Reflective Journal # 1 Name: Emily Grange Clinical site: DRMC RR Date: 8-28-2013 Unit: CVU

CLINICAL ACTIVITIES: Include all that you were able to do or observe I was assisting Kamill Knudson today. I was able to prepare and carry out discharge teaching, give plenty of medications which included giving sub q injections, oral meds, and preparing a pump and hanging IV medications. I observed a cardiac Doppler as well. I assisted in a bed bath and was able to change a chest tube dressing. I assisted Cardiac Rehab in ambulating a 2 day post op CABG patient. I did an initial assessment on a new admit and also placed the new admit on tele monitors. SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I am still slightly off on a few of the cardiac medications, by that I mean that I have a hard time hearing the name and automatically knowing which class it is in. I need to work on my delegation skills when I get busy. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I am great with patients and family. I am able to easily explain and communicate confusing terminology in a way that is easy to understand. I have a good memory so it makes it easy to prioritize my tasks and get them done quickly. I am also very comfortable with the physiological processes behind cardiac medications. I feel comfortable with all of my skills. LESSONS LEARNED: I got a great lesson today on the differences between Beta Blockers and ACE Inhibitors. I also saw firsthand a negative reaction to Ativan. CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. The concepts and exemplars that I feel I covered in depth today are: Perfusion, Comfort, Critical Thinking, Therapeutic Communication, Time Management/Organization, Caring, Nursing Process. Being that I was on CVU all of my patients today had different perfusion problems including HTN, HF, Angina, CVA, CVD, and CAD. I dealt a lot with pain management and patient teaching. I also feel that concepts such as Critical thinking, time management/organization, caring, and nursing process will be/are involved in every future patient contact I will make so those are inevitable and very valuable lessons to be learned. EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback I was with Kamill Knudson today. She was great in letting me take charge with certain tasks. She also made sure to ask me lots of questions about medications. She didnt give me the opportunity to do any charting, even after me asking a few times. She allowed me to give all of the medications and kept me informed and involved with every aspect of her patients care today. Overall, I thought she was great and I really enjoyed the opportunity to learn from her today.

Reflective Journal # 2 Name: Emily Grange Clinical site: DRMC Date: 09/04/2013 Unit: ICU

CLINICAL ACTIVITIES: Include all that you were able to do or observe I was able to give meds a variety of different ways including IVP, IVPB, IM, SQ, and on a pump. I also hung multiple units of blood products. I drew labs from a central line and an arterial line. I accompanied a patient to MRI and observed that procedure. I assisted with and observed an echo and a post CVA speech/swallow evaluation. I observed a central line placement and the set up of CRRT. I performed oral care on an intubated patient.

SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I felt very comfortable with my tasks during this clinical rotation but I found it interesting to see all the different tricks to make the tasks easier and more efficient. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I felt very comfortable with my patient and family education and communication. I also felt comfortable with the lab work portion. I knew my medications well and there physiologic processes. LESSONS LEARNED: This was a particularly difficult day for me as I had just found out that a friend of mine had past away the night before. With that said, a major lesson I learned was how to monitor and keep my emotions in check as not to concern the patients or bring my personal business into my professional setting. This was a difficult lesson to learn. CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. Elimination, Cellular Regulation, Perfusion, Mobility, Critical Thinking, Therapeutic communication, Time management, caring. EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback My preceptor this day was Erica Olson. She was great. She was very knowledgeable and willing to help me learn. She allowed me to do anything and everything that I was capable and allowed to do. She praised what I did know and assisted me with what I didnt. She made me feel very confident in my abilities. I thought she was a great preceptor and I hope to work with her again sometime.

Reflective Journal # 3 Name: Emily Grange Clinical site: DRMC Date: 09-11-2013 Unit: CVU

CLINICAL ACTIVITIES: Include all that you were able to do or observe I was able to give medications in multiple forms including IVP, IVPB, SubQ, NG tube, and Oral. I assisted in showering two patients. I aided in ambulating a patient. I performed a lot of patient education.

SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I need to work on my knowledge of medications and recognizing the names of medications and knowing their classifications right away. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I feel strong in my therapeutic communication and my medication administration. I also feel very comfortable with my lab knowledge and how certain labs effect certain disease processes.

LESSONS LEARNED: Today I learned about coordinating with many different health care team members on a difficult uncooperative patient. I also saw firsthand the importance of allowing the patient to come to decisions on their own and not trying to force them to do what you want.

CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. Elimination, Perfusion, Infection, Mobility, Comfort, Behaviors, Critical Thinking, Caring EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback Today I was with Spencer. He was absolutely wonderful. He was great at letting me do every last thing I was capable and comfortable doing, he was constantly asking if I had any questions and if there was anything in particular I was wanting/hoping to do today. He is a fairly new nurse but I think that allowed him to remember what it was like to be a student and give me a wonderful opportunity. He was very nice and easy to get along with. He was also very intelligent and I learned a lot from him.

Reflective Journal # 4 Name: Emily Grange Clinical site: DRMC Date: 09-18-2013 Unit: Operating Room

CLINICAL ACTIVITIES: Include all that you were able to do or observe I had the opportunity to observe a conscious neurosurgery. The patient had an operation 3 months prior to remove a tumor, however upon removing the skull flap the patients brain swelled and they were not able to complete the procedure. On 9-18-13 the patient returned to the hospital for completion of the original procedure including removal of the tumor and replacing of the skull flap. In order to confirm that no damage had occurred to the patients verbal or motor function it was necessary to keep the pati ent alert and conscious throughout the entire procedure. SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? On the particular day the only thing I felt I was lacking in was the understanding of how the OR is run and where to be and when. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! Pertaining to this particular clinical experience I felt that my complete understanding of anatomy was of great strength to me. I also felt very confident with my knowledge of the drugs used during the operation.

LESSONS LEARNED: I definitely learned that while observing the operation was extremely interesting and educational, OR Nursing is not an area in which I would pursue a career. I felt that the Anesthesiologist and the Surgical Tech have eaten up the nursing aspect. I found the nursing side of this experience to be quite a bit bland.

CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. The main concept I feel was focused on during the clinical was perfusion. There was much conversation before and during the procedure regarding the patients perfusion. Being that we were dealing with the patients brain, perfusion was an extremely important factor. EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback I was supposed to be paired with a nurse named Sam but honestly did not see much of him. Instead I spent a lot of my time with the surgeons Nurse Practitioner, Brian. He was great, I was able to ask him a lot of questions and his explanations were direct, concise, and understandable. Due to my lack of involvement with my nurse and also the fact that I went straight into the OR and left before the procedure was complete I was not able to have an evaluation form filled out nor do I think that it would have pertained to this particular situation as I did a lot of observing and not much in the way of patient care or nursing tasks.

Reflective Journal # 5 Name: Emily Grange Clinical site: DRMC Date: 9-25-13 Unit: CVU

CLINICAL ACTIVITIES: Include all that you were able to do or observe This was a particularly weird shift compared to the others that I have had. Upon arrival to the unit I met my preceptor Michaela. We got report on 4 patients and then sat down to review our charts and get an idea as to what we needed to accomplish that day. Our workload seemed fairly light and we had mostly simple patients. By 1130 that morning we had discharged two patients, both of which I was able to do the discharge teaching for. The third patient we cared for was a pre-op patient that was able to completely care for himself and didnt have much in the way that we need to do other than hourly rounds. The fourth patient I took care of was the difficult case and all I was really able to do with her was hang antibiotics, give meds through her SBFT, draw labs from her IJ, and repeatedly change her bed linens as she had severe diarrhea and was almost completely immobile.

SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? Due to our constant presence in our fourth patients room we fell a little behind on the other not so critical tasks we needed to complete. With that said, I would say that I need to work on my time management skills. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I feel more and more comfortable with my cardiac medications after every shift on CVU so I would say that is one of my better strengths. I also feel that while they are still developing, my critical thinking skills are right where they should be at this point. LESSONS LEARNED: I learned how important pain management is in your patient maintaining a positive outlook on the situation.

CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. Due to my patients condition, I would say the concepts I focused most on during this clinical experience were Pain and Elimination. EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback I liked my preceptor and thought she was very nice. At times, I felt that I was an annoyance to her. I though she was easy to get along with, but I did not feel that I learned much from her. I didnt feel challenged in any way, which is something I enjoy at clinical. Overall, while she was nice I would not want to be paired with her again.

Reflective Journal # 6 Name: Emily Grange Clinical site: DRMC RR Campus Department Date: 10-02-13 Unit: Emergency

