Events

The first step of the Reflective Cycle is to describe the events without judgment or conclusions. In this timeline, the nurse begins the day with a list of clients to assess before surgery. The day included unexpected events when assessment of the second client was interrupted by another healthcare provider, and a schedule change initiated quickly.

Emotions

When describing emotions during reflective practice, stay focused on feelings and don’t analyze—just describe. In this situation consider that the nurse may have experienced anxiety when unable to assess the second client in progression or during the sudden change in the operating room schedule. Perhaps the nurse was frustrated when the physician was upset regarding the schedule change.

Evaluation

Evaluation is the time to analyze how the nurse perceived the experience. During the evaluation phase of reflective practice, focus on no more than two encounters and identify the most concerning events during the experience. Trust intuition at this time and choose based only on individual perceptions of the experience. Were the encounters with team members and clients positive or negative?

Critical Analysis

During the critical analysis phase of reflective practice, compare the experiences of others and analyze what occurred in this situation relative to prior experiences. What was different? What was the same? For example, did negative encounters with team members or abrupt schedule changes produce negative outcomes in the past? What themes are emerging from the critical analysis? For example, this nurse might identify the lack of communication and collaboration among team members as an ongoing issue, placing clients at risk.

Conclusion

In this phase of the Reflective Cycle, the nurse must identify knowledge gained and propose recommendations for practice change. The nurse must own inappropriate actions and remain aware and open to the need for positive change. In this clinical situation, the nurse should not have interrupted an assessment to accommodate another team member and compromise the safety of the client. The nurse should have followed policy and reviewed the procedure with the second client, providing ample time for discussion regarding the procedure and marking of the affected body part. Finally, all team members should have paused during the schedule change to assure client safety before proceeding.

Action Plan

The final step in reflection is the creation of an action plan. This action plan may include recommendations from supervisors but must also contain personally identified actions to strengthen future practice. Consider actions the nurse should take if this situation occurs again. Remember to include strategies to determine if the nursing practice has improved as a result of the action plan. Reflective practice is a synthesis of ideas connected to knowledge, feelings, and attitudes. The goal of synthesis is new insights and perspectives as well as meaningful practice change. 

1

APA FPRMAT, CURRENT REFERENCES, Intext citation, Please put the question before the answer

Deliverable 4 – Making the Best Nursing Decisions

Competency

Synthesize knowledge from the humanities, physical and social sciences, nursing theory, and applied research as a basis for evidence-based nursing practice and clinical reasoning. Scenario

You finished new graduate orientation yesterday on a general medical surgical unit, and today you will independently care for two clients. As you receive a report on the second client at 0730, your Preceptor stops by to ask how the first day by yourself is coming along and reminds you to complete the final items on your training list today before the end of the 12-hour shift.

· Complete the new online training model and quiz on the sliding insulin scale

· Complete the orientation evaluation form

· Sign up for one of the four nursing committees

· Complete and sign the orientation reflection journal

· Attend the new employee luncheon from 1-2 pm sponsored by the hospital physicians

Client 1

Client 2

· 25 year old female 24 hours post-op from a Roux-en-Y gastric bypass

· BMI of 50

· History of hypertension and sleep apnea

· No complications post-operative

· Pain at 4 am, three on a scale of 10

· Nasogastric tube to gravity

· NPOMother stayed overnight but left early this morning to shower and will return later in the afternoon

· Waiting on morning labs

Client 2

· 46 year old male admitted 72 hours prior with severe GERD and difficulty swallowing

· History of alcoholism, hypertension

· Smoked two packs per day for 22 years

· Endoscopy for Barrett’s Esophagus was negative on the day of admission

· Pain at 4 am, two on a scale of 10

· Due to resume clear liquid diet this morning

· Potential discharge later today home with family

· The ex-wife has stayed in a room with a client and has been disruptive at times demanding pain medication and food.

· Waiting on morning labs

Physician orders:

Dietary Consult

Bariatric Behavioral Therapist Consult

0.45% NS intravenous infusion post op

Medications:

Protonix 40 mg once daily, intravenous infusion

Switch to oral Protonix 40mg day of discharge

IV infusion 0.9% NS 50 ml/hour

Resume 50mg Lopressor (metoprolol) PO twice daily after rule out Barrett’s Esophagus

1-2mg Morphine Sulfate IV PRN q 4-6 hours for pain greater than 6 out of 10

TIME

EVENT

0800

You prioritize the need to assess the 46 year old male first since he has 0900 medications and the physician is rounding and should order discharge today. Assessment and vital signs reveal no concerns, ex-wife not present. A physician writes an order to discharge this client today. The client asks you to return in 30 minutes and go over discharge when ex-wife is present to hear instructions. You administer Lopressor and Protonix.

