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This is a reflective essay of a care episode in the domains of clinical nursing associating to decision making by the practitioner, clinical reasoning and processes attributed to the patient care planning and management. As opined by Suhonen et al. (2018), a reflection of the aspects or elements of care or even particular clinical experience is a significant part of the nursing development in their professional practice. Hence, reflection supersedes merely looking back at the past experience, but involves making sense to these experiences and understanding all their dimensions through evaluation and analysis to enhance future experience (Parkin et al., 2020). Even though reflection is disputed as imperfect means to review nursing practice due to chances of biased reflection and poor memory, it still potentially enables both student and qualified nurses to review their practice in the realm of knowledge backed with evidence. Using a reflection approach, this say explore on the care of a young adult with type 1 diabetes, to determine the elements of clinical decision making and reasoning in regards to care and management of such patients. Type 1 diabetes is considerably among the most common chronic diseases affecting about 18 to 20 per 100000 children annually in United Kingdom. Due to its fatality, children with this condition are offered immediate referral to paediatric diabetes care facilities for immediate care. Alongside the above, the essay will also table the elements for care planning for the patient and the processes for arriving at the critical clinical decisions for managing the chronic condition. This essay analysis will be structured within the frameworks of Gibbs reflection cycle that provides guidelines for reliable reflection allowing the nursing practitioner to establish better action plans for future practice (Ardian et al., 2019). Therefore, the essay will begin by a summary of a patient’s health status then proceed to analyse the case through Gibbs reflective cycle and suggest an action plan.
Mary, whose names have been changed to protect confidentiality, is an 18 year old who has just joined university. She was diagnosed with type 1 diabetes at the age of 10. Diabetes is a risk factor to so many chronic conditions like diabetic hyperglycaemia, ketoacidosis, hyperosmotic non-ketotic state and hypoglycaemia, and is more profound in juveniles (Umpierrez and Korytkowski, 2016). Presumably, the pathophysiology of type 1 diabetes results from absolute or severe insulin deficiency due to destruction of beta cells. Mary’s symptoms attributed to ketoacidosis or hyperglycaemia condition. According to research, hyperglycaemia occur when the beta cells of the islets of Langerhans secreting insulin get destroyed and thus stops producing insulin or produce insufficient amount. She also expressed a history of sudden weight loss and symptoms of diabetes polyuria (increased urination), polydipsia (increased thirst) and polyphagia (weight loss and fatigue). She was also found confused by the time she was brought into the medical facility, which is believed to be as a result of cellular dehydration. Borrowing from Gosmanov, Gosmanova and Kitabchi (2018) sentiments, serum osmolality and mental status signified a strong correlation of a patient’s diabetic ketoacidosis and hyperglycaemic hyperosmolar condition. Further, the patient had a dry flushed skin and signs of tachycardia which were due to excess loss of fluid and dehydration and electrolyte imbalances in her body respectively. She also depicted low pH levels that triggered increased respiration rates subjecting her to shortness of breath, and a fruity smelling breath due to increased rate of ketone bodies formation that utilization of acetoacetic acid as a result of high respiration.
Mary’s blood glucose levels got better, prompting the care team to acknowledge her readiness for discharge from the medical ward. Initially, the discharge plan had been agreed, and finalised by the Clinical Nurse Specialist who was up to her care and stability from her chronic severity. It was agreed that she would be discharged to continue with recovery under parental care. However, one of the primary care nurse practitioner objected to the plan given the risk for unstable blood glucose that the patient was subjected to which required experienced blood glucose monitoring. There were fears that inability to actualise the blood glucose monitoring would render the diabetes management a failed medication prompting another hospital admission. In this light, a full case conference and multidisciplinary review was called upon to review the discharge plan; and this was inclusive of the patient primary care nurse who instigated the conference, clinical nurse specialist, the nurse practitioner, and Mary’s primary care giver. All the parties presented their case in the realm of the kind of care that would benefit Mary’s chronic condition. Because of the uncertainty of knowledge and awareness of diabetes management and blood glucose monitoring by the family who would be the immediate home caregivers of Mary, the team decided that the patient be discharged to a nursing home facility nearer to her home to help in management and treatment of the condition. However, the nursing home was quite a distant from their home, prompting the parents to demand that she be discharged home rather than being referred to the facility. To them, the nursing home was quite inaccessible. However, it was quite convincing that the referral to the proposed facility was much better than discharging her to home care since her condition still needed expertise management, otherwise it would grow worse.Feelings: what were you thinking and feeling?
