these results to an online portal. A nurse from the company reviews these results, compiles them, and sends them to the patient's primary care provider. I used this information to correlate her frequent low blood pressure results with her subjective symptoms. After referring to the guidelines for hypertension management from the American Heart Association, I discontinued the amlodipine and instead placed her on an angiotensin-receptor blocker (Whelton et al., 2018).
https://doi.org/10.1161/hyp.0000000000000065
A counseled a patient with diabetes using their glucometer because their A1C was still not at goal. I also discussed continuous glucose monitors, their function, and answered any questions that they had about the device. I provided them an online resource to find out more information and stressed the importance of glucose awareness in diabetes management. The online resource that I provided was the Dexcom website.
https://www.dexcom.com/g7-cgm-system
Ethics
Ethics
Evidence of Achievement
Evidence of Achievement
I was seeing a patient for chronic pain and he looked visibly anxious to be seen for his visit. While talking to him, he stated that he fell recently and that his pain has been out of control. I listened to his concerns and was able to develop a trusting relationship with him. Provision 1 of the ANA's Code of Ethics denotes that, "The nurse practice with compassion and respect for the inherent dignitity, worth, and unique attributes of every person," (Haddad & Geiger, 2023, para. 3). I followed this provision by taking in this information and actively listening without judgement. As a result, he confided in me that he had ran out of his opioid pain medicaiton and resorted to obtaining additional opioid pain medication from an accquaintance. I educated him on the dangers of obtaining these medications from a non-medical professional, but reassured him that I understood his pain and that we would make sure it was managed appropriately. I ordered him to complete a fluid drug screen prior to leaving the office to ensure that he had no other illicit substances present in his urine. I had him follow up within two-weeks to ensure compliance and evaluate the effectiveness of the current regimen.
https://www.ncbi.nlm.nih.gov/books/NBK526054/
I was completing a suboxone visit for a patient who looked visibly short of breath. When I inquired about her history, I found that she had recently ran out of her inhaler and was never prescribed anything else for her asthma. The patient had no primary care physician at this time. After speaking with my preceptor, I made the decision to treat her with and inhaled ICS/SABA combination and schedule her for follow up the following week to establish primary care. I applied the ethical principle of beneficence to asisst with my decision-making. Beneficence means to act in the best interest of the patient to promote good outcomes (American Nurses Association [ANA], 2024, para. 3). SInce she was in an asthma exacerbation, I ethically could not just ignore this issue and instead I used this visit as an opportunity to help her and schedule a formal follow up for evaluation of her symptoms.
https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/
Policy
Policy
Evidence of Achievement
Evidence of Achievement
I was managing care for a patient who was on controlled substances. Per The Delaware Uniform Controlled Substances Act, each healthcare provider who prescribes controlled medications is required to review the prescriptive monitoring program prior to describing the first dose of a controlled substance, for medication reconciliation, and at the discretion of the healthcare provider (Uniform Controlled Substances Act Regulations, 2011/2022, section 9). Prior to recommending a dose adjustment of oxycodone, I used the prescriptive monitoring program to review the patient's medicaiton history because I this was the first encounter I had with this patient. The purpose of this program is to help providers ensure that the patient is not receiving multiple doses of controlled substances different medical professionals.
2. I follow federal and my preceptor's facility's guidelines for opioid dependence management. For this, I followed up with a patient who was being seen monthly and completed a focused exam, review of the medication dose, discussion of adverse effects, and a urine drug screen. I reviewed that the patient had an existing treatment agreement with the office prior to continuing with fluid collection. The urine drug screen was positive for cocaine in addition to his medication.
Since he was still using illicit substances, he violated the contract. I required him to follow up again in a week for another evaluation and fluid drug screening. Per Delaware law, a provider can require the patient to come for subsequent visit and fluid drug screen at their discretion if the contact is violated (Uniform Controlled Substances Act Regulations, 2011/2022).
