Reflection on the Development and Application of a Fundamental Nursing Skill in Nursing Practice - Essay Example

? Reflection on the Development and Application of a Fundamental Nursing Skill in Nursing Practice Introduction Today’s healthcare environment is rapidly changing and for that reason, nurses practicing in it have grown sensitive to the need of evaluating their practice and ensuring that they constantly improve on it and in addition have to consider social, cultural, political, medical and structural issues that affect nursing. This is why it is very essential for nurses to be able to carry out an analysis and clearly respond to these new challenges that keep arising in a very proactive way. As such, development of critical reflective and thinking skills does assist nurses in meeting the ever emerging challenges related to giving needed care in context of a dynamic and rapid change of environment so as to develop into a critically reflective nursing practitioner. There are different approaches to critical thinking and reflective practices. My model for this paper is the Gibb’s Reflective cycle. This paper focuses on a patient with spastic quadriplegic cerebral palsy; he suffers from epilepsy and also scoliosis. Cerebral palsy is a condition whereby there is a brain damage disrupting normal functioning of the body muscles. Spastic quadriplegia is one of the nine forms of cerebral palsy and which is quite common (Banta, 2003, pp.2-18). It disables and a very serious form of cerebral palsy compared to others because it affects the whole body. It causes muscle stiffness or paralysis of all the four quadrants of the body. Such patients cannot walk and have impaired speech functions (Rucker, 1985, pp.206-207). Their necks are floppy due to lack of control and are prone to constant seizures. Epilepsy on the other hand is still a brain disorder that causes repeated seizures which occur as a result of episodes of disturbance to the brain. While Scoliosis is the curving of the spine away from the middle hence goes sideways (Burtner, et al., 1999, pp.748-57). During my recent nursing placement, I undertook a five week program at a learning disability care home situated on the northwest of England. It was quite an experience and worked as an eye opener in my nursing career. At the time of my placement and throughout the period, I happened to observe and took part in a program aimed at feeding the residents within the learning disability care home. In this program, I focused mainly on a resident called James (real name withheld for patient confidentiality reasons). This patient has a medical history of spastic quadriplegic cerebral palsy; he suffers from epilepsy and also scoliosis. As a result of his health condition, James has developed dysphagia, which is a swallowing difficulty and for that reason he has to eat and drink in a way that does not harm him since he has no control of the process and relies on nursing help. About the Gibb’s Reflective Cycle I learnt about the Gibb’s reflective cycle during my nursing study practice. The cycle involves various stages starting with stage one which involves the description of a given event under study. Here, I have to describe in clear detail the kind of event under reflection. This stage includes details such as the place, whoever was there, the reason as to why I was there, what I was doing, the kind of context the event had, the happenings, my part that I played in the event, and others including the results (Stephenson, 1993, pp.1-18). Stage 2 is about how I felt. Here, I try recalling the things that did go on inside my mind and try explaining why this event stuck in my mind. This could entail how I felt before the event took place, what I was thinking at that time, how the event made me feel, how others made me feel, and my take on the outcome, among others. The 3rd stage has more to do with the evaluation process where I try to make a personal judgment of what took place regarding what I felt was good or bad about my experience. This leads to the 4th stage in which case I try to carry out an analysis of the event. Here, breaking down of that particular event into various components for easier and separate exploration takes place. More questions in relation to the answers given in the 3rd stage could come in handy at this point. These could include what I see went well, that which I did well, what others happened to do well, whatever thing that went well or wrong and how other people or myself contributed to this scenario. This leads to the 5th stage which is a conclusion where I make my judgment based on the explored information from my event in the other stages. I develop an insight into people or my own behaviour regarding the contribution made to the event. The main purpose why reflection is carried out is basically to learn from that event. The question of what I think I could have done in a different way from what I did comes to surface. The last stage is stage 6 which is about the action plan. In this stage, I think forward in that possibilities of encountering the event again are thought of and in this case I plan on what I could do if such an event reoccurred. My intuition here is whether I would act differently or not in case such an event reoccurred. This is the Gibb’s reflective cycle in a nutshell. Description of the fundamental nursing skill The nursing skill that I undertook in my program was the feeding process