I felt quite empathetic with Mary’s parents and family who advocated for their daughter to be discharged so they would help manage her situation. I also felt concerned on the kind of burden the family would be subjected to it trying to balance the required blood sugar levels especially on strictness of diet. Additionally, I felt that Mary’s parents could also be involved in the case conference, or at least consulted to consent on Mary’s behalf on the decision for referral against discharge. Altogether, I felt that the multidisciplinary team viewed the case professionally. In Mary’s care management, maintaining her airways patent was a priority. Again, hyperglycaemia and ketoacidosis patients usually require hydration and monitoring of blood gas, lipase, amylase, serum ketones and cardiac enzymes attributing to the care management (Alois and Rizzolo, 2017). Further, the patient was to be monitored for poor skin turgor, soft sunken eyes and dry mucosa which were alarming for hypovolemia complications. Still, I felt that there could be better arrangements for such medication to be provided from home care line, thus it was not the best ethos of clinical practice to overlook the consent of either Mary or her family on the life changing decision to transfer her to another facility. Evaluation: what was good and bad about the experience? The fundamental positive aspect of this experience as a Clinical Nurse Specialist was the insight that I gained of the multidisciplinary team that had a conference to make an informed clinical decision based on Mary’s discharge and referral options. All the team professionals were concerned and meant well for the patient recovery, and management of the diabetic condition after leaving the care facility. They showed professionalism as they listened to other’s experience and thoughts on managing Mary’s case. They also showed positive attitude as they not only focused on wellbeing of the patient but also the capacity of the family or homecare givers to facilitate recommended care management for the patient’s healing. However, the only negative aspect of the experience was overlooking on Mary’s or the family’s consent in regards to her discharge decision. It was not certain that the family were not capable of taking up the homecare responsibility, hence, their involvement was necessary and ethically approved being that such critical clinical decisions significantly impacted a patient’s social, metal and emotional wellbeing, same as emotional and financial wellbeing of those involved like the family or community. Although Mary was the main concern for the care team, involving the family would have been better towards arriving at a better condition that was favourable for both. Analysis: what sense can you make of the situation? Providing care for diabetic patients is not quite easy being that it require a keen watch on the patient’s diet to help in control of blood sugar glucose. It is even more devastating for the juveniles who normally have no knowledge of diet requirements, and most who are diagnosed are profoundly reported to develop type 2 diabetes in their adulthood. Due to the risks of diabetic hyperglycaemia, ketoacidosis, hyperosmotic non-ketotic state and hypoglycaemia as a result of diabetic condition in the youths and children, providing care that offset the severe implications of these chronic conditions to meet every health need of the patient becomes challenging. Generally, type 1 diabetes is a difficult disease to deal with being that its prevalence is high in juveniles who might be oblivious of the impending dangers as well as signs and symptoms of the condition. Although type 1 diabetes prevalence is not common like type 2 diabetes, it’s approximated that about 25000 juveniles below 25 years have type 1 diabetes in United Kingdom (Jurgen et al., 2019). The chances of developing diabetes relies on the gene, lifestyle and environmental factors an individual is exposed. For type 1 diabetes, it’s usually due to the failure of the pancreases to produce sufficient insulin for the body, leading to hyperglycaemia- a condition where the blood sugar levels or glucose is high. If not managed, the long term complications for the diabetic patient would be neuropathy, diabetic nephropathy, cardiovascular diseases, cataract, amputation, ulcerations, infections and diabetic retinopathy. Again, there are other emergency complications that would develop if diabetes is not properly managed like diabetic ketoacidosis (when body is lacking enough insulin leading to high blood sugar levels) and