Reflective Journal #1
Noticing
A patient was admitted for acute myeloid leukemia, not having achieved remission. She
had previously received chemotherapy treatments and stayed due to thrombocytopenia,
neutropenia, anemia, constipation, nausea, and vomiting secondary to treatment. She had
received countless blood and platelet transfusions but her blood counts were continuing
to stay very low.
Subjective and objective data:
o The patients mother stated that the patient seemed to be improving. She reported
no recent nausea or vomiting. The patient had been tolerating drinking fluids and
eating meals. However, mom noticed the patients nose was very runny for the
past week, with no complaints of other symptoms.
o While doing the morning rounds, I noticed that the patient was irritable and
uncooperative. Mom told me that it was just a tantrum and not to feed into it. I
listened to mom and helped the patient go through her morning routine.
o I sat down with the patient and asked if anything was wrong, and she refused to
answer. So I took a mental note to ask how she was feeling around lunch time.
o In the morning, her vital signs were stable.
o In the afternoon, she had a temperature of 100.6 degrees F.
How did you know there was a problem? Abnormal patient presentation or your gut
feeling?
o I had a gut feeling that the patient was acting differently compared to our other
shifts with her.
Interpreting
What other information do I need to make a decision?
Is there anyone else I need to involve or notify?
o I immediately alerted my preceptor of the temperature, and she paged the doctor
right away.
What could be happening and how critical is this situation?
o This situation could potentially be critical. The use of chemotherapy in patients
with AML can cause a prolonged period of neutropenia, which puts the patient at
risk for bacterial, fungal, or viral infections (Schiffer, 2014). After previously
reviewing the CBC, I knew the patients neutrophil count was <1.
Responding
Should I do something now or wait and watch?
o Immediately, the protocols for a neutropenic fever recommend a blood culture, a
broad-spectrum antibiotic, and Tylenol to reduce the fever (Schiffer, 2014). We
drew blood from the patients mediport and did a nasal swab, and sent them to the
lab for testing. We then started IV cefepime.
o Staff would then wait for the lab results to come back and watch if the fever
continued.
How will I know if Im making the best decision?
o I know we made the right decision because we were following hospital protocols.
What interventions can I delegate to other members of the healthcare team?
o I would ask housekeeping to keep the patients room clean and change the
bedsheets daily.
Reflecting
Did I make the right decision?
o I believe that I made the right decision. The patient had contracted C. Difficile
earlier during this hospital stay, and she was put in isolation for 30 days. I would
much rather send labs and start prophylactic antibiotics than see her go through
something like that again.
Did I achieve the desired outcome?
o I have not been assigned to the patient since, so I do not know the cause of the
fever or if the patient improved.
What did I do really well? What could I have done better?
o I noticed the temperature and knew that a low grade fever is more significant with
immunosuppressed patients than their counterparts (Schiffer, 2014).
o I promptly notified my preceptor and we took a repeat temperature after removing
the blankets from the bed.
o I could have practiced speaking with the patients mother about my concerns, but
instead my preceptor spoke with her.
o In the future, I will not be as hesitant to speak with family members and provide
teaching.
References
Schiffer, C.A. (2014). Overview of the complications of acute myeloid leukemia. In: T.W. Post,
Larson, R.A. & Rosmarin, A.G. (Eds.), UpToDate. Available from
https://www.uptodate.com/contents/overview-of-the-complications-of-acute-myeloid-
leukemia?source=search_result&search=AML%20fever&selectedTitle=3~150
