Running head: FORMAL REFLECTION 1

Formal Reflection of Preceptorship Experience

Marielle Briones

University of South Florida

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Formal Reflection of Preceptorship Experience

My clinical time on 5ET, Neuro unit, has been a wonderful and informative experience. I

learned a lot on the floor and became more confident and comfortable performing various

nursing-related skills. One situation that was a very interesting learning experience was during

my 8th shift.

Noticing & Interpreting:

I had taken a morning Neuro check. She was alert and oriented to person and place but

not time. However, as the day went on, the patient was slowly deteriorating mentally. She was

becoming disoriented, agitated, and had flight of ideas and tremors in her extremities. This was

definitely an issue and my preceptor, Emily, and I were wondering if maybe the patient was

going through alcohol withdrawal or delirium. The doctor happened to be in the room as the

patient was getting more agitated and a bit more combative. He asked us if we could put the

patient on a CIWA protocol. Although alcohol withdrawal had crossed our minds, we had no

knowledge from any reports or documents of the patient being a heavy consumer of alcohol. If

she were to be going through alcohol withdrawal, she would have drank a lot the day prior to her

surgery. We had asked the patient prior when she was oriented if she drinks alcohol a lot and she

said she didn’t. That was something we needed to find out from family and/or friends.

Responding:

We started the patient on the CIWA protocol and initially scored her conservatively

because we still didn’t know about her history with alcohol. Depending on her score, Emily

would give her Ativan per protocol and we would follow up with another CIWA assessment. In

the meantime, we would also talked to the patient’s family members. I had talked with her sister

over the phone and politely asked about the patient’s alcohol use. The sister said that the patient
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would only drink 2-3 glass of wine a week and didn’t drink heavy. The patient’s nephew, who

was a hospitalist at Sarasota Memorial, came by and visited and had similar feedback when I

talked to him. The Ativan had calmed the patient down from time to time. Oddly enough, the

patient was starting to talk about alcohol more and more as the day went on. Her admissions

history also stated that she lived alone so family may not fully know her alcohol use. Keeping all

of this in mind, Emily and I continued to use the CIWA protocol. Luckily, the patient had a sitter

who was very helpful and would let us know if anything significant happened.

Support from Journal Articles:

A recent study on the implementation of CIWA found that 20% of patients who were put

on the protocol “had no documentation of recent alcohol use” (Eloma, Tucciarone, Hayes, &

Bronson, 2018). It was eye-opening to see that other hospitals faced similar problems. This

shows that it’s even more crucial for doctors and nurses to perform thorough assessment that

clearly indicate alcohol withdrawal symptoms and risk factors (Eloma et al., 2018). It was

difficult in my situation to find how the patient’s history of alcohol use because there was no

indication in her medical history and she lived by herself so talking to family members was not

100% reliable. Because of this, assessment for alcohol withdrawal symptoms was thorough and

we were cautious when it came to scoring her.

Another thought that crossed my mind, and was even suggested by the patient’s nephew,

was delirium. I didn’t know much about delirium, so I decided to do some research on the acute

condition. Delirium is a complex condition with many variables and risk factors that can cause

the disorder. According to a journal article published in 2015, “delirium is a common clinical

condition in the elderly” and age is a major risk factor (Kukreja, Gunther, & Popp). The patient

was in her mid to late 70’s. The article also states that “pain, dehydration, and surgery” are some
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of the most common triggering factors of delirium; all three were present in my patient’s case

(Kukreja, Gunther, & Popp, 2015). She presented many signs and symptoms of delirium

including “memory deficit, disorientation”, visual and auditory disturbances, and disturbances in

“emotion and sleep-wake cycle” (Kukreja, Gunther, & Popp, 2015). While talking with my

preceptor, we decided to put in an order for a psych consult. The patient had one a few days

prior, but we thought it was best to do another one to see if their evaluation would change.

Conclusion (Reflecting):

Ativan, based on the protocol, decreased the patient’s agitation. I felt like we made the

right choice in following the doctor’s orders and helping the patient calm down. Although the

patient didn’t get back to her baseline mindset by the end of the shift, she could’ve had a worse

outcome if protocol wasn’t put in place. Emily and I were only assigned to that patient once, so I

feel like if were have more days with her, I would have been able to figure out her case even

more. The main eye-opening/ah-ha moment looking back would be how so many nursing skills

were utilized during that shift without me really thinking about it: communication skills with

family members and the doctor, procedural skills in terms of assessment and placing and a new

IV to give her fluids, documentation as I put in orders, filled out the CIWA assessment sheets,

and documented the client’s progress, and critical thinking skills as I thought about what might

be going on with this passed. This experience helped to build my confidence and changed my

outlook on what I knew and how I really handled complex situations. It helped me to see how far

I’ve come from the first preceptor day and encouraged me to continue practicing my skills and

learn more.
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References

Eloma, A., Tucciarone, J., Hayes, E., & Bronson, B. Bronson (2018) Evaluation of the

appropriate use of a CIWA-Ar alcohol withdrawal protocol in the general hospital

setting, The American Journal of Drug and Alcohol Abuse, 44(4), 418-425, DOI:

10.1080/00952990.2017.1362418

Kukreja, D., Günther, U., & Popp, J. (2015). Delirium in the elderly: Current problems with

increasing geriatric age. The Indian journal of medical research, 142(6), 655-62, DOI: