FINAL ADVANCE PRACTICE NURSING (contents).doc

FROM THEORY TO PRAXIS ACKNOWLEDGMENT The researcher wish to express their profound gratitude and sincere appreciation to everyone who is in one way or another gave their valuable help and guidance in the preparation of this work. His parents for moral support and advices To Ms. Ma. Loren Joy Manabat, for her uplifting words during the hard times. His classmates for the company, help and making each and everyone realize the joy of learning the advanced concepts of learning To all the supportive people who unselfishly shared their knowledge. The administration and faculty of Saint Paul University Philippines for bringing this program closer to us, continuous guidance, expert advices, teachings and patience. His practicum adviser, Ms. Sharon S. Calimag for the encouragement, supportive advices and supervision during the program. To Sister Adelina Javellana SPC, Sister Corazon Bunagan, SPC, the supervisors, head nurses and staff of the Notre Dame de Chartres Hospital Baguio City for their hospitality and kindness To the Almighty Father for giving this opportunity as well as the strength and knowledge making the author surpass obstacles and reach his goals in this aspect of his life.

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FROM THEORY TO PRAXIS Table of Contents

Acknowledgement ……………………………………………………

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Hospital Profile………………………………………………………………… 1 Executive Summary……………………………………………………………. 7 Detailed Case Analyses Cardiology ………………………………………………………………… 8 Diabetes …………………………………………………………………… 58 Oncology ……………………………………………………….…………

94

Learning Feedback Diary ……………………………………………………… 120 Best Practices Observed ………………………………………………………. 132 Recommendations and Suggestions …………………………………………… 134 References ……………………………………………………………………… 135 Appendices……………………………………………………………………… 136

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FROM THEORY TO PRAXIS Hospital Profile A. HISTORY Amidst the turbulence in the business environment where the economic conditions have rendered patients in the health care industry powerless, the REBIRTH OF NOTRE DAME DE CHARTRES HOSPITAL (NDCH) came into being to fulfill its raison d' etre. The journey of Notre Dame started when the Sisters of Saint Paul converted their summer house into a 40 bed hospital on October 01,1931 serving Benguet & Balatoc Mining Corp. During World War II, Notre Dame was not spared from the horrors of war. It was bombed by the Japanese soldiers because it became a shelter to the American military. On October 7,1946, Notre Dame rose from the ravages of war. Another 40-bed unit was blessed and inaugurated. A decade later, Notre Dame De Lourdes Hospital was rebuilt and blessed on April 19, 1959. It became a prominent institution in Baguio City, known for its caring and quality service. Unfortunately, on July 16, 1990, the hospital was not spared of the wrath of the devastating earthquake that rocked Baguio City. The hospital was deemed unsafe and tents were built to accommodate their patients. The sisters decided to close the hospital on March 1991. Thirteen years have passed, and the seed that lay buried in the ground has come to life, again... The REBIRTH... The Sisters of Saint Paul of Chartres have come back to fulfil their mission.

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FROM THEORY TO PRAXIS B. BACKGROUND Notre Dame De Chartres is an 85-bed Tertiary care hospital and Teaching/Training Institution. The hospital is located at #25 General Luna Road, Baguio City. The hospital is found within General Luna Road and intersects Assumption Road. It is surrounded by number of schools, two of which are the two biggest universities in the city. It is near the Baguio Cathedral and just across is the Baguio-Benguet PCAG, an emergency alert reporting system. NCDH is the same vicinity with the Hospital of the Sacred Heart along Assumption Road. The hospital is composed of complex buildings and situated on a 15.27 hectares plain flat land with some portion on an elevated plain.

C. VISION AND MISSION STATEMENT VISION Privileged to share in God's saving and healing action, we envision NDCH as a Christ-centered, dynamic and socially responsible global healthcare institution providing holistic quality healthcare services.

MISSION •

Faithfully live and proclaim God's love through compassionate care.

•

Uphold bio-ethical principles and the teachings of the Catholic Church.

•

Develop competencies of health care professionals for integral growth and strengthen partnerships in education, training and research.

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FROM THEORY TO PRAXIS •

Pursue value innovative and socially responsive health care services at par with global standards for sustainability.

•

Assure that Christian stewardship and good governance are practiced.

D. CORE VALUES Transforming lives through Christ-centered health care services

E. ORGANIZATIONAL STRUCTURE Board of Trustees | Medical Director---------------------Administrator ------------Vice President for Education | |

|

|

|

Human Resource Ancillary Svcs Nursing Service Support Svcs

|

|

Finance

Pastoral Care

| Nurse Supervisors | Head Nurses | Staff Nurses

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FROM THEORY TO PRAXIS

F. DUTIES AND RESPONSIBILITIES OF KEY PEOPLE a. Hospital Administrator The hospital administrator responsible for the day to day operational running of the health care institution. In addition, the administrator participates in and coordinates the setting of strategic priorities for the direction of the hospital. Specific duties include recruitment and retention of physicians, overseeing quality, improvement of processes for efficient delivery of patient care, setting standards, oversight of budgets, creating financial and business strategies to assure fiscal viability and health. The hospital administrators also become involved in press relations, public and community affairs, grants management, billing, collections, purchasing of equipment and meeting regulatory standards.

b. Chief Nurse The chief nurse is the executive head of the nursing service. He/She carries full administrative responsibility and authority for the entire nursing service of the hospital. Participates in formulating hospital policies, in developing and evaluating programs and services, assumes full authority and responsibility for development of nursing service policies; Organizes, directs, coordinates, evaluates activities of the Nursing Service Staff which allow for satisfaction and professional growth; Provides means and methods by which nursing personnel can interpret the goals and policies of hospital and nursing

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FROM THEORY TO PRAXIS service to the patient and to the public; Initiates and directs studies, evaluate procedures for the improvement of nursing programs for different categories of nursing personnel; directs nursing personnel in functions related to the clinical training program of nursing students and other affiliates; Prepares with her supervisory staff budget proposal for the nursing personnel; Defines job description for each category of nursing personnel; Recruits and recommends personnel for appointment, promotion or dismissal depending on staffing needs of the services.

c. Nurse Supervisor Nurse Supervisors provide care for patients, but they also oversee the nursing staff. As a nurse supervisor, you ensure that there is adequate staffing in your unit, interact with patient and families, manage issues that arise during your shift, and direct and supervise all aspects of patient care.

d. Unit Head Nurse The head nurse shall direct the performance of nursing functions in his/her units consistent with the philosophy, goals, objectives and standards of care of the nursing service. She/ He shall be tasked with building effective teamwork of people to effective and cost-efficient utilization of facility and other material resources. She/ He has control over the functions of her unit and makes decisions

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FROM THEORY TO PRAXIS regarding both patient care and staff situations as required in these units. The head nurse is directly responsible to the department head.

e. Staff Nurse The staff nurse shall initiate and perform nursing care to meet the needs of the patient within the scope of nursing practice provided by the law within the context of the philosophy, goals objectives and standards of care as established by the profession and the nursing service. The staff nurse shall be actively involved in teaching/ continuing education programs designed to improve quality of nursing care delivery.

f. Auxiliary Service Staff The nurse auxiliary is a person who, having been regularly admitted to a program duly recognized and established in the Philippines, has successfully completed the prescribed course of studies and has acquired the requisite qualifications.

