Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion

Mid-Point Guide for Reflection

Tanners (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 Tanners clinical judgment model (see below).
Background

I came into my shift and received report on a 60 year old female who came into the ED after being referred from her
neurologist. The patient has 3 masses on the brain: 2 that were well established and 1 new lesion that are possible
metastasis from rectal cancer, but rare. The neurologist referred her to the ED for new onset ataxia. The patient has
right-sided weakness at baseline and diminished grips on the affected side. The patient is expected to have surgery
next week to remove and biopsy the masses in the brain. CT scan showed lesions on the left frontal and left parietal
lobe and right cerebellar hemisphere. The patient is A&Ox4 with clear speech and 1 assist to the bathroom. After
receiving report, I attempted to assist the client to the bathroom. The client was very weak and could not stand up
on her own. I rang the call bell to obtain another person for assistance. The PCT and I had to literally pick the
patient up and place her on the bedside commode. We were able to assist her with toileting and back into bed safely.
The decline from 1 assist to 2 assist was very significant. We reassessed LOC which revealed A&Ox1, further
decrease in right sided weakness, and slurred, incomprehensible speech. The on call physician was called and
prescribed a one-time dose of 10mg of Dexamethasone (Decadron) 4mg/mL and a new order of levetiracetam
(Keppra) 500 mg in 0.9% sodium chloride IVPB at 400 mL/hr. Then, sent her down for a follow up CT scan that
revealed an increase in the size of the intracranial masses, surrounding vasogenic edema, and rightward midline
shift. No new acute intracranial hemorrhage noted. The attending physician was also paged to come assess the
patient. After returning from the CT scan the patient returned to baseline. A&Ox4, right sided weakness back to
baseline assessed at initial shift assessment, and speech is clear. In response to this event we rounded on the patient
and completed assessment more frequently and held certain medications that affect the brain per MD order. The
attending physician came and evaluated the patient and agreed that the patient was now stable and back to baseline.

Interpreting

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

My clinical judgement and reasoning consisted of an assessment of the patients orientation. I evaluated the changes
from baseline and determined that an action was needed. With the knowledge that the patient has 3 brain masses
that will cause periodic changes in orientation, I decided not to call a Rapid Response Code. Instead I called the
doctor for more assistance. The doctor ordered the necessary imaging tests and medications to improve the patients
status. The reasoning for the head CT was to evaluate if there were any acute processes, which there was not. The
reasoning for the one dose Decadron was to decrease the edematous regions.

Responding

What written evidence have you drawn upon for the care of your patient in this example? Provide cites/references.
The following article is a five-year study of the effectiveness of the Rapid Response Team at their hospital.
Interestingly, the mortality rates were unchanged and even increased in the critical care setting during this time
frame. The resource of a Rapid Response Team is important and very valuable; however, I believe they should be
used on an individual patient basis. The patient above did not need a Rapid Response called because we understood
the pathology of her brain masses and the cause of her decline was due to the swelling of the brain masses. Once the
appropriate medications were prescribed, the swelling decreased and the LOC returned to baseline.

Mezzaroba, A. L., Tanita, M. T., Festti, J., Carrilho, C. M. D. de M., Cardoso, L. T. Q., & Grion, C. M. C. (2016).
Evaluation of the five-year operation period of a rapid response team led by an intensive care physician at a
university hospital. Revista Brasileira de Terapia Intensiva, 28(3), 278284. http://doi.org/10.5935/0103-
507X.20160045

Reflection-on-Action and Clinical Learning

Based on your experience as a student nurse on a unit with a preceptor, reflect on the differences of working one-on-
one with a preceptor versus a student nurse in a group of students and one instructor.

The preceptorship is a very valuable experience that is very important to my success. Personally, I meshed very well
with my preceptor and the other staff members on the unit. These relationships help me to thrive. The preceptorship
is unique and integral to my success because of the one-on-one aspect of teaching. The preceptor has more time to
explain/ teach, etc. It is also beneficial to work 12-hour shifts so you are there from the beginning to end of the
shift. This helps to understand what is expected of a nurse and how you need to improve your time management
skills. Other clinical just seemed like skills and medications, with the preceptorship you get the entire experience;
the whole story of the patient, the entire care for that day, not just vitals and bed baths. The preceptorship is more
realistic of what to expect as a new grad nurse.

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