My appointment was on a frailty ward in the hospital, which cares for the elderly who have an acute onset of a worsening disease condition or neurological illness, such as Parkinson’s disease, cerebral injury, or tumors such as hemorrhage hypoxia and sub-arachnoid, and who are referred by general practitioners, ambulance teams, and community nurses. Patients who had gotten PEGs, RIGs, or carotid endarterectomy were also cared for on the ward. For this essay, I’ll focus on my personal experience and feelings of how I interacted with a patient named Mrs. Amanda (pseudonym) while on a frailty ward dealing with pain and End-of-Life care. “As a nurse or midwife, you owe a duty of confidentiality to all people who are receiving care,” according to the NMC Code of Professional Conduct (NMC, 2015), “you owe a duty of confidentiality to all those who are receiving care.” Pseudonyms will be used to ensure that they are informed about their care and that information about them is shared correctly.
Throughout the article, I will reflect on how I gave holistic care to Mrs Amanda until her final days on the ward, which influenced my decision to pursue this experience because of the various parts of care that I learned while she was on the ward mentioned in the essay. Care delivery, delegation, prioritization, teamwork, risk assessment, and patient safety will be discussed, emphasizing my role as a supervised student nurse and the roles and duties of those supervising me and their impact on my practice. The conversation will focus on the knowledge reinforcing practice and evidence base for the clinical abilities that I have learned and validating them with the available literature. The essay will include my teamwork peer assessment during fixed teamwork and team-based learning (see appendix 1).
“Effective reflection can allow a professional practice to be enhanced and improved,” according to the RCNI (2015), “and is a process that can enable improvement to be achieved with ease, allow changes, praise to be given where it is due, training or support needs to be identified, modifications to practice to be made, and effective practice to be shared.” for this essay, I’ll be using Gibbs’ (1998) reflective cycle as a model. The Gibbs (1998) reflective cycle has six steps: description, feelings, evaluation, analysis, conclusion, and action plan. There are other reflection models in addition to the Gibbs (1998) models, such as Kolb’s Learning Cycle (1984), Johns’ model of reflection (1995), and Atkins and Murphy’s model of reflection (1994). However, the Gibbs (1998) model encourages me to create an action plan that will allow me to examine my practice, determine what I would change in the future, and enhance my practice.
My mentor Michael (pseudonym), briefed me on the patients in the hospital when I arrived. I introduced myself to the patients because they must know who I am and my status if I’m going to be providing nursing care for them. Following that, I used the time to study each patient’s notes to understand the patients and their illnesses better. Practice effectively, for example, communicating clearly by taking reasonable steps to fulfil people’s language and communication needs and assisting those who need help conveying their own or other people’s needs, as required by the NMC Code 2015. Mrs Amanda was hospitalized during this period after falling in her bathroom at home and being brought in by her relatives. She had also been catheterized while on the ward due to urinary incontinence. She had spent the previous eight weeks receiving holistic multidisciplinary care, such as nursing care, physiotherapy, and occupational therapy. She was due for rehab when medically fit for discharge. “The client is a holistic, autonomous being with the ability to make judgments and choices” (Ramont and Niedringhaus Page 34). The term “autonomy” in nursing ethics refers to a nurse’s obligation to respect a client’s right to make decisions, even if such decisions are not in the client’s best interests. Mrs Amanda, who was being supervised by my mentor while attending to other patients on the ward, cried out to me that she had been admitted with lower back pain and excruciating pain. When I approached her, I noticed she was in discomfort, and once she got my attention, she told me she was in severe pain and needed more pain relievers.
I approached Mrs Amanda and introduced myself, hoping to build a positive nurse-patient relationship. I promised Mrs Amanda that I would speak with a certified nurse and return. I approached Michael and informed him that Mrs Amanda was in excruciating pain and would require pain medication. Then Michael inquired, “Where is Mrs Amanda’s medicine chart?” Instead of procuring the pain relievers for Mrs Amanda, he interrogated me. How do you know she’s in such excruciating pain as you’ve just described? Have you asked her about the pain scale’s trust policy? (For more information, see Appendix 2) What kind of pain relievers were supplied to Mrs Amanda, and when were they administered to her? He continued on and on, making me feel both embarrassed and eager to correct my errors. I could not respond to any of his queries, and I believe I was overwhelmed with sympathy for the patient rather than empathy. Mrs Amanda’s drug chart was brought in, and Michael stated that she is on PRN paracetamol. The last dosage was 30 minutes ago, so she would require a review from the doctor to see whether she needs a different route and dosage of the analgesic.
