nursing

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A critical analysis of my clinical practice and reflection

Introduction

This assignment will discuss the development of my professional skills, learning opportunities, and activities that have developed and benefited my learning experiences. I will use reflection and referrer back to written work in my portfolio this will link the theory to practice and will show a continuous improvement in the knowledge and understanding that I have gained in previous placements, according to Beskine (2009) practice from clinical placements are fundamental in allowing students to put the theory learned at university into practice under the supervision of an experienced mentor.

As registered nurse I must be able to justify any action or decision made, this can be seen throughout my portfolio as I have tried to justify any action or decision I have made through evidence based knowledge and research findings, according to Richards and Edward (2003) who have stated that public trust and confidence in the profession is dependant on its practitioners being seen to exercise their accountability to ensure that the interests of the patient is respected. The Quality Assurance Agency (1997) has defined a portfolio as a structured and supported process undertaken by an individual to reflect upon their own learning, performance and achievements when planning for their personal educational and career development.

As a registered nurse my goals will be to further my life long learning and gain as many skills as possible to enable me to carry out my practice safely and with competence. The evidence of this shall be shown through the ongoing development of my portfolio, which will identify opportunities for growth in my personal and professional life. According to Nursing Midwifery Council (NMC) 2004, “It is necessary to show motivation and commitment through the development and planning of your own learning”. There will also be discussion on the clinical skills laboratories (CLS).

Main Body

The Students rational for choosing the topic of; compression bandaging for leg ulcers; was the shock, when she realised that the estimated cost to the NHS in managing leg ulcers is £300-600 million a year. (Simon et al 2004) In the UK alone, it has been estimated that between 80,000 and 100,000 people will have had a leg ulcer at one time or another, with some remaining unhealed for more than 10 years. (Walker & Adderly 2007). Managing leg ulcers also places a considerable drain on health resources, with district nursing spending between 25-50% of their time treating patients with leg ulcers (Casey 1999), according to Briggs and Closs (2003), a large part of the nurse’s workload especially in the community is taken up with this task, as people get older they are at increased risk of developing arterial and venous incompetence, which is the underlying cause of leg ulceration, improved life expectancy means the number of people with ulcers is likely to rise (Franks and Moffatt, 2007).

The student noticed this more on her final 14 week management placement with the community nurses; half of her time spent with the nurses was taken up with changing compression bandages. Reflecting back, the student looked at her logs from first year [Appendix 1] and noticed that the treatment of leg ulcers has not changed dramatically in these past three years, but the student’s perception knowledge and understanding of this condition has. Reflection provides a framework upon which individuals can modify both perception and behaviour based upon experience (Dewey, 1933; Schön, 1983). It is also considered to be a central part of developing expertise (Sternberg, 1999).

When the student first went to a community placement in 2nd year, she along with her mentor attended a patient with leg ulcers, [Appendice2] she assisted the nurse when she washed the patients leg, using tap water, the leg was dried and a mixture of 50%50 w/w cream; (Ointment containing 50% w/w Liquid Paraffin BP and 50% w/w White Soft Paraffin), was applied below the knee of the leg, then watched as the district nurse, applied a modified form of compression bandaging.

The student and her classmates had practiced this procedure in CLS labs, week three, “Care of the patient with chronic wounds”; the labs are designed to ensure flexibility of use in providing an environment where clinical skills learning can be facilitated to support a diversity of clinical learning experiences and environments. Every year the NHS pays out about £400 million in settlement of clinical negligence claims.  It is increasingly recognised that up to as much as 70 -80% of medical error could be attributed to poor technical skills; those most at risk of committing errors are inexperienced practitioners. Creating simulated scenarios allows us to practice our skills and make mistakes in a safe environment (Engle 2008).

