Nursing: Gibbs Model of Reflection - Essay Example

 Nursing: Gibbs Model of Reflection Introduction This purpose of this essay is to reflect upon an aspect of professional practice that I encountered on placement, using Gibbs model of reflection (1998). This model of six stages encourages practitioners to work through a series of reflective cues. Bentsson (1998) suggests that reflection can be understood and used as thinking and self-reflection helps nurses to learn about actual patrice of the profession and help them evaluate their own practice and performance. Bengtsson (1998) further suggests that nurse need to learn from these experiences and by doing so they may acquire the competences that are needed to teach others. According to Maggs and Bill (2000) evaluating practice through reflection can bring advantages. The proposition is to be familiar with and utilize these benefits along with the knowledge they create. By doing so, this should help develop my skills in further practice In accordance with the NMC (2009) code of professional conduct, the patient’s name has been changed to the name Jim to protect identity. Whilst on placement working on a hospital ward I had the opportunity to be involved around diet due to the amount of surgery we had on the ward. I have decided to use Rolfe’s model of reflection (2001), In nursing education working on the ward offers a possibility of integrates health promotion knowledge and the skills to development of the reflective practitioner. Naidoo and wills (1998) propose the Schonls (1983) concept of the reflective practitioner and Kolbs (1984) experiential learning are useful framework also in the field of health promotions in facilitating the development of a health promoter. The Event This was my first placement on a ward. After the first two weeks, I felt less anxious and started to enjoy knowing the routine of the ward and I seemed more relaxed. My mentor gave me a patient to look after so I felt excited and nervous all at the same time about the situation I therefore gained as much information as I could about the patient. One year prior to surgery, the patient had been experiencing abdominal pain accompanied with constipation and problems in defecating. A number of medications had been administered in the past by the patients GP to help with the constipation but this had only given short term relief. The patient opened his bowels most days with a small, hard constipated result, which did not relief the abdominal pain. The patient had been unable to eat solid food, surviving only on nutritional supplement drinks and had lost one and half stone in weight. Eventually, after further investigation the patient was diagnosed with inflammation of the colon and it was decided to perform an elective surgery by performing an ileomstomy leaving the wound on the patient’s left side. After the operation on the ward, the patient was told that the colostomy would be non reversible. I inquired how he felt about it. He replied that he had felt physically and psychologically prepared for the surgery. I felt that this was a positive sign; even through the surgery resulted in him receiving a stoma. In addition the patient had a relatively smooth post-operative recovery. Diet right after surgery should consist of liquids that are high in protein. After discharged Benign discharged home after fifteen day and then referred to the local stoma nurse for follow-up. The clinic provided the opportunity to look at alternative appliances owning to frequent leak, but a satisfactory one-pice with flange extenders was agreed which worked well What is a colostomy? A surgical procedure that creates a hole or stoma on the abdomen and brings out the end of the colon during the stoma for the reasons of stool expulsion, a colostomy bag is attached to the stoma for stool compilation. A colostomy is normally done due to problems within the colon, such as colon cancer and intestinal trauma, Patients with colostomies should consume food that prevents complications and enables the stoma to heal. Blanked Diet Patients with colostomies should consume regular balanced diet that provides carbohydrates, proteins fats, oils, vitamins and minerals which are nutrients that maintain a healthy body. Some patients may not stand some foods after a colostomy procedure (Rolfes, Shady, R. & Pinna Kathryn. & Whitney, Ellie., 2008). Example of foods that may be tolerated include dairy products, such as milk, cheese and cream to prevent diarrhea and stoma cramps due to food intolerance eat small portions after colostomy procedure and then gradually increase your portion size. Patients should make sure they chew foods properly to avoid a blockage at the stoma site (e.g. raw seeds such as flax seeds sunflower seeds pop corn and raisins) Avoid gas forming foods-patients with colostomy may notice excess gas, bloating and order after consuming gas forming certain foods such as cabbage, broccoli, and baked beans eggs and fish. To prevent odour patients should increase intake of foods that help control odour and gas such as yogurt, butter milk, curded milk and parsley. Dietary supplements such as fish oil and garlic tables can also cause odour. Increase fluids- the colon mainly works to reabsorb fluids and create stool. Colostomies may lead to greater loss of fluids if parts of the colon that reabsorb water are removed, according to the University of Pittsbury. Patients with colostomies should there for increases intake of fluids such as water, soup, Gatorade, and