identify opportunities for improvement in your clinical skills

rder Instructions

Assignment: Journal Entry

Critical reflection on your growth and development during your practicum experience in a clinical setting helps you identify opportunities for improvement in your clinical skills, while also recognizing your strengths and successes.

Use this Journal to reflect on your clinical strengths and opportunities for improvement, the progress you made, and what insights you will carry forward into your next practicum.

To Prepare

• Refer to the “Population-Focused Nurse Practitioner Competencies” found in the Week 1 Learning Resources and consider the quality measures or indicators advanced nursing practice nurses must possess in your specialty of interest.

• Refer to your “Clinical Skills Self-Assessment Form” you submitted in Week 1 and consider your strengths and opportunities for improvement.

• Refer to your Patient Log in Meditrek and consider the patient activities you have experienced in your practicum experience and reflect on your observations and experiences.

In 450–500 words, address the following:

Learning From Experiences

• Revisit the goals and objectives from your Practicum Experience Plan. Explain the degree to which you achieved each during the practicum experience.

• Reflect on the three most challenging patients you encountered during the practicum experience. What was most challenging about each?

• What did you learn from this experience?

• What resources were available?

• What evidence-based practice did you use for the patients?

• What would you do differently?

• How are you managing patient flow and volume?

Communicating and Feedback

• Reflect on how you might improve your skills and knowledge and how to communicate those efforts to your Preceptor.

• Answer the questions: How am I doing? What is missing?

• Reflect on the formal and informal feedback you received from your Preceptor.

My goals and objective (attached)

Patient#1

CC: My depression and anxiety is worsening” HPI:CS is a 14y/o male that was referred from one of the local hospital because he told his fiend that he wanted to kill himself and his friend urged him to seek help, Pt. cell phone was also taken by his father because he was’nt completing his homework and on going through the phone, multiple conversations of sucidal ideation was found. The patient reported unstable moo, that his mood goes up and down with every little provocation. Pt. have curent intent or plan on how to harm himself and have no previous history suicidal attempts. Pt. overreacts after spending time with his friends and ralizing that he was not fitting in, that triggers that suicidal thoughtsThe pt. denies any any gender or sexual identity issues. Reported difficulty concentrating but takes Focalin which helps him. PMH: Pt. have history of ADHD, depressive disorder, and anxiety disorder. First psychitric hospitalization was in sept. 2021, was discharge home after that with psychotherapy and medication management providers. Medication History: Focalin XR 10mg daily, Abilify 2mg QAM, Abilify 4mg QHS, Celexa 40mg QHS,. Pt. is very inconsistent and noncompliant with medication per his parent. Developmental History: Reported normal pregnancy and delivery, no developmental abnormality. Attending regular school, in 9th grade. Family History: Father suffers from depression, mother and two siblings have no mental health issues. Psychosocial:Pt live with parents in Maryland with his two sisters 18y/o and 10y/o. In 9th grade. Attends school regularly. HAve no legal issues. Not sexually active. His Friends and family are his main attachement. Enjoys spending time with his family despite feeling depressed after being with them, listening to music, an dplaying video games. Susbstance Use: Denied alcohol, illigal substance or drug use. Allergy: NKDA, NKFA, No seasonal allergy. Mental status Exam: Alert and oriented to person, place, time, and situation, appearance: well kempt, Good eye contact, speech id normal rate, rhythm, and volume, thought process organized and concrete, denies AH/VA, no signs of delusion noted, mood is anxious, pt. have good insight of illness, good concentration. Pt. in no apparent distress. Treatment Plan: Plan Admit to Residential treatment program Individual, Group, Psychotherapies Restart pt. on current medication Psychiatric follow-up: weekly for first 1 months, then biweekly for 4 weeks, and then monthly thereafter. Physical Examination and medical evaluation by pediatrician Begin class attendance at New Directions Academy