for a patient who is suffering from spastic quadriplegic cerebral palsy; he suffers from epilepsy and also scoliosis. I realized that this kind of patient has difficulties when it comes to feeding since he has problems with personal control and swallowing of food and drinks. For that purpose, keen nursing care needed to be given to ensure that the patient feeds and drinks well and is not suffocated in the process. During this event, other caretakers were there and willing to help me learn the process. An instructor had been assigned to me. The reason for my being at this care home was to learn the skill of dealing with people who have mental disabilities and thus my dealing with this patient who has spastic quadriplegic cerebral palsy; he suffers from epilepsy and also scoliosis was quite appropriate for my study. When feeding drinks to this kind of patient I needed to have a beaker that belongs to the patient and in this case his was blue and had small holes with spout. The drinks needed to be very light and thick liquids are to be avoided. I had to hold his beaker and the jack simply controlled the amount that this patient took in since he has no personal control of the process. The patient is also very sensitive and choosy when it comes to the kind of drink served to him and he therefore; preferred cordial drinks from Robinson. I learnt that fizzy drinks were not to be served to this kind of patient. Amounts taken each time were to be recorded and after doing this, I had to come up with a chart on a daily basis. Given that the patient might need a drink during meal time, it is good to place the drink before him while he feeds so that he is able to signal by pointing at it. I found out that my patient could try out new drinks and thus every time he did try, I had to record and see if he liked it or not. The medication that this patient was under did not allow for serving alcoholic drinks and therefore I had been instructed to avoid them at all costs. This is because the medicines do not mix with alcohol. James is much used to having a family meal and feels at ease when he eats with people around him. He does not prefer eating in a lonely place. This therefore meant that I had to look for a conducive environment that he felt comfortable eating at. For that matter, when it was feeding time, I had to bring him closer to other patients with similar conditions so that he felt he had company. In other cases, I was compelled to call my fellow nurses to engage in conversations so that to create an atmosphere of people talking and sharing a meal with him, even though they did not have to eat anything. He liked people talking and having a general banter. However, this was to be handled carefully since James got amused easily and could get laughing with food in the mouth. Such a case is very dangerous since he cannot control the two processes of eating and laughing and thus very amusing talk was to be avoided at his time of having meals to avoid food choking him. This entailed creating a very sociable atmosphere although calm, which had no sudden noises. The most interesting thing was the fact that I had to be well positioned so that I avoided movements of up and down until I was sure that he had finished his meals. Another point to consider was avoiding asking James any question at the time of his feeding especially when food was in his mouth. The positioning for James, I learnt, was to always eat while he is sited in his wheelchair and the tray on. The pelvis is to be positioned straight up and his bottom part moved as far back in his wheelchair as possible. The lap strap was to be tightened fairly and his legs need to turn to the right a little bit. After this, the feet were to be placed on the footplates and then safely done with ankle straps. The left foot was to be moved ahead of his right one. The headrest was to be in good place and extended forward fully. I was told to confirm in case I was not sure about this. Upright position was very important while he is sitting in his chair. My position was on the right side of James (Hylin, 1984, pp.4-5). The meal was not to be cut in pieces at once. James liked his food being chopped with a folk bit by bit as he feeds and has a strong swallow given that he can chew in a good way. I was surprised that James had a good appetite and could eat decent sized pieces of food. Fresh meals were encouraged and thus ready meals were to be avoided at all costs. James baffled me because he always wanted to be involved in the preparation process for his meals. He enjoyed seeing what he was eating and thus the meals were to be placed on his tray ahead of him at a place where he can see. Normal cutlery of knife and folk were appropriate while feeding him. He would at times ask me to feed him a different kind of food and liked mixed textures and various kinds of food in the mouthful at the same time. Moist and soaked meals were good for him and thus I did avoid dry meals. James has a favourite list of meals he likes eating and thus my choice of what to feed him never went wrong. The feeding process involved me giving him food from his list of favourite meals. I would then cut a forkful one at a time just as if I was eating myself. I would then present this forkful of food to him and wait see if he needed to help me put it in his mouth so as to avoid mechanical feeding. I would then position the food between James’s right side teeth for him to chew. I would