NU263CL Unit 3 Clinical Judgment Journal Entry Example

Two Clocks at 0905: A Clinical Journal Entry Using Tanner's Model of Clinical Judgment on a Unit of Blood Arriving for One Patient as a Glucose of 54 Was Reported in Another, and the Half-Eaten Breakfast Tray Where It Began

[Student Name]

Purdue University Global

NU263CL: Medical-Surgical Nursing III Clinical

Unit 3 Clinical Journal Entry

[Instructor Name]

[Date]

The patients and staff are composite; values and times are bracketed where illustrative, and the student acted under the assigned nurse's supervision and the unit's transfusion and hypoglycemia protocols.

What Happened

I had two patients with my nurse. [Mrs. R.], 70, anemic after a gastrointestinal bleed, was due a unit of packed red cells. [Mr. C.], 58, with type 2 diabetes and pneumonia, had received his correction insulin at [0800] based on a glucose of [212]. At [0820] I collected his breakfast tray; he had eaten a few bites of toast and said he felt "off." I wrote it on my notes and moved on. At [0905] the blood arrived from the blood bank. At the same moment the assistant said, "Mr. C.'s sugar is 54, he's sweaty." I had the blood bag in my hand.

Noticing

Tanner describes clinical judgment as noticing, interpreting, responding and reflecting (Tanner, 2006), a sequence that also underlies the clinical judgment model used in nursing education today (Dickison et al., 2019). At [0820], I noticed the tray and his comment, but I did not connect them to the insulin he had been given twenty minutes earlier. At [0905] I noticed the glucose because someone told me.

Interpreting

A glucose of [54] with sweating is symptomatic hypoglycemia that will get worse until treated, and can lead to confusion or seizures. The blood had its own clock: most hospitals require a transfusion to start within a set time after leaving the blood bank, often thirty minutes, and to finish within four hours (Harding et al., 2023). But Mrs. R. was stable, and a few minutes would not harm her; Mr. C. could lose consciousness.

One clock measured a policy limit; the other measured a man's brain. The glucose came first.

Responding

I told my nurse, gave the blood bag to her to check and hang with a second nurse, and went to Mr. C. He was alert enough to drink, so I gave [15] grams of fast-acting carbohydrate, juice, as the protocol directs, and rechecked in fifteen minutes: [88]. He then ate the rest of his breakfast with me sitting there. My nurse started the transfusion at [0920], within the time limit, with the second-nurse check done.

Reflecting: Two Kinds

Tanner's model includes two kinds of reflection: one that happens during care, as the nurse adjusts in the moment, and one that happens later, when the nurse reviews what happened. In the moment, I made a reasonable choice. Looking back, I see that the collision started at [0820]. A patient who received correction insulin and then ate a few bites of toast and felt "off" was heading toward a low. If I had told my nurse then, he could have been given more food or a glucose check, and at [0905] I would have had only one clock.

What the Handover Left Out

At the [0700] report, I heard Mr. C.'s glucose and his insulin, but not that he had been eating poorly since admission. That fact was in the nursing notes from two days before. Insulin given on the assumption of a full meal is risky when the patient is not eating (Harding et al., 2023).

What My Nurse Asked

Afterward my nurse asked me one question: "When did you first know something was off with Mr. C.?" My honest answer was [0820]. She said that was the useful answer, because the next time I see a half-eaten tray after insulin, I will know what it can lead to. She also said that handing her the blood was the right call, and that I should not apologize for asking for help when two things happen at once. That conversation made the reflection easier to write honestly.

Why the Tray Mattered More Than the Glucose Meter

The glucose meter told me about the problem at [0905]. The tray told me about it at [0820], forty-five minutes earlier, when it was still easy to prevent. Correction insulin is dosed on the assumption that the patient will eat. A few bites of toast means most of that insulin had nothing to work against. The meter measured what had already happened; the tray predicted what was about to happen. Learning to read the tray is learning to see a problem while it is still small.

What I Learned

Noticing is not the same as interpreting. I saw the tray and wrote it down, but did not ask what it meant for the insulin already given.

One Habit, Checkable

After any meal for a patient who received insulin, I will check how much was eaten within thirty minutes and tell my nurse if it was less than half. My instructor can check my notes for these entries each shift.

References

Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing clinical judgment model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis's medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04