Patient #2

CC: I’m depressed, I want to be perfect at everything, I want to be morally perfec, I want to be a parfect partner and friend, I want to be perfect academemically, and in sports” HPI: Pt is a 14y/o CM that was referred from the Hospital for attempting to harm himself by hanging. Pt has a past hsotory of depression, OCD. Pt. reports of worsening depression, mood swings, and unable to use coping skills to not think about self harm, It has gotten to the point to commit suicide. His plan is to use sharp knife to cut himself, punch the walls, tie noose to hang self or scratch himself to death. He stated he is depressed and anxious because he feel he is not a good friend to both his friends and girlfriend, not good academically, athletically, and socially. He stated that he gets A’s but feels he has to be in higher level classes. Feels that all his freinds are passing in strength and pace. Endorsed feeling helpless and hopless sometimes, feeling down, get tited very quickly because of mood swings, sadness because his girlfriend does not like him anymore. Admitted to sleeping and eating well. Endorses decrease concentration. Reported that he compliant with his outpatient treatment but feels his psychotropic regimen and coping skills is not all that effective to cope with his worsening mood. Endorses suicidal thoughts with plan to srcatch self withhis nails. Pt. do not have any nails. Past Psychiatic History: History of Depression and OCD, had one previous psychiatric admission in March 2022, and was discharged to to day hospital in April, 2022. Has had psychotherapy and medication management inthe community. Have previous history of suicidal attemp in march, 2022 by tieing a noose to hang self in the hsopital. Developmental history: Full term , meet all developmental milestone with no complications. Currently in 9th grade. Straight A student. Family history: No psychiatic family history. Psychosocial:Pt. live with his parents, his 17y/o brother, and 12y/o sister. In high school and a full time student. Pt. enjoys cross country, playing base guitar, tennis, and wrestling. He wants to be a Fiancial analyst in the future. Allergies: NKDA, Allergic to Peanuts, causes heart burn, No seasonal allergies. Medication: Abilify 10mg QHS, Zoloft 100mg daily. MSE: Patient is alert and oriented to person, place, time, and situation. Appeared well kempt, intermittent eye contact, speech normal rate, rhythm and volum, concrete thought process, denies AH/VH, mood is depressed, affect is constricted, have good insight of psychiatric illness, Poor judgement. Endorses suicidal thoughts to cut self with his finger nails. Plan: Admit to Residential treatment program and place on suicidal observation protocol Individual, Group, Psychotherapies Psychiatric follow-up: weekly for first 1 months, then biweekly for 4 weeks, and then monthly thereafter. Physical Examination and medical evaluation by pediatrician Begin class attendance at New Directions Academy

Patient #3

CC : “Things have been bad at home” HPI: KD is a 16 y/o male with history of conduct disorder, oppositional defiant disorder, ADHD, depressive disorder. Pt. was hospitalized for five days due to increase agitation and worsening impulsivity. Received Intramuscular dose of Zyprexa in the ER due to increase agitation. It was reported that pt. has being hitting his older neighbor with sticks, stole bikes which was caught on video camera, has ran always from the house four times, and destroyed and stole at a local Toyota car dealership. He has also made threats to kill his mother and sister while they were asleep. He gets into fights with siblings and peers at school and has being suspended and expelled from his former school. He has been playing with matches lately and his mother claimed that he tried to set her house on fire. He recently destroyed his room at home and made treat that he wants to die. He said that he did not want to be admitted that his mother lied, denied going to the car dealership to steal. He said that the 68 y/o neighbor hit him first in the face, denied hitting him with a stick. He said that he touched his mother’s glass bowl and that made his mother mad. He does acknowledged lighting pieces of paper on fire on the street near his house as he was feeling bored. He stated that he will like to live with his father in North Carolina who he referred as “Junkie” According to his mother, the principal of his new school reported that there was a person looking for him with a gun at school. He has destrpyed cookwares at home and thro away good foods. Cutting his younder brother’s cable and internet cord to aggrevate him. Mother thinks that pt. will benefit form RTC instead of coming back home. Pt. reported that Lithium helps with sleep, if he does not take it, he will be up till 5am. Past Psychiatric History: General Statement: Pt. has had multiple psychiatric admissions, Admitted to resident treatment center at age 10 a Hospitalizations: Multiple hospitalization in 2020, , 2021, hospitalized 3x at JHH, University of Maryland 2x, last hospitalized in August 2022 for impulsive behavior and suicidal and homicidal ideation. Was stabilized and discharged back home. Psychotherapy:. Counseling at age 10 years to cope with parental divorce. According to pt.’s mother, he refused to go to individual/family therapy when he was discharged in August 2022. Previous Psychiatric Diagnosis: Conduct disorder, Poor Impulse control disorder, ADHD, depressive disorder, Oppositional Defiant disorder. Substance Current Use and History: Denied alcohol and Substance use, cannabis, abuse of prescription opioids or stimulants. Family Psychiatric/Substance Use History: Parents are divorced, Mother has custody and live with pt. and his siblings in Maryland. Father remarried and moved tp North Carolina, have sporadic and limited contact with patient due his substance use. Pt. father is not involved and has not visited him for 6 years. substance use. Father has history of anxiety disorder,alcohol and subastance use disorder and had been incarcerated for illegal possession of handgun and substances. His sister has a history of of PTSD. Psychosocial History: Pt. was born and raised in Maryland, live with his mother, 18y/o sister and 11y/o brother. In high school, but will like to be a music producer. Denied being sexual active, has never been force to ave sex against his will and has not violated anyone. Pt. enjoys begin on social media and playing video games with friend, enjoys watching television and listening to music. Legal History: Charged in June, 2022 for destroying and stealing from the car dealership and in 2020 for breaking into a vehicle in the parking lot. Medical History: Current Medications: Abilify 10mg 1 tab po at bedtime, Clonidine 0.1mg 1 tab po BID, Lithium 300mg 1 tablet po BID, Risperidone 0.5mg 1 tabpo BID, Albuterol 90mcg 1 puff inhale every 6hrs PRN fro asthma Allergies: No known Drug allergy, No known food allergy, No known seasonal allergy. Reproductive Hx: Born full term, had speech delayed at age 4-5, attended speech therapy for 1 year. Objective: Diagnostic results: CBC, BMP, TSH, Lipid panel, HgA1c, RPR, Urine toxicology screening , and vitamine D. All level normal normal except low Vitamine D level, started on Vitamin D 200mcg daily. Will check Lithium level in two weeks. Assessment: Mental Status Examination: Pt. is alert and oriented to Person, Place, and Time, Apperance is clean, appeared calm and reserved, appered apathetic and hypoactive. Speech is brief and monotone. Thought process is concrete. No symptoms of delusion or paranoia noted, denied auditory and visual haullicination. Mood is anxious and bored, denied current suicidal and homicidal ideation. Have very poor insight and judgement. Poor concentration and inattentiveness. Por recall of past event but can recall some current events. ROS Differential Diagnoses: 1) conduct disorder (CD) 2) Ppositional defiant disorder (ODD) 3) Depressive disorder Assessment and plan: Admit to Residential treatment program Individual, Group, Psychotherapies to addressaggressive and impulsive behavoirs, build effective coping skills, develop safety plan, identify triggers. Psychiatric follow-up: weekly for first 1 months, then biweekly for 4 weeks, and then monthly thereafter. Physical Examination and medical evaluation by pediatrician Begin class attendance at New Directions Academy

