Reflective analysis case studies - Essay Example

Reflective Analysis Case Study A great part of being an effective nurse is one’s ability to objectively look back at an experience and reflect on one’s actions or inactions while caring for a patient. Reflective analysis helps break down the health care experience with a patient and gives the nurse the opportunity to learn from the experience. This paper shall be a reflective analysis case study exploring the nurse’s experience with a patient using the Johns reflective model approach. It shall present the patient’s history and condition prior to and during the admission; and this paper shall also discuss how effective the nurses worked with each other as a team. Description of the experience On the night in question, as a site manager, I was dealing with admissions and bed allocations. A colleague who was working opposite was the first responder that night. She received a call from the Critical Care Unit (CCU) at 2300 hours; the CCU nurses narrated that a female patient was having ongoing chest pains following the use of the commode; nurses also reported changes in the patient’s ECG reading; the CCU nurses also reported that the patient was given a glyceryl trinitrate (GTN) spray. My colleague and I already met the patient the previous night at the Emergency Medical Care (EMC) unit when she was admitted for shortness of breath (SOB), palpitations, and was having pleural effusions drained. Before we left for the ward, we fast beeped the doctor about the patient. We knew from the patient’s admission that she was 64 years old and had a Coronary Artery Bypass Graft (CABG) and an Aortic Valve Replacement (AVR) surgery 13 days prior to her admission. When we got to the CCU, the patient was extremely anxious and frightened; was very short of breath; was having chest pains; and was speaking in short sentences. The patient was also not sweating. The CCU nurses already put her on 15L Oxygen non-rebreath mask. I immediately made my A to G assessment while my friend helped to calm and reassure the patient. The doctor arrived a few minutes after we did and he saw the patient briefly, auscultated her chest, and went to the nurses’ station to write down his orders on the patient’s chart. I went to the nurses’ station to confer with the doctor about his initial findings and his orders. The doctor ordered Digoxin 500 mcg to be given immediately to the patient; he also ordered an increase in the treatment dose of clexane to 90 mg. He also ordered another 12 lead ECG to be done on the patient in 2 hours time; another dose of Digoxin in 6 hours time; IV morphine drip for the patient’s chest pains; a Trop T test in 12 hours time; continuous cardiac monitoring; and a V/Q (Lung Ventillation/Perfussion) scan in the morning. I was about to write my own notes in the patient’s chart, but I already saw that the doctor made notes on the chart regarding the incident and all the details pertaining to it; so I did not anymore write my notes on the patient’s chart. The assigned CCU nurse prepared and administered the ordered meds on the patient. As the patient was in the CCU, she was on continuous monitoring by the CCU nurses. Background factors to this experience The situation must be serious for the CCU to call in for help. When we saw the patient, based on the patient’s diagnostic tests, if the patient’s condition will not stabilize and improve, her condition may get worse. The patient’s previous surgeries are important details that are bound to impact on the patient’s present care. Her positive D-dimer result implies possible PE; the AF is also a strong possibility in the patient. Her chest pain, SOB, palpitations, and diagnostic results support both a possible PE and AF secondary to sepsis diagnosis. I have a background in critical care which enabled me to assist and coordinate with the CCU nurses efficiently. As a site manager, it was part of my responsibility to coordinate patient care with the different members of the health care team. Another factor that bothered me about the incident was the patient’s age. The patient was elderly and as such, her body has already undergone natural wear and tear. Her resistance and her physical fitness have already been compromised by her advanced age. “The health and the health care needs of adults are complex, deriving from a combination of age-related changes, age-associated diseases, heredity and lifestyle” (Mauk, 2006, p. 266). There were various points during her care when I was concerned that multiple complications would ensue from her condition, and these conditions would later contribute to the further deterioration of her health. The key processes for reflection in this experience relate to the efficiency of my actions as a site manager and as a critical care nurse; also, my diagnosis of the patient’s condition based on exhibited symptoms and diagnostic results are key processes for reflection in this case. Reflection: What was I trying to achieve? I was trying to achieve a modicum of stability in the patient’s condition. I knew that by working in coordination with the CCU nurses and the members of the health care team, we would be able to stabilize the patient and prevent possible arrest. I was primarily trying to be a good and efficient leader by making tough decisions on patient care that will ultimately make a difference to the patient’s recovery. Why did I respond as I did? I responded as I did because as the site manager, part of my responsibility was to identify and manage medical emergencies and to make sure that immediate medical attention is given to the patients during such emergencies. It was also my responsibility to interpret diagnostic results, and based on these results, to coordinate with the members of the health care team in order to come up with a plan of care for the patient. As a leader, it was also my responsibility to lead, guide, and support the members of