Improving Clinical Skills

JOURNAL ENTRY
Critical reflection of your growth and development during your practicum experience in a clinical setting has the benefit of helping you to identify opportunities for improvement in your clinical skills, while also recognizing your strengths and successes.
Use this Journal to reflect on your clinical strengths and opportunities for improvement, the progress you made, and what insights you will carry forward into your next practicum.
To prepare:
• Refer to the “Population-Focused Nurse Practitioner Competencies” found in resources below, and consider the quality measures or indicators advanced nursing practice nurses must possess in your specialty of interest.
• Refer to your Clinical Skills Self-Assessment Form you submitted in Week 1, (Attached) and consider your strengths and opportunities for improvement.
• Refer to your Patient Log and consider the patient activities you have experienced in your practicum experience and reflect on your observations and experiences.

Assignment: JOURNAL ENTRY (450–500 WORDS):
Learning From Experiences
• Revisit the goals and objectives from your Practicum Experience Plan. Explain the degree to which you achieved each during the practicum experience.
• Reflect on the three (3) most challenging patients you encountered during the practicum experience. What was most challenging about each? (Note to writer: I have included brief entries of the 3 patients below. Utilize accordingly)
• What did you learn from this experience?
• What resources were available?
• What evidence-based practice did you use for the patients?
• What would you do differently?
• How are you managing patient flow and volume?
• How can you apply your growing skillset to be a social change agent within your community?
Communicating and Feedback
• Reflect on how you might improve your skills and knowledge, and communicate those efforts to your Preceptor.
• Answer the questions: How am I doing? What is missing?
• Reflect on the formal and informal feedback you received from your Preceptor.

Resources to consider:
• American Psychiatric Nurses Association. (2013). Population-focused nurse practitioner competencies https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/competencies/compilationpopfocuscomps2013.pdf
Note: Review the Psychiatric Mental Health Nurse Practitioner Competencies.

3 Patients

62yo M
Dx:

• Attention-deficit hyperactivity disorder, predominantly hyperactive type (F901)
• Impulse disorder, unspecified (F639)
• Moderate intellectual disabilities (F71)
  Medications:
• ARIPiprazole 5mg Daily
• Ritalin 10mg Daily
• Strattera 60mg Daily
• Xanax 1mg Daily PRN
  Patient and caregiver presents for a follow up visit via telemedicine for medication management for Moderate intellectually disability, Impulse disorder, and ADHD. Caregiver stated that patient has been experiencing increased anxiety, often scratches himself when feeling stressed, but occasionally takes Xanax, which successfully calms him down.
  The existing treatment interventions seem to be effective in maintaining stability. The importance of continued adherence to the current treatment regimen was emphasized, along with a thorough explanation of the risks, benefits, and potential side effects of pt.’s medications. The caregiver provided verbal consent to continue with this course of action.
  Denies SI, HI, AH, VH.
  Sleep: good
  Appetite: good
  Treatment plan:
• Continue medication regimen
• F/U in 4 weeks.
  Patient Instructions:
  Take all medications as prescribed.

17yo F
Dx:

• Generalized anxiety disorder (F411)
• Bipolar disorder, current episode hypomanic (F310)
  Medications:
• ARIPiprazole 2mg HS
  Patient and mother presents for a follow up visit via telemedicine for medication management.
  Patient denies worsening of her depressive symptoms and is compliant in taking Effexor, also denies any side effects. However, pt. did report an adverse reaction to Lithium, and continues to experience random anger outbursts and mood swings.
  Discussed treatment options and proposed that she restarts on a low dose of Abilify. The patient and mother were informed regarding the risks, benefits, and possible adverse effects of the prescribed medication, to which both patient and mother verbally expressed consent.
  Passive SI w/o plans or intentions.
  Denies HI, AH, VH.
  Current Suicide risk assessment: No risk for suicide assessed at this time.
  Sleep: fair
  Appetite: good
  PHQ-9 was performed by the pt. and scored 20, severe depression was noted.
  MDQ was performed by the pt. and scored 10, indication that pt. is positive for bipolar d/o.
  Treatment plan:
• D/C Lithium.
• Restart Abilify 2mg QN. – Pt was encouraged to take 0.5 tab on the first few nights.
• Continue Effexor XR 75mg QD.
• Plans of doing labs.
• Continue therapy.
• f/u in 2weeks

18yo M
Dx:

• Obsessive-compulsive disorder (F42)
• Major depressive disorder, recurrent, mild (F330)
• Attention-deficit hyperactivity disorder, predomin (F900)
  Medications:
• Atomoxetine HCl 25mg Daily
• FLUoxetine HCl 20mg Daily
  Patient presents for a follow up visit via telemedicine for medication management for Depression and OCD ADD/ADHD
  Patient reported difficulties in concentrating at school and barely passed his math class. Despite utilizing a medication reminder app, pt. acknowledged a history of poor medication compliance and often disregards the reminders.
  Patient stated his mother is increasingly concerned about his weight loss, which she attributes to the medications he’s taking. However, he reported consistent normal food and fluid intake and hasn’t experienced any side effects from the medications.
  The importance of continuing his current treatment regimen was reiterated to him, and he was educated about the risks, benefits, and possible side effects of the prescribed medications. He gave his verbal consent.
  Denies SI, HI, AH, VH.
  Treatment plan:
• Continue Atomoxetine 50mg QD and Prozac 20mg QD.
• F/U in 4 weeks.
  Patient Instructions:
  Take all medications as prescribed.
  Follow-up with a Therapist is recommended.

NOTE: Please use Resources/References not older than 5-years. (Late 2018/2019 – 2023)