Megan Holowaychuk

Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion
Mid-Point Guide for Reflection

Tanner’s (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 Tanner’s clinical judgment model (see below).
Background

A patient came in that knew he was in A-fib and had a history of A-fib. Immediately we brought him back and put
him on the monitor. He was still in A-fib when we got him on the monitor and he said that the way he gets out is to
be cardio-verted. We performed the cardioversion and he was brought back into normal sinus rhythm. This patient
came in on my second day of clinical, so aside from getting vitals and getting the monitor setup I mostly observed
because of my comfort level. If this was a patient we had gotten further into the semester, I would’ve gotten more
hands on experience.

Noticing

I was intrigued because when I think of someone with a heart problem, I automatically think of the signs and
symptoms of heart failure. With this patient he was only having mild pain and was talking and completely active.
The only signs that showed us that he really had A-fib was the monitor and EKG. Patient was also non-compliant
with medications and lifestyle modifications.

Interpreting

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

To perform the cardioversion on this patient we decided to use propofol as sedation and an electric shock to get his
heart back into a normal rhythm. We did not use corvert to convert him because he stated that the drug used to work
to convert him but it doesn’t work anymore. Propofol was the sedative used because the last time the patient was
cardioverted he felt the whole thing and was in a lot of pain. It was also selected because of how short the effects
last.

Responding

What written evidence have you drawn upon for the care of your patient in this example? Provide cites/references.

For this patient in particular the biggest issue is being noncompliant with medications. The biggest risk for this
patient is that he repetitively goes into a-fib because of his lack of compliance. The next step for the patient would
be a catheter ablation which “involves using small electrodes to scar the heart tissue that generates abnormal
electrical signals” (Thompson, 2015). For this patient, the surgery would mean that the episodes of a-fib would be
significantly decreased and they wouldn’t have to go on medications for it.
Thompson, A.E. (2015). Atrial fibrillation. Journal of the American Medical Association, 313(10), 1070. doi:
10.1001/jama.2015.1337

Reflection-on-Action and Clinical Learning

Based on your experience as a student nurse on a unit with a preceptor, reflect on the differences of working one-on-
one with a preceptor versus a student nurse in a group of students and one instructor.

I enjoy being one-on-one with my preceptor far more than being in a group. I get to hone in on my weaknesses and
work on building those skills versus having to sometimes be held back because of a group. It’s also easier to know
that I have one person that I have to stay with and can talk to about all of our patients. Sometimes being in a group
can make it hard to get learning opportunities because there are so many people that are also looking for the same
experiences. I also have a wonderful preceptor that takes the time to talk over different scenarios with me so that I
can understand them.

Write your midpoint program outcome objectives and discuss you have met them. This section should address all 5
midpoint objectives.

I have not met my objective of giving end of shift report. We’ve had all of our patients discharged by the time the
next shift came on.

We have called the chaplain for some patients just so they could have someone to talk to for emotional support.

I’ve provided patient education for over 3 patients.

I’ve started multiple IVs so I’ve gotten to label multiple specimens and send them to the lab.

I had to reschedule my professional meeting to later in the semester because of a scheduling conflict.

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