Compassion is at the heart of the care we provide, and we respond to each person’s grief, discomfort, fear, or need with humanity and kindness (NHS Constitution 2015). As a nurse, it is necessary to utilize critical thinking to solve challenges connected to direct patient care. As a student nurse, I requested extra assistance because I had no idea what else was going on with Mrs Amanda, who stated that she was weary. Mrs Amanda appeared to be unhappy and in pain after speaking with Michael. One of the healthcare assistants said that Mrs Amanda’s vital signs were between eight and nine, respiration rate 28, oxygen saturations 89-91 percent, and inspired oxygen 14-15 litres via face mask. To maintain safety under the NMC code 2015, I referred Michael to work together to protect Mrs Amanda’s best interests, which was my concern. Because her oxygen levels and blood pressure were low, I made a timely report to the doctors, who reacted accordingly. Blood pressure and heart rate, in my opinion, are critical indicators of a patient’s well-being to avert cardiac arrest. The multidisciplinary team members gathered information that clarifies the nature of the problem and suggests potential remedies.
Doctors take fast action if they believe the patient’s safety, dignity, or comfort is being jeopardized to demonstrate their dedication to their safety and quality of treatment. Doctors recognize and work within their boundaries of competence by prioritizing patient care. Because she had a history of cystic fibrosis, a hereditary illness that makes sticky mucus build up in the digestive system and lungs, the doctor recommended 48 meropenem after a re-evaluation by the doctors who attended the call. I had competency in medicine administration, but on this occasion, I was observed by two qualified nurses, one of whom, Michael, talked me through the procedure while asking me questions about cystic fibrosis, which I answered, but he gave me feedback that I didn’t know enough about the disease, which I turned into positive feedback and read up on. According to the doctor, Mrs Amanda’s goal oxygen saturation was supposed to be 94 per cent and above, but she was deteriorating. According to the ward sister, Mrs Amanda would benefit from Opti flow, and the team agreed to give it a try. An Opti flow is a non-invasive gadget that warms and humidifies the air or oxygen provided to the patient using a nasal cannula. The doctor requested the Opti-flow from the critical care outreach team, but Mrs Amanda was exhausted. “Decision making is a critical thinking process that involves selecting the optimal actions to achieve a desired outcome” (Ramont and Niedringhaus Page 39). For example, one of the nurses demonstrated her bravery and dedication to patient care by informing the doctor that the Opti flow could not continue due to Mrs Amanda’s weariness and inadequate recovery.
The doctor listened to the nurses’ concerns and subsequently requested continuous positive airway pressure (CPAP), which is used to treat obstructive sleep apnea. Mrs Amanda had capacity, so the doctors and consultant informed her and her family that some organs failed to work. One of a doctor’s responsibilities is to retain confidence by being honest, upfront, and acting with integrity. Mrs Amanda was then put on the End of Life Pathway with her consent (see Appendix 3 for the End of Life Pathway for Acute Hospitals), transferred to a side room for privacy, and referred to the palliative team. “Informed consent” is defined as “a client’s agreement to accept a course of treatment or a procedure after receiving complete information from a health care professional” (Ramont and Niedringhaus Page 25). A nurse is supposed to offer safe and competent care to ensure that the recipient of the service is not harmed in any way, whether it is physical, psychological, or material. “Patients who are reaching the end of their life deserve high-quality treatment and care that supports them to live as well as possible until they die, and to die with dignity,” according to the General Medical Council’s 2010 definition.
While she was approaching the end of her life as a patient, she was now nil by mouth due to difficulty swallowing, and the physicians and nurses consented to move her to humidified oxygen for comfort. Mrs Amanda was sweating and fatigued while on humidified oxygen as one of the nuns and I changed her. The ward sister then told the family that she felt tired and should keep her talking to a minimum.
Mrs Amanda’s pain is separated into acute and chronic pain based on its duration, as I learned in a bioscience lecture at university. Acute pain persists for a short period and is usually associated with traumatic tissue injuries, whereas chronic pain lasts for 3 to 6 months and may last beyond the healing period. Intractable pain is defined as chronic pain that persists despite therapeutic measures such as drugs, nursing care, physiotherapy, and occupational therapy, like Mrs Amanda was experiencing. Different. Culture, previous pain experience, emotion, ability to deal with, and even belief may influence pain, and individuals should be treated differently.
When I first learned that Mrs Amanda was now on end-of-life care, I was curious to know about the patient and their condition, but I was also saddened to realize that she would soon be the final office. When I first met the patient, I felt sorrow for her and her family, and during our conversation, she voiced her desire to give up and end it all. Looking at Mrs Amanda, I felt a combination of feelings. I could recognize why she would want to give up, and the only reason I could think of was the pain she was starting to feel all over her body, not just in her back. I was good at problem-solving, but there was a time when I was faced with a circumstance where I could identify the problem but couldn’t come up with a solution owing to a lack of experience in patient end-of-life care. On reflection, it was a wonderful experience because it allowed me to observe how people cope with terminal illnesses differently and the impact on family and caregivers.