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FROM THEORY TO PRAXIS

Executive Summary This narrative report is a collection of learning insights acquired during the Advanced Related Nursing Experience that took place in Notre Dame de Chartres Hospital in Baguio City from November 5 to 22, 2012. The first part is the hospital profile, history, vision and mission statements and the key people that run the organization as one. Following this are the selected cases of patients with cancer, diabetes and heart disease selected by the author. The case studies includes the background of the case, profile of the patients, medical history, laboratory and diagnostic examinations done and the drug studies. The vital part of the case studies are the nursing care plans formulated for them by the author to match their nursing need. The last part of the report presents the daily activity of the author, the best practices observed in the hospital and the recommendations for the areas that need improvement.

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FROM THEORY TO PRAXIS

Case Study: Diabetes This is a case of a 42 year old married woman diagnosed with diabetes. She was diagnosed with Type II diabetes Mellitus in the year 2010 and hospitalized only once. Oral antidiabetic medication was prescribed by her physician but she only took it for 6 months. Until then, she did not bother to take necessary precautions and preventive practices to control her sugar level. This case is a presentation of a possible complication of diabetes in the renal system. Researches present strong evidence of this complication.

Patient Profile Sex

: F

Age

: 42

Address

: Camp 7, Baguio City Benguet

Religion

: Baptist

Occupation

: Human Resource Officer

Admission Date

: November 11, 2012

Chief Complaint

: Fever and Hypogastric Pain

Diagnosis

: Type 2 Diabetes Mellitus

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FROM THEORY TO PRAXIS

PAST MEDICAL HISTORY The patient is known diabetic since 2010 but admits noncompliance to treatment regimen. She was advised to take oral hypoglycemic agent and referred to a dietitian for diet modification but failed to comply. She has no known history of asthma and heart attack and has not been hospitalized due to Diabetes. Her blood pressure is within normal measurements. On an average of twice every year in the past three years, client experiences cough and colds but did not seek medical attention regarding this. Several months after being diagnosed with Type 2 Diabetes, it was found out that she has nephrolithiasis and undergone medical management. No surgical operation has been done.

HISTORY OF PRESENT ILLNESS Four days prior to admission, the client experienced undocumented fever which she medicated with paracetamol, body weakness, loose bowel movement and mucoid stool. Three days prior to admission, she experienced hypogastric pain. Several hours prior to admission, symptoms are still present and fever did not subside. The client experienced cold clammy skin. This is when they have decided to seek medical attention. After thorough examination, the attending physician diagnosed her with Pyelonephritis.

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FROM THEORY TO PRAXIS

FAMILY MEDICAL HISTORY The patient’s mother is a known diabetic and has a history of congestive heart failure. Her father has asthma and died of myocardial infarction.

She has no known food and drug allergies.

HEALTH ASSESSMENT A. Health Perception and Health Management Before admission, patient describes her life as good. She was satisfied with it even though she is aware of her condition. She is a non-smoker and drink wine in moderation and just at least two occasions in a month. She had a kidney stone diagnosed months after she was diagnosed with diabetes. She consulted a physician regarding her diabetes twice in 2010 and several times for her kidney stones which was managed only by medications. She describes her current working condition in San Roque Power Corporation as good. Since she and her husband are working, she does not pay much attention to the nutritional contents of the food they eat for they prefer those that could be easily prepared and accessible which is in her case, meat, poultry and common vegetables sold in the market nearby their home. Healthcare facility is accessible from 15 to 30 minutes away from their home. In cases of mild headache, she only takes paracetamol and never took any other medications.

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FROM THEORY TO PRAXIS She was prescribed with Metformin but stopped taking it after several weeks for she feels as if she is normal without it. According to her, she perceives no noticeable symptom of diabetic after her consultation.

B. Nutrition and Metabolic The patient’s skin is pale looking, dry and cold with supple turgor. She has no noticeable skin lesion. She has an artificial denture and her gums are normal with pinkish color. The patient experienced a weight gain of 10 kilograms in the past six months. Her appetite became fair several days after her admission but she still able to tolerate solid foods being served by the hospital dietary department (diabetic diet). She has no nausea, does not vomit, no difficulty of swallowing, chewing and indigestion.

C. Elimination The patient has normal bowel sound. She has tenderness in the hypogastric area radiating to her left and right flank with pain scale of 6/10. There is no overflow of urine when bladder is palpated. The patient has one bowel movement every day and it does not change even during hospital admission. There is a history of diarrhea that lasted for one day (3 rd day of hospitalization). The voiding frequency of the patient is increased but there is no history of difficulty, retention, pain or bladder spasm.

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FROM THEORY TO PRAXIS D. Activity-Exercise In the workplace, the patient’s activity is reduced due to the nature of her job. He tries to walk herself when needs to go from one place to another as her only form of exercise. In the hospital, when feeling well and walking is tolerable, she walks herself around the room or around the garden nearby the ward. She experiences no difficulty moving and difficulty of breathing during activities. The patient needs little assistance in ADL’s due to movement restrictions of her hands with IV line. Client has normal pulse rate and respiratory rate upon assessment.

E. Sleep Rest Pattern The client usually sleeps 6 to 8 hours at night and has an afternoon nap. She always feels rested afterwards. She has no difficulty sleeping and does not awaken at night except when feeling the urge to void.

F. Cognitive- Perceptual Patient complains an on and off hypogastric pain. Upon assessment, it was identified as flank pain radiating to the hypogastric area with pain scale of 6/10 with no pattern of occurrence and lasts from 1 hour to half a day. At home, she tried to medicate it with paracetamol which according to her gave a little relief. The pain began 3 days prior to her admission.

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FROM THEORY TO PRAXIS G. Self- Perception and Self-Concept During assessment, patient is relaxed and calm and speaks in a soft toned voice that hasn’t changed throughout the interview.

The patient’s major concern at the moment is the changes that she needs to undergo to avoid such situation for the doctor already explained to her that her current condition is possibly a complication of her Diabetes. With regards to lifestyle modification, she verbalize that she believe it would not be a problem for her as long as she will be guided by her health care providers.

H. Role Relationship The patient is living in their residence with her husband and 4 children and as she verbalized, the changes that she needs to undergo would not affect her role as a husband and mother.

I. Sexuality The patient uses contraceptive pills as method of birth control since 2005. She had 3 pregnancies and all of which are born alive. She is not yet into menopausal stage and satisfied with her sexual relationship with her husband.

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FROM THEORY TO PRAXIS J. Coping-Stress There are no overt sign of stress that can be observed during interview and the patient rates her stress handling as good. She dealt with everyday stressor by confronting it with the help of her support system.

K. Values-Belief The patient is a devoted Baptist and is satisfied with the development of her life besides her condition. Her admission made her closer to the Supreme Being and it does not interfere with her religious practices.

LABORATORY AND DIAGNOSTIC EXAMINATIONS

PARAMETERS Color Transparency pH Specific Gravity Glucose Protein Leukocytes Erythrocytes Ketones Nitrates Urobilinogen Bilirubin WBC RBC Amorphous Urates Mucuous Thread Bacteria PARAMETERS White Blood Cells Red Blood Cells

URINALYSIS RESULTS Amber Turbid 6.01 (Acidic) 1.025 Positive+++ Positive +++ Positive +++ Positive+++ Positive+ Negative Negative Negative Too Numerous to Count 4-6 Few Few Few COMPLETE BLOOD COUNT RESULTS NORMAL VALUES 15.9 4.0-10.0 5.40 3.5-5.0

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FROM THEORY TO PRAXIS Hemoglobin Hematocrit Platelet Count WBC Differential Neutrophils Lymphocytes Monocytes Eosinophils Blood Chemistry Potassium Sodium Chloride SPECIMEN Throat Swab