then give him time to slowly close his mouth before I removed the folk so that the food does not spill over. He was shy and thus did not like eye contact when food was in his mouth and so I had to look away from him to give him a chance to chew the food and swallow. After feeding him successfully, I was to remain in my feeding position for about 30 minutes or so to ensure that he does not present any feeding complications such as vomiting or choking. I would then give him a very rigorous cleaning of his mouth to avoid oral complications. My thoughts and feelings when observing and undertaking the skill I was very compassionate and anxious at the same time while dealing with this patient. I felt like to him a world came to a standstill. The fact that he could not do anything and that he had no control whatsoever really hit me hard. I felt that there are still quite a number of needs for these patients with cerebral palsy that have not been met in terms of social stigma elimination, infrastructural and facility development and general health and public awareness. I was not convinced that the healthcare and facilities provided were enough to cater for the needs of these patients. I had a feeling that the main aim of providing healthcare for those people having cerebral palsy was geared towards enhancing activities and them participating in life by making sure that efficient movement is guaranteed, deformities are limited, pain is reduced, and other cognitive and behavioural aspects are addressed (Beckung & Hagberg, 2002, pp.309-316). When doing the exercise, I felt like I was causing more harm to James instead of helping him cope with his situation. The fact that almost all his activities depended on my help was very astonishing. I however, felt the need to help him manage his situation. I thought this skill could further be improved by increasing the level of mobility for James and make him a bit more comfortable with himself and the environment. In this case, I thought of physical therapy so as to strengthen his limbs and in essence avoid contractures. If this could be done often, then I felt the condition could improve. This requires close monitoring and attendance. When the above strategy is combined with careful feeding program, then the nursing skill I learnt will be less of anxiety. The evidence base underpinning the safe performance of the skill The fact that I fed James successfully without him undergoing any form of feeding complication such as vomiting and choking reveals that I followed the required process and did it successfully. Safety while feeding such a patient is of essence since if he happens to choke, the outcome could be very disastrous and it is thus worth being careful and confirming with the instructor when in doubt. The changes made to his drinks were well recorded and evaluated especially in regard to his reaction to new drinks. A chart was drawn for the drinking and feeding periods so that nothing could be missed and good records kept. For the patient to have a normal feeding and swallowing process without disorder while I was undertaking this skill was very important. The relevant physiology The kind of cerebral palsy being handled here is one whereby all the four limbs of the patient are fully affected. This is accompanied by a very severe dysfunction of motor (Rumeau-Rouquette, et all., 1992, pp.359- 366). The muscular control is hard thus bringing about feeding and breathing complications (Hagberg, et al., 1972, pp.1-63). The muscles become very stiff thus causing paralysis of the limbs. Their necks are normally floppy as was the case with James. The patient also has curvature of the spine. What happens is that the outer layer of the brain or the cerebral cortex is damaged. The spasticity aspect of the condition above has more to do with the fact that there is hypertonia and increased muscular tension. There exist disruptions in the communication of brain-to-nerve-to-muscles causing an alteration in the normal rise and fall of these muscles (Brett & Scrutton, 1997, pp.291-331). Affliction of muscles in this manner means that activation occurs simultaneously thus effectively blocking the movement’s coordination. How health and safety risks associated with the performance of the skill were considered and dealt with in practice Chocking Choking is the blockage that occurs in the upper part of airway when one is swallowing food or any object that comes from the mouth part of the body, thus preventing normal breathing and thus causing suffocation. The risk is the patient’s brain may die in a span of four to six minutes leading to irreversible brain death within 10 minutes. People like James are more likely to choke because of the fact that they are not able to control the feeding process and thus eating and breathing at the same time becomes very hard. Treatment for such a person like James is giving him an abdominal thrust so as to create an artificial cough so as to forcefully clear the airway. This is done by first leaning the patient forward slowly and slightly. An arm is placed around him and the other hand’s fist blows in the middle under the ribs. A quick, hard movement is made inward and upward so as to help the patient cough. This could be repeated until James is able to breathe (Sullivan, et al., 2002, pp.461-467). Aspiration This problem occurs as a result of inhalation of substances such as saliva into the lungs of patients in this condition. It