Adult Health Reflective Journal

Noah M. Carpenter

Department of Nursing, Missouri Southern State University

NURS 435: Adult Health IV

Professor Kim Herchenroeder, MSN, RN

March 31, 2024

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Adult Health Reflective Journal

Throughout my two years in the MSSU Nursing Program, I experienced a noticeable

progression during my clinical experiences. Spanning across various clinical locations and

patient populations, I was able to grow as a nurse by utilizing the clinical judgment model and its

applications in my practice. A majority of my clinical experiences during the first year was at the

Freeman hospital, on the medical-surgical floor. Alongside these inpatient situations, I was also

gaining clinical experience through high-fidelity and virtual reality simulations at MSSU. These

allowed for a safe and controlled environment to learn and apply my knowledge to a variety of

scenarios, all while being monitored by the faculty to allow for feedback and greater growth.

During my second and last year in the program, my clinical experiences were majority at the

Mercy hospital, as well as the continued use of the high-fidelity and virtual reality simulations.

While I was able to learn a substantial amount through these experiences, I was further

enriched by the utilization of assignments that corresponded with my clinicals. The most

impactful one would be the use of SimChart, a simulated charting system that allowed for me to

practice one of the most important parts of being a nurse–documenting. This program was very

similar to the real charting systems in the workplace, and allowed for me to practice both the

physical process of charting, as well as the mindset and intentional thinking behind the charting.

After a clinical day on the floor, I would be required to chart over a patient that I had taken care

of, and include a number of items of information such as their reason for admission, their

diagnosis, the list of medications and those that I gave them, their laboratory and diagnostic tests

that were relevant to their stay, and a complete head to toe physical assessment that I had

performed on them during my rotation. The physical assessment was also a major assignment

that was required on every shift, to enhance knowledge and understanding of the process behind
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it as well as give additional practice. The use of these assignments allowed for much further

reflection and a deeper understanding of the nursing process, allowing for considerably more

growth as a nurse.

In all of my clinical experiences, I utilized the clinical judgment model of noticing,

interpreting, responding, and reflecting. Noticing involved picking up on cues and recognizing

things in my environment, such as what a patient may be saying with nonverbal body language

or seeing that their urinal was full and needed dumped, or any patient care tasks that weren’t

being directly asked. Interpreting is the act of taking the noticing information, and processing

what needs to be done regarding it. This would be the process of seeing that a patient needs

something or assistance with a task, and then using critical thinking to decide what needs to be

done about it. Responding is then taking that decision of what to do and putting it into action.

This is the step in which you perform the action or actions that you deemed necessary. Reflecting

is the last step in which you look back on the prior steps and think about what went well, what

went wrong, and what could possibly be done in the future to do better. This step also takes time

to think about if further intervention is needed or if the action(s) performed accomplished the

desired task. The use of this clinical judgment model both helped me to make difficult decisions

while in practice and allowed me to provide the best care for my patients. Utilizing this model

also further reinforced my learning and helped me to integrate it into my practice for use in the

rest of my career.

Adult Health I

Noticing

During my first semester in Adult Health I, there were relatively basic tasks that were asked

of me to notice about my assigned patients. Such tasks were things like noticing if a patient
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needed more water, or if they needed help to use the restroom. Basic patient care tasks were the

majority of what I was noticing, with a beginning step towards more complicated things such as

noticing their labs and vitals as I was beginning to learn about them more. One of the main

examples of what I did in practice was notice if a patient needed help using the restroom or

needed to be cleaned in bed.

Interpreting

During these numerous situations that I had noticed, I had a lot of thoughts about what

was going on. I noticed that nearly every patient on the floor seemed like they would need

perineal care at some point during my shift, and a pattern I interpreted was that it was easier to

assist them to the restroom before cleaning them and their beds. I spoke with my clinical

instructor about this and she helped me to obtain the information that aligned with my thoughts,

most patients required a cleaning every shift, and most nurses and techs would assist them to the

restroom beforehand.

Responding

My nursing response to the situations I described previously in the noticing and

interpreting sections was to assist the patients to the restroom and to give them a bed bath upon

their return. I would do this a couple times during each clinical shift, as time allowed. If the

patient was already clean then I would assist them to the restroom or give them their urinal or

bedpan as needed instead.

