The portfolio is your comprehensive self-assessment of practice; it should include evidence of each indicator within the four clinical Learning Outcomes. The objective is to showcase your learning by including items which illustrate this.
 
The following items must be included in your portfolio:

• My Information Section: Please remember to maintain confidentiality & privacy
• Record of Clinical Hours: Please also remember to complete the total clinical hours form on Blackboard
• RN Feedback: To be completed by an RN who you have worked with more than once
• CE Feedback: Will be completed after each clinical visit by your CE
• Self-Assessment: This is a self-evaluation of your practice against the indicators of achievement. For each Learning Outcome, identity where in your Mahara portfolio you have provided evidence of achievement of each indicator.  
• Additional Evidence: A minimum of 1 piece of additional evidence for each week in clinical.  Some examples of additional evidence to show your learning may include, but are not limited to:

• Written reflection
• Video or audio description/demonstration of skills or explanation of assessment
• Links to media that illustrate your learning with a discussion
• Case Study
• SMART goals and how you achieved these
• Certificates
• Assignments
• Mind maps
• Blogs

Please ensure that you label any documents uploaded clearly with the following format:

• Last Name_First Name_ Student ID_Paper Code_Document title

Name: Natasha Bali

Student ID: 17002354

Paper: NURS601

Current Clinical Placement: Medical & Surgical - Acute Care Hospital

Current Clinical Educator: Helen Mcleod

Monday 22 April 2019

Goal- by the end of the week I would like to become familiar with the ward,  find out where the safety equipment is kept such as fire extinguisher, find out where all the fire exits are located, find out what the protocols are in an emergency situation.

Strategy- look around to familiarise myself with the area that I am working in. Ask my preceptor where the fire equipment is kept and look around for sings which indicate the fire exit. Talk to my preceptor or charge nurse and find out what the protocols are and what is needed to be done in an emergency situation to ensure that patients, clients, and staff are safe.  

Summary- This goal was achieved. There are fire extinguishers in front of the nurse's station, safety equipment is placed in the nurse's stations. While walking around I got more familiar with the area and spotted most of the fire exits which were the double door in between each ward. I, my fellow nursing students and the charge nurse discussed the protocols in an emergency situation.   

Indicator: 1.2

Week 1- Thursday 25 April 2019

I was working alongside my preceptor when I suddenly noticed that one of my elderly patient wanted to get out of bed and go for a walk without assistance and supervision. The patient was at high risk of fall due to his age. As a nurse I want to promote independence however there was a high chance that the patient could fall and injure himself. I was in the dilemma was that I was thinking of how to balance these conflicting issues of patient independence or patient safety (1.9). I decided not to let the patient get out of bed and walk around the ward without assistance because I was afraid that he will fall and hurt himself. Instead, me and my preceptor assisted the patient with getting out of bed and walking alongside him with a low walking frame (2.7). This ensured patient safety. As a student nurse, the right thing to do was to ensure patient safety before patient independence.

indicator: 1.9, 2.7

Week 2- Monday 29 April 2019

Today I decided to work alongside with a different preceptor. This preceptor worked differently compared to my last week's preceptor, this preceptor tends to do things differently e.g. she only looked through the last pages of the clinical notes and got started with her job and she did not use the daily planner as a guide. however, my last week’s preceptor sat down and filled out a planner to ensure that everything is done on time. As a student, I worked as a team and respected and accommodated to the way she worked (4.5). however, in my future practise I will avoid doing that because just by looking at the latest clinical notes and not properly reading or writing down what is needed to be done and what medications are due when then me as a nurse can miss out on important information or might even forget to give a patient their medication. This can cause harm to my patient if I miss out on reading essential information

Indicators: 4.5

Week 2- Thursday, May 2019

during this shift I chose to care for a patient who was on last days of life care (LDL), He was not for resuscitation. His family and the HCT decided to stop doing vital signs assessment on him. During this shift, his daughter decided to stay the night with him. This man was bedridden, he did not talk and 1 day before he even stopped eating. Me and his daughter tried our best to make him as comfortable as possible. He was breathing fine however towards the end of my shift this patient passed away. This was a traumatizing moment for me as it was the first time, I experienced the death of one of my patients.  I was shocked and was unsure of what to do. Me and my preceptor made him as comfortable as possible and covered him up. After that, I went to the nurse's station and asked my preceptor if I could talk to her about what has happened and how I felt about it. I and my preceptor had a small debriefing session which made me feel better (1.10). I had this debriefing session to manage my own emotional response towards the situation and talking to my preceptor made me feel calmer.

