Professional Documents
Culture Documents
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
My patient was a 25yo, G2P1, 37w4d gestation with twins who presented to L&D in labor, but scheduled for an
elective repeat c-section. This situation was challenging because the dynamics of a c-section, coupled with the fact
that she was having twins made the documentation and attention to detail in the OR so much more important.
Another challenging aspect for the care of this patient was that her postpartum, 4th stage of labor which is typically
the 2-4 hours post-delivery, wasn’t typical either. I left this shift feeling like something could go wrong based on
her bleeding and urine output. However, I was assured that the findings were still OK and that she would just have
to stay on the L&D floor longer than the typical singlet, vaginal delivery, until she was stable enough to be moved to
the mother-infant unit.
Noticing
When we initially assumed care of this patient I knew it was going to be an eventful evening because she has arrived
in labor for her c-section at 1830, we assumed her care at 1900, and her c-section was scheduled for 1930. All this
meant that it was my job to perform my shift assessment quickly, make sure her babies were tracing on the fetal
heart monitors successfully, get her up to the bathroom, and prep her for surgery. Thankfully, for us, the doctor was
hung up in traffic so we had a few extra minutes to prepare. The second challenge I noticed was all the detail and
documentation required in the OR during a c-section. As the L&D circulating nurse you document the timing on,
literally, everything. The exact times each person walks in and out of the OR, the times for each step of prep, each
step of surgery, each step of delivery for two babies, placenta, ect. While you’re supposed to be timing everything,
you are also the gopher for the doctor and scrub techs when they need extra supplies, while also being in charge of
verifying 4 counts of all surgical supplies with the scrub tech. It’s just overwhelming the amount of detail required
as the L&D circulating nurse in the OR.
During the postpartum, 4th stage of labor, for this patient I noticed larger amounts of lochia than I’d ever seen
before, but I was reaffirmed that while it was more than I’m used to, that it was still considered “moderate” because
of the fact that she was a cesarean section patient with twins. I’d never cared for a patient with these circumstances
before which would explain the larger amount of lochia for this patient versus every other patient I’d cared for. I
also noticed her urine output from her Foley was barely making the 30mL/hr cut.
Interpreting
Describe the clinical judgment or clinical reasoning that you performed. The example should include
alternatives you considered, and rationale for your decision.
Based on my assessment findings during each fundal check I was concerned about the amount of lochia I was
expressing with each check. We are taught that soaking a pad in one hour is considered heavy bleeding and this
patient was soaking a pad every 30 minutes in the first postpartum hour when we are required to do fundal check
every 30 minutes. My initial thought went to postpartum hemorrhage, but I used my clinical judgement and also
knew that her fundus was firm and midline. If she was hemorrhaging, her fundus would have been boggy and it
definitely was not. I decided to keep my preceptor in the loop on all my findings and express my concerns to get her
feedback. It was at this point that she assured me that we were still OK, but that we would certainly keep an eye on
it as the hours progressed. I was vigilant in performing my fundal checks on time just to make sure the bleeding
wasn’t increasing. All of this was occuring at the same time that her vitals were being taken. Had she been
hemorrhaging her vitals would have told the story as well. Her blood pressure would have been tanking, her pulse
would have be increasing and she would have shown us other symptoms of shock. None of these things were
occuring so I had to trust that the experience and clinical judgement of my preceptor was correct. The other issue
was that she was just barely putting out an adequate amount of urine. She was basically putting out almost exactly
30mL/her for four hours post-delivery. We used clinical judgement and bolused her with IV fluids to increase her
output. Rationale for this action was that she had a spinal and her bladder maybe wasn’t working as efficiently as it
should yet. With the boost of fluids her urine output did eventually creep back up and after our shift she was
transferred up to the mother infant unit without any complications.
Responding
What written evidence have you drawn upon for the care of your patient in this example? Provide
cites/references.
According to a study conducted by Suzuki, Hiraizumi, & Miyake, “the prediction of maternal complications such as
a postpartum hemorrhage requiring transfusion may be more important in cesarean deliveries for twins than those
for singletons, because overdistention of the uterus may weaken the contraction and retraction of the uterine muscles
and increase the risk of substantial blood loss in twin pregnancies” (2012). However, this same study concludes that
the risk factors for postpartum hemorrhage in the c-section of twins includes a gestation age >/= 41 weeks and/or
hypertensive disorders. My patient does not fit any of these criteria, so her initial “heavy” bleeding, which was
actually only moderate in nature, was most likely just due to the circumstances of her delivery since no other
assessment findings support that of an actual hemorrhage.
As I progress in my nursing school career I am learning that every patient presents differently and no one necessarily
goes “by the book” so it will be my job to always consider the worst, but to look critically at all the circumstances
when evaluating my patients.
Socialization is best facilitated when the new nurse feels part of a group. How has this precepted experience
and working one-on-one with a dedicated preceptor helped you to become socialized into the nursing
profession?
I believe this precepted experience has had tremendous benefits socializing me into the nursing profession.
Personally, I already feel like the nurses on my unit are all willing to teach and help out with my questions. I’m
already getting the feel of what it will be like to work with this team and I am excited that I will get that opportunity
in February. Because my preceptor is really great about letting me do everything on my own, under her supervision
I’ve gotten so many opportunities to feel like I’m actually caring for the patient on my own as an independent nurse
and I think the other nurses on the unit see that in me as well. I can confidently say that I feel like I am working
well with the nurses on this unit and I feel like they have already accepted me as a peer, rather than a student, which
feels good.
Write your final program outcome objectives and discuss you have met them. This section should address all
5 final objectives.
Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment Model. Journal of
Nursing Education, 46(11), p. 513-516.
Suzuki, S., Hiraizumi, Y., & Miyake, H. (2012). Risk factors for postpartum hemorrhage requiring transfusion in
cesarean deliveries for Japanese twins: Comparison with those for singletons. Archives of Gynecology and
Obstetrics, 286(6), 1363-1367. doi:10.1007/s00404-012-2461-9