is a swallowing dysfunction due to lack of coordination of swallowing muscles. This could be due to cricopharyngeal dysfunction, incoordination of the same and transient pharyngeal muscle dysfunction. Good positioning as recommended while feeding and after feeding the patient is necessary in handling this situation (Mark, 2003, pp.117-136). Upright positioning of the patient in that case is needed. Thickening of the food taken and feeding him small frequent meals in checked frequency could also be a dietary control. Clearance of the upper part of the patient is necessary and close monitoring should be done. Failure of the patient to respond within 48 hours, calls for admission of broad spectrum antibiotics under doctor’s instructions (Kuperminc & Stevenson, 2008, pp.137-146). Loss of independence The patient loses independence in that he cannot manage himself given that his muscles are stiff and he suffers from low mental capacity. This means that the best he can do can only occur through assistance by the nurse or family member attending to him. The best way to handle this is through careful provision of healthcare. Bite reflex The bite reflex is an involuntary biting that is swift and is normally triggered by oral cavity’s stimulation. Such bites are hard to release especially if the tongue depressor or spoon is in the mouth of the patient (Thompson, 2002, pp.51-57). A shatter proof fork could be used to handle such a case. Dental disorders I found out that people with this kind of condition have a problem with their mouth and normally leads to dental decay and oral odours. This is attributed to the fact that patients like James have difficulties in carrying out their personal oral hygiene. To counter this, the care provider needs to give keen consideration for constant oral hygiene for this patient. This is what I did with James for the time I took care of him (Sullivan, et al., 2002, pp.461-467). Conclusion Healthcare provision to disabled people is very critical to the nursing profession. My experience with the disability care home situated on the northwest of England was both an eye opener and skill enhancer. The patients suffering from this condition of cerebral palsy need careful attention throughout their lives. One of the most important care programs for this vulnerable group is the feeding activity. The main factor leading to the need for close healthcare, while feeding this patient, is the fact that his limbs are stiff and he has no control of the physical processes. Ensuring that the patient feeds well and does not choke is very critical. Other disorders may develop such as choking, dental decays, aspirations, and bite reflex. The future learning needs in relation to my learnt skill is based on the other complications that such patients like James do develop. I would also like to learn how to deal with seizures when they occur especially while feeding him. This is because the patient did not develop any seizures at the feeding time even though his medical history showed that he did develop them while feeding at times. I believe such knowledge would arm me with necessary skills to fully handle the patients with this kind of condition and better place me in my nursing career. List of References Banta, John V. (2003) “Cerebral Palsy, Myelodysplasia, Hydrosyringomylia, Rett Syndrome, and Muscular Dystrophies” in Spinal Deformities: the comprehensive text. Ronald L. Dewald, ed. New York: Thieme, pp.2-18 Beckung E. & Hagberg G (2002), Neuroimpairments, activity limitations and participations restrictions in children with cerebral palsy, Dev. Med. Child Neurol., 44: 309-316 Brett E. M. & Scrutton D (1997), Cerebral palsy, perinatal injury to the spinal cord, and brachial plexus birth injury. In: Brett EM (ed), Paediatric Neurology, England Churchill Livingstone, Edinburgh, pp.291-331. Burtner, P.A., M.H. Woollacott, & C. Qualls, (1999), Stance balance control with orthoses in a group of children with spastic cerebral palsy, Developmental Medicine & Child Neurology, 41(11): pp.748-57 Hagberg B, Sanner G, & Steen M (1972), The disequilibrium syndrome in cerebral palsy, Clinical aspects and treatment, Acta. Paediatr. Scand. 226: pp.1-63. Hylin, D. L., (1984), Positioning of the cerebral palsy patient to facilitate dental treatment. Tex Dent Jour: 101(12): pp.4-5 Kuperminc M. N. & Stevenson RD (2008), Growth and nutrition disorders in children with cerebral palsy. Dev. Disabil. Res. Rev., 14: pp.137-146. Mark W (2003). Cerebral palsy. In: Disorders of development and learning, BC Decker, Hamilton, Ontario, pp.117-136 Rucker, L. M., (1985), Prosthetic treatment for the patient with uncontrolled grand mal epileptic seizures. Spec Care Dent, 5(5): pp.206-207 Rumeau-Rouquette C, du MC, Mlika A (1992). Motor disability in children in three birth cohorts. Int. J Epidemiol; 21: pp.359- 366 Stephenson (1993), In Reflective practice in nursing: the growth of the professional practitioner, ed. A.M. Palmer, S. Burns and C, Bulman 1994, Blackwell Scientific Publications, Oxford, UK and Boston, USA, pp.1-18 Sullivan PB, Juszczak E., Lamert B, Rose M, Ford-Adams ME, & Johnson A (2002). Impact of feeding problems on nutritional intake and growth: Oxford Feeding Study II. Dev. Med. Child. Neurol., 44: pp.461-467 Thompson, N.S., (2002), Effect of a rigid ankle-foot orthosis on hamstring length in children with hemiplegia. Developmental Medicine and Child Neurology, 44(1): pp.51-57 Read More