REFLECTIVE CRITICAL ANALYSIS
CLINICAL UPDATE TEMPLATE
Applying Tanner’s Model of Clinical Judgement
NURS 2701
CSI Name: Yvonne Fairclough Learner Name: Ana Caunter
Noticing
Noticing (includes):
• Gathering complete and accurate data (includes subjective and objective data) o Always gather
data directly from the persons involved (individual, family, group, community)
o Sources of data will vary depending on the type of nursing situation - E.g., include data from
sources such as the chart including medical history, lab results, identified patient care
requirements such as medical and interprofessional team orders, consults and notes
• Using systematic approaches (e.g., primary assessment, focused assessment, evidence-based
assessment tools such as pain assessment numeric scale)
• Recognize normal from abnormal findings and identify the most critical
Patient V is a 68-year-old female admitted on January 17, 2026, to the G6 inpatient surgical
unit following a left dynamic hip screw (DHS) fixation after sustaining an intertrochanteric hip
fracture. Prior to this admission, she had a retrograde intramedullary (IM) nail placed for a
distal femur fracture in December 2025. Her postoperative course has been medically complex.
She experienced a Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) on post
operative day one and was transferred to the C7 unit for her heart issues, then to the ICU, and
later discharged to rehabilitation. While in rehab, she fell again and sustained another fracture
on the same side, requiring further surgical intervention.
Intertrochanteric hip fractures occur in the proximal femur and are common in older adults
due to an increased risk of falls, decreased bone density, and frailty (Tyerman et al., 2023).
Surgical fixation using a dynamic hip screw allows for controlled compression at the fracture
site to promote healing, but it also results in significant inflammation, tissue trauma, and
postoperative pain (Foss et al., 2008, Grezda et al., 2021, Liau et al., 2025). Her femur fracture
was repaired using retrograde intramedullary nailing, which involves insertion of a rod into the
medullary canal to stabilize the bone. Both procedures contribute to substantial nociceptive
pain during recovery (Birlie et al., 2023, Foss et al., 2008).
Her medical history is significant for end stage renal disease requiring chronic hemodialysis,
type 2 diabetes mellitus, peripheral vascular disease with previous bilateral bypass grafts,
hypertension, hyperthyroidism, and a previous NSTEMI. These comorbidities complicate her
recovery. Diabetes impairs wound healing due to microvascular damage and reduced immune
Aug2025
SC & LG
, response (Tyerman et al., 2023). Peripheral vascular disease compromises blood flow to the
lower extremities, increasing risk of ischemia, and delayed healing (Johns Hopkins Medicine,
n.d.). Renal failure affects fluid balance, electrolyte regulation, and medication clearance,
requiring careful monitoring of blood pressure and perfusion (Deabes & Essa, 2024,
Kyriakopoulos et al., 2024).
She has multiple surgical wounds on her left hip and anterior upper leg. She also has an
unstageable sacral pressure injury requiring collagenase treatment. Repositioning and pressure
redistribution are evidence informed interventions to prevent worsening tissue damage
(Registered Nurses’ Association of Ontario [RNAO], 2016). Additionally, she is incontinent and
requires assistance with hygiene. Although she is able to feed herself, she requires
encouragement and typically consumes approximately fifty percent of her meals.
She is alert and oriented to person, place, and time, though she previously experienced
hallucinations earlier in hospitalization. She primarily speaks Spanish and has limited English,
creating a language barrier that impacts communication and assessment. She has a supportive
husband who works late shifts and usually visits later in the day, as well as three adult children.
Discharge is planned in three days pending stability.
During my shifts, I performed two sets of vital signs. On the first assessment, her blood
pressure was 158/43, temperature 37.4 °C, pulse 72, SpO2 99%, MAP 75, and her pain was
reported as 8 out of 10. On the second assessment, her blood pressure dropped to 110/46,
temperature 36.8 °C, pulse 68, SpO2 98%, MAP 62, and pain remained 8 out of 10. Although
lower blood pressure readings were generally consistent with her baseline trend throughout
admission, the drop in MAP to 62 was borderline low, as adequate tissue perfusion generally
requires a MAP above 65 (Tyerman et al., 2023).
When I entered her room for the second site of vitals, she initially appeared calm. However,
when I asked about her pain, she stated it remained at an 8 out of 10 despite receiving her
scheduled morning acetaminophen. She then began crying and expressed significant distress.
Due to the language barrier, she struggled to describe the quality of her pain. I asked her to
point to the areas that hurt the most, and she identified her left hip surgical site and her lower
back where the pressure injury is located. While attempting to explain her discomfort, she
became increasingly distressed and began asking for her husband.
In the moment, I focused heavily on her reported pain level and surgical discomfort but did not
immediately recognize the emotional component contributing to her distress. I also did not
fully connect the hemodynamic trend in her blood pressure and MAP with potential perfusion
concerns until later reflection.
CSI feedback:
Good, you noted the MAP, which stands for Mean Arterial Pressure, which represents the
average pressure in a person's arteries during a single cardiac cycle (heartbeat). It is a more
accurate indicator of blood flow (perfusion) to vital organs than systolic or diastolic numbers
alone. MAP is utilized in intensive care units (ICU) to manage patients with conditions like
sepsis or head injuries.