The nurse explained that there where different causes for the ulcers and also different dressings and compression therapies. The student also looked up the pathophysiology, and the psychological effects of the condition, linking theory to practice, reading journals and articles the student got an overview of the disease, failing venous valves lead to blood pooling in the veins. This is confirmed by the use of a Doppler ultrasound, which tests the flow of blood in the leg. Cells and fluid, from the blood leak into the surrounding tissue, causing oedema. Red blood cells, leak into the tissue and break down, resulting in brown staining of the skin known as, haemosiderin. Further tissue damage occurs when white blood cells clump together to cause inflammatory reactions. Congestion in the veins results in reduced blood flow. Tissues do not receive adequate nutrition and the skin becomes dry, flaky and itchy. Lipodermatosclerosis can also occur, caused by fibrosis of the fatty tissue, making the leg hard and woody to touch, this makes the skin fragile and scratching or trauma may lead to ulceration of the leg and a chronic wound that could take weeks or months sometimes years to heal (Stud 2009).

According to (RCN 2006), (SIGN 26, 1998) compression bandage therapy is the gold standard treatment for venous leg ulcers. The bandage types are classified depending on the degree of sub bandage pressure they exert on the limb, the highest pressure is up to 40mmHg at the ankle (resting pressure), gradually reducing to about 17mmHg just below the knee Anderson (2008). Achieving this healing depends mostly on the patient’s willingness to accept clinically effective care; many of the patients feel that they cannot carry on with the treatment as the compression bandaging is uncomfortable.

The graduated compression starts with the highest pressure at the ankle, this squeezes the lower leg as the calf muscle changes shape on movement, but the muscle movement is constrained by the compression bandage with the effect of increasing the squeeze on the veins in the legs, as the muscle movement is concentrated inward and if the vein is relatively intact it will more likely close with the extra pressure from the compression (Anderson 2008). This movement may prevent the backflow of blood as the calf muscle is strong and the speed of the venous blood is increased it could mean that the white blood cells are less likely to clump together thus reducing inflammation in the blood vessel (Oduncu et al 2004).

Using compression this way, will increase flow, reduce venous reflux and ankle oedema, therefore improving the microcirculation and encourage the healing process (Board and Harlow 2002). As the flow improves nutrients reaching the skin again will improve the sensitivity and dryness of the skin. The compression therapy is not a cure it may be a lifelong process where the patient has to be properly supported.

The patients psychological wellbeing is also monitored, (Jones et al 2008), studies carried out show that patients with chronic leg ulcers suffer from depression and feel socially isolated, they restrict their social lives because of the exudates and odour leaking through the bandages. In many cases the ulcer will heal with relative ease once the oedema is under control approximately 12 weeks (Moffat et al 1992). Larger ulcers may take months or years to heal, (Palfreyman et al 2007) effective treatment should help reduce the symptoms and quality of life for the patients, this is why a holistic approach is needed to ensure the patient’s psychological needs are also met; this in turn may encourage compliance on the patient’s part.

The student is now in her final placement which is back in the community, she has her own case load of four patients. One of these patients has a leg ulcer, she wears compression stockings, while this is not a chronic ulcer great care still has to be taken, as the recurrence rate of venous ulcers is high, hosiery helps to reduce the risk and prolongs the time in a healed state (Bradley 2001).

The student also went out with the district nurse who is mentoring her, she allowed her, under her direct supervision to wash and apply the dressings to one of her clients who has a chronic leg ulcer, it is recognised that students must be given opportunities to participate in various clinical skills, the NMC (2006) requires mentors to be able to support student nurses develop nursing competencies, while being professionally accountable for the student, and also provide support and assessment while on placement.

Prior to undertaking the wound dressing, the student had to demonstrate an appreciation of the theoretical and practical aspects underpinning the procedure of compression bandaging to the mentor. This was done by the student reading journals on wound care, looking up articles on the internet, and then discussing them with her mentor. The client’s consent was given, this allowed the student to carry out the procedure. The student read the last entry in the care plan to see what dressings where used previously. Then she gathered all the equipment that she would need, Towels, cream, water, a dressing depending on how bad the leg would depend on what dressing was used. The bandaging comes in kit form and is priced according to size from £5.65 to £10.58 (Scottish drug tariff 2007).

Reading the care plan the student knew that this patient has had a chronic venous leg ulcer, for about 6 weeks, the measurements were taken at every dressing change to see if the ankle circumference has changed due to the reduction of oedema. The leg was stripped down, it was very wet and smelly, the dirty dressing then went into the bag provided and disposed of in the bin. The leg was washed with Epaderm Cream, this is very effective in moisturising the leg it counteracts the loss of essential oils from the skin.

