Weekly Clinical Guided Reflection/Analysis Sample
(Must show reflection and analysis in answers)
- (Safety) How did you incorporate a standard precaution and infection control guideline?
Which National Patient Safety Goals did you use in your practice? (Choose one you have not chosen before.)
-Our hospital’s operating room puts emphasis on infection control and prevention. Health care providers adhere to the set infection prevention standards and disciplines. The standards include using sterile equipment and proper disinfection of the surfaces. Reusable medical equipment and products are reprocessed by use of an autoclave. The staff uses personal protective equipment, particularly in the current coronavirus pandemic to minimize risk of infection transmission. Further, to prevent postoperative infections, antibiotics are widely used.
-Moreover, personal hand washing techniques and sanitization within the hospital helps reduce infection transmission within the hospital. The hospital setting largely borrows from the World Health Organization and Centre for Disease Control and Prevention set guidelines. The 2020 National Patient Safety goals commonly used include the first (identifying patients correctly), third (using medicine safely) and the seventh (prevention of infection).
- (Concept Care Map) What is the highest priority problem for your patient? What is the rationale for this choice?
-The highest priority problem in the patient discussed is traumatic brain injury (TBI).
-Rationale: Without quick interventions, TBI accounts for significant mortality. Further, TBI can result into severe complications such as seizures, raised intracranial pressures with risks of brain herniation and focal neurologic deficits. As such, it must be the priority during management.
- (Concept Care Map) What is the pathophysiology for the highest priority patient problem for each of your patients as it applies to the patient’s situation?
-TBI refers to a non-congenital and a non-degenerative brain insult from external force that results into physical, cognitive and psychosocial impairment with associated altered mental status. The mechanism of injury in TBI involves falls, motor vehicle accidents and assaults (Dawodu, 2019). The presumed MOI in the patient includes an assault. Pathophysiological processes involved can either be primary (occurs at the moment of trauma) or secondary-effects prolong for a long time after the trauma (Dawodu, 2019). The primary injuries can manifest as intracranial hemorrhages. The patient is stated to have subdural hematoma, subarachnoid hematoma and intraparenchymal hemorrhages which all include primary injuries. Possible secondary processes in the patient discussed include raised ICP, cerebral edema and brain herniation.
-The patient present with impaired consciousness with history of assault, impaired mobility and speech difficulties which raises suspicion for TBI.
- (Concept Care Map) Evaluate the patient goals for each of your patients (from your concept care map).
The patient presents to the emergency department with history of an assault, altered mentation, and speech abnormality. The first goal of management is to secure the airway patency and perform cervical immobilization due to risk of neck injury. The second goal is to restore the breathing as the patient presents with acute hypoxemic respiratory failure therefore, oxygen is administered. Maintenance of circulation is the third goal since the patient presents with low blood pressures of 108/68. Further, alleviation of pain is the fourth goal of management of the patient. Since the patient is also at risk of getting seizures, seizure prophylaxis is mandatory.
- (Clinical Judgment) What did you learn about the concepts of the week from your patient(s) and experiences at clinical?
I learnt about the principles of emergency medicine. Patients’ life threatening conditions are managed first without worrying about the diagnosis. For example, the patient is at risk of airway obstruction and cervical spine injury. As a result, airway patency is secured, oxygen administered and cervical spine immobilized.
- (Clinical Judgment) Think of one clinical decision you made which enhanced your patient’s care by addressing their cultural, developmental, and social characteristics.
Cultural: During every physical examination of the patient, I included a chaperone (her elder sister). This action was meant to enhance patient’s comfort and security during the procedures. It is of note that other cultures/religion such as Islam do not allow male care providers to closely touch or have a close relationship with female patients.
Developmental: Being an adult, the patient is capable of making her own decisions; however, due to her unconscious state, I involved her sitter (elder sister) in every decision concerning her treatment. For example, consent for craniotomy.
Social: The patient was unconscious during the first few hours of admission; however, as she regained consciousness, she needed to talk to her close relatives. I ensured I called her elder sister anytime the patient made a request.
- (Clinical Judgment) Share an “ah-ha” moment of insight you experienced or witnessed today in clinical.
-A moment of relief that we experienced as part of the care team is when the patient regaining consciousness few hours post craniotomy. Being that she was severely injured, we risked losing her; however, that was not the case. Weekly Clinical Guided Reflection/Analysis Sample
- (Clinical Judgment) Share one thing you plan to do differently next week in clinical?
-I plan to engage more in performing ABCDE in patients presenting with critical conditions. Even though I observed and learned the procedures, I did not actively participate in doing them. I’ll do more phlebotomy, IV access, oxygen administration, endotracheal intubation and oropharyngeal airways. My actions will be directed towards gaining more skills in the emergency department other than just acquiring knowledge.
- (Patient Education) How did you assess the readiness of your patient and family member to learn?
-After regaining consciousness, the patient was curious to know how she arrived at the hospital and the events prior to her admission. Patients’ curiosity is enough evidence that they are ready to learn.
