Clostridium Difficle Infection - Term Paper Example

 «Clostridium Difficle Infection» Content Page Introduction- 3 Search Strategy-3 Reflection Model-4 Stage of awareness of new experience or uncomfortable feelings and thoughts-4 Description of the event and key features of the event-6 Analysis of feelings, challenges and identification of current knowledge and new knowledge-8 Evaluation of relevant experience and its application in problem solving-10 Identification of learning-14 Conclusion-16 Reflective Essay on Nursing Management of Clostridium Difficle Infection Introduction In this essay, reflection on the nursing management of a patient with Clostridium difficle (C.difficle) will be discussed with reference to current literature. Reflection is evaluation and examination of thoughts and actions of oneself. For health practitioners, reflection means focusing on the interaction of oneself with colleagues and environment in a particular situation so that they are able to evaluate their own behavior. “Reflection gives scope for better understanding of oneself so that existing strengths can be used to build-up for future actions "(Somerville and Keeling, 2004). In order to be an effective practitioner, one must be able to identify one's strengths in approaching a problem, assess one's level of competency and improve on what one thinks are the weaknesses so that when the same problems arise in the future, the right approach can be adapted. Reflection is also an opportunity for professional growth and development to increase competence in the nursing practice (Alexander, Fawcett and Runciman, 2006). Search Strategy Search for literature for this essay was done using internet data base, Google Scholar. The terms used were “clostridium difficle” and “nursing management”. Since the topic is mainly on reflection, “reflection” and “nursing” was used to retrieve articles providing information about reflection in nursing practice. The library was also searched for material in this regard. Since communication is core to the management of Clostridium difficle nursing management, literature pertaining to this topic was searched using the search terms “communication”, “nursing”, and “bad news”. Reflection Model Every nurse-patient encounter is unique and there are no fixed solutions to many nursing problems. Advances in the 21st century are seeing many new developments in the field of healthcare forcing the nursing faculty to reinforce effective and appropriate education. This becomes of primary importance by virtue of the nature of the profession nursing is. As such, the primary goal of nursing is to provide quality health care to patients. Reflection is now the corner stone of the professionalism of nursing. Hence many nursing educators have incorporated reflective practice as a part of nursing education. The reflection in this essay will be described using the 5 stages of Atkins and Murphy's (1994) model of reflection. Skills which will be applied in reflection using this model are description, self-awareness, critical analysis, synthesis and evaluation. This model was selected because is simple and uncomplicated model that be used for reflection of nursing practice. Stage of awareness of new experience or uncomfortable feelings and thoughts 79 yr old Mr. P (name of the patient is changed to maintain confidentiality as per NMV Code, 2006) was admitted to the hospital for mobility assessment due to previous history of recurrent falls. During his stay in the hospital, he developed crampy abdominal pain and loose stools. He also became dehydrated. Several tests were performed to ascertain the cause. The pathology results of stool specimen revealed clostridium difficle infection. Following the diagnosis, the nurse, who was a part of the team taking care of him, met him and announced the results. Clostridium difficle infection is a common associated infection in many health care settings in various countries including Scotland (Health Protection Scotland, 2009). The patient is managed in isolation because of high rates and chances of transmission. However, isolation itself is associated with significant physical and mental morbidity and thus health practitioners need to keep this in mind while evaluating and managing patients with Clostridium infection (Health Protection Scotland, 2009). Hospital-acquired C.difficle infection is an accident, or rather a failure on the part medical fraternity to prevent acquisition of the disease by the patient who is admitted otherwise for some other cause (Perrow, 2004). The patient and their family members need empathy and education about the nature and course of the disease and this can be delivered only through appropriate communication skills so that neither the informant nor the recipient is at stress. Infection with C.difficle is not only associated with significant morbidity and mortality, but also with significant stigma medically and socially (Health Protection Scotland, 2009). I have seen several outbreaks of this infection in this hospital either due to lack of proper measures on the part of health care team or due to innocent transmission of the infection from one person to another. Whatever was the cause, the disease had severe impact on the patient and their family members in several ways, especially emotionally. Depression, anger and fear were common emotional outbursts on disclosure of the diagnosis. While working in the department, I observed excellent support and care from the health practitioners. The support was extended both physically and psychologically. Through my observation and working with the health care team, I learnt strategies to not only prevent and manage C.difficle, but also to understand the psychology and physiology during the disease process. This knowledge can be applied in my future encounters with patients with the disease. Being placed in the infection control team and associated with Cleanliness Champion programme, selection of this topic for reflection was natural to me. My modules in holistic nursing care and communication and professional relationship in nursing, and also my observation and participation in the prevention and management of C.difficle