Journal Entries for Preceptorship Reflection in Medical-Surgical Nursing Unit Prompt 1: Therapeutic Communication In my

Journal Entries for Preceptorship Reflection in Medical-Surgical Nursing Unit

Prompt 1: Therapeutic Communication

In my clinical practice, I once had a difficult time speaking with a patient and his family regarding their patient's worsening condition and informing the patient he had stage 5 kidney disease. I said there is only a possibility to stay alive through a dialysis process, evidently. The relatives of the patient looked worried, and the patient, too, looked depersonalized; hence, approaching him was sensitive. In this, I used a therapeutic model of communication where I listened to them carefully, asked them questions that did not have standard answers, and used lots of empathetic remarks. I kept my eyes focused on my client, kept my hands relaxed, and occasionally touched the client's arm, making sure to lean slightly forward in my chair to demonstrate interest. Though keeping the patient at arm's length, he slowly shared his anxieties, and the family started enquiring about dialysis. My answer was compassionate and focused on providing information about the treatment and both informative and emotional needs. I discovered the value of time and adequately prepared the circumstances for discussing uncomfortable issues by strengthening that experience. In future practice, I would improve my nonverbal communication in order to sustain supporting the manifestation of emotions and also support the delivery of technical details in a beneficial influencing manner. When discussing with the patient and his family about the worsening of kidney disease and possible dialysis, the stakes of such conversation were immensely high in terms of sensitivity and message clarity. I spoke quietly and encouragingly, gestured, looked at her as kindly as I could, and explained each step to her. I also focused on their perceived problems and used a summary of what I understood, giving the client an opportunity to correct me. (Arnold & Boggs 2019).

Prompt 2: General Knowledge and its Clinical Application

There was one particular case of caring for several clients with different but concurrent medical issues that needed to be prioritized according to physiology and vital acuity. The first visit was with a patient complaining of chest pains. As such, signs signified a probable case of cardiac arrest. Pathophysiology was an area that I focused on during my education and knowledge in this area enabled me to understand the dangers that this patient faced immediately after suffering a myocardial infarction, thereby aiding me in prioritizing this patient. After the successful initial consolidation of the first patient, I looked after a patient with severe refractory vomiting and diarrhea for the next three days, suggesting a possibility of an electrolyte imbalance, which, if left unchecked, can lead to further complications such as dehydration or even hypovolemic shock state. Finally, in this worrying category, I treated a patient who needed a refill of his prescription and who could not get to his primary care physician. Most of the interventions I chose appeared appropriate for each patient, but I realized that I have little knowledge of how to handle electrolyte disturbance in gastrointestinal diseases. Thinking about this, I would like to learn more about fluids and electrolytes in order to improve aspects of functionality that pertain to prioritization in multi-patient interactions while concurrently not neglecting care for each person. During the clinical experience, situations arise where a nurse is faced with the treatment of care to two or more clients with different needs, such as acuity; pathophysiology helps to make fast but efficient decisions. Within my first hour, a patient came in with a complaint of chest pain and was having a suspected myocardial infarction. I applied physical assessment parameters like heart rate, oxygen saturation, etc., when performing this assessment.

Prompt 3: Client Care Prioritization

One day, when the ER received several critical cases in a single day, I found myself learning how to effectively and appropriately prioritize. I decided to start with a patient who presents with respiratory distress because respiratory dysfunction is a severe condition that can quickly become critical. From the assessment, I established that my patient had difficult, shallow and rapid breathing, oxygen saturation level was low, and they had cyanosis. After this, I proceeded to ensure the patient was stabilized with oxygen administered, and the healthcare team informed me that I went on to address other patients with less severity. For instance, in one patient who had a laceration that mandated suturing, I decided that the procedure could wait while I focused on providing respiratory support. Another ethical consideration was felt when another patient complained of severe abdominal pain. (Wilkinson et al. 2011).

 I understood their uneasiness, and I clarified the purpose of prioritizing respiratory illness cases. This realization made me understand that when making decisions, it is extremely crucial to bear in mind that patient and their families need to be informed of what is going on in the course of the stressful moment. I also cemented my knowledge that the best practice is triage based on the severity of the threat, which is very important so that all patients get the attention they need in time. Thus, in the ER, also with a high rate of patient turnover, I prioritized respiratory distress as it could often be lethal. This was the first case where this approach needed to be addressed by performing a quick evaluation of the possible insult that has caused the deterioration of breathing. Then, I dealt with clients who did not require immediate attention, and it was my task to be as careful as possible given the time constraints.

