Patient Scenario Encountered in Practice - Case Study Example

A Reflective Case Study Using a Reflective Model on a Patient Scenario Encountered in Practice Introduction In this reflective case study, I will reflect on the care delivered to a patient as a first responder; the identity of this patient will be kept undisclosed for the reasons of confidentiality in the NMC Guidelines. Throughout this assignment, she will be referred to as Hilda Parish. The patient arrived at the hospital via LAS, after collapsing at home on February 18, 2009. The previous history suggests her to be generally unwell for quite a few days before this episode. On presentation, she was reported to have slurred speech and to be weak and confused. After LAS attended the scene, they found her GCS to be 11/15, and a spot measurement of random blood sugars resulted in a value of 2.5 mmol/L. Through this reflective case study assignment, I will critically review the care provided by me as the first responder. I will also analyse whether the care was in conformity with the NICE guidelines (Qureshi et al., 2005). For this assignment, I would use Gibbs model of reflection since this is useful in nursing, and this adds to the new knowledge in order to develop a care plan within a single reflective cycle (Wilding, 2008). Gibbs Cycle Reflection is a process of self-inquiry and transformation towards realising desirable practice as a lived reality. As such, reflection is both the research and developmental tool. By reflecting on my everyday practice, I have a chance to become increasingly mindful of myself within the practice, care delivery, and the way I do it. I may become more aware of the way I think, feel and respond to situations as they unfold. I may become more sensitive to the people within those situations, whether patients, their friends or relatives, or my colleagues. As a consequence, I can respond more in tune with my values and more skillfully with my patients and others, which is desirable from me as a person delivering care. The reflexive narrative is presented as an exemplar of researching self as a process of self-inquiry and transformation (Souter, 2003). The exploration of reflective learning also stimulated me to pull together my ideas of what we do when we engage in the immensely complex process of learning something. To begin with, however, it was difficult to discern where to begin. It has been suggested that using a framework would be better (Chabeli and Muller, 2004), so it makes the reflective process structured and guided. I personally feel those who are very experienced would not need a framework for reflection. For me as a nurse as a means of reflective practice, I have and would always prefer to have a framework, and I choose the Gibbs (1988) reflective cycle in my reflections on my practice. From my experience and previous reflective episodes, I have seen that reflection is a dynamic and cyclic process. Therefore, a framework with overt cyclical approach would be most suitable. Gibbs formulated his reflective cycle while attempting to explain experiential learning, and in each step of the cycle, the reflective practitioner is faced with a series of questions that both guide and provide structure to the reflective process on practice. This process starts with a phenomenon and description of the event, and in each step, there are questions that lead to further critical analysis leading to a plan of action and then re-reflection on the changes. Reflections needs to take place at a conscious level that allows a nurse to make decisions about her learning, and critical analysis of such will also consider thoughts and ideas, evaluation of them, and making conscious informed choices about the future course of action in a given scenario. Most of the student life nursing placements lead to experiences which are based on observations in the clinical scenario of actions or practice of other people. This definitely helps the nurses to gain experience and technical skills. However, reflection is a process to review those experiences, so a closer and critical examination leads to further learning leading to more skills and expertise (Jasper, 2003). Moreover, this can be a great way to look back at personal experiences to assess learning, categorize the knowledge, and areas of gaps in learning. Gibbs model was chosen since it was easy to use in a repetitive manner during subsequent reflections. Therefore, this assignment would comprise of reflections on my experience on this patient according to the following cycle. Description It was night 9 pm on February 27, 2009. I just came for my shift, and the night form indicated that Hilda had a low GCS, and her EWS was yellow. These two entries indicated very limited information, from which I could draw any inference, yet I needed to attend the patient in the ward as the first responder as a part of my duties (ALSG, 2001). To be straight, other relevant information was missing. It was not possible for me to reach a decision or any other assumptions. I thought this patient must need immediate help, and I decided to rush to the scene. This was more so because when I just came to my shift, this form was handed over to me by the healthcare assistant, so I did not have a chance to make further enquiries. I did not know what the situation of the ward was since