Young Jin Kim

Week #6 Weekly Reflections

1. Am I getting more comfortable with the use of the nursing

process to plan and evaluate nursing care? (Give examples of how it
is better now or problems that still bother you).
Yes, I am getting comfortable. My top three priority nursing
diagnoses were HTN, ineffective peripheral perfusion, and risk for electrolyte
imbalance. Other concerns during my shift included excess fluid volume,
impaired tissue integrity, and risk for infection based on the low WBC
counts. This week I began to set the expected outcome unique to my patient.
For example, the goal for HTN was "The patient will remain asymptomatic"
rather than "The patient will have B/P within normal range," which was
unrealistic for this particular individual. And I implemented my nursing
interventions accordingly. The patient remained symptom free for HTN as
evidenced by frequent V/S monitoring and assessment, although the
verification of the assessment was made valid by the help of the translator
later in the day. The patient's pulses on the low extremities were weak but
the cap. refill was less than 3 sec., and there were no signs of neuropathy on
the CMS check. Her labs for all the electrolytes were within normal ranges
and she didn't have any signs of hyperkalemia, (nausea, fatigue, or tingling
sensation) based on my communication. She didn't have signs of fluid
overload as evidenced by absence of crackle, edema, tachycardia, SOB, S3,
jugular vein distention and LOC change. Also the ostomy and the skin around
the ostomy looked intact, and there were no signs of infection. I am
beginning to enjoy the process of setting diagnosis and goals unique to
patients, implementing interventions accordingly, and evaluating.
2. Were my nursing diagnosis and plan of care individualized for my
patients? (Give examples of how you did this.) Do I have difficulty in
this area? (Explain).
Based on the diagnosis and trends in the charting, I saw that the
priority concern for my patient was hypertension because her baseline was
very high. Therefore, her B/P and the signs of hypertension had to be closely
monitored. Also because the patient had IV fluid for several days with only
a clear diet, she was at risk for fluid overload and electrolyte imbalance.
Other common post-op complications caused by limited physical activity
including risk of DVT/pneumonia/atelectasis/pulmonary embolism/bleeding
weren't applicable for this patient. However, impaired communication due to
the language barrier was the biggest challenge in my caring for her

effectively. I overlooked how language the barrier can impact nursing care
when I was planning the nursing diagnose, so I didn't include this in the prenursing diagnose. It was a valuable lesson for me to learn about the legal
and safety implications of language barrier in caring for patients.
3. How are my assessment skills developing? Am I being as
thorough as I need to be? What areas are still difficult for me and
what am I doing to improve? (Be specific).
I am becoming very comfortable with assessment. Today I asked the
instructor to help me find the pulses on the lower extremities, which I'd had
difficulties finding and rating. The patient's brachial and radial pulses were
very strong but the ones on the low extremities were weak. Perhaps her low
heart rates and weak heart contractibility caused the weak perfusion to the
low extremities. Therefore, I wanted to make sure she was having perfusion
to the low extremities and planned opportunities to learn to identify weak
pulses. After this experience I feel much more confident in performing
physical assessment. I identified the patient's clear lung sounds, slow and
weak heart sounds with normal S1 & S2, hypoactive abdominal sounds and
good cap. refill. Also I inspected the ostomy bag and the surrounding skin.
Everything was intact. However, I regret that I didn't see the patient's not
having stool during my shift as a red-flag. The primary nurse noticed but
didn't address a concern about it although she double-checked with me if the
ostomy bag was empty. I assumed it wasn't problematic since the patient
was on a clear diet and the bag was replaced that morning. But it occurred to
me in the morning that I should see where the patient disposed the old stool
and I wanted to see how the stool looked. In fact, I attempted to ask the
patient but gave up because of the communication problem. I neglected my
duty to inspect the stool. I should've pursued translation service as soon as
the manager advised to do so. But I didn't because I only related the advice
to oral care but nothing else. I acknowledge that I didn't carry out my nursing
duty as expected. From now I will make a sincere judgment on every single
nursing intervention and get everything done with precision and evaluation.
4. What new skills did I implement this week? How did I do? What
could have helped me to improve? Did I ask for help when I needed
it?
I implemented to hang a Tylenol IVPB. Hanging an IVPB is not a new
skill. But what was new today was that 1. I learned that all meds that are
administered simultaneously have to be checked for compatibility 2. The
central line has to be verified for the placement by X-ray before

administration 3. The air in the IV tubing should be checked both before and
after hooking up the bottle or bag and also right before starting the drip to
ensure safety. Patient education and communication are a big part of
medication administration. I admit that my explanation to the patient how
the medicine works wasn't proficient. Although I knew how it works, the
words weren't organized well in front of the patient and the instructor. I need
improvement. From now I will organize what I will say to patients including
pre-assessment for med administration and education before I start to gather
supplies for med administration.
5. How is my time management progressing? What areas of
difficulty have I found and what can I do to improve? How do I
monitor my time management while in the clinical area?
I only had one patient this week and the patient didn't even want to
have bed bath or oral care. So I didn't have a problem in time management.
But as mentioned above I missed the timing for calling a translator, which
could've improved the quality my nursing care of the entire day if I had done
this in a timely manner. I am noticing that any unpredictable event can occur
throughout the day. I have been trying to put most of my
effort into completing the planned tasks to have satisfactory time
management. But I see that being flexible for a new task and still getting
everything done in a timely manner are real qualities of nurses' time
management. I think my inflexible approach to adhere to my plan impacted
my judgment for not having kept up immediately on the manager's advice to
seek a translator. I am reflecting deeply on this issue.
6. Was I involved in making referrals for my client in any way? How
could the nursing role in this process have been strengthened?
This week's experience was a huge lesson for learning how important
communication is between a nurse and patient, and among health care
professionals. Unfortunately, I didn't initiate help from a translator. I
misinterpreted the manager's advice as an option limited to oral care, which
my patient clearly refused again. But I understand that the manager saw the
need for the translation. For communication with my patient, the translation
readily eased both me and the patient. I really wish I had used the service
earlier. I truly feel sorry for the patient for having restricted and delayed her
ability to communicate.