Indicator: 1.10

Week 2- Friday 3 May 2019

By the end of this week, I began to see a culture of nursing which was that nurses do not take the respiration rate of a patient while doing vital signs assessment, I noticed that this was being done by all nurses to save time (1.6). We have been taught that it is essential that we take the respiration rate because it is the most significant and effective way to find if a person has any illness such as cardiac arrest. This can be monitored by observing how many breaths a person takes in a minute. If they are taking more than 20 breaths per minute then that can be an indicator of a critical illness (Butler-Williams, 2005). While taking vital signs I ensure that I take the respiration rate to find out if the patient has any critical illness. Increased respiration rate can be an indicator of infection and heart implications.

Reference

Butler-William, C. (2005). Increasing staff awareness of respiratory rate significance. Nursing Times 101(27), 35. Retrieved from: https://www.nursingtimes.net/clinical-archive/respiratory/increasing-staff-awareness-of-respiratory-rate-significance/203787.article

Indicator: 1.6

Week 3- Monday 6 May 2019

Today I had a young female patient who had rheumatic fever like symptoms. However, it was not confirmed if she had rheumatic fever. She had a fever, strep throat, and rashes all over the body. The HCT was unsure of what she had and what has caused her to have these symptoms. Just to keep everyone safe she was placed on contact precautions. Before entering her room, we ensured that we wore PPE gears such as gowns, gloves, and masks. It was important for us to wear the PPE gear to protect ourselves and the people around us from being infected by any disease through contact with this patient (2.7).  It was important that we wore the PPE gear outside the room before walking into the room and taking off the PPE and disposing the PPE gear into the rubbish before walking out of the room, and then wash our hands after that to stop any infectious diseases from doing any harm to me, my HCT and the other patient (1.7). we ensured that the patient always had PPE gear outside her room however at one point there was not gown left for us to wear before walking into the room so I informed the charge nurse and she showed me where the PPE gear is kept, by reporting this incident I was able to manage the risk of getting myself or anyone else infected (4.10). The HCT took some swabs and blood tests to query if she had rheumatic fever or any other infectious disease which the HCT should know of. Her results came back negative so she did not have rheumatic fever or any other bacteria or virus in her body. Once she was cleared by the HCT that she does not have rheumatic fever or any contagious infection then she was the off contact precaution and she was allowed to move around and even leave her room. She mentioned to me that she was getting bored with staying in the same room and eating the same hospital food. Therefore, I recommended to her that there is a few shops and cafes downstairs so if she wanted, she could go for a walk, get some food and then come back up (3.8) she agreed to it. This was a way I supported my patient’s personal resourcefulness by giving her some option to distracting her and making her less bored during her stay at the hospital. She looked much happier after she came back from her walk. 

Indicators: 1.7, 2.7, 3.8, 4.10

Week 4- Wednesday 22 May 2019

Today I was informed that one of my patients will be discharged and referred to the old age home facility where he would be taken care of. I and my preceptor made a referral to the HCT at the old age home that the patient was going to. We gave information such as why he was admitted to the hospital, what medications she is currently on, what kind of diet he is one and any other information that the HCT at the facility wanted to know about, we also gave a plan to support recovery after being discharge (2,6, 4.7). Me, my preceptor and the HCT discussed a plan on how to help this patient recover e.g. had poor diet and did not take enough, therefore, he was encouraged to take more fluids, continue doing a fluid chart and bowel chart, also take his weight daily, encourage him to drink fortisip drink for his weight (4.4). After that, my preceptor booked the ambulance and informed me that the ambulance will be here in an hour so she told me to get the patient ready while the HCT get his paperwork sorted out. I gained informed consent, I then went and assisted the patient with a shower, asked him what he preferred wearing then got him dressed. After that I quickly packed all his stuff and handed his stuff to him, by then the ambulance was here to pick him up, the HCT came and gave the patient a copy of all the paperwork and gave the paramedics a quick handover (2.6). They then wheeled the patient to the transition lounge (2.6). By assisting my preceptor with the process of discharge I was able to demonstrate my understanding of the process of discharge, I did as much as I could myself however I let my preceptor do the part of the process the I was unsure about.

