Clinical_Encounter

According to Pakman (2000) critical incident analysis is defined as 'individual episodes in which there has been a significant occurrence (either beneficial or deleterious) which are analysed in a systematic and detailed way to ascertain what can be learned about the overall quality of care and to indicate changes that might lead to future improvements'.In the following critical incident that I encountered in a clinical placement I utilize the Gibbs Reflective Model. Gibbs reflective models is fairly straightforward and encourages a clear description of the situation, analysis of feelings, evaluation of the experience, analysis to make sense of the experience, conclusion where other options are considered and reflection upon experience to examine what you would do if the situation arose again (Gibbs 1998). Unlike many other models (with the exception of Boud) Gibbs model takes in to account the realm of feelings and emotions, which played a part in a particular event. My rationale for using the reflection framework to the clinical encounter is to try and demonstrate my ability to link theory to practice during the process of reflection. I also choose the Gibbs model to help me structure this paper. Pseudonym will be used to protect as stated by the Nursing and Midwifery Council (NMC) 2002). The keywords will be defined. The reflection of clinical encounters is crucial to the provision of safe, high quality healthcare services to patients REF. Nevertheless, multidisciplinary medical professionals’ fail in their duty to deliver care and allow bad practice to go unchallenged by constantly not reflecting they tend to fail to improve care. It is essential to analyse the incident and make decisions about how future similar incidents should be dealt with. Reflection, in this instance, is defined as a way of analysing past incidents to promote learning and improve safety, in the delivery of health care in practice REF. With this in mind this essay will critically discuss the theory and practices of medical management of a critical ill patient. Reflective practice is an important tool in facilitating individuals to explore their own practice and examine the clinical decision making process. It requires nurses to question their practice thus enabling nurses to move away from ritualistic regimes to an evidence based approach (Carey 2000) (NMC 2006) supports this by claiming that reflection is a mandatory in relation to Post registration education and practice. This is argued by Dartington cited by Bond and Holland 1998) who claims that contemporary nursing has been dogged by a negative expectation that nurses should not think, that is to engage in a process of reflection about one’s work it’s efficacy and significance. It made me question an aspect of my beliefs, values, attitude and behaviour. It has helped me in some way and has had a significant impact on my personal and professional learning. DESCRIPTION The incident reflected upon in this essay takes place in a critical care environment, to which I was new thus I was assigned a mentor to work with. We were allocated a 68 years old gentlemen Mr. Steve Thomas our patient will simply be referred to as Steve. He was diagnosed with right-sided streptococcal pneumonia (formerly called pneumococcal pneumonia) an infection and inflammation of the lungs (Tortora and Graboskwi 2000). This was associated with type II respiratory failure; he was on high doses of intropes and sedation. In the early morning Steve started deteriorating with signs of hypotension, hypoxemia, he was on pressure control ventilation which is with pressure control 22cmH2o,Peep 10cmH2o and Fi02 80 pulse oximetry showed oxygen saturation of 97-99 %. Since my mentor had no opportunity for orientating me to the unit I was unaware of what was expected of me. I offered to help my mentor with some tasks. She utilised me as a runner getting assistance from junior colleagues, since she had not had the opportunity to show me the charting or anything on the unit. This was due to the fact that I had to be supervisered for all tasks to be carried out, since I was still new to the environment. However, Steve started further respiratory deterioration by late morning; the oxygenation saturation had dropped to 88-91%. The initial assumption regarding the desaturation was the saturation sensor problem on finger and the saturation probe was changed to another finger, as there was no ear probe available. Adam and Osbourne (2003) support this by maintaining that “the probe position should always be checked if a fall in saturation occurs”. I also observed that since beginning of shift Steve had not be repositioned or suctioned at all. I was tempted to inform my mentor this matter, who then decided to do a blood gas (see results on appendix 1a). PH 7.28 Pco 3.29kpa, Po2 7.76kpa, Hco3 29.7 mmol/L, BE = 4.8 mmol/L Sats91%, My mentor