Clinical Reflection

A. Clinical Strengths & Needs
• Strengths:
I had a wonderful experience at clinical today and learned a great amount. I feel as I am becoming more confident with working with my resident as well as others. Strengths included demonstrating effective clinical decision-making and safety in practice (objective 5), communicating with the client (objective 2), and implementing strategies to promote, maintain and restore health (objective 4). An example of how I demonstrated objective 5, was when I was feeding a resident that I was unfamiliar with. First, I checked for any diet restrictions, then I made sure to give the resident small bites as I was unfamiliar with her eating style. I would rather it take longer for the resident to finish the meal

then have them aspirate or choke. An example of objective 2, was I explained to my resident that I needed him to learn forward towards the Nursing Assistant so I could do listen to his lungs from his back. By continually, explaining the procedure to my resident I am practicing for when I care for other people. All residents/patients need to know what is going on; this can help ease the nerves of some people. This also connects with objective 4, because during this assessment my resident didn’t hear me when I told him I needed him to say “99”. I implemented the strategies of talking louder and looking for facial cues that may demonstrate he didn’t hear me. Not doing an assessment could lead to missing important information such as an abnormal findings.
• Needs:
Today, I tried to assist my resident from the wheelchair to his bed and it was extremely difficult because he was unable to help me. Fortunately, the CNA was there and showed me her strategy for assisting him from the wheelchair to the bed. She did this by using a gait belt and putting both the residents’ knees in between her knees; while I used the gait belt and had the resident put his knees touching mine. Therefore, something I need to work on is to gain strategies for assisting my resident. I am thinking implementing some of the CNA’s strategy as well as having my resident place his hands on my forearm. As time goes on, I will learn other strategies to better assisting my resident as well as future residents/patients.

B. Focused Assessment/Clinical Note (format TBA per instructors)
SOP note:
Subjective: ask how breakfast was; responded with “good”.
Objective: smiling, didn’t talk much, temperament was clam and relax.
Planning: Asking more questions such as how are you doing today or what did you have for breakfast; gather more subjective information from the resident.
Clinical Assessment:
Demographics: Initials: RC; Age: 96; Gender: male; Ethnicity: Caucasian.

Well-groomed, dress appropriately. BP 108/60; pulse 70; respirations 24; temperature 96.2 ̊. A&O * 1; resident was asleep; earlier resident was able to follow demands, state name, but was limited verbally. Resident affect was pleasant. Integumentary assessment: no new lesions; skin smooth and cool to touch. Respiratory assessment: skin light beige with yellowish undertone; red conjunctiva and eyes watery; pink lips; pink mucous membrane; no clubbing; nails dirty with yellowish/pink undertone; AP: lat ratio 1:2. Anterior symmetrical expansions; short breaths; no tenderness; no masses; wheezing lung sounds. Posterior symmetrical expansions; no tenderness; no masses; tactile fremitus present and equal Bil. Vibration diminishes ½ way down; no CVA tenderness; resident unable to lift clavicle up all the way…; no egophony. T. Zakrajsek, SN,

WSU.
C. Clinical Learning Objectives
• List 2-3 learning objectives for this week
1) Complete the part D of RCP before next Monday, September 28th. I will do this by completing at least 6 medications a day.
2) Get a good grade on the first health assessment exam. I will accomplish this by studying for at least two hours each day.
• Offer a brief summary of how your objectives were met or not met from last week (Begin by restating your objectives from last week.)
1) Improve med.

calculation skills by practicing problems from the med. calculation book every day.
2) Being successful on the first pathophysiology exam.
3) Becoming more efficient with strategies of verbally communicating with my resident.
I was able to meet all my objectives; I studied for the med. calculation exam, therefore improving my skills. It’s important to understand and correctly calculate medication to avoid med. error which can be dangerous. I studied very hard for my pathophysiology exam hence I received a good grade on the first exam. And lastly, I am beginning to implemented strategies to aid me in communicating with my resident more; however I want to continue to prefect these skills. My resident doesn’t talk a lot but I need to make sure I am able to continue to communicate with him as I need to know how he’s feeling.

D. Did you meet with your well elder this week? Yes X No 

What did you accomplish? Yes, met with our well elder today and finished our third meeting. Topics discussed were elimination, sleep/rest, and activity/exercise. Our well elder answered all question as well as shared stories with us. We are scheduled to meet with our well elder next Monday the

28th.