Indicators: 2.6, 4.7, 4.4

(a word document copy of the blog has been attached under additional evidence to clearly show each indicator)

Week 1- Tuesday 23 April 2019

Description

During this week I worked in room 3 and assisted my preceptor with 4 patients, I did not take care of any patient by myself because I was still familiarising myself with the environment and how things should be done in the ward. On my second day of the, I had the opportunity to care for an elderly Russian patient who was admitted to the ward due to a fall. She had injured her back and was in pain. This patient was unable to verbalize or understand English, she was communicating to us in Russian. The patient did not have any family members with her most of the time which made it difficult for us to communicate with her. I tried to communicate with her however I saw that she was unable to understand my nursing instructions and she just shook her head (3.6). I used a non-verbal form of communications to communicate with her, I used gestures, I observed her body language and observed her facial expression (3.5). I did this because I thought that she might under what I was trying to say through non-verbal communication. The patient did not look happy or comfortable therefore I asked my preceptor if it is possible for us to get a Russian interpreter to help us understand what she is trying to say, my preceptor informed me that an interpreter can only be requested by the charge nurse or receptionist. I went and talked to the charge nurse and requested for a Russian interpreter and I explained to the charge nurse that we will be able to have a better health outcome for this patient and make her more comfortable if we understand her needs and the charge nurse agree to it (3.7, 2.5). Once the interpreter arrived, she informed me that the patient was in pain and she was requesting for PRN medication which was paracetamol. My preceptor went to get the medication while I continued communicating with the patient and trying to make her comfortable. Once my preceptor brought the medication and handed over the medication, the patient refused to take the oral paracetamol tablet because she was finding it difficult to swallow the tablet. We did not force her to take the medication because every individual has the right to refuse therefore, we let her take self-governorship of her healthcare which is also the kawanatanga element in the treaty of Waitangi (1.1). I questioned my preceptor if maybe we should try giving her liquid form paracetamol because then she won't miss her regular medication and she also won't have any issues with swallowing it, my preceptor agreed to it however we still seek for clarification by the doctor that was taking care of the patient and the doctor said it is fine if we give her the liquid form paracetamol instead of the tablet, the doctor also changed that information in the medication chart (4.9). together with my preceptor I went and took out the right medication, right dosage of liquid paracetamol, it was a PRN medication so it was for the pain, we checked when it was last given to avoid overdosage, I ensured that it was the right route, I then took the medication to the patient, checked if it was the right patient by asking her name, DOB and checking her NHI number on her wristband, after all, that I administrated the medication with the supervision of my preceptor, I then documented it in the medication chart with time administrated, dosage administered and my initials and then my preceptor co-signed it for me (2.4)    

Feeling

This situation at first, I was very nervous, scared and I felt horrible because this patient was trying to communicate with me but I was unable to understand what she was trying to say. However, once we go the interpreter to come in and translate what she was trying to say then I felt more relaxed because I then knew that the patient was in pain and that she was requesting for paracetamol.

Evaluation

This was a good experience because I was able to use non-verbal communication to conclude that the patient was uncomfortable and I also got the chance to find out how to request for a translator.

Analysis

I have realized how important language is and how it can become a huge barrier if I am caring for a patient whose language I don't understand. This can cause major complications in an individual’s health care. There is important to have an interpreter because they help to build a bridge between the patients and the health care team (Squires, 2018). The translation process ensures that accurate and culturally specific information is provided between the patient and the health care team (Squires, 2018).

 Conclusion

I could have gained information regarding how to request for an interpreter or told the charge nurse to request for the interpreter straight away instead of using non-verbal communication because that left the patient in pain for longer and made the patient irritated.

