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Reflective Journaling

Name: Kristina Maldonado Date: July 6, 2018

Noticing
 Subjective and objective data:
o Upon initial morning assessment, my preceptor and I found the patient to be asleep and
breathing quite loudly and slowly. The patient’s respirations were 8 per minute and she
was difficult to wake up. When we woke her up, she was groggy and would fall asleep
mid sentence. The patient was on a PCA pump, and the night nurse collected a
surveillance culture because the patient was hypotensive.
 How did you know there was a problem? Abnormal patient presentation or your “gut feeling”?
o I had the patient twice prior so I was able to recognize that her current breathing was not
her baseline. I did have a gut feeling that something was off.
Interpreting
 What other information do I need to make a decision?
o Before making a decision I would like to know when the last time the patient pushed her
PCA pump.
 Is there anyone else I need to involve or notify?
o The patient’s provider needs to be notified regarding her PCA pump.
 What could be happening and how critical is this situation?
o The patient could be experiencing respiratory depression and sedation as an adverse
effect.
Responding
 Should I do something now or wait and watch?
o I think the provider should be notified now.
 How will I know if I am making the best decision?
o With respirations being 8 per minute, the patient could be retaining CO2, which could
then lead to respiratory acidosis. This should be avoided. Calling the provider is the best
decision rather than waiting any longer. If we were to wait and not discontinue the PCA
pump, the patient could press the PCA pump again and become sedated.
 What interventions can I delegate to other members of the healthcare team?
o In this situation, I think it would be best for the nurse to take the patient’s vital signs
rather than a patient care technician. The nurse should also be the one to read the
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patient’s continuous CO2 monitor. We also obtained and ABG as ordered by the
provider.
o Signs of opioid toxicity include respiratory depression, decrease in level of
consciousness, pinpoint pupils, and hypotension. Opioid toxicity can be life threatening
and adversely effect various body systems. If respiratory depression is present, it should
be recognized and treated with an opioid antagonist (Ostwal, Salins, & Deodhar, 2017).
The patient’s provider did not think Narcan was necessary perhaps because the patient
was arousable, but the provider did order the PCA to be stopped due to her respirations.
Reflecting
 Did I make the right decision?
o I believe the right decision was made. The provider ordered us to discontinue the PCA.
The patient was also on a continuous CO2 monitor, and fortunately her levels were
normal. However, it did take the patient the majority of the shift to return to baseline. The
provides did not think Narcan was necessary.
 Did I achieve the desired outcome?
o The desired outcome was achieved, but throughout the shift we had talk to the provider
regarding the patient’s pain management regimen. It seemed like the provider’s were
struggling with what combination of medications they were going to put the patient on.
 What did I do really well? What could I have done better?

o I feel like I understood all of the assessments and interventions we were doing for the
patient, which was great! I could have followed up with the patient’s pain more
thoroughly throughout the day.

References
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Ostwal, S. P., Salins, N., Deodhar, J. (2017). Reversal of opioid-induced toxicity. Indian Journal
of Palliative Care, 23(4), 484-486. doi: 10.4103/IJPC.IJPC_117_17

Reflective Journaling Grading Rubric

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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?