Final Y2S2
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | By finals, I have completed the following assignments: -88 CPEs -4 journals using additional research articles -Holistic nursing care plan -Teaching plan -learning plan -weekly clinical worksheets + medication lists By finals, I have practiced within my scope: -Care and management of a 3 patient assignment -mental status exam assessment -Columbia Suicide Severity Rating Scale – Documentation – Accuchek monitoring – IM injection -medication administration x2 -VS + unit temps |
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| Strengths (Things you did well consistently): | I continue to demonstrate confidence and competence in the clinical setting. I demonstrate leadership among my peers through teamwork/collaboration and participation in post-conference. I model professionalism through my communication and accountability. I form appropriate therapeutic nurse-client relationships with my patient assignments. I practice professional and therapeutic communication in all interactions with my peers, staff, and patients. I am able to manage my time appropriately by completing mental status exams and CSSRS for 3 patient assignments with timely mannered documentation. I demonstrate confidence and an understanding of the 10 rights of medication administration. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | I want continue to review common psychiatric diagnoses and familiarize myself with the clinical manifestations and implications. I want to continue to improve upon my time management skills as I move towards consistently caring for a 3(+) patient assignment in fourth year. I plan to continue to review the medication administration process in order to maintain competency and confidence with this skill |
Midterm Y3S2
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | By midterm, I have completed the following assignments: -30 CPEs – 2 journals using an additional research articles -learning plan -weekly clinical worksheets By midterm, I have practiced within my scope: – Care and management of a 2 patient assignment -mental status exam assessment – Documentation – Accuchek monitoring – IM injection -VS |
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| Strengths (Things you did well consistently): | I demonstrate leadership among my peers through teamwork/collaboration, participation in post-conference, and modeling professionalism in communication and accountability. I am able to form appropriate therapeutic nurse-client relationships with my patient assignments and model professional and therapeutic communication in all interactions with my peers, staff, and patients. I am able to manage my time appropriately, completing mental status exams for 2 patient assignments with timely mannered documentation as well as completing my clinical worksheets. I am also able to perform an IM injection following IM injection CPE. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | I want to continue to improve upon my time management skills as I move towards consistently caring for a 3 patient assignment as the goal is to improve efficiency in clinical practice/care. I also want continue to review common diagnoses seen on the unit and familiarize myself with the clinical manifestations and implications. |
FINAL EVAL Y3S2
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | By finals, I have completed the following assignments: -88 CPEs -4 journals using additional research articles -Holistic nursing care plan -Teaching plan -learning plan -weekly clinical worksheets + medication lists By finals, I have practiced within my scope: -morning care -medication administration including subcutaneous injection and IV medication -head to toe assessments + documented my findings for two patients -taken VS + documented my findings for two patients -completed progress notes/DARs -performed a simple dressing change – performed accucheks By finals, I witnessed the following during clinical: -dressing change -blood drawn by co-assigned nurse |
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| Strengths (Things you did well consistently): | I demonstrate leadership through teamwork/collaboration with my peers and the WRH staff, participation in post-conference, and modelling professionalism. I am able to form therapeutic relationships with my patients and communicate therapeutically with patients. I ensure that personal care and pain management needs are met. I am able to perform a HTT assessment, determine if my findings are abnormal or normal, document my findings, and communicate with my co-assigned nurse. I demonstrate time management through my ability to care for 2 patients, ensuring care needs are met and documentation is done in a timely manner. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | I will continue to practice my medication administration skills. I will continue to review and explore patient diagnoses, lab values, and diagnostic tests to improve my knowledge, application, and critical thinking skills. I will continue to practice my DAR charting. |
MIDTERM – Y3S1
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | By midterm, I have completed the following assignments: -55 CPEs – 1 journal using an additional research articles -learning plan -weekly clinical worksheets By midterm, I have practiced within my scope: -morning care -head to toe assessments + documented my findings -taken VS + documented my findings -completed progress notes/DARs -simple dressing change By midterm, I witnessed the following during clinical: -dressing change -blood drawn by co-assigned nurse |
