BSMCON NUR 3111P

African Americans are at higher risk for gastric

cancer than whites. The incidence of gastric cancer
also increases with age (Lewis, 2011, page 998).
Patients father had heart disease. Former smoker
and drinks alcohol.

Secondary medical diagnosis #1

A.Fib.
Atrial fibrillation may develop acutely with stress. And usually occurs in a patient with heart disease (pt has family hx of heart disease) (Lewis
Blood pressure increases as a result of stress and pain (Lewis, 2011
Lovenox, sub Q, 40mg, anticoagulants/low-molecular weight heparins, accelerates formation of antithrombin III-thrombin complex and deactivates thrombin.
Nitrostat, 0.4mg tablet sublingual PRN for chest pain, a vasodialator and nitrate. Reduces cardiac oxygen demand.

(H.L., 74)

Gastric Cancer

Protonix 40mg PO before

Gastric cancer probably begins with a nonspecific mucosal injury as a result of infection, autoimmune-related inflammation, and repeated exposure Entereg,
to irritants12mg
such tablet
as bile,
an
PO,
Priority Nursing Diagnosis:
Deficient knowledge regarding self-care and discharge needs as evidenced by request for information.

Measurable outcome w/ timeframe:

The patient will initiate necessary lifestyle changes and participate in therapeutic regimen at the time of discharge.
Nursing interventions you used with rationales:
1) Discuss avoiding or limiting use of alcoholic beverages.
a.) Minimize risk of pancreatic involvement.
Lives with a female friend, walks with neighbor regularly, former smoker
2) Advise client to note and avoid foods that seem to aggravate the diarrhea.
a.) Although radical dietary changes are not usually necessary, certain restrictions may be helpful
3) Review activity limitation, depending on individual situation
a.) Resumption of usual activities is normally accomplished within 4-6 weeks.
Evaluation: Goal met. Patient seemed understanding of the requirements involved with going home and continuing to heal.
Discharge planning, compliance with medications and reminding patient of the risk of falls and to take things slow. And help him

Bilirubin 1.3 MG/DL high, from

Protein 6.1 g/dL low and Album
A-G ratio 0.6 low, albumin and
Chloride 109 mmol/L from slig

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Post-Practicum
This section must be completed by the stated due date/time and given to your instructor.
Document the assessment you completed for one or two patients, comparing systems and
describing normal and abnormal data. Remember to focus your assessment according to the
patients condition.
Assessment
Safety
Focused
assessment

Skin/Wounds

Respiratory
Cardiovascular

Gastrointestinal

Genitourinary
Neurological
Musculoskeletal
IV Lines
Drains/Equipment

Findings
Bed in low position, bed wheels in locked position, bathroom light kept on, fall
risk. Pt given call bell and told to ring for help when needed to get up.
Pt had distal gastrectomy, cholecystectomy, and appendectomy on 8/27.
Incision upper, midline abdomen, open to air and healing. Irregular heart
sounds, clear lung sounds, regular bowel sounds. Abdomen soft and non-tender.
Pain rated 3 out of 10.
Postoperative upper midline abdominal incision- dry, open to air and healing
well. Skin color appropriate for race, warm, dry and intact. Brisk cap refill. R
and L Lower extremity edema +1. Elastic turgor
SpO2: 98% on room air. Respirations 18. Clear lung sounds bilaterally.
Unlabored breaths.
Heart rate 89. Blood Pressure 159/52. S1 and S2 were audible with no murmur
heard. Radial and pedal pulse +2. Carotid, brachial, radial, posterior tibial and
dorsalis pedis pulses felt equal bilaterally. No JVD noted.
Bowel sounds heard in all quadrants. Abdomen is soft and nontender. Last
bowel movement 9/3. Postoperative upper midline abdominal incision- dry,
open to air and healing well.
Ambulates to bathroom to void, continent. Last bowel movement 9/3.
Alert and oriented x3. Clear speech with slight slurring of words. Calm. CN
intact.
Equal handgrips. 5/5-muscle strength on push/pull upper extremities. Steady
gait.
Saline lock in right hand 18G leaking.
Saline lock in right antecubital 22G intact.

