Commentry

The aim of this commentary is based on reflection during a practical assessment with my colleague, me and the assessor in the simulation centre. Firstly, a brief introduction of the scenario will be given, followed by a retrospective review of my performance and my response to the feedback I received from the assessor. A summary will follow on my accomplishments during my studies and the implications for future development. During this commentary, Gibbs (1988) model of reflection will be used, followed by a brief conclusion. My chosen scenario represents Mrs. Dora Green who is 76 years old. It is known that her past medical history included a myocardial infarction (MI). Her husband recently passed away and their daughter lives far away. Mrs. Green currently suffers from rheumatoid arthritis. It is also known that Mrs. Green’s body mass index is 16 which according to Perry (2009), any BMI below 18.5 can be considerate as underweight. Our assessment started with a brief handover, by the staff nurse (the assessor) of Mrs. Green who arrived on the ward following a hemicolectomy and complaining of severe abdominal pain, where we noticed that Mrs. Green seemed very frail. The staff nurse (assessor) assigned each of us a role to carry out the vital signs assessment. According to the Nursing and Midwifery Council (2002) all student nurses should be able to demonstrate patient assessment, which we demonstrated by using the ABCDE (Airway, Breathing, Circulation, Disability and Exposure). We had to demonstrate the importance of infection control and universal precautions by using the alcohol gel for our hands. NICE guidelines (2003), states “that hands should be cleaned with soap and water if they are visibly soiled, or with alcohol gel before and after direct contact with every patient, only if they are not soiled”. Therefore, the correct procedure was taken by using the alcohol gel rub for our hands. During this scenario personal protective equipment (PPE) such as disposable gloves and aprons were used. Nice guidelines (2003), suggests “PPE must be worn once, during an assessment, where exposure of body fluids, blood, secretions or excretions are visible and was part of our learning outcomes in the clinical skills, supported with related theory topics. Part of the Essence of Care module’s learning outcomes, included risk assessment and moving and handling. Firstly we had to demonstrate that the environment was clear of any hazardous objects that might cause harm to the patient or staff and by showing our knowledge, we ensured that Mrs. Green’s bed’s brakes were on and that the bed was not able to move. We also had to show the importance of moving and handling and manual handling skills, gained during the Essence of Care module by demonstrating that appropriate posture was maintained while delivering care to Mrs. Green, by raising the bed to waist level. The core learning unit states that according to the Manual Handling Operations Regulations Act (1992), both employers and employees are given a framework for assessing risks by looking at the task, individual, load, environment and others (TILEO). (http://www.corelearningunit.nhs.uk/Rubicon.aspx) We followed on by introducing ourselves and seeking consent from the patient to carry out the assessment. Eliopoulos (2001) suggests “consent should be obtained from a patient before carrying out any procedure. Grandis et al (2003) argues “that although consent was sought from the patient, the patient needs to understand what the consent is relating to”; therefore, a brief description was given of each other’s role within the assessment. Firstly we assessed Mrs. Green’s airway by talking to her and observing for any gurgling noises or if she is able to answer back. Mrs. Green was able to answer which indicated that there was no obstruction to the airway or any partial obstruction by any gurgling noises. We immediate carried on with the assessment by looking at the patient’s breathing. Mrs. Green breathing was assessed through a visual assessment by looking, feeling and listening approach. Jevon (2010) indicates that the ABCDE assessment is a very important to assess a critically ill patient which can be detected by using the Early Warning Score guidelines (EWS) and local protocols and accurately measuring of respiratory rates is a fundamental part of an assessment including an important baseline observation skill’. This assessment involved the rate, depth and rhythm of breathing, ensuring that the patient was not in any distress, while breathing or by using the accessory neck or chest muscles while breathing. During the breathing assessment Mrs. Green’s oxygen saturation were monitored, where Jevon (2010) states “that if the saturation level is below normal range, a patient might indicate early signs of respiratory distress” and therefore I had to know what the normal range for saturation levels needs to be. Baillie (2005) argues that patient’s with high hypoxemia, oxygen saturation readings can become less accurate where a more in depth assessment needs to be carried out