SAINT PAUL UNIVERSITY PHILIPPINES

Tuguegarao City, Cagayan 3500

JOURNAL OF LEARNING INSIGHTS/ PROBLEMS

ENCOUNTERED/ACTIONS TAKEN/SUGGESTIONS AND
RECOMMENDATIONS AND BEST PRACTICES WITNESSED

_________________________________

In Partial Fulfillment of the Requirements for the Degree

MASTER OF SCIENCE IN NURSING
Major in Adult Health

By:

JISELMARI ALTHERYN D. BULAN, RN

MARCH 2017

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 JOURNAL OF LEARNING INSIGHTS

Learning as described by Leonardo Da Vinci is the only thing the mind

never exhausts, never fears and never regrets. I am a type of person who loves
learning and studying. I could actually consider myself before as an achiever. When
I started my Masters Degree in 2015, I was at a phase where I had backed down
from my previous self trying to be humble and acknowledging that maybe I am not
that person I have considered great anymorethat after 5 years of being stuck away
from my nursing career I'm already as clueless (or maybe even more) as a beginner.
But this step I took, enrolling for a master's degree was somehow my move to re-
opening myself to knowledge and embracing new learning experiences which I
believe will help me to eventually be more confident about myself and my abilities
as a nurse. In the same year, I also took the scary move to finally apply for a nursing
job at a hospital and be trained by senior nurses who are younger than me. And
now, my journey has been more than a year and counting. I've already learned and
explored a lot, yet everyday there's always new things to learn and avenues to
explore. As part of our requirement for the degree, we need to complete our advance
nursing practicum. And so here follows my everyday journal about my learning
activities and insights during our 3-week stay at Perpetual Succour Hospital in Cebu
City.

March 6, 2017 (7 AM 3 PM)

Activities: General Orientation and quick tour to some parts of the Hospital

Insights/Learnings:
We have arrived at Perpetual Succour Hospital before seven oclock in the
morning. Actually, yesterday, I and 2 of my classmates tried the route from our
dormitory to the hospital. We have learned to not hesitate asking directions and be
willing to talk to the locals about which jeepney we should take since there are
routes designated to jeepney thru letters +numbers.

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 We had to wait a little bit for Sister Gau because at that time she was a little
busy. We were entertained first by Sister May, who I've heard was once a dean of
Nursing for 4 years at SPUP. We also met Sir Christian who is an Ilocano and lived
in Gattaran, Cagayan. It was so nice to meet and talk to people who can relate to
topics regarding our city and province.
On this day I have learned the vision and mission of PSH, its history and
development the 80 years of existence and service. The Nursing service training
officer, Ma'am Line Abellana, was the one who gave us the birds eye view of the
hospital. She also mentioned some guidelines and important reminders for
employees, staffs and interns. After which, Sister Gau came to us and gave more
input about our stay and practicum in PSH. She has emphasized the importance of
team work, compassion and faith.
Today, I have learned that things dont happen the way I expected it. First,
I should have not expected a well coordinated agreement between my school and
PSH. Despite that, I am greatly thankful to Sister Gau and the rest of the Nursing
division for giving us a warm welcome.
Finally today, I have learned to be more familiar with the surroundings and how to
get to the hospital from our dormitory and back.

March 7, 2017 (8Am-8pm)

Activities: Orientation for CVL and General In-patient Wards

Insights/Learnings:

For the first 3 hours, we had an orientation regarding the General in-patient
wards and the cardiovascular lab, with the presenters Maam Christy Hisoler and
Maam Pearly Pulgo respectively. Ma'am Christy mentioned all the wards in the
General in-patient and what each unit caters to. We asked her a few questions like
the structure of nursing responsibilities in the ward, the division of labor and etc,.
She was very enthusiastic in answering all our questions.