14.3 0.43 231

11.0-15.0 0.370-0.380 140-450

0.76 0.24 0.00 0.00

0.4-0.7 0.20.0.40 0.00-0.06 0.00-0.04

3.15 135 101.2 KOH Test

3.5-5.3 135-148 98-107

RESULT Positive for Fungal Spores Only GRAM STAIN Specimen: Throat Swab

Result: Smear shows a mixture of few gram negative (-) cocci occurring singly and in pairs and few negative coccobacilli. Pus cells and few epithelial cells are noted. GLYCOSILATED HEMOGLOBIN Result: 8.2% Reference Value: 4.3- 6.4% ABDOMINAL ULTRASOUND Impression: o Medullary nephrocalcinosis, bilateral with acalyceal stones o Sonographically normal liver, pancreas, spleen and urinary bladder o Normal size anteverted uterus with thin endometrium o Negative for adrenal masses

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FROM THEORY TO PRAXIS

PATHOPHYSIOLOGY Genetic predisposition and age are the two distinct predisposing factor the patient have. She is 42 year old with a diabetic mother. Type 2 Diabetes affects 90% to 95% of people with disease. It occurs more commonly in people who are older than 30 years of age and obese. The two main problems related to insulin in type 2 DM are insulin resistance and impaired insulin secretion. Insulin resistance refers to a decrease tissue sensitivity to insulin. The exact mechanism that results to insulin resistance and impaired insulin secretion in type 2 diabetes are unknown. To overcome insulin resistance, and to prevent the glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level at a normal or slightly elevated level. This is called metabolic syndrome. However, if the beta cells cannot keep up with the increased demand for insulin, the glucose level rises and type 2 diabetes develops. Because type 2 diabetes is associated with a slow progressive glucose intolerance, its onset may go undetected for many years. If the patient experiences symptoms, they are frequently mild and may include fatigue, polyuria (which the patient encountered weeks before her diagnosis and several times before admission), polydipsia, poorly healing skin wounds, vaginal infections or blurred vision. Because of the extra glucose in the urine it provides an excellent source of food for any pathogenic microorganism. This increases the risk of getting bladder or kidney

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FROM THEORY TO PRAXIS infections which is in the case of the patient, we may assume that the diabetes contributed to the development of pyelonephritis.

DRUG STUDY Levofloxacin Class

:

Antibiotic, Flouroquinolone

Therapeutic Action

:

Bactericidal

Dosage

:

500mg tablet once a day

Indications

:

Acute Pyelonephritis, Community Acquired Pneumonia, Bacterial Sinusitis, Chronic Bronchitis, Chronic

Bacterial

Prostatitis, Post-exposure inhalational Anthrax

Nursing Responsibilities : Arrange for culture and sensitivity tests before beginning of the therapy Continue therapy as indicated for condition being treated (7 to 14 days for pyelonephritis) Administer oral drugs without regards to meals with a glass of water. Separate oral drug from other cation administration including antacids, by at least 2 hours. Monitor drug response. If no improvement is seen or relapse occurs, repeat culture and sensitivity test Ceftriaxone Sodium Class

: Antibiotic, Third Generation Cephalosphorin

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FROM THEORY TO PRAXIS Therapeutic Action

: Bactericidal

Dosage

: 1g every 8 hours

Indications

: Urinary Tract Infection, lower respiratoty infection, gonorrhoea, intra-abdominal infection, pelvic inflammatory disease, septicimea, bone and

joint

infections and meningitis

Nursing Responsibility : Culture infection and arrange for sensitivity tests before and during therapy.

Instruct patient to report diarrhea, difficulty of breathing, unusual tiredness or fatigue, pain at injection site. Proglitazone Class

: Antidiabetic

Therapeutic Action

: Resensitizes tissues to insulin; stimulates insulin receptor sites to lower blood glucose and improve the action

of

insulin, decreases hepatic gluconeogenesis and

increases

insulin-dependent muscle glucose uptake.

Dosage

: 30mg tablet once a day

Indications

: Monotherapy as an adjunct to diet and exercise to improve glucose control in patients with type 2

mellitus As a part of combination with a sulfonylurea, metformin and insulin when diet, exercise, plus a single agent

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FROM THEORY TO PRAXIS alone

does not result in glycemic control in type 2

diabetes Nursing Responsibility : Monitor liver function tests before therapy and during the therapy to monitor effectiveness of drug Administer without regards to meals Arrange consultation with dietitian to establish weight loss program and dietary control as appropriate Patient Education

: Do not discontinue this medication without consulting your health care provider; continue with diet and

exercise

program for diabetes control Take this drug without regards to meals. If a dose is missed, it may be taken on the next scheduled time.

If the

dose is missed on the entire day, do not take double

dose

the following date Monitor urine and blood very closely for glucose and ketones while adjusting to drugs Use barrier contraceptives if currently using with hormonal contraceptive

Metformin Class

: Antidiabetic

Therapeutic Action

: Exact mechanism is not understood; possibly increases peripheral utilization of glucose, decreases hepatic

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FROM THEORY TO PRAXIS glucose production, and alters intestinal absorption of

glucose. Dosage

: 850 mg tablet twice a day

Indications

: Adjunct to diet to lower blood glucose with type 2 diabetes mellitus in patients who are 10 years old or

older

and extended release in patients 17 years old and

older As part of combination therapy with sulfonylureas or insulin when either drug alone cannot control glucose

levels in patient with type 2 diabetes

mellitus Nursing Responsibilities : Monitor urine and serum glucose level to determine effectiveness of drug and dosage Arrange for transfer to insulin therapy during periods of high stress Patient Teaching

: Do not discontinue this medication without consulting health care provider Swallow extended release tablet as whole, do not crush , break or chew.

Ketorolac Class

: NSAID, Nonopioid Analgesic, Antipyretic

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FROM THEORY TO PRAXIS Therapeutic Action

: Anti-inflammatory and analgesic activity; inhibits prostaglandins and leukotriene synthesis.

Dosage

: 30 mg ampule every 8 hours daily intravenously

Indications

: Short term management of pain (up to 5 days)

Nursing Responsibilities : Be aware that patient may be at risk for CV events, GI bleeding, renal toxicity, monitor accordingly. Keep emergency equipment readily available at time of initial dose

in case of sever hypersensitivity

reaction.

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From Theory to Praxis

26

NURSING CARE PLANS Assessment

Nursing Diagnosis

“May mga pagkakataon lang na madalas akong mauhaw at madalas maihi katulad ngayon.” As stated by the patient.

Imbalanced Nutrition: More Than Body Requirements related to insulin deficiency with inability to utilize nutrients as evidenced by frequent urination, increased thirst and elevated blood glucose level

Glycosylated Hemoglobin = 8.2%

Goal of Care Short term goal: After 5 days of nursing interventions, client will maintain adequate caloric and nutritional intake as evidenced by resolving symptoms of hyperglycemia

Nursing Intervention

Rationale

Ongoing assessment: •Weigh the patient on initial and subsequent contact

 To establish baseline and comparison for future reassessment

•Assess for signs of hyperglycemia

 Hyperglycemi a results when there is inadequate insulin.

•Review blood glucose history •Assess current eating habits

 To establish baseline of blood glucose level  To identify the foundation for developing an individualized diet

Evaluation After 5 days of nursing interventions, client have maintained adequate caloric and nutritional intake as evidenced by resolving symptoms of hyperglycemia Goal met.

FROM THEORY TO PRAXIS plan. Therapeutic interventions:  Establish goals with patient. Review progress towards goals on each subsequent visit.