0830

You assess the 25 year old post bariatric surgery client. Vital signs and morning labs are within acceptable limits, and client reports pain two on a scale of 10. While assessing for bowel sounds, you notice the nasogastric (NG) tube not secured to the nose, and the client reports the tube partially came out when she blew her nose but she was able to push it back in with no pain. You document NG tube in place and assist the client to the bathroom.

0900

You return to 46 year old client and review discharge instructions with the client and ex-wife, discontinue the IV infusion, remove the intravenous catheter, and complete discharge summary.

0945

Transport stops by to take 25 year old client to meet with a support group for bariatric surgery clients — you okay transport.

1000

Physician stops into see a bariatric client and is upset you let her leave for support group before rounding. You report no concerns, physician reviews chart and writes discharge order for later in the afternoon if no vomiting or pain. The NG tube can be removed at noon by the Nurse Practitioner, and a diet of clear liquids resumed at 6 pm if no vomiting or gastric distention. Call immediately if any vomiting or signs of gastric distention occur.

1030

You take a break to complete orientation reflection journal, orientation evaluation, and online sliding insulin scale training module and quiz.

1130

The 25 year old bariatric client returns from the support group, you see her ambulating in the hallway, and you notice the NG tube is missing. The client states the tube fell out of her nose when she stood up to introduce herself. She has no complaints of nausea and no evidence of gastric distention. You document the NG tube was removed accidentally by the client.

1200

46 year old male client calls and expresses frustration at a time to discharge. He wants to be home by 3 pm for his son’s birthday party. You call transport who assures you and the client they will arrive before 1 pm to discharge the client.

1215

Morning documentation complete, all orders are in the system, and both clients are stable. You are amazed at how smooth the first day is going. You head to the new employee luncheon with your Preceptor.

1330

You return from lunch and find the 46 year old client discharged, and you must prepare for a new admit from the emergency room with rule out pancreatitis. You feel apprehension since this will be your first admit, so you reach out to your Preceptor to review policy and procedure for new admissions.

1345

While working with your Preceptor, the Certified Nursing Assistant stops by and reports the 25 year old client refused an afternoon visit from a member of the bariatric support group, complaining of fatigue. Her noon vital signs were blood pressure 90/40, heart rate 112, and respiratory rate 28. Your Preceptor assures you these vital signs, and fatigue often occurs with this type of client. She susgest, the client is probably depressed, ready to go home, and suggests to let her rest for the afternoon.

1415

The new admit from the emergency department arrives with two pages of physician orders and a communication challenge since he speaks and understands only Spanish. He has pain in the abdomen and begins vomiting. Seeing you are now very busy, the Preceptor offers to “look in” on your 25 year old client and will take care of any concerns. Also, she will order a translator to assist with the new admit, while you focus on taking care of the physician orders.

1730

Finally, all orders for the new admit are in the system; pain decreased, no further vomiting, and he is resting comfortably. While waiting for lab results, you decide to check on the 25 year old client.

1745

On the way to the client’s room, the Nurse Manager stops and asks you to take a moment to fill out a volunteer form for one of the four nursing committees on the Unit.

1815

You return to the 25 year old client’s room and find her unresponsive, pale, with no heart beat or respirations. The abdomen is distended and hard. Attempts are made for resuscitation but are not successful. The client is deceased.

1900

You prepare to leave to go home. The Nurse Manger stops you and asks to debrief the situation. After reviewing the chart and discussing the situation, she is concerned and sees errors in your judgement and actions. She is sure the client’s death will be a sentinel event and warrant a review by the Internal Review Board.

Instructions

To prepare for debriefing with the Internal Review Board, the Nurse Manager asks you to submit an internal memo with your analysis and perceptions of the events that occurred, including:

Description of the errors that occurred

Support choices with rationales

Description of why the errors occurred

Support choices with rationales

Strategies for appropriate actions to avoid errors identified

Support strategies with rationales, nursing theory and evidence from the literature

Ideas stated with professional language and attribution for credible sources with correct APA citation, spelling, and grammar

RUBRIC

Exemplary and detailed descriptions of errors linked to client outcomes.

All rationales were strongly stated, relevant and contained knowledge synthesized from the humanities, physical, and social sciences.

Exemplary and detailed descriptions of why errors occurred.

All rationales were strongly stated, relevant, and contained supporting evidence.

Exemplary descriptions of actions to avoid client death.

All rationales were relevant and strongly stated including support from nursing theory and credible evidence from the literature.

Communication is professional, well-constructed, and succinct and contains comprehensive detail.

Minimal to no spelling and grammar errors that do not detract from the audience’s ability to comprehend the material. 

ources used are credible, support the purpose of the assignment, and contain insignificant to no APA errors