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Patient was 54 year old with alcohol disorder. He was in chest tube, nasal cannula, IV meds. 

 

Concept: Clinical Judgement     Student Reflective Journal

This guide for writing a Reflective Journal is to help you think about a given situation encountered in clinical during the past week and your response to that situation.  The situation can be a specific physiological patient problem such as an elevated temperature, respiratory difficulty or lab abnormality.  You may choose to describe a situation involving family members.  The situation can be a description of your role in interdisciplinary problem-solving or may describe an ethical issue you met in practice.

 

Use the guide for reflection as a way to tell the story of the situation.  The guide provides you with a way of thinking about patient care that supports the development of your clinical judgement based on Tanner’s Model.  Instructions: Describe a nursing situation you encountered this week.

Phases Questions

Situation

 

Background
Describe your relationship to the patient at the time you noticed the situation (e.g. previous contact). 
Describe your formal knowledge (e.g. physiology, psychology, and communication skills), previous experiences with a similar problem or personal experiences that helped guide you work in this situation. 

(Patient-Centered Care, Teamwork and Collaboration)

 
Noticing
What did you notice initially? 
Describe what you noticed as you spent more time with the patient/family.

(Patient-Centered Care)

 
Interpreting
Describe what you thought about the situation (e.g. cause, patterns).
Describe any similar situations you have encountered before in practice including similarities/differences compared to this situation.
What other information (e.g. assessment data) did you decide you needed?  How did you obtain this information?

(Patient-Centered Care, Informatics and Technology,  Safety and Quality Improvement)

 
Conclusion 
What did your observations and data lead you to believe?  Include pertinent pathophysiology and /or psychopathology.

 

 
Responding
After considering the situation, what was the goal for your patient/family/staff? What was your nursing response and/or interventions?  List all the actions you took.
Describe stressor you experienced.

(Patient-Centered Care, Professionalism, Safety and Quality)

 
Reflection
What happened?  How did the patient respond?  What did you do next?
Describe 3 ways your nursing care skills expanded during this experience.
Name 3 things you would do differently in a similar situation.
What additional knowledge, information and skills do you need when encountering this kind of situation in the future?
Describe any changes in your values of feelings as a result of this experience.  (Safety and Quality Improvement, Professionalism)
 
SCIENCE
HEALTH SCIENCE
NURSING
NUR 099

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