As the student knew that her mentor was going to ask her to perform the task, she looked up her reflective diaries in her portfolio and read back on them to see how she carried out the procedure then, and how she felt about carrying them out. According to Redfern and Hull (1997), portfolios offer an important contribution in the form of a step-by-step method that reflects practice.

The student had written an account of her past experience in the first year log, as she had not used a model of reflection it was difficult to remember how she felt carrying out the procedure, she did describe the task well enough but the feeling and evaluation would have been useful, how did she feel about the task, was the wound really odorous, was the patient satisfied with the outcome, would she have carried out the procedure the same way, coming back to the present task the action plan would have been very handy.

Gibbs model for reflection (1988), the student has applied this model to most of her work throughout the three years of placements, but at the beginning of her training she did not, she now realises that using models of reflection in essays and practice portfolios gives written evidence that shows critical thinking, and relates theory to practice. Using the six stages of Gibbs reflective model, description, feelings, evaluation, analysis, conclusion, action plan, by using this model the student can analyse her learning experience, and present this as evidence against NMC standards. The student also looked out and read tissue viability journals and wound supplements and searched the internet for wound care information. Current governmental policies have called for all professional groups to work within a framework of evidence-based practice (EBP) which is underpinned by continuing professional development. The essence of all this is to ensure that all health care professionals operate within a framework of clinical governance that assures clinical competence and provision of quality health care. (Basford and Slevin, 2003).

Once the leg was washed and dried a hydrocolloid dressing was applied, this helps absorb some of the exudates, the student then applied the wool padding using a simple spiral technique with a 50% overlap, this helps to protect bony prominences and pads the ankle out. The third step is a light conforming bandage, the foot is flexed to 90 degrees and the bandage is applied from the toes to the knees also using a simple spiral technique with a 50% overlap. The forth step is applying the cohesive bandage, the student made sure the mentor was happy with what was done so far before carrying on she also asked the patient if he was alright, then keeping the foot flexed to a 90 degree angle the bandage was applied with a 50% overlap and a 50% stretch, ensuring the heel was completely covered.

The student felt cautious about carrying out the final stage of this procedure because of the implication, for instance if the dressing was too tight it may cause trauma to the leg, but the mentor supervised all the way through the procedure, when the bandaging was finished the student felt that she had carried the task to the best of her ability, there was a feeling of satisfaction the bandage looked neat and secure the patient offered no complaints. When the student had asked his consent he told her that he would say immediately if he felt uncomfortable, because of the exudates the bandage would only be on for two days not a week as is the usual time in between dressing. The patient will be holistically re-assessed each week and his progress recorded, the student filled in the patients care plan and her mentor countersigned, as a student nurse preparing to register with the NMC you have both a legal and professional duty of care. This should be demonstarted in your ability to keep a record and full account of any assessment and care that you have planned for or provided (NMC 2004).

The student didn’t think she could have done any better, she was pleased that he mentor allowed her to carry out this procedure, a little weary about the 50% overlap and stretching the bandage, but was confident in her practice, the task went smoothly. The student will continue to reflect and study leg ulcers and compression bandaging to further her knowledge.

The mentor observed the student performing the task, under direct supervision, she assessed that the student was working to the correct and appropriate standard for her level of training, this will be recorded in the students assessment practice record and signed. While in practice mentors are assessing students against the NMC standards of proficiency, they are not only assessing their practical skills, but their knowledge levels and attitudes which underpin their practice (Richards and Edwards 2003).

Conclusion

In this assignment I have disscused the learning opportunities and the activities that have helped develope my professional development in the area of compression bandaging for the care of leg ulcers. I have shown that reflection and reference to previous work and teaching materials have developed my skills, confidence, knowledge and intuition in the care of managing leg ulcers and applying the appropriate dressings and therefore linking my theory to practice. I have shown the ability to justify reasoning for any actions or decisions which I make through evidence based practice, knowledge and research findings.

For my professional development and future practice I will continue to futher my life-long learning and gain as many skillls as possible to enable me to carry out my practice safely and with competence. The evidence of this shall be shown through the ongoing development of my portfolio which will identify opportunities for growth in my personal and professional life.


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