Aug2025
SC & LG
CLINICAL UPDATE TEMPLATE
Applying Tanner’s Model of Clinical Judgement
NURS 2701
CSI Name: Yvonne Fairclough Learner Name: Ana Caunter
Noticing
Noticing (includes):
• Gathering complete and accurate data (includes subjective and objective data) o Always gather
data directly from the persons involved (individual, family, group, community)
o Sources of data will vary depending on the type of nursing situation - E.g., include data from
sources such as the chart including medical history, lab results, identified patient care
requirements such as medical and interprofessional team orders, consults and notes
• Using systematic approaches (e.g., primary assessment, focused assessment, evidence-based
assessment tools such as pain assessment numeric scale)
• Recognize normal from abnormal findings and identify the most critical
Patient V is a 68-year-old female admitted on January 17, 2026, to the G6 inpatient surgical
unit following a left dynamic hip screw (DHS) fixation after sustaining an intertrochanteric hip
fracture. Prior to this admission, she had a retrograde intramedullary (IM) nail placed for a
distal femur fracture in December 2025. Her postoperative course has been medically complex.
She experienced a Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) on post
operative day one and was transferred to the C7 unit for her heart issues, then to the ICU, and
later discharged to rehabilitation. While in rehab, she fell again and sustained another fracture
on the same side, requiring further surgical intervention.
Intertrochanteric hip fractures occur in the proximal femur and are common in older adults
due to an increased risk of falls, decreased bone density, and frailty (Tyerman et al., 2023).
Surgical fixation using a dynamic hip screw allows for controlled compression at the fracture
site to promote healing, but it also results in significant inflammation, tissue trauma, and
postoperative pain (Foss et al., 2008, Grezda et al., 2021, Liau et al., 2025). Her femur fracture
was repaired using retrograde intramedullary nailing, which involves insertion of a rod into the
medullary canal to stabilize the bone. Both procedures contribute to substantial nociceptive
pain during recovery (Birlie et al., 2023, Foss et al., 2008).
Her medical history is significant for end stage renal disease requiring chronic hemodialysis,
type 2 diabetes mellitus, peripheral vascular disease with previous bilateral bypass grafts,
hypertension, hyperthyroidism, and a previous NSTEMI. These comorbidities complicate her
recovery. Diabetes impairs wound healing due to microvascular damage and reduced immune
Aug2025
SC & LG
, response (Tyerman et al., 2023). Peripheral vascular disease compromises blood flow to the
lower extremities, increasing risk of ischemia, and delayed healing (Johns Hopkins Medicine,
n.d.). Renal failure affects fluid balance, electrolyte regulation, and medication clearance,
requiring careful monitoring of blood pressure and perfusion (Deabes & Essa, 2024,
Kyriakopoulos et al., 2024).
She has multiple surgical wounds on her left hip and anterior upper leg. She also has an
unstageable sacral pressure injury requiring collagenase treatment. Repositioning and pressure
redistribution are evidence informed interventions to prevent worsening tissue damage
(Registered Nurses’ Association of Ontario [RNAO], 2016). Additionally, she is incontinent and
requires assistance with hygiene. Although she is able to feed herself, she requires
encouragement and typically consumes approximately fifty percent of her meals.
She is alert and oriented to person, place, and time, though she previously experienced
hallucinations earlier in hospitalization. She primarily speaks Spanish and has limited English,
creating a language barrier that impacts communication and assessment. She has a supportive
husband who works late shifts and usually visits later in the day, as well as three adult children.
Discharge is planned in three days pending stability.
During my shifts, I performed two sets of vital signs. On the first assessment, her blood
pressure was 158/43, temperature 37.4 °C, pulse 72, SpO2 99%, MAP 75, and her pain was
reported as 8 out of 10. On the second assessment, her blood pressure dropped to 110/46,
temperature 36.8 °C, pulse 68, SpO2 98%, MAP 62, and pain remained 8 out of 10. Although
lower blood pressure readings were generally consistent with her baseline trend throughout
admission, the drop in MAP to 62 was borderline low, as adequate tissue perfusion generally
requires a MAP above 65 (Tyerman et al., 2023).
When I entered her room for the second site of vitals, she initially appeared calm. However,
when I asked about her pain, she stated it remained at an 8 out of 10 despite receiving her
scheduled morning acetaminophen. She then began crying and expressed significant distress.
Due to the language barrier, she struggled to describe the quality of her pain. I asked her to
point to the areas that hurt the most, and she identified her left hip surgical site and her lower
back where the pressure injury is located. While attempting to explain her discomfort, she
became increasingly distressed and began asking for her husband.
In the moment, I focused heavily on her reported pain level and surgical discomfort but did not
immediately recognize the emotional component contributing to her distress. I also did not
fully connect the hemodynamic trend in her blood pressure and MAP with potential perfusion
concerns until later reflection.
CSI feedback:
Good, you noted the MAP, which stands for Mean Arterial Pressure, which represents the
average pressure in a person's arteries during a single cardiac cycle (heartbeat). It is a more
accurate indicator of blood flow (perfusion) to vital organs than systolic or diastolic numbers
alone. MAP is utilized in intensive care units (ICU) to manage patients with conditions like
sepsis or head injuries.
Aug2025
SC & LG
