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Case study of demonstrating learning in practice

The purpose of this assignment is to provide evidence that will demonstrate my learning in practice. It will contain four reflective accounts that will display my ability to meet the learning outcomes of this module. Amulya (no date) describes reflection as a process of exploring your own actions and experiences, and further states that the purpose of reflection is to develop learning. Johns (2004), expands on this and describes different layers of reflection, for example reflection in action. This type of reflection occurs at the time of experience, pausing to make sense of the situation and proceeding to a desired conclusion. I will be reflecting on experiences, which is defined by Johns (2004 p 50) as “learning through experiences”, thus changing perceptions of myself, practice and gaining new insights. Benner (2001) supports learning from experience and states that through experiences it enables the nurse to move from, competent to proficient, further stating that the proficient nurse will be able to hone in on the most important problems. These learning outcomes will be addressed in turn, discussing what I have learned and highlighting areas for future development. Further evidence can be viewed in Section 2, Appendix’s 1 to four and Section 3; these documents are my learning contracts from the placement I completed.

Learning outcome 1 is to recognise and explain the inter-related nature of aetiology, pathophysiology and clinical features of named conditions that cause health care problems. The appropriate evidence based management required and the anticipated outcomes. Campbell (2006) states an understanding of physiology and pathophysiology is deemed necessary in the understanding of treatment and the management of patients, thus improving patient care. Dunning (2003) supports this view and says the nurses understanding of pathophysiology and classification of the disease process such as diabetes improves the care they provide.

This is a reflective account, of an episode of care, which I was involved in. My patient had been admitted for ketoacidosis. Diabetes UK (no date) describes ketoacidosis as acidity of the blood caused by excessive amounts of ketones. Johnson (2004) expands on this and states it occurs from the lack of glucose entering the cell which is used as energy. As a result the body then uses its own store of fat as an alternative for energy and this use of energy produces an acid known as ketones. Dunning (2003) describes clinical features as hyperglycaemia, which is a result of decreased use of glucose by the cells and the increased glucose produced by the liver; dehydration and electrolyte loss resulting from polyuria and lastly acidosis is due to the breakdown of fatty acids and production of ketones. They go on to say that symptoms include, increased thirst, this is the bodies attempt to flush out the ketones; fatigue, abdominal pain, kussmauls breathing and tachycardia. As the ketones rise the person may also start to vomit, however vomiting reduces the urine output thus reducing the flushing out of ketones. As a result a coma will develop and this if left untreated can be fatal. Diabetes National Service Framework: Standard (2002) states treatment for ketoasidosis , consists of the administration of insulin, potassium and fluids. Brunner & Suddarths (2004) says fluids are given intravenously to manage dehydration, insulin would be given as a 5 unit bolus every hour, however the amount of insulin to be administered is calculated by the amount of glucose detected in the blood. This is what is referred to as an insulin sliding scale, the set amounts are shown on the insulin recording documentation. Potassium is also given to manage the electrolyte loss.

Johnston (2004), states, Ketoasidosis is caused by missed dose of insulin, illness or infection or a sign of undiagnosed or untreated diabetes. My patient suffers from diabetes type 2, and had missed his morning dose of insulin as he was going on an early morning fishing trip and thought he would be fine without his insulin until tea time. Campbell (2006) states, there are two types of diabetes mellitus; type 1 and type 2. Further stating that, diabetes is said to be caused by genetic predisposition or possible environmental triggers, causing an autoimmune attack on the pancreases Beta cells. Additionally, states Type 1 is the complete destruction of Beta cells, people with this type will always be insulin dependent. Where as in type 2, is a reduced function in beta cells, or more commonly, a disease of the insulin receptors. Campbell (2006) further describes Beta cells as a detector of blood sugar, when blood sugars rise, the beta cells produce insulin. He goes on to say that “Insulin lowers blood glucose levels by converting soluble glucose into insoluble glycogen for storage in the liver and muscles” Campbell (2006 p,24).

Although my patient became well very quickly and was discharge two days later, during the time I was caring for him, I established that he was not taking his insulin regularly, was a heavy drinker, suffered from depression and his diet was poor. Additionally, this was not the first time he had been admitted for ketoacidosis. Having spoken to my patient regarding these concerns and offering him help from other professions, he refused and would only consider input from the diabetic nurse.

