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CLINICAL LOG TWO
WEEKLY CLINICAL LOG NUMBER TWO
Roshan Jan Muhammad
Date: 8st October to 15th October, 2012
Setting Site: Care Center, Bayview Johns Hopkins Hospital
Medicine wards, Bayview Johns Hopkins Hospitals
Preceptor: Ms. Carolyn Bailey
Alphie Rahman (CNS medicine units)
COURSE OBJECTIVES
 Apply knowledge from the science and humanities to CNS practice.
 Demonstrate advanced skills and expertise in the diverse roles of the CNS via integration
of care across the continuum and through three spheres of influence.
PERSONAL OBJECTIVES
 Observe operationalization of dynamic roles of CNS performed by preceptor and relate
them to national CNS competencies and Scope of Practice and Standards of Professional
Performance for the Acute and Critical Care Clinical Nurse Specialist by American
Association of Critical Care Nurses (AACN).
 Demonstrate clinical expertise in the management of critically ill patients as evidence by
active involvement in bedside clinical rounds every day, participation in two patient care
conferences and one mortality meeting.
 Enhance my clinical knowledge by reviewing best practice guidelines on care issues
identified during clinical practicum pertinent to acute/critical care as evidenced by onetwo guidelines review upon completion of every 24 hours of clinical.
 Review nursing, patient and system sensitive outcomes related to critical care; their
monitoring mechanisms; and comparison with national benchmarks.
OBSERVATIONAL NOTE
My clinical activities during this period are described in two sections. First paragraph
summarizes the actions that I performed with my preceptor. Whereas, the second paragraph lists
activities performed with Alphie (CNS medicine areas, Bayview). I was able to shadow Alphie
for a day to assess, discuss and appraise her activities as a CNS in acute care setting. This
arrangement was facilitated by my preceptor on my request in order to observe and compare the
role dynamics of CNS in acute and long term care facility.
I attended Joint Practice Committee (JPC) meeting at the care center and listened to the
presentations delivered by various clinical and non-clinical departments on their outcome
indicators. One of the presentations in the meeting was on failure mode effect analysis (FMEA)
project report on safe medication management. This weeks’ experience also involved review and
discussion of implementation plan for institution wide initiative called “language of caring” with
my preceptor. I independently reviewed and assessed complicated patients in the plaza center
and stroke rehabilitation unit. This involved discussion of clinical plans and related suggestion
with various multidisciplinary team members like respiratory therapist, charge nurse and the
physician. I attended patient care round on one unit to acquire understanding of multidisciplinary
CLINICAL LOG TWO
collaborative practice. Finally, I observed the role of CNS while addressing ethical issue of
“HIPPA” violation by one of the staff.
I had an opportunity to discuss the role transition and key responsibilities of Alphie as a
CNS. We also delineated on variation in scope of CNS activities within acute and long term
facility. I participated with her in arranging logistics for critical care competencies
recertification. I attended policy review committee meeting with her, where she presented
amendment in blood transfusion policy for approval. I accompanied her in welcome and
introductory session for the new nursing staff and I observed her discussing progress evaluation
of a novice nurse during probationary period. I intend to spend one more day with her to
complete the desired goal.
Reflection: Research competency (continuous quality improvement)/leadership/Change
agent
This week, JPC meeting was a unique learning experience. This committee monitors the
performance and progress of clinical and nonclinical departments through outcome indicators;
facilitates quality improvement and patient’s safety endeavors in the care center; supports
preparation for JACHO accreditation; and outlines annual strategic plans for quality related
matters. The meeting included presentation on clinical indicator from 2 of the care center units
and support service department followed by FMEA presentation on medication management
safety. Later, I discussed with my preceptor to understand the contribution of CNS in quality
improvement and patient safety venture and I reviewed the indicator report prepared by my
preceptor. The following 2 roles of CNS surfaced during the discussion. First, CNS is
responsible to monitor the universal clinical indicators defined by joint commission for long term
care setting; report monthly progress to the JPC; and take remedial actions in case of
performance deviation from the bench mark. Second, she is responsible to mediate translation of
institution wide quality initiatives to the nursing staff with the help of unit managers. It is
consistent with Fulton (2010) description of CNS role in quality improvement patient safety. She
delineates that the role is not restricted to data collection for monitoring purposes only, but CNS
also conceives and translates the organizational quality mandate. I believe CNS can contribute a
lot in the area of quality improvement and patient’s safety. During the review of indicator report
prepared by my preceptor, I found that the performance measurement was consistently
suboptimal in one of area. However, detailed systemic action plan or thorough review of the noncompliance was not conducted to address the issue. Benton (2010) describes that the
performance improvement is similar to nursing process that requires assessment, goal specific
planning, implementation and evaluation. There are several performance improvement
methodologies like plan, do, study and act (PDSA); focus, analyze, develop, and execute
(FADE); and fish bone quality circle process to guide CNS’s to systematically address the
correction process than just monitoring. During this process she can utilize her research
competencies as well to explore most appropriate and evidenced based intervention to ameliorate
the practices pertinent to areas of non-compliance.
