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Reflective Journaling

Name: Kristina Maldonado Date: June 15, 2018

Noticing
 Subjective and objective data:
 This patient was day +2 post-bone marrow transplant and upon initial morning
assessment the patient complained of chest pain that radiated to her shoulders. The
patient also reported pain in her esophagus, but had no difficulty swallowing. These
symptoms were news to the night nurse who was with us for report. The patient reported
the pain to be pressure-like, and with an intensity of about a 4 out of 10. The pain was
present throughout the night.
 How did you know there was a problem? Abnormal patient presentation or your
“gut feeling”?
 I was with my nurse during this initial morning assessment, and given the patient’s
symptoms my nurse quickly took the lead. Although I was not the one asking the
questions, I personally found the patient to appear particularly fatigued and pale. I took
orthostatic vitals for the patient and within the three-minute wait between taking her
blood pressure sitting and standing, the patient felt so weak and dizzy that she had to sit
back down. I knew then that the patient was not in good conditions. I did have this patient
once previously on the unit before she received her transplant. The patient’s blood
pressure readings met the criteria for positive orthostatic vitals.
Interpreting
 What other information do I need to make a decision?
 I would have liked to verify if she was feeling any unusual heart palpitations, but I did
not get to. I wish I had been more familiar with her cardiac history, but I do not think this
patient had any significant cardiac issues. The patient had a history of GERD, so I asked
the patient if she was experiencing any heartburn because of the pressure-like chest pain
she was experiencing, but the patient reported that what she was currently experiencing
was different than GERD. When I reflect back, GERD was unlikely to be the causative
factor here. I think my nurse and I had all of the proper information to know that the
provider must be contacted immediately.
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 Is there anyone else I need to involve or notify?


 Yes, the patient’s mid-level provider needs to be notified.
 What could be happening and how critical is this situation?
 My nurse verbalized to me that she thought that the patient was manifesting signs and
symptoms of mucositis/esophagitis. Although my nurse thought it was the beginning of a
mucositis/esophagitis, because the patient reported radiating chest pain, she wanted to
rule out any cardiac issue immediately. I agree that any cardiac issue and the potential
possibility of a myocardial infarction needed to be ruled out immediately.
Responding
 Should I do something now or wait and watch?
 I do not think it would have been appropriate to wait and watch any further.
 How will I know if I am making the best decision?
 My nurse made this decision, but I think my nurse made the appropriate decision to
notify the provider given the patient’s manifestations. I think this was the best and safest
decision.
 What interventions can I delegate to other members of the healthcare team?
 My nurse and I initiated telemetry and my nurse began drawing labs for troponin,
CKMB, and a BMP. The EKG technician performed an EKG. Repeat orthostatic vitals
could be delegated to the patient-care technician, but I do not recall whether this action
was delegated.
 It would have been more prudent to do a cardiac workup than to just wait and see if the
patient exhibited further signs of mucositis, because many chemotherapeutic agents are
cardiotoxic. Many chemotherapeutic agents can cause arrhythmias, prolonged QTc
intervals, systolic dysfunction, hypertension, and myocardial ischemia (Truong & Yan,
2014).
Reflecting
 Did I make the right decision?
 I think the correct decision was made. It is better to rule out any cardiac issue than to not
do so.
 Did I achieve the desired outcome?
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 The desired outcome was achieved. We closely monitored the patient throughout the day,
and all cardiac labs were within normal limits. EKG was normal. The physician wanted
the patient to rest in bed and avoid ambulation. Throughout the day, I saw an
improvement in the patient’s pain and fatigue. The patient was too fatigued to shower, so
my nurse and I wiped her down with CHG wipes. We did assess the patient’s mouth and
gave the patient Magic Mouthwash. The patient reported an alleviation of her discomfort
with this intervention.
 What did I do really well? What could I have done better?

 Personally, I did doubt whether the patient could be truly having some sort of cardiac
event, but I am glad I was able to witness all that I did for it was a true learning
experience for me. My nurse was a great example and she sought out her patient’s safety
first and foremost. I followed my nurse and helped her execute the orders well. Although
I had my doubts at first, soon after I appreciated my nurse’s attention to detail and the
decision she made. I was fully on board with what she did. I could have paid more
attention to the lab values that came back from the blood work we drew. Next time, I will
look out for those values and follow-up more closely.

References

Truong, J., & Yan, A. T. (2014). Chemotherapy-induced cardiotoxicity: detection, prevention,


and management. Canadian Journal of Cardiology, 30(8), 869-878.
doi: https://doi.org/10.1016/j.cjca.2014.04.029

Reflective Journaling Grading Rubric


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