Reflective writing during nursing clinical placement - Essay Example

Reflective writing during nursing clinical placement During clinical placement in A & E: Event: Looking after for a patient admitted in A&E taking drug overdose. WHAT WAS THE EVENT? It was a night shift in accident and emergency section. I was assisting my mentor, the head nurse in A & E section. A teenager was brought in by the medical staff, he was slender and weak, partially in state of paranoia, and had stains of vomit on his shirt. The person, who brought in the teenager, told us that they have found this junkie from the suburbs of the city. He was caught by the police for using amphetamine in the public. My mentor told me that it was a test of nerves to look after drug abusers. Their states vary extensively, and it is important to determine that which drug has been used, and what was the most obvious mode of intake of that drug. She predicted that amphetamine was ingested orally by this patient, so we had to wash out out his stomach by using activated charcoal. The purpose of activated charcoal is to remove amphetamine from GI by vomiting (Amphetamine.com, 2014). Diazepam and Lorazepam are used to calm down the patient. To recover dehydration intravenous injection of fluids may be used (Lewis, et al., 2013). Hyperthermia is controlled by using wet blankets and ice packs. Intravenous diazepam is administered during amphetamine overdose when seizures are present. For hypertension nitroglycerin and labetol is recommended . If the state of the patient is in danger, serotonin toxicity must be administered (Amphetamine.com, 2014). Drug addicts are hard to manage, it is not only their physiological state that needs to be considered, but their psychological state must also be taken into the account. Moreover, as a nurse, I need to be vigilant to take control of the situation. Further, while looking after a drug intoxicated individual, one must be aware of the chemical, physiological and neurological changes that might take place in an individual on administration of an antidote. WHAT DID I LEARNT FROM THE EVENT? Looking after drug addicts is one of the trickiest parts of the job. A nurse needs to be vigilant in order to treat such cases. Drug overdose can defined as the excessive intake of a drug or drugs. It may be caused unintentionally or by deliberate measures. Amphetamine can be described chemically as catecholamine that causes release of norepinephrine. Further they inhibit the reuptake of norepinephrine, but do not affect the serotonergic system. This stimulation results in tachycardia, arrhythmias, increased systolic and diastolic blood pressures and peripheral hyperthermia (Boynd, 2008; Caroline & Kowalski, 2008; Connell, 1957). There are various changes in the behavior that are caused by abuse of amphetamine. They include paranoia, hyper vigilance, poor judgement, and anger (Caroline & Kowalski, 2008), while nausea and vomiting are GI symptoms of amphetamine abuse. Respiratory depression, seizures, coma and cardiac arrhythmias may prove lethal (Caroline & Kowalski, 2008; Lehne, 2013). HOW CAN I APPLY THIS LEARNING TO NURSING PRACTICE? There are various learning outcomes associated to this particular case. First of all most of the amphetamine users are young, they use this drug for gaining mental energy, though it’s a misconception. Amphetamine addicts can show multifaceted symptoms, and they not only include physiological anomalies, but they also show psychological imbalances. Moreover, the mode of delivery of the drug is the first question that one needs to determine, because without having the knowledge of the mode of intake, it becomes hard to apply the primary measures. This incident also taught that what are the medicines regularly used in case of treating of amphetamine drugs. Further, it made understand that how to deal with patients who have been regularly using this drug. Though it is never pleasing to see a youth lying on the bed under the effect of a drug, but this event added a lot of new information in my knowledge about treating patients with amphetamine overdose. I learnt how to calm my nerves, and what to do if the situation gets worse, plus I learnt the way of dealing drug addicts. 2. During clinical placement in orthopaedic ward: Event: Removal of wound drain for the first time WHAT WAS THE EVENT? Alex was in the orthopaedic ward for past four days. He was moved here after undergoing the thoracoscopic surgery. He was suffering from pneumonia and he was diagnosed to have fluid filled lungs. He was recovering fast; however, his mobility was still limited due to the wound drains that were inserted in his body at the sight of incision. It was my duty to look after Alex, I used to give him medicine, talk to him about his family, and would regularly measure wound drainage. I was supposed to report all my observations regarding wound drainage to Alex’s surgeon. On the fourth day, when I went to take the readings for wound drainage, I found out that the drainage level has dropped down. I reported it to Alex’s surgeon, and he told me that it was the time to remove the drain. I have had chance of observing my mentor while carrying out drain removal, however, I had never done it