NU298CL Unit 3 Night Shift Reflective Journal Example

Something to Help Him Sleep at 0140: A Reflective Journal Entry on the First Night a Preceptor Reviewed Decisions Only Afterward, When a Composite 81-Year-Old Man Asked for a Sleeping Pill and the Answer Turned Out to Be His Bladder

[Student Name]

Purdue University Global

NU298CL: Capstone Clinical

Unit 3 Reflective Journal Entry

[Instructor Name]

[Date]

The patient, preceptor and night are composite; values and times are bracketed where illustrative, and all medications and procedures followed existing orders and the unit's protocols.

The Arrangement Changed at 1900

Until this night, my preceptor approved each decision before I acted. At the [1900] huddle she told me that from tonight she would review my decisions at set times instead, at [2300], [0300] and [0600], unless I called her. I felt pleased and nervous at once.

What Happened

[Mr. E.], 81, was on day two of treatment for pneumonia. At [0140] he rang and said he could not sleep and wanted "a sleeping pill." He was restless, pulling at his sheets. His medication record listed diphenhydramine at bedtime as needed for sleep, ordered on admission.

A Sentence He Could Not Finish

When I asked how he was feeling, he started, "I just want to get home to my..." and stopped, looking at the window. He did not finish. I asked him to recite the months in reverse order, starting from December, as a quick check of attention. He reached October and stopped. Earlier that evening he had answered the same question correctly. Sudden inattention and fluctuating awareness in an older adult are core features of delirium (Inouye et al., 2014).

The pill would have helped me more than him: it would have ended the call light, and it might have tipped a confused man into a worse night.

Why the Drawer Stayed Shut

Diphenhydramine is strongly anticholinergic, and the Beers Criteria advise avoiding it in older adults because it can cause confusion, urinary retention and falls (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). Giving it to a man who might be becoming delirious could make his confusion worse. I did not give it. I also did not dismiss his request; I asked what was keeping him awake.

Six Hundred and Forty Milliliters

He said he "had to go" but could not. He had last voided at [1900]. A bladder scan showed [640] milliliters. Urinary retention is common in older men, especially when acutely ill, and can cause restlessness and agitation that look like insomnia or delirium (Harding et al., 2023). I called my preceptor at [0155], as she had said I could. She came, agreed, and we followed the unit's retention protocol with a straight catheter under the existing order. [700] milliliters drained. By [0230] he was asleep.

What I Brought to the Decision

I knew the Beers Criteria from pharmacology and the delirium screen from my medical-surgical rotations. I did not know, until that night, how easily an ordered PRN could look like the right answer. The record said diphenhydramine was ordered; the patient asked for a sleeping pill. Both pointed the same way. Only the assessment pointed elsewhere.

What My Preceptor Said

At the [0300] review, she said I had done two things right: I assessed before I medicated, and I called when I needed a second person rather than waiting for the review time. She also suggested I report the diphenhydramine order to the day team, since it remained active for a patient who might be delirious. I added it to my handoff.

How It Felt to Decide Alone

When I left his room the first time, I was tempted to give the pill simply because it was ordered and the decision would be over. Deciding not to give it meant staying with an uncertain situation for another fifteen minutes, which felt uncomfortable without my preceptor beside me. Calling her at [0155] did not feel like failing the new arrangement; it felt like using it the way she intended.

What I Learned

A request for a sleeping pill is a symptom, not a diagnosis. In older adults, restlessness at night can come from delirium, pain, a full bladder, constipation, hunger, fear or noise. The medication answers none of those, and some it makes worse.

One Habit for Later Nights

Before giving any as-needed sleep medicine to an older adult, I will check four things: attention, pain, bladder and the time of the last bowel movement. I will chart each check. My preceptor can verify the habit in my notes at each review.

Still Unresolved

It is not yet clear to me to judge when an older patient's sleeplessness is simply sleeplessness, and when it is safe to give a sleep aid. I plan to ask the pharmacist which options the unit uses for older adults who truly cannot sleep.

References

American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

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

Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922. https://doi.org/10.1016/S0140-6736(13)60688-1