infection further enhanced the need to select this topic for reflective study and discussion. The following event triggered me to study and learn about C.difficle infection through review about the disease process, prevention and management and also to learn about the importance of communication skills in any nursing practice. Description of the event and key features of the event As part of my learning, I accompanied the nurse, who was a part of the team taking care of the patient, when she visited the patient. The nurse was confused as to how to divulge the information to the patient and his wife who was visiting. He also had to inform them that Mr.P would be moved to isolation ward to prevent transmission of infection to others. As he walked into Mr. P's room, he said “Hello Sir, how are you doing? There is some important information I need to divulge. I know it's difficult for you, but the tests have shown that you have Clostridium infection. I am afraid we have to move you to isolation. I promise, that we will do our best and take good care of you.” As Mr. P heard this, he burst into tears and asked “Am I dying?” He appeared very unhappy that he was being shifted to isolation room. I felt very sorry for the couple. They were really old. I said “Why don't you call your children for help Sir?” Mr. P replied “Oh.. don't bother. We don't want to trouble them.” As I walked out of Mr. P's room, I pondered over many aspects of management. I realised how important communication was in nursing and medical practice. Mrs. P then came behind us and told the infection control nurse that the attending nurse, who knew the diagnosis was not coming close to her husband. The wife said “she knew about the diagnosis and she does not want to come to him because she feels even she may get it”. The infection control nurse turned towards her affectionately and told her “Do not worry Madam, we will deal with the disease and issues shortly. Let me know if you need any help.” The woman then felt relieved and went to her room. I followed the management of this patient closely. I observed a holistic management of C.diff including successful communication skills between the infection control nurse, one of the ward team members, patient and his family. This nurse explained to the patient and his family the reason for isolation and provided them with an information leaflet about the disease. Since C.difficle is a highly contagious disease, measures to prevent spread to others was discussed with the patient and his wife. Importance of hand washing was stressed. The infection control nurse offered Mr P magazines and made sure his television was working to prevent loneliness. Stringent measures were taken to prevent spread of infection. The antibiotics of the patient were changed and oral vancomycin was started. After 10 days of hospitalization, the patient was discharged. This case became a learning exercise for me in terms of management of a transferable disease . Deliberate and systematic use of reflection is an effective learning tool and must be applied consciously with effort every time it is used man (Bulman and Schutz, 2004). The author agrees with this because in order for an objective to be achieved, one must formulate a process or a series of steps in order to have a guide for the plan of action to be effective. Analysis of feelings, challenges and identification of current knowledge and new knowledge Nurses play an important role in the health promotion of an individual due to their direct contact and proximity with the patients. The role of nursing is authenticated in helping people move towards independence in all activities of daily living. They take up the role of a family member. Their actions have an impact on the individual and affect their levels of dependence/independence (Roper et al, 2002). The relationship between a nurse and a patient is of therapeutic nature and based on the provision of care, guidance and assistance of the patient (Neal, 2007). It is shaped mainly by four concepts namely, trust, power, intimacy and respect (Neal, 2007). Trust is a critical concept in the nurse-patient relationship because, the patient is in a vulnerable position and the patient places trust in the nurse as soon as he or she enters the health care setting. As such, illness makes an individual vulnerable and this is exaggerated in the presence of unfamiliar surrounding, relationships and situations. In case of Mr.P, the patient was very disturbed about his condition and needed to be handled with trust and care. It is through trust that the physician and nurse were able to convince the patient about isolation management. Delivering bad news is a major issue for health care professionals. Nurses have a trusting relationship with their patients and hence are in a position to deliver bad news such as terminal illness or newly diagnosed cancer. However, the manner in which such information is delivered merits attention and nurses need appropriate training in effective communication. Without training in communication skills, nurses may feel uncomfortable communicating the bad news and may not be in a position to discuss all aspects of care and management. Communication skills are very essential in any patient-nurse interaction and good communication skills must be taught to the nurses right from the commencement of nursing training (Chuhan and Long, 2000). Communication between nurses and patients has multiple dimensions like content of dialogue, affective component and behaviors other than verbal. Communicating bad news appropriately demands proper knowledge of the disease and its prognosis and good communication skills (Back and Arnold, 2006). Improper manner of delivery of bad news not only leads to uneasiness but also poor psychological adjustment for the patients and their close relatives (Mager and Andrykowski, 2002). Receiving bad news is a situation of crisis for the patient. The patient expresses severest form of anxiety, uncertainty, confusion, fear of losing control over his or her life and helplessness (Mager and Andrykowski, 2002). Following certain recommendations as far as communicating bad news is concerned helps physicians