1 Christy Larsen Clinical Journal 9 Shift 3/16/2014

PRIORITIZTION:

Again we had our patient that fell the 50ft. He had been fine since Friday night and we thought he wouldn't be much of a problem. He was fine and letting us give him medications and interacting with us, until about midnight and he lost it again. He became our priority patient again. We also still had our patient who was taking the 8-12 mg of Dilaudid for pain. Her SATS kept dropping to 88 or 89 so we put her on 2 L of oxygen. Next we had two text book Lap appy patients, and a SBO. They didn't require much. Just pain medications and that was it.
THINGS THAT WENT ACCORIDNG TO PLAN:

We were able to stay on schedule with our medications and we were able to keep up on our patients pain. Also we were able to get all of our paperwork done in a timely fashion. Things weren't nearly as busy as the night before.
SITUATION WHERE NURSING MADE A DIFFERENCE:

See Challenging:
OUTCOME:

See long and short term goals:

LESSONS LEARNED:

We really had to work as a team tonight to help on of our patients. It was comforting to know that if I worked here that I would have such support from the staff. When our patient got confused and started getting angry with us we had CNA's and the other RN's and the hospital security come and help us. We worked really well together.
THINGS I WOULD CHANGE IF I WAS ABLE TO DO A DO OVER AND WHY:

I wish that I followed my instincts to say things more. Again I had a chance to try and talk this patient down and I was afraid to say the wrong thing and so I didn't say what I wanted to. I felt the need to distract him, but wasn't sure how and so I thought about getting him to tell me about his favorite song but thought it was silly so I said nothing. I really need to trust myself. It couldn't have hurt anything to try. I guess I just didn't want to look silly in front of all the other staff there.
CHALLENING:

My patient who had the 50ft fall still had a sitter, but had been fine since Friday night. Our sitter needed to go home and so they let him go. within 2 hours he changed again. We passed the room and realized that he had moved a crossed the room and did not bring all of his stuff with him. We were really nervous that he had pulled his Foley and his chest tube out. Luckily he hadn't. We tried talking him back into bed and he just got up and got his walker and said he was leaving. No amount of talking was making him turn back. We decided we'd try to just take him on a walk and see if we could get him to go back. He did not. He went to the front door and tried to open it. I had to get in his way and we had to call security. We tried talking him down for 15 minutes and finally had to give him a Haldol shot. Then guided him to a wheel chair and got him to his bed. He was very upset with us the rest of the shift, but we didn't have anymore problems. If the sitter hadn't left that whole thing may not have happened. Especially since he was a big guy. It was a great experience for me to have with my preceptor. 4/26/2014 5:01 PM

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LEARNING THAT TOOK PLACE DURING MY SHIFT:

Team work was a big one. Therapeutic communication of a person who isn't exactly oriented. It is a big job to deal with them and it is something that will probably take a lot of experience to deal with more effectively.
LONG TERM GOAL:

Therapeutic Communication: Utilize effective communication techniques with individuals, families, people in groups, and members of the healthcare team with the RN role. Caring: Demonstrate caring behaviors that incorporate client and family advocacy; respect for persons and cultural diversity; and ethical principles.
SHORT TERM GOALS:

Therapeutic Communication - Communicates assertively and responsibly with distressed, aggressive, or unpopular clients/colleagues. Caring - Demonstrates interest in clients and client care by giving individualized, quality, nursing care to complex, difficult clients, and in resolving difficult problems/situations.
SKILLS PERFORMED:

IV try, medication administration, charting, shift change report, chest tube and foley care, IM injections, client intervention. Instructor _______________________ Date____________________ Points_________

4/26/2014 5:01 PM

3 Christy Larsen Clinical Journal 11 Shift 3/22/2014

PRIORITIZTION:

Our pyleonephritis patient was still there and we were concerned he was going to be a major priority again because of his confusion. He was still trying to get up without us, but he wasn't as big of a priority as we thought. The actual priority was a new admit that had a chest tube (a new one we've not dealt with). She had a lot of family there and they were very concerned about her and they wanted to now everything about her case and the results of the diagnostics the minute they happened. We still had our de-gloved lady and she just slept the whole time and didn't even require pain medication until 4 am. Next we had our patient with abdominal pain and one who had a broken leg which was in a cast.
THINGS THAT WENT ACCORIDNG TO PLAN:

Our patients were safe and cared for through the night. We were actually pretty slow because things went so smoothly. I did most of the shift independently and was trusted to do that by my preceptor.
SITUATION WHERE NURSING MADE A DIFFERENCE:

When we were doing our assessment we noticed our patient's IV was not super clean, but we did not flush it to check because she had fluids running. We administered an antibiotic and when it was done for some reason decided to check it out further. Her arm looked fine, but when you compared it to her other arm we realized it was swollen and that her IV was infiltrated. If we hadn't looked at it we would have just continued to give her the antibiotics and her steroids all night long in that bad IV.
OUTCOME:

See long and short term:

LESSONS LEARNED:

Even the most experienced nurse can have a bad 'skills' day ie missed IV's. see challenging for more information.
THINGS I WOULD CHANGE IF I WAS ABLE TO DO A DO OVER AND WHY:

I wish we would have noticed her IV was bad before we administered her antibiotics. All of the antibiotics just went into her arm and probably didn't help her at all.
CHALLENING:

My chest tube patient had an IV that looked weird. It was a little crusty with blood and when we got a closer look her arm was a little swollen. We had just administered an antibiotic and I'm pretty sure that it all went into her arm. We D/C'd that IV and attempted to start a new one. I didn't even try because she was pretty beat up and seemed like a hard stick. My preceptor tried it twice, another staff from the ER tried it twice, and the charge nurse tried it twice and FINALLY got it. Poor lady was a good sport about it.
LEARNING THAT TOOK PLACE DURING MY SHIFT:

A thorough assessment is a good idea. Maybe not just checking the IV site for phlebitis but also for slight differences in both arms. If we had done that at the beginning of the shift we would have known what was going on. Now I am going to add that to my assessments. I'm already looking at the arms when I check the reflexes and when I check pulses so it won't take much more to compare the arms really fast. 4/26/2014 5:01 PM

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LONG TERM GOAL:

Technical Skills: Demonstrate the ability to use complex equipment and perform complex procedures in providing care for acutely ill clients. Therapeutic Communication: Utilize effective communication techniques with individuals, families, people in groups, and members of the healthcare team with the RN role.
SHORT TERM GOALS:

Technical Skills - Identifies and follows established standards when performing more complex, advanced procedures. - I had never seen the new chest tube that was being used on this patient and so I researched it and read the materials that came with it. Therapeutic Communication - Gives/receives nursing change of shift report in an effective manner. - My last shift change was my best. When my preceptor wanted to start telling a piece of information, I was able to let her know I got it and go from there.
SKILLS PERFORMED:

Watched multiple IV insertions. chest tube care, administer medications, Charting/documenting, problem charting Instructor _______________________ Date____________________ Points_________

4/26/2014 5:01 PM