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The purpose of this reflective essay is to critically analyse the clinical assessment and nursing care of a patient suffering from an Myocardial Infarction (MI). This essay also reflect my personal experience and knowledge I gained in a coronary care unit (CCU) which will be useful in my future development. I used Gibbs model to reflect on my experience of caring for a patient with a Non ST elevation MI or NSTEMI (Gibbs 1988).The National Service Framework (NSF) for coronary heart disease (CHD) set standards for the prevention, diagnosis and treatment of CHD (DH 2000).Myocardial Infarction (MI) is one of the major causes of morbidity and mortality in the United Kingdom (NICE 2002).
Reflective practice is one of the key processes of learning within the health professions. It enables you to reflect on actions taken and analyse what you may have done differently and how you will handle similar situations in the future. Learning comes from how you handle different incidences and experiences and reflection is a key part of this. There are a number of models to choose from such as John’s model of reflection (1994), Kolb’s learning cycle (1984) or Atkins and Murphy’s model of reflection (1994). However, this essay will use Gibbs’ model of reflection (1988) to critically analyse the clinical assessment and nursing care of a patient suffering from a Myocardial Infarction (MI). This essay will use the model as devised by Gibbs as a framework.
Gibbs’ model of reflection (1988) is based on six separate elements. It would be worth looking very briefly at each stage before continuing. Stage 1 of this model is the description. It requires you to set out the context of the event such as who was there and what was happening? Stage 2 is feelings. This is how you felt about the event and how you felt about the outcome. Stage 3 of Gibbs’ model is the evaluation. This requires you to consider the experience as a whole. What went well and what do you feel wasn’t so successful. Stage 4 is an analysis of the event as a whole. It requires you to break down the event into it’s separate parts and look at each part in more detail. What sense can you make of the situation? Stage 5 is the conclusion. This stage invites you to question what you might have done differently or what more could you have done given all the facts. The final stage of Gibbs’ model of reflection is an action plan. What would you do if you encountered the situation again? What about your actions would you change? This is the structure that this essay will follow.
Stage 1: Description
I was working as a nurse in a Coronary Care Unit (CCU) in London. NMC guidelines (2004) requires healthcare providers to protect all patient’s confidential information. From this point I will be referring to the patient as Henry.
Henry is a 45 year old male who was admitted into the Accident and emergency Unit of the hospital where I was working with crushing chest pains radiating to his left arm and his back. Henry had had no previous or family history of coronary disease. The initial observations showed that he had stage 2 high blood pressure (138/78), a heart rate of 85, respiration of 15 and a temperature of 36.5 degrees centigrade. Saturation was 100% at 28% oxygen via face mask. An ECG done in A&E showed ST depression in leads 11,111 and AVF less than 1mm. TroponinI was>32ng/ml.
In A&E an initial dose of aspirin and 300mgs of clopidogrel was given to Henry. 80mgs of Clexane was also given, along with 5mg of morphinesulphate. 2 puffs of GTN spray was also administered. He was then transferred to CCU for further management. I first came into contact with Henry that morning when he was handed over to me. He had been in a stable condition when he was admitted to the CCU and had said that he had had a pain free night but later complained to one of the senior sisters that he had in fact been suffering but didn’t want to disturb anyone since the pain occurred from 4am onwards.
When I first encountered Henry he was pale, cold and clammy. GTN spray was administered and I also started oxygen at 28% as his saturation was at 98%. Henry had said his pain was in his central chest and back regions. His ECG results showed ST depression 2mm in leads 11,111,aVF. At this point his BP was 126/80,his heart rate was 100, his respiration rate was 19 and he had a temperature of 36 degrees centigrade. Once I had informed the registrar of this I started a GTN infusion and his blood pressure dropped to 110/76.
I then wanted to assess the level of pain that Henry had said he was in. I used a numerical rating scale to determine the level of his pain. This numerical scale provides a valuable measure of the understanding of the intensity of pain (Thompson et al, 1994). He had initially scored an 8 out of 10 but after the GTN infusion was administered this dropped down to 5.
He was then started on 50mgs of Tirofiban in 200mls of normal saline and 20,000units of heparin infusion. During this time the registrar arranged for an emergency angiogram at a nearby hospital in London. I arranged for the transfer to be made in the hour. Upon his return, angiogram on his return I checked his angio site for bleeding. I did an ECG and placed him on a cardiac monitor. I checked pedal pulse and did circulatory check in his right leg every hour. I advised him to stay in bed for few hours to avoid bleeding.
When it was discovered that Henry had an Inferior NSTEMI he was scheduled to have an emergency percutaneous transluminal coronary angioplasty (PTCA) which is performed by passing a balloon tipped catheter from an artery in the groin or arm and guided to the blocked artery of the heart (American Heart Association, 2008).The balloon is then inflated and removed, leaving in metalstent which squashes the fatty deposit that has been blocking the artery and therefore allowing blood to flow more easily. Jowett and Thompson (2003) argue that this method is very useful in alleviating symptoms and improving the prognosis of the patient.
I was able to explain the procedure to Henry and then prepared him for the operation by shaving his groin and checking his bloods (including a coagulation screen). I also inserted venflon for intravenous access administered medications such as aspirin, informed the next of kin. The angiography had shown that Henry had 70-90% stenosis in proximal and midsegment section of vessel. The left coronary artery was free of obstruction therefore patient had PCI with drugeluting stents in the right coronary artery.
The procedure was successful and I was able to start Henry on the first phase of his cardiac rehabilitation before his discharge. This involves a risk factor assessment and giving advice on how to lead a healthier life through reducing stress, having a healthier diet and taking regular exercise. I also gave him advice on his new drug regiment which would be an important part of his rehabilitation. Of course, longer term rehabilitation is required for patients who have gone through what Henry has gone through. He agreed to attend a exercise program once a week to be conducted in the hospital.