deliver the news effectively. Prioritization is the first step in the process of preparation to deliver bad news (Metzger et al, 2008). The nurse must identify certain key points which the patient must retain. He must also analyze what to expect from the patient after the encounter and what decisions must be taken at the end of the meeting. Lack of proper communication from nurses is the most common complaint among patients (Back and Arnold, 2006). It is important for the nurse to tailor the discussion based on the preferences and other aspects of the patient. The age of the patient, literacy status, sex, social status, cultural norms, religious faiths, race, ethnicity, previous health care experience, financial status, health care policy, employment- all must be taken into account while discussing about the disease. After providing emotional support, the nurse must discuss plans of care and management. This includes helping the patient understand the course of the disease, the modes of treatment and their success rates and support services (Back and Arnold, 2006). The nurse must assess and gauge the preferences of the patient and an individualized discussion must be held (Metzger et al, 2008). The emotional state of the patient and the readiness of the patient to engage in further discussion must be ascertained. Epstein, who is the Director of the Rochester Center to Improve Communication in Health Care, quotes "ultimately, we need to structure our health care system so that it fosters excellent communication and improves access to information, particularly among those patients who are most disadvantaged" (Science daily, 2007). Evaluation of relevant experience and its application in problem solving Reflective practice is very important for the nurses. According to Jasper (2006), "reflective practice is a technique for learning from experience that is applicable to all students in health-care professions.” However, it is important for nurses in particular for a number of worthy reasons. According to the NMC, (Somerville, and Keeling, 2004), it is the duty of the nurses to provide care that is to the best of their ability to the patients. In order to impart this duty, they need to have good knowledge, possess good skills and display appropriate behavior during their interaction with patients and their colleagues. They are obliged to act as per the expectations of their profession. In order to make it possible for them to constantly update their professional knowledge and skills, reflective practice becomes essential. Also, nursing is a profession which thrives on mutual support and understanding between colleagues. This interaction and communication are essential aspects of this profession. Self-awareness, self-direction and keeping in touch with environment help to build the culture of mutual understanding (Somerville, and Keeling, 2004). All this is possible through reflective practice wherein there is feedback on the impact of their actions on their patients, the families of the patients, their colleagues and ultimately on the organization. This experience has enhanced my knowledge about C.difficle infection prevention and management. It has also come to my understanding that patients at risk for development of this infection must be monitored for identification of the disease in early stages. Patients who are on antibiotic administration, administration of drugs like proton pump inhibitors, antihistaminic drugs, non-steroidal antiinflammatory drugs, narcotics, laxatives and antiperistaltic drugs are at increased risk of development of clostridium difficle infection. Similarly those who are old and on chemotherpay also have high chances of contracting the infection. Dehydration and dyselectrolemia are very common in this disease and thus serum electrolytes must be evaluated constantly. Other tests include serum albumin, complete blood picture, stool examination and stool assays for C.difficle infection. Leukocytosis may be seen. Stools examination may reveal blood and leucocytes. Of the assays, stool culture and glutamate dehydrogenase enzyme immunoassay are the most sensitive tests (Aberra et al, 2009). Diagnosis of C.difficle needs detection of the toxins of the organism in the specimen stools. Pseudo membranous colitis is diagnosed by histopathology or endoscopy. Detection of toxin is mainly by immunoassay and cell cytotoxicity assay. Bacterial culture is essential to prove the strains causing the disease and also to ascertain antimicrobial susceptibility (Aberra et al, 2009). The transmission is by feco-oral route. C.difficle is easily transmissible among health care workers, patients and environment. Thus, standardised practices for infection control need to be robust to decrease the incidence of the disease. These practices also prevent the transmission of other infections (NHS Scotland, 2009). The most important practice is good hand hygiene. Environmental contamination is a significant factor in the propagation of the disease and hence highest standards of cleaning are to be maintained in hospitals (HIS, 2010). One of the major risk factors for acquisition of the disease is antibiotic administration, especially cephalosporins. Thus, hospitals must have policies which restrict the use of antibiotics, promote the use of antimicrobials which are associated with lower risk of C.difficle infection and impart prescriber education. Disruption of the host defense which is usually mediated by the microflora of the bowel that is indigenous invites infection with C.difficle. Loss of colonisation resistance leads to florid growth of the bacteria. Such a loss occurs due to administration of antibacterial agents (HIS, 2010). Research has shown that the most important determinant of acquisition of infection is host immunity. Hence, severe infection control measurements must be employed to those who have decreased immunity (HIS, 2010). To control transmission of the organism in an outbreak situation, rapid and reliable diagnosis must be made, restriction of the movement of the staff, restriction of cohorting of patient and restriction of movement of the patient and his family members must be made (HIS, 2010). Patient care