The Heart of Nursing: A Reflective Examination of ICU Patient Care

The reflection in nursing practice is important because it assists the nurse to make sense of their experience to learn their strength and weakness which are to be improved for being a better practitioner. In this assignment, the case study of a patient in the Intensive Care Unit is to be reflected in which I played a part in the care activity. The care episode of the patient is described in detail in appendix 1 and the key care needs are deconstructed in appendix 2. In this reflection, the mentioned patient cared is chosen to be discussed because during the person’s care many hindrances were faced due to which continuous and effective support to ensure quality care could not be provided. The Kolb's Reflective Tool is to be used for developing the reflection regarding the mentioned nursing care. This is because the use of the tool allows critical analysis of the patient condition and needs to reflect the problem in decision-making in care and the appropriate steps taken to resolve them. According to the NMC Code of Conduct, the confidentiality and professional code of working is to be maintained throughout the reflection (NMC, 2018). The four key themes on which the reflection is to be based include documentation, medication administration and management, breathing and inter-professional working.

The documentation of the patient's medical condition is important in nursing as it facilitates to ensure timely and effective delivery of care support to patients. Moreover, it avoids risk of duplication or malpractices in care, in turn, helping the service providers and health professional plan effective treatment and maintain continuous care (Martin et al. 2017). According to Kolb’s reflective model, the first phase is developing concrete experience and the second phase is reflecting on the developed experience (Fewster-Thuente and Batteson, 2018). In the given case study, it was experienced that effective medical documentation of the patient was executed but the health professional and nurses often used abbreviations to mention documentation regarding the care of the patient. According to NMC Code of Conduct, medical documentation of the patient is to be done in detailed manner without abbreviations along with proper date and timing avoiding any nature of manipulation (nmc.org.uk, 2018). Thus, it indicates that effective documentation of the mentioned patient in the case study by following NMC Code was not done.

In the study by Díaz Hernández and Cruz-Gonzalez (2018), inclusion of abbreviations in medical documentation of the patient leads to create confusion and misunderstanding among the health professionals to determine which care is being provided to the patient. This is because the abbreviations for the care are often misinterpreted by the nurse and health professionals due to lack of knowledge and skills. As criticised by Jafarzadeh et al. (2016), lack of proper medical documentation of patient leads to create error in care during transfer of shifts between nurses. This is because the next nurse in the shift may not have proper skill and understand of the abbreviation leading the individual to deliver hindered care to the patient. It is evident from the case study, as I identified that next nurse after my shift faced difficulty to determine the way care for the individual is to be provided due to presence of abbreviation of information in the medical documentation of the patient.

The Kolb’s reflective cycle in the third phase refers to abstract conceptualisation which indicates learning from the experience (Hurley, 2019). In this aspect, the experience led to the learning that effective documentation in detailed manner for the patient’s medical condition is to be made to avoid hindrance and error in care during delegation or change in shift of the nurses. The active experimentation is the last phase of Kolb’s reflective cycle which indicates that planning to improve the learning from the experience is to be maintained (LI and LI, 2017). In this phase, the reflection of the case study regarding medical documentation of the patient-led to plan that full form of the abbreviation is used in documentation is to be mentioned at the end of the report so that it can be referred to avoid confusion for delivery of care.

In relation to documentation, the breathing activity of the patient is also analysed to determine the way lack of proper documentation of the activity in the patient by the nurses posed to develop health issue. According to Roper-Logan-Tierney nursing model, breathing is one of the vital activities of daily living (Holland and Jenkins, 2019). This is because breathing helps intake of oxygen to be delivered to all parts of the body for their proper functioning and release of carbon dioxide from the body to help the body remove waste (de Moura et al. 2015). According to Kolb’s reflective cycle, the concrete experience mentions that effective primary assessment of breathing rate of the patient is maintained by counting and recording respiratory rates to ensure high standards care is provided. However, it is mentioned by Aguilar et al. (2013) that continuous assessment of respiratory rates of the patients is often overlooked due to which it creates hindered effect on the health management of the patients. In the case study, I ensured that continuous breathing assessment of the patient is executed. The observation regarding breathing for the patient indicated that paradoxical breathing from both sides of the chest is not contacting in proper manner. Since the patient was unconscious, thus OLDCART acronym was unable to be performed to determine the breathing efficiency of the patient. The OLDCART acronym stands for onset, location duration, characteristics, aggravating factors, relieving and treatment for assessing pain of the patient regarding any health aspect (Pérez, 2018).