such as blood gas analysis. Circulation was assessed by doing a capillary refill, observing the colour of the patient’s skin including the patient’s temperature due to hypothermia. Eliopoulos (2005) states that hypothermia, in elderly patient is defined as one of the major complications postoperatively. During this time Mrs. Green’s blood pressure and pulse rate was monitored by using the appropriate equipment and by using the skills that was learned during the Essence of Care module. Eliopoulos (2003) suggests that “extra care should be taken when assessing an older patient’s circulation, due to some causes that might influence the circulatory system, such as decreased blood flow to the coronary arteries, decreased elasticity of the blood vessels and less efficient cardiac oxygen usage”. Walker (2003) argues “accurate monitoring of blood pressure in a postoperative patient, that experiencing a hypovalaemic shock, can stay within normal range where as an increase in the respiration and pulse rate can indicate a sign of shock. Grandis et al (2003) describe hypovalaemic shock, in a physiological perspective, when the intravascular volume is reduced which is reduced in the venous return, a decrease in ventricular filling and total cardiac output. Disability assessment included the assessment of Mrs. Green’s level of consciousness, by doing a neurological screen by asking general questions, and found that she was semi conscious. Walker (2003) points out that during a patient’s disability assessment, “the orientation and responsiveness, of a patient’s general condition, postoperatively, gives you a general overview of the patient’s condition”. If there are any changes further action should be taken and should be reported to a senior member of staff. Exposure assessment involves a full “top to toe” assessment needs to be carried out while respect and dignity should be maintained. We had the opportunity to explore dignity and respect in more depth in the Professional Issues in Health module. Webster and Byrne (2004) states “that the needs of older people need to be met but their right to maintain their dignity and respect too”. Walker (2003) suggests “that temperature measurement is vital during this assessment”. “It was recognised that it is often left out and can lead to pyrexia and hypothermia”. Due to Mrs. Green’s frailness and low body mass index (BMI) she is prone to hypothermia, and therefore should be kept warm. Attached equipment needs to be seen to ensure that it is properly instituted and working properly. Other observations can be carried out such as blood glucose, urine testing and nutritional assessment. Draper (2008) identifies “the environmental control can be assessed during exposure”. During the exposure assessment, any risk of pressure sores should be reported and appropriately assessed using the Waterlow Score, Kenworthy et al (2002) suggests that factors such as weight, mobility, medical conditions and mental condition can contribute to a higher risk of pressure sores. To prevent Mrs. Green from getting any pressure sores, all bony points such as heels and shoulders should be monitored and regularly turning. Although I was aware of being assessed, formatively, I felt confident and relaxed and according to the assessor I achieved all the learning outcomes with excellent effort. To be able to work with my colleague, I was also able to demonstrate that I have the capability to work within a team and according to the NMC (2002a); nurses are expected to work co-operatively within a team by respecting other member’s skills. Maslin-Prothero (2001) suggests “that being part of a group or team can be more effective, by developing new skills and to share different experiences and ideas, and by showing good team work, we worked together and were able to share our findings through verbal communication skills. We were also able to carry out our assessment within our given time and according to Pearce (2007), time management can reduce stress where it can have a positive impact on once health. From the feedback received, from the assessor we were able to demonstrate good communication skills by explaining our findings to each other in a kind and professional way. Taylor (2000) claims that communication is an important interpersonal skill and everybody uses this skill but within a profession, these skills should be refined and be introduced to develop communication skills in a professional manner. During the feedback I was able show the assessor of my understanding and knowledge gained during assessment. Baillie (2005) states that it is crucial in documenting and reporting any abnormal observations during patient’s vital signs assessment. In conclusion, this commentary has helped me to reflect back on my performance during a formative assessment by using Gibbs model of reflection. Although I done well during the assessment I would like to keep on practising the skills taught to me during the Essence of Care module and to be able to relate and demonstrate the knowledge gained from all other modules during my studying.