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 I also learned what procedures they perform in their CVL unit. Ma'am
Pearly explained the procedure both the invasive and non-invasive cardiovascular
procedures. After the discussion/orientation, we were told to proceed to our
respective area of assignment. We were divided into three groups. Our group was
assigned to the General in-patient first. Ma'am Cheska Sta. Ana, one of the Head
Nurses of the General in patient met our group and she toured us around the wards.
I have learned how the aerocom (pneumatic system) basically works, the set-up of
the units among other things. She showed us the very high tech CBS monitoring kit
they use, which needs a QR code so they always wear it with their IDs. She also
showed us the forms and explained to us the use of the forms and how they're being
filled up. I have truly enjoyed the tour. Ma'am Cheska had been so nice and patient
in answering our questions.
After the tour, she assigned 2 of us at the 4th floor/oncology ward and the
other 2 at the 3rd floor. We were introduced to the staff and then she left us on our
own. There, we were able to witness firsthand their endorsement process. Although
we were not able to go with them with their rounds because we have not noticed
when they went. Apparently, we haven't noticed them because they didn't go
together earlier because the station was so busy. I was a little confused of the
endorsement and the rounds but I know that in a few days, I'll get to familiarize
myself with their routine.

March 8, 2017 (6am 6pm)

Activity: Unit observation and interviewing patient for case study

Insights / Learnings:
Today I have learned to be brave and commute alone from our dorm to the
hospital, since my classmates/dormmates schedule was at 7am and mine was at
6am. Today we were able to witness full-scale endorsement and we also went with
the nursing rounds. I learned at 4th floor ward, usually there are 2 charge nurses
and 2 primary nurses, and they distribute patients accordingly to the census. I
was kind of confused about their medication endorsement since it seemed that

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medications on the medication table dont lessen. I appreciate the way all nurses
take notes of special endorsement of all patients and they also have their own
notebooks. I was amazed to see a lot of resident doctors doing their
rounds. I learnedthat they are the ones who refer patient's status such as lab results
and other stuffs. I saw how the charge nurse and primary nurse respond to situations
like when their patient went restless. Today I was able to find a case for DM and a
case for Oncology. I was only able to interview my patient for DM. I have realized
how cebuano's can be so accommodating. Im just so glad that the patient can
understand and speak the Tagalog language well.

March 9, 2017 (6am 6pm)

Activity: Station observation and patient - interview

Insights / Learnings:
Today I was able to be a little more familiar o the set up at the Oncology
Ward. I have joined the endorsements and the rounds again. I have learned that the
charge nurse takes care of the entire chart and doctors orders and carries them out
and then endorses the orders to the primary nurse.
Today, there was only one charge nurse since the census was not that high. I
have reviewed the patients charts and studied the forms and how they are being
arranged. They have a 24-hour patient assessment and care record which includes
assessment per shift and the nurses notes. I'm also amazed that aside from the
charge nurse reviewing the charts prior to endorsement to the incoming shift, the
head nurse also reviews them one by one. I also envy them a little because a
pharmacist goes to the station, checks the chart and reviews if a patient is for
discharge, if so the pharmacist then makes a discharge instruction plan and be the
one to instruct the patient or the significant other.
I was able to review my patientscase for Oncology and interviewed her for
important data. I also helped one of the OJT nurses in verifying and double
checking a PRBC for transfusion.

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March 10, 2017 (6am 6pm)
Activity: Station observation

Insights / Learnings:
For three consecutive days I have been travelling to and from the hospital,
I can coffee say that I am already familiar with the way. The past few days, primary
nurses were so busy that I couldnt ask them with their medication routine but today
I had the chance to do so apparently, as I was told, the p.m. shift nurses prepare for
all medications for the next day, they are the ones who request for the medicines
and other things needed by the patients. Primary nurses also lay the medicines for
the next shift but there is still medication endorsement prior to start of each shift. I
realized that outgoing shifts cant go home if they still have back logs, I.e.
out/dislodged IV lines that need to be reinserted. I also learned how to manipulate
the aerocom although I still get a little startled every time an aerocom capsule
is being received.
Today, I also went to the medical records section to copy some lab results
of my Onco Patient, since she has been discharged earlier and I have neglected to
copy everything. But first I had to ask permission from the nursing office. I learned
that they are really accommodating with our request as long as it is communicated
properly.

March 11, 2017 (6am 6pm)

Activity: Station observation

Insights / Learnings:
Today is our last day at the ward and it kinda made me sad cause I have
enjoyed my rotation there. I'm very happy to say that I have learned more and more
bisaya words each day at the ward. Ma'am Angene, explained how their
communication system at the hospital works, they call it the medsys which was
a little the same with our hospital information system at the institution where I

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work. I was confused at first because the format is different but eventually I got
how it works.
One of the cancer patients condition went toxic, the charge nurse referred
to the ROD and was then referred to the attending consultant. But the significant
others have decided to sign a DNR. I've witnessed how they handle such scenarios,.
Generally, my exposure at the ward had been very fruitful. I have learned a
lot of things and have gained friends among other things.