Because my understanding of the condition was limited, I chose to explore this condition further, after accessing literature regarding the care of patients with this condition. I could clearly see that it was a condition that had the potential to cause many other conditions. National Institute for Health and Clinical Excellence (NICE) guidelines (2009) on the care of people with diabetes, support these finding, stating diabetes is a serious health condition that can have an effect on most areas of the body.

Conclusion

Having cared for this patient and explored the literature and guidelines surrounding the care and management of patients with diabetes, I have now gained new insights into the condition. For future learning I will be continuing to develop my knowledge on the conditions related to diabetes and the management of these.

Learning outcome 2 is to critically discuss the role of the nurse and members of the inter-professional team in the holistic assessment and management of care, with particular respect to the clinical, interpersonal and therapeutic skills employed across a range of acute care contexts. Barrett, et al (2005) discussed that the quality of care provided to the patients resides in how effective the team work together. This is supported by the Department of Health’s (DoH) (2000) health policy which places inter-professional working as a priority to improve the service provided to patients. Muetzel (1988) describes a therapeutic relationship as being based on a partnership, which he describes as an association between two parties, in a joint activity which incorporates, physical, psychological and spiritual level of communication between people that has meaning and value.

This is a reflective account of an episode of care I was involved in regarding a lady, who was brought to the ward from A&E after falling, whilst out shopping and sustained a fracture to the right hip. After receiving a hand over from A&E staff I explained to my patient I would be coming back to take some details from her. When I arrived back with the relevant care pathway she was looking very nervous and somewhat upset. I immediately put my paperwork down, got a chair and sat down beside her. This was the beginnings of the therapeutic relationship where we engaged in a conversation where she explained she was feeling scared about going to theatre the next day. I didn’t dismiss her feelings, I said I understood her concerns, yet I assured her she was in the best hands and we would take care of her. I explained procedures to her such as our fasting policy, in a very relaxed manner, maintained a smile and gave reassurance that the team looking after her were very good.

She seemed to become less nervous and I continued to carry out observations and fill out the care pathway. Care pathways utilise, multi-disciplinary teams, to ensure integration, between health and social care (NHS 2010), thus ensuring that the holistic approach to patient wellbeing has been adopted. This care is consistent with NICE, (2009) guidelines on hip fractures. Before going off shift I went back into the ward to say good night, my patient said she was doing fine and said “it was nice to be cared for and have been greeted by someone friendly”. I thought it was very nice of her to compliment me. On reflection I could see that I was not as organised as a fully trained member of staff, however all tasks were completed and I had applied Rogers (1996) core conditions and at that point my patient was relaxed and trusted me to provide her with “best care”.

The day after surgery she was assessed by a physiotherapist and occupational therapist (OT), who are part of the wards Multidisciplinary Team (MDT). This involvement has further developed my understanding of the assessment of patients prior to discharge. Having been directly involved in the assessment of this patient and many others, I have become familiar with the assessment of daily living activities. This is a nursing model which focuses on the activities of daily living. For example sleeping, mobilising and personal care and suggests that the assessment process should be formed around daily living skills (Aggleton & Chamers 2000). However, the assessment is carried out by the OT’s and the result of this assessment will be discussed between nursing staff and OT’s. My placement area works very closely with the MDT, the team comprises of Nursing staff, Physiotherapist, Occupational Therapist (OT), consultants, doctors and a nurse specialist in orthopaedic surgery. There is a daily MDT meeting, which normally takes place in the morning, our role as a nurse is to liaise with the other team members. During this meeting new patients who need to be seen are discussed, patients who are ready for discharge are highlighted as well as patients who are improving. Changes to how a patient can mobilise or changes to equipment are then discussed. The outcome of this meeting is passed on to Nursing staff during handover and documented in the nursing notes there is also a section in the care plan designated for each member of the team this allows all staff to see clearly what has been documented. Good records are vital when caring for a patient, which is stated by the Nursing and Midwifery Council (NMC) (2010). As well as, updating mobility assessment documentation, our role as a nurse is extensive, we support with personal care, administer medications, liaise with doctor and consultants, provide support to family members, also referring patients for further rehabilitation, this may be in their own home or into a step down hospital.

Conclusion

This has been the first time I have managed a patient from admittance to discharge with minimal support. Although, this patient recovered well and there were no problems, this proved to be a good learning experience. I followed instructions guided by the care pathway, and the, DoH (2004) toolkit, which is use by MDT’s, to ensure a simple and smooth discharge from hospital. For future development I will continue to gain more confidence when communicating with the MDT and doctors.