This was my first interaction with a patient with acute pain and end-of-life care. I learned a lot and gained a lot of information, particularly regarding acute pain management, by asking multiple questions and establishing a solid patient-nurse relationship. The nursing team had developed an excellent professional relationship with the patient and their family over this time. The patient had plenty of opportunities to express any worries or issues, such as how she felt was important and wanted her needs to be met. As a result, I used the trust’s pain scale tool to track her pain growth. I found the tool useful for successful pain management because it indicated when we needed to adjust her analgesia to ensure she was in the least amount of discomfort possible.
The NMC code 2015’s principle of sustaining professionalism supports good service and care environments by voicing concerns when issues develop that jeopardize quality, safety, or experience. “Autonomous evidence-based decision making by members of an occupation who share the same values and education characterizes professionalism.” Professionalism in nursing and midwifery is achieved via intentional connections and circumstances that support professional practice. Professional nurses and midwives take responsibility for their actions and accept it” (NMC 2015). Nursing is a compassionate profession, and we must listen with empathy to what service users and patients want to provide the care they deserve. According to Michael, Mrs Amanda’s pain may require a new assessment by the palliative team. I went to tell Mrs Amanda about it. When I arrived, I introduced myself with the hopes of maintaining our professional relationship as a nurse and obtaining consent. I told her that she would require a reassessment by the palliative team to see if she needed a different pain reliever or if the amount needed to be increased and that the doctor would be notified. As I listened and explained empathically to her, this helped settle her down a little.
“Palliative care teams seek to improve the patient’s quality of life when they are dealing with problems associated with life-limiting illnesses, and they aim to prevent and relieve suffering by identifying their need for high-level assessment and treatment of pain and other problems that can be physical, emotional, social, or spiritual,” according to the trust’s local policy. Mrs Amanda was very unhappy with her medication when one of the palliative team members arrived on the ward and told the doctor to prescribe PRN midazolam 2.5mg, given to her via intravenous. “High-strength midazolam should be explored in palliative care and other settings where a higher strength may be more appropriate to provide the specified dose, and the risk of overdosing has been assessed.” NICE Drugs 2018, according to the BNF.
“Having mental capacity” indicates that a person can make their own decisions, according to the Mental Capacity Code of 2005. As stated by the Mental Capacity Act, a person is unable to make a decision if they are unable to “understand the information given to them, retain that information long enough to make a decision, weigh up the information available to make a decision, communicate their decision – this could be through talking, sign language, or even simple muscle movements such as blinking an eye or squeezing a hand.” Mrs Amanda, on the other hand, had capacity, and the multidisciplinary team made sure she was included in her care. Patients may request that life-sustaining measures, such as treatment, be withdrawn, but there is no ethical or legal distinction between withholding and withdrawing treatments. It is usually more difficult for health care professionals to withdraw a treatment than to decide not to start it in the first place. “Nurses must recognize that discontinuing therapy is not the same as discontinuing care” (Ramont and Niedringhaus page 33). As the primary caregivers, nurses must ensure that the client receives sensitive care and comfort measures as their condition advances.
There is no evidence that catheters are used in end-of-life or palliative care (Fainsinger & Bruera, 1991). Urinary incontinence caused by the relaxation of the urethral sphincters of the bladder can signify impending death (WHO 2003). The NMC Code 2015 emphasizes the need to use various verbal and nonverbal communication strategies and cultural sensitivity to better understand and respond to personal and health conditions. I advised Mrs Amanda that the catheter would be removed for her comfort and that an absorbent pad would be provided, which she agreed to.
“The annual rate of urinary tract infection in women is over 20%, while it is only 0.1 percent in men” (Ramont and Niedringhaus page 413). Because they are caused by Escherichia coli, a prevalent bacterium in the gut environment, urinary tract infections account for 40% of all nosocomial infections. Women are more susceptible to urinary tract infections because of the small urethra and its proximity to the anal and vaginal areas. Nurses provide advice and guidance on hygiene and food to help patients avoid recurrent urinary infections, such as boosting fluid intake. As a student nurse, I vowed to take responsibility for all patients and their families or carers, treating them with respect and decency at all times while providing the best care possible, taking into account teamwork and according to the NMC 6C’s of nursing. So, as an advocate for Mrs. Amanda, I made sure that her comfort rounds were completed and comfortable before her final offices on the ward. (For a comfort round, see appendix 4)
In addition to caring for Mrs. Amanda, I was given the opportunity to participate in a meeting with the hospital’s palliative care team, which reinforced the importance of good communication skills and accurate record-keeping to ensure that all parties involved in Mrs. Amanda’s care were aware of what was going on. I felt I was gaining confidence, especially with family members, in terms of communication because I had established a friendly and trusting professional relationship.
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