Clinical_Skill

Reflection on a Clinical Skill The purpose of this assignment is to reflect upon a clinical skill that I undertook whilst on my second year community placement. I have chosen to use Gibbs (1988) model of reflection. In accordance with the Nursing and Midwifery Council (NMC), The Code of Professional Conduct (2008), confidentiality shall be maintained and all names changed to protect identity. The clinical skill I have chosen to reflect upon during this assignment is the monitoring of capillary blood glucose (CBG). I have chosen this skill as during my previous acute placements as a student I was not permitted to undertake them, and whilst in the community the Primary Care Trust (PCT) allows it. Having yet to develop this skill I thought that by reflecting on carrying it out would help me to gain the knowledge and confidence needed to perform it in the future. According to Siviter (2004) reflection is about gaining confidence, identifying when you could have improved, learning from your mistakes and about your behaviour, viewing yourself as others do, self awareness and changing the future by learning from the past. Description During a routine daily visit with my mentor Jane, a District Nurse, to Nisha, an elderly Asian lady who was Diabetic, Jane asked me whether I would like to take Nishas CBG. As I had only started doing CBGs during this placement I thought it would be a good learning opportunity so I agreed to do it. Jane asked Nisha whether she minded me doing her CBG and although she did not speak very much English she understood and consented for me to do it. I went into the kitchen and washed my hands. I returned to the living room where Nisha was and asked her whether her hands were clean, to which she answered yes. I then assessed that Nisha was sat down on a low sofa, and thought it best to kneel down and lay my equipment out on the coffee table so that they were all to hand. Once checking that the blood glucose monitor had been calibrated and that the test strips were in date I opened a test strip and placed it into the monitor. I then put on gloves and asked Nisha whether she was comfortable and ready and which finger she wanted me to use, she said yes and held up her right third finger so I got the single use lancet and pricked the side of Nishas finger, disposing of the lancet into the sharps box. The blood came immediately and I applied it to the test strip and waited for the result, in the meantime I held a clean cotton wool ball to Nishas finger to stop the bleeding. I discarded the test strip and my gloves and recorded the CBG.I then washed my hands again. Once we had left Nishas property my mentor commented that I had done very well, but should have asked Nisha to wash her hands before commencing the CBG test. Feelings When Jane, my mentor, first asked me if I wanted to do Nishas CBG I felt slightly nervous as I had only done a few previously and was aware that she would be observing me through the procedure which also gave me reassurance that if I were to do anything wrong she would be there to highlight it. Once Nisha had consented to me doing the CBG I felt pleased that she trusted me to carry out the process, which allayed my nerves. During the procedure I was aware that my mentor was watching me, which once again made me anxious, but she was encouraging me the whole time and totally supportive. When I instantly got blood once pricking Nishas finger I felt a sense of relief that I had done it correctly. Once the whole process was over Nisha held my hand and smiled and in broken English said “thank you, thank you”, I was humbled by her response as I felt I was just doing my job. Overall I was satisfied with my performance and felt positive that I wouldn’t be so nervous next time round. Evaluation On the whole performing this clinical skill went really well, and having not had much practice at doing this particular skill I was glad to have had the opportunity to do it whilst under direct supervision from my mentor. I think that my communication with Nisha, even though she spoke little English was very good and that I had formed a strong therapeutic relationship with her. I feel that on reflection I should of asked Nisha to wash her hands before the procedure, and that my mentor should have ensured this, to guarantee that the reading was not contaminated. Analysis I will start by looking at the skill and the evidence supporting it. CBG monitoring is part of many diabetics daily routine. If a patient’s CBG goes up (hyperglycaemia) or down (hypoglycaemia) it can cause the patient to become unwell (Baillie, 2009). Dougherty & Lister (2008) state that in the short term CBG monitoring can prevent hypoglycaemia and ketoacidosis and in the long term can considerably lower complications arising that could affect the patient both vascularly and neurally. Patients can control their condition through diet, oral hypoglycaemic agents, insulin therapy or a combination of the above, (Higgins, 2008). By asking Nisha whether she minded me performing the CBG my mentor had gained informed consent in accordance with the NMC (2008), who say that consent must be gained before any treatment is commenced. I washed my hands following the Ayliffe (1978) technique in order to prevent the spread of infection, Pratt et al (2007) state that hands must be decontaminated between each and every episode of patient care. I asked Nisha whether her hands were clean, as one of the main causes of inaccuracy of CBG readings are fingers that are contaminated with foodstuffs (Alexander et al, 2000). I assessed that Nisha was sat comfortably on a low sofa, Jamieson et al (2007) says to ensure patient comfort and prevent any injury occurring should the patient feel faint during the procedure . I then knelt down and laid my equipment out on the table, as Baillie (2009) suggests that all equipment needed for a procedure should be within easy reach, and avoid any twisting or stooping which could cause me injury, in line with the PCT Moving and Handling Policy and Procedure (2006). I then checked the CBG monitor had been calibrated and that the test strips were in date, to prevent false positive/ negative readings (Hastings, 2009). I then put on my gloves and asked Nisha whether she was ready and which finger she wanted me to use, Jamieson (2007) says that gloves should be used to prevent the patient and nurse from any potential blood borne infection. The NMC (2008) state that you must allow patients to make decisions about their care, and also that patients should be treated individually and with dignity. Suhonen et al (2007) conclude that individualised patient care leads to positive patient outcomes, such as patient satisfaction, patient autonomy and patients perceptions on health related quality of life. I used both verbal and non-verbal communication, which involved speaking slowly and clearly so that Nisha could understand what I was saying. I also used non-verbal communication through touch, eye contact, facial expressions and body language, (Funnell et al, 2009). I then using a single use lancet, in accordance with PCT (2005) policy on blood glucose monitoring, pricked the side of Nishas right third finger and disposed of the lancet into the sharps box. Baillie (2009) suggests that the third, fourth or fifth finger should be used as the thumb and index finger are important for touch, and to use the side as it is less painful. To prevent injury sharps and unused drugs must be placed in disposal boxes at the point of use, (Dougherty and Lister, 2008). I applied cotton wool to stop any bleeding and then disposed of the test strip and my gloves, washed my hands again using the Ayliffe (1978) technique and recorded my findings. Hastings (2009) recommends applying pressure briefly to the puncture site to prevent painful extravasation of blood into the subcutaneous tissues. The Department of Health (2007) state that to reduce the risk of cross infection any waste must be disposed of appropriately. Flores (2006) maintains that it is important to wash your hands after removing gloves as bacteria can contaminate them through small defects in the gloves or during removal. Records should be completed as soon as possible following an event (NMC, 2008), and as a student all documentation needs to be countersigned (Siviter, 2004). My mentor said that I should have asked Nisha to wash her hands, not if they were clean the rationale being the same as previously stated, (Alexander et al, 2000), and also Cowan (1997) also agreed that patients hands should be washed to ensure a non-contaminated result. Conclusion In conclusion I now appreciate how in depth a “simple” CBG procedure actually is, when done correctly. I have looked further for evidence stating that patients hands should be washed before the CBG test is performed and realise that I should have asked Nisha to do so as the result could potentially have been wrong. On reflecting on undertaking this skill I have developed my learning of the need to carry out this procedure and the importance of it to a Diabetic. I have also found that following guidelines is vital to accurate results. Action Plan In future when I carry out this procedure I will continue to practice as I have done as long as this is in line with local trust policy and supporting evidence. I will always ensure that the patient washes their hands before commencing the process, as this is what evidence suggests is good practice and also important for an accurate result. Word count 1579