A Myocardial Infarction (MI) can have a huge psychological effect on a patient. The changes that a patient is required to make to their lifestyle after suffering an MI can also have a damaging psychological consequences. Before Henry was discharged I had him fill out a questionnaire that would help determine his depression and anxiety levels based on the Hospital Anxiety and Depression (HAD) scale.
Stage 2: Feelings
As a nurse I know that it is impossible to give round the clock, exclusive care to just one patient. I had other patients to attend to on that day who needed my care just as much as Henry. However, I still felt frustrated that Henry was in so much discomfort and I was also annoyed with myself for not having picked up on this when he had been initially handed over to me. It was left up to the senior sister to tell me that he had been pain during the night. I also felt frustrated that he didn’t feel like he could tell anyone about the pain that he had been experiencing.
I felt that on the whole my communication skills had been lacking on this occasion. Had my communication skills been better, I could have picked up on the pain Henry was in much sooner. This is perhaps the strongest feeling I have about this experience.
Overall I felt relieved that I was able to discharge Henry. CHD is a massive killer in the UK and working on the CCU one experiences many outcomes that aren’t as positive as Henry’s. Of course, I know his life is going to have to dramatically change as a result of his MI but I felt like I had done my best to prepare him for these changes.
Stage 3: Evaluation
This stage requires a reflection of the experience as a whole and to look at the aspects that were successful and also to look at aspects that weren’t so successful.
Overall I was pleased at the outcome of this experience. However, there are always areas that could be improved on. Perhaps the greatest failure came from not knowing soon enough of the chest pain that Henry had suffered through the night. Had his pain been reported or picked up on sooner then I could have possibly prevented some of the myocardial damage. The GTN infusion could have been administered sooner. The purpose of this infusion is partly because it is useful for analgesia but also because it is useful for the control of ischaemia as it relaxes the smooth muscles, arteries and veins leading to vasodilatation (Hatchett and Thompson, 2007). Had I known of Henry’s chest pain right from the start it would have been possible for me to administer this as soon as he was handed over to me.
The CCU I work in follows the ESC guidelines for management of NSTEMI. In accordance with this, I started Tirofiban and Heparin infusion. Tirofiban is a nonpeptide mimetic antagonist of glycoprotein 11b/111a receptor. Because Henry was limited by unstable signs and symptoms, protocol states that Tirofiban in combination with Heparin and Aspirin will have lower incidence of ischemia.
I thought that the care that Henry received before his PTCA and the speed in which he was able to have this surgery was a great success. The PTCA was also a particularly successful. In the BHF Randomised Intervention Treatment of Angina (RITA3) trial of patients with NSTEMI, invasive strategies (PTCA or CABG) were found to be better when compared with more conservative strategies (Collnolly et al, 2002).
I also felt that the care Henry received after his PTCA was very successful. The long term effects of this are yet to be realised but in the short term I felt that Henry responded very well to the lifestyle changes he was being asked to make. The long term care of patients who have suffered from CHD requires coordination across many different health care professions. It is often for patients to slip through the cracks and skip the parts of the rehabilitation that they find too hard. However, I felt that Henry was determined to get back to a normal life as soon as possible.
Stage 4: Analysis
The purpose of Gibbs’ model of reflection (1988) is to learn from your experiences. I feel that this stage has been adequately covered by the description given in Stage 1. In this previous section I have given a step by step breakdown of the events as they unfolded. Each part from Henry’s admission, to his treatment to the initial stages of his rehabilitation have been covered in sufficient detail above.
Stage 5: Conclusion
As already mentioned, one of the areas which I felt was most inadequate throughout this whole experience was communication. Jowett and Thompson (2003) argue that in the highly technical and invasive atmosphere of a CCU, good communication can sometimes be lacking. Ashworth (1984) argues that a patient needs to feel like healthcare professionals such as nurses need to be helpful, competent and approachable. Nurses in turn have to recognise the individual needs of the patients in their care. This is an area where there were obvious failures. Henry didn’t feel able to express the fact that he was in pain because he didn’t want to be a nuisance. In an CCU where it is a highly charged atmosphere, it is possible that the patient may feel quite a lot of discomfort but won’t speak up because they may feel that they are inconveniencing someone or also they may feel that everyone in the CCU is probably feeling worse than them so they should just deal with the pain and not speak up. This failure to communicate is both the fault of the patient and the healthcare professional but the healthcare professional should be able to recognise when a patient is in pain.
Stage 6: Action Plan
Clinically I feel all the proper guidelines and protocols were applied in the case of Henry. As has already been stated, what was lacking is the communication. I am likely to encounter similar situations again as a nurse in a CCU. CHU is a leading health concern in the UK so it is important that one is able to learn from experiences and use them when encountering similar situations. The role of nurse in a CCU is one that is rapidly evolving and changing so it is important to learn from experiences and apply this learning to everyday practice.
What my experience with Henry has taught me is that I need to treat each patient as individuals with individual problems and with differing levels of communication skills. Some patients are good at communicating what they feel while others aren’t. Spotting that Henry was in pain sooner may have led to less damage of his heart tissue. Of course the damage had already been done before he came into hospital but I may have missed signs that I should have picked up on when he was initially handed over to me. As nurses we should be striving to make the patients in our care as comfortable as possible. This especially important in a CCU where patients are having to deal with a variety of problems and a wide range of emotions. It is easy to get caught up in the highly charged atmosphere and not see the patients as individuals. This is something that I aim to work on in my future career as a nurse.
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