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Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion


Final Guide for Reflection

(Example MUST be different than that provided at mid-point)

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

My patient was a 25yo, G2P1, 37w4d gestation with twins who presented to L&D in labor, but scheduled for an
elective repeat c-section. This situation was challenging because the dynamics of a c-section, coupled with the fact
that she was having twins made the documentation and attention to detail in the OR so much more important.
Another challenging aspect for the care of this patient was that her postpartum, 4th stage of labor which is typically
the 2-4 hours post-delivery, wasn’t typical either. I left this shift feeling like something could go wrong based on
her bleeding and urine output. However, I was assured that the findings were still OK and that she would just have
to stay on the L&D floor longer than the typical singlet, vaginal delivery, until she was stable enough to be moved to
the mother-infant unit.

Noticing

When we initially assumed care of this patient I knew it was going to be an eventful evening because she has arrived
in labor for her c-section at 1830, we assumed her care at 1900, and her c-section was scheduled for 1930. All this
meant that it was my job to perform my shift assessment quickly, make sure her babies were tracing on the fetal
heart monitors successfully, get her up to the bathroom, and prep her for surgery. Thankfully, for us, the doctor was
hung up in traffic so we had a few extra minutes to prepare. The second challenge I noticed was all the detail and
documentation required in the OR during a c-section. As the L&D circulating nurse you document the timing on,
literally, everything. The exact times each person walks in and out of the OR, the times for each step of prep, each
step of surgery, each step of delivery for two babies, placenta, ect. While you’re supposed to be timing everything,
you are also the gopher for the doctor and scrub techs when they need extra supplies, while also being in charge of
verifying 4 counts of all surgical supplies with the scrub tech. It’s just overwhelming the amount of detail required
as the L&D circulating nurse in the OR.

During the postpartum, 4th stage of labor, for this patient I noticed larger amounts of lochia than I’d ever seen
before, but I was reaffirmed that while it was more than I’m used to, that it was still considered “moderate” because
of the fact that she was a cesarean section patient with twins. I’d never cared for a patient with these circumstances
before which would explain the larger amount of lochia for this patient versus every other patient I’d cared for. I
also noticed her urine output from her Foley was barely making the 30mL/hr cut.

Interpreting

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

Based on my assessment findings during each fundal check I was concerned about the amount of lochia I was
expressing with each check. We are taught that soaking a pad in one hour is considered heavy bleeding and this
patient was soaking a pad every 30 minutes in the first postpartum hour when we are required to do fundal check
every 30 minutes. My initial thought went to postpartum hemorrhage, but I used my clinical judgement and also
knew that her fundus was firm and midline. If she was hemorrhaging, her fundus would have been boggy and it
definitely was not. I decided to keep my preceptor in the loop on all my findings and express my concerns to get her
feedback. It was at this point that she assured me that we were still OK, but that we would certainly keep an eye on
it as the hours progressed. I was vigilant in performing my fundal checks on time just to make sure the bleeding
wasn’t increasing. All of this was occuring at the same time that her vitals were being taken. Had she been
hemorrhaging her vitals would have told the story as well. Her blood pressure would have been tanking, her pulse
would have be increasing and she would have shown us other symptoms of shock. None of these things were
occuring so I had to trust that the experience and clinical judgement of my preceptor was correct. The other issue
was that she was just barely putting out an adequate amount of urine. She was basically putting out almost exactly
30mL/her for four hours post-delivery. We used clinical judgement and bolused her with IV fluids to increase her
output. Rationale for this action was that she had a spinal and her bladder maybe wasn’t working as efficiently as it
should yet. With the boost of fluids her urine output did eventually creep back up and after our shift she was
transferred up to the mother infant unit without any complications.

Responding

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

According to a study conducted by Suzuki, Hiraizumi, & Miyake, “the prediction of maternal complications such as
a postpartum hemorrhage requiring transfusion may be more important in cesarean deliveries for twins than those
for singletons, because overdistention of the uterus may weaken the contraction and retraction of the uterine muscles
and increase the risk of substantial blood loss in twin pregnancies” (2012). However, this same study concludes that
the risk factors for postpartum hemorrhage in the c-section of twins includes a gestation age >/= 41 weeks and/or
hypertensive disorders. My patient does not fit any of these criteria, so her initial “heavy” bleeding, which was
actually only moderate in nature, was most likely just due to the circumstances of her delivery since no other
assessment findings support that of an actual hemorrhage.

As I progress in my nursing school career I am learning that every patient presents differently and no one necessarily
goes “by the book” so it will be my job to always consider the worst, but to look critically at all the circumstances
when evaluating my patients.

