Nursing Reflective Essay.

Reflective journals X3 and decision making episodes X2 , an introduction and a conclusion. Please, refer to the attached documents.

Nursing Reflective Essay

Introduction
I am working in a 100-bed private hospital and my recent duty to provide care in a 12-
bed Critical Care Unit (CCU). A large portion of our CCU patients are post-surgical patients
with complications. In addition to this, we also provide care to patients with severe pneumonia,
different form of shocks, strokes and acute decompensated heart failure, among others. In these
cases the patient necessitate a close hemodynamic screening and in some cases mechanical
invasive or non-invasive ventilation.
Care provided to the patients who have required invasive ventilation; I obtained
considerable amount of knowledge and skills during this semester. My nurse unit manager is my
in-practice support person. She corrected me, point out my mistakes to make my performance
better.
I have been working in CCU and Cardiac Cath Lab for many years. Plus, I have
completed a post-graduate diploma in heart catheterization (nursing), which is helping me in
providing better patient care. Providing care to patients who are on hemodynamic support is my
active practice area. Besides, research has a significant role; it helps me to be friendly with recent
advancement in patient care.
During this semester, I have investigated renal support indications, health assessment, a
plan of treatment, and recovery frameworks for the hypotensive patient and various measures of
considering patients requiring renal help. Recently I have attended a haemodialysis practical
study day where I was incited the most ideal approach to manage a start, keep up and complete
hemodialysis sessions similarly as unequivocal machines research tips. Bringing about getting
such learning, I am induced that I can supervise patients with hemodynamic and renal
complexities.

# Reflective Journal One
Patient problem/description:
My first journal entry is regarding a 65 years old Caucasian male patient admitted to the
emergency division with shortness of breath. Signs had begun around 2 days earlier and had
constantly intensified with no related, infuriating, or extenuating factors noted.
Issue/what happened:
At the start of my shift a patient admitted to the hospital had reported difficulty in
breathing. The patient was critically ill and rapidly decompensating with multisystem organ
failure. The fundamental treatments of the patient spun around the respiratory failure with altered
mental status.
Ideas for learning/what I have learnt:
I found that not every case of shortness of breath is COPD or congestive heart failure
(CHF). A past stacked up with hypothyroidism should raise the vulnerability of myxedema coma
in a patient with any cognitive changes (Hawatmeh et al., 2018). A certified hypothyroidism
emergency prompts critical multiorgan faliure (Wankanit et al., 2018). Myxedema is the
wonderful imitator sickness that affects all organ structures. It can easily be confused with
congestive heart failure, COPD exacerbation, pneumonia, renal injury or faliure, or neurological
insult (Heksch and Henry, 2018 and Assar and Baffoe-Bonnie, 2019).
Action plan/where I can develop further:
As I was new to this case and the care of the patient, I need a further insight to this
treatment to feel confident with management of patients when issues rise.

What would I do differently?
I will keep on closer watch as these patients should be checked in a concentrated thought
condition with relentless telemetry (Lamos, Woodworth and Munir, 2015).
References:
Assar, S. and Baffoe-Bonnie, A. (2019). A 45-Year-Old Man Presenting With Sudden Onset of
Shortness of Breath. Clinical Infectious Diseases, 68(9), pp.1603-1605.
Hawatmeh, A., Thawabi, M., Abuarqoub, A. and Shamoon, F. (2018). Amiodarone induced
myxedema coma: Two case reports and literature review. Heart & Lung, 47(4), pp.429-431.
Heksch, R. and Henry, R. (2018). Myxedema Coma due to Hashimoto Thyroiditis: A Rare but
Real Presentation of Failure to Thrive in Infancy. Hormone Research in Paediatrics, 90(5),
pp.332-336.
Lamos, E., Woodworth, G. and Munir, K. (2015). Carotid artery aneurysm resulting in
myxedema coma. Interdisciplinary Neurosurgery, 2(2), pp.120-122.
Wankanit S, Mahachoklertwattana P, Anantasit N, Katanyuwong P, Poomthavorn P.
Myxoedema coma in a 2-year-old girl with untreated congenital hypothyroidism: Case report and
literature review. J Paediatr Child Health. 2019 Jun;55(6):707-710. [PubMed]