Action Plan

If a situation like this arises again where there is a language barrier between me and the patient, then I will request for an interpreter straight away and write it clearly in the patient's clinical notes that this patient is unable to communicate in English to ensure that an interpreter is with the patient at all times. This will avoid any miscommunication and ensure the safety of the patient.  

References

Squires, A. (2018). Nursing Management. Nursing Center, 49(4), 20-27. Retrieved from https://www.nursingcenter.com/cearticle?an=00006247-201804000-00007&Journal_ID=54013&Issue_ID=4596181

Indicators: 1.1, 2.4, 2.5, 3.5, 3.6, 3.7, 4.9

Week 2- Monday 29 April 2019

Description

during this week I got the opportunity to care for 2 patients by myself however within my scope of practice. I decided to take care of a Samoan 90-year-old man. This man had a minimal understanding of the English language which made it hard for me to communicate with him. However, this man always had his daughter or son in law with him 24/7 to help out with his cares and needs. I offered a Samoan interpreter but his family declined it and said that they would prefer talking on behalf of their dad and interpret the information to their dad (3.1, 3.4). while doing this patient’s cares his son in law assisted me and verbalized how certain things should be done to be culturally safe. While giving him a bed bath his son told me that it could be inappropriate to touch his face or head, I respected that and did not take the flannel near his face or head, instead I just gave the flannel to the patient and requested him to clean his face by doing that I promoted independence for the patient by using gestures to make him understand what I was requesting, by doing this I was able to show respect towards the patient through non-verbal communication  (1.3, 3.2, 3.3).    

Feeling

This situation made me feel happy because I would see that this was a proper patient-centered care as his preferences, values, and needs were being fulfilled respectfully. 

Evaluation

This was a positive experience for me because it gave me a chance to reflect on my own personal values and how it could have impacted the patients that I was caring for (1.4). I reflected that being more sensitive towards my patients’ values, culture and beliefs will have a better outcome for my patient and his healthcare

Analysis

There is a process of achieving culture safety towards a patient through nursing practice. The first process is called culture awareness, this is when a nurse is aware of their patient's cultural values and beliefs if not then the nurse tries to be aware of the patient's values (Nursing Council, 2011). The second process is called culture sensitivity, this is when a nurse begins to reflect on their own cultural values and beliefs, and also start to think about how their own cultural values can impact the person receiving care (Nursing Council, 2011). The last process is cultural safety, this is the outcome that enables safe services to the people receiving care (Nursing Council, 2011).  

Conclusion

I could have asked the patients daughter and son in law about how he would prefer to have the bed bath done and ask him if there is any cultural value that I should be aware of while giving him a bed bath. I would have been culturally aware of what the patient’s values is, which would have then helped me be culturally sensitive and eventually culturally safe.

Action Plan

Next time if this situation arises then I will reflect on my own values and practice this will remind me to be sensitive to the cultural needs on my patient instead of allowing my cultural values and belief impact the needs and health care of my patient.  

References

Nursing Council. (2011). Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and Practice. 7-11. Retrieved from https://www.google.co.nz/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=2ahUKEwi5k7q4yrziAhXUXSsKHXuSBb4QFjABegQIDBAE&url=http%3A%2F%2Fwww.nursingcouncil.org.nz%2Findex.php%2Fcontent%2Fdownload%2F721%2F2871%2Ffile%2FGuidelines%2520for%2520cultural%2520safety%2C%2520the%2520Treaty%2520of%2520Waitangi%2C%2520and%2520Maori%2520health%2520in%2520nursing%2520education%2520and%2520practice.pdf&usg=AOvVaw1rEDsvc3sjdoim2cJ5h9HJ

