NRNP 6810 Week 11 Reflection Example

Reflection Using Gibbs' Cycle: A Father's "She's Not Herself" Filed Under History, and What It Should Have Changed

Student Name

College of Nursing, Walden University

NRNP 6810: Primary Care Approaches for Children

Instructor Name

Month Day, Year

Reflection Using Gibbs' Cycle: A Father's "She's Not Herself" Filed Under History, and What It Should Have Changed

Description

Three weeks into the term, a father brought his 3-month-old daughter to clinic for a cough that had started two days earlier. Early in the visit he said, "She's not herself. She's quieter than usual." Her temperature was 37.6 °C, heart rate 150, respiratory rate 40, and oxygen saturation 98%. Her lungs were clear and she had mild nasal congestion. I wrote in the history, "Father states infant 'not herself,'" examined her, found nothing more, and planned supportive care for a cold. Before the family left, my preceptor asked the father what he meant by "not herself." He said she had taken 2 ounces at each of her last two feeds instead of her usual 4, and had not cried for a feed all morning. A catheterized urine sample showed a urinary tract infection, and she was treated that day.

Feelings

At the time, I felt confident; the vital signs were within the ranges on the card in my pocket. Afterward I felt embarrassed that I had written the most useful sentence of the visit and then treated it as background.

Evaluation and Analysis

What went well: I recorded the father's words in quotation marks, so they were not lost. What went badly: I did not ask what they meant, and I let a normal-looking set of vital signs outweigh them.

The first course idea I missed was the caregiver as the person who has watched the child across days. The father had seen his daughter at every feed for three months; I had seen her for fifteen minutes. His statement was a comparison with her own baseline, which no exam finding of mine could supply. The evidence supports treating that comparison as data. In a systematic review of clinical features for identifying serious infection in children in developed countries, parental concern was a strong red flag in a primary care study, with a positive likelihood ratio of 14.4 (Van den Bruel et al., 2010). I had heard a red flag and written it down as a quote.

The second idea was that findings must be read against the norms for the child's age, and read with evidence behind the norms. I called her vital signs normal because they fell within a printed table. When I later read the systematic review by Fleming et al. (2011), I learned that published reference ranges for children's heart and respiratory rates often disagree with centiles derived from data on healthy children, sometimes crossing the median. Her heart rate of 150, while calm and nearly afebrile, sat above the median for her age on those centiles. That did not make it abnormal, but it made it something to weigh alongside the father's concern rather than a reason to set that concern aside.

Part of why I moved on was the structure I was working in. The note template puts history in free text and vital signs in fields that turn red when a value is out of range. Nothing turned red, and free text never does. I was also running behind, and a normal set of numbers felt like permission to finish. Neither of these excuses the omission, but both explain how easily it happened, and both will be present in the next clinic too. That is why the change I describe below has to be a habit that works inside the template, not a resolution to try harder.

The two ideas point to the same error: I treated one source, the numbers, as the finding, and the other, the father, as the story. Gibbs' cycle asks what sense can be made of the situation (Gibbs, 1988). The sense I make of it is that I had ranked the evidence by where it appeared in the note rather than by what it could tell me.

Conclusion

When a caregiver says a child is different from usual, I will treat that as a finding to be examined, not a quote to be recorded.

Action Plan

In the next course, whenever a caregiver describes a change from the child's usual self, I will ask two follow-up questions before examining the child: what exactly is different, and since when. I will record the answers under the objective heading as caregiver-observed change, with the caregiver named, and I will address it by name in the assessment. My preceptor in the next course can check this by reading the assessment section of any note where a caregiver reported a change and confirming it is addressed there. I will also replace the pocket card with age-based centile charts and look up any vital sign that sits above the median before calling it normal in a child whose caregiver is worried.

References

Fleming, S., Thompson, M., Stevens, R., Heneghan, C., Plüddemann, A., Maconochie, I., Tarassenko, L., & Mant, D. (2011). Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: A systematic review of observational studies. The Lancet, 377(9770), 1011-1018. https://doi.org/10.1016/S0140-6736(10)62226-X

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit, Oxford Polytechnic.

Van den Bruel, A., Haj-Hassan, T., Thompson, M., Buntinx, F., & Mant, D. (2010). Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: A systematic review. The Lancet, 375(9717), 834-845. https://doi.org/10.1016/S0140-6736(09)62000-6