Clinical Applications of Nursing Diagnosis - Essay Example

?Appendix: Clinical Scenario A 44 year old white Anglo Saxon male client was admitted to drug and alcohol detoxification unit for detoxification fromlong term use of alcohol – approximately 1 x bottle of Vodka daily. Client is obese with weight of 165Kg; Difficulty sleeping due to be investigated for same as yet has not had any sleep studies? Sleep apnoea. Further history indicates patient is diabetic with insulin infusion. Developed central chest pain, described as crushing in nature. With nil radiation. Diaphoresis and short of breath is also observed. He saw a Registered Nurse who gave him two Ibuprofen tablets and sent him to bed saying that he was having musculoskeletal chest pain. A nurse’s aid who is also a second year nursing student at university saw the client , took his blood pressure which was found to be elevated at 185/112. His heart rate was rapid at 113 beats per minute. The clinical picture indicated that the man was most probably having a heart attack. The student / nurse called an ambulance. As per unit protocol an accident/incident form was filled. Chest pain is a common occurrence with older patients. In the Emergency Department, chest pain needs to be isolated as cardiac or non-cardiac in origin. Physical assessment and proper history taking is very important in identifying the type of chest pain the patient is experiencing. This will also help the health care provider prioritize the plan of care. Proper assessment and history taking through detailed interview could have helped greatly in avoiding errors and reducing incidence reporting. This also indicates that the quality of care is improving. Pain is a very subjective matter. McCaffrey defined pain as whatever the person experiencing pain says it is, existing whenever the person communicates or demonstrates it does (McCaffrey, 1986). Chest pain is one of the most common complaints in emergency departments of hospitals and acute care centers, so common that immediate evaluation and correct diagnosis is very important in the patient’s survival. The situation describes a 44 year old Anglo-Saxon male client presenting with crushing chest pain. History shows long term use of alcohol, obesity, diabetic with insulin infusion, diaphoresis and shortness of breath. The Registered Nurse who first assessed the patient missed critical information such as taking the vital signs of the patient. Vital signs, particularly blood pressure is very important in the assessment of pain. Increased blood pressure usually indicates severe pain (Cox). High blood pressure and tachycardia are symptoms of a heart attack. These symptoms plus the crushing chest pain, diaphoresis and shortness of breath are warning signs of heart attack and is should be considered a medical emergency. Clinical Governance Clinical governance is a term used by the National Health Service to describe a systematic approach in maintaining high standards of care and aims to continually improve the quality of services delivered in the clinical practice environment. Clinical governance is defined as a framework which helps all clinicians – including nurses – to continuously improve quality and safeguard standards of care (Royal College of Nursing). The role of clinical governance in this situation is to correct any mistakes that the drug and alcohol detoxification unit failed to detect. The purpose of clinical governance is to maintain and improve standards of patient care. In this scenario, it will improve the inadequate partenership between and among health care professionals dealing with the patient. It will also improve delivery of health care in other elements of clinical governance such as education and training, clinical audit, clinical effectiveness, research and development, openness and risk management. In education and training, the staff of the unit are equipped for drug and alcohol detoxification but they also need to continually update themselves with regards to medical cases in order for them to promptly idnetify life threatening symptoms such as mentioned in the scenario. Knowledge of the signs and symptoms of medical conditions means prompt intervention and appropriate treatmetnt. As an advance practice nurse, it would be best to complete the assessment of the client through detailed interview, carefully noting the history of the client that is relevant to his present health condition.as independent practitioners, APNs have the privelege not available for registered nurses in the ED. The APN can order some tests to be performed in order to verify whether the chest pain is of cardiac origin. Though the patient was admitted for alcohol detoxification, his chest pain becomes the priority of care. In this scenario, the most likely diagnosis is acute coronary syndrome or myocardial infarction (MI). Male clients above 40 years old are more predisposed to MI. The patient is also has diabetes and is on insulin infusion which indicates that his blood sugar is poorly controlled. The contributing factors in the client’s situation would be his history of diabetes and alcoholism. The Registered Nurse who took care of him first failed to properly assess the client according to protocol. In Clinical Governance, it is very important to deliver quality care, which means assessing the patient properly in order to provide the most appropriate plan of care. When the nurse failed to obtain his blood pressure at the onset of chest pain, s/he already failed to deliver quality and appropriate care. Preoccupation of the idea that the patient was admitted for detoxification made the nurse relax a little with the assessment that lead to