Since this involved events surrounding a complex decision making at higher level where I am being guided by my mentor consistently, I felt John's model of structured reflection will be useful, and I will follow that in this reflective process (Johns, 1995, 226-235). Consequently, I will pay greater attention to my thoughts and emotions surrounding this event of my recent past experiences.
This is the story of a patient whom I cared for in my placement in the critical care unit. In my placement in the critical care unit, my mentor assigned this patient to me. This is a middle-aged female patient who had abdominal surgery for her Crohn's disease and had been transferred to the intensive care unit for stabilization in a critical condition following anaesthesia. The intention of admission was to stabilize her and help her complete recovery form anesthesia so she can be extubated in the intensive care unit (Adam and Osbourne, 2005, 1-11). At assignment, I assessed her to find that she was sedated, was having very poor spontaneous breathing response, and intubated. She was connected to monitors, and a central venous pressure (CVP) line was inserted. A separate IV line was there, and it was running frusemide infusion at 2 mg/h since she was quite edematous. She was also advised hydrocortisone 50 mg intravenously three times a day along with her medications (Evans, 1998, 8-12). They diagnosed her to be in acute renal failure, and the management was expectant in that it would lead resolution of renal failure quickly. On my systematic assessment on assignment, my examination revealed that she has moderate oozing from her abdominal wound. However, her urine output was less than 40 mL/h, and from the urine in the bag, I thought that her urine was very concentrated. This is unlikely in an edematous patient with frusemide infusion. She was connected to ventilator at a PEEP of 10 to support her breathing. The striking feature was that her CVP was falling (Fitzpatrick and Donnelly, 1997, 271-279), and at the time of my care it was at 6. This was an obvious incongruence, and I discussed this with the Junior Doctor about her situation and requested him to reassess the condition. The doctor refused to relook at the situation and told that it was going fine. I felt frustrated since this patient needed to be assessed immediately for revising the management plan, and I had hardly anything to do (Dowling et al., 1996, 1211-1214).
From my academic learning, I knew that acute renal failure is not uncommon in a patient with prolonged and mutilative surgery. However, the care management must be collaborative in the critical care setting, since nurses remain closely attached to the patients during care delivery monitoring the patient on a minute-to-minute basis. Therefore, I felt I have a chance to know her progress or deterioration better than anyone else (Hudak & Galo, 1997, 16-26). Quite frequently, acute renal failures in postoperative patients are results of fluid depletion or dehydration, since the volume loss in the intraoperative period can be inadequately noticed. As the nurse in charge of her care, I felt the urge to actively participate in her care, and my input from that angle was to reassess her fluid status once again and to