In your reflection, could you describe the episode of care and how you assessed, planned, delivered, and evaluated person-centred care?
While I was in the rehabilitating ward for five weeks, a practice assessor assigned me to care for a patient, whom I will refer to as Emmanuel, to maintain confidentiality under the Nursing and Midwifery Code. Emmanuel is 40 years old and has suffered a hypoxic brain injury. Hypoxic brain injuries occur when the supply of oxygen to the brain is restricted. The lack of oxygen causes the gradual death and impairment of brain cells. Following a cardiac arrest, the patient sustained a significant hypoxic brain injury, which impacted his level of consciousness and severely impaired his abilities. Damage to the brain has caused prolonged disorders of consciousness, including a vegetative state.
The patient underwent a tracheostomy procedure to manage their airways and facilitate ventilation. I understand that patients who experience cognitive and neurological impairments following a cardiac arrest often have difficulties breathing and managing secretions. The patient had a percutaneous endoscopic gastrostomy (PEG) tube inserted to provide nutrition and administer medication. The patient is unable to give consent due to a stroke. “I am responsible for carrying out all nursing interventions for the patient during my shift.” Nursing interventions involve suctioning the patient’s tracheostomy when required, administering nutritional requirements and medication through the PEG, and ensuring overall well-being. I hesitated about the tracheostomy suctioning procedure, which required advanced skills. I did not have prior experience in this area of my nursing training. However, with the guidance of an under-practice assessor from the nurse, I felt confident enough to proceed. “I provided care with a person-centred approach and adhered to appropriate infection control protocols to ensure patient safety. As my patient had a cognitive impairment and was unable to provide consent, I made sure that all interventions were in the patient’s best interest.
I explained the procedure to the patient and used a non-touch aseptic technique to prevent infection. To minimise the risk of coughing, I must assess the patient’s need for suctioning and perform suctioning if necessary. “I will remove the old dressing and clean the patient’s trachea using proton water and a cotton wound. This will help to clean the trachea and the area around the back of the neck to reduce the risk of infection. Then, I will remove the inner cannula and suction the tracheotomy tube to clear any secretions from the airway.” I have to connect Yankauer, the connecting tube, and the suctioning catheter size for the patient. Catheter suctioning size depends on the size and type of tracheostomy tube in place and on the individual patient’s needs. The appropriate catheter size will ensure adequate secretion removal and prevent airway tissue trauma. Before starting the procedure, I ensured that the suction unit was functioning properly and set up correctly. The doctor used a recommended trachea tube and a 10 mL syringe to clear the secretion and mucus from the patient’s airway. I made sure to document the amount of secretion aspirated from the patient. Aspirating the tube before suctioning is essential to prevent potential complications such as infection or respiratory distress. This also helps keep the airway open and ensures effective suctioning by removing any material that may have accumulated within the tube. I attached the manometer between the suctioning catheter and the suction source to maintain the correct pressure range of 10–15. If the balloon is under-deflated, using a 10-ml syringe to inflate it is always recommended.
“I made sure that the suctioning pressure was at a safe and appropriate level. Maintaining the right suction pressure is essential to prevent damage to the airway and ensure the suctioning process is effective. Then, I inserted the suctioning catheter gently into the tracheostomy tube and limited the suctioning time to 15-20 seconds. This was done to minimise the risk of hypoxia and avoid any irritation or harm to the patient.” While inserting the catheter, if the patient coughs and there is resistance, the catheter must be removed. If there is no resistance, you can continue to insert the catheter deeper. I closely monitored the patient’s response and vital signs during and after suctioning and provided oxygen as necessary. After suctioning, I placed the suction tube in a container of saline water while the suction machine was still on and raised it until it was cleared of mucus. I removed the tube from the saline water and cleared the mucus inside the inner cannula before drying it. I cleaned the tracheostomy site with Prontosan wash and ensured that the site was kept clean and dry. I noticed signs of infection and skin irritation around the stoma site during the procedure. Following organisational policy, I disposed of all tracheostomy waste in the orange bin bag.
Also, Emmanuel had a percutaneous endoscopic gastrotomy (PEG) for enteral feeding and medication administration. Before I administered feeding and medication to a patient, I had gained consent from the patient when administering the afternoon medication. The patient refused to take afternoon medication, so I must respect that patients have the right to refuse medication. I explained to him that this medication is vital for you to take at this time because levetiracetam is to prevent patients from having focal seizures, and still, patients say no. So, while I waited for some minutes to check if the patient was in distress, I found out that the patient went out with a physiotherapist and was very tired, which is why he refused the medication. I informed my practice assessor that the patient refused the medication, and I would wait for 1 hour and ask for consent again to see if the patient would give consent. I returned in 1 hour and explained to the patient that I would administer through his PEG. He was happy for me to administer the medication, and he blinked his eye to say yes, so I flushed the PEG with 60 mL of water first to see if the peg was not blocked. I administered Levetiracetam medication and prescribed 250 mL of water to the patient through PEG feeding. I learned that if the patient is distressed, they can refuse medication, and as a student nurse, I have to get to know my patients better and advocate for them if they cannot consent to treatment.