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| Strengths (Things you did well consistently): | I consider time management to be a strength of mine. I am able to complete my head to toe assessment and take vital signs in a timely manner which allows me time to start other activities. I am also able to manage my time outside of clinical which allows me to complete my clinical assignments on time. I am able to collaborate and effectively work with both my peers and the staff which allows us all to provide better care for the patients. I am also able to perform simple dressing changes following the simple dressing change CPE and perform a head to toe assessment according to faculty CPE. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | I consider my documentation to be an area of improvement. I want to improve on providing more specific detail in my charting to accurately communicate my findings to the staff. I will continue to work on adding more detail to my charting to improve. I also want to increase my understanding of abbreviations and medical terminology. I also want to continue to explore labs/ dx tests that I am unfamiliar with. |
FINAL EVAL Y2S2
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | As of final, I have completed the following assignments: 87 CPES 3 Journals 1 teaching pamphlet (in substitute for journal 4) – on Dental health 1 teaching plan – based on nursing care plan 1 Nursing care Plan 1 Health screening compilation – vision, hearing, oral health, growth/development, lice screening 1 learning plan 1 IPE log e-portfolio updates As of final, I have practiced within my scope of practice in school health placement by: Performing health screenings on JK, grade 2 & 3 students -hearing included Rinne test, Weber test, and whisper test (along with health teaching regarding protecting ears) -vision: snellen test (health teaching focused on protecting and improving vision) -oral: assessing oral, dental, mucosal health + health teaching on brushing teeth + flossing -growth+development: assessed height+weight and percentile (health teaching on healthy eating) -head lice: checking for nits and lice (health teaching on what head lice is and how to manage or get rid of it) I also participated in discussions during pre and post conferencing about social determinants of health. Exploring the impacts of the determinants on students and their families’ health allowed me to be more open-minded and understanding when working with students. |
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| Strengths (Things you did well consistently): | A strength includes documentation. I am able to accurately document my findings when screening my students as well as communicating abnormal findings to my clinical instructor and my student’s teacher. I consider time management to be a strength of mine. I am able to complete my health screenings in a timely manner. I am also able to manage my time outside of clinical which allows me to complete my clinical assignments on time. I am able to collaborate and effectively work with both my peers and the staff which allows us all to provide better care for the patients. I also understand and am able to apply the process of safe medication administration in clinical. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | Despite improving, an area of improvement continues to be my communication. I believe that I should practice modifying my communication to meet the needs of each of the students I work with. I as well ensure that I am creating a welcoming environment for my students and both talk to them and actively listen to them. |
MIDTERM Y2S2
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | As of final, I have completed the following assignments: 87 CPES 3 Journals 1 teaching pamphlet (in substitute for journal 4) – on Dental health 1 teaching plan – based on nursing care plan 1 Nursing care Plan 1 Health screening compilation – vision, hearing, oral health, growth/development, lice screening 1 learning plan 1 IPE log e-portfolio updates As of final, I have practiced within my scope of practice in school health placement by: Performing health screenings on JK, grade 2 & 3 students -hearing included Rinne test, Weber test, and whisper test (along with health teaching regarding protecting ears) -vision: snellen test (health teaching focused on protecting and improving vision) -oral: assessing oral, dental, mucosal health + health teaching on brushing teeth + flossing -growth+development: assessed height+weight and percentile (health teaching on healthy eating) -head lice: checking for nits and lice (health teaching on what head lice is and how to manage or get rid of it) I also participated in discussions during pre and post conferencing about social determinants of health. Exploring the impacts of the determinants on students and their families’ health allowed me to be more open-minded and understanding when working with students. |
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| Strengths (Things you did well consistently): | A strength includes documentation. I am able to accurately document my findings when screening my students as well as communicating abnormal findings to my clinical instructor and my student’s teacher. I consider time management to be a strength of mine. I am able to complete my health screenings in a timely manner. I am also able to manage my time outside of clinical which allows me to complete my clinical assignments on time. I am able to collaborate and effectively work with both my peers and the staff which allows us all to provide better care for the patients. I also understand and am able to apply the process of safe medication administration in clinical. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | Despite improving, an area of improvement continues to be my communication. I believe that I should practice modifying my communication to meet the needs of each of the students I work with. I as well ensure that I am creating a welcoming environment for my students and both talk to them and actively listen to them. |
FINAL Y2S1