# Reflective Journal Two
Patient problem/description:
My second reflection journal is on a 19-year-old male, had complaint about new frontal
headache, odynophagia, and pyrexia. He experienced a right-sided focal seizure and was moved
to our therapeutic facility for neurological evaluation.
Issue/what happened:
A brain magnetic resonance imaging established dissipated nonenhancing T2/Fluid
Attenuated Inversion Recovery (FLAIR) hyperintense wounds inside the left crown radiata.
Empiric treatment with heartbeat methylprednisolone was facilitated and looked for after with a
prednisone decrease. He stayed unsettled however, capable of participating in physiotherapy and
was as time goes on released to inpatient rehabilitation.
Ideas for learning/what I have learnt:
An adolescent with a lot of responses and signs those were stick out and astounding at the
hour of introduction. In the contemporary setting, our patient would have been investigated for,
and likely set out to have, NMDAR encephalitis (Titulaer et al., 2013). As the trademark
suspected of NMDAR encephalitis didn't yet exist, no such finding was made in our patient,
embodying how positive contemplations are reliant upon an establishment verified in time
(Broadbent, 2013).
Action plan/where I can develop further:
Insistence of the unassuming beginnings and flawed limits that incorporate our insight
should lead authorities from the essential for sureness and toward an invigorated spotlight on the
patient experience (Sharma, Khandelwal and Shamy, 2014). Current principles and treatment
figurings will unavoidably be changed and superseded, yet pondering individual patients will

remain necessary to the demonstration of medication (Day, Tang-Wai and Shamy, 2016). Right
when our available decisive thoughts disregard to typify the patient experience, we should be
glad to reconsider, reassign, or reexamine frameworks; to combine new information at whatever
point possible; and to face creating request (Isaac, 2013).
What would I do differently?
I think I worked inside my capacity.
References
Broadbent, A. (2013). Book ReviewJeremy Howick, The Philosophy of Evidence-Based
Medicine. Chichester: Wiley-Blackwell (2011), 248 pp., $61.95 (paper). Philosophy of Science,
80(1), pp.165-168.
Day, G., Tang-Wai, D. and Shamy, M. (2016). A Case Study in the History of Neurology. The
Neurohospitalist, 6(4), pp.181-184.
Isaac, J. (2013). Thomas S. Kuhn. The Structure of Scientific Revolutions. Introduction by Ian
Hacking. Fiftieth Anniversary Edition. xlvi + 217 pp., index. Chicago/London: University of
Chicago Press, 2012. $15 (paper). Isis, 104(3), pp.658-659.
Sharma, M., Khandelwal, P. and Shamy, M. (2014). The complexities of acute stroke decision-
making: A survey of neurologists. Neurology, 82(10), pp.904-904.
Titulaer, M., McCracken, L., Gabilondo, I., Armangué, T., Glaser, C., Iizuka, T., Honig, L.,
Benseler, S., Kawachi, I., Martinez-Hernandez, E., Aguilar, E., Gresa-Arribas, N., Ryan-
Florance, N., Torrents, A., Saiz, A., Rosenfeld, M., Balice-Gordon, R., Graus, F. and Dalmau, J.
(2013). Treatment and prognostic factors for long-term outcome in patients with anti-NMDA
receptor encephalitis: an observational cohort study. The Lancet Neurology, 12(2), pp.157-165.

