Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion

Final Guide for Reflection

(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

From one recent experience I encountered in clinical was when a patient was going back and forth in a hypertensive
emergency. The patient had a psychiatric history and was on methadone from a previous drug addiction. My
preceptor and I were on the edge all day of whether or not to hold this patient’s blood pressure medications when
they ranged from 200/100-60/30. After receiving hemodialysis, the patient’s bp was stable. Steadily gaining
throughout the day, we administered their medications and with talking to the provider all day on how to manage
this patient. The patient’s BP dropped to 54/32. The patient was still awake but very lethargic. Next, the Rapid
Response Team was called. The patient remained stable and asymptomatic. So, my preceptor apologized for calling
a rapid, but all the nurses understood her actions and supported her. After starting a 500ml fluid bolus of normal
saline and albumin 25% through the IV. The blood pressure was barely touched even going at the fastest rate
possible. So the on-call hospitalist thought to get a Central line placed for easier access and also the patient is a hard
stick and pulled out their last IV. So, I got to watch a central line be put in and I got to assist the doctor with the
procedure. It was an amazing experience and luckily, the patient remained stable after initiating some fluids. Much
background included the patient being dehydrated and not wanting to eat the hospital food. There were several
aspects that aided in my learning as a student that I will bring forth with me towards my individual career. Did I also
say that this patient is a 43 year old with type 2 diabetic and no history of cardiac disease.

Noticing

After noticing the BP of 54/32, immediately, we called a Rapid. The patient needed more attention than that of an
individual nurse. We needed a team and provider to get orders and help fast to maintain this patient’s hypotensive
state. Whether the patient was symptomatic or not, a Rapid should have been called because this was far outside of
the patient’s normal baseline vitals. I saw how confident my preceptor was in initiating that call and how she knew
she needed help. We prioritized this patient first, and had other nurses watch over our other patients. This support
system on the unit was reassuring and exactly what a unit needs to consist of when handling a patient emergency.

Interpreting

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

We performed the clinical judgment of holding the patient's blood pressure meds after receiving hemodialysis
because of the patients’ blood pressures being stable or within defined limits. The patient had several blood pressure
medications to administer that day and during dialysis we had to hold those prior to. So, initially I thought how do
you know when 2 give blood pressure medications if the morning meds were held? After talking to the provider, we
gave two of the smaller dosage prescriptions to maintain the blood pressure, but the patient still bottomed out. There
were blood pressure medications including Cozaar, metoprolol, lisinopril, hydralazine, and several others in which
this patient was prescribed daily. As one can see, the decision on which blood pressure medications to give and to
hold was a challenging call.

Responding

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

After finding an article relating towards better patient outcomes after a rapid response team is called to the room,
there is never a doubt in my mind that I will never hesitate to call them if my patient is deteriorating, and I need
help. Whether we needed a doctor in the room first or not, an extra set of hands is very helpful in keeping a patient
alert and stabilized. I have recently found out that emergency teams will most likely be called for reasons such as
hypotension, decrease in neurological status, or for a patient being oliguric. The patients that were a part of the study
that did not benefit from the team being called were mainly for reasonings related to a long time before a team
responded or other inconveniences such as no one available to respond to the call. With that being said, I will always
call a rapid as soon as I am starting to doubt my patient’s worsening condition. I will not over use them, but I will
not want to delay a call that a patient is in need in case of what other possible conditions another patient may be in.
Of course, as a patient is starting to decline, I will get a charge nurse or other fellow nurses at the station to get their
opinion on what they think I should do if calling a Rapid response is the only option I have left or available. I
understand that this is a daily occurrence and patients will bottom out a lot, but it is my duty to make sure that when
I am administering blood pressure medications that their BP is within the defined pararmeters and that I will
cautiously monitor my patients throughout their onset of symptoms or heightened/low blood pressures. This was a
great learning experience in what to do in an emergency and I am glad that I utilized it for my own individual
learning.