I realized during the discussion that only those indicators are being monitored that are
required for federal/state certification or JACHO accreditation. However, the role of CNS in
quality improvement is broad. It encompasses identification of opportunities for improvement
that addresses or enhances patient safety issues, clinical competence and practice concerns
CLINICAL LOG TWO
(Benton, 2010) Therefore, proactive systematic methodologies like ‘FMEA’ can also be very
helpful for CNS’s to address the quality concerns beyond the scope of accreditation.
Nevertheless, both the CNS’s I worked with had never used any of the improvement process
mentioned above. I have used PDSA and fish bone quality circle for various quality
improvement initiatives before. However, FMEA was a new thing for me. While reviewing the
literature I came across very interesting IHI link that shares the details of various successful
FMEA projects. CNS’s can use this site as a guidance to pick appropriate quality initiatives for
their practice setting. The site link is shared with the preceptor.
Reflection: Clinical Expert/Collaborative practice
I spent few hours in patient care that involved review of 3 medically challenged patients.
I conduct comprehensive assessments of these patients, reviewed their care management plans
and shared concerns with relevant multidisciplinary team members. Here I want to present one
case scenario where I acted as a clinical expert and collaborator. A 65 years old patient, with
COPD, IHD, CRF and CHF was admitted for a cardiac rehabilitation. During the visit to the
patient, I found that he was not breathing well. He was tachypnic, short of breath, diaphoretic,
orthopnic, was using accessary muscles and had bilateral crackles on auscultation (-) other
cardiac symptoms on review of system. Considering his medical history, It was evident that he
was experiencing decompensated cardiac failure. The in-charge nurse was immediately called;
the physician was informed; and ABG’s and Pro-BNP was sent to confirm fulminant cardiac
failure after discussion with the physician. Meanwhile, vital signs and oxygen saturations were
monitored and patient was administered diuretics. Pro-BNP is a peptide that is elevated as a
response to atrial stretch secondary to fluid over load in heart failure patients (Moser et al.,
2009). The elevated Pro-BNP confirmed the diagnosis and patient was moved to acute care
setting. According to Spross (2010), this is a demonstration of clinical expertise as an advanced
practice nurse. She describes that clinical experts have ability to rapidly scan the situation;
identify salient and relevant clinical information; and conduct focused assessment to determine
which potential clinical condition best explains the acute deterioration.
I feel that being CNS I can offer more in such situation. The nurse assigned to the patient
had only 6 months working experience. Care center is a long term facility but it caters relatively
sick patients for such care setting. Having said, the staff is not trained to pick subtle or early
signs of clinical deterioration and they are not prepared to handle critical situation like one
mentioned in the scenario. In such situations, CNS can be utilized as a consultant to help the staff
manage and stabilize the patient. Beitz (2010) describes that consultation is the process of
working with individuals helping them to resolve actual or potential problems related to the
health status of clients. I suggest that the mechanism needs to be established where staff are
trained to detect early signs of clinical deterioration and initiate consultation to the CNS. And we
as clinical experts can assist them in managing patients using our clinical expertise; act as a role
model for nurses; and can also coach, educate and support the staff through on the spot
education.
Note: I am planning to spend more time with Alphie next week. Therefore, reflection on
observed differences between the roles of CNS in acute versus long term facility would be
presented in next clinical log.
CLINICAL LOG TWO
Subjective evaluation
During this week I have gained insight on some more roles of the CNS. Coordination and
collaboration with leadership to execute quality improvement patient safety endeavors was the
most important entry that I explored. I was able to develop an understanding on how clinical
indicators are defined, monitored and reported in the system. I was able to enhance my
knowledge on FMEA process through which practice and health care system problems are
systematically addressed to achieving the goal of quality improvement and patient safety.
