Journal # 3

Name: Nicole Mercedes

Revised date: 7/28/2017
Noticing
Subjective and Objective data:
o Pt. was a 65 Y/O male presenting to St. Josephs hospital with complains of
cough, increasing dyspnea, increasing sputum production, and rectal bleed.
Patients past medical history consisted of Chronic Obstructive Pulmonary
Disease (COPD) which made him oxygen dependent at home as well as in the
hospital (2L O2 via nasal cannula). He also had history of atrial fibrillation (A.
fib), Hypertension, hyperlipidemia, peripheral vascular disease, depression and
chronic lower back pain due to a motor-vehicle accident, for which he took MS
contin.
o Upon admission patient had a respiratory panel done, a test for legionella (a type
of bacterial that causes a type of pneumonia), and a urinary strep test, all of which
were negative. His first set of blood cultures came back positive with staph, but
there was suspicion for contamination so he had pending repeat blood cultures.
His chest X-ray showed opacities, which were probable for pneumonia, in the
base of the right lung as well as right upper lobe nodules which were suspicious
for being neoplasms. He had a CT of the pelvis and abdomen which showed fecal
stasis, and a lesion at the rectal wall. Finally, he had a colonoscopy which found a
rectal mass.
o Based on the findings the plan for the patient was antibiotics, steroids, nebulizer
treatments, and continuation of oxygen. He also had a MRI pending which was
done on one of the days I was there to stage the mass, and a consult to a colorectal
surgeon. I was around when the surgeon came in to see the patient, and the plan at
that time was to first clear up the patients current respiratory problems and then
to follow up outpatient with oncology providers who would take his insurance to
discuss possibility of treatment with chemo, radiation and surgery.
How did you know there was a problem? Abnormal patient presentation or your
gut feeling?
o During my morning assessment, aside from a few wheezes the patient was WNL. I
did however notice that he had some tremors when picking things up, but when I
tested his musculoskeletal activity and neuromuscular activity he did excellent so I
asked him if there was a cause for the tremors to which he replied that it was the
nerves from everything going on. As the day went on, and he got visitors, and his
pain was under control his tremors got much better, Id say they went away.
However, around maybe four in the evening when I went to check in on him for
rounds I noticed that his demeanor had changed, that his eyes were reddened and
glazed over and that he was shaking again, and this time more than in the morning. At
this time, he told me he was in a lot of pain and that he wanted to speak to my
 preceptor. I asked him what concerns he had, and if they were any that I could help
him with. He proceeded to tell me that he just wasnt feeling well, at this point I
asked him to elaborate a little and explain what kind of things he was feeling if it was
a different type of pain or if it was a new symptom of some sort. I then remembered
from my morning assessment that he told me hed been shaking because of the nerves
with all the new information being thrown at him about cancer and possible
treatment. I remembered that in the morning hed gotten some type anti-depressant
medication, so I asked him if it was anxiety that he was feeling. He replied yes.
Interpreting
What other information do I need to make a decision? Is there anyone else I need to
involve or notify? What could be happening and how critical is this situation?

o At this point, I needed to look in his PRN medications to see first if he was due
for pain medication because I knew that could also exacerbate his anxiety and
next I needed to check to see if he had some medication ordered for anxiety PRN.
I found that he was due for some pain medication, but that he had no PRN
medications for anxiety. This wasnt necessarily a critical situation, but the
patient was not looking too well, he seemed extremely uncomfortable and with
everything going on I knew that something for anxiety would help him.
Responding
Should I do something now or wait and watch? How will I know if I am making the
best decision? What interventions can I delegate to other members of the healthcare
team?
o I decided to go to my preceptor, and discuss the situation with her, and my
thoughts on what we should do for him which was to call his provider and ask for
something PRN for anxiety. We called the provider, and suggested Xanax. My
preceptor wrote down the order, and begin the process to put it in the chart.
While doing this, we encountered a problem with a pharmacy error message
contraindicating the amiodarone for the patients a. fib with the Xanax as it
would increase the effects of Xanax. At this point, my preceptor allowed me to
go on the phone with pharmacy to ask more about this and if such a low dose of
Xanax would have any effects mixed with the amiodarone. The pharmacist said
the effects would be very mild in such a low dose and to go ahead and give it and
to monitor the patient. At this point, we charted this encounter on the phone with
the pharmacist, and got the PRN medication for the patient.
o With the help of my preceptor, I made the right decision, to ask and make sure
that the Xanax was okay to give with pharmacy. I know it was the right decision
because we consulted the experts on medications and their effects.
Reflecting
 Did I make the right decision? Did I achieve the desired outcome? What did I do
well? What could I have done better?
o I felt happy with the decisions I made on this day because I feel like I helped and
advocated for my patient based on what they presented with even if they werent
sure how to put in words at first. He didnt come out and tell me directly that he
had anxiety. However, given his history of depression and the news of cancer
combined with financial and insurance stress it wasnt very difficult to see in the
symptoms that he was presenting with such as; the shaking, the teary-reddened
eye and sad demeanor that it may be what he was experiencing.
o About an hour later I went back to check in on him to see if both his pain and
anxiety had improved, and to talk to him about his concerns with everything new
going on for him. He seemed calmer, he was not cheery but was already showing
improvement in his demeanor. Since he was much calmer at this point I decided
to try some therapeutic communication, in terms of letting him vent and talk about
his feelings on the situation, and all the new information hed gotten that day. I
noticed that in the morning when a few of his providers went into see him that he
was distraught and not really in the moment. I also noticed that some providers
kind of zipped in and out of the room without fully making sure he understood
everything, not all but some. This kind of communication I believe between the
providers and patient wasnt very centered on him and what his thoughts and
questions were, and so this may have been what also contributed to his increasing
anxiety later that day (Gebhardt et al., 2017). After my sit down with the patient,
he genuinely thanked me for taking care of him that day and for taking time to
talk to and listen to him. I feel like I did exactly what I shouldve done, and that I
achieved my desired goal which was to help him feel more comfortable and less
anxious about his situation.
 Citation
Black, P. (1197). Use of the clinical exemplar in performance appraisals. Use of the clinical

exemplar in performance appraisals.Retrieved July 28, 2017, from https://www-ncbi-

nlm-nih-

gov.ezproxy.hsc.usf.edu/pubmed?myncbishare=usfhslib&dr=abstract&holding=usfhslib

&term=Use of the clinical exemplar in performance appraisals.&search=Search.

Gebhardt, C., Gorba, C., Oechsle, K., Vehling, S., Koch, U., & Mehnert, A. (2017). Breaking

Bad News to Cancer Patients: Content, Communication Preferences and Psychological

Distress. Breaking Bad News to Cancer Patients: Content, Communication Preferences

and Psychological Distress. doi:10.1055/s-0043-113628