CLINICAL ACTIVITIES: Include all that you were able to do or observe My day in ER was so exciting. First of all it felt like being at home, I was so comfortable and relaxed, I felt very at ease when asking questions. In my ER experience I was able to perform a lot of medication administration including Versed, Vecuronium, Succinylcholine, Amiodarone, Dilaudid, Morphine, and Zofran. I placed two foley catheters, I placed an OG tube, I confirmed breath sounds for the physician post intubation, and with all of that I was able to participate as an active member of the care team for a post cardiac arrest patient. I also did a few EKGs and placed a couple IVs. All in all I had a very exciting and active/busy day!! SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I need to improve on my IV push rates, meaning that I am still uncertain on how fast to push certain medications. I also need to continue to improve my time management skills. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! My knowledge of how the ER works definitely made a huge difference, I already knew where everything was and how the process works. I also am a good friend of the nurse I followed as well as the physicians and other ER staff on shift. My knowledge of lab values and ER medications made my shift run smoother. LESSONS LEARNED: I learned extensively how things run from the nurse perspective which is totally different from what I am used to. I also learned a lot about heart rhythms. CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. Elimination two foleys placed, Lasix given Perfusion Cardiac arrest pt, Admit to cath lab, pt with PVD Inflammation I had a pt. with Pancreatitis Mobility ankle fracture Comfort pain meds given Critical Thinking Post arrest patient Technical skills Foley placement, OG placement Therapeutic Communication used with all patients every day Time Management/Organization Extremely crucial in emergency medicine Caring EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback Aside from being a good friend of mine, Kraig Winterton was great to be paired with. He is great at asking you questions to get a feel for your level of knowledge. He explains concepts in ways that are easy to explain and he is willing to let you do anything you are comfortable with. He made my experience fun and educational. I was very appreciative of the effort he put in to helping me learn and would be great to pair students with in the future!

Reflective Journal # 7 Name: Emily Grange Clinical site: SIM LAB CLINICAL ACTIVITIES: Include all that you were able to do or observe This week we were in sim lab and we got to practice our technical skill and participate in a mock simulation. We were able to exercise our critical thinking skills and improve our technical skills under a time limit to see if we were able to manage our time appropriately and improve our efficiency and accuracy when carrying out individual nursing tasks. SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I need to improve on my ability to quickly and accurately calculate medication dosages in my head. I also need to continue to improve on my organization and therapeutic communication. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I feel very strong in my technical skills and my ability to accurately and efficiently carry them out in a short amount of time. I also know that throughout my career I will continuously improve on my critical thinking skills but I feel very confident about where they are. LESSONS LEARNED: I learned many tricks to quickly carry out different tasks. I also learned easy ways to quickly recognize s/s of certain disease processes. CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. We covered a bunch of different concepts and exemplars including perfusion when we practiced giving blood products and heparin and discussed the adverse effects of both and things that can go wrong. We covered therapeutic communication in the simulations on Day 2 and how you should relay information to patients about their condition. We extensively covered critical thinking and many others. EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback It was great to be back in the lab with Mark. He is great at explaining and helping us to reach our own conclusions with minimal guidance. He helped to test my critical thinking skills and he encouraged my strengths, which boosted my confidence. When it came to my weaknesses all of his criticism was very constructive and helpful. I respect Mark and value his opinion and knowledge. Date: 10-18-13

Reflective Journal # 8 Name: Emily Grange Clinical site: DRMC RR Campus Date: 10-23-2013 Unit: W3 MONC

CLINICAL ACTIVITIES: Include all that you were able to do or observe This was a great clinical day. I didnt get to experience much out of the ordinary but I still learned a lot. The skills I was able to do were mainly pass medication. I also got to not so much participate but listen in on a palliative care consult.

SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I would like to improve on my knowledge behind the physiological effects of the different cardiac medications. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I feel that I am very sufficient in my therapeutic communication and my lab knowledge. I feel also that I have a lot of initiative. LESSONS LEARNED: I learned a lot about dealing with the sensitivity of patients who have recently been told that they were dying. I also learned more into the value of prioritization and the persuasiveness that the nurse can have on the physician if approached correctly.

CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. Much of my focus this clinical day was on therapeutic communication and time management. EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback My preceptor was Jocelyn. She was so awesome. She is a fairly new nurse that graduated from DSC so she was completely understanding of my situation and the types of things I would be interested in accomplishing for the day. I felt that I could relate to her and I felt like she communicated well with me on our objectives for the day. She let me do all tasks that needed completing. We had a very interesting group and other than medications there was not much that needed to be done but she was great about her hourly rounding on all patients. I thoroughly enjoyed precepting with Jocelyn and would love having the opportunity to work with her again!

Reflective Journal # 9 Name: Emily Grange Clinical site: DRMC Date: 10-30-2013 Unit: MONC

CLINICAL ACTIVITIES: Include all that you were able to do or observe I was able to give a lot of meds and start an IV during this clinical experience. I also assisted a patient to the restroom and changed a brief. I got to work on my charting skills and I was able to do 4 full assessments.

SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I am at the point where I feel completely comfortable with the skills that I encounter frequently but the skills that I dont get to do very often are what I am nervous about. I am concerned that when the time comes to do those skills I will not be confident and that I may forget something. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I feel very strong in my medication knowledge and my ability to give oral and IV medications. I also feel more than capable with my IV starts. I have been complimented often and feel comfortable with my initiative and my therapeutic communication.