hyperglycaemic hyperosmolar state (when insulin is produced but it doesn’t work properly leading to rise in blood glucose), and these were the fears of the multidisciplinary specialists while making their thoroughly thought clinical decisions for Mary’s discharge case. Conclusion: What else could you have done? One fundamental conclusion I learned from the case analysis was the significance of questioning every clinical decision making process, as they should be backed with strong evidence. Again, attributing to the significant role played by the multidisciplinary teams in the clinical decision making process, it’s inevitable that prejudice and personal agendas do exist. For this situation, there is not much I could do at my position, but the fact that the patient’s consent nor the family’s opinion were neither considered in making decision on discharge was a matter of concern as it is part of clinical practice mandate. It’s also clear that the team were more resilient to referring the patient to a nursing facility with an undermining knowledge of the capacity and the willingness of the patient’s family to take the responsibility, given their living condition and concern for their minor. In this provision, I felt that the team would have maintained the nursing guidelines all through, and consider the consent and opinion of the family of the patient before arriving at the final discharge decision. I underserved my duties by failing to raise such concerns. Action Plan: If it arose again, what would you do? In my future practice, the incident has opened my perception especially in making critical clinical decisions of care, including discharge plan. I would thus ensure that either the patient’s consent or close family’s opinion is considered and incorporated into any clinical decision making process where necessary. Again, the incident has brought forth the aspect of evidence based practice, therefore, I would also gather all necessary policies and guidance related to such cases related to patient care so as to be able to make a sound and reasoned decision for the patients. Finally, other than having detailed information of alternative care plan and support for such patients, I would ensure that the impacts of such clinical decisions to a patient’s home and family are considered before a final decision is agreed. Conclusion From this reflective analysis, it’s clear that such decision making processes are very complex despite being guided by certain principles of care and code of professional conduct. Insofar, its significant to ensure that all the aspects of the patient’s needs are met and considered while making such critical decisions of a patient’s life, and these should not only be considerate of their safety and medical needs. This brings to assurance that alternative plans and all perspective of the patient’s life and wellness must be considered before such decisions are finally agreed.
Alois, C.I. and Rizzolo, D., 2017. Diabetic ketoacidosis: Heralding type 1 diabetes in children. Journal of the American Academy of PAs, 30(7), pp.20-23.
Ardian, P., Hariyati, R.T.S. and Afifah, E., 2019. Correlation between implementation case reflection discussion based on the Graham Gibbs Cycle and nurses’ critical thinking skills. Enfermeria clinica, 29, pp.588-593.
Gosmanov, A.R., Gosmanova, E.O. and Kitabchi, A.E., 2018. Hyperglycemic crises: diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). Endotext [Internet]
Jurgen, B., Baker, C.N., Kamps, J.L., Hempe, J.M. and Chalew, S.A., 2019. Associations Between Depressive Symptoms, Fear of Hypoglycemia, Adherence to Management Behaviors and Metabolic Control in Children and Adolescents with Type 1 Diabetes. Journal of clinical psychology in medical settings, pp.1-11.
Parkin, S., Locock, L., Graham, C., King, J., Montgomery, C., Gibbons, E., Churchill, N., Ziebland, S., Martin, A., Gager, M. and Chisholm, A., 2020. Understanding how front-line staff use patient experience data for service improvement: an exploratory case study evaluation. Health Services and Delivery Research, 8(13).
Suhonen, R., Stolt, M., Habermann, M., Hjaltadottir, I., Vryonides, S., Tonnessen, S., Halvorsen, K., Harvey, C., Toffoli, L. and Scott, P.A., 2018. Ethical elements in priority setting in nursing care: A scoping review. International journal of nursing studies, 88, pp.25-42.
Umpierrez, G. and Korytkowski, M., 2016. Diabetic emergencies—ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nature Reviews Endocrinology, 12(4), p.222.
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