before. Removing a drain is not as simple as it seems, therefore, it is necessary that understands the importance of following the standard protocol. Before removing the drain it is compulsory to inform the patient about the procedure, and its associated measures. Further, the patients must be informed about adverse effects that may occur due to carelessness, and they must be asked to take care of it, otherwise it may produce undesired consequences (Skills for Health, 2010). It is important for a nurse to support the patient throughout the activity, moreover, one must try to minimize distress or pain, and every step should be carried with the consent of the patient and doctor’s approval. I also learnt the importance of record keeping, and observation. Taking down notes and sharing it with other related medical staff is also important. In case of any mishaps, one must not be hesitant in calling the help of seniors, never to compromise on patient’s health. WHAT DID I LEARNT FROM THE EVENT? My first ever drainage removal taught me that how important was to understand the physiology of skin and its anatomy (Skills for Health, 2010). I also learnt how to ensure a sterile or infection wound drainage, because if an individual is not careful enough regarding the hygiene it may lead to bacterial or fungal infections, open wounds are breeding ground for the pathogens (Flynn, 2001). In case bacteria have gained the access to the wound, a nurse must know how to identify the infection, and it is the duty of a nurse to inform the concerned doctor (Skills for Health, 2010). I learnt how to differentiate between bodily fluid and the irrigation fluid; this helped me in determining the actual water loss. Further, I equipped myself with the techniques for measuring wound drainage and removing wound drains (Gurusamy, et al., 2011). HOW CAN I APPLY THIS LEARNING TO NURSING PRACTICE? As nurse I need to be providing best possible care to every patient. I have learnt how to provide assistance to patients under pain. Taking down observations and sharing it with doctors proves helpful, as the state of the patient becomes clearer in one’s mind. Further, it is important to follow standard protocols. In practice one cannot compromise on the standards. I have learned how treat a patient in emergency situations, and what are the precautionary measures that one needs to consider before removing a wound drain. Thus the experience of working in an orthopaedic ward proved helpful in adding one more skill to my nursing portfolio. 3. During clinical placement in Acute Medical Unit: Event: Giving subcutaneous injection (Clexane) WHAT WAS THE EVENT? A patient in acute medical unit was reported to be at a risk of suffering from deep vein thrombosis. The doctor recommended injecting him with clexane; to prevent the clotting within the veins. This is a very delicate situation, because while administering low molecular weight heparin, bleeding must be prevented to maximum. It is a lot different from giving intravenous injections. Selection of injecting site is also very important, clexane should only be injected in abdomen, and it could be injected at distance of 5 cm from the umbilicus, scars or bruises. Therefore, my mentor told me to bring the patient in such a posture that reveled abdomen region. This is to prevent the damage to umbilical vein; moreover, abdominal has a relatively thick subcutaneous layer as compared to other parts of the body (Kuzu & Ucar, 2001; Klingman, 2000; Maria, 2011). Moreover, she told me that I had to administer the drug slowly, because slow release increases the absorbance of clexane. I learnt that before injecting the drug into the subcutaneous layer, one must raise the skin, this maintains a steady contact between needle and the layer. Needle of the injection must be inserted vertically at 90 degree angle in order to reach the subcutaneous layer (Maria, 2011; McConnell, 2000; McGowan & A, 1990). To prevent bleeding, even slightest movement must be avoided. Time is also a crucial element, the drug should be released into subcutaneous layer as slowly as possible, and this minimizes the pain, and maximizes the absorption by tissue. Needle should be removed vertically, the way it was inserted. Patients should be told that they are not supposed to rub the injection area. These are some of the technical details that I learnt about subcutaneous injection of clexane (Balci & Celebioglu, 2008; Chamberlain, 1980; Chan, 2001). WHAT DID I LEARNT FROM THE EVENT? In this exercise I learnt the physiological importance of clexan, and the purpose of using it. Clexane belongs to the class of low molecular weight heparin. It is usually used to prevent or treat patients who are suffering or are at risk of having a deep-vein thrombosis or a pulmonary embolism. Subcutaneous injections are a delicate business; a nurse needs to be well organized to administer the drug. HOW CAN I APPLY THIS LEARNING TO NURSING PRACTICE? Subcutaneous injections are very useful; they can also be used to inject drugs other than clexane. However, care must be taken in administering the drug via this channel. While working in acute medical unit this technique comes in handy, especially while dealing with patients who are at risk of deep vein thrombosis. It is imperative for a nurse to know, when and how to administer a drug subcutaneously, because there are certain drugs that cannot be injected into the veins directly. Further, there are hormonal injections that are also delivered subcutaneously. 