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Guide for Reflection
Guide for Reflection Using Tanners (2006) Clinical Judgment Model
Program Thread: Safe, Quality, Evidence-based Practice
Introduction
This experience in clincals was a great one for me. I really enjoyed my patients and he seemed to enjoy having me there.
Last week, my patient was nonverbal and fairly unresponsive so I was happy to have patient I could interact with. I was
able to go down to his Lexiscan Stress Test with him early in the morning and that gave us lots of time to chat. And later on
I was able to take a walk (and take a few stairs) with him and Physical Therapy and even order him a special lunch. Overall
it was a great day and I learned a lot as well as gained much experience.
Background
Before I walked in to get report with the off going nurse, I had not met the patient before. I had read up on his chart on
Tuesday and was familiar with condition. In this situation, I spent a good deal of time sitting and talking with the patient.
We have been taught about therapeutic listening and being fully present and I know I put those skills to use that day in
Clinical. I believe my role as a nurse in the situation was to be there, intentionally present for the patient. He was going
down to the Stress Test and would receiving some worrisome news. I believe my presence was able to help him cope and
simply give him somebody to talk to. I felt very happy to be a part of the care for such an awesome gentleman and I was
excited to learn and practice as much as I could.
Noticing
When I first walked in and received report by the off going nurse, the patient was groggy. It turned out that that was simply
because he had just woken up. He was a shy, soft spoken man but after warming up to you, would talk quite a lot. I could
tell he was aware of the test he was having that morning. He seemed alert and oriented although, when asked what year it
was, he said, "hold on, you just had to ask me, give me a minute." I then asked him if he knew who the president was and
he knew right away. The doctors seemed real involved with his case. I believe there were three or more times a doctor came
into his room to talk with him. I think that is impressive of the doctors to take the time to visit face to face with their
patients. My patient seemed to really appreciate it as well. His brother stopped by for a little while after the test and his
daughter and niece came to visit him around lunch time. They were all very involved and interested in his care and he was
happy to have them there.
Interpreting
I thought the situation was very interesting. After reading about causes of stomach cancer, I suspect my patients smoking
history has something to do with his cancer. I have never worked with a patient with gastric cancer or stomach surgery
before. I have had patients with A. Fib and Hypertension before and see similarities in the medications ordered for them.
My patient didnt like his meal that came from nutrition services but had really just wanted a simple bowl of chicken noodle
soup. I told him I would see what I could do and try to get him something different. I asked the nurse manager because he
was standing right outside and he helped me get the phone number and I made the phone call. Within fifteen minutes, my
patient was happily eating his soup. This was great because he had been NPO for the stress test the previous night and was
going to have to be NPO that night too for the cardiac cath. I was really happy to help.
Responding
My goal for my patient is to be ready for discharge. He needs to know and comply with taking things slow when he gets
home instead of jumping right into the way he was before his surrey. The Physical Therapist recommended that in regards
to the daily walks he takes with his neighbor, that he should start small. Walking only a third of the way he used to walk
first and slowly add more distance as he gets his strength back. The patient needed to be reminded to comply with taking
his medications for the entire prescriptions and to attend his follow up appointments. He would be sent home with lots of
paperwork; one to especially look at it the list of what complications to keep an eye out for and to call his doctor if he
experiences them. I was stressed at first with the thought of going with my patient to the Stress Test. It turned out to be fine
and we had good conversation and I learned a lot. I was also stressed because the doctor had to give him somewhat bad
news that he needed to stay another night for a cardiac cath the following day because of the Stress Test results. I was
worried at how he would handle that news.
Reflection-in-Action

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My patient seemed to have a busy but good day. I think he enjoyed my company at the Stress Test and throughout the
morning. His family seemed very involved with his care and very interested in his discharge details. In speaking with him,
he seemed compliant with taking medications (except strong narcotics), taking it slow and resting. He kept telling me he
couldnt wait to get home so he could relax because at the hospital he can never get comfortable and people are always
coming in to speak with him. I enjoyed the day and tried to care for him the best I could. I kept open communication
between his assigned nurse and I and was apart of his entire morning.
Reflection-on-Action and Clinical Learning
Three ways in which my nursing skills improved as a result of this clinical experience are as follows: 1.) I was able to
develop my therapeutic listening skills. 2.) I practiced my IV flush skills and was able to see an IV line that needed to be
removed. And lastly, 3.) I was able to see how much it means to a patient to take special time to treat them how they
deserve, as an individual. Towards the end of our day, I walked into my patients room to check on him and noticed he had
not eaten his lunch. An hour before, I had helped him set his lunch up and he was ready to go because he had been NPO for
his test. I asked why he hadnt eaten and he told me it was not appetizing to him. I remembered that we could call nutrition
services and make requests. He simply wanted chicken noodle soup. I told him I would make a phone call and do what I
could. After using my recourses to find the number, I called and asked for a bowl of soup to be sent to him room and with
fifteen minutes my patient was eating his lunch. It made me feel good to be able to help him in that way and show him that
I genuinely care.
Next, three things I might would do differently next time if I encountered a similar situation in the future would be as
follows: 1.) I would talk with the patient more. There was one instance that the doctor came in with his results from the
Stress Test saying that he needs a Cardiac Cath done the following day to confirm or deny possible problems. When the Dr.
left, the patient seemed a little uneasy. I stayed and talked with him for a minute and reassured that he had great doctors but
them left him alone. Looking back, I should have stayed with him longer and discussed the Cardiac Cath. 2.) I did not
discuss the M in the box with my patient, next time I will be more diligent in teaching my patient. And lastly, 3.) I would
like to have a closer partnership with my patients nurse. His nurse was great but I want to pick their brain about what they
are doing. It's difficult for me to interrupt her because I know she has other patients and I don't want to put her behind. I
could have known more about the Cardiac Cath so that I could have explained some to my patient after the doctor told him
he would be having it the following day. There were no changes to my values or feelings as a result of this experience.

List two goals for the next practicum experience:

1. I want to improve my skills and confidence in assessing.
2. I want gain some confidence when introducing myself to other health care providers.

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Lasater Clinical Judgment Rubric Scoring Sheet

Developed by Kathie Lasater, Ed.D.; Based on Tanners Integrative Model of Clinical Judgment (2006)

Student Name: Rachel English

Date/Time:

9/3/14

Clinical Judgment Components

Noticing:
Focused Observation:

D A E

Recognizing Deviations from Expected Patterns:

B D A E

Information Seeking:

D A E

Interpreting:
Prioritizing Data:

D A E

Making Sense of Data:

D A E

Responding:
Calm, Confident Manner:

D A E

Clear Communication:

D A E

Well-Planned Intervention/Flexibility:

D A E

Being Skillful:

D A E

Reflecting:
Evaluation/Self-Analysis:

D A E

D A E

Commitment to Improvement:

Summary Comments:

Clinical Site: PTU SMH

Notes