the failure to diagnose the condition earlier on. This failure also lead to incident reporting which would have been avoided if proper assessment was performed. Clinical decision making is the heart of clinical encounters or operational decisions therefore, it also follows that the better our decisions, the more successful and effective clinical practice be (Hall, Noble, & Smith, 2009). In quality and safety standards set by NHS, safety and quality are related but does not overlap. Safety means that individuals make errors all the time. In order to maintain safety of all clients, we need to identify factors that affect errors such as fatigue, stress, interruptions, complexity, and transitions. One strategy to minimize errors or avoid mistakes is to strictly implemet protocols when it comes to assessment of patients. In this scenario, the unit could make sure that vital signs are taken accurately and recorded regradless of the reason for admission or chief complaint. By doing so, mistakes are avoided and plan of care is improved because the nurse has a good database of the patient. Once the safety issue is maintained, quality care comes to play. Quality of care is very hard to define and measuring quality is a comples process. Quality theory suggests that overall quality will be improved more in the aggregate by raising the level of performance of all providers rather than ?nding a few poor performers and punishing them. Changing the system is especially helpful in improving quality since large number of providers maybe affected simultaenously. Category of the Incident The incident falls uder clinical governance and accountability. The revised framework for clinical governance is not only for clinical standards to be met, but also, to challenge clinicians and advance practice nurses their autonomy as clinicians (Starey). The elements of clinical governance include education, clinical audit, clinical effectiveness, risk management, research and development and openness. In terms of education, it is imperative that the staff of the unit engage in continuing education since skills learned during training gets outdated quickly. The mistake of the registered nurse in the scenario could be attributed to lack of continuing education. Had the nurse been receiving updates from different professional groups, the situation would have been carefully and properly assessed. The scenario also lead to a conduct of clinical audit. Clincial audit is a systematic review of procedures used for diagnosis, care and treatment, examining how associated resources are used and investigating the effect care has on the outcome and quality of life for the patient (Department of Health). Conducting a clinical audit in the unit is a cyclical process that will help improve the quality of clinical care delivered since it requires participants to agree to audit plans and standards, measuring performance against those standards, reviewing standards in the light of performance and adapting the system before repeating the cycle. Quality is a characteristic of health care that one needs in a health care system not just for the reason that the patients paid for the service but it is the sole responsibility of the health care team to provide the quality standard care for the patients. Donabedian has suggested that quality of care can be divided by type of measurement into structure, process, and outcome. Structure refers to whether or not a particular characteristic is present. Process refers to the way that care is delivered, and examples of process measures are whether a Pap smear was performed at the recommended interval or whether an aspirin was given to a patient with a suspected myocardial infarction. Outcomes refer to what actually happens, e.g., the mortality rate in myocardial infarction. Quality improvement strategies are made available in order to continuously provide quality care to patients. One of these strategies is benchmarking. Benchmarking is an improvement process used to discover and incorporate best practices into operation (Damelio). It allows the organization, or in this case, the unit to think as a team in order to identify and understand elements of superior or world-class performance in particular work process. For example, in the clinical scenario mentioned, there are instances where the comptenecy of the staff can be questioned particularly when the registered nurse ignored the chest pain and assumed that it is just a muskuloskeletal chest pain. The nurse demostrated ascertainment bias in this situation. The nurse did not assess further thinking that the patient was admitted for detoxification and nothing else. The nurse manager of the unit can call for a benchmarking activity where they can discuss flaws in the current process and devise possible interventions that can be used to improve the situation. The safety and quality of health care in this clinical scenario can be improved through the use of clinical governance, employing strategies that will identify areas for improvement that can be remedied through benchmarking procedure and clinical audit. References Cox, Helen. Clinical applications of nursing diagnosis: adult, child, women's, psychiatric, gerontic, and home health considerations. University of Michigan: F.A. Davis, 1997. Damelio, Robert. The Basics of Benchmarking . Portland, Oregon USA: Productivity Press, 1995. Department of Health. What is clinical audit? UK: Department of Health, 28 May 2009. Royal College of Nursing. Clinical Governance: An RCN Resource Guide. London: Royal College of Nursing, 2003. Starey, Nigel. "What is Clinical Governance?" Hayward Medical Communications, May 2001. Read More