it was time for handover. So I decided that it would take a long time to ring the ward for further information. Since the ward was not far from my base, I went immediately to the ward. The NICE guidelines suggest that a patient must be attended within 15 minutes of presentation (Armitage et al., 2007). Although presentation is not appropriate here due to the fact that the patient was already admitted to the hospital, this emergency has occurred as an incident in the hospital ward. The assessment at least partly is directed towards assignment of low-risk or high-risk brain injury. It was immediately important to note the status of the GCS (Shah, 1999). On my way there, I was hoping my decision to assess the patient first was not wrong, since otherwise, I was supposed to hit the fast bleep for medicos to attend the ward. I was considering my decision on this, and I felt that since the ward has indicated that her EWS was yellow, it would be worthwhile to decide that it would be prudent to have an assessment myself. This confusion happened due to the fact that the form was incomplete, and the ward staff always tends to send incomplete information. This is a constant issue in our work since ward staff forgets that we do not know the patient. There should be a clear protocol for entering all patient information in the sheet (Lundgren-Laine and Suominen, 2006). It is evident that she had respiratory compromise. Although maintaining airways, she was showing froths from the mouth, perhaps following the fit. She had been suctioned to avoid aspirations, and she was not speaking. Her respiratory rate was 22, and she was saturating 90% on room air on a non-rebreather mask with 15 L of air. Air entry was quiet but with bilateral wheeze. The BTS guidelines suggest oxygen for hypoxemia, which was appropriately started in her case. For that a target saturation range has to be established and depending on that oxygen needs to be prescribed according to the target saturation range. The guidelines also state that the patients' needs to be monitored by the people who administer oxygen. This oxygen therapy must begin immediately and recorded, and the indicator of change would be the oxygen saturation that is measured by pulse oximetry, with the target being achieving normal to near normal oxygen saturation (O'Driscoll et al., 2008). Feelings When I arrived at the scene, the medical SHO was already on the ward with the patient. I came to know from the history that Hilda suddenly went into a low GCS of 7/15, and simultaneously, she had two episodes of tonic-clonic fits. When I approached her, she had no apparent reaction. She was lying on her side, appeared still; looked like, she was asleep. Her eyes were closed. When I spoke to her, she was unresponsive (McNett, 2007). When I touched her, there was similarly no response. Obviously, the data suggested hypercapnia and need for initiation of respiratory support and oxygen therapy. The ward nurses are experienced to handle such situations, but they have hardly any training to implement and monitor oxygen therapy (Jennett, 2002). Delay in such situations may cause further detriment of her situation. I thought it was necessary to know the background of Hilda, and I wanted to go through her records. In this busy environment, it was difficult to take to anyone who could provide a detailed history. When the patient was brought to the hospital on the day of the incident at home, the initially A-G assessment found that she was maintaining the airway and was able to speak in full sentences. However, her breathing was not up to the mark. She was de-saturating on room air. Her initial oxygen saturation was 89%. This was assumed to be low, and rebreather bag ventilation was initiated at that time (Howell, 2002). On 15L of oxygen breathing, her oxygen saturations improved to 98% with a respiratory rate of 20 breathes per minute. Her cardiac examination revealed her blood pressure to be 128/54 with a varying irregular heart rate of 45 to 60, and CRT was greater than 2 sec. The GCS was found, however, to be 15/15. She was alert and oriented to time, place, and person. There was jaundice around the eyes. She has been being treated for her baseline kidney disease with 1 L of fluid restriction. The capillary blood glucose measured at this time was 8.1 mmol/L. Other significant findings on examination were, she had a low temperature of 35.0 degrees Centigrade, although she was warm to touch. She had oedema in her both knees. The skin appeared dehydrated and to feel, it was paper type. Her husband was the only one from the family who accompanied her. She was admitted for observation, electrocardiogram, urinalysis, other relevant blood tests, and x-ray as indicated. This indicates there is a reversible cause of decline in her GCS which is operative. The initial, rapid, ABCD, airway, breathing, and circulation, as well as neurologic disability assessment of the patient are meant to identify life-threatening problems (Castle, 1999). If conditions are identified that present an immediate threat to life, appropriate interventions are required before proceeding to the secondary assessment. She was assigned early warning signs, yellow. Evaluation The A-G assessment revealed that Hilda was maintaining airways, although not speaking. There was foaming from her mouth following the