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Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion


Final Guide for Reflection

(Example MUST be different than that provided at mid-point)

Tanners (2006) Clinical Judgment Model

Describe the most challenging moment or event you experienced recently. What actions did you
take and what would you have liked to do differently? What specific actions are you taking to
improve the outcome in future situations or to prevent recurrence of the situation? To answer this
question, use the guide for reflection using Tanners clinical judgment model (see below).
Background

On October 10th I had a 91 yo. Female admitted with dysphagia. She had failed the swallow test three times and had
much difficulty in opening her mouth. She would repeatedly bite her tongue on accident, causing a lot of oral
bleeding. The plan was to have MRI done of the neck and EGD to determine the cause. She had 1 son who was very
involved in her care and was a DNR. The DNR also stated no feeding tubes. She had not eaten in nearly 5 days by
the time she was admitted.

Noticing

I noticed that her son was hyperactive in her care and had a lot of worry. He asked a lot of the same questions. I
could tell he was overwhelmed and was most likely not comprehending everything we (the entire team, including
physician) were telling him. The pt was A/O x4 and the son wanted to limit her phone calls because they were just
friends who were working her up. During the day she welcomed a phone call from a friend who just wanted to say
they were thinking about her. The son was upset by this, but I politely stated that if the pt says its OK, then I will
continue to help her with her phone calls.

Interpreting

Describe the clinical judgment or clinical reasoning that you performed. The example should include alternatives
you considered, and rationale for your decision.

I was able to go down with the patient for her EDG as I had not seen any endoscopy before. Anesthesia had major
concerns for multiple reasons. For one she was a DNR and if the sedation was too much there was a risk for
complications. Additionally, she was not able to open her mouth and her neck was too stiff to be able to be to
intubate if necessary. The Dr. was going to place a dobhoff tube, but when I called the floor asking for the supplies
they stated it was against her advance directive. The pt then told the Dr. she did not want a feeding tube but felt
pressured by her son to get it done, but she denied it. The Dr. still wanted to try to investigate what was causing the
dysphagia and stiffness. He was able to numb the throat with the spray just enough to look back, almost like
bronchoscopy. He discovered an esophageal stricture and determined that the stiffness could have been caused by
polymyalgia rheumatica. He ordered IV steroids hoping they would help, but would take multiple days to reach their
full effect. Going back up the floor with the pt, she remained NPO and was still not receiving nutrition. Moving
forward we had to do what would be best for the patient. Based on her NPO status, we asked to get a palliative
consult, which in turn resulted in a hospice consult.
Responding

Fortunately, I had the same patient for the next 2 shifts. On day 2 she now on comfort care measures. We still kept
her on telemetry for a while as she had tachy-brady syndrome. We wanted to wean off the BP meds to see how
she reacted in a safe way. We focused on oral care as she was now using scopolamine. Since she would not swallow,
she had severe difficulty in clearing her secretions. The scopolamine really helped but resulted in a very mouth. She
also had a RLE venous stasis ulcer wound requiring daily wound care. Using my nursing judgment, I pre-medicated
the patient with morphine prior to the wound care, which she tolerated well. With the goal being outpatient hospice,
we had to explain to the son the normal response the body was having. The patient was very sleepy, probably due to
her lack of nutrition and body slowly shutting down. She was only getting PRN morphine as 2mg, so a relatively
low dose. He kept saying the morphine was making her sleepy, so we had to re-educate multiple times that this was
a normal response. I could tell he was avoiding sitting next to his mom and talking her. Maybe out of sadness and
denial. I encouraged him to go in and visit, even when she was sleeping because she could still hear him. She
remained completely A/O x4 for the remainder of her time with us at RCH.

Case management had worked very hard to get her inpatient hospice services and she was even approved to go to
the Bon Secours hospice house. The son refused everything as he wanted her to go to a long-term care facility that
could contract with a hospice agency to provide hospice services. I am not sure why he kept refusing, my own
response is his denial of her dying and also having hope she may recover. Robert Kastenbaum writes about how in
America we are a death-denying society versus a death-accepting society and I find that to be true in most cases
I have witnessed. Because of the back and forth with case management, this extended her stay with us for at least 3-
4 days longer, since this rolled into the weekend.

After her being discharged, I felt proud of the care I was able to provide to her and her family during this hard time.
I have noticed that palliative and hospice situations have been my most memorable and rewarding patient
experiences. Maybe this is a sign on what I am meant to do as a nurse. We received an invitation to this patients
funeral 2 weeks later.

Corr, C. A. (2014). The Death System According to Robert Kastembaum. Omega: Journal of Death & Dying, 70(1).
13-25. doi:10.2190/OM.70.1.c

Reflection-on-Action and Clinical Learning

Socialization is best facilitated when the new nurse feels part of a group. How has this precepted experience and
working one-on-one with a dedicated preceptor helped you to become socialized into the nursing profession?

After being a summer extern, going into immersion was an easy transition. My preceptor worked well to introduce
to me to any and all hospital staff. After weeks passed, other members of the interdisciplinary team were more
willing to come to me and update me on things. I would say I felt a part of the group in most cases.
Write your final program outcome objectives and discuss you have met them. This section should address all 5 final
objectives.

Final Point Objections:

Communication and Collaboration goal: Present all of my pts during IDRs


Goal Met. 95% I presented my patients during IDRs. During 1 shift, a nurse asked me to go help another patient
while I should have been rounding on my patients with my preceptor. This was a little frustrating because my
preceptor and I should be viewed as 1 person, but I also understand when patient needs are priority.

Caring and the Health Care Ministry: Have the confidence to provide substance abuse/rehab services in
collaboration with case management. Goal Met. I had a pt who had multi drug addition. It was during the
weekend that she was discharged and CM was not there to round. I provided this patient with a list of services and
encouraged her to seek help, which she stated she wanted.

Servant Leadership and Global Health: Know the process of using the tele med machine.
Goal Not Met. Not typically used during day shift. Did not have a lot of time to read current policy on this. I did
however, watch a night shift nurse use the tiger text to message physicians during the night shift.

Safe, Quality, Evidence-based Practice: Provide medication education/side effects via handouts/white board on
all patients. Progressing towards goal. This is something I will focus on during my orientation period. Some days
started off so fast I was not able to give this the attention it needed and deserved.

Professionalism and Commitment to Lifelong Learning: Participate in Shared Governance meetings and goals.
Progressing towards goal. I participated in helping with the SG article of the month hand out and the unit specific
in services.

Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of Nursing Education, 46(11), p. 513-516.