Delaware Uniform Controlled Substances Act: https://regulations.delaware.gov/AdminCode/title24/Uniform%20Controlled%20Substances%20Act%20Regulations.shtml/
Leadership
Leadership
Evidence of Achievement
Evidence of Achievement
I acted as a leader to collaborate with the medical assistants for my plan of care. I delegated an EKG to be completed on a patient complaining of nausea and chest discomfort. The female patient was middle-aged and had the following risk factors for ACS: diabetes, hyperlipidemia, and obesity. The patient was presenting with symptoms that could be associated with an acute coronary syndrome. American Heart Association guidelines denote that an EKG is part of gold standard for a workup of angina (Virani et al., 2023). While the EKG did not show any acute findings, I referred the patient to cardiology for evaluation because this pain was persistent over a couple weeks.
https://doi.org/10.1161/cir.0000000000001168
2. I communicated my knowledge about practice standards to my preceptor when prescribing blood pressure medication to a patient. The patient was having an adverse reaction to amlodipine with dizziness and pedal edema. Based on the AHA guidelines, this is a contraindication to continuing this therapy. Therefore, due to her uncontrolled diabetes, I thought about her risk of renal injury. I decided to place her on lisinopril, which is indicated to prevent renal injury and slow progression of proteinuria (Whelton et al., 2018, 8.1.6 section), Since the blood pressure was still 130/80s, I educated the patient on the medication and explained why we needed to continue antihypertensive therapy.
https://doi.org/10.1161/hyp.0000000000000065
Independent Practice
Independent Practice
Evidence of Achievement
Evidence of Achievement
I use the USPSTF guidelines in every patient encounter for their routine health maintenance. I had a 74-year old female patient present for chest pain and palpitations. During her visit I ordered and reviewed her EKG, ordered a thyroid panel and referred her to cardiology. At the end of the visit, I noticed that she did not return for a repeat DEXA scan after being reccomended to follow up in 2 years when she went in 2022. The USPSTF reccomends screening females for osteoporosis at age 65 and above (United States Preventative Services Task Force [USPSTF], 2018). I educated her about the importance of this health maintenance screening and we discussed her results; she was diagnosed with osteopenia. After explaining the procedure, she was amenable to repeating this screening.
SOAP Note 4 - Metabolic
This SOAP note includes the encounter for the patient who needed to follow up with a repeat DEXA scan.
SOAP Note 4 Metabolic.docx2. When a patient presented for a suspected ear infection, I employed diagnostic measures to assist in making my diagnosis. I used the Rinne and Weber tests with a tuning fork to determine the extent of hearing loss. My patient had increased bone conduction in comparison to air conduction and the sound lateralized to her affected ear. Upon inspection, I was not able to visualize the landmarks of her tympanic membrane. Based on my assessment and patient interview, this led me to the diagnosis of acute otitis media. I was able to apply my knowledge from a similar case study that I completed this semester to come up with differential diagnoses for why she would be experiencing hearing loss in her affected ear.
Week 3 Case Study - Hearing Disorders
Week 3 Pre Class Assignment Primary Care.docxHealth Delivery Systems
Health Delivery Systems
Exemplars
Exemplars
I was treating a patient for depression who presented for a follow up visit. The patient did not wish to continue on her SSRI, yet was unsure how we should proceed to treat her depression. I introduced the concept of therapy and provided her resources for the National Alliance for Mental Illness (NAMI). By providing this resource, the patient said she was interested in contacting this center for therapy references and coping strategies. I learned about the importance of community resources from my mental health case study in primary care.
Week 13 Case Study.docx
2. I also used health delivery systems each day at clinical with the electronic medical record. I used the Azalea Health software system to access patient charts, review labs and notes, and update patient information. During a medicare wellness visit, I completed a medication reconcilliation with a 70 year old gentleman who was being treated for multiple conditions. I used the edit chart function to update his medications. I adjusted the doses,, frequency, method of intake, and prescribing physician as indicated. As a result, future providers who access his chart will have accurate information to help guide their treatment.
Quality and Safety
Quality and Safety
Evidence of Achievement
Evidence of Achievement
I was conducting a follow up visit for a group home patient with uncontrolled diabetes. I was concerned because her A1C level was still not at goal (9.0%) even after adding a DPP-4 to assist in glucose control. I weighed the risks versus benefits of placing this patient on insulin and ultimately decided against this due to the patient's underlying cognitive impairment. Per her group home representative who accompanied her to the appointment, they check the patient's blood sugar daily before breakfast. As someone who lives with diabetes, I recgonized that other people may not recognize hypogylcemia until the patient is incapacitated. I could not guarantee that her blood sugar would be checked regularly, so I opted to place the patient on an SGLT-2 inhibtor instead. I learned about the different classes of diabetes medications during our mid-semester seminar. The speaker helped me understand the omnious octect and its relation to the mechanism of action of each glucose-lowering agent. I have provided my seminar reflection as evidence of my increased competency and confidence with prescribing medications for diabetes. I am passionate about endocrinology and I love any opportunity where I can apply my knowledge to guide my plan of care.