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | By finals, I have completed the following assignments: -88 CPEs -4 journals using additional research articles -Holistic nursing care plan -Teaching plan -learning plan -weekly clinical worksheets + medication lists By finals, I have practiced within my scope: -morning care -medication administration including subcutaneous injections (x2) -head to toe assessments + documented my findings for two patients -taken VS + documented my findings for two patients -completed progress notes/DARs -performed two simple dressing changes -performed a dressing change for a JP drain – performed accucheks -removed staples from a surgical incision (replacing with steri strips) -changed a flange for a urostomy By finals, I witnessed the following during clinical: -the removal of a JP drain from the neck + removal of sutures -wound care + sterile packing of perianal abscess -IV insertion + care -wound care using sterile technique -care + change of colostomy bags – complex dressing change |
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| Strengths (Things you did well consistently): | Time management is a strength of mine. I am able to complete my head to toe assessment and take vital signs before 0800 for two patients. This allows me time to start other activities. I am also able to manage care for both of my patients. I am able to collaborate and effectively work with both my peers and the staff which allows us all to provide better care for the patients. I am also able to perform simple dressing changes following the simple dressing change CPE. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | I consider my documentation to be an area of improvement. I want to improve on providing more specific detail in my charting to accurately communicate my findings to the staff. I will continue to work on adding more detail to my charting to improve. I also want to improve my ability to write detailed nursing diagnosis and goals for my patients. |
MIDTERM Y2S1
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | By midterm, I have completed the following assignments: -58 CPEs -2 journals using additional research articles -Holistic nursing care plan -Teaching plan -learning plan -weekly clinical worksheets + medication lists By midterm, I have practiced within my scope: -morning care -medication administration including a subcutaneous injection -head to toe assessments + documented my findings -taken VS + documented my findings -completed progress notes/DARs By midterm, I witnessed the following during clinical: -the removal of a JP drain from the neck + removal of sutures -wound care + sterile packing of perianal abscess -IV insertion + care -wound care using sterile technique -care + change of colostomy bags |
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| Strengths (Things you did well consistently): | I consider time management to be a strength of mine. I am able to complete my head to toe assessment and take vital signs before 0800 which allows me time to start other activities. I am also able to manage my time outside of clinical which allows me to complete my clinical assignments on time. I am able to collaborate and effectively work with both my peers and the staff which allows us all to provide better care for the patients. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | I consider my documentation to be an area of improvement. I want to improve on providing more specific detail in my charting to accurately communicate my findings to the staff. I will continue to work on adding more detail to my charting to improve. I also want to increase my understanding of abbreviations and medical terminology. |
FINAL Y1S1
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | I protected client from physical harm by identifying them using their bracelet and asking for their full name before providing care. I also protected clients from physical harm by completing environmental scans of their room searching for safety and falling hazards. I also ensured that their beds were always at the lowest height. I protected my client from psychological by demonstrating indicators from the Therapeutic Nurse-Client Relationship Practice Standard, Consent Practice Standard, and Ethics Practice Standard. I introduced myself and my role to my client. I got my client’s consent before providing care to her and refrained from discussing her health status outside of the clinical setting with people who are not a part of her care team. I promoted my client’s well-being by assessing her health status and reporting unusual symptoms to the RPN. I demonstrated accountability by emailing my professor indicating that I won’t be able to submit the Learning plan assignments by the deadline and also offering a time and date when I will submit the assignments by. I sought out support when I performed oral and denture care on a resident. I clarified with my professor the process to ensure that I was doing it correctly. I modelled a professional presence by continuing to dress in the clinical uniform. I demonstrated a professional presence by completing assignments for clinical, keeping my phone in bad while I’m on the floor, and introducing myself to the residents and staff. I introduced myself to a new staff member to promote effective collaborative work. I displayed initiative by asking PSW staff for residents to perform dental and oral care so that I can reach my learning goal of this semester. I demonstrated collaborative skills working with my peers as we worked on the Health Fair. I’m aware of the different types of abuse and the duty of the nurse which is to intervene or report the abuse to higher authorities when they witness any forms of abuse. I evaluate my nursing practice through my QA Learning Plans. I demonstrate an understanding of the Nursing Faculty Policies by refraining from administering medications and utilizing mechanical lifts on residents. I demonstrate time management and organizational skills by completing my assignments for clinical. I have completed another journal to meet the self-reflective requirements of the Faculty. I provided full perineal care (using proper hand hygiene) to facilitate a positive outcome for my client. I determined what social determinants affect my client to help me develop a care plan that meets her health needs. I researched the anatomy, physiology and pathophysiology