# Reflective Journal Three
Patient problem/description:
My third refelction is on a 32 years old female who sedated day one post cardiac arrest.
After waking and severe coughing she went in pulseless ventricular tachycardia (VT).
Issue/what happened:
I recognized, in the rush to resuscitate and begin the cisatracurium, we had fail to adjoin
the periphery nerve trigger or train of four (generally known as TOF). The first reading was
three, which shows there is simply moderate loss of movement (Cairo 2016 pp. 300). We turned
up the cisatracurium and the accompanying scrutinizing was one. Patient wound up hypertensive
and tachycardic, we gave a bolus of fentanyl and propofol, by then extended the part/hour.
Ideas for learning/what I have learnt:
A TOF score on two or three demonstrates the patient is sufficient crippled (Cairo 2016
pp. 300). A couple of effects of a patient being under calmed can be hypertension, tachycardia,
arrhythmias, ventilator-tolerant asynchrony, and unsettling influence and pressure (Aitken,
Marshall &Chaboyer 2015 pp. 171). The tachycardia and hypertension that the patient was
having experienced may have been realized by being under-calmed.
Action plan/where I can develop further:
I had considered one other patient that had an incessant NMBA implantation going, so I
expected to research further on TOF and sedation/nonappearance of torment necessities. Most
therapeutic guardians realize that the use of weakening masters requires and
sedation/nonappearance of torment necessities (Franzee et al. 2015). If a patient is stifled and

under quieted, there had been circumstances where patients experience post-traumatic stress
issues (PTSD). This is required to observing what is being said/dealt with in their condition,
anyway unfit to move (Tasaka et al. 2016).
What would I do differently?
Put the TOF screen on prior before sedate the patient to ensure TOF check. Also, I ensure
my patient was sufficiently calmed and nonappearance of torment.
References:
Aitken, L, Marshall, A &Chaboyer, W 2015, ACCCN’s Critical Care Nursing, 3rdedn, Elsevier
Australia, Chatswood, NSW 2067.
Cairo, JM 2015, Pilbeam’s Mechanical Ventilation-Physiological and Clinical Applications,
6thedn, Mosby, United States of America.
Franzee, EN, Personett, HA, Bauer, SR, Dzierba, AL, Stollings, JL, Ryder, LP, Elmer, JL,
Caples, SM & Daniels, CE 2015, ‘Intensive care nurses knowledge about use of neuromuscular
blocking agents in patients with respiratory failure’, American Journal of Critical Care,vol. 24,
no. 5, pp. 431-439, viewed 8 Aug 2019, http://dx.doi.org/10.4037/ajcc2015397.
Tasaka, CL, Duby, JJ, Pandya, K, Wilson, MD & Hardin, KA 2016, ‘Inadequate sedation during
therapeutic paralysis: Use of bispectral index in critically ill patients’,Real World Outcomes, vol.
3, pp. 201-208, Spingerlink database.

Clinical Decision Making Case 1
Situation (briefly include what happened)
A 65 years old Caucasian male patient admitted to the emergency division with serious
shortness of breath. The patient was unimaginably wiped out and rapidly decompensating with
multisystem organ failure. The fundamental care of the patient spun around the respiratory
failure joined with altered mental status.
Action (clearly outline what I did and why)
The second day of the affirmation patient's shortness of breath was not improved; Testing
was performed to join TSH, free T4, BNP, repeated vein blood gas, CT yield of the chest, and
echocardiogram.
Outcome (briefly include what was the result and why)
I found that not every case of shortness of breath is COPD or congestive heart failure
(CHF). A past stacked up with hypothyroidism should raise the vulnerability of myxedema coma
in a patient with any cognitive changes (Hawatmeh et al., 2018). A certified hypothyroidism
emergency prompts critical multiorgan faliure (Wankanit et al., 2018). Myxedema is the
wonderful imitator sickness that affects all organ structures. It can easily be confused with
congestive heart failure, COPD exacerbation, pneumonia, renal injury or faliure, or neurological
insult (Heksch and Henry, 2018 and Assar and Baffoe-Bonnie, 2019).
Plan (where to from here so I can develop further)

