Stephanie Cruz- I pledge

Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion
Mid-Point Guide for Reflection

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

The patient was a female in her 50s. In the past year she was diagnosed with bladder cancer. In the hours upon
meeting the patient she was informed that the cancer metastasized to her liver. She was hospitalized due to sepsis.
She had a urostomy. Overnight her temperature increased to 102.2, her pulse was 146, and her blood pressure was
also elevated. Her MEWS score was a 6. We administered Tylenol and informed the doctor. He instructed us retake
vitals and call back. We rechecked in 30 minutes and her temperature was the same. We called back and he
instructed us to give her a bolus of 500 ml. Her fever, blood pressure, and heart rate decreased and her MEWS
returned to a 3. The next night, her temperature increased to 103 and Acetaminophen was given immediately. The
next night, I checked her temperature and it was 99. I gave her Acetaminophen to prevent another spike in her
temperature. Her temperature did not rise and her MEWS did not raise above a 3.

Noticing

On the first evening, I noticed the patient was shivering and was flushed. She wanted more blankets and I informed
her that her symptoms were from her fever and should not be insulated further to deflect increasing temperature.
When her fever broke she was diaphoretic and I performed comfort measures like a cool rag. She refused ice packs.
Through her whole hospital stay, she remained so strong. Her husband was with her for two of the nights that I was
there. On the third night, she was supposed to be discharged but the ambulance was late. She stayed another night
but her husband stayed home because he was expecting her home (they live an hour away). While performing my
shift assessment on the third day, she started to tear up. Here was a strong woman who was always so sweet and
kind having a vulnerable moment. I stopped assessing and went to her side and just let her know I was there for her.
At this point I developed a bond with her and I shed some tears as well. It was one of my most heartfelt moments on
my nursing journey.

Interpreting

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

When the MEWS scores was increased at a level 6, measures were taken to reduce the parameters that were causing
it to be increased. Acetaminophen was administered. The doctor ordered a 500 mL bolus to improve her blood
pressure and heart rate.

Responding

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

In the nursing care plan book, it states to assess for the presence of chills and a febrile state. By the third night, I was
more in tune with her signs and symptoms and was able to be more proactive. It was important to keep assessing the
patient to make sure her condition was not deteriorating into septic shock. Her blood pressure did not have an
extreme drop showing vasodilation. We administered antibiotics and insulin until the decision was made for comfort
measures only. I gave pain meds, sodium bicarb, and antipyretics that were ordered.

(Gulanick & Myers, 2014)

Reflection-on-Action and Clinical Learning

Based on your experience as a student nurse on a unit with a preceptor, reflect on the differences of working one-on-
one with a preceptor versus a student nurse in a group of students and one instructor.

I am more immersed with multiple patients. I am also more independent with my care. It is a heavier work load
working with a preceptor. I am now in charge of completing and documenting three patients. I also assist the nurse
with all the other patients. This floor can be very busy with a 6 patient assignment. It is definitely teaching me time
management and skills to help improve my efficiency.

Write your midpoint program outcome objectives and discuss you have met them. This section should address all 5
midpoint objectives.

1. Mid-point: Effectively give shift change report for two patients

I effectively give shift reports on three patients.

2. Mid-point: Provide compassionate care in accordance with Bon Secour policies and beliefs
I have provided compassionate care

3. Mid-point: Complete cultural questions on admission to unit

I have completed admission assessments and questions.

4. Mid-point: Participate in appropriate safety measures according to Bon Secour protocols. These include but
not limited to appropriate infection control protocols and fall prevention.
I have participated in safety measures. I have also participated in in service education.

5. Mid-point: Make a phone call to another specialty- ie doctor, another floor

I discussed this with Ufei. I will receive report on the next admission. I have given updates to a doctor but
they were on the floor.

Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of Nursing Education, 46(11), p. 513-516.

References

Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.).

Philadelphia, PA: Elsevier/Mosby.