Prompt 4: Evaluation and Documentation

In a hypertensive crisis case, I managed a patient who had been admitted with features of avoidance of organ failure due to hypertension and was being treated with Hydralazine and Nitroglycerin. As an adverse reaction, I expected low blood pressure, lightheadedness and other signs of tachycardia. Throughout this task, every time I provided my account of the patient's response, I made sure I was detail-oriented in that I recorded the patient's blood pressure changes, side effects and the patient's verbal acknowledgment of the symptoms. On the same note, the use of documentation was precise and enabled the healthcare team to make necessary changes on the course of treatment in the plan and avert possible complications that may arise out of aggressive blood pressure lowering. Thinking about this, I realized the importance of documentation as a factor in the delivery of patient care, particularly when it comes to issues related to medication changes. I learned to pay attention not only to the results and signs deciphered by me but also to the patient's personal experience of the treatment. Information gathered from this experience pointed towards the need to pay attention to details in making documents to facilitate decisions in clinical practice that are ever-changing. It was important to closely observe a hypertensive crisis patient who was administered Hydralazine and Nitroglycerin to be able to modify treatment according to the patient's response. These kept records of blood pressure effects resembling a mild headache, dizziness or nausea, which diagnosed possible side effects. The ability to constantly observe patient status ensured that when the patient's condition dictated closer observation, the care plan could be changed to ensure that blood pressure was consistent, therefore showing how documentation forms a basis for constant patient management. (Potter et al. 2021). 

Prompt 5: Interprofessional teamwork

I studied this concept closely after I had to consult with the Respiratory Therapy (RT) team when a patient with severe respiratory problems fainted and needed intubation to be intubated. As a nursing student, I consulted with the RT to assist in clearing the patient's airway immediately and helping as needed in order to observe his technique. The RT team provided clear and prompt collaboration, whereby they were able to effectively evaluate the patient's respiratory condition and make the necessary changes in the ventilator settings. This interprofessional teamwork made the response quick, which helped to stabilize the patient's condition in the end. From this synergy, I was able to understand the significance of being brief while communicating; also, I got to know how every individual is important when handling emergent circumstances in an organization. Thinking about this, I learned that integrating with other professionals, like Respiratory Therapy, leads to better patient results due to diverse expertise. I plan to build my competency further through ineffective client-centered interprofessional communication in service to patients. Mechanisms of staff cooperation are considered important, especially in the case of a severe patient needing intubation, where extensive work of the respiratory therapist is appropriate. There was synergy in our operations as I was arranging the equipment and taking records of patients' significant signs while the therapist was practicing intubation. Specifically, this experience emphasized that interprofessional teamwork is effective in emergent situations because shared responsibilities are an advantage to the patient.

 Prompt 6: Delegation and Supervision

When working on one shift with a great number of assignments, I learned how to delegate tasks and assign stable patient vitals and intake-output monitoring to the CNA. I realized the need to practice the rights of delegation, which means distributing a task in accordance with the skills and capabilities of a team member. Given the fact that CNAs are trained to do the vital signs and intake-output assessments, I delegated these ones so that I could spend more time on other clinical chores. I then went around to inform one of the LPNs that they should help me with the wound care of another of our patients so that I could attend to some of the other emergent cases that we received. Thinking about it, I understood that efficient communication is vital when assigning and delegating tasks, and supervising those tasks is important in order to ensure high standards of care. My reaction to the feedback was positive since every participant noted that delegation improved the flow of work in the team. In the future, I am going to develop this competency more by being more sensitive to situational contexts and also getting to know more about the distribution of tasks in accordance with the talents of the team members. It was necessary to think about what tasks were suitable for delegating and who was qualified to perform the work – CNA, LPN, or RN. For stable patients, I delegated a CNA to conduct a vital examination and assessment of intake/output, which is well within a CNA's ability. That means the LPN assisted in medication administration with supervision, whereas I assumed more difficult actions. After delegation, I got feedback, and he affirmed that the tasks were well-defined and doable, hence improving team performance.

Prompt 7: Cultural Competence

In one instance, I attended to a patient who was a Jehovah's Witness who refused blood products as a result of the stand they held, yet their hemoglobin level was critically low. As their wish, I consulted with the other practitioners to give them an iron infusion that would help them with their anemia problem. My communication was modified, guiding them that there were some imperative things related to iron infusion which may be risky or may give benefit to the patient, and at the same time, they patiently listened to all their worries. This made expand my knowledge on culturally sensitive care as I have to deal with the patient's belief system. In this particular interaction, I learnt pretty much about honoring prevailing cultural beliefs whilst at the same time adequately educating the patients. (Potter, 2009).

