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Reflective Journaling

Name: _____Ashley Joseph______________________ Date: ___2/7/18___________

What's reflection?
“Reflection is a conscious, dynamic process of thinking about, analyzing, and learning from an
experience that gives you insights into self and practice. These new insights, in return, help you respond
to similar clinical situations with a changed perspective” (Assalyn, 2011)
Please submit a reflective journal describing an experience in your clinical setting. Follow the prompts
below to organize your thoughts, analyze experiences and gain insights. Requirements include:
1. A total of three (3) journal submissions , one journal approximately every 5th shift.
2. One peer reviewed reference within 5 years. Cite and reference using APA format.
3. Upload journal assignments via Canvas as a word document in a timely manner.
4. Use this format as your template to assure that each area is addressed.
Noticing
 Subjective and objective data:
The patient presented to the hospital for abdominal pain and was diagnosed with
perforated appendicitis. During all of this, it was discovered that he also had a tumor in his
cecum. During surgery, the appendix and tumor were both removed. Later on, the tumor was
diagnosed as malignant. Since my floor is a telemetry medical surgical floor, the patient’s heart
rate was constantly monitored; he consistently stayed with a sinus tachycardia rhythm with a
heart rate of 130s-140s. The surgeon stated that this is from the patient being in pain even though
the patient had a Patient Controlled Analgesic (PCA) pump with morphine. His hemoglobin was
being monitored every morning, and it went from 9.0 to 8.6 to 7.0. Since a patient can get a blood
transfusion after reaching a hemoglobin level of 7 or below, he was given one unit of blood when
I was not there. His hemoglobin went to 10.0 but dropped again to 9.2. A CT scan of his abdomen
showed there was fluid in his abdomen. My nurse stated that his abdomen felt firm on Friday, but
his surgeon told her that it was a soft abdomen. He also constantly had a low-grade fever of 99
degrees Fahrenheit. When I had him the next day, I assessed him after finding out he still has
tachycardia and a new blood level of 8.1. His abdomen felt firm to me and I did not hear much
bowel movement. The night shift told us that they called a sepsis alert on him because his lactic
acid was 1.8 and his temperature reached 106 degrees Fahrenheit. The surgeon still decided to
take the patient up for surgery that day for a venous port placement. When my nurse and I looked
in his chart, we found out his heart rate reached 182 and he was being transferred to a cardiac unit
because he was being placed on a Cardizem drip for atrial fibrillation and tachycardia.

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 How did you know there was a problem? Abnormal patient presentation or your “gut
feeling”?
I knew that there was a problem because of many signs, such as the patient would
consistently have a heart rate of 130-140s for about a week. This shows his heart is trying to
compensate for something else going wrong. The fact that his hemoglobin continued to drop even
after a unit of blood worried me because it should start to increase. Since the CT of his abdomen
should fluid build-up and his hemoglobin was dropping, I was worried he may be having a
hemorrhage after the major abdominal surgery he had. We did not know what the fluid was, but it
was still serious signs of a possible bleed if he continues to have low blood levels after a blood
transfusion. The sepsis alert told me this is more serious than the surgeon believed, and his
abdomen definitely felt firm to me. He should not have gone for another surgery after just being
put on sepsis alert. His body is already struggling and was not ready for more trauma.
Interpreting
 What other information do I need to make a decision?
I was still closely following my nurse since this was during my first few shifts of
preceptorship. However, I felt as though it would be important to find out exactly the type of fluid
that was in his abdomen to determine if it was an active bleed.
 Is there anyone else I need to involve or notify?
His primary care provider should have been notified that he was on sepsis alert but being
taken into another surgery by his surgeon. The charge nurse should have also been
notified to see if they could step in and prevent the patient from continuously having a
possible abdominal bleed. A cardiac consult could have been placed to handle the
tachycardia. I feel as though the surgeon was refusing to believe that this situation was
critical, so another surgeon or doctor should have been consulted to look at the patient’s
situation with an unbiased situation.
 What could be happening and how critical is this situation?
This patient could be having an active hemorrhage in his abdomen post-operation. There was
signs that he will be going into septic shock if the situation is not handled emergently. It was a
very critical situation especially since he was put on sepsis alert. Something serious was
occurring after his abdominal surgery, but the surgeon refused to acknowledge the CT’s finding
of fluid in the abdomen and the firmness of the abdomen. The tachycardia was showing that the
patient’s body was trying to compensate for fluid loss, and the low grade fever was illustrating
that his body is trying to fight off an infection.

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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?
Include evidence-based practice (peer reviewed) here to justify why you might make one
decision over another.
As a nurse, it is important to do something immediately when a patient is having many
signs and symptoms of sepsis and hemorrhage after a major operation. Catching the possibility of
Systematic Inflammatory Response Syndrome (SIRS) or sepsis early is important in order to treat
it before it worsens. Sepsis can lead to death if not treated early enough. “Prompt treatment is the
key to improving patient outcomes and decreasing patient mortality rates” (Hamilton, 2015).
Nurses must advocate for our patients even when authority figures like surgeons are intimidating
and do not agree with your findings. Suspecting SIRS or sepsis is very serious and should not be
overlooked in order to prevent your patient from dying. “Understanding the pathophysiology of
sepsis and recognizing early warning signs of SIRS will allow clinicians to make appropriate
treatment interventions. Many patients either ignore or are unable to recognize early warning
signs and symptoms of an infection therefore, healthcare providers must be advocates for these
patients (Hamilton, 2015).
I will know I am making the best decision for this patient because his many signs of SIRS
and possible sepsis shows that something needs to be done immediately to save this patient’s life.
I could have the patient care technician document the patient’s temperature, respiratory rate and
heart rate as proof of signs of SIRS. I will also have the PCT notify me if these vital signs worsen.
There could be an infectious disease consultation to help identify SIRS and help prevent septic
shock. The critical care team can also be notified that this patient may need to be transferred into
an ICU unit to treat SIRS.
Reflecting
 Did I make the right decision? Did I achieve the desired outcome? What did I do really
well? What could I have done better
Since I only had this patient after the SIRS alert was called, I could not do much about preventing
it. I did not have much of an opportunity to treat the patient before his condition worsened. I was
correct about the SIRS, but I should have spoken up about the patient not being ready for another
surgical procedure. The venous port placement worsened the patient’s condition. I did assess and
find the signs of possible abdominal bleed and understand the lab results of his hemoglobin and
lactic acid are showing possible hemorrhage and SIRS. However, I could have advocated better
for the patient to prevent the SIRS from happening if I had him before it happened.

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References
Hamilton, Rachel, "The Pathophysiology of Sepsis" (2015). Master of Science in Nursing (MSN) Student
Scholarship. 119.

https://digitalcommons.otterbein.edu/stu_msn/119

Adapted from:

Asselin, M.E. & Cullen, A.H. (April 2011). Improving Practice through Reflection. Nursing2011, 41(4), 44-46

Gillespie, Mary. (2009). Helping novice nurses make effective clinical decisions: the situated clinical decision-making framework.
Nursing Education Perspectives, 30(3), 164-170.

Tanner, C. A. (June 2006). Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing. Journal of Nursing
Education, 45(6), 204-11.

Reflective Journaling Grading Rubric


Criteria S/U Notes
Did the student interpret the case situation
accurately?

Did the student present evidence of data analysis?

Did the student draw logical conclusions?

Did the student decide on an appropriate course of


action?

Did student evaluate the outcome(s) of their


action?

Did the student identify their strengths and areas


for improvement?

Did the student use a Peer Reviewed Journal


within 5 years and did it correlate appropriately to
the case situation?

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