-Further, the patient showed readiness to learn by following every instruction given concerning medication and ambulation.
Identify any learning barriers; possible resolution to barriers.
-Speech pathology- the patient has inaccurate verbalizations and anomic aphasia
-Cognitive impairment- the patient has TBI, cerebritis with impairment of cognitive functions
-Pain- Postoperative patient in pain, and showing difficulty in processing information
–Cognitive behavioral therapy to help her communicate
What content did you identify that you should teach your patient and/or family?
-Surgical site infection prevention
-Adherence to pain medication
What teaching strategies did you use?
-Open ended questions to seek clarification of the mechanism of injury
-Teach back method
-Demonstration since the patient has a speech abnormality
What teaching aides did you use?
-Photos and graphics
-CT Scan CDs
- (Patient Education) How did you verify their learning?
-There was difficulty communication; however, the patient was able to learn. The patient adhered to instructions given. The patient took the pain medications as instructed. She was able to ambulate as instructed by the help of nurses.
Did they learn the content? If not, why not?
-Yes. The patient learnt. Teaching by demonstration significantly helped the patient learn. The demonstrations fortified conversations and impacted the patient positively.
- (Communication) Describe a therapeutic conversation you had with a patient or family member. Name the therapeutic communication technique you used?
-Seeking clarification- After the patient regained consciousness, we asked her open-ended questions concerning the events prior to morbidity and she vividly elaborated. The same questions were directed to the sister, who also gave a nuanced description of the history.
-Active listening- As the history was narrated, we actively listened
-Empathy- as a nurse, our role is to practice with emotional intelligence. Our understanding of the patient’s feelings, thoughts and emotional state improves her satisfaction
How did the person respond to your therapeutic communication technique?
-Initially, the patient was unconscious and thus unable to communicate. Her elder sister gave the details required. After craniotomy, she had mild improvement and was able to communicate; however, subtle difficulties were evident.
Upon reflection, what would you have done differently?
I would have allowed the patient enough time to rest post operatively before initiating a conversation with her
Describe one communication barrier you observed. How did it interfere with the communication?
-Cognitive impairment- The patient could not process simple information. She had trouble remembering the conversations
-She was also in pain, tired and irritable, aspects that made her reluctant to talk about her feelings
- (Professionalism) Which standard of practice from the California Board of Nursing Rule did you implement? (Choose one you have not chosen before.)
-The California Board of Nursing Rule standard of practice that encourages inter-professional collaboration (IPC) was used as a nursing strategy.
How did you implement it?
-Delegation of duties to every nurse to ensure teamwork. Further, creation of a culture where all health care providers are regarded as equal enabled IPC to thrive. This is unlike the ancient times where nurses were solely regarded as physicians’ accomplices.
- (Leadership & Management) List interventions from your Concept-Care Map that you could only legally delegate to unlicensed personnel (UAP).
-Taking vital signs
-Helping patient ambulate within the wards
-Patient education concerning personal hygiene
-Bathing the patient
How did you advocate for your assigned patient(s)?
-I educated the patient about need for infection control post operatively, need for ambulation and the importance of adherence to her medications
-I contacted a psychiatrist to evaluate her and help manage her anxiety problems
- (Quality Improvement or Evidence-Based Practice) Identify and explain a quality improvement project at your hospital – or – identify an evidence-based practice used in the care of your patients. Weekly Clinical Guided Reflection/Analysis Sample
-The use of antibiotics prophylactically post operatively in our setting significantly reduces post-operative infections
- (Concept Care Map) List all of the interventions with cited scientific rationales for the highest priority problems pertaining to the patient.
-Administering Enoxaparin (Lovenox): 30mg=0.3 ml, SQ, Injection, Q12hr for 30 days. For spinal/epidural hematoma
-Administering Trazodone 100mg=2 tab, PO, QEvening, for 30 days: Depression and anxiety. To prevent suicide risk in young adult (Guzman & Ament, 2017)
-Administration of Acetaminophen 650mg 2 tabs, PO, Q6hr, for 30 days. PRN Pain and temperature °C
-Docusate administration 100mg=1 cap, PO, Cap, BID, for 30 days. Hold for diarrhea
-Administering Sertraline 25mg=1 tab, PO, Daily. Suicide risk in young Adults (Guzman & Ament, 2017)
-Craniotomy- To evacuate the hematoma
-Insertion of endotracheal tube- an intervention for the compromised airway
Weekly Clinical Guided Reflection/Analysis Sample References
Dawodu, S. T. (2019, June 27). Traumatic Brain Injury (TBI)-Definition, Epidemiology, Pathophysiology. Retrieved Dec 3, 2020, from Medscape: https://emedicine.medscape.com/article/326510-overview
Guzman, E. D., & Ament, A. (2017). Neurobehavioral Management of Traumatic Brain Injury in the Critical Care Setting. Critical Care Clinic, 423-440 https://doi.org/10.1016/j.ccc.2017.03.011.