According to Karim et al. (2017), endotracheal (ET) tube is referred to the flexible plastic tube used for patients to help them breathe. The ET tube is later connected to ventilator to ensure proper oxygen is delivered for breathing. Moreover, the study by Chelly et al. (2019) mentions that intubation during accident leads to ensure proper breathing is executed by the individual without any blockage. The review of the experience regarding breathing assessment of the patient indicated that use of respiratory support such as ET tube and intubation was appropriately done for the individual ensuring proper breathing assessment and monitoring is ensured for the patient. The arterial blood gas test ensures measurement of acidity and oxygen along with carbon dioxide level in the blood helping to check the functioning efficiency of the lungs (Kim et al. 2018). This test was also performed in case of the mentioned patient leading to review that effective activity was performed by me and other associate nurses to keep a check on the breathing efficiency of the patient. It led to abstract conceptualisation that breathing support is to be effectively used for patients in the ICU to ensure their proper breathing ability is maintained. This led me to learn that arterial blood gas test is vital to be performed to assess breathing efficiency and ET tube along with intubation is to be used for ICU patients to ensure their proper breathing.

The sedative medications such as propofol, benzodiazepines and others are used in the ICU for the patients for making them show response to mechanical breathing with efficiency (Burry et al. 2017). In case of the mentioned patient, it is seen that vasopressors and inotropes are provided to as use of sedatives have contributed to reduce the patient’s blood pressure while under ventilation in the ICU. The mentioned patient was seen to be provided five medications indicating the patient is under polypharmacy. As per Kim et al. (2018), polypharmacy is administered during multi-morbidity which creates negative effect on the patient's health. This is because polypharmacy acts to reduce the efficiency of action of individual medication to overcome health issues in the patient.

Similarly, from the use of such medications to help stabilise and maintain life, seen interprofessional working being maintained to collaborate effectively from a wide range of health professionals being involved in patient care. As the patient had several issues are seen, health professional, collaborating to obtain safe and effective care as expert ideas and skills can be shared (De Groot et al. 2019). However, it has seen implication when one day a doctor would not accept input from a different health professional and seen a uni-disciplinary approach being upheld and seen them making decisions without taking any information from other, who were specialised in this area. Meaning the patient was placed in unsafe practice, without them acknowledging the patient ethical considerations or personal-centre care goals, by not collaborating correctly. It was signifying, that not only doctor needing to be re-educated but also the professionals around the patient, by not following their code of conduct and standing up to the doctor for unsafe procedures (NMC, 2018).

By reflecting on the key elements, it has been shown that EBP is vital for a nurse to widening their knowledge on why we do specific procedures a certain way (Burns, 2018). The examination of the elements highlighted some implications from nurses using abbreviations to documentation which can see care delivery being altered. Meaning that at re-educating nurses on the importance of documentation has on patient care and advising them on the code of conduct they must maintain (NMC, 2018). Also, the earning opportunity, myself needs to take on learning more medications and their purpose and side effects, to remain professional. While also not, delivering any medication that I am unaware of to prevent any serious health implication to patient I care for. Finally, looking at how collaborative working needs to be maintained in practice while informing leadership styles in each practice to make sure all professionals maintain throughout care so personal centre-care is maintained and one individual does not make decisions. However, from these few implications, showed that the nursing practice was maintained to high standards, and they had also utilising EBP to perform throughout the practice. I will utilise the learning I have obtained and justify it to progress in my professional development and use it to mentor future students by ingraining how it is essential for students to recognise that EBP will help them progress in a clinical area and their general studies.

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References:

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Burns, D. (2019) Foundations of Adult Nursing. 2ndedn. London: Sage Publication.

Burry, L.D., Williamson, D.R., Mehta, S., Perreault, M.M., Mantas, I., Mallick, R., Fergusson, D.A., Smith, O., Fan, E., Dupuis, S. and Herridge, M., (2017). Delirium and exposure to psychoactive medications in critically ill adults: A multi-centre observational study. Journal of critical care, 42, pp.268-274.

Chelly, H., Bahloul, M., Ammar, R., Dhouib, A., Mahfoudh, K.B., Boudawara, M.Z., Chakroun, O., Chabchoub, I., Chaari, A. and Bouaziz, M., (2019). Clinical characteristics and prognosis of traumatic head injury following road traffic accidents admitted in ICU “analysis of 694 cases”. European journal of trauma and emergency surgery, 45(2), pp.245-253.

De Groot, K.,Triemstra, M.,Paans, W., andFrancke, A, L. (2019)'Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews'.Journals of Advance Nursing; 75(7): pp. 1379-1393.

de Moura, G.N., do Nascimento, J.C., de Lima, M.A., Frota, N.M., Cristino, V.M. and Caetano, J.A., 2015. Activities of living of disabled people according to the Roper-Logan-Tierney model of nursing. Rev Rene, 16(3).

Díaz Hernández, S.H. and Cruz-Gonzalez, I., (2018). Incidence and preventability of medication errors and ADEs in ambulatory care older patients. The Consultant Pharmacist®, 33(8), pp.454-466.

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Holland, K. and Jenkins, J. eds., (2019). Applying the Roper-Logan-Tierney Model in Practice-E-Book. Elsevier Health Sciences.

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Kim, S.H., Na, B.G., Lee, E.C. and Park, S.J., (2018). Arterial blood gas test to decide whether to reconstruct single or both the arteries in living donor liver transplantation. Hepatobiliary surgery and nutrition, 7(6), p.440.

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Appendices:

Appendix 1:

Patient Story:

In the intensive care unit (ICU), a male patient was transferred from theatre after being admitted by the air ambulance into accident and emergency. The male patient, 55 years old, had been on a peddle bike when a head-on collision occurred with a car travelling 60MPH. The patient was intubated at the scene with an endotracheal tube put in place to maintain his airway. The patient had been in surgery to have an external ventricular drain (EVD) but in place, to drain the high amount of hydrocephalus. The patient also had an intercostal drain placed on his right lung pleural space and pins to help heal the fracture on his left leg. The patient was already catheterised from theatre and had remained unconscious throughout.

The patient was placed on one to one constant nursing observation. However, it was seen that the abbreviated form of documentation often created issues in delivering proper care to the patient. Thus, effective steps in the remedy of the aspect were done by mentioning full form against the abbreviations used in the document at the end of the page. Documentation was vital and hourly, fluid, GCS, medications, all vital observation were placed on the critical care chart. The critical care chart provided information of all access lines in situ, last bowel movement, Richmond Agitation and Sedation Scale(RASS) scoring and CFS drainage, colour and hight of the drain. All fluid input and output were monitored hourly to obtain a negative or positive balance. Due to the patient having al alter levels of consciousness, a nasal gastric (NG) tube was inserted for him to gain his nutritional requirements and monitored every six hours for positioning and length while changing his tapes daily to avoid pressure damage.

Due to the patient injuries, two hourly turns were facilitated by utilising the log roll technique to keep the spine straight. This seen reliving pressure off different areas thought to turn the patient while monitoring the skin and using ointments to protect any breakdowns in the skin. They were being reviewed daily by the physio, who helped him with limb movements and communicating the next steps in his treatment. While listening to the patient's family and gaining an understanding that he liked to be clean-shaven along with mouth care, brushing his teeth and suctioning were performed due to he being unable to do it themselves. Due to being intubated, the cuff pressure was checked throughout the day to maintain a secure fit, and the tape on his face and his positioning were adjusted to stop pressure damage from occurring.

The patient began exhibiting seizure activity; the doctors administer carbamazepine. An MRI was requested. The patient's temperature spiked to 40.1 degrees. The doctor requested that blood, urine, wound swab and sputum samples to be sent off. In the meantime, ice packs and fans were put in place to help reduce the patient's temperature. The results showed that the patient had sepsis, and the sepsis protocol was started. Fluids and antibiotics were started immediately. However, the patient's temperature remained high, and the doctor put a cooling line into his femoral artery. After this, the patient's blood pressure dropped dramatically, and he was placed on inotropes to maintain good blood pressure so that circulation could be monitored. The lack of exact specification of the inotrope to be provided to the patient in the document created confusion among other nurses when the patient was managed by them in the next shift. However, with immediate intervention from the health professional the issue was resolve where the person mentioned the specific inotrope medication referred to be administered to the patent. The patient was placed on an additional medication that needed his feed to be switched off two hours before and two hours after to avoid complications. Handing this over to the next staff was vital for the patient to be able to receive his medication on time. Throughout this time, the patient's arterial blood gases were taken to monitor his electrolytes, and when the patient's lactate rose to 6.8, this information was passed on to the on-call doctor so that the patient could receive the correct treatment and intervention.