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

?Spastic Quadriplegic Cerebral Palsy Patient: Placement Report Introduction 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 confidentiality reasons) the NMC Code of conduct require nurses to respect patient confidentiality at all times (NMC, 2011). In this work I will be using the Gibbs reflective cycle 1998 to guide me in writing and reflecting my thoughts and feelings about my experience. The Gibbs reflective cycle consists of six stages of and helps leaners reflect on what they have learnt or experiences they have gone through (Park & Son, 2011, pp 3-4). 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- the difficulty someone may have in initiating a wallow or the sensation that foods or liquids are somehow hindered in their passage from mouth to stomach- (WGO, 2007, p.5) and for that reason he has to eat and drink in a way that does not harm him and relies on nursing assistance. 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 is quite common (Banta, 2003, pp.2-18). It disables and is 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 they 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 electrical disturbance to the brain. While Scoliosis is the curving of the spine away from the midline, hence goes sideways (Burtner, et al., 1999, pp.748-57). Spastic quadriplegic cerebral palsy patients and the feeding process I realized that patients with health conditions such as James have 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 as fluid or food particles are likely to accidently sucked into the lungs. The swallowing process is governed by the swallowing centre in the medulla, and in the mid-oesophagus and distal oesophagus by largely autonomous peristaltic reflex that are coordinated by the enteric nervous system. If in the process of swallowing respiration does not stop, fluids and other food particles may enter the lungs causing suffocation (WGO, 2007). During the entire period and specifically during the above mentioned event, other experienced care assistants were available to guide me through the process besides the mentor whom I had been assigned to. The purpose of being at this care home was to learn and improve on my skills of handling people with mental disability and James proved to be the best person to observe and learn from and thus fit a case study description. In the process of fluid feeding, it was important that I have a personal beaker that was dedicated to this activity and for this patient. His beaker was blue with small holes and a spout. Dysphagia may occur in two primary forms and these include Oropharyngeal Dysphagia where patients have a problem initiating a swallow as the cervical area is mostly affected. The second is Oesophageal Dysphagia that is located in the distal Oesophagus a little bit lower than the location of the first type. With clinical examination it is possible to establish which is which so that a specific management technique is used. The patent in this case had to be fed very light liquids and I had to hold his beaker because he had no personal control, while the jack controlled the inflow. The patient was very sensitive and choosy on drinks preferring only cordial drinks from Robinson. I learnt that such patients should not take carbonated drinks and this is because the drinks contain gas that may cause a gas bloat thus aggravating the situation and the gas may also lead to choking (CSA, 2011). I had to keep a record of all the fluid intake and draw a chart on a daily basis. During meal time the drinks had to be in close proximity so that the patient could just point at them and he is given. While feeding him on the drinks I realised that he could try out many drinks and when he did I recorded them down. The only drinks that he could not take are the alcoholic ones which I learnt that interfere with the prescription drugs that the patient was taking. James likes having a family meal and eating when around people makes him feel at ease. He did not like eating alone and when I learnt this I had to ensure that he finds a conducive place where he was comfortable eating at. I came up with a strategy where I moved him to other patients’ with similar conditions so that he notices he has company. Some other time I had to call in a few other nurses, who engaged him in a conversation and shared his meal. James liked people talking and having a general banter although this was handled carefully as he got amused easily and laughed with food in his mouth, a situation that was dangerous due to the fact that he could not control the two processes and therefore chances food choking were high. The best idea was to create a sociable environment free of sudden noises or questions. I had to also position myself well during feeding to avoid movements until he finished eating. I learnt that James was to be fed while sitting on his wheel chair with the tray attached. He was to be positioned between 60-90° to facilitate the flow of the fluids (Layne, 1990, pp. 44). The lap trap was to be tightened fairly and his legs had to lean to the right and this is to allow for easy breathing and flow of food. His feet were to rest on the foot plates and safely strapped. The left foot was to be moved ahead of his right leg while the headrest was to be in a good place and extended forward fully (Layne, 1990). I learnt that it was important for such patients to maintain an upright position. My position was on the right side of James (Hylin, 1984, pp.4-5). James meal was not to be cut in piece at once but bit by bit by a fork as he eats. Interestingly he had a good swallow, could chew food well and a good appetite. Fresh foods were encouraged and this is because patients with this condition are usually malnourished because of difficulty in eating and therefore