broth the intake of caffeine beverages such as tea and coffee should be minimised because caffeine is a diuretic and cause patients to loss fluids. (Sylvia Escott-Stump), (Stanfield, Peggy., Hui, Y.H., 2009). Multidisciplinary Team (MDT) involved in the Colostomy Multidisciplinary teams are groups of professionals from different fields of medicine who come together to provide comprehensive assessment and consultation in medical cases. The multi disciplinary team were involved in the ileomstomy surgery since more than one health professional was required to assist in the operation. The MDT combines mutually individuals who have expertise in various areas of medicine and care, and typically meet as frequently as on weekly basis to talk about the diagnosis, treatment and care of individual patients. The health professionals included in the multi disciplinary team are a colon and rectal surgeon, a general surgeon, a specialized stoma therapy nurse, a gastroenterologist, a histopathologist, a dietician, an enterostomal therapist, a primary nurse, a psychologist and social workers. Every MDT has a set of core members, but other specialists may join the team from time to time. Members of the multidisciplinary team become involved with the patient/family either through direct referral from the primary nurse, physician, or other team members by attending patient care conferences; helping the patients with pre-admission questionnaire that would identify at risk patients. An enterostomal therapist known as an ET is a registered nurse who has specialized training and certification in the care of ostomies and wounds. The dietician plays an important role after the surgery by making food charts for the patient with the help of a dietician which include information about the food allowed and strictly not allowed after the surgery. It is extremely important to take care of the diet after the surgery since appetite and digestion is disturbed in and for some time after colostomy. A gastroenterologist helps to assist the digestive system and plays an important role in diagnosing colostomy. A primary nurse is needed to take care of the health and needs of the patient. The colon, rectal and general surgeon are the ones who perform the surgery. A psychologist is needed to counsel the patient and his family since any form of anxiety before and after the surgery is not good for the health of the patient. If the family is aware of the outcomes it would be easier for them to take care of the patient and to give him some satisfaction that he would start living a normal life soon. The primary purpose of the multi disciplinary is to help team members treat difficult cases; however they may fulfill a variety of additional functions and identify service gaps and breakdowns in coordination or communication between the professionals working on the case. This also increases the professional skill set and comprehension of individuals or team members by giving them a forum for getting the knowledge about the strategies, resources, and approaches used by various disciplines. The team together is responsible for working out the treatment plan, deciding whether further tests are needed, making appropriate referrals to specialist services, making sure the team has all the members needed for the pre-operative assessment and post-operative care. The team works in unity to collect information and keeping all the records of the patient from the start till the end. Role of a Dietician A dietitian helps a person with recent colostomy in choosing a balanced diet. The right diet is important to make the treatment successful and to provide relief to the patient from the foods that cause gas and odor. The patient was losing weight and needed a dietician to guide him to regain health as it is surgeries tend to make the patients lose weight due to anxiety and majorly due to blood loss. The dietician made weekly food charts for the patient so that he can eat and digest according to his digestive system. As the patient complained of constipation which persisted for a very long time hence the dietician prescribed him fluids and soft food till his digestive system got back to normal. Role of an Enterostomal Therapist (ET) Nurse ET nurses play the most important role among the multi disciplinary team members in the treatment of colostomy as an ET nurse has to provide preoperative and postoperative counselling to the patient and his family. The pre-operative services include counselling regarding planned surgical procedure; how the surgery will affect the patient’s social life, sexual life and personal life. They educate them about the daily management of the ostomy because initially the nurses would be there to take care of them but later on they would have to manage on their own. The ET nurses mark the stoma site on the abdomen before surgery and help the patients to cope with the fear of the surgery and counsel the family to be encouraging in the period of rehabilitation. Post operatively the ET nurses guide the patient about their diet and exercise. The ET nurse assesses the patient’s fluid and electrolyte balance and plans interventions aimed at maintaining/restoring balance. They provide long term follow-up care in outpatient settings; such as ongoing counseling, education and ways to inspect for complications requiring medical intervention. They can recommend suitable ways to prevent and manage skin breakdown which may occur due to immobility, friable skin, and incontinence and/or radiation