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My aim of this essay is to reflect on my learning outcome pressure sore care and management. Pressure sores also known as decubitus ulcers. Benbow (2006) defines it as areas of localized tissue damage as a result of excess pressure, shearing or friction forces. To reflect on my learning process, I am going to apply Gibbs’ reflective model, which is a renowned model in reflective practice. This model requires passing through six stages to complete one reflective cycle. These six stages are description, feelings, analysis, evaluation, conclusion and action plan and I am going to explore in these six steps how I achieved my learning outcome.
In the first stage of Gibb’s reflective model (1988) I will describe the event which inspired me to get competent in pressure sore management. My placement area was a nursing home setting where almost all service users are old age people who are prone to get pressure sores so I had seen many pressure ulcers. However, one particular service user whose pressure wound I will never forget. I will address her as Mrs. N to maintain her confidentiality (NMC 2008). She is an 86 yr old, suffering from dementia and doubly incontinence. She had a big, black and hard wound on her right hip. The skin was intact but it was extremely discolored. According to EPUAP (European Pressure Ulcer Advisory Panel) guidelines, it was grade 4 pressure wound as there were full thickness skin loss and it was covered by necrotic tissues. It was getting foul smell and the wound started to debride from the sides in a few days.
The second stage of Gibbs’ reflective cycle requires me to reflect on my feeling for the event. It was my first day in that unit and I went with a nurse in Mrs. N’s room where she was going to do her pressure wound dressing. I had no idea about her wound’s grade. I started to assist the nurse and as she opened the dressing I was shocked. I did read the description and seen pictures for grade 4 pressure wound (EPUAP guide to pressure ulcer grading) but never seen it in my past practice so it was absolutely shocking for me. I felt very disgusted. I tried to put myself in her place and when the nurse was touching her wound I was feeling like it’s happening to me but the most tragic thing for Mrs. N was that she was not able to express her pain as a result of her dementia. The study conducted by Bale s., C. Dealey et al (2007) had found shocking revelations about the effect of pressure ulcers, amount of pain and its effect on a patient’s life. I was thinking what could be the reason behind it. Is it our negligence or something else for what patient was suffering?
Third stage of Gibbs’ reflective model needs reflector evaluates the event. According to NICE guidelines, a patient who is at risk of developing a pressure ulcer should be assessed within 6 hours of admission (NICE 2003). While in Mrs. N’s case she has been in the nursing home for a long time so her assessment should have been ongoing as she was prone to develop it. The other thing I evaluate was that nurse remains very busy during her shifts so she relies on support staff regarding the patient’s condition so there are chances that nurses missed to assess Mrs. N for pressure sore on regular interval. According to Mockridge and Antony (1999), the nurse must have basic knowledge of pressure ulcer prevention, healing and treatment to avoid the occurrence and discomfort. There are many risk assessment tools to assess patient for pressure ulcer development which I have been familiar during my learning process. These scales known as Norton scale, Waterlow scale and Branden scale (Norton et al. 1985, Branden and Bergstrom 1987, Waterlow 1991 and 1998). It could have been possible to prevent Mrs. N from getting that worse ulcer by carrying out assessment based on one of these scales.
Analysis is the fourth stage of Gibbs’ reflective model (1988). My knowledge about the pressure sore care and management was very limited. According to the code (NMC 2008) ‘you must take part in appropriate learning and practice activities that maintain and develop your competence and performance.’ I decide to get competent in pressure sore care and management as I am going to be a qualified nurse I should have the knowledge and skill to practice safe (NMC2008). I analyzed from this event that first step to become competent in this skill is to learn a proper risk assessment skill using one of the risk assessment tools because prevention is always better than cure. To justify this, during my learning process I carried out some assessment on service users who were vulnerable. I used Waterlow scale (Waterlow, 1998). This assessment helped me to classify ulcer. The classification of wound helps to determine the most effective treatment (Daugherty and Lister, 2008). The next aim should be to minimize the pressure on pressure area. To apply this in my placement area I followed NICE guidelines which suggested that there must be a position changing schedule (NICE 2003). Thus, I participate with my team and we prepared position turning charts for the service users who were at risk of developing a pressure ulcer.
The other factors involve in preventive managements are pressure relief devices i.e., cushions and mattresses, pressure area skin care specially in incontinence patients and ongoing assessments. The next step after the assessment is planning. It is very crucial aid which leads the patient towards fitness. I prepared and the update care plan by following NICE (2003) guidelines and my placement area policy and procedures. I discussed it with my mentor, my colleagues and other support staff to get suggestion and to improve quality of care (NMC 2008). Apart from all above factors, the important management step in grade 3-4 ulcers are dressing. I also analyzed that I need to perform ulcer dressing on Mrs. N’s ulcer to get confidence and to know my abilities. Before starting dressing I discussed with the nurse about dressing materials used for Mrs. N and prepared trolley using aseptic technique. My mentor observed me carry out dressing and I followed the steps as done by tissue viability nurse. I also practice for dressing on grade-2 and grade- 3 pressure sores under supervision which gave me self-assurance. The nursing care is not complete without an evaluation. It helps nurses to critically evaluate the patient’s condition whether it is stable, has deteriorated or improved. During evaluation process I found that our care plans were making significant effects on patient care and helped us to promote their health.
In the fifth stage of Gibbs’ reflective cycle I am going to draw a conclusion following my learning process. I have become competent in the care and management of pressure ulcer. It had provided me skill to practice confidently. If nurses caring of Mrs. N had used their skills and knowledge, then they could have prevented pressure ulcer. There must be busy working environment where for the nurse it is not possible to give detailed attention on every service user but according to the code (NMC 2008), the nurse should work with others to protect and promote the health and well-being of those in her care. I certainly learn the importance of close observation in health care practice.
The final stage of the reflective cycle (Gibbs, 1988) is an action plan which facilitates the reflector to plan for the future. It needs you to prepare a plan of actions to take if the situation arises again and also plan for improvement in future practice. I planned that I will perform pressure ulcer dressing whenever there will be a patient requiring pressure sore dressing to get expertise, to increase my confidence and knowledge . I will read more research articles in this area to dig up more and to deliver the best care based on the best available evidence (NMC 2008). I am also planning to discuss this topic with fellow peers.
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