Learning outcome 3 is to recognise the value of clinical decision making and practice in accordance with professional, ethical and legal frameworks that ensure the primacy of client interest and well-being. NMC (2008) states, that you are accountable for your actions, omissions and decisions, further stating, that you must work in a professional ethical manner. NMC (2004), Standards of Proficiency for Pre-registered Nursing Education, highlights, the need to act in accordance to the code as well as in accordance with legal frameworks.

This reflective account took place whilst working on placement. I had just started on shift and had not received a hand over and the porter arrived to collect a patient to theatre. I was the only person available to accompany her, I was told all her paperwork was in order, so off I went. On arriving at the waiting area I began to collect the relevant documentation from her file, although the consent section on the pre-theatre check list stated she had consented, I could not find the consent form. When one of the recovery nurses came to ‘check list’ the patient I informed them I could not locate the consent document. She went through the file and produced a piece of paper, which she explained was a consent form, which had been signed by her husband, as she must be unable to consent herself. My patient was asleep and was unable to answer any of the checklist questions.

On returning to the ward I was given a hand over, where I discovered, my patient had dementia and could not consent herself, she also had a living directive which stated she was not to be resuscitated. I had not cared for anyone before that lacked capacity and was not familiar with the document. Although from working on another placement I had some understanding of living directives. My lack of knowledge in this area has directed my learning to look further into these two areas. I have sense accessed DoH (2001) document on Good practice in consent implementation; consent to examination or treatment and am now familiar with the four types of consent forms used.

Consent is an ethical and legal requirement that is cited in the MNC (2008) code of conduct and needs to be sought from all patients before carrying out treatments or care. It is fundamental to good practice, its principle is that people have the right to decide what happens to their bodies. This principle is also conducive with the Human rights Act (1998). This is also supported by the Department of Health, Social Services and Public Safety (2003). Dimond (2008) states, when a person is unable to consent themselves, someone such as carers, relatives or someone in the health care profession can consent for them, in their ‘best interests’. The ‘best interests’ is a key principal when a patient is incapable of making their own decisions, working in the best interests of the patient is to consider what the patient wants. The DoH (2003), further highlighted that decisions made in the best interests should not only consider medical interest, but, individual values and preferences when the patient was competent, as well as considering quality of life. The best interests is also cited by the Mental Capacity Act (2005), according to this act someone can be deemed as having lack of capacity when they have an impairment of functioning of the brain or mind. MIND (2009) also endorses working in the best interests of the patient. There is no doubt that my patient lacks of capacity and this decision had been made under this act several years ago. When my patient had capacity she appointed her husband as her advocate who would act on her behalf when her mental health had deteriorated, she had also written a living directive as mentioned above.

Living directive are also cited in the Mental Capacity Act (2005), stating that, after such time as the person lacks capacity to consent they can make specific requests regarding continuation or treatment not to be carried out. It is important to note that my patient has clearly stated she must not be resuscitated this statement is specific and does not state that vital treatment should be denied. It is my assumption and that of the health care providers that every effort is made to protect and preserve life, however it is also stated in the NMC (2008) code of practice that I must respect and uphold the decisions made by my patients regarding their care and the right to refuse treatment. These principles are also stated by the General Medical Council (GMC) (2008).

I was involved in her care whilst she recovered from surgery, during this time although consent could not be sought, the principles of best interests also apply to providing personal care and assisting with eating and drinking and taking medication.

Conclusion

From being involved in the care of this patient and exploring the surrounding literature. I now have developed a more in-depth understanding of the complexities of consent. For future learning I will continue to develop my knowledge regarding current legislation and will be looking at how a person is assessed to establish lack of capacity.

Learning outcome 4 is to demonstrate the ability to apply key concepts and theories, deploy a range of cognitive and transferable skills and problem solving strategies in the management of a client with acute care needs. To demonstrate my achievement of this learning outcome I will be exploring the relevance of blood pressure (BP) in our clinical assessment and the management of a patient who was hypotensive post operatively, as a result of hypovolaemia.