quickly informed the shift coordinator the poor blood gas results. The shift coordinator came to assess the patient and immediately started manually ventilating the patient by bagging on15 Lt of oxygen (Fio2). Endotracheal suctioning was performed for the first time during the shift and copious amount of muco-purulent secretions were cleared out. Chest auscultation reveleaved that both lungs bases were quieter. Steve still remained desaturated 88 –91% on pressure control 26 cmH20, peep 12 h2o and Fi02 100. The consultant anaesthetist arrived and planned for an urgent bronchoscopy, which was performed immediately and showed large mucus purulent and blood clots in right lower lobe. A broncho alveolar lavage cleared out large quantity of bloodstained muco purulent secretions and a specimen of sputum was collected. Steve was kept fully sedated and paralysed through out the incident. After bronchoscopy Steve started showing gradual improvement in oxygenation and the oxygen saturation increased to 95% The repeated blood gas showed ph 7.30 Pco2 -5.90 po2 10.81 hco3 29.23 BE 4.7 and saturations 96%. FEELINGS The second element of Gibbs model I am using is exploring of feelings. At the time of this incident, many emotions were running through me. Being made a runner, initially made me feel very upset inadequate and helpless. Due to the fact that the environment was new and I had no idea of were to find the necessary equipment, I need to depend on my fellow colleagues to guide and support me throughout the shift. I felt embarrassed for my lack of not knowing some of the equipment names, which was required at the time. I felt that my lack of not knowing was so obvious to my mentor and other nurses on the unit. I was also concerned about what impact it might have on her relationship with me since i was to work with her for sometime. At the same time, I realised that her concerns were justified – I had been aware of my lack of knowledge when I joined the environment, Benner (1994 cited in White 2001) claims that the nurse entering a new environment will initially enter at the novice stage. As it was my first day of work in that atmosphere, I could not show any evidence of my performance and involvement in patient care even though my mentor was extremely busy. In hindsight, I understood that her intention was to help me to do better; I felt very uncomfortable and even ashamed to have to acknowledge my poor performance at this incident. I felt guilty because I thought Steve had been harmed and I had not done anything about it. I also felt anxious about confronting this issue and trying to develop the confidence I needed, as a consequence I felt under pressure. Even though, this incident caused me discomfort and added pressure in the short term, I realise that it was a very significant event in my work. As a result of the reflection I was forced to reconsider my behaviour at work, became more aware of how others viewed me. Fortunately, my mentor gave me advice on how to gradually develop the confidence I needed. I also sought help from some of my friends. This incident was therefore, very important, because without it I would still not be able to deal with it if it was to arise again. More importantly, it has helped me to acknowledge and work on areas for improvement, which will be beneficial in all aspects of my work. It may also lead to me feeling more in control and experiencing fewer nerves if it occurs again. I also had the feeling of uncertainty of not knowing whether my mentor knew the implications and what was going to happen to the patient that made me feel stressed. I was thinking Steve could have been suctioned with a frequency due to the bad chest infection and regular repositioning. I was surprised that the Physiotherapist did not attend to the patient because of his unstable condition, at the moment I felt that this could have encouraged postural drainage. AARC 1991 supports this and claims that it is postural drainage therapy which is designed to improve the mobilization of bronchial secretions perfusion, and to normalise functional residual capacity (frc) based on the effects of gravity and external manipulation of the thorax. However, Fink 2002 argues that postural drainage requires considerable investment of time and has been shown to have limited benefits in most patients. Moor and Woodrow (2004) maintain that the exact timing to carry out suctioning procedure cannot be identified, however suctioning when patient condition changes maybe dangerous practice. Overall, this incident has had a positive impact on both my work and on the development of skills needed in my future. Evaluation By means of Gibbs model I will explore what was positive and negative about the situation, my mentor could have been assertive and requested a patient who required less interventions to enable her have sometime to orientate me to the