Reflection-on-Action and Clinical Learning

Socialization is best facilitated when the new nurse feels part of a group. How has this precepted experience and
working one-on-one with a dedicated preceptor helped you to become socialized into the nursing profession?

My preceptor immediately welcomed me and made me feel like I was supported on the unit in my immersion. She
went out her way to introduce me to everyone. There were several occurrences in which she challenged me and gave
me time to critically think on my own. After she explained her way to complete an IV or a a quick bed bath, there
were several tips and tricks that I was not aware of. Yes, there need to be short cuts in healthcare, or else all the
work would not get done in the 12 hour shifts. My preceptor was an advocate for me and for that I was eternally
grateful because of how much I want to advocate for my patients and my future students that I will teach alongside
me. I enjoyed having a relationship and getting undivided attention in times when I have questions or other instances
in that the professors were not always around. Getting the one on one time is never underappreciated in how much
the students that are not as experienced need to rely on them for guidance. I was an example and my preceptor stood
by me the entire time I needed her until she challenged me to do it myself or when I gained confidence enough to
fulfill it on my own. I enjoyed using my preceptor as a conversation starter when socializing. I told the other nurses
how informative she is and that she is very hard working. Of course, they all understood who I was talking about
and then it initiated conversations about where I want to go and that all the previous BSMCON students wish the
most success and encouragement for myself after graduating. It is like a never ending cycle of students and nurses
encouraging the next class and I found that extremely reassuring. Most of the fellow students were understanding
and wanted to go out of their way to help me. It was not solemnly my preceptor that aided in my success but the
entire unit as a whole.
Write your final practicum goals and discuss your progress toward meeting them. Please address all 3 goals.

1. By April 15th at 8 pm, I will be able to successfully manage 3-4 patients with medications,
assessments/documentation, and communication between healthcare team members and
doctors involved in patient care.

On April 10th, 2022, at 10 pm, I was able to carefully assist and manage 3-4 patients. Most of the
rotations, I had 3 permanent patients, with one incoming from the Emergency department and
then discharging another that day. I had completed documentation, medications, and manage all
orders on a minimum of three patients by the end of my required hours.

2. By April 24th at 8 pm, I will be aware of the symptoms and side effects of at least 5
common cardiac drip medications (heparin, coumadin, amiodarone, digoxin, milrinone)
and I will be efficient in hanging the medications with no assistance needed from my
preceptor. In other words, I will be able to manage them successfully.

After finishing up my immersion, I have worked with several drips and how to properly maintain
a patient on a drip on April 10th, 2022, at 9pm. I have worked with Heparin, amiodarone,
digoxin, and milrinone drips. All of which, I had to rate verify, understand the importance of
having new bags ready when they are running out, being resourceful of supplies and tubing, and
how to use my patient as a source of whether the drips are becoming therapeutic or not. By
saying this, I mean understanding that blood labs are expected to be sent within particular times
and the entire drip management is a strict protocol that nurses are expected to adhere to.

3. On April 24th at 8 pm, I will improve my confidence, professionalism, and display a

proper tone of voice when speaking with doctors and other staff members. I will take all
the calls that correlate with my patients and improve my assertiveness as needed.

I have progressed towards this goal on April 10th, 2022, at 8pm. I was not able to take all calls, especially in a
hypertensive emergency, but I have gained confidence and the understanding of all it takes prior to making the call
to the provider. I have made successful calls without assistance, but I have learned that I can always call or ask
questions when I am experiencing doubt of administering a medication or what to do correctly following a surgery
or procedure. I am gaining assertiveness in my tone of voice and fading away with the hesitancy that comes along
with no prior experience.
References:

Calzavacca, P., Licari, E., Tee, A. et al. (2008) A prospective study of factors influencing the outcome of patients

after a Medical Emergency Team review. Intensive Care Med 34, 2112.

https://doi.org/10.1007/s00134-008-1229-y

Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of

Nursing Education, 46(11), p. 513-516.