I kept an eye on my nursing notes and comprehended that I had not enough learning in
this particular case, I realized that there is always a scope of improvement.
References
Assar, S. and Baffoe-Bonnie, A. (2019). A 45-Year-Old Man Presenting With Sudden Onset of
Shortness of Breath. Clinical Infectious Diseases, 68(9), pp.1603-1605.
Hawatmeh, A., Thawabi, M., Abuarqoub, A. and Shamoon, F. (2018). Amiodarone induced
myxedema coma: Two case reports and literature review. Heart & Lung, 47(4), pp.429-431.
Heksch, R. and Henry, R. (2018). Myxedema Coma due to Hashimoto Thyroiditis: A Rare but
Real Presentation of Failure to Thrive in Infancy. Hormone Research in Paediatrics, 90(5),
pp.332-336.
Wankanit S, Mahachoklertwattana P, Anantasit N, Katanyuwong P, Poomthavorn P.
Myxoedema coma in a 2-year-old girl with untreated congenital hypothyroidism: Case report and
literature review. J Paediatr Child Health. 2019 Jun;55(6):707-710. [PubMed]

Clinical Decision Making Case 2
Situation (briefly include what happened)
A 19-year-old male protested of new frontal cerebral agony, odynophagia, and pyrexia.
He experienced a right-sided focal seizure and was moved to our medicinal facility for
neurological evaluation
Action (clearly outline what I did and why)
Empiric treatment with heartbeat methylprednisolone was coordinated and sought after
with a prednisone decline.
Outcome (briefly include what was the result and why)
Through the range of about a month, his autonomic uncertainty offset and the level of
mindfulness improved. He remained dazed to place and time yet had the choice to share in
physiotherapy and was over the long haul discharged to inpatient recuperation.
Plan (where to from here so you can develop further)
The way wherein we understand and examine illness does and will continue to, change
(Broadbent, 2013). Right, when our available characteristic thoughts disregard to epitomize the
patient experience, we should be anxious to reconsider, reassign, or reevaluate structures; to
intertwine new information at whatever point possible; and to go facing rising requests (Isaac,
2013).
References
Broadbent, A. (2013). Book ReviewJeremy Howick, The Philosophy of Evidence-Based
Medicine. Chichester: Wiley-Blackwell (2011), 248 pp., $61.95 (paper). Philosophy of Science,
80(1), pp.165-168.

Isaac, J. (2013). Thomas S. Kuhn. The Structure of Scientific Revolutions. Introduction by Ian
Hacking. Fiftieth Anniversary Edition. xlvi + 217 pp., index. Chicago/London: University of
Chicago Press, 2012. $15 (paper). Isis, 104(3), pp.658-659.
Conclusion
By receiving relevant and advance education and training, I am moving forward to
enhance my experiences, knowledge and skills for patient care in invasive ventilation.
Undergoing training which is concern about the treatment of patients who need invasive
ventilation would exceptionally help me in improving the services that I offer them. For instance,
the planning enables one to precisely recognize the patients who can go with non-invasive
ventilation rather than invasive ventilation. Nepean Public Hospital offers standard and extensive
study days on airways management and ventilations. These days often revolve around the latest,
evidence based practices in regulating ventilated patients. I will go to these reliably.
To improve my capacities to consider the patient getting hemodynamic assistance, I will
focus on joining the data from invasive and non-invasive hemodynamic support with the
constant checking of patients' physical and neurological conditions. This extensive system in
assessing patients can guide better nursing interventions therefore, positive health conclusions.
Finally, I will endeavor to improve the aptitudes and experience for patients who need
renal assistance by encountering progressively training programs that can furnish me with
dynamically useful skills and capacities. Also, I have requested to NUM of the open ICU to
allow me to learn by helping the nurses, spending more time with them in the unit while giving
Continuous Renal Replacement Therapy (CRRT) to any of their patients and she was

welcoming. She raised a couple of questions that might be outdone as soon as possible. This will
help me in expanding sensible aptitudes appropriate to a patient requiring renal assistance.