environment. Conversely, I recount feeling good about sharing my concerns with my mentor when she asked me to reflect on the incident. Pakmam 2000 claims that a learning system… must be one in which dynamic conservatism operates at such a level and in such a way as to permit change of state without intolerable threat to the essential functions the system fulfils for the self. Besides allowing my mentor to concentrate on her work it gave me a chance to just observe some good things that she was doing. For instance doing her safety checks before anything else. In hindsight by feeling bad in my self by not challenging my mentor in allowing other people to assess me I was aware of myself to other nurses. I later realised my mentor had accepted a patient who required a lot of interventions because she wanted me to see a bit more on my first day. The positive effect I felt was that the patient condition improved after intervention was carried out. The negative part was I was upset and getting stressed and did not think to act on time or suggest anything to my mentor. I should have also supported my mentor regardless of me being orientated to the environment because she might have overlooked those things cause of the way she was prioritising her care. For instance, I could have suggested to my mentor about rolling the patient and suctioning. My mentor could also have asked her colleagues to supervise me while I was doing the procedures. I feel that the pulse oximetor reading should have altered my mentor to the hypoxemia before other clinical signs occurred. I could have asked my mentor to let someone assess me while I was carrying out some of the tasks, for instance repositioning or suctioning. I was not aware of how bronchoscopy could be quickly neither performed nor familiar with the equipment and settings. As I was used to seeing lung tissues on a screen during brochoscopy in my own unit. I wanted to ask to look through but since it was an emergency situation I did not ask since everyone was new to me. My apprehension increased when I saw the amount of blood stained muco-purulent secretions coming out. From clinical experience I am aware that If Saturation is less than 91% it should necessitate immediate treatment the body has a difficult time becoming oxygenated and saturations of less than 70% are life threatening. I felt my mentor and the nurse in charge did not communicate well because the shift coordinator could have been aware of the incident a bit earlier Analysis Steve had sputum retention, which contributed to further collapse of his alveoli, leading to oxygen de saturation. When I analysed this incident, I realised that even though I wanted to do some nursing interventions I had limitations to do any procedures since no one new or had any evidence of my nursing practice since I was new to the environment. Steve was diagnosed with right sided pneumonia in which a wide spread of infection to the right lobes of the lungs caused accumulation of fluid and pus in the alveoli and airways. This meant that there was reduced or no ventilation to the affected areas and deoxygenated blood flow through these areas. Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation, ventilation/ perfusion (V/Q mismatching and intrapulmonary shunting. V/Q mismatching is the most common cause of hypoxemia and is usually the result of alveoli that are partially collapsed or partially filled with fluid alveolar collapse for (example atelectasis) alveolar consolidation or excessive mucus accumulation e.g. pneumonia) are the common cause of intra pulmonary shunting (the mixing of unoxygenated blood which has not participated in gas exchange) which lowers the average level of oxygen present in the blood (Tortora and Graboskwi 2000) Pulmonary blood vessel constrict in response to hypoxia. The potassium channel K, which lies in the vascular smooth muscle membrane opens in response to hypoxia leading to membrane depolarisation. This results in the opening of a calcium channel, which allows extra cellular calcium to enter the cell and this in turn triggers smooth muscle contraction leading to vasoconstriction. This hypoxic pulmonary vasoconstriction in these areas direct blood towards better ventilated parts of the lungs where there is a higher oxygen concentration. Also the fibres of the sympathetic nervous system innervate the pulmonary vessels release noradrenaline, which acts on smooth muscle causing further vasoconstriction. In other words hypoxic pulmonary vasoconstriction tends to promote an optimum V/Q ration for the lungs as a whole by increasing the V/Q ration in areas of the lungs where it is lower than normal Davies and (Moores 2003) Intubated critically ill patients have a decreased ability to clear their own secretions due to reduced level of consciousness, poor cough effort and discomfort, and require endotraceal suction to prevent increased airway