 Assist patient to identify eating pattern that needs changing  Refer to a registered dietitian for an individualized instruction

 Instruct patient to take

 Patient involvement in the treatment plan enhances adherence to treatment regimens.  To provide the basis for individualized diet plan  An individualized meal plan based on weight, blood glucose and lipid pattern should be developed for each patient 

Each

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FROM THEORY TO PRAXIS Oral Hpoglycemic Agent as directed

 Instruct the patient to exercise. Refer to the Pgysical therapy department for appropriate exercise.

medication acts on different site of glucose metabolism. The patient must be informed regarding this to maximize each medication’s effects.  Exercise improves lipid pattern and assists with weight loss.

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FROM THEORY TO PRAXIS Assessment

Nursing Diagnosis

“Sabi ng doctor kailangan ko na daw magsaksak ng insulin paglabas ko ng ospital,hindi ko pa nga alam kung pano e”, as verbalized by the patient.

Risk for ineffective therapeutic regimen management related to complex medical regimen and knowledge deficits

Complex medical regimen Insufficient knowledge about diabetes and its treatment

Goal of Care After 3 days of nursing intervention, the client will: Demonstrate ability to maintain blood glucose level within defined target range Demonstrate knowledge of diabetes selfcare measures

Nursing Intervention  Determine patient learning needs.  Evaluate selfmanagement skills, including ability to perform procedures for blood glucose monitoring  Assess financial resources for health care

 Ensure that the patient has knowledge about symptoms, causes, treatment, and prevention of hyperglycemia  Ensure that the patient has knowledge about the symptoms, causes, treatment and prevention of hyperglycemia.

Rationale  This dictates the amount and type of information necessary.  This determines the amount of education necessary  The cost of medication may become barrier to management of Diabetes.

Evaluation After 3 days of nursing interventions, the client:  Demonstrated the ability to maintain blood glucose level within defined target range  Demonstrated knowledge of Diabetes and its treatment

 Elevated glucose levels in patients with previously diagnosed diabetes indicate the need to evaluate diabetes management.  Frequent episode of hypoglycemia in individuals with previously diagnosed diabetes indicate the need to

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FROM THEORY TO PRAXIS evaluate diabetes management.  Teach relationship between medication management and blood glucose control

 Teach the patient how to use blood glucose results in overall diabetes management: review basic patterns management.

 Evaluate effectiveness of every instruction

 Approximately 90% of persons with Diabetes will require oral antidiabetes medications, insulin, or both  Instruction allows the patient to identify when therapy adjustment need to be made in diabetes treatment  Evaluation provides opportunity to correct errors in technique. Education is an ongoing process that requires reinforcement over time.

 Instruct the patient on Diabetes management during illness. o Instruct to take all

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FROM THEORY TO PRAXIS medications. o Self-monitor blood sugar every 2 to 4 hours o Drink 8 ounces of fluids every 4 hours. Sugar free drinks are recommended when the patient is able to maintain normal carbohydrate intake. Substitute drinks containing sugar when the individual cannot tolerate food as in anorexia.  Instruct when to contact primary provider; Blood glucose levels higher than 300mg/dL, vomiting for more than 2-4 hours, symptoms of dehydration or symptoms suggesting development of HHNS.

 Early treatment of hyperglycemia prevents HHNS occurrence.

 Instruct the patient about planning for diabetes management when travelling such as putting medications in carry-on luggage.

 Some travel may involve time changes that may disrupt the patient’s usual routines.

 Refer to social services to help with financial resources

 Non-adherence to a treatment plan may occur because of

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FROM THEORY TO PRAXIS limited resources in purchasing medications and blood glucose monitoring supplies. Some costs may not be covered by health insurance.

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FROM THEORY TO PRAXIS

Assessment

Nursing Diagnosis

Goal of Care

“Ang dahilan ng pagpacheckup ko eh pagsakit ng puson hanggang sa balakang,” as claimed by the patient

Acute pain related to infectious process (pyelonephritis)

After 2 days of nursing intervention, the patient will: • •

Pain scale of 6/10 upon assessment

•

Positioning to avoid pain Sighing Reduced interaction with the environment Elevated temperature Elevated WBC Fever (T= 37.8 C) Turbid urine

•

Report pain is relieved (3/10) Follow prescribed pharmacological regimen. Verbalize nonpharmacologic method that relieves pain Demonstrates use of relaxation skills and diversional activities, as indicated for individual situations

Nursing Intervention

Rationale

• Asses pain characteristics.

• The first step of pain management strategies

• Observe signs and symptoms associated with pain such as BP, heart rate, temperature, restlessness and ability to focus.

• Some people deny the existence of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.

• Assess patients knowledge of the array of pain relief strategies available.

• Some patients may not be aware of the effectiveness of nonpharmacological methods and may be willing to try them, either with or instead f

Evaluation After 2 days of nursing intervention, the client:  Reported pain relief  Was able to follow prescribed pharmacological regimen without miss  Verbalized nonpharmacologic method that relieves pain  Demonstrated use of relaxation skills and diversional activities, as indicated for individual situations

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FROM THEORY TO PRAXIS analgesic medications.

• Anticipate need for pain relief

• Respond immediately to complaint of pain

• Provide rest periods to facilitate comfort, sleep and relaxation.

• One can most effectively deal with pain by preventing it. • In the midst of painful experience, a patients perception of time may be distorted. Prompt response to complain may result decreased anxiety for patients. • Patient experience of pain may become exaggerated with fatigue.

• Pain

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FROM THEORY TO PRAXIS

• Administer analgesic as ordered evaluating effectiveness and observing signs and symptoms of untoward effects

• Provide anticipatory instruction on pain causes, appropriate prevention and relief measures • Instruct the patient to report pain • Instruct the patient to evaluate and report effectiveness of

medications are absorbed and metabolized differently by patients, so their effectiveness must be evaluated individually. • Knowledge about what to expect can help the patient develop effective coping strategies for pain management • Relief measures may be instructed • Relief measures could be modified to produce more satisfactory comfort levels

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FROM THEORY TO PRAXIS measures used

Assessment Objective: Hyperglycemia Physical immobilization

Nursing Diagnosis Impaired skin integrity related to altered metabolic state (hyperglycemia) and Physical immobility

Goal of Care After 2 hours of nursing intervention, client will demonstrate correct foot care practice

Nursing Intervention

Rationale

•

Assess the general appearance of the foot. Assess the hygiene.

•

This provides the basis for future education.

•

Assess the status of the nails. Asses skin integrity.

•

Pressure over bony prominences leads to callus formation. This condition can lead to the development of skin breakdown.

•

Atherosclerosis results in gradual

• •

Note the presence or absence of callus formation or corns.

Evaluation After 2 hours of nursing intervention, the client was able to demonstrate correct foot care practice.

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FROM THEORY TO PRAXIS

•

Assess the circulatory status of the foot by palpation of peripheral pulses.

•

Assess for infection

•

Examine hosiery and shoes

•

Teach the patient to inspect feet daily for cuts, scratches and blister. Use a mirror to examine the bottom of the foot. Instruct the patient to use both visual and tactile inspection.

•

decrease of blood supply in the foot. Symptoms might be present due to neuropathy

•

Maceration between the toes predisposes the patient to infection

•

All surfaces of the foot must be examined including skin between the toes. Touch will identify skin surface alteration that are not evident by sight.

•

This replaces moisturizing effects lost by autonomic neuropathy. Select lotion with low

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FROM THEORY TO PRAXIS

•

•

•

Encourage use of moisturizing lotion at least once daily. Avoid areas between the toes.

Report signs of infection immediately to the primary provider. o Area of skin breakdown o Increase in temperature as compared to the same area of the opposite foot. o Discharge that develops an odor.

alcohol content to prevent drying of the skin •

Early treatment is essential in prevention of complications.

•

Careful daily assessment reduces risk of injury to the foot.