Reflecting

Describe stresses you experienced as you responded. Describe how your nursing care

skills expanded during this Adult Health I clinical experience. Provide specific example(s).
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I experienced a small to moderate amount of stress during my clinical experiences, that

was mainly due to my inexperience in the inpatient healthcare field. I had never worked in a

hospital before nor had I performed any kind of bed bath or cleaning, so it was a lot to take in

during the first few shifts. Combined with the sensory overload of being on the floor for the first

time and the general anxiety of feeling like I knew nothing, it caused a small to moderate amount

of stress, which I believe actually benefited my learning. It allowed for me to want to consume

more knowledge and to take in everything I could to allow for me to not feel as inadequate.

My nursing care skills expanded a large amount, as I was able to learn how to take vitals,

interact with patients, assist in basic patient care tasks such as assisting to the restroom and

cleaning, as well as a beginning stage of recognizing vitals as well as laboratory results.

Adult Health II

Noticing

During my second semester, in Adult Health II, there were more things that were asked of

me. This included things such as being able to take vitals signs and notice when they were

abnormal for the patient, understand laboratory results and know the normal ranges, perform

more complex tasks such as inserting foley catheters and nasogastric tubes and begin to

understand more medications.

Interpreting

While I was in these situations, I thought a lot and also recognized some patterns. When I

was taking blood pressures, if they were agitated or talking, their results would be much higher,

while if they were asleep then it may be lower. I also interpreted that with the use of charting

technology, I was able to see the patient’s lab results and interpret what the causes and effects

may be utilizing my new knowledge. I had help from my clinical instructor in connecting some
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of the dots when it came to these laboratory values, as I was still learning them, but with

assistance I found it easier to make the connections on my own.

Responding

When I was taking the patient's vitals, my goal was to get the most accurate reading as

possible to ensure that medications are working as intended and/or may need to be given, and to

give them the best care possible. In order to do this, I would respond by performing the actions to

take their vital signs in the correct, evidence based way. One example was when I was obtaining

the blood pressure from a newly admitted patient, and when the reading came back abnormally

high compared to their baseline, I asked them to try and relax for a moment to see if their reading

could return to normal. I allowed them to rest in bed for about five minutes and rechecked their

blood pressure and it had returned back to normal. If I hadn’t allowed for that to happen, then

they may have been given an increased dose of their blood pressure medication which could

have caused their blood pressure to drop below the intended target.

Reflecting

There were some stresses that I experienced during my responses, as well as many ways

in which my nursing care expanded during my clinical journey from Adult Health I to Adult

Health II. The stress I experienced was more related to having more responsibility during my

clinicals, and having a nurse that relied on me to take vitals signs and do a head to toe

assessment. Throughout the stress, I was able to immensely grow in my nursing care, as I was

able to more confidently assess both vitals as well as the patient with a head to toe assessment.

My values about high quality of patient care stayed the same, and were actually further

reinforced by having more patient interaction to build upon my empathy and compassion. One

example was when I was caring for a patient that was at the end of their life, and I was able to
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help provide them comfort and peace during the remainder of their stay by cleaning them and

brushing their teeth. Being able to humbly serve those in need as well as improve their life in any

way possible is very important to me, and being able to apply that in clinical is an amazing

experience.

Adult Health III

Noticing

In Adult Health III, there was a steep increase in what was asked of me to notice in my

patients and tasks. After being checked off on how to pass medications, it was expected for us to

be able to administer medications, understand the indications and side effects of them, and be

able to properly prime, initiate and maintain intravenous medication pumps, while also being

able to start intravenous lines to pump them through. We also are asked to be able to recognize

and understand many more disease processes as well as laboratory results that coincide with

them, and know what interventions may be done to manage them. One example was when I was

passing medications for a patient, and they didn’t know what the medication was for. I was able

to both inform them of the indication as well as the side effects, all while priming the tubing for

the intravenous line, combining multiple skills at once.

Interpreting

During my clinical rotations, I noticed a lot of patterns while I was thinking about the

situations. I interpreted that most patients have medications that they take at home, but they may

not know or remember what the indications or side effects may be. I obtained this information

through discussion with my clinical instructor, and we came to the conclusion that people may be

informed at the beginning, but over time they forget what the use is and that may lead to a

decreased compliance with their medications since it seems unimportant. An example was with
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the patient in the previous section, as they were receiving a maintenance medication but they

were unsure about what it was used for and what side effects may come from it. Being able to

inform this patient allowed for a better understanding of their care and resulted in a more

compliant and happy patient.