of my client’s medical diagnosis, so that I can educate myself on the symptoms my client may experience. I demonstrate the relational skills of listening, empathy, and questioning to show my knowledge of relational practice. With my knowledge of aging, I’m aware of the potential risks my client may experience such as shortness of breath due to having anemia and emphysema. I promoted her mental through social interaction. I read her bible to her and did an exercise program with her. I identified social determinants my client experiences while living in a nursing home, so that it could help me determine her needs and develop goals for her. I used the Code of Conduct Practice Standard from CNO to support my nursing approach. I reviewed the Mosby video on dental and oral care to support my nursing practice. I assessed my client’s pain using the Pain Assessment Tool. I then identified her need and developed health goals with interventions to overcome her health need. Knowing that my client is at risk of social isolation, I developed a short and long term goal with interventions to reduce her risk. I collaborated with peers to identify resources for the Health Fair on the respiratory system. I facilitated client ownership by asking if the goals I developed for my client were achievable for her. I applied Erikson’s stages of life, Prochaska’s state of life, Maslow’s Hierarchy of needs, and Piaget’s theory. Piaget’s Cognitive Stages assess the client’s cognitive stage and their ability to form abstract logical thoughts. Erikson’s Stages of Life determines what stage of life the client is at. Maslow’s Hierarchy of needs to assess what stage my client is in. Prochaska determines how likely the client’s current behaviour is going to change. The frameworks assist me in developing an effective care plan. I practiced workplace safety by raising the bed up to a comfortable working height as I provided a bed bath for a resident. I collaborated with my peers on a teaching plan designed for fifth graders to promote respiratory health. I monitored the effectiveness of my client’s care by modifying the exercise program I designed for my client because I determined that the exercises were not appropriate for her. I used the outcome of my original exercise program to modifying the exercise to better suit my client’s needs. I confirmed her understanding by reviewing the modifications with her. I ensured that the modifications were something my client was willing to do. I document on the IPAAP sheet on my client to demonstrate accountability and communicate to other members of my client’s health care team. I advocated for my client by informing the RPN that my client was still in pain despite receiving medication. Despite the different beliefs on residential care my client and I have, I continue to provide her care and refrain from imposing my beliefs on her. I established and maintained professional boundaries with my client by reminding her that March 21st is my last day with her. I informed her that I wouldn’t be returning. I also reviewed the interventions from the care plans, so that she can continue to practice the interventions. To provide a safe environment for the client, I put my client’s wishes before my beliefs knowing that I can’t impose my beliefs and values onto her. I’m aware that before providing treatment, I must obtain informed consent. Based on ethical practice, I prioritized my client’s wishes when modifying the exercises from her exercise program I developed. I experienced an ethical conflict regarding my client. She did not want me to report to the RPN about her pain despite it worsening. I used the framework to assist me in working through the conflict. I’m aware that in terms of ethical responsibilities, nurses are expected to uphold the ethical values outlined in the CNO Ethics Practice Standard. For legal obligations, PHIPA, Health Care Consent Act (HCCA), and the Consent Practice Guideline and Confidentiality and Privacy Practice Standard guide how I and other nurses perform in terms of maintaining client privacy, confidentiality, and security including via social media. Additionally, nurses are not allowed to share any client information on social media. I’m aware that CNO represents all nurses and works to protect the public. RNAO provides practice guidelines that support nurses and their practice, advocates for health public policy and works to promote excellence in nursing practice. The Faculty of Nursing focuses on the practice of University of Windsor nursing students. Huron Lodge provides facility policies and procedures on various topics to support a culturally safe and healthy working environment. I participated and contributed to team development when collaborating with my peers on the Health Fair project. I advocated for and promote healthy public policy by practicing proper hand hygiene using the 5 moments of hand hygiene for additional support. I practiced within my scope by refraining from using the mechanical lifts to transfer residents and refraining from administering medication. I practiced within my scope by feeding, providing perineal care, performing bed and tub baths, and changing briefs. I met my goal of being able to communicate while feeding older adults and providing dental and oral care. |
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| Strengths (Things you did well consistently): | A strength of mine is communication. I am able to effectively communicate with my peers, the staff, and the residents. I also developed the ability to modify my communication style based on the needs of the client. Another strength of mine is the ability to perform basic nursing skills. I have developed the ability to feed residents and adjust based on their needs. I can provide perineal care and bed baths safely and effectively. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | An area of improvement is my reflective journals. To improve, I will continue to use the guidelines and templates as the foundation for my journals. Another area is my CPE documentation. To improve, I will continue to incorporate relevant theory to support my actions in the clinical setting. Another area of improvement includes self-care. This year, I experience a stressful event that added on to the stress of school. To improve my self-care, I will continue to go to the gym and practice self-meditation/relaxation techniques. |
