Category Archives: Reflections: Year 2

REFLECTION ON MALE CATHETERISATION

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On this day I visited a male catheter patient with my practise supervisor. The patient was on long term catheter due to urine retention. His catheter is changed every twelve weeks so he was due for it to be changed. I first read his care plan. Introduction given and consent gained . I was to remove his catheter and re-catheterised him under the supervision of my practice supervisor. I gathered all that I will need and set my sterile area. I first opened my catheter pack and deflated 9mls of water from the balloon I then removed the old catheter and cleaned the patient. After washing my hands I had my sterile gloves on and with non touch aseptic technique successfully inserted a new catheter. A clear urine of 150mls came out into the leg bag. He was then made comfortable. The care provided was documented and dignity and privacy was maintained. All this was done under the supervision of my practise supervisor.

It was an opportunity for me to insert a male catheter. It helped me to practice the skill of male catheterisation. I am gaining confident in catheterising patients. This nursing care is relevant to the NMC (2018) code of practise effectively and preserve safety. Aseptic non touch technique was used and I successfully inserted the catheter under the supervision of my practice supervisor without any problem.

REFLECTION ON EPISODE OF CARE IN THE COMMUNITY

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For my episode of care I did district nursing with my practice supervisor. On this day according to our handover we visited eight patients. All care was done under the supervision of my practice supervisor. The care of the patients were prioritised by checking the blood glucose level of the diabetics patients and administer their insulin. Consent is always gained and the reading of patients care plan before any nursing care maintaining confidentiality, dignity and privacy. Three of the patients were diabetes. One patient had libra on. Blood glucose was checked post breakfast and insulin given. I checked two of the patients their blood glucose before administering their insulin with pen insulin and insulated. Before I administered any medication I always abided to my six rights of medication administration, expiring date, batch number, allergies and my hand hygiene. The rational for checking the blood glucose is to know the level before administering the insulin. To know whether the patient is hypoglycaemia or hyperglycaemia. One patient had her tracheostomy neck strap changed. Myself and my supervisor washed the patient`s neck and changed the strap. The rational was to have the neck cleaned with clean strap provided as a routine. I administered enoxaparin injection to one patient to prevent blood clot. Together with my practice supervisor we undress and redressed the bilateral leg ulcers of a patient. The patients legs were swollen and exudated. We washed both legs and applied different dressings complying to infection control policy. The dressings applied were viscos paste, zetuvit pad, k-soft, k-lite and yellow line. The rational of the care of the leg ulcers was to help with its healing and to prevent any infection. We visited this patient who had pressure ulcer wound on the hand. The old dressing was taken off the wound cleaned and aquacel foam dressing applied. All pressure areas were checked and the patient was made comfortable. All care was delivered under supervision, documented on hard copy and emesis.

Effective communication always took place, person- centred as patients were always involved in their care and everything was evidence based.

What did you do well?

I checked patients blood glucose afterwards following the six rights of drug administration I administered their insulin as prescribed. Under the supervision of my practise supervisor rotating the injection areas to avoid build up of fatty tissue. The undressing and redressing of a patients bilateral leg ulcers. The administration of enoxaparin through subcutaneous injection.

What would you have done differently?

I was with my practise supervisor who monitored and supported me through out to make sure quality of care was delivered according to the NMC (2018) code and NICE guidelines.

Describe how you have begun to work more independently in the provision of care and the decision making process.

When we get to a patient after introduction, I get the blue folder and read the care plan. The care plan and my handover sheet enables me to know the care to provide for the patient. I am able to check the patient`s blood glucose level, administer the insulin as prescribed and document in patients notes. I am able to do all this independently under the supervision of my practise supervisor. I am able to independently undress leg ulcers and redress them according to the care plan. If the leg is dry, with no blisters or exudate together with my practise supervisor decide on new dressings to use as the ulcer is healed or is healing. A new care plan is then made for the patient or discharged from the district nurses.

What learning from this episode of care could be transferred to other areas of practice?

Checking of blood glucose level and administration of insulin as prescribed having in mind the normal and abnormal range.

Checking of care plan and gaining consent always before any procedure maintaining respect, dignity and privacy, person-centred and effective communication.

Assessment of pressure ulcers and its management to prevent infection and the use of right dressings to support its healing.

Administration of insulin with pen insulin and insulator.

