Nursing Practice: Notes from Personal Journal

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Introduction

Reflecting on one’s own practice experiences as a healthcare professional is important for learning from mistakes and improving for the future. All experiences will have positive and negative aspects, which means that every situation has an impact on one’s development as a specialist and an individual (Koshy, Limb, Gundigan, Whitehurst, & Jafree, 2017). In this reflection, I will address my shift activities, discuss assessment techniques, provide lessons learned and challenges, evaluate strengths and weaknesses, and explore the issue of patient safety.

Responsibilities

On my shifts at a post-operation unit, I was responsible for caring for four patients, each of whom was recovering after a surgical procedure. As a career, I was to administer medication, prevent pressure ulcers through turning and eliminate any signs of infection on surgery sites. These responsibilities allowed me to develop effective time management skills. In terms of delegation, I contacted the IV team when needed as well as asked nursing assistants to take patients’ vital signs when I did not have time to take them myself.

Comparison to Past Experience

Compared to the previous experience, my assessment technique has improved significantly. I conducted the head-to-toe assessment of patients and checked their lab values to maintain them within recommended thresholds. An important takeaway was learning how to document patients’ assessments. A new lesson learned during my shifts was giving pain medication to my patients – it had to be a priority. I wrote down the times when the medication was administered to keep track of the schedule and ensure that the patients do not experience any pain.

Reflecting on my previous journal, I was unable to document the experience on the first shift due to technical issues (not having my password and username) (Koshy et al., 2017). This made me focus more on my responsibilities such as changing sheets, giving patients medication, and completing head-to-toe assessments. On the positive side, I considered the issue of risk reduction: I was very aware of my hygiene such as washing hands with soap and wearing gloves at all times. Also, I also made patients wash their hands and prevent them from touching their surgery wounds, and avoiding myself to do so when checking their condition.

Caring for Patients

The four patients for whom I cared were recovering from surgery, and all of them required different care. The first patient had abdominal surgery and was given staples; the second had left hip surgery, the third had total hip surgery and was on patient-controlled anesthesia and was at high risk of respiratory distress, the fourth had ear surgery and did not stay in the unit for too long.

When caring for these people, I took care in controlling their pain levels, educating them on post-surgery care, responded to their calls for help, monitoring vital signs, checked surgery sites for infections, and completed head-to-toe assessments. In terms of medication, I administered Heparin to prevent blood clots because the patients did not move enough and stayed in bed (Nagata et al., 2017). Oxycodone was given to relieve moderate to high levels of pain.

Conclusion

Overall, I would like to point out that my experience of caring for four patients in a post-operation unit gave me new knowledge and skills. I learned how to manage my schedule based on patients’ needs and vital signs. I was effective in conducting head-to-toe assessments and became more prepared to address any challenges that had appeared along the way.

References

Koshy, K., Limb, C., Gundogan, B., Whitehurst, K., & Jafree, D. J. (2017). Reflective practice in health care and how to reflect effectively. International journal of surgery. Oncology, 2(6), 20-24.

Nagata, K., Browne, K., Suto, Y., Kumasaka, K., Cohmetti, J., Johnson, V., … Pascual, J. (2017). Early heparin administration after traumatic brain injury: Prolonged cognitive recovery associated with reduced cerebral edema and neutrophil sequestration. Journal of Trauma and Acute Care Surgery, 83(3), 406-412.

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