Student Name: Dave Jay S. Manriquez CPE 4: Class 201509
Instructor Name: Asal Makhmour September 2, 2016
SELF REFLECTIVE JOURNAL MIDTERM
(What is not working -> Plan to correct it)
1. Time Organization
What is not working: In duty, I am always in my own pace. I do not have that sense of urgency
that the job require me to do. I tried to hassle up and do things on time. But I guess there are times
that I am really behind schedule. I am the type of person that I schedule myself on things that I
need to do on a specific time but with my own pace. But I guess on the career that I chose time is
an asset need to be valued. The reason behind why I fall off schedule is that I talked too much with
my patient which is good because I am able to establish rapport and the same time know the reason
why they are hospitalize, but the downside of it I am consuming too much time and sacrificing
other important staff like general assessment.
Plan to correct it: Well, to organize my time properly I to need to focus my mind on the things
that I need to do. For example, at the beginning of the shift I need to check directly the blue and
red binder to check the admitting diagnosis, v/s schedule, diet, activity, IV being hook up, and any
drainage. I will be also checking for allergies, code, medical history if any, latest doctors order,
and lastly the medication scheduled and PRNs. After that I may go directly to check the night shift
report on the staff room. If there is still time before 0730 for the morning shift report I can meet
one of my patient who’s my number 1 priority to take a quick QPA and v/s. After the report I may
see my second and third patient doing same stuff with the 1st patient. At exactly 0800, I need to
chart all the vital signs I had taken and fill out the 24 hours flowsheet with my assessment findings.
If I am assigned for that particular day to give medication I will be checking the chart if I have
medication due to be given. Perform any nursing skills and assessments necessary prior to giving
any medications. Recheck doctors’ order again, take note for significant laboratory results. Do
morning care, provide patient with new gown and blankets. Make a draft for the interdisciplinary
notes. Take the first break, when return do medication or any skills that is available to do. At 1200
to start writing notes to the interdisciplinary sheet, take last break, help the staff with their other
patient. At 1330 join the post conference together with my classmates and instructor before calling
the day off.
2. Medication Administration
What is not working: I am very disorganize with my first medication administration attempt. I
am late in giving the medication. I am not prepared with my medication. It took me a long time to
prepare the medication. I am leaving the binder anywhere. I forget to bring the MAR with me to
the patient room to identify them. I forget my two identifiers, my instructor need to prompt me
with it. I am putting the MAR on the patient bed instead of just holding it.
Plan to correct it: My second attempt for drug administration is much smoother because I already
learnt my lesson from the first attempt. What I did to improve my performance is that I take note
all the advice that my instructor is telling me with my first try. What I am doing is that I am taking
it one patient at a time. I am getting their MAR from their binder, so that I can return the binder
on the shelf. I take the MAR with me and prepare all the medication I needed by getting them out
from the ward stock (omnicell) or patient specific (cart). I prepare the medication by doing 3
checks and 7 rights. I go inside the patient room bringing the MAR with me, do two identifiers,
and providing information to the patient about the medication they are receiving. I make sure that
they are taking the medication by staying with them. I’m no longer putting the MAR on the patient
bed. After giving the medications I am documenting it right away by signing.
3. Focus Assessment/Head to Toe Assessment
What is not working: At first I am not confident of what I am doing. I know what to assess but I
have doubt in myself if I am doing it correctly. It take me a long time until now to complete my
assessment, and the fact that I’m talking to the patient so much especially if I just meet the patient.
Plan to correct it: In doing my focus assessment I need to be direct and task oriented, but off
course I will not be forgetting that I’m still dealing with a human being. If I have question to the
patient it need to be direct and on point. I need to do my physical assessment from head to toe for
at least 5 mins. I need to time myself in order to be trained. I need to train myself in using the
different equipment’s to aid me with my assessments like the bladder scanner and Doppler,
although I have already used them, I need to be expert and fast in using them. If there are abnormal
findings on my vital signs I need to report it immediately to the primary nurse and maybe after an
hour I will take again the vital signs to further confirm it and doing continuous monitoring.
4. Writing Nurses Notes
What is not working: I admit that my English word are really limited and my vocabulary is not
that much. When I am writing my wording is quite long and flowery instead of being direct. I have
problem in looking for the right words to shorten up my sentences. Because of these when I am
writing it will really take a lot of time before I can compose and finish what I am doing. Another
thing is that I am not writing my assessments immediately to the 24 hour flow sheet. If I am busy
there is a possibility that I miss things that I need to write in the 24 hour flow sheet.
Plan to correct it: In regards to writing in the 24 hours flow sheet and interdisciplinary notes I
just need to shorten up my writing but still direct to the point. I need also to be specific for any
task that I have done and be clear in my notes like doing a wound dressing. I need to write in there
the things I used in cleaning the wounds, how I clean the wounds, the description of the wound,
and the dressing I applied to cover the wound. I also need to write my focus assessment, significant
findings, and the things I’ve done to correct the situation. I just need to organize myself so that I
can finish my writing on time and not be delayed.
5. Nursing Skills
What is not working: At first I am hesitating to do any nursing skill. I do not have the confidence
in doing any nursing skills. I am so anxious if someone is watching me while performing any
Plan to correct it: Since I already brought home all the practice kit with me, I am practicing at
home just opening the tray, to maintain sterility and preventing from being unsterile. I am
reviewing my old notes from the lab regarding different nursing skills and drug administration. I
am taking down all the instruction and comments done by my instructor while performing a skill.
I am observing the staff while they are doing a nursing skill and learn from it. I am asking questions
when in doubt. Now, if there is an opportunity to perform a skill I will just grab it, I will no longer
hesitate, and I will no longer be fearful. This is the career I chose. I’ve done it before even though
I lost that confidence cause I been away for so long as a nurse. I am regaining back that confidence
by doing it.