fit, and this was suctioned. On room air her oxygen saturation was 90%, and her respiratory rates were 22. On the face of this desaturation, she was placed on non-rebreather mask (Ruholl, 2006) ventilation on 15L of oxygen. On auscultation, there were bilateral wheezes but the air entry was quiet. An ABG done showed a pH of 7.04, PCO2 of 9.12, PO2 of 30.62, HCO3 of 14.3, a base excess of -13.5, and an oxygen saturation of 99.1. Her serum electrolytes showed a sodium of 137.8, potassium of 3.56, and a chloride of 109. The cardiac assessment revealed her heart rate to be 150 beats per minute, blood pressure 150/58. CRT was greater than 2 s. The attached observation chart showed that the 12-lead electrocardiogram revealed a fast atrial fibrillation. No peripheral access was possible, and with Venflon, a femoral line was established. Neurological examination revealed a GCS of 6/15, but the pupils were equal and reacting to light. There had been no further fits. The eyes were localizing to pain stimulus. The physical examination revealed a temperature of 35.5; the skin was warm to touch. All four limbs were hypotonic with bilateral plantars. There was evidence of leg oedema. Skin like previous examination was fragile and papery. Family was called to intimate the patient's condition. Full assessment of the charts was done. From the ABG, it was evident that the patient was having metabolic and respiratory acidosis (Simpson, 2004). It was decided that she will be placed on BiPAP. Sodium bicarbonate and calcium gluconate would be injected. The fast atrial fibrillation will be treated with Digoxin. Given this status, a physiologic monitoring plan would be justified. Emergency warning status needs to be adjusted as appropriate depending on the resuscitation status. Analysis BTS Guidelines state that oxygen is the treatment of hypoxaemia, and the extent and type of oxygen supplementation is to be prescribed according to target saturation range, and monitoring would dictate the therapy. The aim of all oxygen therapy is to achieve normal to near-normal oxygen saturation in patients who are at risk of hypercapnic respiratory failure. As highlighted in this case study, as per BTS guideline, high concentration oxygen was administered when it was noted that the patient was desaturating, and as demonstrated this had been recorded in the patient's health record (O'Driscoll et al., 2008). In these acutely ill patients, such as this, the oxygen saturation should be checked by the pulse oximetry, and blood gas estimation is a supplementary examination. The BTS guidelines suggest that all critically ill patients should be assessed and monitored with the use of a recognised physiological track and trigger system. I recollect, Hilda was put on 15L of non-rebreather mask oxygen. This prescription was made to achieve a target saturation of 94 to 98% for most acutely ill patients. It has been elucidated in the BTS guidelines that oxygen administration should be conducted by a staff who are trained in oxygen administration through appropriate devices and adjustment of appropriate flow rate. Both myself and SHO were there, and we both assessed Hilda. This patient needed BIPAP, and therefore, SHO informed the medical registrar. The medical registrar attended the patient, and his diagnosis was probable cerebrovascular accident. The registrar being the trained medical staff is capable of advising BIPAP. For my assignment, I am going to discuss the BiPAP, which could correct her acidosis (Shoulders-Odom, 2000). The family was informed about her condition and the decision to place her on BiPAP. The severity of her situation indicated that she might not survive the night. The initial settings of BIPAP were IPAP 18, EPAP 4, O2 2L. The guidelines say maximum therapy as soon as possible. I asked the medical register why he would not increase the settings to the maximum. With that, he increased the IPAP to 22 and EPAP to 6 following the second ABG at 23.30 hrs. This showed the pH to be 7.11, pCO2 9.97, pO2 12.63, HCO3 18.2, base excess -7.8, and O2 saturations 94.2. Her sodium was 136.3, potassium 4.01, chloride 107. This means that IPAP could be increased further to achieve the maximum possible oxygen saturation (Stoltzfus, 2006). On reflection, I must accept that at that time, I was not confident as I am now, and the reason could perhaps be I just started my course at that time, and I was not exposed to evidence from research. Now, I am sure I would be able to back up my decisions with research-based evidence, and therefore, my decisions regarding the management of such patients would be more effective. For every professional being new to the role is a part of the work, and gradually experience gathers and confidence builds up with a coworker who can demonstrate trust. The second ABG demonstrated worsening of the pH and pCO2 along with the increase in the setting of the BIPAP (Cross et al., 2003). The medical register decided to refer the patient to the ITU. The patient needed to be shifted to a safer area, and the medical register felt that given the patient's critical condition, the ITU may accept the patient. However, this delay may appear to be a hindrance to the patient's outcome. Conclusion When Hilda's optimum care was the issue, the decision making became the most important aspect of the care. Luckily for