the health care team in order to ensure that they were performing their tasks and responsibilities and consequently realizing their full potential. I had a feeling that the patient’s condition was a complication of her previous surgeries. I knew it was important for me to give the doctor as much information as I could accurately supply in order to allow immediate interventions to be done for the patient. The sepsis which led to the atrial fibrillation is most probably caused by the CABG and/or the AVR surgeries. It is possible that after her surgeries, bacteria from a variety of sources could have gotten into her system. Macrophages, which are white blood cells, are activated by the ingestion of bacteria and by stimulation through cytokines secreted by CD4 T cells. This is supported by the high WCC. The macrophages are then stimulated to produce inflammatory responses in the necrotic or infected tissue (Hotchkiss & Karl, 2003, p. 140). Due to infection, the ejection or the contraction of the heart muscles would now be decreased and the atrial fibrillation will manifest in the patient (Salman, et.al., 2006). Some studies have revealed that atrial fibrillation is common in patients with sepsis. The risk factors attributing to atrial fibrillation include old age, low ejection fraction, and coronary artery disease. The patient is elderly and has had a history of coronary artery disease; therefore her risk in incurring atrial fibrillation due to sepsis is high (Calkins, 2004). Atrial fibrillation is also supported by her SOB, palpitations, increased pulse rate, and increased C-reactive protein. The D-dimer result in the patient also strongly indicates pulmonary embolism. Several studies claim that a possible complication after surgery is a deep vein thrombosis (Sutherland, 2009). Deep vein thrombosis can develop at the lower calf. After surgery, a patient’s limited movement can lead to blood clots that can travel up the veins and lodge in the smaller veins or arteries of the body – in some cases – the pulmonary blood vessels (Sutherland, 2009). The patient’s positive D-dimer test indicates possible pulmonary embolism. Her shortness of breath and anxiety are also possible manifestations of pulmonary embolism (EMedicine, 2009). She is at great risk for developing the PE because of her advanced age and because of her recent surgery. The pleural effusions may also be caused by the pulmonary embolism, as blockage of the pulmonary blood vessels can cause accumulation of fluids in the pleural space. The improper drainage of fluids caused by the blockage of blood vessels will result to excessive fluid in the pleural cavity (Rubins, 2008). The crackles and decreased air entry into the left side of the lungs support a diagnosis of pulmonary embolism (Stobo, 1996, et.al., p. 88). What were the consequences of my actions for: Myself? As a result of my actions, I was able to take a more active participation in the care of the patient. As a site manager, my duties mainly revolved around coordination and management of hospital services for the patient. During the incident, I was able to personally assure myself that the CCU nurses were being given the assistance they needed. I was also able to assert myself among the CCU staff as an efficient leader, especially when medical emergencies are involved. What were the consequences of my actions for: the patient/family? As a result of my actions, the patient was able to receive immediate and efficient care from the health care team. Through immediate coordination with the different members of the health care team, the patient’s physiological problems and psychological problems (anxiety and nervousness) were eased. I was also able to show confidence and the efficiency of the health care team in handling the patient’s situation. What were the consequences of my actions for: the people I work with? As a result of my actions, the health care team was able to coordinate their efforts with each other in order to stabilize the patient. I became a relay station and a bridge between the patient and the CCU nurses; between the CCU nurses and the attending physician; and between the patient and the attending physician. A health care member occupying a managerial position is responsible for coordinating nursing services (Rowland, 1997, p. 148). Through my actions, the attending physician was able to immediately assess, diagnose, and order vital meds and procedures for the patient. The CCU nurses were also able to perform clear and guided nursing care for the patient. How did I feel about this experience when it was happening? I felt the usual nervousness I normally felt when medical emergencies occur in the hospital. I also felt that the experience was testing my leadership skills; and I knew that I had to step-up and exhibit confident skills to ensure that the health care team in my supervision will also step-up. I was also concerned about the patient’s advanced age – that she would not be fit enough to survive the incident. I also felt that the decisions that I would be making with the health care team would ultimately mean the life or death of the patient. Therefore, I knew that as a leader and site manager that we had to work efficiently with each other in order to stabilize the patient. I also felt that the health care team substantially complied with the AF care pathway prescribed by the NHS NICE Guidelines. The ECG to confirm the diagnosis was conducted, after which further investigations and tests were ordered in order to assess the risk of stroke and to prevent further deterioration in the patient’s condition. Management and a care plan were immediately formulated in order to avert the patient’s arrest. Monitoring was continuous until the patient reverted to normal sinus rhythm. Follow-up and monitoring was also ordered and conducted on the patient (2006, p. 40). How did the patient feel about it? The patient was very anxious and