March 13-14, 2017 (7am 7pm)

March 15-17, 2017 (11am-7pm)
Activity: Cebu Cancer Institure Observation

Insights / Learnings:
It had been my first 2 days of observation at the Cebu Cancer Institute. We
were oriented by Ma'am Mel at the pediatric and adult ambulatory chemotherapy.
She had oriented us with the set up, the compounding area, the nurses station and
the staff corner. We have witnessed how they aseptically insert an IV line to their
patients. Ma'am Gayle, had been very ideal, she had observed aseptic techniques
and she was talking to the patient very calmly so as to in a way reduce tension and
pain of the patient.
Meanwhile, at the brachytherapy area, we have been oriented by Ma'am
Hope who is the brachytherapy nurse. She was also accompanied by Ma'am Daryl,
who is training to become a brachytherapy nurse as well. We were lucky to have
witnessed brachytherapy for a patient with Endometrial Cancer on the 1st day and
a patient with Cervical Cancer on the 2nd day. I have also witnessed an external
radiation therapy using the LINAC to a patient with Breast Cancer.
We also had a meeting with Sister Gau and she had scheduled us for an
exposure at the Hemodialysis Unit.

March 15-17, 2017 (6am 11am)

Activity: Hemodialysis Unit Obseration

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Insights / Learnings:
I have greatly enjoyed my exposure at the hemodialysis unit. I have truly
learned a lot of things. So much so that I have started to be interested and I'm
actually already thinking of being a Certified Renal Nurse someday. I was able to
handle patients who have different sites of catheter placed, like AVF, IJ catheter,
and even a permanent catheter. I have learned the parts of the forms they use and
they've actually let me fill up some of documents. Unlike at the other unit, they let
us take and monitor the patients vital signs. They HD NODs have also taught us
the computation of gain weight and accumulated weight. I have also learned the
importance of the solutions and the color codes for each. At first, I was still a little
confused, about the tubes and other stuffs but I eventually have been more familiar
to the machine. I was able to build rapport with every patient even if language was
still quite a barrier. It was so nice that there were like 3 Doctors who visited the
patients while the procedure was ongoing. Actually, Dr Madrid, who is a fellow
kind of gave me a test and asked me 10 Bisaya words and to give one complete
sentence in bisaya, and I'm so happy that I did a perfect job.
I was also able to witness an ongoing blood transfusion while on
hemodialysis. Ma'am marysol explained the procedure to me and it had cleared the
confusion I was having at that time.
My exposure at the Hemodialysis unit had been full of learning, laughter
and I'm also happy to have gained more friends.

March 19, 2017 (6am 6pm)

Activity: Orientation at the Operating Room.

Insights / Learnings:
Three of my classmates who were with me in PSH are OR nurses, so they
have asked Sister Gau if she could let us visit the operating room for even just a

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day. And as expected of Sister Gaus hospitality, she had allowed us with so much
enthusiasm.
Sir Lats, the nurse supervisor for the OR-PACU was the one who did the
orientation. He showed us the set up, the autoclave machine they use for sterilizing
the instruments and the Heart-Lung Machine. He also explained some of the
procedures and he discussed more on heart surgeries. He showed us how to prep
for a heart surgery and what instruments are needed and they're importance during
the procedure.

March 20-25, 2017, 2017 (6am 6pm)

Activity: Cardiovscular Lab Observation

Insights / Learnings:

It was our week-long exposure at the CVL. It's only an ambulatory dare as
well. Hear procedures like 2DED, sress test and non stress test and etc for the non-
invasive procedures. We have witnessed and learned how they do the 2DED,
threadmill stress test and the dopamine stress test. Ma'am Vianne explained about
the Normal versus patients with MI seen in the 2DED and how it can be detected
what part of the heart is affected. They also showed us his we could determine
presence or regurgitation or stenosis. I've also learned how to check the flow of
blood and turbulence means there's a problem.
One of the most fun exposure I had was at the invasive procedure unit. We
are lucky to have been witnessed 2 Cases of Coronary Angiography. It was my first
time to witness and watch and I really had fun. I'm really amazed on how it was
done, and really quick.

