Assignment: Clinical Daily Journal

Assignment: Clinical Daily Journal
Assignment: Clinical Daily Journal
Please include in the Journal how to meet the objective of Healthy People 2020 initiative.
Daily Journals (see p.8 course syllabus for format). Students are required to maintain a written journal of their activities in the clinical area. The journal should include how you are meeting both the course and your personal goal (s) and objectives. This also provides a vehicle for communicating with your clinical instructor, a means of evaluating your progress as well as self- reflection. Entries should be made for each clinical day and the journal should be submitted according to format on p. 8 course syllabus or per your professor’s instructions/preference.
· I am doing community service in a Daycare Center for children age 3-5 years of age. I usually go on Wednesday from 11:00 am through 4:00 pm and Thursday from 7:00 am through 2:00 pm. I help feed the kids, clean after their messes, play with them in the court yard, take the male kids to the bathroom etc.
Journal format:
Headings as follows should be boldfaced:
Date of the activity.
What did I do? (Brief description of the activity)
What did I learn from this activity? (Personal reflection)
What were the positives about the experience?
What were the negatives about the experience?
What recommendations can you offer to enhance this learning experience?
What Are the Benefits of Keeping a Clinical Journal?
If you’ve ever watched Grey’s Anatomy, you’ll recall that Meredith uses her mother’s clinical journal notes as a source of inspiration and reflection.
“What a terrific idea!” I thought as a rookie nurse when I saw an episode where she did this.
“I need to start keeping a clinical journal!”
I would file away scenarios I saw in the ICU so that if I had a patient in a similar position in the future, I would have some kind of prior knowledge to draw on.
It helped me gain confidence and gave me a means to track my development from deer-in-the-headlights beginner to still-terrified-but-better-poker-face ICU nurse.
A clinical journal can assist you in a variety of ways in a position with a high learning curve and several opportunities to learn from experience.
It might assist you in gaining knowledge from previous experiences.
A journal can assist you in not just learning from your experiences, but also in applying what you’ve learned in future situations.
Let’s imagine your patient’s oxygen saturation level drops rapidly after the nurse administers IV dilaudid.
His chest moves up and down, but his oxygen level continues to drop.
You stand there watching as the nurse places one hand in front of the patient’s nose, tilts his head back, and elevates his chin (need a visual?
Here’s a video).
Suddenly, the patient begins to breathe again, and the oxygen saturation level rises.
What the hell happened just now?
When given opioids, some patients’ airways collapse, especially after surgery when they are still recuperating from anesthetic agents.
The patient was still trying to inhale, as seen by his chest moving up and down, but his airway remained blocked.
To check for air movement, the nurse placed her palm in front of the patient’s nose.
She conducted a chin-lift procedure to open the airway when she noticed no breath was moving.
The patient began to breathe again, and the oxygen level rose.
You reflect on what prompted the occurrence, what evaluations were made, what the solution was, and how the patient responded as you record this scenario in your journal (sounds a lot like the Nursing Process, doesn’t it?).
What will you do the next time you observe a patient occluding their airway?
Hopefully, you’ll try a chin-lift or jaw thrust maneuver (one of the simplest and most beneficial things a nurse may perform for a patient with airway-related respiratory compromise!) as well as calling for assistance.
Consider how confident you’ll be the next time you take a report on a patient who you suspect may be at risk for an airway blockage, such as a patient on a PCA for obstructive sleep apnea.
Debriefing after clinical is the MOST valuable technique you can use to help you progress from a beginner nurse to the expert nurse you desire to be, whether you’re a student or a practicing RN.
Download the debriefing form I made for you and use it every time you finish a clinical rotation or a work day.

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