Indicators: 1.3, 1.4, 3.1,3.2, 3.3, 3.4

Week 3- Friday 10 May 2019

Description

Yesterday my CE informed me and my fellow peers that she will be coming to meet us individually to give her an indication of where we are at with regards our learning and how we are doing with things. She told us that she would like for us to give her a fully informed ISBAR handover and she would like us to at least do one assessment on the patient that we have chosen. I was able to give my CE an ISBAR handover. I was able to identify my patient, I was able to talk about the situation of my patient (patient had rashes all over her body, fever, pain, and she was being queried for any infection or rheumatic fever), I was able to talk about the background of my patient (patient did not have any medical history however while doing the assessment she mentioned that she has the same exact symptoms 2 years ago when she was in  Australia), I told my CE what assessment I was going to do a skin assessment (inspect, touch), cardiac assessment (RR, HR, PR, BP), input and output chart (eating, drinking, voiding and bowel movement). However, I was unable to explain why I prioritized my assessment in this certain way. After discussing the assessments with my CE and breaking each assessment down I was able to explain why I prioritized my assessments in that manner however I decided to do the cardiac assessment first. After that, we went to the patient and the patient was under contact precaution so me and my CE got into the PPE gear (gloves and gown). I gained consent from the patient to do a cardiac and skin assessment. Each room has its own vital signs equipment however there was not any in this patient’s room, therefore I had to take off my PPE gear and go look for a set of vital signs equipment. When I found the equipment, I went back towards the room and wore the PPE gear outside the room and then carried on with my assessment (1.7).  After that my CE gave me feedback on what I did well and what I need to improve on. She mentioned that I need to start thinking about why I'm doing whatever I'm doing. After that session with my CE, I reflected on my practice and identified what I need to improve on to make me a competent nurse (1.5). After reflecting on what I needed to improve, I started working on developing my knowledge regarding each assessment and why I'm doing it. I ensured that I was prepared and organized for each assessment that I did and gave a rationale for why I'm doing whatever I am doing (2.1). Also being organized with all equipment for taking vital signs before entering the patient's room. This shows that I'm organized and prepared to do the assessment.   

Feeling

Before meeting my CE, I was really nervous because I was unsure of what she expects of me and I was afraid that I will not be able to give her explanations if she asked me any questions. However, while giving her the ISBAR and doing the assessment I felt less nervous because she was correcting me and supporting me when needed. By the end of the meeting, I felt more confident and comfortable regarding my practice.

Evaluation

This was a good experience because it gave me the change to reflect on my own practice and it gave me indications of where I needed improvement. It always gave me a reason to go over each assessment and explain why each assessment is done.

Analysis

The cardiac assessment has four components which are HR, PR, RR, and BP. If a person has an infection in their body then their BP will decrease

Conclusion

I could have done more research regarding all nursing assessments prior to meeting the CE. I could have also done more reading with the patients note to find out more regarding the patient's health and also talk to the patient regarding her past medical history since she did not have any notes regarding her past history in her folder.

Action Plan

Next time I will ensure that I am organized with all the equipment needed to do the assessment so that I do not have to leave the patient waiting while I'm looking for the equipment. Next time I could also prioritize each assessment by thinking about what I am going to do and why I'm doing this.