Teach patient to

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FROM THEORY TO PRAXIS inspect the shoes daily by feeling the inside of the shoe for irregularities in the lining, sharp objects in the sole of the shoe, or foreign bodies in the shoe. •

•

Teach the patient to avoid thermal injuries by: o Testing the temperature of bath water with the elbow, wrist or thermometer, o Avoiding use of heating pad, hot water bottles or electric blankets o Maintaining a safe distance from heat sources Instruct the patient to always wear protective

•

Sensory neuropathy may result in normal pain and temperature sensation. These changes increases risk for burns.

•

This prevents foot injury.

•

Soaking can macerate the skin and increases the risk of infection

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FROM THEORY TO PRAXIS footwear.

Assessment

Nursing Diagnosis

Goal of Care

•

Instruct the patient to avoid soaking feet.

•

Instruct the patient to trim nails across and to file sharp corners to match contour of the toe.

Nursing Intervention

•

This prevents foot injury

Rationale

Evaluation

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FROM THEORY TO PRAXIS “Masyado na ngang madami ang dapat iconsider para makontrol ko tong Diabetes ko ngayon e.” Objective: Complex medical regimen Requirement for changes in lifelong basis Increasing self care requirements to maintain blood glucose control

Risk for ineffective coping related to complex medical regimen, requirements of change in lifelong basis and increasing requirements to maintain blood glucose control

After 2 days of nursing interventions, the patient will: •

•

•

Be able to perform self-care behaviors Identifies stressors that interfere with ability to control diabetes Develops appropriate action plan to deal with stressors

 Assist patient to identify the situations that cause anxiety or increased stress.

 A starting point is to ask the patient what he or she finds most difficult to do. The patient may be able to cope with only one health behaviour change at a time.

 Help patient identify thoughts and feeling associated with stressors.

 Feelings of anger, denial and depression are frequently associated with a chronic disease

 Help patient to identify stressrelated

 Guiding the patient to view the situation

After 2 days of nursing interventions, the client was:  Able to perform self-care behaviors  Able to identify stressors that interfere with ability to control diabetes  Able to develop appropriate action plan to deal with stressors

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FROM THEORY TO PRAXIS diabetes problems and issues o which the patient wants to work.  Help the patient identify adaptive coping strategies

Provide education needed to enable the patient to perform self management behaviors like:

into smaller parts may make the coping more manageable.

 Anxiety can be reduced when the patient has anticipated a stressor and developed a plan to reduce or avoid the stressor.

 Anxiety can be reduced when the patient has technical knowledge and ability to perform the self care behaviors required for blood glucose

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FROM THEORY TO PRAXIS o Self-Blood Glucose monitoring o Medication administration o Adjustment of therapy for exercise and illness o Meal planning Hypo/hypergl ycemia management

 Assist patient in examining available resources to meet goals. Review health care resources that are available for use

control. On adherence to requirements may occur because of patient misunderstandi ng of information.

 Social support increases the ability of the patient to deal with stress

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FROM THEORY TO PRAXIS  Provide positive reinforceme nt for use of adaptive behaviors

 Reinforcement increases the patient’s confidence in his or her ability to perform specific behaviors

 Acknowled ge that change may not be possible

 The patients readiness for change may prevent alterations in behavior

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From Theory to Praxis

45 Case Analysis: Oncology

INTRODUCTION Cancer is not a single disease with single cause; rather it is a group of distinct diseases with different causes, manifestation, treatments and prognoses. The scope, responsibilities and goals of cancer nursing ae as diverse and complex as those other nursing specialty. Cancer nurses must be prepared to support patients and families through a wide range of physical, emotional, social, cultural and spiritual crises. Like other chronic diseases, cancer can result to the patient’s depression and helplessness as with the following case to be discussed. In this report, a case of a 42 y/o housewife who was diagnosed with Liver Cancer in September 2012 will be discussed. Loss of appetite and difficulty sleeping made her seek health care attention. She was advised to undergo surgery but opted to try medications until her condition got worse. In November 9, 2012, due to diarrhea and body weakness, she was brought to Notre dame De Chartres Hospital Baguio City and after assessment of the medical history and diagnostic procedures, she was admitted to the Mere Marie Anne Ward for further management.

PATIENT PROFILE Age: 42 Sex: Female

FROM THEORY TO PRAXIS Civil Status: Married Educational Attainment: College Graduate (Dentistry) Occupation: Insurance Sales Agent Address: Ma. Aurora, Aurora

PAST MEDICAL HISTORY In 2011, the patient experienced fever, cough and colds occurring almost every other month which is unusual for her. She then thought that these symptoms that might be an indication of weakening of her immune system is a part of the aging process. From December 2011, she began experiencing difficulty sleeping and loss of appetite. Though admittedly said she admit that time that something is wrong, she opted not to seek medical attention yet and observe further her condition. In September 2011, she decided to seek medical attention due to consistent symptoms. She undergone series of medical examinations and diagnostic tests wherein it was found a mass in her liver which they suspect malignant. The physician prescribed multivitamins and referred her to an oncologist for further management. She was advised to undergo a surgery which aims to remove totally or partially the mass found depending on the results of evaluations the medical team will conduct but she refused. Her condition become worse and other symptoms manifested but she was able to manage difficulty sleeping then, until in November 9, 2012, she was brought to the hospital due to to diarrhea and body weakness, she was brought to Notre dame De

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FROM THEORY TO PRAXIS Chartres Hospital Baguio City and after assessment of the medical history and diagnostic procedures, she was admitted to the Mere Marie Anne Ward for further management.

FAMILY MEDICAL HISTORY The patient’s father died of Pneumonia in 2009. The patient’s mother is presently living with them in healthy condition. She (the mother) has controlled hypertension but no history of chronic illnesses. History of cancer can only be traced on her grandmother (Breast cancer) on the paternal side and a far relative also on the paternal side (Ovarian cancer).

HEALTH ASSESSMENT A. Health Perception- Health Management Pattern Though restless and loses focus, client is able to answer interview questions with provided intervals for rest. She is cooperative and no signs irritability during the interview. She admits having diminishing smell and taste sensation. She describes her health status as poor for her condition makes her unable to perform normal activities of daily living and she’s not satisfied with it. She started smoking when she was 21 years old and stopped when she was 40 years old, an occasional drinker (4 glasses of beer every month) with no history of drug use. The patient has no history of other chronic disease, with tetanus immunization she completed after the birth of her 4th child. She is not sure if he completed her infant immunization.

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FROM THEORY TO PRAXIS Aside from consultations leading to the diagnosis of Liver Cancer, she had not availed/sought health care assistance in the past year. She is currently an insurance sales agent and during her healthy days were exposed to noise and extremes of weather. The working environment is different from time to time for she has been assigned in different areas. The patient lives with her husband and four children in their home at Ma. Aurora which she rates the condition as good. The only problem she identified where the limited technology present in the area like telecommunications and internet. While waiting for her decision regarding the management of her liver cancer, her physician prescribed multivitamins which she took once daily before admission. When she was admitted, the doctor prescribed Piperacillin-Tazobactam, Furosemide, Vitamin K and Paracetamol mst medications are given intravenously. She believes that this regimen is the best for her as it is prescribed. The patient does not have history of accidents and falls the past year. She has problems with healing which she noticed in the mid-2012.

B. Nutritional-Metabolic Pattern She lost roughly 20 kilograms since the last six months which she attributed to loss of appetite. Usual meal that she can tolerate without vomiting is soup, bread and small amount of fruits. She makes sure that she drinks at least 1 liter of water per day.