LESSONS LEARNED: I learned what Venofer is and I learned much about charting in Tandem and about time management.

CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. Therapeutic Communication, Cellular regulation, Perfusion, Comfort, Critical thinking, Time management.

EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback My preceptor was Jacqueline. She was awesome!! She was great about answering all of my questions and allowed me to do a lot. She was very helpful with my charting and had a very positive attitude. She was easy to work with and made me feel very confident in my future as a nurse!!

Reflective Journal # 10 Name: Emily Grange Clinical site: DRMC Date: 11-6-13 Unit: MONC

CLINICAL ACTIVITIES: Include all that you were able to do or observe On this clinical experience I was able to give medications, perform discharge teaching, and perform wound care. One of my patients had severe cellulitis on both feet. The patients left heel had a very deep wound to it. I was able to irrigate and dress both feet.

SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I felt very comfortable with all skills and situations experienced during this clinical.

SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I feel very comfortable with my medications and lab knowledge. I also feel good about my therapeutic communication.

LESSONS LEARNED: Out of the four patients I started the shift with, I ended the shift with only one as all of them were discharged. With that said there were not many new lessons learned this experience. I did however have a challenging preceptor and I learned that if approached in the right way any bad situation can be made positive.

CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. Skin integrity, perfusion, inflammation, and cellular regulation were all well discussed. EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback This shift I was placed with Shane. I expected it to be difficult and indeed at times it was. After establishing some common ground and making it known to him that I had medical experience, Shane was more than happy to let me follow him around. He still seemed uneasy about allowing me to do anything and most of the time he was difficult to keep track of. In the end, if I could find where he ran off to, we got along fine and it wasnt a terrible experience.

Reflective Journal # 11 Name: Emily Grange Clinical site: DRMC RR Date: 11-13-13 Unit: Specialty Recovery

CLINICAL ACTIVITIES: Include all that you were able to do or observe In my specialty recovery experience I was able to start multiple successful IVs and push Zofran IV. I was also able to perform multiple assessments.

SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? As far as this experience goes, I feel very confident with all of the skills I put to use today. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I feel that my therapeutic communication and bedside manner are strong. I am also fully confident in my IV placement skills.

LESSONS LEARNED: I learned about the reasons and necessity for having a heart cath done. I also learned how slowly blockage of coronary arteries can develop and how serious it can be if it goes too long without diagnosis. These are things that I already knew a lot about, but I learned about them in much more detail.

CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. The main concept that was focused on today was Perfusion.

EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback My preceptor was Miriam Marshall. She was floated from CVU but had worked in SR several times. She was very helpful and informative. It was great working with her, she had full confidence in my abilities which allowed me to be able to play my part with out any doubts.

Reflective Journal # 12 Name: Emily Grange Clinical site: DRMC Date: 11-20-13 Unit: ER

CLINICAL ACTIVITIES: Include all that you were able to do or observe During this clinical experience I was able to draw up and give multiple medications. I performed multiple assessments and I also placed several IVs and drew up labs. I got to assist with interpretation of lab work and got interpret an ABG. I placed an NG tube and I also place a Foley catheter.

SPECIFIC AREAS TO IMPROVE: What do you feel were your weaknesses or areas of deficient knowledge? I felt very comfortable with all of my skills during this clinical experience. SPECIFIC AREAS OF STRENGTH: What do you feel were your strengths or areas you think; I get it! I am confident in my lab interpretation and coming up with possible interventions and diagnoses based on lab work. I am 100% confident with my medication administration. My IV placement is great and I am very comfortable with that as well.

LESSONS LEARNED: I learned about the function and benefits of an MRI vs. CT or XR. I also learned about the clinical manifestations of a bulging intervertebral disc.

CONCEPTS: Focus on one or more of the Nursing Concepts/Exemplars included in this course. The main concept I encountered during this clinical is that of Comfort. Every patient that I encounter was in severe discomfort and wanting pain medication. There were a few patients that I was able to provide relief using a non- pharmacological intervention. EXPERIENCE WITH NURSE PRECEPTOR: Include preceptors name and specific feedback My preceptor was Cory Thompson. Cory was great. He is a good friend of mine, which helped me to feel very comfortable asking him questions. Cory was great about testing my knowledge and asking me a lot of questions. He was trusting of my abilities and allowed me to take over on a few patients and run the show in a manner of speaking. It was great to feel like I had an important roll in the care of these patients. Being back in the ER was wonderful and felt very comfortable. Cory is a wonderful preceptor who remembers what it was like to be a nursing student and made sure to accommodate my curiosity and eagerness.