Reflective Practice in Regulating COPD - Essay Example

Reflective Practice in Managing COPD Table of Contents Introduction 3 Reflective Model 4 Reflection on Respiration Rate as Determinant of Health Deterioration 4 Conclusion 8 Bibliography 10 Introduction Recently, a middle-aged, male patient was admitted to the emergency room complaining of difficulty in breathing. The patient, when interviewed by the attending physician, was unable to give details of his medical history due to his present condition. The patient had no companion at the time of the incident. As a nursing care practitioner in the emergency ward, there was a need to assess the situation analysing the present condition of the patient and give prompt and appropriate intervention. Upon admission, the patient’s blood pressure was 110/60, heart rate was 130 and respiratory rate was 30. Early warning scoring was immediately undertaken to determine the severity of the condition based on observable symptoms. The patient scored 6 on the EWS and the attending physicians immediately prescribed a salbultamol nebulizer and oxygen therapy. After 15 minutes, based on clinical observation, the patient’s condition improved. His respiratory rate was lowered to 23 and heart rate at 123 bpm. However, his blood pressure dropped further to 95/55mmHg. Despite exhibiting signs of improvement, the patient’s EWS rose to 8 and contravened the clinical observations. The intensive care specialist was immediately called in to intervene. In the case described above, there was a need to develop reflective practice in nursing care delivery especially in emergency cases. Relying on observable symptoms may not be enough to make a correct diagnosis and decision. The intent of this discourse is to demonstrate the effective use of reflective model framework to execute the Greenwood’s Level 2 (2002) framework for reflection. Reflective Model Greenwood’s (2002) framework for reflection is composed of six stages. The first involves a description in detail of the event. The second stage includes how assumptions, beliefs, values and attitudes of an individual are reflected in his/her actions. Stage three is evaluation. The nursing care practitioner evaluates if the measures employed are consistent with nursing care delivery standards. Stage four is analysis of the event. This involves more detailed inquiry on the items evaluated in the previous stage on which aspect of nursing-related theories were relevant in the choice of action taken. Stage five is synthesis. At this stage, the individual already developed his own insights. The nursing practitioner is also able to view the situation at all angles. It is also at this stage that the individual developed alternatives to the actions undertaken previously to improve outcomes. Finally, the nursing practitioner reflects on alternative actions to take in the light of the experiences. Reflection on Respiration Rate as Determinant of Health Deterioration Stage 1: Detailed Description of the Event A middle-aged male patient was admitted to the emergency ward complaining of breathing difficulty. At the time of the incident, the author was part of the hospital’s emergency team. The responsibilities include assisting the attending emergency physician, provide initial diagnosis and interview of the patient and coordinate the tasks of the team members. On that particular day, one of the emergency physicians took over the case while other team members did their assigned tasks. The initial diagnosis of the patient was conducted and recorded. Since the patient had a difficult time giving his medical history, the author decided to prepare an early warning scoring (EWS) to determine the seriousness of the case. Included in the range of possible disorder was chronic obstructive pulmonary disease (COPD) because the patient did indicate that he was a smoker. According to Johnston, Rattray & Myers (2007), early warning scoring system is an important decision making tool especially for practitioners who needed to decide “on when or how to intervene and when to call for help.” (p.220) The scoring includes patient’s physiological data like heart rate, blood pressure, respiratory rate, body temperature and other relevant information. A minimum score of 3 mandates the assistance of the medical staff (p.221). COPD was considered because the patient exhibited symptoms associated with Dyspnea. Dyspnea is a common symptom among COPD patients and immediate pharmacological relief must be administered to restore physiological functions (Schlecht, Schwartzman & Bourbeau 2005, p.187, Merck Manuals Online 2007). The American Thoracic Society (1998) defined Dyspnea as “difficult, labored, uncomfortable breathing, an awareness of respiratory distress, the sensation of feeling breathless or experiencing air hunger, and an uncomfortable sensation of breathing.” (p.322) However, one must also be aware that there are about 3-7 multiple types and the condition could also be associated with other conditions like “physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses.” (p.322) Nevertheless, COPD was not discounted because the patient did indicate that he was a smoker. It was judgment call on the part of the emergency nurse and the attending emergency physician concurred with the observation. Hence, the intervention priority was the elimination of the Dyspnea. However, fifteen minutes after the intervention, the patient’s vitals were deteriorating. This implied known, observable symptoms are not always associated with COPD despite the physiological manifestations of the patient. Stage 2: Reflection on Individual Actions The author at that time of the incident was confident that the assessment was correct. However, it turned out that the patient had a more serious condition that went beyond the scope of the expertise of the nursing practitioner. The initial intervention, however, did give temporary relief to the patient but it was not enough. It was through the observations made using the early warning scoring system that triggered the need to call for assistance from the intensive care unit. The outcome was an eye-opener for the emergency team. First, it made the author realize that not all known symptoms associated with a particular disease are necessarily true in all situations. Second, the value of using early warning scoring