Responding

My patient goal during the prior situations was for the patient to be able to demonstrate

understanding of the medication that they were receiving. I utilized the teach back method as I

was administering it to ensure that they properly understood what they were receiving, and

would hopefully be able to retain that information upon discharge. The patient was able to teach

back all of the mediation information correctly, so I felt comfortable and confident in their

knowledge and continued to administer the medication.

Reflecting

Describe stresses you experienced as you responded. Describe ways in which your nursing care

expanded during these clinical experiences in as related to Adult Health II clinical experiences.

Describe any changes in your values or feelings as a result of your Adult Health III clinical

experiences. Provide specific example(s).

I experienced fewer stresses during this semester than compared to the prior two

semesters, and I believe that it is due to having more clinical experience. I still experienced a

general stress from being in clinical and being worried that I may make a mistake, but I felt more

confident in my practice, and even during my stress of administering controlled medications, I

felt secure in my knowledge.

My nursing care improved majorly due to being able to perform more nursing-based

tasks such as administering medications and providing information on them. Being able to do
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more tasks as compared to the previous semester was daunting, but rising to the challenge

allowed me to have more reinforced values and beliefs. A major example that I still remember

was during my clinical rotation at the Mercy hospital, where I was speaking to a patient who was

admitted for a chronic condition. They had been readmitted a large amount of times over the past

few years, but they remained positive and optimistic. This was, according to her, mainly due to

the positive atmosphere that the nurses and staff maintained while helping her, and that really

inspired me to continue being the bright light to the people in their darkest times.

Adult Health IV

Noticing

Adult Health IV clinical experiences asked a lot more of me than previous clinical

experiences. Along with the expectation of being able to competently practice all previously

learned skills, I was now required to be able to be functioning as what was essentially a new

graduate nurse, under the precepting of a nurse. New skills that I was asked to accomplish would

also be the management of more critically ill patients, as well as being able to utilize clinical

judgment effectively in a critical scenario. One example of me utilizing these skills would be an

experience during a clinical day at the Mercy hospital. I was asked to help with inserting a

nasogastric tube into a patient who was on contact precautions. Upon entering the room, in my

correct PPE, I was tasked with recalling my skills and knowledge of how to insert a nasogastric

tube, while also having to utilize clinical judgment to make decisions about what aspects of the

procedure may change since the patient was on contact precautions. I had to use a specific

stethoscope that was left in the room as well as understanding that it would be difficult to see if

the tube was in the correct place since the patient was coughing and violently shaking due to

their illness.
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Interpreting

There were many thoughts that I had during these situations, and utilizing both my

clinical judgment as well as my preceptor and clinical instructor, I was able to process all of

them. A major pattern that I noticed was that critically ill patients usually are unable to speak

and/or are at a reduced orientation level, leading to the utilization of clinical judgment to assess

their needs. An example was the patient whom I inserted the nasogastric tube in, who was unable

to cooperate by swallowing during the insertion, and unable to speak and follow commands to

assist in ensuring that the tube was properly placed. Speaking with my preceptor and my

instructor allowed for me to conceptualize my thoughts and talk them through, allowing for

better understanding and comprehension.

Responding

My identified nursing interventions was for the patient to be able to receive the best

possible care even while unable to advocate for themselves. Being able to advocate for the

patient and provide the best care is a very high priority for me, since they are currently unable to

do it for themselves, as in the case with the patient who I inserted the nasogastric tube into. They

were disoriented and unable to speak coherently, but that shouldn’t affect the care that they

receive, so my goal was to ensure that I perform the best possible care for them.

Reflecting

There were many stresses that I experienced as I responded, but they were mainly due to

me being worried about messing up during my practice, but once I was able to have confidence

in myself and my knowledge, they went away. I feel like I’ve learned more during this last

semester than all the other semesters combined, just because I’m in such a more critical

environment and there is a lot more than I can do. My feelings and values are even more
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reinforced now, and I believe that they are solidified into what they will be for when I become a

nurse.

If I were to encounter any situations again, then I would want to be sure that I try and do

as many possible things as I can. Especially in the earlier semesters, I was sometimes hesitant to

volunteer to do things out of fear that I would fail, but knowing what I know now, it is better to

try and to fail than to not try at all. One example of this was during the second semester, there

was an opportunity to put in a foley catheter, but I was hesitant due to the fact that I had not done

one before, and the patient was experiencing hematuria, and I was afraid to further cause more

pain. If I could go back in time, I would remind myself to do as much as I can to get even more

experience.