Reflective Journaling

Please submit a reflective journal describing a situation that forced you to use your clinical
decision making skills. The journaling should be done weekly, however, only a total of 7 are
due. Journals should be submitted via Canvas in the designated journaling area. Please save
as a word document and enter your journal in this format to assure that each area is addressed.
Each journal should address the following topics:

Noticing
Subjective and objective data
My patient is a 52-year-old male who drove himself to the hospital and was intubated in
the ER. My patients admitting diagnosis was respiratory failure and his history includes B
Cell lymphoma (in his 5
th
round of chemo), anemia, sarcoidosis, hypertension and
gallstones. On assessment my patients vitals were all within normal range, crackles and
rhonchi were heard in all lobes of his lungs, he had bilateral pedal edema, had a foley
catheter, on 50 of propofol, restrained, on tube feeding and is on droplet precaution for
influenza and an opportunistic pneumonia infection.
How did you know there was a problem? Abnormal patient presentation or your gut
feeling?
Within the first hour of our shift we were notified that the patients doctor would like to
attempt to extubate him today and respiratory therapy would be coming in about one
hour. My nurse and I prepared him for extubation by discontinuing his propofol and
notifying his family members of the plan of care. The extubation was successful and in
the next few hours my patient was eating again, taking prescribed medication, having
BMs and talking with his family. However, following his extubation my patients blood
pressure remained elevated despite receiving prescribed blood pressure medication.
Around 4pm my patient was wailing his arms at us through the window to come in and
stated that he felt short of breath. At this point in time my patients O2sats were at 85%
and my preceptor felt that it was due to anxiety about his family going home. I stood next
to my patient and preceptor and attempted to comfort him for a minute until I realized
that his O2sats continued to drop. At that point I told my preceptor that I was going to go
and get respiratory therapy just in case. It took me about 2 minutes to get respiratory
therapy and by the time I returned with RT my preceptor was bagging our patient and his
O2sats were now in the 40s. If it werent for the fact that I was able to get RT to our
patient so quickly this situation would most likely have turned into a code. However I was
able to bag our patient while RT set up to re-intubate him and my preceptor was able to
assist RT and contact my patients provider to get permission for intubation. Eventually
my patients provider arrived and together each member took on a role, our patient was
re-intubated, became stable again and within the hour a chest X-ray was taken to
confirm placement.

Interpreting

What other information do I need to make a decision?
Vitals, history, risk for PE?
Is there anyone else I need to involve or notify?
Respiratory Therapy and the patients provider
What could be happening and how critical is this situation?
Patient may be going into respiratory failure or throwing a PE, which is life threatening.
Responding
Should I do something now or wait and watch?
I should get the respiratory therapist and upon return assist by bagging patient or
assisting my preceptor or respiratory therapy in any way possible.
How will I know if I am making the best decision?
By asking am I prioritizing?
What interventions can I delegate to other members of the healthcare team?
Delegate intubation to provider and respiratory therapy
Can include evidence-based practice here to justify why you might make one decision
over another.
Evidence based practice as seen on
http://www.aafp.org/afp/2004/0201/p599.html suggests screening patients at risk
for pulmonary embolism by using two validated clinical decision rules to
determine the likelihood of pulmonary embolism. The Wells decision rule uses
only the history and physical examination, whereas the Wicki decision rule also
requires the results of arterial blood gas measurements and a chest radiograph.
Without using these screening tools, it is difficult to make a decision regarding a
pulmonary embolism before it shows symptoms.

Reflecting
Did I make the right decision?
Reflecting on this experience I wonder a few things Firstly, what caused the sudden
shortness of breath my patient experienced? I couldnt help but think he threw a PE.
However, I had to leave and was not able to see the results of tests ordered. If it wasnt
a PE then I wonder if my patient simply was not ready to be extubated. Whatever the
case was I felt that this was an excellent learning experience.

Did I achieve the desired outcome?
I was able to respond to a situation that turned out exactly how an emergency situation
should- with all participants remaining calm and collected while each member did their
job and ultimately we did not need to call a code and our patient stabilized. In the future I
feel that I would handle this situation similarly, however if RT werent readily available as
in this situation I would need to know the number to reach them and be prepared to call
a code.
What did I do really well? What could I have done better?
I responded quickly and calmly. In hindsight, there may have been some very subtle
signs that my patient was not tolerating extubation well, such as some anxiety and
restlessness. In the future I would spend more time evaluating these signs.
Adapted from:
Tanner, C. A. (June 2006). Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing. Journal of Nursing
Education, 45(6), 204-11.

Gillespie, Mary. (2009). Helping novice nurses make effective clinical decisions: the situated clinical decision-making framework.
Nursing Education Perspectives, 30(3), 164-170.












Reflective Journaling Grading Rubric

Criteria S/U Notes
Did the student interpret the case situation
accurately?



Did the student present evidence of data analysis?


Did the student draw logical conclusions?


Did the student decide on an appropriate course of
action?



Did student evaluate the outcome(s) of their action?


Did the student identify their strengths and areas for
improvement?