therapy. ET nurses have special nursing skills and understanding in the promotion of a better patient care both in the hospital and the community. They are also involved in the special care of draining wounds, fistulas and decubitus ulcers. They can assist in cost-effective management of draining wounds and fistulas. They can also assist in correcting or containing fecal or urinary incontinence. ET nurses have to attend and take part in seminars and workshops in order to keep themselves up-to-date on new techniques and information related to patient care. This way they can carry out more research work resulting in the best possible care for the ostomate. (Keane, Claire, B., 1986). (Kearney, Nora. & Richardson Alison., 2006). Role of a primary nurse The nurses assess the level of anxiety of the patient and his family prior to surgery and plan appropriate interventions aimed at reducing anxiety. It is the responsibility of the nurse to examine the patient’s perception of the surgery/medical intervention and to plan interventions aimed at attaining a positive self-concept. (Rosdahl, Caroline, B. & Kowalski, Mary, T., 2008). A nurse, after understanding the diagnosis, explains it to the patient and his family along with its prognosis and planned surgical intervention and reinforces education of the patient and his family based on the readiness and the ability to learn. In collaboration with the team, the nurse measures the potential effect of Colostomy/Ileostomy surgery on the patient’s lifestyle and provides support to maintain a healthy lifestyle by educating the patient and his family. A nurse understands the frustrating behavior and grieving response of the patient due to the fear of surgery and tries his/her best to facilitate the patient and make him as comfortable as possible. (Parboteeah, Sam, P., 2003). Colostomy When the large intestine, also known as the colon, is involved in the medical problems, a new passage is created to allow the elimination of stool from the body. The colon and rectal surgeon along with a general surgeon open the abdominal wall via surgery. The surgeons then connect the colon to the outside abdominal wall of the body. This procedure is known is colostomy and the making of an opening in the abdomen on the outside of the body is called a stoma. (Biggers, Donald, J. 2007). It was important to educate the patient before the surgery in order to reduce anxiety of the patient and his family. Since colostomy was a new experience for them and the thought of wearing a bag all the time was itself a disturbing thought. Diagrams, photographs and examples of equipment were used to explain the patient what the outcomes of the surgery may be. The patient was concerned about his body image, lifestyle and sexual life. The patient was relaxed and informed that his lifestyle would be better and more comfortable than without colostomy and he was informed that his sexual life would not be affected. Some counselling was done to his partner also. The colostomy tends to begin in function, three to six days after surgery. Initially, a nurse or more specifically an enterostomal therapist took care of the colostomy. An ET while taking care of the patient provided education on how to care for the colostomy on his own as later on the patient would have to take care of the stoma and the skin around the stoma himself. (Rayson, Elizebeth., 2003). A stoma resembles the skin on the inside of the lower lip, as it is red in colour and oval in shape. For the purpose of elimination of the stool, a drainage bag or pouch is attached to the skin around the stoma. The stool then drains into the pouch. The size of the pouch is determined by the size of the stoma. There may be variation in the size of the stoma initially due to swelling and fluctuation of weight. After surgery, the stoma is checked and examined after every three weeks when the swelling is seen to be subsided. The final size and type of pouch suitable for the patient would be decided and set about three months after colostomy because after three months a person’s weight and size are most likely to gain stability. (Berman, Joel, A., 2001). (Fischer, Josef, E. & Bland, K. I., 2007). The Patient was told about the different types of pouches available. For the convenience of the patient, most of the pouches are odour-resistant and disposable. It is the responsibility of the primary nurse or the ET to help the patient in deciding the pouch which suits and fits him well. It is important to keep the skin around the stoma in a good condition which is why before applying a fresh pouch the skin around the stoma is washed gently with a mild soap. During the cleaning of the skin, usage of gauze dressing to cover the stoma is recommended. The next step is to dry the skin completely by gently patting it with a gauze pad. Rubbing the skin with the gauze pad is discouraged and thus it should be avoided. (Majid, Aljafri, A. & KingsNorth, A.N., 2002). Nystatin powder can be used on the skin around the stoma to prevent irritation and yeast growth. It should be used if suggested by a health care provider. A skin barrier which may be in the form of a wafer or a paste is applied on the skin in order to protect the skin from the drainage of the bowel contents through the stoma. The back cover of the adhesive surface of the pouch is then removed and the bag is pressed down around the stoma for around thirty seconds. The pouch should immediately be removed and drained when it fills from one-third to one-fourth