This week, I was able to demonstrate few roles like clinical expert and collaborator. Also
I was able to review evidenced based guidelines on two topics (CHF and MI) defined in the
personal goals and objectives to support my role as a clinical expert.
Specialty Textbook Review
Chapter 10 Advanced dysrhythmias
Summary: Peterson (2009) provides information on selected arrhythmias and their
management that has critical implications into patient care. The author explains mechanism of
action potential of pacemaker cells and ventricles and relates it to various conduction
abnormalities witnessed in clinical situation. She has categorized mechanism of arrhythmias as
altered pulse formation and altered impulse conduction. Altered pulse formation is a result of
altered/abnormal automaticity, early after depolarization, and delayed after depolarization.
However, altered impulse formation is due to electrophysiological changes secondary to reentry
mechanism and myocardial ischemia. The chapter describes in length about supraventricular and
ventricular arrhythmias; disorders of repolarization; mechanism of aberrancy versus ectopy; and
pharmacological and electrical management of aforementioned arrhythmias.
Critique: Though the chapter does not cover electrophysiological variations in its
entirety, however, for the first time, I got clarity on the concept of aberrancy and reentry
phenomena. I am certain that this would be helpful in clinical setting because the treatment
choices differ based on underline mechanism of arrhythmias. Moreover, Brugada syndrome and
WPW syndrome was something new that I have not witnessed in clinical setting. I look forward
to integrate this knowledge into practice. Nevertheless, the chapter referred ACLS guidelines
published in 2005, whereas, the recent version published in 2010 has proposed quite a few new
recommendations as well.
Chapter 11 Acute coronary syndrome (ACS)
Summary: In this chapter, Munro (2009) reinforces key concepts related to diagnosis and
management of stable/unstable angina and ST/NSTEMI based on ACC and AHA guidelines
published in 2007. I found grading criteria of angina and symptomatic variation in differential
diagnosis of chest pain very important as several clinical conditions mimic angina. Knowing the
specifics of differentials help to rule out or rule in cardiac origin of chest pain.
Critique: By virtue of publication date, it does not include ACC/AHA recommendations
published thereafter. Thus, following reference was also reviewed to know recent additions for
the management of ACS.
CLINICAL LOG TWO
Additional reference reviewed
Summary: Wenger (2011) presents key modifications proposed by ACC and AHA in the
management of patients with unstable angina/NSTEMI after 2007 guidelines. First modification
is regarding the timing of acute interventional therapy in NSTEMI. It reveals that immediate
cardiac catheterization does not offer benefit over initial medical stabilization. Second
recommendation supports the use of triple antiplatelet therapy in high risk patients, with dual
antiplatelet therapy appropriate for all other patients (LOE 1a). The guideline adds prasugrel in
thienopyridines drug category. This addition is supported by study (LOE 1b), in which prasugrel
was found to be associated with better results in reducing stent thrombosis and endpoint of death
due to cardiovascular cause compared to clopidogrel. Third recommendation is regarding blood
glucose control. Instead of stringent blood sugar regulation, moderate blood sugar control
(<180mg/dl) is recommended. Fourth modification endorses that early invasive strategy is
reasonable in patients with mild (stage II) and moderate (stage III) CKD following adequate
hydration before contrast is administered.
Chapter 12 Heart failure (HF)
Summary: In this chapter, Moser et al., (2009) provides comprehensive details of
pathology of HF and illustrates related neurochemical, structural and functional changes
precipitating and/or aggravating HF. The author also describes 4 stages in the development of
HF, differentiates pathological processes in each stage, and describes clinical presentation and
management of patient as per staged wise acuity grading. The management section in the chapter
incorporates pharmacological and non-pharmacological measures recommended by American
College of Cardiology (ACC) and American Heart Association (AHA). It also addresses
challenges in management of HF patient due to comorbidities like COPD and Renal failure that
limits the optimal use of available drug regimen.
