Reflective Journal: Clinical Assessment in Post-Operative Care

This reflective journal entry details a student's experiences in a post-operative care unit at the Royal Darwin Hospital, focusing on two patient cases: one involving cardiovascular surgery and another involving brain surgery. The student utilizes the Gibbs reflective model to analyze each experience, describing the situations, their feelings, evaluations, and analyses of the events. The first reflection involves a patient with hypertension, diabetes, and substance use, while the second involves a patient recovering from brain surgery and suffering from migraines. The student reflects on providing holistic care, acute care, and the importance of emotional intelligence and applying learned techniques. The conclusion summarizes the key learnings from clinical assessments and the application of the Gibbs model, highlighting the acquisition of observational skills and evidence-based care. The report also includes an action plan for future considerations, emphasizing the importance of further research and analysis to enhance patient care outcomes.

Journal Reflection

Table of Contents
INTRODUCTION ..........................................................................................................................4
MAIN BODY ..................................................................................................................................4
Gibbs reflective model ...............................................................................................................4
CONCLUSION................................................................................................................................6
REFERENCES................................................................................................................................7

INTRODUCTION
Reflective journals are personal records of students’ learning experiences. Students typically are
asked by their instructors to record learning-related incidents, sometimes during the learning
process but more often just after they occur. Clinical Assessment is a way of diagnosing and
planning the treatment which involves evaluation of any patient problem to figure out what is
wrong. Report will lay emphasis on Gibbs reflective model. It will be based on Post-operative
care.
MAIN BODY
Gibbs reflective model
Reflection 1
Description- I was being placed at the Royal Darwin hospital in post -operative care unit. I
worked as a nurse over there. I took care of patient who underwent cardiovascular surgery.
Service user was also suffering from hypertension and diabetes. This was the main reason he
suffered from the cardiac arrest. Patient also had a habit of drinking alcohol and smoking cigars.
Feelings- When I was treating the patient I was extremely emotional by seeing the service user
in pain. The effect of anaesthesia was also seen in her as she was in unconscious condition. I felt
pity over her condition. As a nurse I was engaged in providing her with acute care. So that she
can feel better.
Evaluation- I have evaluated that during my placement, I learnt about how to provide holistic
care to post-operative patients. This care helped me in identifying the patient’s current situation.
I analysed that Individual patient’s l have different psychological and emotional responses to
surgery influenced by the type of surgery they are having and why they require that surgery.

Analysis- During my placement as a nurse in post-operative care unit, I have analysed that this
work gave me the opportunity to learn about how to provide acute care to patients. I was also
able to be friendly with service user. It was very helpful in my career.
Conclusion- I learnt about providing evidence based care to post-operative patient suffering
from cardiac arrest. I also attended number of ward services that helped me in increasing my
observational skills. It also supported me in better understanding of patients.
Action Plan- For future consideration, I will have deep research on the problems faced by
service users. This will allow me to contextualise my learning and also enhance the care I
provided. It will also improve the health outcome of patients(Levin and Diaz-Arrastia, 2015).
Reflection 2
Description- I was being placed at the Royal Darwin hospital in post -operative care as a duty of
nurse. The patient being assigned to me had undergone Brain Surgery for the diagnosis of Brain
haemorrhage. The patient was also suffering from the Migraine and this made the person more
aggressive and uncooperative. The reason behind this operation was the blockage in his veins in
the brain which made to rise the Blood clots in the nerves of his Brain. The patient also had the
habit of consuming unwanted drugs as a solution to his problems. Migraine was much severe that
the patient use to be more disturbing and angry while the treatment.
Feelings- While during my treatment I was much afraid and felt pity on patient as he was much
aggressive but had to bear severe pain. At times the patient would also shout over his treatment
as due to pain and the reduction of anaesthesia over the time. But considering my profession as
priority and sticking up to my basics and what I have learnt before, I applied the same and
handled the situation accordingly.
Evaluation- I have evaluated to during my placement that to provide a proper physiotherapy
during the post-operation period and have learned its different techniques that are used to
improve the condition of the patient. What I have mainly learned is about the trigger points to
targeted of the patient so as to help him recover fast and with less pain as well. Also, my I had
better experience in identifying different problems and their solution for patient;s condition
during post-operation period.

Analysis- During my placement as a nurse in post-operative care unit, I have learnt how to get
away from the emotions and apply the basics of my knowledge and perform properly in critical
situations. I also analysed to create the positive understanding with the patient and remain
mentally strong for the success of the treatment. This placement also helped my in analysing
different types of situations arsed during the treatment with acute care for the patient. Overall it
was beneficial part of my career learning and experience.
Conclusion- I learned about assisting all the basic components of treatment required during the
treatment after Brain haemorrhage operation and also learned to create a positive mindset during
the treatment without showing emotions. It also made me learn about the few points that can be
pressed in order to provide relaxation and improvement of the pain being suffered by the patient.
On observing my fellow mates and my seniors treating the same type of patients also helped me I
acquire more knowledge in this field and learn different techniques.
Action Plan- For future opportunities I would like to make a deep research and analysis of the
problems being faced by the service users. Also, I would make a research on my observed
techniques from my seniors and their consequences after its application. This will let me have the
complete turn around knowledge regarding my area of specialisation and also help grow in my
career(Haynes and et.al., 2018).
CONCLUSION
From the above report it is observed that the study of clinical assessment in different type
of situation for the patient. The report consisted Gibbs reflective model which was based on the
reflective report on Post-operative treatment of the Cardiovascular patient and Brain
haemorrhage patient. The both reports analysed the different critical problems and finding out
the appropriate solution to them and thus availing the benefits gained by the placement in certain
departments by an individual. The report lastly concluded by the different learnings from the two
departments of the placement and also focussed on future implications being discussed by the
individual.

REFERENCES
Books and journals
Haynes, S.N and et.al., 2018. Scientific foundations of clinical assessment. Routledge.
Levin, H.S. and Diaz-Arrastia, R.R., 2015. Diagnosis, prognosis, and clinical management of
mild traumatic brain injury. The Lancet Neurology. 14(5). pp.506-517.