Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion

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

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

I had a patient one day who was admitted for sepsis. This patient had an extensive history of
alcohol abuse and has and many trips to the hospital. When we came on shift the patient was
very drowsy and lethargic and could not even wake up enough to eat or take medications. I will
call this patient PB. PB had an exceptionally large family with many siblings, sons, and
daughters. PB family members were coming in and out of the room all morning long and each
one wanted an update. I did my best to update all the family members with her plan of care and
condition. As the day went on PB started to wake up and became a bit more restless and have an
increased work of breathing. I spent a majority of my day in the room with PB because of all the
care that PB needed. PB needed extensive lab work all throughout the day looking at her
electrolyte and blood content. By the end of the day my patient appeared sicker than in the
morning and was placed on CPAP. When two of PBs daughters came back in the evening and
saw how PB appeared they were sad, confused, angry, and upset. They did not understand how
when they left PB did not look like this and how the patient ended up this way.

Noticing

Throughout the day I noticed this patient become more restless, agitated, and have an increased
work of breathing. I also noticed how involved each family member was. I also noticed that the
family members were relying heavily on one particular family members judgement who worked
in a hospital. I also noticed how lethargic and out of it this patient was even though she was
becoming more restless. I also noticed that if certain family members came into the room
throughout the day the patient became more agitated and restless.
Interpreting

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

As the day continued on and PB work of breathing increased and she became restless I
interpreted this to mean that she needed some help to relieve how hard she was working to
breathe. I suggested that we get PB on a CPAP machine to increase the pressure of oxygen that
the patient was intaking. Also, because the family members kept requesting updates and were in
and out all day long, I made sure to update them as they came in and what was happening. I
made sure to reiterate that PB was extremely sick but was stable at this time. When PB lab work
came back, the electrolytes were all over the place with some being high and some being low.
So, because of this we had to do a lot of replacing of electrolyte along with give PB a bag of
PRBCs. This patient only had two IV’s, so we had to do a lot of checking to make sure certain
medications were compatible. I also suggested that we should try to get more IVs on this patient
and also possibly contact the PICC team to help us because PB was an extremely hard stick with
tiny veins. At the end of the day when PB daughters came and were inconsolable regarding the
patient’s condition, I explained to them what had happened throughout the day after they had
left. I also reiterated that PB had been extremely sick since being admitted and this was a part of
the care plan that hopefully would make the patient better. When both daughters were still
inconsolable after explaining what had happened, I asked them if they would like to step outside
of the room because PB was becoming restless and agitated due to the commotion that was
occurring. I said that we could talk more about the pateints condition down the hall in the
private room but that if they wanted to stay in the room with the patient they would need to calm
down because the agitation was causing PB to become restless and the patient needed a quiet and
calm environment to get rest and heal.

Responding

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

When the patient started to become restless when the daughters were in the room upset and
confused about PB condition I asked them to either calm down or leave to promote a healing
environment for the patient. Upon further research, I found an article that reiterates what I said
to the family members. In this article by Bazuin & Cardon (2011), it states that in an ICU
setting, promoting a quiet, restful, and balanced environment is what is best for healing. The
article also states that family and friend should be present as long as the environment remains
restful and calm (Bazuin & Cardon, 2011).

Reflection-on-Action and Clinical Learning

I think that working one-on-one with a preceptor has made me more socialized into the nursing
profession. It has taught me what a typical 12 hour shift is like. It has also taught me how to
socialize and ask for help from other nurses. I think what people may not understand in school is
that nursing is not a solo profession. The floor has many nurses on a unit and also a charge nurse
and these individuals are also there to help you out and provide you with knowledge regarding
something you may not feel comfortable with. There were a few times when my preceptor had
only done something once before and wanted someone else in the room to one, help her
complete the task safely and two, help explain to me what was happening because she was still
not an expert on what was occurring. That lesson for me was especially important because your
peer nurses are there to help you someone else may be more comfortable with a certain skill than
you are and vice versa.

Write your final practicum goals and discuss your progress toward meeting them. Please
address all 3 goals.

1. By the end of my 225 hours, I will have given an accurate, organized SBAR on one ICU
level patient.
a. By the end of my practicum experience, I was able to give an accurate and
organized SBAR. I gave shift report to night shift coming on and I also gave a
transfer report to a patient being transferred to a different unit and also to a
nursing home. I did this by jotting down notes and creating an organized report
sheet on the patient before calling report. When I enter into my nursing career I
will continue to work on my organization and continue to work on my confidence.
2. By the end of my 225 hours, I will have completed the documentation/paperwork/called
report for an admission or transfer of an ICU level patient.
a. One day we had a patient who was transferred back to the nursing home where
the patient came from. That day, I called report and also gathered all the
paperwork that was necessary for that patient to be able to go back to the nursing
home.
3. By the end of my 225 hours, I will have accurately communicated my patients’
assessments and needs in an organized manner to the interdisciplinary team during
morning rounds.
a. By then end of my immersion, I was doing interdisciplinary rounds every
morning. Before 10 am, I would organize my thoughts on each patient and fill
out a little cheat sheet. I made sure to jot down the most important things that had
happened since the last rounds that the team should be updated on and also made
 sure to voice my concerns about anything in their plan of care that did not seem
clear.

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

Bazuin, D. & Cardon, K. (2011). Creating Healing Intensive Care Unit Environments. Critical Care Nursing
Quarterly, 34(4), 259-267. Http. //doi: 10.1097/CNQ.0b013e31822b8f76