Critique: In this chapter, treatment modality of cardiac resynchronized therapy (CRT)
was a new information for me. Though the chapter suffices the basic information, however, I
would need to review more references to learn the ECG interpretation of patients on CRT. The
most recent references used in the chapter is of 2005. Thus, it does not incorporate recent
development in the management of heart failure patients. For instance use of hydralazine and
isosorbide nitrate is proven to improve morbidity and mortality outcomes of HF patients with
African American ethnicity, however, this information is not included in this chapter
(Authors/Task force members (2012). Heart failure is often the most common cardiac pathology
encountered in acute care setting. Therefore, it is crucial for me to stay connected to most recent
development related to HF management. Following additional reference was reviewed for most
recent update on the topic.
Additional reference reviewed
I reviewed guidelines for the diagnosis and treatment of acute and chronic heart failure from
Authors/Task force members (2012). This article mainly focuses on principle changes from the
2008 ESC guidelines that are listed below:
1. The benefit of mineralocorticoid receptor antagonists (MRA) probably extends to all
patients with systolic HF.
CLINICAL LOG TWO
2. The guideline describes a new indication for the sinus node inhibitor called “ivabradine”.
The drug is a selective inhibitor of a sodium-potassium channel in the sinoatrial node.
Thus, has a dampening effect on the heart rate originating from SA (LOE IIa and IIb). It
should be considered in patients with systolic HF who have sinus rhythm with EF <
35%, having HR > 70/min and persisting symptoms despite B-Blocker, ACE inhibitors
/ARB and MRA. However, this drug is awaiting FDA approval in USA.
3. Expanded indication for cardiac resynchronization therapy from LBBB QRS morphology
(Ia) to non-LBBB QRS morphology (IIa)
4. New information on the role of coronary revascularization in HF.
5. Recognizes the growing use of VAD in heart failure.
6. The emergence of trans-catheter valve interventions.
The article also lists treatment that is not recommended due to unproven benefit to HF
patients. It includes Renin inhibitors (aliskiren) and oral anticoagulants. It also mentions
treatment that is believed to cause harm in patients with symptomatic heart failure, for instance,
calcium channel blocker (with an exception of amlodipine and felodipine) due to negative
inotropic effects (III b); NSAIDS and COX-2 inhibitors because of propensity to cause Na and
H2O retention (III b); addition of ARB to the ACE inhibitor or MRA due to high risk of renal
dysfunction and hyperkalemia (III c).
Reference
Authors/Task Force Members, McMurray, J. J., Adamopoulos, S., Anker, S. D., Auricchio, A.,
Bohm, M., . . . Ponikowski, P. (2012). ESC guidelines for the diagnosis and treatment of
acute and chronic heart failure 2012: The task force for the diagnosis and treatment of acute
and chronic heart failure 2012 of the european society of cardiology. developed in
collaboration with the heart failure association (HFA) of the ESC. European Journal of
Heart Failure, 14(8), 803-869. doi: 10.1093/eurjhf/hfs105
Beitz, J.M. (2010). The clinical nurse specialist consultatnt role: Issues and pragmatics. In
Zuzelo, The clinical nurse specialist handbook. 2nd edition ( pp183-209). Saunders:
Elsevier
Benton (2010). Creating a culture of quality. In Fulton, Lyon & Goudreau. Foundations of
clinical nurse specialist practice (pp 165-168). Springer Publishing Company:New
York.
Institute for Health Care Improvement. (IHI). All FMEA tools. Retrieved from
http://app.ihi.org/Workspace/tools/fmea/AllTools.aspx#3
Moser, D. K., Riegel, B., Paul, S., Lennie, T. A., & Kirkwood, P. L. (2009). Heart failure. In In
K.K. Carlson (Ed.), Advanced critical care nursing (pp. 237-275). Saunders: Elsevier.
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Munro, N. (2009). Acute coronary syndrome. In In K.K. Carlson (Ed.), Advanced critical care
nursing (pp. 207-236). Saunders: Elsevier.
Peterson, K. J. (2009). Advanced dysrhythmias. In K.K. Carlson (Ed.), Advanced critical care
nursing (pp. 173-202). Saunders: Elsevier.
Spross, J.A. (2010). Expert coaching and guidance. In Zuzelo, The clinical nurse specialist
handbook. 2nd edition (pp187-225). Saunders: Elsevier
Wenger, N. K. (2012). 2011 ACCF/AHA focused update of the guidelines for the management
of patients with unstable Angina/Non-ST-elevation myocardial infarction (updating the
2007 guideline): Highlights for the clinician. Clinical Cardiology, 35(1), 3-8. doi:
10.1002/clc.20964; 10.1002/clc.20964