system became more relevant to emergency nursing care delivery. In the outcome of the emergency procedure, the nursing practitioner valued giving immediate relief more than giving the “appropriate” relief to reduce the patient’s discomfort. Stage 3: Evaluation Essentially, the intervention did provide temporary relief to the patient. But it failed to completely control the health deterioration of the patient. The actions were inconsistent with nursing care delivery that emphasized correctness and accuracy. The early warning scoring system proved to be an indispensable tool for evaluating patient conditions especially in emergency cases. Finally, what should have been done was to conduct a more extensive review of the case of the patient before concluding that his symptoms were actually COPD related. Stage 4: Analysis In analysing cases exhibiting symptoms similar to Dyspnea, the American Thoracic Society (1998) suggested that standard spirometry and lung volume measurements be used to assess the patients. Using this metrics could confirm or discount the probability of COPD (p.326). Spirometry is the most accurate method of measuring respiratory obstruction and it is recommended that the test be performed for smokers who are over 35 years of age (Diagnosing COPD 2004, pp.29 & 36). Takahashi et al (2003) considered cigarette smoking as a consistent determinant of the development of COPD in smokers. Statistics show that 10-15% of smokers eventually developed COPD. The author worked along this information to decide on the possible symptoms of the patient. The diagnostics done on the patient was not adequate to make a correct prognosis. However, the presence of EWS results did save the patient’s life because it triggered the need for more serious examination by an intensive care specialist to determine the real cause of the patient’s discomfort. In nursing care delivery, the primary concern of the emergency staff was to seek immediate relief of the abnormal breathing and heart rate because these when left unattended could escalate to more serious conditions. Stage 5: Synthesis The emergency situation revealed that some cases of Dyspnea do not necessarily confirm COPD. The probability of other caused of the condition is broad. Therefore, it is important for the emergency care practitioners to know more about related conditions to avoid the similar problem encountered. Tkáˇc, Man & Sin (2007) noted some other diseases do accommodate COPD depending on the gravity. If “mild to moderate COPD [is present], cardiovascular co-morbidities and cancer predominate; whereas in more advanced disease, osteoporosis, cachexia, and peripheral muscle weakness become the leading extra-pulmonary complications of COPD.” (p.47) The nursing care practitioner is on the right track when determining the deteriorating respiratory condition of the patient implied more serious outcomes. Considine (2005) wrote that respiratory distress is a precursor to more serious event like cardiac arrest. The use of indicators such as the early warning scoring system helps mitigate the risks (p.624). Considine (2005) also indicated that that the nurse plays an important role in identifying and recognizing the signs and symptoms of respiratory dysfunction so that appropriate intervention be applied (p.624). Stage 6: Alternative Actions Should another similar emergency situation occur, the emergency team members are now aware of the other possible physiological dysfunction aside from COPD. If and when the same emergency occurred, the following strategies are followed: 1) The emergency nurse must conduct an interview to extract as much medical history as possible that will aid in proper diagnosis of the illness; 2) The emergency team will continue to use early warning scoring (EWS) systems to evaluate emergency patients; 3) In addition to EWS, the team will consider the standard spirometry and lung volume measurements if the patient has the same symptoms as they provide more accurate indicators; 4) The emergency team will not discount other problems associated with the symptoms; 5) The emergency team will immediately consult a thoracic specialist or intensive care specialist if condition deteriorates the soonest possible time; 6) Finally, after each emergency case, the team will regularly review its intervention procedures to improve emergency care delivery. Conclusion Reflective practice is an important strategy to improve emergency care delivery. In the foregoing discussion, the relevance of reflective practice is emphasized especially in ensuring patient safety and recovery. With reflective practice, critical thinking is involved in every action and decision. In the case presented, reflective practice allowed the practitioner to evaluate his/her actions to determine weaknesses. These weaknesses are rectified and find ways to improve the positive outcomes. The nursing practitioner must be aware of the clinical conditions associated with the respiratory disease so emergency procedures applied are appropriate. Bibliography American Thoracic Society. 1998. Dyspnea Mechanisms, Assessment, and Management: A Consensus Statement. American Journal of Respiratory Critical Care Medicine, Volume 159; pp.321-340. Considine, J. The Role of Nurses in Preventing Adverse Events Related to Respiratory Dysfunction: Literature Review. Journal of Advanced Nursing, Volume 49, no.6; pp.624–633. Diagnosing COPD. 2004. Thorax, Volume 59; pp.27-38. Greenwood, ___. 2002. (Please fill out the necessary bibliographic information) Johnstone, C.C., Rattray, J. & Myers, L. 2007. Physiological Risk Factors, Early Warning Scoring Systems and Organizational Changes. Nursing in Critical Care, Volume 12, no.5; 219-224. Merck Manuals Online. 2007. Chronic Obstructive Pulmonary Disease (COPD) [Online] Available at: http://www.merck.com/mmpe/sec05/ch049/ch049a.html?qt=COPD&alt=sh [Accessed 11 October 2007]. Schlecht, N.F., Schwartzman, K. & Bourbeau, J. 2005. Dyspnea as Clinical Indicator in Patients with Chronic Obstructive Pulmonary Disease. Chronic Respiratory Disease, Volume 2; 183-191. Takahashi, T. 2003. Underdiagnosis and Undertreatment of COPD in Primary Care Settings. Respirology, Volume 8; pp.504-508. Tkáˇc,J., Man, S.F.P, & Sin, D.D. 2007. Systemic Consequences of COPD. Therapeutic Advances in Respiratory Disease, Volume 1, no.1; pp. 47-59 Read More