Reflection-on-Action and Clinical Learning

Socialization is best facilitated when the new nurse feels part of a group. How has this precepted experience
and working one-on-one with a dedicated preceptor helped you to become socialized into the nursing
profession?

I believe this precepted experience has had tremendous benefits socializing me into the nursing profession.
Personally, I already feel like the nurses on my unit are all willing to teach and help out with my questions. I’m
already getting the feel of what it will be like to work with this team and I am excited that I will get that opportunity
in February. Because my preceptor is really great about letting me do everything on my own, under her supervision
I’ve gotten so many opportunities to feel like I’m actually caring for the patient on my own as an independent nurse
and I think the other nurses on the unit see that in me as well. I can confidently say that I feel like I am working
well with the nurses on this unit and I feel like they have already accepted me as a peer, rather than a student, which
feels good.
Write your final program outcome objectives and discuss you have met them. This section should address all
5 final objectives.

1. Give concise and accurate SBAR report on 2 complicated patients.


a. I have definitely met this goal by reporting on 3 complicated patients since midpoint. In one shift
had 4 patients. Three were pre-eclampsia patients with significant history and the other was a less
complicated postpartum patient. I successfully gave SBAR report on all three Pre-E patients that
morning by reviewing each of their charts, the notes, and the meds to be administered about 2
hours before shift change. Having a clean copy of my own notes was very helpful in keeping all
the information flowing in a concise manner.
2. Encourage laboring patient with relaxation and breathing techniques
a. I finally had the opportunity to care for a laboring patient who was actively pushing for 2 hours.
Up to midpoint, my patients all went to the OR for a c-section or they had their babies within 5-10
minutes of pushing. With this particular patient she was exhausted and losing hope that she was
going to be able to keep going much longer. I was able to coach her through breathing, give her
O2 as a supplement and help her push more effectively through each contraction. Afterwards the
Dad asked if we are always that encouraging and “cheerleader-like” through deliveries. After I
smiled and said yes, both Mom and Dad said how helpful it was to have such a group of
encouraging nurses throughout that process. It was a great moment to be a part of!
3. Provide non-judgemental care to all patients regardless of situation and/or attitudes.
a. I cared for one patient who was using cocaine and heroin at the beginning of her pregnancy. She
eventually was able to get on subutex to get off the drugs, but this was my first patient whose baby
was going through withdrawal. I was able to care for her without any judgement and it was
empowering to watch her with her baby, try to fight through her struggles to breastfeed and
provide all the care she could for her baby. It showed me that no matter what situations people
come from, the bond between mother and baby is so strong and there are people out there who
truly are trying to do better, get clean, and be the best mother’s they can for their babies. With
that, every time I walked in and saw her trying to breastfeed and care for her baby I made sure to
encourage her and tell her what a great Mommy she was. She was so sweet and I think she
appreciated the support and encouragement from us that evening.
4. Demonstrate proficiency and competence in caring for a cesarean section patient in the OR
a. As described in my example discussed above, I believe I showed competence in the OR with this
patient because I was able to help my preceptor record all the items that needed to be documented.
I was able to assist with grabbing supplies that the scrub tech asked for and I was able to document
everything into ConnectCare once the delivery was complete and the patient was stable and back
in her room. Although I’m not to the point of remembering everything that needs documenting,
I’ve been assured by my preceptor that it takes time to get it all down, and that she was very
pleased with the progress I’ve already made at becoming independently proficient in the L&D RN
role, inside the OR.
5. Independently identify own strengths and opportunities in practicum performance.
a. I have continued to be an advocate for my own learning and success within the practicum setting.
An example of this is my recognition of that fact that I am not confident in starting IVs. Because
of this, I actively seek out opportunities to practice this skill at every chance I get and I’ve actually
gained a lot of confidence in this area because of it. I recognize that my biggest strength continues
to be my ability to connect with my patients and be a therapeutic presence with my care. My
preceptor has even commented on several occasions, that even with “difficult” patients, that they
all love me because of my positivity and smile. It makes me feel good to know that a strength I
see in myself is also conveying to the RNs that I will eventually be working beside.
References

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

Suzuki, S., Hiraizumi, Y., & Miyake, H. (2012). Risk factors for postpartum hemorrhage requiring transfusion in
cesarean deliveries for Japanese twins: Comparison with those for singletons. Archives of Gynecology and
Obstetrics, 286(6), 1363-1367. doi:10.1007/s00404-012-2461-9