C. Elimination Pattern

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FROM THEORY TO PRAXIS The patient has at least three bowel movements per day since her diarrhea is controlled occurring not on the same time each day. Mostle she passes soft to liquid light colored stool.

D. Activity-Exercise Pattern The patient does not manifest cyanosis, with weak but palpable pulses. Extremities are cool. Capillary refill is delayed (5 seconds). The patient, does require assistance in ADLs due to weakness and fatigue. She used to sleep on 1 pillow during bed time. She walks at least 1 meter without experiencing difficulty. She used to be an insurance sales agent. During free time, she stays with her family and do some household chores at home.

E. Sleep-Rest Pattern The patient usually sleeps at least 10 hours per night and usually has a morning and afternoon naps of 1 hour each. She stated that one of the first symptoms that manifested in the early stage of her illness was difficulty falling asleep but later on, the symptom diminished and she is now able to sleep easily, does not usually awakens at night and wakes up at 7:00AM. Cognitive-Perceptual Pattern During interview, she has no reports of pain and barely felt pain in the course of her illness.

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FROM THEORY TO PRAXIS Internal and external factors lingering on the patients mind makes it difficult to decide on major decisions to make for her life and the situation. The one who mostly decides for her is her husband who is her primary caregiver at home.

F. Self-Perception and Self-Concept Pattern During the assessment, the patient is calm with monotonous voice and looks in the eye of anyone talking to her. Her major concern is her death. She does not know when or when the right time would come and her readiness for it. She has a neutral view for herself.

G. Role-Relationship Pattern No speech or communication problems noted during the assessment. In Ma. Aurora, she lives with her family. She finds no difficulty in her parenting skills and the family did not experience any loss the past year. She had four pregnancies in which all children are born alive and term. She has stopped menstruating at the age of 40 but prior to that, she uses birth control pills for contraception. During her admission, she had a history of vaginal discharge that lasted for a day only.

H. Coping-Stress Tolerance Pattern Client admitted that she cries when nobody is around due to the hopelessness she felt. But she is now learning to accept her situation.

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FROM THEORY TO PRAXIS At present, she rates her stress handling as average and her primary way to do it is to share emotions and feelings to her husband She verbalized that by having a conversation with her husband, she feels relief. In her case, the interval of symptom experience and health care consultation is 9 months.

H. Value-Belief Pattern The patient is a Roman Catholic and confessed that in the early stages of her illness, her faith was moved but began to regain it again after some time. She keeps on praying to the Supreme Being and wishes to attend the mass as soon as she can.

LABORATORY AND DIAGNOSTIC EXAMINATIONS PARAMETERS White Blood Cells Red Blood Cells Hemoglobin Hematocrit Platelet Count WBC Differential Neutrophils Lymphocytes Monocytes Eosinophils Electrolytes Potassium Sodium

HEMATOLOGY REPORT RESULTS NORMAL VALUES 15.1 x 10^3 4.0-10.0 3.53 x 10^6/uL 3.5-5.0 110 g/L 11.0-15.0 0.338 0.370-0.380 408 x 10^3/uL 140-450 0.87 0.12 0.01 0.00

0.4-0.7 0.20.0.40 0.00-0.06 0.00-0.04

3.05 145.3

3.5-5.3 135-148 98-107

ASCITIC FLUID Color: YELLOW Transparency: SLIGHTLY TURBID Volume: 88 mL WBC: 1-3 cells/uL RBC: 4-8 cells/uL i

FROM THEORY TO PRAXIS TUMOR MARKER TEST CEA >200 AFP 1.74 HEPATITIS PROFILE Anti-HBS: Prolonged bedrest nursing respiratory and are indicated only interventions, the cardiac status before for hemodynamic client was able to initiating activity unstable patients. If tolerate progressive the patient is stable, activity, as activities can be evidenced by HR gradually and BP within progressed. Assisted expected range and hygiene and no complaints of ambulation are dyspnea or fatigue. appropriate to reduce physical deconditioning associated with bed rest. >Observe response to activity. Signs of abnormal response includes the following:

>Close monitoring serves as a guide for optimal activity progression

FROM THEORY TO PRAXIS

• Increased HR of 20 beats/min over resting rate during activity, or 120 beats per minute • Increased BP of 20 mm Hg systolic during activity • Chest discomfort • diaphoresis • Pallor • dyspnea • labored breathing • excessive fatigue/weakness >Encourage adequate rest periods, especially before activities (ADLs, visiting hours,meals)

>Rest before activities provides time for energy conservation

>Provide light

>This facilitates

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FROM THEORY TO PRAXIS meals

digestion and reduces energy needs

>Instruct patient not to hold breath while exercising or moving about in bed and not to strain during bowel movement

>These activities stimulate Valsalva Maneuver, which affects endocardial repolarization and predisposes the patient to ventricular dysrhythmias.

>Provide emotional support when increasing activity

>This reduces reduces possible anxiety about overexertion of the heart

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FROM THEORY TO PRAXIS

Assessment “San pa ba ito nakukuha maliban sa pagkain ko ng matataba, babalik pa ba ako sa normal?” as verbalized

Nursing Diagnosis Knowledge Deficit related to unfamiliarity to disease process, treatment and recovery as evidenced by multiple questions

Nursing Goals

Interventions

Rationale

Evaluation

After 8 hours of nursing interventions, the patient will verbalize understanding of condition, need for observation in critical care unit, diagnosis of treatment of MI and healing process of MI

>Encourage patient to verbalize concerns.

>The patient must be an active partner in follow up care

After 8 hours of nursing interventions, the patient verbalized understanding of condition, need for observation in critical care unit, diagnosis of treatment of MI and healing process of MI

>Provide information on the following: • Diagnosing MI •

Healing Process

•

Medications

•

Expected return to prior lifestyle (2

>Explaining procedures may reduce anxiety. >It takes 6 weeks for necrotic tissue to be replaced by scar tissue >Patients may not realize that a clot has caused MI thinking instead that cholesterol plaque is the culprit >More than 85% of patients return to full activity level

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FROM THEORY TO PRAXIS or 3 months)

Assessment “Ang ikinatatakot ko lang, baka maulit ito. Muntik na ako mamatay.” As stated. Narrowed focus on the source of the fear

Nursing Diagnosis Fear related to threat to health status as evidenced by narrowed focus on the source of the fear

Nursing Goals After 8 hours of nursing intervention, the patient will verbalize reduce fear, and demonstrate positive coping mechanism

Interventions >Acknowledge awareness of patient’s fear

>Allow patient to verbalize fears of dying. Reassure patient that most deaths occur before reaching the hospital. >Offer realistic assurances that recovery is fully anticipated >Maintain confident assured manner

Rationale >Acknowledgemen t of patient’s feeling validates the feeling and communicates acceptance of those feelings >Anxiety can be reduced when patient has accurate knowledge of realistic prognosis; hospital mortality rate is only 5% >These measures enhance the patients optimism about recovery

Evaluation After 8 hours of nursing intervention, the patient was able to verbalize reduce fear, and demonstrate positive coping mechanism

>The staff’s anxiety may be easily perceived by the

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FROM THEORY TO PRAXIS

>Explain in simple terms various aspect of MI and clarify misconceptions >Assure patient and significant others a continuous monitoring that will ensure prompt intervention

patient. The patient’s feeling of stability increases in a calm environment > This reduces anxiety >This provides a measure of safety >Anxiety may escalate with excessive conversation, noise and equipment around patient.