nervous about the experience. She was also a nurse, so she knew that the symptoms she was feeling implied dangerous possibilities. She also knew that her body may not be physically fit to survive the episode. But she was reassured by my friend’s presence; the sight of a familiar face helped ease her anxiety. She was also confident in the health care team’s ability to handle the emergency. I knew how the patient felt about the experience because I asked her how she was feeling and she honestly said that she was feeling nervous and frightened. During my A to G assessment, I also noticed her anxiety and nervousness. Her palpitations, chest pain, and shortness of breath may be signs of an anxiety attack, not just of the AF or a possible PE (Health Central, 2009). By keenly observing the patient, I was also able to observe non-verbal cues indicating her anxiety and nervousness. I knew that “both verbal and non-verbal communication techniques can encourage free flow of information and provide meaningful data for evaluation” (Crisp, et.al., 2006, p. 571). Influencing Factors: What internal factors influenced my decision-making? I felt influenced by my duties and responsibilities as a site manager. I knew that I had the responsibility of handling the emergency and of coordinating with the members of the health care team. I felt influenced by my personal need to expertly and efficiently face the challenge I was encountering at that time (Johns & Freshwater, 1998, pp. 7-8). A part of me was also influenced by the fact that the patient was a friend of my colleague and was a former nurse. I did not want to let my colleague and the patient down. However, this concern was not a main source of influence in my decisions. I knew I had to be objective in my decisions and to treat the patient like any other patient. What external factors influenced my decision – making? External factors that influenced my decision-making were the professional and legally mandated duties and responsibilities of a nurse and a site manager that I had to comply with. These rules required me to handle medical emergencies in the hospital, to coordinate services in the hospital, and to ensure that there were no errors in the administration of care to the patient by myself and by the members of the health care team. What sources of knowledge did / should have influenced my decision – making? The sources of knowledge that influenced my decision-making was my previous training as a critical care nurse, my basic knowledge and skills as a registered nurse, and now my present knowledge and skills as a site manager. These knowledge and skills earned and honed through my years in the nursing profession influenced the decisions I made during the incident. The NHS National Institute for health and Clinical Excellence Guidelines (2007, p. 8) emphasizes that the “staff caring for patients in acute hospital settings should have competencies in monitoring measurement, interpretation and prompt response to the acutely ill patient appropriate to the level of care they are providing”. As a former ICU nurse, I knew that a call from the unit meant that the patient may go into arrest; and this call influenced me to call immediately for the doctor. As a site manager, I knew that the rules and regulations mandated and required me to handle the medical emergency in the hospital and to coordinate the services of the health care team. And based on my skills as a former ICU nurse and now as a site manager, I was also able to make a tentative diagnosis of the patient based on the diagnostic results at the time of the emergency. Could I have dealt with the situation better? I think I could have dealt with the situation better. I could have made my own notes in the patient’s chart instead of relying on the doctor’s notes. By making the proper annotations in the patient’s chart, nursing care administered to the patient at the time of the emergency will be documented. Even if my notes will only be an echo of the doctor’s notes, nevertheless, for legal purposes, it is mandated for nurses to write the progress notes in the patient’s chart. The doctor’s and the nurse’s actions differ from each other. Many health experts point out that, “although nurses’ notes were at one time not considered a permanent part of the patient’s medical record, the importance of these notes is now recognized and they are generally retained with the remainder of the chart” (Smith, 2005, p. 14). A doctor’s role is to diagnose and to order treatment for the patient; hence, such actions would be contained in his notes. A nurse’s role is to administer medications, to monitor the vital signs, and to render bedside care to the patient; therefore, such actions would be contained in her notes. What would be the consequences of these choices? The consequences of these choices would be an improved documentation of the patient’s progress from her admission to her discharge. The patient’s chart is now also more compliant with the legal requirements and with the mandates of the nursing profession. The nurse’s notes also form part of nursing diagnosis. Many nurses believe that nursing diagnosis “allows them to describe their specific contributions and activities” (Gordon, 2005, p. 33). In retrospect, I now realize that filling in my own notes in the patient’s chart would also allow different colleagues in the nursing profession to check and see the progress of the care given to the patient at different points during her hospital stay. Learning: How do I now feel about this experience? I feel that this experience was a huge challenge for me and for the health care team considering the age and the symptoms that were manifested by the patient. But, I also feel that it was a challenge that we were able to successfully meet through our efficiency and our healthy coordination with each other. I now feel that I can efficiently coordinate the efforts of the health care