4. During clinical placement in orthopaedic ward: Event: Importance of early detection of possible complication of post-operative patient. WHAT WAS THE EVENT? A person under my care in orthopaedic ward complained me about the pain, around his knee joints. He had recently undergone knee replacement. I told him that it was due to the surgery, so I gave him some pain reliever. However, he continued to complain, and it seemed unusual. There were no apparent signs or symptoms except for complain of pain. I discussed the matter with his surgeon, and the doctor asked me to arrange a few tests for the patient on immediate basis. I went to diagnostic lab and referred the case to the admin. After receiving his CT scan and PET scan results, the doctors confirmed that this patient was suffering from osteolysis. The patient got confused after hearing the term “osteolysis”. Therefore, to I explained it to him that osteolysis is the degeneration of bones; it results into thinning and cracking of bone. It is one of the post-operative complications that may occur in patients who have undergone knee replacement surgery (Jim, 2007;Julie, 2002; Net CE, 2012). It begins due to the unacceptance of implanted material. The plastic implanted in knee joins is detected as an antigen by white blood cells (Harper, et al., 2007) Heather, 2004). As a response to this invasion, immune response is generated. White blood cells not only digest the plastic, but they also attack the bones near the joint replacement (Antall, 2004; Carol, 2005;Cindy, 2006; Courtney, et al., 2000; Elwin et al., 2006;Net CE, 2012). My explanation did not proved to be of any help, because the patient became even more worried. I was nervous, so I referred my problem to the chief nurse, and she assured me that I did the right thing, because it is our duty as a nurse to provide truthful information to our patients. WHAT DID I LEARNT FROM THE EVENT? Some of the things regarding nursing skills that I learnt from this experience are explained as follows. The first step is to obtain an accurate and thorough assessment of patients prior to, during and after the surgery. Review common complications of patients undergoing abdominal, orthopaedic, cardiovascular, respiratory, neurologic, obstetric and genitourinary surgeries (Truven Health Analytics Inc, 2014). Describe the development, course, and management of postoperative nausea and vomiting. Describe the cardiovascular complications that may occur in the postoperative period and appropriate interventions. Discuss the development and management of postoperative neurologic complications. HOW CAN I APPLY THIS LEARNING TO NURSING PRACTICE? Once a person is admitted into the hospital, he or she becomes a liability on the medical staff. The role of nursing is very important especially in postoperative stage, because now the patient is bound to recover; any act of carelessness may result into undesired consequences. Most of postoperative complications are attached to tangible signs or symptoms, but in case osteolysis, there are no such signs. Therefore, the outcome of this experience added some new information to my knowledge of postoperative complications, which will come in handy while taking care of patients who have undergone surgical joint implants. Moreover, I can share this experience with new trainees, and try to play my part to the maximum extent. 5. Infection Control What was the event? It was my second month at the hospital, every day I used to get a chance of learning something new. My mentor put me in charge to look after an elderly man, named Mr. White. He was 80 years old. He had undergone transurethral resection, it is a very common surgery related to prostate gland. People above sixty have poor regeneration system, and their immune system, also becomes weak. Postoperative care after a surgical procedure is a very delicate matter, especially when dealing with patient with slow recovery rate. A weak immune system invites infectious attacks from the pathogens that are very common in the hospitals. After the surgery, the doctors prescribed Mr. White to remain in the hospital for a week for proper monitoring. He was frail and weak; however, he was an interesting person to have conversation with. It was my duty to look after Mr. White, I used to give him his medicines, change his catheter, and provide him with his meals. Since, prostate is in close proximity to urethra, patients have to use catheter to urinate. The catheter provides opportunity to the microorganisms present in the urine or in the environment to infect the urinary tract of the patient. Same happened with Mr. White, while excreting he used to complain for burning and pain. I became worried; I analyzed his urine bag, and saw pus and blood. The presence of pus indicated that there was some infection, so without wasting any time I sent his urine sample for urine culture. When the reports arrived I took them to the doctors. They prescribed Vancomycin and