>Reduce unnecessary stimuli . >Explain all procedures as appropriate, >Information allays keeping explanation anxiety. basic. >Diversion can be >Provide relaxing, prevent diversional material anxiety and prevent feelings of isolation >Establish rest periods during care >Pacing activities and procedure. helps the patient relax and gain

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FROM THEORY TO PRAXIS emotional balance

Assessment

Nursing Diagnosis

Nursing Goals

“ Palagay ko sir magbabago ang buhay ko paglabas ko pagdating sa mga nakagawian ko, sa pagkain at sa mg adapt ko ingatan”, as verbalized

Risk for ineffective coping

After 8 hours of nursing interventions, the patient will be able to identify his own coping behavior, identifies his psychological and social support system and implement positive coping mechanism

Objective: Recent change in health status Perceived change in health status

Interventions

Rationale

Evaluation

>Assess specific stressors

>Accurate appraisal facilitates development of appropriate coping strategies

>Assess available or useful past and present coping mechanism

> Successful adjustment is influenced by previous coping success

After 8 hours of nursing interventions, the patient was able to identify his own coping behavior, identifies his psychological and social support system and implement positive coping mechanism

>Evaluate resources of support systems available to patient at home

> Older persons with lifelong cardiac disease may have reduced contact with significant others

>Assess the level of understanding and readiness to learn needed

>This provides an important starting point when intervening with

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FROM THEORY TO PRAXIS lifestyle changes

patients

>Encourage verbalization of concerns

>Acknowledging awareness of the challenges related to recovery can open doors for ongoing communication

>Encourage patient to seek information that will enhance coping skills

>Patients who are not coping well may need more guidance initially

>Provide information that patient wants or needs.

>With shortened exposure to cardiac rehabilitation services, patients can easily become overwhelmed by the large number of changes that are expected of them in a short time. Lifetime changes should be considered over a lifelong period. >To provide

>Provide reliable

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FROM THEORY TO PRAXIS information about the healing process so that misconceptions can be clarified.

reassurance and confidence about resuming activity

>Point out signs of positive progress or change

>Patients who are coping ineffectively may not be able to assess progress

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FROM THEORY TO PRAXIS

Assessment

Nursing Diagnosis

Nursing Goals

Interventions

“Pwede na daw akong lumabas pero andami naming iniresetang gamut makkalimutan k pa kung kelan iinumin yan e.” as verbalized

Risk for ineffective therapeutic Regimen Management

After 8 hours of nursing interventions, the patient will:

>Assess patient’s health values and belief

Complexity of therapeutic regimen

>describe system of taking medication >verbalize intention to follow prescribed regimen

>Assess previous pattern of adherence

>Asses for risk factors that may negatively affect adherence with regimen

Rationale

Evaluation

>Health behavior models propose that patients compare factors such as perceived susceptibility to and severity of illness or complications with perceived benefits of treatment in making decisions regarding adherence to therapy

After 8 hours of nursing interventions, the patient was able to: >describe system of taking medication >verbalize intention to follow prescribed regimen

>Long term therapy provides more opportunity for non-adherence >Knowledge of causative factors provides direction for subsequent interventions

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FROM THEORY TO PRAXIS

>Simplify drug regimen

>Include patient in planning treatment regimen

>If negative side effect of prescribed treatment are a problem, explain that many side effects can be controlled or eliminated

>The more often patients have to take medicines during the day, the greater the risk of non compliance >Patients who become comanagers of their care have a greater stake in achieving positive outcome. >To prevent or control occurrence

>This encourages >Include significant support and others in assistance in applications and reinforcing teachings appropriate behavior and

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FROM THEORY TO PRAXIS facilitating lifestyle modification

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From Theory to Praxis

99

LEARNING FEEDBACK DIARY WEEK 1 : EMERGENCY DEPARTMENT/ OUT-PATIET DEPARTMENT DAY 1 Time 9:30AM – 10:00 AM

Activities Courtesy call and meeting with Sr. Corazon Bunagan, the NDCH Nursing Service Directress and orientation

regarding the policies and

profile of the hospital. 10:00AM – 10:110AM

Hospital Tour

10:30AM – 12:00NN

Orientation to the area done by the ER head nurse Patient assessment and observation

12:00NN – 1:00PM

Lunch Break

1:00PM – 3:00PM

Assist in the provision of quality care to patients.

3:00PM – 4:00PM

Participate in patient endorsement and aftercare.

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 2 Time

Activities

7:00 AM- 7:30AM

Endorsement

7:30AM- 4:00PM

Staff shadowing Cases encountered:

FROM THEORY TO PRAXIS ST Elevation Myocardial Infarction Lung Cancer Breast Cancer Hypertension Assisted for a follow up check-up of client with pacemaker with a possible complication

3:00PM – 4:00PM

Participate in patient endorsement and aftercare.

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 3 Time

Activities

7:00 AM- 7:30AM

Endorsement

7:30AM- 4:00PM

Nursing Care of Patient with Emergency Conditions: Spontaneous Abortion Ethical considerations were applied in care of a patient with suspected spontaneous abortion Asthma Multiple Sclerosis

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FROM THEORY TO PRAXIS 3:00PM – 4:00PM

Endorsement

4:00PM – 6:00PM

Post Conference

6:00PM- 7:00PM

Documentation

DAY 4 Time

Activities

7:00 AM- 7:30AM

Endorsement

7:30AM- 4:00PM

Nursing Care of Patient with Emergency

Conditions Rabies Bite Vehicular Accident Woman in Labor Hypoglycemia Body weakness 3:00PM – 4:00PM

Participate in patient endorsement and aftercare.

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 5 7:00 AM- 7:30AM

Endorsement

7:30AM- 4:00PM

Nursing Care of Patient with Emergency Conditions Diabetes Ketoacidosis

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FROM THEORY TO PRAXIS Venous Stripping Myocardial Infarction 3:00PM – 4:00PM

Participate in patient endorsement and aftercare.

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 6 7:00 AM- 7:30AM

Endorsement

7:30AM- 4:00PM

Nursing Care of Patient with Emergency Conditions Myocardial Infarction Glaucoma Renal failure End Stage Renal Disease Gonorrhoea

3:00PM – 4:00PM

Participate in patient endorsement and aftercare.

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

WEEK 2: FATHER LOUIS CHAUVET WARD DAY 1 Time

Activities

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FROM THEORY TO PRAXIS 7:00AM-7:30AM

Endorsement

7:30AM-8:30AM

Bedside Endorsement

8:30AM-4:00PM

Orientation Staff Shadowing

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 2 Time

Activities

7:00AM-:7:30AM

Endorsement

7:30AM- 8:00AM

Bedside Endorsement

8:00AM-3:00PM

Nursing Care of Patient with Health Alterations Asthma Cholelithiasis Case Analysis: Diabetes  Review of files  Assessment

3:00PM-3:30PM

Endorsement

3:30PM-4:00PM

Bedside Endorsement

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

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FROM THEORY TO PRAXIS DAY 3 Time

Activities

7:00AM-:7:30AM

Endorsement

7:30AM- 8:00AM

Bedside Endorsement

8:00AM-3:00PM

Nursing Care of Patient with Health Alterations

3:00PM-3:30PM

Endorsement

3:30PM-4:00PM

Bedside Endorsement

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 4 Time

Activities

7:00AM-:7:30AM

Endorsement

7:30AM- 8:00AM

Bedside Endorsement

8:00AM-3:00PM

Nursing Care of Patient with Health Alterations

3:00PM-3:30PM

Endorsement

3:30PM-4:00PM

Bedside Endorsement

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 5 Time 7:00AM-:7:30AM

Activities Endorsement

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FROM THEORY TO PRAXIS 7:30AM- 8:00AM

Bedside Endorsement

8:00AM-3:00PM

Nursing Care of Patient with Health Alterations

3:00PM-3:30PM

Endorsement

3:30PM-4:00PM

Bedside Endorsement

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 6 Time

Activities

7:00AM-:7:30AM

Endorsement

7:30AM- 8:00AM

Bedside Endorsement

8:00AM-3:00PM

Nursing Care of Patient with Health Alterations

3:00PM-3:30PM

Endorsement

3:30PM-4:00PM

Bedside Endorsement

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

WEEK 3: MERE MARIE ANNE WARD DAY 1 Time

Activities

7:00AM-7:30AM

Endorsement

7:30AM-8:30AM

Bedside Endorsement

8:30AM-4:00PM

Orientation

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FROM THEORY TO PRAXIS Staff Shadowing 4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 2 Time

Activities

7:00AM-:7:30AM

Endorsement

7:30AM- 8:00AM

Bedside Endorsement

8:00AM-3:00PM

Nursing Care of Patient with Health Alterations A patient with myocardial infarction was brought in the ward while waiting for an ICU bed. Proper care was rendered and assistance to diagnostic examinations were done.