All the things I have learned at Perpetual Succour will always be treasured. The
memories I have made and the friends I have gained will always be kept in my
heart. It is such joy to realize that there are more things a nurse can learn if given

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the opportunity. As nurses, it is but our duty to ensure our patients satisfaction of
our care. Continued learning will help us better attain this goal. Hence, as a nurse,
I shall always keep in mind that each day that I care for and value others in need, I
am making a difference in more ways than I could ever imagine!

PROBLEMS ENCOUNTERED/ACTIONS TAKEN

In every journey, bumps on the road is inevitable. But like a journey we

pass and get through every bump. On our very first day at Perpetual Succour
Hospital, we were truly shocked when Sister Gau told us that she was not expecting
our arrival on that day. And because of that, she said that they were not prepared.
The surprise was clearly seen on her face. Apparently the email from our school
has just arrived on that day. She told us that had already talked to the administrator
of the Asilo for our accommodation from March 8-13 and afterwards we would
transfer to the hospital dorm for free. However, since it was not coordinated well
and followed up earlier, plus we were not aware of the plan, we already have paid
a month of accommodation at the dormitory we have found online. I was kind of
upset since I could have saved a lot of money for our accommodation. We have
tried to talk to our dormitory if we could withdraw some of our money so we could
transfer to the dorm, but they won't allow us since we've already signed a contract.
All we were left to do was accept it and move on.

Another problem we had was the fact that they didn't allow us to be hands
on with the patients but only to observe. Sometimes it felt awkward just standing
by and watching the staff do their thing. What I would was to find some things to
do that I could help in some way, like folding chart forms, stamping on their
medication cards, making cotton balls and OS. Although they were kinda ashamed
when we do all those things, but I have insisted since I really wanted to help.

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 One of the major problems, was the language barrier. The staff and
employees there do know how to speak English and Tagalog but they feel
uncomfortable and uneasy. Sometimes they forget that we couldn't understand
bisaya, so they talk to us with the language. What I did was to try my very best to
learn as much Bisaya Words as I can.

SUGGESTIONS/RECOMMENDATIONS

Primarily, I suggest that next time the school initiates and mandates graduate
school students to finish their practicum at a certain location very far from the University,
they should at least make sure that it is well coordinated with the institution. They should
also explore and present the resources and options to students ways they can be able to
save some money like on accommodation or other stuff. I have felt manipulated and was
left with no choice, it would be a shame should there be more graduate school students that
would feel the same way in the future.

I also suggest that the university should talk to PSH regarding our duties and
responsibilities there. They should at least allow patient care and interaction. Also, it would
be nice if students be rotated at the ICU as well. PSH is a great hospital and there are
countless of things to learn that could be beneficial to a learner. It could be recommended
to other graduate students, but they should solve the problems first.

BEST PRACTICES WITNESSED

A "Best Practice" can be defined as a technique or methodology that has

proven reliably to lead to a desired result. At a minimum, a best practice
should: demonstrate evidence of success, affect something important and have the
potential to be replicated or adapted to other settings. During our advance nursing
practicum at Perpetual Succour Hospital, I have witnessed several practices which I
think can qualify as their best practices.

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Here are some of their best practices:
They have a 24 hour assessment and care record which includes a physical
assessment per shift together with their nurses notes
Prior to endorsement of the ward, they have an initial endorsement for priority
Patients, and special concerns like who is on feeding, for CBS monitoring and
etc.
Prior to the end of each shift, the head nurse or a clinical nurse review each
patient chart to make sure that all orders were carried out.
There's a pharmacist who visits the station and check the doctor's orders for
medicines and if a patient is for discharge, they are the ones who prepare the
discharge instruction form and also instructs it to the patient or significant
other.
The staff practice proper hand washing prior to every patient contact
The institution is very keen in observing the prevention of the spread of
infection, that's why there are a lot of wall mounted hand sanitizers around
the hospital premises.
They also have code nurses who are being called for incidence of code and who
are the ones who check the Crash cart everyday.
At the Cebu Cancer Institute, they have a very ideal way of preparing
chemotherapeutic agents. There are two pharmacists who prepares it in the
compounding room. The pharmacists wear self protective equipment. This
therefore limits the exposure of the staff to the cytotoxic drug.
The institution also promotes and prioritizes patients safety and they have
safety warnings in each area.

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