resistance, blocking of the airway and a reduction in gaseous exchange Robb 1997 cited in White 2001) This is supported by Worthley 1994 cited in Wood1998) who claims that routine suctioning every four to six hours and as necessary, yet this is not backed up with research findings in any literature. Steve was not suctioned for more than six hours in spite of having copious amount of secretion during the previous days. This contributed to the adherence of sticky mucus plugs and blood clots in the lower lobe. I assumed that the blood clots could be from the previous suctioning as Steve had low platelets count. There was a chance of release and floating of these mucus plugs into the upper airways. If Steve was repositioned, so that the visual secretions could have made the suctioning much easier. Lung hyperinflation is a technique mainly used by physiotherapists to mobilise and remove excess bronchial secretions, reinflate areas of pulmonary collapse and improve oxygenation Berney and Denehy 2002) Manual hyperinflation involves delivering tidal volumes to airway pressures of 40cmH20 or a tidal volume that is 50% greater than that delivered by the ventilator. Some studies suggest that the technique mimics a cough whereby removing sticky secretions Ref. Due to these reasons manually hyperinflation was done in this instance. Fiberoptic bronchoscopy is a medical procedure that allows visual examination of the airways (Mathur, 2005) One of the diagnostic indication for bronchoscopy in intensive care is pneumonia as there might be some collection of sticky mucus plugs in the lower airways which cannot be removed by routine suctioning Steve needed a bronchial lavage to clear the lung. When investigated this procedure, I felt that there could have been some complications including larygngospasm, brochospasm, anaphylaxix, pneumothorax and cardiopulmonary arrest. Action plan To complete my reflection using the Gibbs reflection model. I will explore on what I have learnt and consolidate my finding during this reflective exercise to influence my future practice. The experience highlighted to me the importance of asculating the chest and listening to breath sounds. I felt that routine suctioning and regular repositioning is necessary in such patients to avoid further complication and continuous blood gases to avoid gases to avoid confusions. If Steve had been suctioned or repositioned that could have reduced his stay in ICU that would have reduced the financial implications on the unit. Furthermore, psychological distress due to the delay in normalisation for Steve could lead to reactive depression (Woodrow 2006). I became more aware of the easy access of some equipment on the unit when I had to go and get equipment with support workers. I also learned the importance of reflecting it is a skill that can be learned with individual’s potential to become an effective decision maker being enhanced by education and practice. By using Gibbs as a framework, I have been able to through examine aspects of a snapshot view of a nurses daily work The purpose of a nursing model s to help those who use them understand more fully what they are and why they are doing it. Aggleton and Chalmers 2000. I believe Gibbs model enabled me to achieve this n and learn that special knowledge is embedded in evaluative frames, Whist the notion of reflective practice is almost universally agreed to be a good thing. It has been suggested that it has taken on a common sense meaning used in common sense terms rather than with reference to the literature. According to Dyke (2006) it has taken on a common sense meaning in common sense terms rather than with reference to the literature This is argued by John cited in white 1997 who claims that by reflecting on experience in a structured and analytical way, new knowledge and theory for future practice is generated. I embrace John’s argument, as reflection through Gibbs model empowered me to consider several actions I should have taken to improve my experience and would now put into practice if this situation arose again. For instance I should have used more research now like I do now to gain more in depth knowledge about Steve’s condition. Thus increasing my competency knowledge and confidence, creating an effective patient advocate. It is however now acknowledged that the standard of care expected from a professional is objective, due to an individual’s attritibutes for example inexperience (Jones and Cook 2007. I felt my mentor got enough support from the other team involved. For example if the shift coordinator had come round after we took hand over to find out how we were getting on she might have spotted the deteriorating and point my mentor the right direction. I now challenge unprofessional practice at bedsides and will continue to learn how to approach things in a professional manner to encourage safe management of patients. Conclusion