The Concept of Reflective Nursing - Assignment Example

Reflective Nursing Tracheotomy Order No:155924 Pages – 10 – 6530 The concept of “Reflective nursing” is not new. But researchers all over the world strive to improve the already existing pattern of nursing. Thus the curriculum was reconstructed to incorporate “clinical learning spiral” (Stockhausen, 1994). This spiral helped nurses to develop competency of reflective practice. The objective was that reflection would lead to change and positive outcomes for patients undergoing treatment and nursing care. Reflection can be defined as--- “the throwing back of thoughts and memories in cognitive acts such as thinking, contemplation, meditation and any other form of attentive consideration in order to make sense of them, and to make contextually appropriate changes if they are required”. (Taylor 2000, p.3). The Phenomenon: A Trachostomy was to take place and the nurse on duty had to render appropriate assistance while the doctor did the surgery. She seemed quite nervous as she felt herself inadequate for the job. The factors that contributed to this experience was that she was not well equipped to handle this situation. She is a new hand and has no prior experience. A Tracheotomy or Tracheostomy is a surgical procedure which is performed on the neck of a patient to open a direct air passage by making an incision in the trachea and performing an operation. The difference between a tracheostomy and tracheotomy is quite small for the fact that the hole made is permanent. If a cannula is used, the unsutured opening heals into a patent stoma within a week. If a tracheostomy cannula is removed (decannulation) the hole would heal in about the same time. The raw edges of the trachea can be sutured to the skin with absorbable sutures to facilitate cannulation. The term tracheostomy is considered by most to be synonymous with tracheotomy. In ancient times, this procedure of slitting the throat to save a life was condemned by people for they considered it to be “semi- slaughter”. But later, when this procedure was perfected and in turn helped a great many people, it opened doors for medical heroism and gained a respectable place in medical history. In the 17th century, Fabricus thus said –"This operation redounds to the honor of the physician and places him on a footing with the gods." (Cited by HB Webster 1999 ) Tracheotomy is performed for several reasons – some of them are – Maxillofacial injuries Tumors of the head and neck Bronchial cyst Mechanical ventilation and trachea toilet (for comatose patients and patients undergoing surgery of the head and neck.) Failure of endotracheal intubation. Some of the complications that may arise due to a Tracheostomy are – Pneumothorax Fistula Injury to blood vessels or nerves Bleeding Dislodged tube Respiratory arrest Pulmonary dysfunction Tracheal stenosis Some of the symptoms for a Tracheotomy are - Dyspnea Stridor Inspiratory - Usually a supraglottic obstruction being sucked into the glottis with inspiration. Expiratory - Usually a sub-glottic obstruction being blown up into the glottis during expiration. Biphasic - Both of the above or a lesion isolated to the glottis (eg, edema) Voice change Decreased or absent breath sounds Pain Cough Drooling Bleeding Restlessness Hemodynamic instability (late) Loss of consciousness (very late) Intubation: This is a procedure to prepare a patient before undergoing Tracheotomy. Intubation refers to the placing of a tube internally or externally into the orifice of our body. There are two types of Intubation. One is the endotrachael Intubation where the tube is placed into the mouth of the patient and the nasotrachael Intubation where the tube is passed through the nose. With tracheal Intubation the airway passages are restored and the lower airways are protected from aspiration. Intubation can be used for: Patients who are in comatose or intoxicated. Patients under going Brochoscopy. Patients under going laser therapy or stenting of the bronchi. In Intensive care medicine. In emergency medicine In cardio pulmonary resuscitation. Procedure experienced: The patient was prepared and made to lie on the bed in an operation theatre or in the ITU. Blood test is done to ensure that the patient would not encounter problems due to clotting. The nurse helps the patient to remove dentures or any fixtures in the mouth and she administers sedatives to make the patient drowsy. The patient is then put on a pulse oximeter (a small device clipped gently to the finger or ear lobe of the patient to monitor the blood and oxygen levels. Other monitors such as the blood pressure cuff and electro cardiogram are also used. The back of the throat is sprayed with a local anesthetic to numb the tissue. (Jeanie Barone Physiologist, Gale Encyclopedia Published in Dec. 2002) Bronchoscopy: The physician used a bronchoscope which he inserts into the nose or mouth to visualize the air passages clearly. The bronchoscope is a long, narrow, fiber optic, lighted tube that