MIDTERM Y1S1
| Summary of progress (Discuss concepts identified in the course, learning plan progress, skills) | I have protected my client from physical harm by identifying my client before providing care I identify my client by looking at their bracelet and asking the client for their full name. Additionally, I perform environmental scans of my client’s room to look for potential safety/falling hazards. I demonstrated accountability by identifying myself to my clients by stating my full name and that I am a University of Windsor 1st year nursing student. I sought out assistance when I didn’t know how to change the briefs of my client. I asked my clinical instructor for assistance. I model a professional presence by wearing my clinical uniform which consists of navy blue scrubs with the embroidery, non-mesh shoes, no earrings, and my hair tied up. I demonstrated a professional behaviour through my participation in GPA training and completing my clinical assignments. I have identified myself to clients and my healthcare team including a new PSW staff member. I demonstrated initiative my volunteering to assist my instructor in giving a client a bed bath. I was able to demonstrated confidence by being able to state the process of performing a bed bath and my focus was on entirely on the client watching her facial expression to ensure that I was not causing any pain or discomfort. I demonstrate collaborative problem-solving strategies through my use of communication while working with my peers as we performed a bed bath. I demonstrate my knowledge of the Faculty of Nursing policies by refraining form administering medication and transferring clients. I have completed self-assessment requirements of the Faculty of Nursing through my completion of two journals. I demonstrate professional leadership by building relationships with my peers through collaboration on nursing skills, participating in GPA training activities and balancing practicing my nursing skills and meeting with my client. I demonstrated knowledge in anatomy and physiology when performing perineal care cleaning from “clean to dirty”. I used communication as I worked with my peer to assist a stimulated client with transferring and I also completed the Bill 18 e-Learn module which discussed workplace safety. I completed GPA training which focused on gentle persuasion approaches for people with dementia. I also practiced the use Accu-Chek for glucose monitoring. I used evidence-based research to research the medical diagnoses of my client. I completed a Morse Fall Scale and Braden Scale assessment to determine my client’s needs regarding falls and pressure ulcers. I have also assessed my client’s vital signs. I assessed my client’s musculoskeletal system to help me develop a care plan based on their fall risk in which I developed a nursing diagnosis, a short and long term goal, and interventions to meet the goals. I have completed the Health Promotion Model on my client to determine how likely she is to engage in exercise. I have an understanding of basic infection control practices by performing hand hygiene when entering and exiting a client’s room. I maintained professional boundaries by establishing a termination date with my client, informing her that my last day is March 14, 2019. I have demonstrated the ethical value of client choice by ensuring my client makes an informed decision and respecting their decision. I advocated for my client to receive a new oxygen tank after her previous one was empty. I’m aware of the emergency preparedness by being able to locate the fire equipment on the fourth floor. I practice within my scope by performing baths, partaking in feeding, making occupied and unoccupied beds and assisting in dressing clients. I also practiced within my scope by refraining from administering medication and transferring clients. I’ve completed a practice reflection and learning goal on feeding. I created weekly activities that will help me reach my learning goal on how to feed older adults. |
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| Strengths (Things you did well consistently): | One of my strengths includes modelling and demonstrating professional behaviour and presence. I come to class on time and in full dress code. I also follow other policies such as no gum chewing and cellphones. I leave my phone in my bag and I refrain from bringing gum to class. Another strength of mine includes participation. In class, I participate as often as possible. I engage in clinical activities and include my own well thought out ideas. By participating, I am able to attain more knowledge and skills that I can later apply in my clinical placement. Other strengths of mine include my ability to perform bed baths and change briefs. |
| Areas for Improvement/Growth (Things you need to work on): Must be addressed in your learning plan for the next clinical experience | For my reflective journals, I need to follow the journal template more accurately. I have been provided a template that describes what should be written for each section. I don’t always follow it; sometimes I miss a few requirements for a section and other times I include information that’s either unneeded or meant for a different section in my journal. To improve, I will carefully read the criteria. I also need to improve in supporting my CPE documentations with relevant theory. To improve, I will work to improve supporting theory such as the Practice Standards provided by the CNO. Additionally, I need to improve on feeding and full perineal care. To improve these skills, I will continue to practice feeding the clients and working with a staff member to practice perineal care. |