PCU nursing floor shift report

Read the course outcome so you have an idea what to write in the response if needed.
Please help me edit what I have already and just make it flow smoother for the paper. Can add more details for questions 2-5 if needed. Keep it simple.

Course outcome listed below:
1. Interact professionally and develop confidence in providing nursing care in an acute /ambulatory / community care setting.
2. Experience the realities of the work setting in professional nursing practice:
a. Provide patient care for patients in an acute / ambulatory/community care setting per agency protocols/policies.
b. Learn the communication processes and chain of command for communicating patient needs to other health care professionals in the acute / ambulatory / community care setting.
c. Administer safe, competent nursing care while working at the clinical care site.
d. Participate in patient education and discharge teaching in the acute /ambulatory /community care setting and in the community when possible
e. Acquire additional clinical practice of previously learned clinical skills.
f. Enhance confidence and comfort in the performance of clinical skills, as applicable in acute /ambulatory / community care setting.
3. Gain additional experience as a member of a health care team and enhance socialization in the reality of the work setting.
4. Develop future employment opportunities and build an employment history in an acute / ambulatory / community environment
5. Explore career goals in an acute / ambulatory / community care setting.

Questions and my answers.

1. Activities completed this shift to meet externship objectives: (may submit bullet point format)

-¬ Performed head to toe assessment: neuro check, blood pressure, HR, RR, temp, and SPO2.
¬ Performed a condom catheter for patient who fractured 4 ribs and is anuria, but afraid that he is incontinence.
¬ Removed Purewick and replaced it due to incontinence.
¬ Administered OxyContin for pain management for patient that underwent back surgery.
¬ Remove IV from patient’s right foot.
¬ Check blood sugar level for Diabetes Type 1 patient on NJ feeding tube. Administer insulin injection.
¬ Changed tube feeding and Peptamen AF formula.
¬ Priming IV tube, administering 0.9% sodium chloride, piggy-back azithromycin; and administer Tylenol (narcotic makes patient paranoid) and synthroid for patient with history of hypothyroidism, hypertension, lumbar stenosis.
¬ Assist with removal of rectal tube for patient with C. Diff. Patient was distended and unable to pass flatus. After the rectal tube removal, patient had one bowel movement, mucus and serous.
¬ Reposition patient every hour for patient A+O x 1

2. Objectives for next shift: (may submit bullet point format)
¬ To improve on time management with 3 patients from assessment, administering medications, and providing patient care.
¬ To acquire additional nursing clinical practices of the previously learned skills.
¬ To gain additional experience on working in the healthcare sector.

3. Areas of accomplishment: (submit in narrative form—not just a listing)

I was able to provide comfort care and communicate with a patient that only speaks Spanish. The blue phone was useful for translating within the hospital. Since patient had removed 3 IVs prior to the shift. She had no fluids and the physician had ordered antibiotics but was not administered. I explained to the patient and her daughter why patient needed IV access. My preceptor and I were in the patient’s room for about 40 minutes trying to put in the IV and wrapping it to prevent her from pulling it out per daughter’s request Patient’s daughter is her proxy. Patient was scheduled for an epidural injection but unable to get it due to pneumonia infection. Furthermore, provide care to patient with multiple fracture from fall. Elevated his legs to help with edema pitting +3, and helped with wound care for 4 location of weeping laceration.
Effectively communicating with patient that is A+O x 1 with c. Diff, informing patient before doing any procedure. Assessing wound vac is intact. Assessing NJ tube (patient attempted to removed it 4 times). GJ tube dry and intact, serosanguinous color.

4. Areas of concern or areas for improvement: (submit in narrative form—not just a listing)

I still need to improve on time management and provide cluster care. I was in the patient’s room for assessment/vitals, then I needed to administer medications, reposition patient, check orders, etc. I feel behind. Also, when I was in the patient’s room, I had to go get supplies multiple times because I came in for one time but something else came up. It was especially difficult with the altered mental status patient with c. diff., because I was in that patient’s room for the majority of the time.

5. Preceptor’s suggestions: (may be completed by preceptor or student): (submit in narrative form—not just a listing)
My preceptor encouraged me to take my time with time management. The best way is to be organized. By do a quick introduction and a focus assessment. While I’m in the patient’s room initially to notice, what is missing or the patient need so I would have it ready the next time I return the room. Since we were short staff, the altered mental status patient did not have a sitter, but my nurse informed me that it would be helpful to ask the charge nurse if that option would be available.