3:00PM-3:30PM

Endorsement

3:30PM-4:00PM

Bedside Endorsement

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 3 Time

Activities

7:00AM-:7:30AM

Endorsement

7:30AM- 8:00AM

Bedside Endorsement

8:00AM-3:00PM

Nursing Care of Patient with Health Alterations

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FROM THEORY TO PRAXIS 3:00PM-3:30PM

Endorsement

3:30PM-4:00PM

Bedside Endorsement

4:00PM – 6:00PM

Post conference

6:00PM- 7:00PM

Documentation

DAY 4 Exit interview with Sr. Corazon Bunagan SPC

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FROM THEORY TO PRAXIS

Reflection Based on Jean Watson’s 10 Primary Carative Factors

Formation of Humanistic-Altruistic System of Value Nursing with loving kindness could be observed to most of the employees of the hospital. The prevailing culture of altruistic values upholds the dignity of patients confined in the hospital. This practice is reflected in their vision and mission statements which serves as their guide in everyday interactions with coworkers and patients.

The installation of faith hope Notre Dame de Chartres practice not just within the standards of quality healthcare but also the standards of being hospital of Christians. The hospital accepts patients of any religion and encourages everyone to come closer to the Supreme Being especially in moments of sickness.

Cultivation of sensitivity to one’s self and to others The interpersonal interaction is also important for the nurses of NDCH. Their practice meets the ideal practice of establishing patient rapport and being sensitive to their emotions.

The development of a helping-trust relationship

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FROM THEORY TO PRAXIS The mode of communication between nurse to coworkers and nurse to patients are continuous be it by means of conversation or through other channel. This open communication provides opportunity to connect to the patients and effectively assessed their needs. On the other hand, this open communication channel between nurses and coworkers makes them work harmoniously resulting to a more effective provision of healthcare.

Promotion and acceptance of the expression of positive and negative feelings The balanced workload of the nurses provides them ample time to talk to the patients. By doing this, nurses are made aware of the patients’ able to provide their nursing needs. Although this was supposed to be an ordinary scenario in hospitals, the current situations does not prove so in most hospitals in the region. It is just an evidence of the quality of healthcare one can avail in NDCH.

Systematic use of the scientific problem-solving method for decision making Effort to understand patient condition and helping them explore alternatives are common practice of nurses and employees. Solutions are easily identified by the patients through the help of resource persons of the hospital and proper education and couselling done by the nurses.

Promotion of interpersonal teaching-learning. Every time a nurse speaks with the patient, there are always health teaching

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FROM THEORY TO PRAXIS being shared and feedback are encouraged. This practice is evident in nurses especially in the wards where most health education occurs immediately before the time of discharge.

Provision for a supportive, protective and /or corrective mental, physical, sociocultural and spiritual environment. These are one of the things that make the hospital different from the others. Services of follow up care, counselling by social workers and the sisters of St. Paul helps clients explore solutions and develop goals in life.

Assistance with the gratification of human needs Assisting to meet patient needs, upholding dignity and promoting privacy are satisfactorily met in the hospital. Patients rarely complains about the nursing service the hospital provides but are very thankful for assisting them to recovery.

Allowance for existential-phenomenological forces The acceptance on how the patient view his/her own situation is important to attain individual patient goals. During the praxis, no conflict of belief between the nurses and patients was observed. This implies that the nurses are aware that the acceptance of patient views are relevant in establishing goal towards recovery.

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FROM THEORY TO PRAXIS

Best Practices Observed Educating patients regarding their rights and responsibilities Upon admission, clients are given copies of the patients’ rights and responsibilities which serves as their guides to measure standards of care they receive and assess which among the nurse’s does to them are within proper conduct. This protocol saves patients from ignorance of their rights.

Endorsement Logbook The risk for discontinuity of patient care is lessen through a logbook being used by

charge

nurses

in

which

documentation

of

the

treatment

and

special

orders/endorsement are written and could be reviewed whenever necessary. Special announcements are also written so that it will reach all the nurses working on different shifts during the day.

The 7s Philosophy The 7s Philosophy does not only exist on hard boards posted on hospital walls. It is being practice every time a nurse is on duty.

Satisfying Nurse-Physician Relationship

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FROM THEORY TO PRAXIS This was the first thing I observed when I was exposed in the Emergency Room. Physicians on duty works smoothly with the nurses and other members of the healthcare team. Co-signature on Medication Administration Record Two nurses are required to check the medication to be administered to patient. This practice reduces the risk of erroneous medication administration. Given the common situation in most hospitals that doctors imply to nurses that they are the key people in the healthcare team therefore they are of higher importance and must be treated above of what is usual, NDCH physicians seems to be different.

Quality Assurance Practices Quality assurance are done on different levels. There is a quality assurance done on specific units on an unannounced date and the Nursing Audit of all the units conducted once a month.

Computerized System of Patient Records Records are accessible and medication inventory including anticipation of client needs are made easy through their system.

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FROM THEORY TO PRAXIS

Suggestions and Recommendation I acknowledge the excellence of Notre Dame De Chartres Hospital in providing quality healthcare. As a contribution to its continuous effort to uplift the quality of care they provide, here are some recommendation for minor problems encountered:  More garbage bins on accessible areas  Patient, relatives and significant others education on waste segregation  Immediate disposal of sharps, vials, ampules and used syringes  More in-service training for staff  Personal protective equipment readily available for use  Effort to train staff (especially the juniors) to handle uneventful situations

Furthermore, I recommend that the good practices of the hospital be implemented continuously to achieve satisfactory results

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From Theory to Praxis

114

References Diabetes New Zealand. (n.d.). Diabetes and Infection. Retrieved November 30, 2012, from Diabetes New Zealand: http://www.diabetes.org.nz/about_diabetes/complications_of_diabetes/infections American Diabetes Association. (n.d.). Nutrition Recommendations and Interventions for Diabetes. Retrieved August 19, 2012, from http://care.diabetesjournals.org. Bautista, J. N. (2007). Understanding Human Diseases. Doenges, M. E., Moorhouse, M., & Murr, A. C. (2008). Nurse's Pocket Guide. Karch, A. (2008). Focus on Nursing Pharmacology. Karch, A. M. (2008). 2008 Lippincott's Nursing Drug Guide. Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddharths's Textbook of Medical Surgical Nursing (Vol. Volume 1). (H. Surrena, Ed.) Philadelphia PA: Lippincot William and Wilkins. World Health Organization. (2012, February). Cancer. Retrieved June 18, 2012, from World Health Organization: http://www.who.int/mediacentre/factsheets/fs297/en/

FROM THEORY TO PRAXIS

Appendices

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FROM THEORY TO PRAXIS

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