Reflective Journaling #1

Noticing
Subjective and objective data
- My patient was a 90 year-old female who sustained 6
th
-9
th
rib fractures
on her left side from a MV! She also had a haemothora" on the right side# which was
being treated with a chest tube! $uring my %&00 M assessment ' noticed my patients
lung sounds were diminished anteriorly# laterally# and posteriorly in all lobes! fter my
assessment my patient(s physician came and removed the chest tube! )he site was
covered with a four by four and tegaderm! ppearance of the incision site was noted as
well as the condition of the dressing!
*ow did you +now there was a problem, bnormal patient presentation or your -gut
feeling.,
- n hour after the chest tube was pulled ' wanted to re-assess my
patient(s lung sounds since she had just had the chest tube pulled! /pon this follow up
assessment ' heard new crac+les in both right and left upper lobes! 'n addition# the right
upper# middle# and lower lobes sounded more diminished than they had in my previous
assessment and they were more diminished than the left lobes! ' as+ed my preceptor to
reassess as well to confirm my findings!
'nterpreting
0hat other information do ' need to ma+e a decision,
- ' needed to loo+ at any changes in respiration status via vital signs and
assess whether my patient was using any accessory muscles to breath and assess
whether it loo+ed li+e she was breathing better on one side versus the other by
comparing chest e"pansion on both sides! ' also needed to loo+ at the chest tube
dressing to assess any changes in drainage! 12 sats and respirations were revealing
good o"ygenation and nothing had changed from baseline! 't did appear that the pt(s left
chest was e"panding larger than the right! 3t was also on 24 N5! 3t(s chest tube
dressing loo+ed the same as it had previously!
's there anyone else ' need to involve or notify,
- My preceptor and ' paged the trauma team 6primary team for my patient7
to inform them of the change in status of our patient! )he trauma team nurse practitioner
responded to our page and told us to continue to monitor our patient and update them
with any worsening of condition!
0hat could be happening and how critical is this situation,
- 1ur patient could have had a pneumothora" post removal and8or the
chest tube may not have been ready to come out yet8the haemothora" may not have
been completely treated yet! My patient could also have been in pain8breathing may be
painful so she might not be breathing to her full e"tent!
9esponding
Should ' do something now or wait and watch,
- fter tal+ing to the N3 with trauma ' spo+e to the family 6patient did not
spea+ any :nglish and family was in the room 2;8< to interpret and support the patent7
about the importance of using the 'ncentive Spirometer 6'S7# especially since the change
in her respiratory assessment! =amily said they had been taught how to use the 'S and
they have been using it with her over the past few days! ' wor+ed with the patient with
the 'S at least once every hour and the patients( family wor+ed with her in between! )he
patient(s baseline 'S readings ended up being between 2>0->00 ml and she was not in
the -best. region of the 'S! ' continued to strictly monitor the patient(s respiratory status
and reassessed lung sounds ?@ A 2 hours! )rauma doctors came by twice more
throughout the shift and assessed the patient8spo+e with family! )he morning "-ray came
bac+ with the result that the patient did have a small right pneumothora"! )rauma team
made the decision to continue to monitor the pt# use the 'S# and have another chest "-
ray done in the morning! 3t(s 12 sats and respirations had made no alterations from
baseline with 24 N5# the chest tube dressing remained intact8no changes# and '
monitored8assessed pt(s pain freBuently to ma+e sure pain did not interfere with
breathing!
*ow will ' +now if ' am ma+ing the best decision,
- ' will +now if ' am ma+ing the best decision based on my assessment of
my patient# particularly her respiratory status! ny improvements or deteriorations would
give me an understanding of whether or not ' was ma+ing the best decision!
0hat interventions can ' delegate to other members of the healthcare team,
- ' did not delegate any interventions to members of the healthcare team
but ' did delegate the 'S intervention with the family!
5an include evidence-based practice here to justify why you might ma+e one decision
over another!
9eflecting
$id ' ma+e the right decision,
- ' felt that ' had made the right decision notifying the trauma team when '
did! ' also felt li+e ' made the right decision to continue to monitor the pt(s respiratory
status closely and discuss any changes8no changes when trauma team came to assess
the patient! ' also felt that ' made the right decision to assess and treat pt(s pain as
needed in order to get the best 'S use8outcomes!
$id ' achieve the desired outcome,
- ' felt that ' achieved the desired outcome in that the patient(s respiratory
status did not deteriorate! 3M assessments of lung sounds concluded that the pt no
longer had crac+les and her right upper lobe sounded less diminished than she had
earlier in the day! )he patient continued to use the 'S at least ?@ hr and we ambulated to
the commode C-; times with the lift team assistance!
0hat did ' do really well, 0hat could ' have done better,
- ' thought ' did a good job assessing my patient and implementing
interventions! ' thin+ ' could have done better with communicating with the physicians!
dapted from&
)anner# 5! ! 6Dune 20067! )hin+ing 4i+e a Nurse& 9esearch-Eased Model of 5linical Dudgment in Nursing! Journal of Nursing
Education# ;>667# 20;-@@!
Fillespie# Mary! 620097! *elping novice nurses ma+e effective clinical decisions& the situated clinical decision-ma+ing framewor+!
Nursing Education Perspectives# C06C7# @6;-@<0!
9eflective Dournaling Frading 9ubric
Criteria S/U Notes
$id the student interpret the case situation
accurately,
$id the student present evidence of data analysis,
$id the student draw logical conclusions,
$id the student decide on an appropriate course of
action,
$id student evaluate the outcome6s7 of their action,
$id the student identify their strengths and areas for
improvement,