Reflective Essay on the Importance of Nutritional

Introduction:

In this essay, using John’s Model of Reflection 2000, I will reflect on scenario where a student nurse encountered a patient with CKD stage 3B and failed to conduct a nutritional assessment because she felt the patient’s condition was too complex for her to handle. Here, I begin by identifying the importance of regular nutritional assessment to CKD patients, and how failure to conduct regular assessment endangers the patient’s life.

Chronic kidney disease (CKD) is characterised the presence of abnormalities in blood biochemistry, urine analysis, histopathology or imaging (Kopple et al, 1989). According to Hakim & Levin (1993), patients with CKD develop malnutrition as a major feature, and this malnutrition may be of different degrees depending on the CKD stage. Nonetheless, the more advanced stages of CDK experience high malnutrition characterised by loss of appetite, impaired absorption and digestion, metabolic acidosis and dysgeusia Fein et al (2003).

The importance of nutritional assessment for patients with CKD has widely been documented in academic research papers. For instance, one study by Malgorzewicz et al (2011) found a 40.7% improvement of patient appetite after receiving nutritional supplements for three months. Specifically, a study by Malgorzewicz et al (2011) found that the patient’s normalised protein catabolic rate (a protein indicator) increased above 1g/kg per day while receiving the nutritional supplement. This is important because a normal protein catabolic rate of 1 and above indicates that the patient is under an optimum nutritional intake, while one below 0.8 g/kg per day indicates a sub-optimal nutritional intake. Hence, conducting a regular nutritional assessment is important in establishing the patient’s protein catabolic rate to determine their nutritional requirements. Besides, it is important to have a regular nutritional assessment and management of such patients especially considering the fact that many studies have shown that malnutrition has led to increased mortality (Health & Care Professionals Council, 2016).

A Reflection on the Student’s Initial Handling of the Referral

In the video, the student nutritionist failed to take up a referral because she felt the patient’s condition was too complex for her. In this scenario, I opine that the student acted unprofessionally by rejecting the referral in such a manner. Whereas she was not comfortable with handling the patient, it would be better if she informed her supervisor, in prior, that she could not handle the patient, and why she felt that way. Otherwise, leaving the referral on the supervisor’s desk seemed against professional conduct which requires caregivers to be proactive in giving care to patients. By leaving the referral on the table, she put the patient at risk because no one else could have bothered to assess the patient without knowing that she had rejected the referral. In my case, I would have dealt with the situation in a better way by either asking for support from the supervisor or requesting for the patient to be reassigned to a different nutritionist. HCPC (2016) points out that the importance of cooperation and inter-professional teamwork in healthcare settings is to ensure that practitioners support each other in delivering safe and quality care for the patient. Moreover, HCPC (2016) identifies professional negligence as one of the causes of patient risks. Therefore, faced by a similar scenario, I would prefer working within a team or with an assistant who understands how to deal with patients with low BMI and CKD stage 3B, rather than rejecting the referral and endangering the patient’s life.

If I were the supervisor, I would have taken a different administrative approach to ensure that such a scenario does not reoccur. For instance, I would designate a peer mediator within that department or unit who is able to control processes and ensure that none of the nutritional department members acts in an inappropriate manner – whenever a difficult situation arises. According to Dahlkemper (2018), approaching issues through peer mediation is successful because it is confidential and voluntary. From this scenario, I have learned that proactivity is a key aspect of delivering safe and quality care to patients. This learning will be of specific relevance to my future career for three major reasons. First, it has changed the way I will approach referrals because I now realise that if I intend to reject a referral, I should do it in a professional and procedural manner, including contacting my supervisor and discussing about it. This scenario has also changed my perception of ethical practice because now I understand that certain unethical practices such as nonprocedural rejection of referrals may endanger the patient’s life. Thirdly, I have learned that how I communicate with my supervisor in every aspect of my work, including how I handle referrals, is crucial to the patients’ safety and well-being. Henceforth, I intend to be more open to my supervisors about my capabilities or incapability, so that alternative solutions can quickly be identified to promote the health and well-being of the patients.

A Reflection on the Student’s Communication with the Supervisor

Communication with colleagues in the workplace, including supervisors, is an important aspect of delivering quality care. From the video, there are significant aspects of the conversation between the student and her supervisor that are worth noting. For instance, I notice how the supervisor is able to skilfully bring up difficult issues with the student and how well she has was able to guide the conversation in a productive direction.