team; and this has added to my experience and my confidence as a leader and as a manager. I feel that I need to be more prudent about writing in the nurse’s notes in order to achieve proper documentation and adequate compliance with legal and professional mandates of nursing care. How have I made sense of this experience in light of past experiences and future practice? I have made sense of this experience in light of past experiences and future practice by drawing on my past skills, knowledge, and training as a critical care nurse; and my present experience and abilities as a site manager. As a nurse with intensive care training, I knew from previous experience that the symptoms, observations, and diagnostic results being presented by the patient were possible indications of impending arrest. I also knew that we had to work fast and efficiently in order to stabilize the patient’s condition and therefore avert possible arrest. And I knew that despite the skills of the CCU nurses in dealing with the emergency, they needed a leader to assist and guide them in making the best nursing care decisions for the patient. I have made sense of the experience by seeing it through the eyes of a critical care nurse and as a site manager. How has this experience changed my ways of knowing: empirics? This experience has changed my empirical knowledge about elderly patients. I always thought that the elderly patients are highly vulnerable during medical emergencies; that it would be really difficult to stabilize their condition. This experience has taught me that not all elderly patients are bound to be forever incapacitated by a medical crisis or emergency. Many elderly patients are remarkably resilient, and with adequate support from friends and family they have the ability to be survivors. The patient in this case showed remarkable courage and resilience and I believe that these qualities helped her overcome her health crisis. I learned now not to underestimate elderly patients. How has this experience changed my ways of knowing: moral knowledge This experience has changed my moral knowledge in the sense that it has reinforced my previous belief about diagnosing and treating a member a friend or one’s own family. I could observe at various stages during the care of the patient that my friend was really concerned about the patient. Although she helped calm the patient down, I could see that she was fighting a huge battle to stay objective about the case. Now, I fully understand and appreciate how important it is to just let the rest of the medical team take care of one’s own family or friends. How has this experience changed my ways of knowing: Personal – self awareness This experience has improved my self-awareness. I am now more aware of my skills and my capacity as a leader and as a manager. I am also more aware of my ability to handle emergencies and juggle my roles as a manager and as a caregiver. How has this experience changed my ways of knowing: Aesthetics – the art of what we do, our own experiences The track and trigger response that was set-up with the CCU nurses improved the response of the health care team in caring for the patient. The incident was able also to improve and increase monitoring for the patient. The Centre for Clinical Practice NICE (2007, p. 28) emphasizes that “the frequency of monitoring should increase if abnormal physiology is detected...”. As a result of the incident, more tests, medications, and monitoring were ordered on the patient. These additional orders were able to reveal and confirm that there was a pulmonary embolism in the patient; consequently, her septic condition was also addressed and neutralized. She was successfully treated. The incident was also able to improve the teamwork and communication between and among the different nurses in the different units with the members of the healthcare team. The NICE Guidelines emphasize that in AF patients “good communication between healthcare professionals and patients is essential” (2006, p. 5). Health experts point out that nurses are in a perfect position to enable coordination of patient care. These experts point out that the nurses are with patients 24 hours a day and they can immediately raise the ‘alarm’ to alert the health care team when the patient needs immediate care. They also quickly and accurately point out that “when something needs to happen differently, it is often the nurses who are mobilizing their team members so that the patient gets the right service at the right time” (Lamb, et.al., 2008). Works Cited Calkins, H., 4 June 2004, Predicting Atrial Fibrillation After CABG, Journal Watch Cardiology, viewed 18 June 2009 from http://cardiology.jwatch.org/cgi/content/full/2004/604/2 Centre for Clinical Practice NICE, July 2007, Acutely ill patients in Hospital, NICE Clinical Guideline 50, viewed 18 June 2009 from http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf Community Health Care (n.d) John’s Model of Structured Reflection, Bolton Primary Care Trust, viewed 18 June 2009 from http://www.communityhealthcarebolton.co.uk/SHA/LLL/resources/reflective/JOHNS.doc Crisp, J., et.al., 2006, Potter and Perrys fundamentals of nursing, New South Wales: Elsevier Australia. 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Stobo, J., et.al., 1996, The Principles & Practice of Medicine, Connecticut: Appleton & Lange Sutherland, S., 8 May 2009, Pulmonary Embolism, EMedicine from WebMd, viewed 18 June 2009 from http://emedicine.medscape.com/article/759765-overview Walsh, M., 2004, Nursing frontiers, London: Elsevier Appendix Observations Female, 64 year old patient CABG and AVR 13 days PTC Reported ECG changes HR-127 bpm SOB Palpitations Anxiety Speaking in short sentences No sweating O2 sat: 96% 12 lead ECG: AF secondary to sepsis Bilateral crackles; reduced air entry at left side WCC-14.7 d/L D-dimers-4.3 CRP-85.8 Platelets-671. Later reverted to sinus rhythm Read More