equipment must remain in the patient's room only. The nurse and other health care professionals must use protective equipment prior to entering of the room and remove it before leaving. Any detected C.difficle case must be reported to the General Registrar Office of Scotland (GRO, 2008). While this is what I have found in literature, my observation in this case and several other cases of C.difficle infection was different. Though the infection nurse was aware of some prevention strategies, she was not completely educated about measure to prevent in spread and strategies to manage it. Several barriers exist for evidence based practice both from the health professional' side and also from the patients. According to a study by McKenna et al (2004, p.178), barriers to evidence based practice include "the limited relevance of research to practice, keeping up with all the current changes in primary care, and the ability to search for evidence -based information.” Other barriers include “"poor computer facilities, poor patient compliance and difficulties in influencing changes within primary care" (McKenna, p.178). Poor access to information, time constraints and poor awareness of evdience are other causes for ineffective application of evidence based practice (Lai et al, 2010). The duty of the nurses with reference to the disease is to assist the patients to decrease the health risks associated with the infection and to recognize and address typical and specific characteristics of the patients towards the disease and it’s treatment. Nurses are also expected to provide education, information and resources to the patients, with considerations to various factors like effectiveness, safety, cost of planning and care delivery, and to collaborate with older adults, care giver and health care team to deliver comprehensive care to the patient (ANA, 2001). The main treatment is to discontinue the offending agent and replace the antibiotic with a less offending antibiotic such as metronidazole 500 mg thrice a day through oral route must be given throughout the course of the disease. Vancomycin may also be given (Aberra et al, 2009). Antibiotic administration must be based on their tolerance too, because drugs like vancomycin can have nasty side effects like hot flushes (Aberra et al, 2009). Identification of learning Reflection is important for nurses in particular for a number of worthy reasons. According to the NMC, (Somerville, and Keeling, 2004), nurses have a duty bested upon them to provide care that is to the best of their ability to the patients. In order to impart this duty, they need to have good knowledge, possess good skills and display appropriate behavior during their interaction with patients and their colleagues. They are obliged to act as per the expectations of their profession. In order to make it possible for them to constantly update their professional knowledge and skills, reflective practice becomes essential. Also, nursing is a profession which thrives on mutual support and understanding between colleagues. This interaction and communication are essential aspects of this profession. Self-awareness, self-direction and keeping in touch with environment help to build the culture of mutual understanding (Somerville, and Keeling, 2004). All this is possible through reflective practice wherein there is feedback on the impact of their actions on their patients, the families of the patients, their colleagues and ultimately on the organization. In this reflective exercise, I learnt about various support strategies to support patients who are isolated because of C.difficle infection. The nurse taking care of the patient was very kind to him and his relatives. She educated them about the nature of the disease, the prognosis and the need for isolation. She advised them about measures to prevent strategies. Excellent communication skills and kind approach towards the patient help the patient adhere to isolation norms and conditions. I understood the psychological needs of the patient. Initially when the patient was informed about isolation, he was disturbed and showed signs of anger, fear and depression. Excellent communication from the nurse and doctor helped the couple calm down. One of the core clinical skills in medicine is good communication. Improper communication makes the patient confused about the diagnosis, unsure about the need for further treatment and uncertainty of the therapeutic intention of care and management (Fallowfield and Jenkins, 1999). Insensitive approach of communicating bad news increases the distress of the patient and his or her relatives. It also impacts the ability of the patient to adjust and adapt (Fallowfield and Jenkins, 2004). This experience also helped me realise about the need for effective communication especially while delivering bad news. Conclusion Reflective activity is a big part in the development of nursing practice. With the current trends in the nursing practice, and the advancement in the nursing profession, nurses are able to look into the concept of effective practice. While reflection is the key to successful learning process, current literature plays a major role in these developments. Through updated journals and texts, present studies by critics and writers, we are able to meet the goals for the improvement of analytical thinking skills such as being able to identify problems that might arise, being aware to new or different ideas, and anticipating the consequences of one’s actions. This reflection exercise has enhanced my knowledge about nursing management of clostridium infection and the need for effective communication skills for an isolated patient. References American Nurses Association. (2001). Scope and Standards ofc Gerontological Nursing Practice (2nd edition). Washington, D.C.: American Nurses Publishing. Aberra, F.N., Gronczewski, C.A, and Katz, J.P. (2009). Clostridium Difficile Colitis: Differential Diagnoses & Workup. Emedicine from WebMD. Retrieved on 31st October, 2010 from www. emedicine. C.Difficle/186458-diagnosis.htm Atherton J S (2009) Learning and Teaching; Reflection and Reflective Practice. 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