me, that night, I had a night nurse practitioner (NNP) on duty with me. That meant, I was not completely tied up with Hilda's care, while decision was being made about her care and the place of care. As the senior most nurse on duty in the Hospital at Night, I was supposed to be available at all times to answer calls from other wards, triage, and depending on seriousness, I was supposed to prioritize calls. When the number of calls is very high, it would definitely be illegitimate to be tied up with one patient. However, this is often the case when someone is on duty without an NNP. The standards of practice suggest that missing an important call and missing a sick patient are both violations of accountability. This always causes worry about my nursing registration since both the points of views are unacceptable professionally (Hendry et al., 2007). Although one cannot be at two places at the same time, the rules seek that I should not miss an important call while tied up with a critical patient, and attending a critical patient is must and should not be avoided while busy triaging a call. The third ABG showed a slight improvement. The BIPAP was needed to be set to maximum of EPAP to 24 and IPAP to 6. At 2:00 am, the ITU doctor reviewed the case. It seemed impossible since the ITU doctor opined that setting up to maximum levels would not be suitable at least as apparent from the patient notes, and it was felt that it would not produce acceptable outcomes. Now, on reflection, I feel, I would have suggested Hilda to be removed as soon as an EMC bed was secured. I did not do this at that time, since evidence suggests that it can be detrimental to move a patient unnecessarily or too many times. The attached report on the fourth ABG and observations suggested that there had been improvement in ABG and pCO2, but the GCS was still low. The plan was to do a CT scan of Hilda once she had stabilized and off BIPAP. The problems that I encountered were many. Apart from my comparative inexperience, the ward staff was not confident, and none of them were trained to nurse any patient with BIPAP. Following of guidelines is very important in the care of such patients. Initially, I put her on BIPAP, which I procured from another part of the hospital. I hoped that I could do a trial on the ward to see if she can tolerate it in the ward. If she could tolerate, then she could be moved to one of the wards where staff was trained and had skills and expertise to use and monitor a patient on BIPAP. For a safe and appropriate care, the number of staff must be adequate and proportionately more while maintaining the BIPAP. I arranged a bed for her in the Emergency Medical Centre (EMC), since the female respiratory ward had already a patient who needed BIPAP. It seems there was a need for more BIPAP beds in the hospital of our size (Rose. and Hawkins, 2008). This reflective account tells about my experience in the care of Hilda. A low GCS may have many reasons, but respiratory failure is one of the important causes of such. The decision of BIPAP was accurate as per guidelines by BTS. While practically implementing these outlines usually arterial blood gases dictate the management as has been highlighted in this case scenario. However, application of such measures may become difficult depending on the set up of the treatment. There are clear cut guidelines regarding movement of the patient, and on the contrary limited resources within the hospital may also hinder care. The inexperience and deficiency of skills of the nurses, the failure of the medical officers to implement guidelines all can affect care. That night despite my duties, I had to attend the patient as a first responder, and experience count there also. The deficits that I demonstrated are now clear to me, since academically I feel I could diagnose the case. Skill and expertise are important parameters of such care, which I lacked at that time; however, now given another opportunity, I can deliver the care in a much more efficient manner. When I saw the doctor was not following the guidelines, it was difficult for me to bring his attention to the fact, since such kind of emergency care is basically teamwork, and communication skill and leadership abilities are important to accomplish these, and I lacked both at that time. Hilda was demonstrating acute failure of ventilation. This is a critical medical condition. Although it is not a diagnosis, and I think as highlighted in Hilda's case, it is the end result of a multitude of disease processes that may culminate in to arterial hypoxaemia and hypercapnia as have been demonstrated in this care. This reflective assignment focuses on the key critical management issues which include appropriately administered oxygen therapy, analysis of the precipitant factors, and provision of guideline approved assisted ventilation. Regarding ventilatory assistance, this can be provided in both invasive and non-invasive manners. For me to say, this assignment allowed me to find out areas of my strengths and weaknesses, so I can deliver care better in the next opportunity based on the guidelines. Reference List Advanced Life Support Group (ALSG) (2001) Acute Medical Emergencies: The Practical Approach. London: BMJ Books. Armitage, M., Eddleston, J., Stokes, T., (2007). 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