NR 575 Week 5 Practice Readiness Appraisal Example

Practice Readiness Appraisal at Week 5 of the Second Practicum: Four Aims With Verdicts, the Situations I Would Not Yet Take On Alone and What Would Have to Change

Student Name

College of Nursing, Chamberlain University

NR 575: Acute Care Practicum II

Instructor Name

Month Day, Year

Practice Readiness Appraisal at Week 5 of the Second Practicum: Four Aims With Verdicts, the Situations I Would Not Yet Take On Alone and What Would Have to Change

How This Appraisal Is Organized

The four surviving aims from my week 2 revision memo appear below in the same order, each with a verdict of closed, partly closed or open, and the events that support it. The appraisal then turns to the situations I would not yet take on alone, what makes each hard and what would have to change. A closing paragraph states how ready I think I am, and on what basis. My preceptor read this document and added one comment, quoted at the end.

Aim 1: Plan Offered First on Rounds

Verdict: closed.

Support: five intensive care rounds forms collected in weeks 2 to 5; "plan offered independently" marked on four. On the fifth, a patient with new septic shock, the intensivist asked for the plan before I had finished the overnight events, and my preceptor answered. The four marked forms include two ventilated patients.

Aim 2: Ventilator Decisions Over Consecutive Days

Verdict: partly closed.

Support: daily ventilator decisions, cosigned, for two patients for two consecutive days each: the patient with status asthmaticus in week 3 and a patient with pneumonia and moderate lung injury in week 5. A third patient is needed before the end of the term, and my preceptor has agreed to assign me the next newly intubated patient on my days so the two consecutive days can be planned. In both cases my plans were cosigned with one change each; the changes concerned checking for trapped air before a rate increase and lowering the tidal volume by 30 mL for the patient's predicted weight.

Aim 4: Arterial Lines Under Ultrasound

Verdict: partly closed.

Support: one radial arterial line placed in week 4 with the intensivist in the room, on the second pass, recorded in a procedure note. One observed in week 2. One more placement is needed.

Aim 5: Family Meetings With a Pause After Hard News

Verdict: partly closed.

Support: one meeting led in week 4, about a 79-year-old with a stroke and no expected recovery of swallowing. My preceptor's written comment reads, in substance: after explaining that recovery was unlikely, you waited and asked the son what he was thinking, and he told us about his father's wishes; you moved to options too quickly when the daughter began to cry. So the change held once and slipped once in the same meeting. A second meeting is planned for week 7.

Situations I Would Not Yet Take On Alone

First, a ventilated patient whose plateau pressure rises overnight. I have made plans for two patients with a preceptor available. I have not yet been the person who notices a change at 03:00 and decides alone whether it is trapped air, a mucus plug or a pneumothorax. What makes it hard is that the decision needs a bedside examination and a hold maneuver within minutes, and in severe asthma hyperinflation can drop the blood pressure quickly (Leatherman, 2015), and I have done holds only with someone beside me. What would change it: two more overnight-style scenarios in the simulation lab, and at least one occasion on the unit where I perform the hold and state the cause before my preceptor speaks.

Second, a family meeting in which family members disagree. My one meeting this term included a son and daughter who reacted differently, and I handled the daughter's distress by moving on. What makes it hard is holding two reactions at once while still responding to emotion before moving to decisions, which is the order serious illness communication calls for (Bernacki & Block, 2014). What would change it: the second meeting this term, and a debrief with my preceptor afterward on that specific moment.

Third, end-of-life symptom management without a palliative care consultant in the room. My evidence map from week 4 shows no evidence for ethical practice and none for this. I have watched it twice. What would change it: writing the plan for comfort-focused care for at least one patient, reviewed by my preceptor, before week 8.

Readiness, Stated Plainly

On the aims I set, I am closer to independent practice in presenting and in daily ventilator planning than I was in week 1, and I am not yet independent in any of the three situations above. Ten percent of nurse practitioners in one national survey felt very well prepared for practice when they finished their programs, and about half felt only somewhat or minimally prepared (Hart & Macnee, 2007). I do not take that as reassurance; I take it as a reason to name the situations precisely so a first employer can see them.

My preceptor's comment, added to this document: "Agree with all three open situations. The family meeting is closer than you think."

What Has Changed Since the Revision Memo

The revision memo in week 2 assumed that ventilated patients would be plentiful; they are, but most stay only two or three days, which is why aim 2 needs a third patient rather than more days with the first two. It assumed one family meeting by week 4, which happened. It did not anticipate that the second arterial line would depend on finding a patient whose line is placed during day hours, which is less common than I expected because many are placed in the emergency department.

Evidence I Could Not Collect

I could not collect a form for rounds on days when the intensivist ran rounds at the bedside without the standard form. I could not observe a second arterial line before placing one, because the only one placed on my days in week 3 was done during an emergency. And I have no evidence yet of managing a deteriorating patient alone, because I have not been alone; that absence is the first situation listed above, not an oversight. Each missing piece of evidence is recorded so that the week 8 memo can say whether it was later found or remained missing.

Consistency With the Week 4 Map

The week 4 map marked ethical practice with no evidence. This appraisal links that gap to the third situation above. The map marked procedures partly met on the basis of last term's punctures; this appraisal adds one arterial line, so the map will be updated in week 7.

References

Bernacki, R. E., & Block, S. D. (2014). Communication about serious illness care goals: A review and synthesis of best practices. JAMA Internal Medicine, 174(12), 1994-2003. https://doi.org/10.1001/jamainternmed.2014.5271

Hart, A. M., & Macnee, C. L. (2007). How well are nurse practitioners prepared for practice: Results of a 2004 questionnaire study. Journal of the American Academy of Nurse Practitioners, 19(1), 35-42. https://doi.org/10.1111/j.1745-7599.2006.00191.x

Leatherman, J. (2015). Mechanical ventilation for severe asthma. Chest, 147(6), 1671-1680. https://doi.org/10.1378/chest.14-1733