NU140CL Unit 8 Clinical Journal Example

The Walk That Ended at the Bedside: A Clinical Journal Applying Driscoll's Three Questions to a Composite Shift When a Planned First Walk After Surgery Stopped Because the Patient Grew Pale and Dizzy

[Student Name]

Purdue University Global

NU140CL: Nursing Fundamentals Clinical

Unit 8 Clinical Journal

[Instructor Name]

[Date]

The patient, nurse and shift are composite; values are bracketed where illustrative.

What?

On my seventh clinical day I cared for Patient G, a composite 72-year-old woman on day one after a right hip replacement. Our care plan, which I had written the night before, set a goal for her to walk to the end of the hallway with a walker and the physical therapist's techniques at [10 a.m.]. At 9:50 I checked her lying blood pressure, [132/78], and helped her sit on the edge of the bed. Within a minute she said the room was spinning, her face went gray and she gripped the bed rail. Her sitting blood pressure was [106/62] and her pulse had risen from [82] to [104]. I told her we would not walk yet, helped her lie back down with her legs supported, called my nurse and stayed with her. After ten minutes lying down her pressure was [128/76] and she felt better. My nurse reviewed her chart with me: she had received an opioid at 9:15, had drunk little since surgery, and her hemoglobin that morning was [9.8], down from [12.6] before surgery.

So What?

The walk was the right goal, and stopping it was the right decision. What I learned is why the plan did not fit the morning. I had planned the walk around the therapy schedule without thinking about what else would affect her blood pressure when she stood: the opioid given 35 minutes earlier, low fluid intake and the blood lost during surgery. Each of these makes a drop in blood pressure on standing more likely in an older adult after joint surgery (Potter et al., 2023).

I had planned the walk for the time on the schedule, not for the condition she would be in at that time.

I also noticed what I did well. I checked lying blood pressure before she sat up, which gave me a baseline, and I recognized the warning signs before she stood, when a fall would have been much more likely. I was nervous, but I did not try to push through to meet the goal I had written.

My nurse pointed out something I had missed: I should have sat her up in stages, first with the head of the bed raised, then legs over the side for a minute or two, before standing. That approach gives the body time to adjust and lets symptoms show while she is still sitting.

Talking with Patient G afterward added something the chart did not show. She told me she had felt lightheaded in the bathroom early that morning but had not mentioned it because she "didn't want to be a bother." If I had asked her directly how she felt when she last stood up, before starting, I would have learned that the drop had already happened once. Asking that question is now part of my checklist before any first walk. I also felt the pull of the goal I had written: part of me wanted to try again ten minutes later so the plan could be marked as met. Recognizing that pull, and choosing the patient over the paperwork, was the most important part of the morning for me.

Now What?

The plan was revised that afternoon, adding risk for adult falls, linked to the drop on sitting, as a named problem so the whole team would see it (Herdman et al., 2024). Her walk was moved to two hours after her pain medicine instead of soon after it, she was encouraged to drink more fluids, and sitting up was done in stages with blood pressure checked lying, sitting and then standing. Her nurse informed the provider about the hemoglobin and the drop on sitting. That afternoon she walked halfway down the hall without symptoms. The next morning, with the same staged approach, she reached the end of the hallway and back, which met the original goal a day later than planned.

For my own practice, I will build the timing of medications, fluids and recent laboratory results into any mobility plan, not just the therapy schedule. I will sit patients up in stages after surgery and check their blood pressure at each stage. And I will remind myself that a plan is a starting point to be checked against the patient in front of me. Driscoll's framework helped me move from feeling that I had failed my goal to seeing what the goal had not accounted for (Driscoll, 2007).

References

Driscoll, J. (2007). Practising clinical supervision: A reflective approach for healthcare professionals (2nd ed.). Elsevier.

Herdman, T. H., Kamitsuru, S., & Takáo Lopes, C. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification, 2024-2026 (13th ed.). Thieme.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2023). Fundamentals of nursing (11th ed.). Elsevier.