References

Indicator: 1.5, 2.1, 1.7

Week 5- Tuesday 21 May 2019

Description

I decided to take care of 91-year-old female was admitted to the ward for upper GI bleed. This patient (Ms. A) was having symptoms such as black tarry bowels (melena) and a large volume of vomiting blood (haematemesis). She had the call bell ringing because she wanted to pass urine. Ms. A normally was able to mobilize independently with a low walking frame however during this time frame she needed assistance alongside with mobilizing because she felt light-headedness and fatigue, this was due to the huge amount of blood loss from melena and haematemesis. I identified that there was no walking frame in her room so I quickly went and got a walking frame from the storeroom before I assisted her with getting out of bed and walked her to the toilet (4.8). After she finished passing urine, I got her up from the toilet and while doing that I checked if there was any blood present in the urine but there was not, then I took her back to her bed. She verbalized that she felt extremely weak therefore I decided to do a cardiac assessment for her which consisted of respiration rate, pulse rate, heart rate, and blood pressure. The reason I decided to do this assessment first because I wanted to find out if Ms. A is becoming anemic (2.2, 2.3). If a person becomes anemic then their blood pressure will decrease because due to widening of the blood vessels and decreased blood volume the heart will not be able to pump blood efficiently, heart rate will increase because the heart tries to recompense by working harder this then increases the heart rate and the amount of blood pumped, respiration rate will increase because blood (filled with oxygen and nutrients) flow is reduced to vital organ, therefore, Lung function degrades due to blood vessels in the lungs leaking fluids, which starts to accumulates this the makes it difficult for a person to breath, pulse rate will increase(Maggio, 2018). While doing the assessment I gave Ms. A the results, and also gave her the rationale of why I am doing the cardiac assessment and I ensured that Ms. A was able to understand important information regarding her health care (2.2, 2.8). I done the assessment and documented the results clearly, timely and accurately in the EWS chart (4.6). Ms. A was scoring 6 according to the calculation of the EWS, according to legal protocols if someone is scoring 6 or 7 then we have to monitor vitals every 60 mins and also get the doctor involved. I informed my preceptor about the EWS chart and then me and my preceptor informed the doctor (1.8). The doctor checks Ms. A blood test results which showed that her blood count level was really low. Therefore me, my preceptor and the doctor discussed what we could do about the huge amount of blood loss (4.2). The doctor decided to give Ms. A a blood transfusion, the doctor wrote in the medication chart about what type of blood Ms. A need and how much blood to be transfused. I recognized the role of a doctor and how they are able to determine what will be a better outcome for each patient (4.1). I had the opportunity to work alongside my preceptor, the doctor and Ms. A to plan and evaluate a care for Ms. A. this provided Ms. A with a better and safer outcome (4.3) Before doing the transfusion we had to gain informed consent from Ms. A, keeping in  mind that her my cultural, belief and will be different to hers and that she might refuse to have the transfusion due to her being Christian, which she informed me about earlier during my shift however she did not refuse it. My preceptor prepared and administrated the blood transfusion. I first checked her vital signs every 30 mins 

Feeling

I felt confident while taking each step because I knew that I will be able to back myself up with rationales of why I took each step. My confidence also helped me ensure the safety of the patient especially by getting other medical team members involved in Ms. A health care.  

Evaluation

The was a good experience because I got the chance to work and discuss better health care for my patient with the doctors. This situation made me gain more confidence by working alongside doctors and my patient to provide a better health outcome for my patient.

Analysis

Heart rate increases which indicate that a person is becoming anemic because of the supply of oxygen to the tissues and when the oxygen-carrying capacity of the blood is reduced. Under circumstances of relaxation, a rapid rate flow red blood cell and tachycardia have an increase in minute volume of cardiac output then this is the first indicator to anemia (Watson & William, 1957). After a blood loss of more than 1000 ml there would be a significant change in blood pressure and heart rate, after a loss of 25–35% of blood volume hypotension with significant tachycardia and rise in respiratory rates would occur, after a 40% blood loss profound shock occurs (Pacagnella, Souza, Durocher, Perel, Blum, Winikoff, & Gülmezoglu. 2013).

Conclusion

I could have also done an input and output chart by monitoring how much she eats, drinks, voids and moves her bowels. Lack of nutrients in a person’s diet and also dehydration can cause a drop in blood pressure.  Therefore, by doing this assessment I will be able to monitor if there is any melena, also if she eating and drink adequate amount, if she is voiding if not then is, she dehydrated, if she is moving her bowels if not then is, she constipated.

Action Plan

Next time if this situation arises then I will ensure to do an input and output chart to ensure if the blood pressure drop is caused by a large amount of blood loss or if there is another reason for the patient’s blood pressure to drop suddenly.  

References

Maggio, P. (2018). Sepsis. Retrieved from https://www.msdmanuals.com/en-nz/home/infections/bacteremia,-sepsis,-and-septic-shock/sepsis

Pacagnella, R. C., Souza, J. P., Durocher, J., Perel, P., Blum, J., Winikoff, B., & Gülmezoglu, A. (2013). A systematic review of the relationship between blood loss and clinical signs. PloS one, 8(3). doi: 10.1371/journal.pone.0057594  

Watson, J. & William, P. (1957). The heart in anemia. Circulation 8(1). 111-116. https://doi.org/10.1161/01.CIR.8.1.111  

Indicators: 2.2, 2.3, 1.8, 4.1, 4.2, 4.3, 4.6, 4.8

(a word document copy of the reflection has been attached under additional evidence to clearly show each indicator)