What did you do well?
It was my first time caring for a patient with a tracheostomy, so everything was new to me. Before the procedure, I researched the most recent tracheostomy care guidelines and best practices. I approached the procedure with empathy and patience, maintaining my composure throughout. I ensured that the suctioning pressure was correct and that the patient was comfortable.
What would you have done differently?
Tracheostomy care was a completely new experience for me, so before the procedure, I felt anxious. I was worried about potential complications associated with tracheostomy care, such as respiratory distress. However, the practice supervisor and I asked questions and sought guidance to ensure we were well prepared. In the future, if I face this complex procedure again, I will not hesitate to ask the practice supervisor for help and gain more knowledge. I understand that everyone starts somewhere, and asking for help signifies dedication to providing excellent care. And I asked questions and sought guidance. I believe that when I face this complex procedure, I will not hesitate to ask the practice supervisor to help and gain more knowledge. Everybody starts somewhere, and asking for help signifies dedication to providing care.
Describe how you have begun to work more independently in the provision of care and the decision-making process.
I worked more independently by ensuring that I had the necessary supplies for the procedure. I maintained appropriate infection control methods throughout the procedure by wearing my PPE and performing the procedure using an aseptic. I took more initiative in my work by ensuring I had all the required supplies for the procedure. I maintained appropriate infection control methods during the procedure by wearing personal protective equipment (PPE) and using an aseptic non-touch technique. I also positioned my patient correctly to ensure their comfort throughout the procedure. I also collaborated with my colleagues to ensure the patient received holistic care using a non-touch technique. I positioned my patient appropriately. I collaborated with colleagues to provide holistic care for the patient.
What learnings from this episode of care could be transferred to other areas of practice?
I understand that independent practice comes with experience. So, to boost my confidence, I will always seek guidance from practice assessors and a multidisciplinary team when faced with complex procedures.
Practice Assessor feedback
Based on the student’s reflection, your observation and discussion of the episode of care, please assess and comment on the following:
(Refer to Criteria for Assessment in Practice.)
If any of the Standards are ‘Not Achieved’ this will require a re-assessment, and the Academic Assessor must be informed.
Standard of proficiency
Promoting health and preventing ill health
Discusses the possible influences on the person’s or group’s mental health and physical health and can highlight a range of factors impacting them and the wider community.
Yes achieved
No not achieved
Comments
Bertha was able to identify the complications of a post-brain injury and how they affect a person’s life and health in the long run. She was also able to learn how different multidisciplinary teams work together to improve patient’s condition through medication, rehabilitation and nursing care. She is able to learn during her placement how we are able to assess what level of rehab the patient needs and how simple things like goals can make their life a little better.
Assessing needs and planning care
Utilises relevant knowledge and skills to undertake a comprehensive assessment, continually monitoring a person’s condition, interpreting signs of deterioration or distress and escalating appropriately.
Yes achieved
No not achieved
Comments
Bertha was able to check the patient’s physiological observations and use the NEWS score to determine if the person is well or unwell. She is also able to identify if the patient with brain injury is deteriorating based on their baseline presentation (level of wakefulness, response to stimuli and NEWS score.)
Providing and evaluating care
Applies relevant knowledge and skills in the provision of more complex, person-centred, evidence-based care, demonstrating effective communication skills and the ability to document effectively.
Yes achieved
No not achieved
Comments
Bertha was able to use the tracheostomy care skills she learned and apply it day to day in her shift. She was able to confidently suction patients and escalate to the nursing staff when the patient has difficulty of breathing, is overproducing secretions or is desaturating. She is also able to do PEG care and administer medications through PEG with confidence.
Improving safety and quality of care
Undertakes relevant risk assessments, discusses risk management and can propose improvements to enhance the quality of care.
Yes achieved
No not achieved
Comments
Bertha was able to raise concerns when the patient becomes ill and is able to administer proper nursing care under supervision. She does not hesitate to ask questions and seek guidance when she is unsure what to do. She is able to follow guidelines and take the lead whenever possible.
Coordinating and leading nursing care
Supports the person/persons receiving care and their families in maintaining independence and minimising disruption to their lifestyle, demonstrating understanding of the need for multi-agency working.
Yes achieved
No not achieved
Comments
Bertha was able to work with patients and relatives well. Whenever the family calls for assistance, she will gladly volunteer to check on the patient and administer care when needed. She also does not hesitate to facilitate queries of families to the staff and she is able to work well with the nursing team