This is a reflective account regarding a patient, whose care I was involved in during placement. My patient is an eighty five year old lady who was admitted with a fractured hip, which was operated on. However, after ten days the wound was not healing and was still oozing. It was decided that she would be taken back to theatre to wash out the wound. Pre operative observations on my patient tended to fluctuate, on occasions she was tachycardic recorded at 102 to 105 and hypotensive, recorded at 95/52. (Dougherty & Lister 2008 p, 623), a state, Hypotension, is the term used to describe “low blood pressure”. Waugh & Grant (2006) say, uncorrected hypotension leads to an insufficient blood supply to the brain and other essential organs such as the heart itself and the kidneys. It is a serious and potentially life threatening condition.

Pre operative observations are used to establish a base line, to compare future measurements on and a marker, of physiological changes post operatively (Dougherty & Lister 2008). However in my patient’s case, due to the base line pulse being around 95 to 102 and BP being recorded at 95/56, her deterioration was missed by recovery staff. I took handover on her return to the ward, they reported no concerns, as observations were the same as pre- operatively.

BP, is defined by, Campbell (2006 p108) “as a combination of pressure that is generated by the contraction of the ventricle and the resistance of the blood flow as it passes through the arterial system”. He further states the equation for this is “cardiac output x peripheral resistance”.

I monitored my patient’s blood pressure using electronic sphygmomanometers. (Dougherty & Lister 2008) describe a sphygmomanometers as a, device which consists of an inflatable cuff to restrict blood flow, a measuring unit, a tube to connect the two. Going on to say to take an accurate reading ideally the brachial artery is used, however in the event the arms are damaged the popliteal artery can also be used. The person must have their sleeve rolled up, the cuff needs to be the right size for the patient and they must be relaxed, sitting or lying still.

Blood pressure is measured in numbers, the first number is the systolic pressure, which is the maximum pressure in the arteries when the heart beats and the blood is pushed around the body. In healthy adults it is typically around 120mm Hg (Waugh & Grant, (2006). The second reading, is the diastolic pressure, this is minimum pressure in the arteries between heart beats, when the heart relaxes to fill with blood and in healthy adults is about 80mm Hg Waugh & Grant (2006). The difference between systolic and diastolic pressures is known as the pulse pressure Waugh & Grant(2006). It is an important aspect of the readings obtained as narrowing or widening of this figure can be indicative of serious disease states, such as cardiogenic shock or hypovolaemia.

On receiving the handover I was initially not concerned due to her base line observations being much the same as reported by recovery staff. However hospital policy states observations must be done on arrival back to the ward. At this point her blood pressure was 79/46, pulse 105 respiratory rate 14, and temperature was 34.5 in the right ear and 35.5 in the left ear. My patient was now scoring six on the Modified Early Warning Score (MEWS). I was on my way to report my findings, when the doctor from the ward appeared and I asked him to assess my patient and explained the clinical changes that had occurred. At this point I called for my mentor to assist, as I am aware of my own limitations and accountability. He instructed us to stop the Hartmans fluid and infuse her with 250ml of Volplex and a further 250mls was given as no changes in observations were noted. Volplex according to the British National Formulary (2008, p, 480) is a “plasma substitute”. IS Pharmaceuticals Ltd (2008) further describes Volplex as a colloidal plasma substitute which increases blood volume cardiac output stroke volume blood pressure and urine output which protects the kidneys from the effect of hypovolaemia. As well as Volplex, 2units of blood was also given as her haemoglobin was 7.6.

I feel that not only can I carry out the skill of taking accurate BP’s, both with the use of electronic and manual sphygmomanometers. I also understand the relevance of blood pressure in clinical assessment and this skill can also be transferred to any ward setting, a GP’s practice, done in the community or in any care home or nursing home setting.

Conclusion

I was aware that hypotension post- operatively could be caused by dehydration but was unaware that Hartmans was a sufficient enough fluid at this stage, which would not increase her blood volume thus increasing blood pressure. As a result of my involvement in the care of this patient and due to my further research I am now fully aware of the importance of blood pressure in clinical observations and the management hypotention in acute care. Although, I have not highlighted hypertension in my account I have briefly covered this in my research. However For future learning I will be looking in greater depth at the complications caused by the long term effects of hypertension.

Summary

From working on this acute module and researching my subject choices I have learned the importance of have an underpinning knowledge on pathophysiology, clinical manifestations and the evidence based management of these conditions. Though the process of reflection I have uncovered gaps in my knowledge and brought to my attention areas for future learning, these areas have been highlighted throughout my reflective accounts. The NMC (2008) support lifelong learning and state that I must keep up to date with new knowledge and skills and deliver care that reflects on the best available evidence.

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