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Running head: SELF-REFLECTIVE JOURNAL: INFORMATICS

Self-Reflective Journal: Informatics Name Course Professor Date

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SELF-REFLECTIVE JOURNAL: INFORMATICS

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Self-Reflective Journal: Informatics Pre-Planning Nursing informatics refers to a nursing specialization that enlightens the professionals on integrating nursing science and computer knowledge as a strategy aimed at conceptualizing how to effectively handle data in nursing practice (Austria, 2017). It is an essential aspect of the nursing process because it provides the insights that primary caregivers require to analyze the patterns present in the data sets documented in healthcare institutions. It also provides the expertise that aids in detecting errors in the data collection systems and formulating effective strategies that meet the medical needs of your patients. Introduction Nursing informatics also has a notable impact on nursing practice. It provides the knowledge required to articulate critical nursing content accurately. Kaiser Permanente utilizes the EPIC system as a healthcare provider to store, organize, access, and share electronic medical records on the verge of providing quality care to patients. This essay, therefore, will focus on how useful the EPIC system was in the continuous management of my patient through access to previously stored data and how it influenced the administration of an anticoagulant medication to my patient. Background This week I encountered a 52-year-old female patient with a history of gastric bypass surgery followed by 3 revisions ranging from 2001 to 2018. She also has a history of DVT and PE. Most recently, she was admitted for an abdominal infection that required tissue debridement. My patient was prescribed Enoxaparin, which is an anticoagulant that helps prevent the formation of blood clots. It is used to treat or prevent a type of blood clot called deep vein thrombosis

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(DVT), leading to blood clots in the lungs (pulmonary embolism) (Schlottmann & Buxhoeveden, 2018). Before administering the medication, I wanted to ensure my patient’s platelet count was within the normal range. Given that this medication is known for causing thrombocytopenia, I wanted to make sure her platelet count was not below the normal range, as well as assessing if she had ever had previous complications. I found EPIC to be very useful in going back multiple days to trend her platelet counts as well as how she had been tolerating each dose. Noticing While analyzing the patient's chart, I noticed that her last dose of Enoxaparin was administered in her left arm. Given this information, I suggested using the right arm for the next dose. I gave the patient the option of choosing, and she also agreed to use the opposite arm. Based on previous administration records of this medication, I was able to ascertain that the patient had been tolerating each dose without complications and follow up assessments provided no documentation that the patient had ever experienced any long-lasting side effects. Interpreting Upon seeing my patient, I noted that her entire abdomen was wrapped and packed with kerlix gauze after undergoing surgery. Given this circumstance, I knew the abdomen would not be an appropriate injection site for this medication. The most apparent solution to counter her problem would have been to administer the anticoagulant medication into the outside of her arm to prevent any repeat instances of DVT or PE occurring, as well as averting any further discomfort. This was my first time administering an anticoagulant to a patient, therefore, I have no previous experiences that precisely relate to this situation. Although, I once had a patient with a GI bleed and had to take similar precautions to monitor for signs of bleeding, such as any excessive

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blood in the urine or stool. These precautions are also taken when administering any type of anticoagulant to protect the patient from any type of immoderate bleeding. Responding My main goal as a professional was to ensure that I guarantee the patient’s wellbeing and earn her trust, which would be necessary for her healing and response to treatment. By performing a head-to-toe assessment earlier that morning, it helped to determine the appropriate injection site in which to administer this medication. Typically, the abdomen would have been the injection site of choice, but given my patient’s current situation and level of pain, I felt it best to avoid her stomach region entirely. By doing this, the administration was successful without causing any further discomfort to the patient. Reflection-in-action The patient responded positively to the provided dose of Enoxaparin. She showed no resistance during the administration process and upon assessment, the patient stated that she didn't feel any pain or swelling at the injection site. I also implemented patient teaching to ensure the patient knew to make me aware of any excessive bleeding or discomfort that may follow at the injection site. During on a conversation with my patient previously that morning, she disclosed that following her surgery, she was not informed of the signs and symptoms of infection in which she should be monitoring. Because of this, she wound up back in the hospital with a severe abdominal infection. This taught me the importance of always implementing patient teaching following any procedure or administration of medication. By ensuring my patients are aware of any and all side effects to beware of, I can provide a more timely intervention if necessary. Reflection-on-action and clinical learning

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My experience taught me the significance of continuously double checking and verifying all documentation related to caring for my patient. Generally, the EPIC system is an excellent record-keeping program since it helps trace the patients’ past information to help understand their current situation (Hertzum & Ellingsen, 2019). Moreover, it assists in compliance towards patient safety and aids in early intervention. In this experience, my researching skills expanded by retrieving and evaluating data concerning the patient’s past. If I were to face such a scenario again, I would conduct a thorough evaluation of the patient’s condition, establish an open communication rapport to discover any pertinent information that may be missing from the chart, and carry out regular examinations to understand whether there is any further decline or improvements in my patient’s condition.

SELF-REFLECTIVE JOURNAL: INFORMATICS References Austria, P. J. M. (2017). Exploring the influence of informatics in nursing: The Filipino student nurses' perspective. On-Line Journal of Nursing Informatics, 21(2). Hertzum, M., & Ellingsen, G. (2019). The implementation of an electronic health record: Comparing preparations for Epic in Norway with experiences from the UK and Denmark. International journal of medical informatics, 129, 312-317. Schlottmann, F., & Buxhoeveden, R. (2018). Laparoscopic Roux-en-Y gastric bypass: Surgical technique and tips for success. Journal of Laparoendoscopic & Advanced Surgical Techniques, 28(8), 938-943.

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