they lack vital nutrients (stroud, Duncan, & Nightingale, 2003). James wanted the whole process of food preparation in his view and therefore I had to allow him to see. His mental state did not deter him from using normal cutlery. He requested different kinds of food and liked mixed textures and various kinds of food simultaneously. Moist meals were preferred and this is because such food could easily be formed into a cohesive food bolus in the mouth and swallowed easily (Buchman, 2006, p. 65). The feeding process began by him selecting food from his list of favourite meals. I then used the fork to cut one piece at a time and present it to him to eat. I would help him if he needed it put in his mouth as I was avoiding mechanical feeding. I would help position the food in his right side teeth, wait for him to close the mouth and chew. He could not eat while being watched so I looked away for him to chew and swallow. After feeding I watched him to ensure no complications resulted such as vomiting or choking and then thoroughly clean his mouth to avoid oral complications. Many things come into consideration when feeding patients with conditions such as that of James. As mentioned earlier, confidentiality is important when dealing with such patients because of the several issues involved. During feeding the patient uses a beaker, a feeding cloth and a fork. This shows how vulnerable they are and at the same time it works to belittle them and make them look like small children. Some patients may not accept to use these because of self-image and esteem issues and therefore a thorough understanding of the patient is required before using any method in helping them. James had no such complications and this was an advantage I had. I felt a lot of compassion while taking care of James. I knew there were others with cerebral palsy out there who could not get access to specialized health care like James, and could not do anything. A number of needs for these patients are still unmet and these could be in terms of social stigma, infrastructural and facility development and general health and public awareness. I felt that the facilities were not enough to take care of these patients. Though the facilities are lacking, the health care providers have continued to ensure that these people are engaged in activities that allow them participate in a normal day to day activities, helping them move with ease, reducing deformities, pain and ensuring that other cognitive and behavioural activities are addressed (Beckung & Hagberg, 2002, pp.309-316). While attending to him, I felt like I was causing him more harm instead of helping him cope with the situation. I felt bad that he had to depend on me on virtually everything. I felt the need to help him manage his condition and thought of ways to increase his mobility in order to make him comfortable with his environment and himself. The best strategy is thought of was physical therapy and this was important because it would strengthen his limbs and avoid contractures. Engaging him in physical therapy coupled with close monitoring and a careful feeding program could help improve his condition. The very fact that I was able to feed James successfully without him developing any form of complications such as vomiting or choking proves that I followed the correct procedures. Safety for such patients is of paramount importance as choking for example could block his normal respiration causing suffocation that could lead to death if not attended to urgently. The most important thing that I learnt is that one should always confirm in cases that they are not sure of what is expected at any given incident and thus the mentor happened to be of great importance to me at the institution. After giving the patient new drinks, it was necessary to record them and how much he took. I drew a chart afterwards and continued to keep good records for the entire period. I learnt that good record keeping is not only important for my current patient but also in my nursing profession. It was especially important in this situation so as to facilitate a normal feeding and swallowing process for my patient. Research shows that spastic cerebral palsy is the most common and occurs in over 80% of all cerebral palsy cases. These people are hypertonic and have a neuromuscular impairment that stems from an upper motor neuron lesion located in the brain and the corticospinal tract or the motor cortex (Rumeau-Rouquette, et all., 1992, pp.359- 366). The damage impairs some nerve receptors in the spine making them unable to receive gamma amino butyric acid, and this leads to hypertonia in those muscles that is signalled by the damaged nerves. Spastic quadriplegia happens when all the four limbs are equally affected. These individuals are most of the time unable to walk because of the fact that their muscles are too tight and it takes a lot of effort to get them to walk (Stanley, Blair, & Alberman, 2000, pp. 50-60). HOW HEALTH AND SAFETY RISKS ASSOCIATED WITH THE PERFORMANCE OF THE SKILL WERE CONSIDERED AND DEALT WITH IN PRACTICE CHOKING Choking is defined as the presence of a foreign body within the airway causing a partial or complete obstruction. This condition is uncommon but a preventable cause of cardiac arrest. Choking prevents breathing and could lead to asphyxia that leads to anoxia that eventually causes death of an individual. The individuals only manage to survive on the oxygen stored in the blood for a few minutes before they pass out completely (Stanley, Blair, & Alberman, 2000). The risk here is that due to lack of oxygen, the brain may die in a short while. In James case, he was very likely to choke due to the fact that he could not be able to control the expansion of the epiglottis to coordinate his breathing. Various methods of treating such patients exist