has a small camera at its tip. This camera displays images on a video screen or camera. It allows the physician to clearly examine the larynx (voice box) trachea (windpipe) bronchi (air passages leading to the lungs) and bronchioles (smaller passages from the bronchi.) There are two types of Bronchoscopes – one is flexible and the other is rigid. The flexible Bronchoscope is favored because it allows ample visibility of all the tiny bronchioles as it can be maneuvered. The rigid bronchoscope does not allow free movement by the physician and as a result he is unable to derive a proper diagnosis. The significant factors that led to this situation were - because the nurse was not familiar with the equipment the physician was asking for. She kept messing things up as she passed wrong instruments which in turn made the doctor annoyed and tense. Sedation: Sedation is given to reduce anxiety, fear and stress and to also lower the intake of water. Sedation is given based on the amount of stimulus and responses. The administration of the sedatives given should be monitored 7 days before and 7 days after the operation to ensure the comfort of the patient. Sedation is given intravenously with either sterile saline or glucose. The amount of sedation for each patient is determined by a Sedation Intensive care score (SEDIC) which consists of five levels of stimuli (from normal speech to nailbed pressure) and five levels of responsiveness(from normal contact to no contact) The sedation given to a patient undergoing Tracheostomy is usually a combined infusion of 50mg Morphine and 50mg Midazolam. Propofol can be added if high doses of Morphine and Midazolam are needed. (eg. For frequent neurological evaluation is warranted especially for patients with a head injury. The sedation keeps the patient in a semi-conscious state. He knows what is taking place but at the same time he does not feel the pain or stress. Patients who are being weaned away from Midazolam are given low doses of oral Benzodiazeppines, whereas patients who are agitated or delirious are given Haloperidol. It is also to be observed that ICU patients receiving mechanical ventilation needed less intravenous sedation. These patients spent less time in the bed and achieved better results. (Pain/Anesthetic News. Article dtd. 4th April 2006) Procedure continued: An intravenous (IV) line was inserted into the patient’s arm and his blood pressure, oxygen level and heart and respiratory rate were continuously monitored. For sedation the patient was administered Propofal and Alfentanil Aticulm before Intubation. He was also given oxygen through a nasal cannula and spraying on the throat was done to avoid gagging. The physician then advanced the Bronchoscope slowly into the patient’s throat. There was great difficulty sending the Bronchoscope down and it seemed to be stuck because it had gone into the percutaneous tissue that surrounded it. As a result the patient started to bleed profusely. The patient was unable to breathe and went into systole.(The part of the cardiac cycle in which the heart muscles contract pumping the blood into the main blood vessels.) The patient showed great discomfort as it blocked visibility. The physician quickly took charge of the situation and suction was done to remove the excess blood from the area. Consequences: The physician knew that she was a new hand without experience and told her so in no plain words. The nurse felt ashamed that she did not take the trouble of equipping herself in order to be of good use to the physician during such an important situation where a patient’s life is involved. The patient therefore suffered many setbacks due to the negligence and ignorance of the nurse. It was a life threatening situation and it was solely the nurse’s fault. There was no apparent reason for such a situation to take place because the patient did not have any neck abnormalities. Therefore we conclude that it was haste and negligence on the part of the doctor as well as the inadequacy of the assisting nurse. (Sicard, Michael W. "Complications of Tracheotomy." The Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences.) Systole: Systole is derived from the Greek “Systole” meaning a “contraction” or a “drawing together”. This refers to the time period that the left ventricle of the heart contracts. “Systolic pressure” is basically the maximum arterial pressure during contraction of the left ventricle of the heart. In taking a blood pressure reading, the first number is the systolic pressure. Since the patient was bleeding profusely, his blood pressure decreased and this made him go into “Systole” (The Nations # 1 heart program by US News and World Report, Heart and Vascular Institute Cleveland.) Hemorrhage: The most fatal and dramatic of complications during a Tracheotomy is massive hemorrhage, so adequate care should be taken in the initial stages to avoid such a situation. Hemorrhage of any kind whether small or big is life threatening if it blocks the trachea or air