This experience I realized the importance of cultural sensitivity in relation to patients, and I would like to keep developing my perspective of the cultural differences I am working with, when interacting with people. I once encountered a Jehovah's Witness patient who denied reception of blood transfusion due to his faith which called for me to change my behavior. We talked about other treatments and finally agreed on iron infusion. Such an encounter, stressed the importance of respect for culture and the ability to adapt to the host country's culture in designing patient care. I realized that such situations should be anticipated and preparation of the other options is crucial to trust and patients' values promotion.

Prompt 8: Communication of Care Tasks

When treating a patient with sepsis, I got the following abnormal laboratory values which pointed to a life-threatening condition: Lactic acid 6.7. I quickly communicated this value to the charge nurse since I knew this indicated that the patient sepsis was getting worse. Because the last reading taken an hour before had been 2.2, I repeated the procedure by taking a new specimen to make sure that the reading was correct. This enable the team to respond early, modify the care plan to deal with the sepsis in a more aggressive manner. From this experience, I was able to understand how determining this conclusion provides better verification on any unexpected lab result hence emphasizing the importance of timely communication. In the future, I need to pay more attention to developing the skills of communication when the tension is high and to check crucial results for patients. Evaluating a critical Lactic Acid value of 6.7 called for a sense of emergency and accurate decision making as to placing the call to the RN. I engaged the use of articulated language and followed this by a repeat specimen collection to verify on the reading while avoiding unnecessary interventions. The clear explanation helps ensure that patients understand their responsibility

Prompt 9: Education

A kidney stone sufferer clearly needed relief from pain, as well as information about how to alleviate the condition. I educated him to take Naproxen as pain reliever and Flomax to facilitate the passage of stones and told him to adhere to dosing regimen and drink water. I also described possible adverse reactions and what would be expected in case of need for further appointment. When I thought of this, I was able to see that the patient was more likely to understand what I was saying if I didn't use complex terms and if I presented my information on posters. Based on the assessment of the identified GLS, I propose the following: Enabling patients to ask questions to boost their understanding and asking them questions repeatedly to check their comprehension besides seeking group consensus before ending the educational process. This approach will make a good all point to see that the patients are independent and informed in their treatment. While teaching a patient about Naproxen and Flomax for kidney stones, I ensured that they clarified the proper way to use it, side effects and signs to watch out for. Teach back was also used and I made written instructions based on the client's situation and confirmed the client's comprehension. Although the patient had seemed to understand the instructions given to them, looking back at the moment, I thought about how best to improve educational delivery in future to help reach each patient's understanding in the best way possible; this may include the use of pictures and videos as part of educating the patient. Further, I would enunciate more questions in order to check retention commitments and guarantee that clients understood all the information provided to them. This taught me the importance of differentiated instruction and the importance of patient grossed nucleated methods that help support patient enablement.

Prompt 10: Confidentiality and Privacy

When conducting management of a case with personal details, it was difficult at times to secure a patent's information due to high traffic of patients in the facility. For the reason for patient's right to privacy I did not disclosed information to other people in crowded places and only allowed the chart to be accessed by authorized personnel. I also made it a point that no patient identifying information was evidenced when updating the electronic health record. While going through such experience I was able to understand the importance of balancing on information sharing and confidentiality. This situation helped me appreciate how to practice ethically in protecting the patient's identity because in explaining a sensitive diagnosis, I had to transfer to a different section due to noise. I was very careful to prevent personal data to appear on the charts and complied with the HIPAA standards on information management. Analyzing this case, I realized that additional training in handling the privacy protocols would enhance my capacity in handling such cases. More specifically, I would support the provision of staff-only work spaces that is being utilized for the purpose of patient care so that greater measures of patient confidentiality could be maintained, so that further evidence of ethical and appropriate interaction with patients will be observed by the reviewers.

References

Arnold, E. C., & Boggs, K. U. (2019). Interpersonal relationships e-book: professional communication skills for nurses. Elsevier Health Sciences.

Potter, P. A. (2009). Fundamentals of nursing. Mosby Elsevier.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2021). Fundamentals of nursing-e-book. Elsevier health sciences.

Wilkinson, J. M., Treas, L. S., Barnett, K. L., & Smith, M. H. (2011). Fundamentals of nursing. Philadelphia: FA Davis Company.