From time to time, the supervisor was trying to display a collaborative attitude to the student and as a result, the student began to change the way she perceived the problem. In my opinion, it is this collaborative attitude that enabled the student to accept working with another supervisor in attending to the patient. Ideally, by proposing that the task could be achievable if the student worked with another supervisor, she brought out the notion of teamwork and collaboration, and its importance in delivering safe care. I am therefore not surprised that the student finally accepted to handle the referral.

Another factor that influenced the student is the manner in which the supervisor was non-reactive and friendly to her. She did not display any element of hostility; neither was she demanding to the student. The supervisor’s actions corroborate with the assertions by Burton & Ormrod (2011) that whereas various issues and conflicts may arise among practice setting, the secret to resolving these issues lies on how they are approached.

Nonetheless, as a supervisor, I would approach the case differently by encouraging the student nutritionist to sit down with her earlier supervisor and talk openly about what was bothering her rather than being reactive by leaving the referral document on the desk. I would only intervene if they failed to work out the issues. I would also consider building a mutual support base for the for both the student nutritionist and her supervisor by encouraging her and her peers to brainstorm and find better solutions; and develop a better working environment where student nurses openly bring issues to their supervisors. If the student had good self-confidence, she would have easily approached her supervisor and explained her inability to handle the patient’s complex condition. Hence, another important thing I would do is to encourage the student to learn and develop good communication styles that articulate self-confidence and enable her to be more confident in making requests within the working environment.

Nutrition Assessment Plan

A patient can develop a CKD due to various health conditions and diseases. According to Malgorzewicz et al (2011), CDK may result from failure to properly take the prescribed medications for chronic diseases or failure to proactively seek medical assistance. Nonetheless, a properly developed assessment plan can mark the beginning for proper treatment of CKD. The following section highlights a brief assessment plan that could be used by the student to assess the patient. First, according to Mazairac et al (2011), it is recommended that while assessing CKD patients for malnutrition, it is important, to begin with, a nutrition-focused physical examination so as to determine their current nutritional status. Nonetheless, the following table illustrates the timeline within which the student could have assessed the patient’s nutritional deficiencies:

For purposes of preventing CKD progression and potential Kidney failure, Anderson (2000) recommends that the patient should be referred to medical nutrition therapy because it is highly likely that positive patient outcomes can be achieved when the nutritional therapy is begun as early as possible upon diagnosis of CKD (Sutton et al, 2007). Afterward, according to Anderson (2000), there should be a follow-up after every 1-3 months for a period of 1 year to identify if any nutritional deficiency could be emerging. The follow-ups would also be effective in monitoring the general condition of the patient.

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References

• Anderson JJB. Minerals. In: Mahan LK, Escott-Stump S, eds. Krause’s Food, Nutrition & Diet Therapy. 10th ed. Philadelphia: Saunders; 2000:113-117.
• Burton, R., & Ormrod, G. (2011). Nursing: transition to professional practice. Oxford, Oxford University Press.
• Dahlkemper, T. R. (2018). Nursing leadership, management, and professional practice for theLPN/LVN. Fein PA, Mittman N, Gadh R, Chattopadhyay J, Blaustein D, Mushnick R, Avram MM. Malnutrition and inflammation in peritoneal dialysis patients. Kidney Int 2003;64:S87-91.
• Hakim RM, Levin N. Malnutrition in hemodialysis patients. Am J Kidney Dis 1993;21:125-37 Health & Care Professionals Council. Standards of conduct, performance, and Ethics. London: HCPC. 2016.
• Kopple JD, Berg R, Houser H, Steinman TI, Teschan P. Nutritional status of patients with different levels of chronic renal insufficiency. Modification of Diet in Renal Disease (MDRD) Study Group. Kidney Int Suppl 1989;27:S184-94. Mazairac AHA, de Wit GA, Penne EL, et al. Protein-energy nutritional status and kidney disease-specific quality of life in hemodialysis patients. J Renal Nutr. 2011;21(5):376-386.
• Malgorzewicz S, Rutkowski P, Jankowska M, Debska-Slizien A Rutkowski B, Lysiak-Szydlowska W. Effects of renal-specific oral supplementation in malnourished hemodialysis patients. J Renal Nutr. 2011;21(4):347-353. Sutton D, Higgins B, Stevens JM. Continuous ambulatory peritoneal dialysis patients are unable to increase dietary intake to recommended levels. J Renal Nutr. 2007;17(5):329-335.