and these depend on the kind of choking that is being experienced. Partial choking may be managed through encouraging the person to cough so as to clear the airway (Stanley, Blair, & Alberman, 2000). The patient may at times be given water that may aid in clearing the throat but the problem with this is that the water may find its way into the lungs. Another method is through back slaps or blows where an individual is hit on the back with the person hitting them placing their heel of the hand on the upper back of the victim. For complete obstruction, the abdominal thrust method is the most appropriate (Buys, 2005, pp. 60-65). In this method, the nurse stands behind the patient putting both hands around the upper part of the abdomen. He/she then forces the patient to lean forward. He/she should clench their fist and place it between the umbilicus and the inferior to the xiphisternum (Sullivan, et al., 2002, pp.461-467). The nurse then holds the other hand of the patient and pulls sharply inwards and upwards. This process should be repeated five times alternating with the back slaps (Stanley, Blair, & Alberman, 2000). The last two methods are preferred because they produce significantly higher airway pressures increasing the chance of dislodging foreign bodies in the airway. Abdominal thrusts ay cause injury such as rib fracture, oesophageal rupture and gastric rupture. It is therefore advisable that after the choking episode a patient is reviewed by a doctor (Pete & Mursell, 2010, pp. 70-75). ASPIRATION It is a swallowing dysfunction that occurs due to the lack of coordination of the swallowing muscles. This problem occurs as a result of the inhalation of substances such as saliva into the lungs. The dysfunction could be due to cricopharyngeal dysfunction and incoordination and transient pharyngeal muscle dysfunction. To help patients with this condition good positioning during feeding is important (Mark, 2003, pp.117-136). Upright positioning of the patient is important to enable the smooth flow of fluids to the patient’s stomach to avoid aspiration. Close monitoring of patients is a must and if the patient develops complications it is important that they get a doctors attention immediately. In most cases such patients are put on broad spectrum antibiotics (Kuperminc & Stevenson, 2008, pp.137-146). Loss of Independence and privacy The patient as explained in the introduction has Spastic quadriplegia coupled with epilepsy and these two conditions necessitate that he be placed under twenty four hour surveillance. He cannot do most activities on his own and therefore he needs assistance from the nurses and other family members. To handle this situation would be to provide him with appropriate health facilities for example the wheelchair to facilitate movement and at the same time put him on medications that would enable him stay without being monitored unless in serious conditions that require attention. Another thing is that these patients are fed using a beaker, a feeding cloth and a fork. Bite reflex Bite reflex can be defined as a swift, involuntary biting action that may be triggered by stimulation of the oral cavity. The bite in some instances could be difficult to release for example when a spoon or tongue depressor is placed in a patients mouth. To help such patients it is therefore advisable to use a shatter proof fork (Thompson, 2002, pp.51-57). The nurses should also stand at a safe distance and be careful while giving the patients food to avoid being bitten. Dental disorders In my final assessment of such patients like James, I found out that they have a problem with their mouth leading to dental decay and oral odours. This problems result from the fact that these patients have difficulties in maintaining proper personal oral hygiene. The mental problems coupled with immobility of the limbs make it difficult for them to think rationally and perform such activities. In order to solve this problem it is of essence that health care providers be assigned to specific patients so that they can take care of their oral hygiene (Sullivan, et al., 2002, pp.461-467). This is exactly the same thing I was doing for James that made him not to develop oral hygiene problems. Conclusion People with disabilities of any kind require specialized care and the provision of such care is the work of the nurses and other care givers. My experience while working at the disability care home exposed me to various issues that are considered in the management of patients with cerebral palsy. The most important part was the feeding process of the patients that needed close supervision to prevent patients from choking. The reason for close supervision is the fact that their limbs are stiff and therefore have very little control if any of their physical processes. Other conditions that are likely to develop in case of absence of supervision include aspiration, dental decays, and bite reflex. I experienced and learnt a lot of skills in handling these people but there were others that I did not experience. I would like to learn how to deal with such patients in case they develop seizures. James did not develop any and therefore I did not have the opportunity to learn from them. James medical history showed that he did develop seizure before during feeding times. If these seizures did develop I would have learnt a lot on how to handle them thus enriching my knowledge of such conditions and help me in handling other patients that I will meet 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. 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International journal of Gastroenteroloy and Hepatology, 52(7): 1-12. WGO. (2007). Dysphagia. Retrieved 2012, from World Gastroenterology Organization: http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/08_dysphagia.pdf Read More