Assignment_Rubric

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• List View

Excellent Good Fair Poor

Assimilation and Synthesis: Content Reflection 45 (45%) – 50 (50%)

Reflection demonstrates a high level of critical thinking in applying and integrating key course concepts and theories from readings, lectures, and/or experiences. Insightful and relevant connections are made through contextual explanations and examples. 40 (40%) – 44 (44%)

Reflection demonstrates moderate level of critical thinking in applying and integrating key course concepts and theories from readings, lectures, and/or experiences. Connections are made through explanations and/or examples. 35 (35%) – 39 (39%)

Reflection demonstrates minimal critical thinking in applying and integrating key course concepts and theories from readings, lectures, and/or experiences. Minimal connections made through explanations and/or examples. 0 (0%) – 34 (34%)

Reflection lacks critical thinking. Superficial connections are made with key course concepts and resources, and/or assignments.

Assimilation and Synthesis: Personal Growth 27 (27%) – 30 (30%)

Expresses solid evidence of reflection on own work. Demonstrates substantial personal growth and awareness of deeper meaning through inferences, well developed insights, and significant depth in awareness and challenges. Synthesizes current experience into future implications. 24 (24%) – 26 (26%)

Expresses moderate evidence of reflection on own work. Demonstrates satisfactory personal growth and awareness through some inferences, insights, and challenges. There is mention of the future implications of student’s current experience. 21 (21%) – 23 (23%)

Expresses minimal evidence of reflection on own work. Demonstrates less than adequate personal growth and awareness through limited or simplistic inferences made, insights, and/or challenges that are not well developed. Minimal thought of future implications of student’s current experience. 0 (0%) – 20 (20%)

Expresses inadequate evidence of reflection on own work. Personal growth and awareness are not evident and/or demonstrate an impersonal experience. Lacks personal insights, challenges, inferences, and/or future implications are overlooked.

Written Expression and Formatting 14 (14%) – 15 (15%)

Well written and clearly organized using standard English, characterized by elements of a strong writing style and basically free from grammar, punctuation, usage, and spelling errors. 12 (12%) – 13 (13%)

Above average writing style and logically organized using standard English with minor errors in grammar, punctuation, usage, and spelling. 11 (11%) – 11 (11%)

Average writing style that is sometimes unclear and/or with some errors in grammar, punctuation, usage, and spelling. 0 (0%) – 10 (10%)

Poor writing style lacking in standard English, clarity, language used, and/or frequent errors in grammar, punctuation, usage, and spelling. Needs work.

APA 5 (5%) – 5 (5%)

Contains no APA errors. 4 (4%) – 4 (4%)

Contains one to two (1–2) APA errors. 3.5 (3.5%) – 3.5 (3.5%)

Contains three to five (3–5) APA errors. 0 (0%) – 2 (2%)

Contains more than five (>5) APA errors.

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