Tazocine to Mr. White. These medicines are high potency antibiotics. Moreover, the doctors recommended me that I should take more care about Mr. White’s hygiene, and should try my maximum to prevent infection in the near future. WHAT DID I LEARNT FROM THE EVENT? The two major lessons that I learnt from this experience were that one must not feel reluctant in asking for assistance from diagnostic labs, and never to compromise on hygiene of the patient under care. Moreover, the sooner you determine the causative agent for the infection, the sooner you can treat the patient, and it saves time, money and health. HOW CAN I APPLY THIS LEARNING TO NURSING PRACTICE? The transurethral resection is one of the most common surgical operations. They are not very serious, but there are high chances for the spread of infection in the postoperative state. I am aware of these few basic facts, and I believe by applying my skills and observation, I can curtail the chances of urinary tract infection from expansion. 6. Moving & handling of post-operative patient What was the event? While I was still new at the hospital, I came across an athlete, who happened to have undergone orthopaedic surgical procedure. He was in his recovery phase; he had a bone injury that prevented him from walking and even standing up right. I was on a round with my mentor, when we saw him trying to stand up on his own. We hurried towards him, and told him not to take such an initiative on his own until next two weeks. Moreover, we asked him, what did he want, he told us that he wanted to stand up and walk to the toilet. We agreed to help him. By the time we lifted the patient, she made revise the whole manual handling protocol. At first I was reluctant in bringing the patient close to me, but she insisted me to minimize the distance. So, she said in a sarcastic tone that have you forgotten the basic principles of manual handling. Then she questioned me about biomechanics and body mechanics. I told her the difference between the two that biomechanics is about internal loading of bodily muscles, while body mechanics assesses the position or movement of body. She told me it was very important to keep four basic principles of manual patient handling that are maintain wide and stable base of feet; keeping patient close to your body; keeping work to be done in front; and setting appropriate bed height. Further, she told me to be careful about my body posture. She elaborated on the precautionary measures that once must apply in order to avoid musculoskeletal strain. Meanwhile, we were able to make our patient to walk 4 meters that was roughly two times the distance between toilet and his bed. This walk of four meters took at least 10 minutes; excluding the time we spent in lifting and settling him down. WHAT DID I LEARNT FROM THE EVENT? In this exercise I learnt the practical application of biomechanics, and body mechanics. I learnt how to manually handle a patient in a post-operative state. Further, I became aware of some of the key principles that are imperative to manual handling, and mobility of post-operative patients. HOW CAN I APPLY THIS LEARNING TO NURSING PRACTICE? I can apply this practice while performing my duty in post-operative units. Moreover, I can teach newcomers about the method of handling, and I can teach them the techniques for avoiding musculoskeletal strain. I have learnt the method of facilitating independence into post-operative orthopaedic patients. References 1. Amphetamine.com, 2014. Amphetamine .com. [Online] Available at: http://www.amphetamine.com/treatment/amphetamine-overdose-treatment.html [Accessed 10 July 2014]. 2. Antall, G. F., 2004. The Use of Guided Imagery to Manage Pain in an Elderly Orthopaedic Population. Orthopaedic Nursing, 23(5), pp. 335-340. 3. Balci, A. R. & Celebioglu, 2008. Effect of injection duration on bruising with subcutaneous heparin: A quasi- experimental within subject design. International Journal of Nursing Studies, Volume 45, pp. 812-817. 4. Boynd, M. A., 2008. 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Lehne, R. A., 2013. Pharmacology for nursing care. Elsevier Health Sciences. 25. Lewis, S. L. S. R. D., Margaret, M. H. & Linda, B., 2013. Medical-Surgical Nursing: Assessment and Management of Clinical Problems.. Elsevier Health Sciences, Volume 1. 26. Maria, R., 2011. Guideline for the Subcutaneous Administration of Low Molecular Weight Heparin (Enoxaparin). Nottingham: NHS Trust. 27. McConnell, E., 2000. Do’s & Don’ts: Administering Subcutaneous heparin. Nursing, n.a(n.a.), p. n.a.. 28. McGowan, W. & A, W., 1990. Administering heparin subcutaneously: an evaluation of techniques used and bruising at the injection site. The Australia Journal of Advanced Nursing , 7(2), pp. 30-39. 29. NetCE, 2012. 9076: Postoperative Complications. [Online] Available at: http://www.netce.com/coursecontent.php?courseid=797 [Accessed 11 July 2014]. 30. Skills for Health, 2010. CHS133 Remove wound drains. [Online] Available at: https://tools.skillsforhealth.org.uk/competence/show/html/code/CHS133/ [Accessed 11 July 2014]. 31. Truven Health Analytics Inc, 2014. Allina Health. [Online] Available at: http://www.allinahealth.org/mdex/ND7658G.HTM [Accessed 11 July 2014]. Read More