1

Reflective Journal #1
Name: Anthony Ortiz Date: February 25, 2018
Noticing
 Subjective and objective data:
A patient presented to the emergency department with complaints of persistent nausea and vomiting over
the course of the three days prior. The nausea and vomiting had occurred sporadically over the last several
months. She also complained of chest pain, shortness of breath, and dizziness. She was a 77 year old
woman who has a history of hyperlipidemia, arrhythmias, and stomach cancer. As far as the patient was
aware, she was in remission as of July 2015. The patient admitted that she was not proactive in sticking to
follow up appointments. After being admitted to our floor, the patient was unable to keep anything down
and refused to take anything by mouth as she would throw it back up shortly thereafter. The patient also
stated that her stools were dark in color. The patient was placed on total parenteral nutrition and was
given medication only through her IV. An echocardiogram was performed and showed that the patient
had atrial fibrillation with rapid ventricular response. A biopsy was ordered, in which results showed the
stomach cancer had returned and had spread to surrounding organs. The medical team believed that the
gastrointestinal concerns were likely due to the return of the cancer, while the a-fib caused the chest pain,
shortness of breath, and dizziness.
 How did you know there was a problem? Abnormal patient presentation or your “gut feeling”?
I knew there was a problem when the patient was unable to hold down any food or any of her
medications. The patient was pale, fatigued, and didn’t seem to have the strength to perform many
activities of daily living. Considering the nausea, vomiting, and her medical history, my “gut feeling” told
me that perhaps her cancer had returned or that it had at least caused more damage than previously
indicated to the gastrointestinal tract.
Interpreting
 What other information do I need to make a decision? Is there anyone else I need to involve or
notify? What could be happening and how critical is this situation?
Some necessary information that would guide the nursing plan of care would be what the doctor intended
to prescribe and/or order in order to not only control the a-fib, but also to combat the cancer. The patient
was immediately placed on medications to control the a-fib, and we followed orders to administer digoxin
and metoprolol to the patient via her IV. Some important individuals to consult would be a cardiologist
and oncologist in order to cooperate and develop a plan of care for the arrhythmia and cancer.
Considering that the cancer has already spread to other organs, this situation is quite critical in that it can
become much worse if interventions aren’t implemented as soon as possible.
Responding
 2

 Should I do something now or wait and watch? How will I know if I am making the best
decision? What interventions can I delegate to other members of the healthcare team? Include
evidence-based practice (peer reviewed) here to justify why you might make one decision over
another.
Acting immediately is a crucial course of action. In order to provide some relief and keep the patient’s
arrhythmia in check, it is imperative that we implement the orders for the cardiac control while the
physicians develop a plane of care to combat the cancer. The digoxin and metoprolol are going to play
key roles in maintaining the patient in a normal sinus rhythm. In patients with a-fib with RVR, “both
digoxin and beta-blockers reduce the ventricular rate and both may improve symptoms” (Fauchier et al.,
2016). Interventions that I can delegate to other members of the healthcare team are vital signs to keep
track of the patient’s baseline and any changes, assistance with ambulation and toileting as necessary, and
providing comfort and support aids to ensure the patient is well rested.
Reflecting
 Did I make the right decision? Did I achieve the desired outcome? What did I do really well?
What could I have done better?
I feel that the nurse and I made the right decision. As part of a healthcare team, we are tasked with the
duty to work as a cohesive unit in providing the utmost in care for our patients. Following the doctor’s
orders in administering the patient’s cardiac medication is an imperative part of her plan of care. The
desired outcome was achieved as the patient remained in a normal sinus rhythm while on the digoxin and
metoprolol. I feel that I followed orders, listened to the patient’s concerns, and adjusted care based on
their needs quite well. I feel that I could have done better by communicating with the family members
more and involving them in the patient’s care so that they could feel as though they were part of the team
to restore the patient’s health.

Reference:
Fauchier, L., Laborie, G., Clementy, N., Babuty, D. (2016). Beta-blockers or digoxin for atrial fibrillation
and heart failure? Cardiac Failure Review, 2(1): 35-39. doi: 10.15420/cfr.2015:28:2