Bon Secours Memorial College of Nursing

NUR 4143 - Clinical Immersion

Mid-Point Guide for Reflection

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

The most challenging moment I have experienced would be with a patient who came to the ER and eventually to our
unit with DKA and a blood sugar in the 900’s. The patient was stable by the time he came to PCC but was now on
an insulin drip and a unit of blood due to his hemoglobin dropping. It was really interesting to be able to titrate the
insulin drip based on the patient’s blood sugar, as well as seeing the steps for blood administration. The challenging
part after the patient was stable and was taken off the insulin drip and now on corrective insulin, was he continued to
refuse his insulin injections because he felt 5 units was a waste of insulin. After educating the patient on the
importance of corrective insulin, even in smaller amounts, he was still noncompliant.

Noticing

The actions I towards the beginning of my day with the patient was monitoring his blood sugar every hour and
titrating it according to the blood sugar results, as well as monitoring the patient’s vitals in 15-minute increments
and then continuing with one-hour increments. When the patient was eventually shifted to corrective insulin three
times a day, he refused his 5 units that was needed to correct his blood sugar before he ate his lunch. I educated the
patient on the importance of having the insulin, especially after his blood sugar was extremely high when he came to
the ER, but he still wasn’t understanding or complying. I asked the patient why he did not want to take his 5 units of
insulin and he stated that “it was a waste of insulin and not worth spending the money on it.” I reiterated to the
patient that I was here to help improve his health, but he continued to deny the insulin, so I respected his wishes and
held the insulin.

Interpreting

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

The clinical judgement I used was advocating for my patient’s health my educating on the importance of insulin and
how it regulates the patient’s blood sugar to help decrease events such as DKA from happening. There were not
many alternatives that I was faced with during the situation. I educated the patient on my point of view and
acknowledges theirs as well about the importance of insulin, and when the patient was still not compliant, I sought
help from my preceptor to talk to the patient as well, but the patient still did not comply. I eventually sought help
from my preceptor because I wanted to try all methods of communicating about insulin education, before holding
the medication.
Responding

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

Using previous knowledge that we have learned in class, as well as research articles. I educated the patient on what
DKA was which consisted of a high blood sugar due to there not being enough insulin in the body. I began to
explain that because there is not enough insulin in the body, the body begins to break down fats for energy which in
return creates more acid in the blood. After explaining DKA, I educated how insulin regulates the body’s blood
sugar to decrease the risk of DKA occurring.

Howson, A. (2018). Diabetic Ketoacidosis. Health Library: Evidence-Based

Information.

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.

Immersion has been an amazing learning experience so far. I have seen myself grow in critical thinking and overall
nursing skills. Working one-on-one with a preceptor is an entirely different view than working with multiple
students in a group on a unit. I definitely enjoy working one-on-one with my preceptor aside from the group because
I am able to focus and experience more from it but have also retained so much knowledge from my experience
within a clinical group that I have utilized in immersion.

Write your midpoint practicum goals and discuss your progress toward meeting them. Please address all 3
goals.

1. Time management  I believe my time management skills have improved compared to the beginning of
immersion. I have found my own flow to making sure medications, assessments, and education is all done
in a timely manner. I still do struggle with some circumstances when the day does not run smooth, but
eventually I am able to get back on track.
2. Using clinical judgement  my overall goal was to use clinical judgement to document assessment
correctly, but I feel I have improved on as well. I am able to assess four patients at a time and usually do
them correctly (according to my preceptor) and help deliver appropriate care based on what I assessed.
3. Increasing critical thinking skills  my goal for critical thinking was to use this skill to connect my
patient’s diagnosis and history with the medications that was listed in their MAR. Throughout these few
weeks I have seen myself become more and more comfortable with each medication and being able to
quickly identify that the medication the patient is receiving is important for treating their care.

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