passages. Bleeding that occurs during this procedure is mainly due to the result of errors in surgical techniques. The common sites of bleeding are the anterior jugular veins or the Thyroid Isthmus. Feelings of the nurse: The nurse had a low self esteem, because she could not live up to the situation that was life threatening to a patient who depended solely on her. She lost her self confidence because she did not live up to what was expected of her. She realized that the patient suffered so much because of her. She knew that the patient’s life was at stake when she saw how much of blood was lost and as a result the patient had gone into systole. All through the procedure she had a feeling of remorse on account of her actions. Results: Once again an attempt was made to carry out bronchoscopy. Three sets of tracheotomy were used and it was successful only after five attempts were made after calling in other colleagues to lend a helping hand. Because of this the patient had to be sedated for a long time and he also developed a Haematoma around the neck. This occurred not because of any fault of the patient, but by sheer negligence of the physician as well as the nurse. As a result the patient had to suffer unnecessarily undergoing long hours of both pain as well as heavy sedation. The Nurse’s experience and reflection: The nurse who was attending to the patient, felt inadequate because she had no prior experience in assisting the physician for such a procedure. She did not understand properly what the consultant wanted and hence made him a bit annoyed with her. In this case it would be better to have well trained hands on the job to act diligently especially when it entails a life – death situation. The nurse felt very guilty when she saw the patient almost going to die. She felt ashamed because she could not live up the physicians speed in dealing with the condition of the patient. She was not well equipped to understand the different instruments the physician was asking for. The nurse felt depressed as she was not capable of living up to an important situation. In future if she feels that she is unable to handle a situation such as this she should be brave enough to say so and instead send someone who has good experience with such an operation. The confidence level of the nurse was at its lowest because she could not live up to such an important situation which entails the life of another human being. Other choices- What could have been done: There are a number of techniques that could have been used to stop the bleeding, but there is no emphasis laid on any particular method. Some advocate the use of intra bronchial epinephrine with decubitus positioning of the bleeding hemithorax, balloon tamponade, bronchial artery embolisation and Nd-YAG laser photoresection to control the haemorage. Some advocate a temporary bronchus blocker and apply a fibrin sealant or even use a saline solution bronchial wash. Learning: In order to deal with such a life threatening situation, only very experienced nurses should be used. A lot of practical knowledge and hands on experience is necessary to tackle a job such as this. If a nurse is assisting a Tracheotomy for the first time, another experienced hand should be together with her to show her the ropes, so that such a situation never occurs. The nurse on her part, should equip herself by reading literature on the different operations she is supposed to know and she should also witness other experienced nurses when an operation is taking place. In this way she can build up a good self esteem and confidence and this will enable her to live up even to the most difficult situation she may encounter in future. References: www.answers.com/topic/intubation www.bcm.edu/oto/grand/12194.html Boyd, E. & Fales, A. (1983). Reflective learning: Key to learning from experience. Journal of Humanistic psychology 23(2)99-117. Carper, B, (1978). www.cat.inist.fr/?aModele=afficheN&cpsidt=17266718asp www.clevelandclinic.org/heartcenter/pub/glossary/s Fabricus,(17th century) “This operation…………the Gods”. Cited by HB Webster – 1999) www.findarticles.com/p/articles/mi_m0984/is_6_127/ai_n14708151 www.healthatoz.com/healthatoz/Atoz/ency/tracheotomy-jsp Jeanie Barone Physiologist, Gale Encyclopedia ( Published in Dec. 2002) www.journals.cambridge.org/production/action/CjoGetFulltext?fulltextid=401896 www.medicinehealth.com/bronchoscopy/article_em,htm www.medscape.comviewarticles/1542176 www.mdterms.com/script/main/art.asp?articlekey=16204 Pain/Anesthetic News. Article. (dtd. 4th April 2006) “Reflective Nursing” “clinical……spiral” (Stockhausen, 1994) “Reflective Nursing” “the throwing back of thoughts………..are required” (Taylor 2000, p.3) Sicard, Michael W. "Complications of Tracheotomy." The Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences.) The Nations # 1 heart program by US News and World Report, Heart and Vascular Institute Cleveland.) www.tracheostomy.com/what.htm www.tracheostomy.com/complica.htm www.wikipedia.org/wiki/Tracheotomy Read More