Seminar Summary.docx2. I was completing a follow up visit for a diabetic patient who had no documented foot exam. I used the American Diabetes Association's updated standards of care to review their screening recommendations for this patient. Based on the guidelines, people with type 2 diabetes should be screened annually for diabetic peripheral neuropathy with a monofilament test I obtained a 10-g monofilament device and completed and documented this exam (ElSayed et al., 2023, 12.18 section). I also addressed the patient's gaps in their knowledge and educated them on the rationale behind annual foot exams. If I did not use the updated guidelines, I could have missed this necessary assessment piece and the patient may have sustained an injury to their foot from lack of sensation. By using up to date guidelines, I ensure that my care is evidence-based and safe.
I also completed a case-study in my primary care course that helped me understand what measures are required for a patient who presents with diabetes mellitus.
Diabetes Case Study Week 5.docxReferences
References
References
American Nurses Association. (2024, February 12). Why ethics in nursing matters: Ethical principles in nursing. ANA. Retrieved December 1, 2024, from https://www.nursingworld.org/content-hub/resources/workplace/why-ethics-in-nursing-matters/
ElSayed, N. A., Aleppo, G., Bannuru, R. R., Bruemmer, D., Collins, B. S., Ekhlaspour, L., Gibbons, C. H., Giurini, J. M., Hilliard, M. E., Johnson, E. L., Khunti, K., Lingvay, I., Matfin, G., McCoy, R. G., Perry, M., Pilla, S. J., Polsky, S., Prahalad, P., Pratley, R. E.,...Gabbay, R. A. (2023). 12. retinopathy, neuropathy, and foot care: standards of care in diabetes—2024. Diabetes Care, 47(Supplement_1), S231–S243. Retrieved December 1, 2024, from https://doi.org/10.2337/dc24-s012
Global Initiative for Asthma. (2024, May 22). 2024 gina main report. Global Initiative for Asthma - GINA. Retrieved October 13, 2024, from https://ginasthma.org/2024-report/
Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A.,...Shaw, L. J. (2021). 2021 aha/acc/ase/chest/saem/scct/scmr guideline for the evaluation and diagnosis of chest pain: A report of the american college of cardiology/american heart association joint committee on clinical practice guidelines. Circulation, 144(22). Retrieved December 1, 2024, from https://doi.org/10.1161/cir.0000000000001029
Haddad, L. M., & Geiger, R. A. (2023). Nursing ethical considerations. StatPearls [Internet]. Retrieved December 1, 2024, from https://www.ncbi.nlm.nih.gov/books/NBK526054/
Uniform Contolled Substances Act Regulations, 24 U.S.C. § 9 (2011 & rev. 2022). https://regulations.delaware.gov/AdminCode/title24/Uniform%20Controlled%20Substances%20Act%20Regulations.shtml/
United States Preventative Services Task Force. (2018, June 26). Recommendation: Osteoporosis to prevent fractures: Screening. Retrieved October 27, 2024, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening
Virani, S. S., Newby, L., Arnold, S. V., Bittner, V., Brewer, L. C., Demeter, S., Dixon, D. L., Fearon, W. F., Hess, B., Johnson, H. M., Kazi, D. S., Kolte, D., Kumbhani, D. J., LoFaso, J., Mahtta, D., Mark, D. B., Minissian, M., Navar, A., Patel, A. R.,...Williams, M. S. (2023). 2023 aha/acc/accp/aspc/nla/pcna guideline for the management of patients with chronic coronary disease: A report of the american heart association/american college of cardiology joint committee on clinical practice guidelines. Circulation, 148(9). Retrieved December 1, 2024, from https://doi.org/10.1161/cir.0000000000001168
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A.,...Wright, J. T. (2018). 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the american college of cardiology/american heart association task force on clinical practice guidelines. Hypertension, 71(6). Retrieved November 29, 2024, from https://doi.org/10.1161/hyp.0000000000000065
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