because if it gets over weight there are chances of the bag to come off and spill causing embarrassment for the patient and his family and discomfort to the people around him. (Borwell, Barbara., 2005). The ET educated the patient about colostomy irrigation. It is a procedure in which fluid is inserted into the bowel through the stoma which is regulated for the passage of stool. This way constipation can be avoided. The ET educated the patient when and how he needs to perform this procedure. (Phillips, Robin., 2005) After the surgery The patient should be encouraged to ask questions and should be asked how he feels about having a colostomy. The questions are addressed by the multi disciplinary team. The patient most commonly asks about body image and sexuality. The pouch does not hinder in the patients sexual activities since pouches come in different sizes and the person can wear a small pouch when needed. The patients show concern about changes in the lifestyle. The psychologist can counsel the patients and help them regulate a normal lifestyle just like before. (Boon, Nicholas, A. & Davidson, Stanley., 2006). When the patient returns home, homecare nurses or ETs visit the patients and help them to adjust to day-to-day living. Some organizations such as United Ostomy Association are available for providing support to such patients. (United Ostomy Association., 2000). Complications of Colostomy The patients are informed before hand when to call the health care professionals for help. For example when they feel irritation in the skin and infection is seen and felt from stool that fails to drain properly. Another complication of Colostomy is Diarrhea, which is the passage of watery stool. Stool may get backed up in the bowel and require manual removal. Hernia may also occur if there is a bulge in the skin around the stoma or partial obstruction of the stoma. Patients are advised by the ETs to avoid heavy lifting after surgery. Bleeding is another major complication especially if the patient experiences excessive or continuous bleeding around the stoma. It should be reported to the physician immediately after it starts. Phantom rectal is a sensation produced when the body feels the needs to evacuate even when the rectum is no longer connected to the bowel. (Wolff, Bruce, G., Fleshmann, James, W. & Beck, David, E., 2007). The intestines or the stoma area can be blocked due to the lack of output from the stoma, distended abdomen or severe cramping. If the blockage is not treated it may lead to small intestine perforation. Infections tend to occur after surgeries. The signs which confirm the occurrence of infections are fever, unusual odour and changes in the size or appearance of the stoma. Skin infections may occur when the highly acidic bowel contents leak onto the skin surrounding the stoma. Severe skin irritation can prevent a good seal around the stoma causing misfit of the pouch. (Corman, Marvin, L., 2005). Conclusion Following Gibb’s model of reflection I have analysed that Colostomy was the right decision for the patient as he had digestive problems since a year. Jim experienced constipation and hence problems in defecation. After the diagnosis of inflammation of the colon, the MDT suggested colostomy. It was already informed to the patient that a wound would be left on the patient’s left side. This was the first stage of the reflection. The second stage of reflection includes my feelings about the surgery. In this case, it was easier to counsel the patient and the family was also cooperative. It was disturbing to see the patient lose so much weight and his inability to digest and defecate normally. The patient was mentally prepared psychologically and physically for the surgery. He was counselled in detail about the care he would need after the surgery. The third stage involves my evaluation of the experience. According to me it was a good experience since the surgery was needed by the patient and it helped the patient get relieved from the pain. I tried my best to facilitate the patient with all the queries he had related to the surgery and it gave me satisfaction to see the patient satisfied with the efforts of the MDT. The fourth stage of reflection includes the outcome of the experience. After examining the lifestyle of the patient before and after the surgery, I realized that the surgery in this case was beneficial to lead a comfortable life instead of a life which disturbs the social and personal life of an individual. The fifth stage includes the steps I could have taken to improve patient care. The sixth stage refers to the action plan which the MDT formed in case of failure of the surgery. Reference Berman, Joel, A., 2001. Understanding Surgery: A Comprehensive Guide for Every Family. Branden Books. Biggers, Donald, J., 2007. The Colostomy: A Lifesaver. Booklocker.com. Boon, Nicholas, A. & Davidson, Stanley., 2006. Davidson's principles and practice of medicine. 20th ed. Elsevier Health Sciences. Borwell, Barbara., 2005. Bowel Cancer: Foundations for Practice. John Wiley and Sons. Colorectal Cancer from http://www.unboundmedicine.com/nursingcentral/ub/view/Diseases-and-Disorders/73561/all/colorectal_cancer Colostomy Care from http://www.medicineonline.com/articles/C/2/Colostomy-Care/info/Overview-&-Description.html Colostomies: A Radical Approach to Bowel Management from http://www.craighospital.org/SCI/METS/colostomies.asp Corman, Marvin, L., 2005. Colon and Rectal Surgery. 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