REFLECTION ON EPISODE OF CARE

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I did my episode of care on a stroke ward. All care was delivered under the supervision of my practice assessor. I cared for all six patients in the bay, but I will specifically talk about the care delivered to one particular patient. This patient is eighty-eight years old and was admitted for a stroke. She had L-side weakness, aphasia, and a reduction in mobility. The handover, of the patient was taken from the night nurse. Firstly, I introduced myself, asked what she preferred to be called, and gained consent before performing any duty. I always applied my hand hygiene and PPE when needed. I did my safety checks to ensure the suction and oxygen were working, and oxygen masks, yankers, and other equipment were available. I then read her care plan on the cerner to obtain more information about her. She was nil by mouth and was receiving nasogastric feed, which was started at 5.48 am. It was supposed to run for 15.4 hours when it was handed to me. This patient had a medical history of atrial fibrillation, confusion, type 2 diabetes, hypertension, and hypothyroidism. After following the eight rights of administration of drugs, I administered all her morning medications. Since she had an NG tube and the medications were tablets, I had to crush them. Her morning medications were as follows: colecalciferol, digoxin, famotidine, IPC, levothyroxine, metformin, sterile water, and verapamil. Patient observations and all the purposes, side effects, and contraindications of the medications were checked before the administration.

Personal care was given to the patient. All pressure areas were checked. The patient opened his bowel, which was documented

The patient had hyperglycemia with a capillary blood glucose (CBG) of 19.6 mmol/L when checked. My practice assessor, who was told, also informed the doctor, who increased the metformin for the patient.

200 ml of sterile water and IPC were the only prescribed medications for the patient in the afternoon. I used the purple 60 ml syringe to give the water through the NG tube under supervision with my PPE on. I did the afternoon observation of the patient. The patient’s CBG was rechecked, it was now 18.5 mmol/L. She was repositioned every two hours, her pad changed, and made comfortable. She slept a bit, and her family also visited her.

I did my risk assessments, such as the waterlow score, and because she scored 27, I ordered an air mattress for her to prevent pressure sore. I checked her skin integrity to make sure there was no pressure sore. It was intact. Fall risk assessment was also done including her careplan. I did my nursing documentation using the wards template. Everything was done under my practice assessor supervision.

I administered the patient’s evening medication after going through the eight rights of medication. The medication she had was famotidine and metformin after crushing them. I gave the drug through the NG tube. I first stopped the feed and flushed it with sterile water, gave the medication after mixing it with water, and flushed again with water after kinking the line. The patient was made comfortable with the feed still going. All care was documented and handed over to the night staff before going home.

The care delivered was evidence-based and person-centered. Although the patient was not bringing out words, she responded to communication with her hand and eyes.

What did you do well?

I independently cared for a stroke patient with an NG tube under supervision. Care was delivered according to the policies and procedures of the hospital. After checking the CBG and the observations, I reported all the abnormal readings to my practice assessor. Her CBG was 19.6 mmol. My assessor also informed the doctor, who increased the patient’s metformin. Patient CBG was later rechecked, which was then 18.5 mmol. Through the waterlow risk assessment I did, the patient was moved from a normal bed to a pressure-relieving mattress to prevent pressure sores.

What would you have done differently?

Nothing since I worked under the supervision of my practice assessor. I sought her advice and help in the decisions I made. She supported me in making sure the quality of care was delivered according to the NMC (2018) code, NICE guidelines, and hospital policies and procedures.

Describe how you have begun to work more independently in the provision of care and the decision making process.

I can care for the patient independently under supervision. After filling out the patient Waterlow risk assessment, the score was 27, which was above normal. I then discussed with my assessor that the patient should have a pressure relief mattress instead of the normal mattress. The patient was then transferred onto a nimbus mattress to prevent pressure ulcers. The patient was having high CBG, so the doctor was informed, who then increased her metformin and asked us to monitor it. While giving patients personal care, I check all the pressure areas. Throughout my care, I made sure I maintained my protective equipment when needed, especially hand hygiene to prevent cross-infection.

What learning from this episode of care could be transferred to other areas of practice?

I have acquired a better understanding of stroke. I can deliver quality care to stroke patients who have NG tube.

REFLECTION ON COMMUNICATION, CONSENT AND MENTAL CAPACITY ACT

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On this day I learned about Communication, Consent, and Mental Capacity. The lesson started with a class discussion about people with communication difficulties and their impact on us during practice. Communication difficulties become a barrier and make it challenging to interpret and understand the intentions and actions of others. Types of communication barriers are physical, emotional, and language. Stroke and some people with learning disabilities, such as autism, do have communication difficulties. We also shared our experiences working with such people. I shared my experience as to how, when working with children with learning disabilities, some children communicate with the Picture Exchange Communication System (PECS) and Makaton. I also talked about how stroke patients struggle to speak due to their sickness, making them have slurred speech. They sometimes have to write their needs on paper, and it is complicated for them to accept the idea that they used to talk very well but, due to illness, are not able to communicate. There was a group discussion about the importance of consent. Afterward, the whole class shared what was discussed in the group. Consent is essential in healthcare for reasons such as empowering and involving patients in their care, bringing about patient care, serving as legal protection for both the patient and staff, giving patients choices, ensuring patients know the advantages and disadvantages of the procedure, and agreeing to what is about to take place. Subsequently, before consent takes place, professionals must ensure that the method has been explained to both the patient and their family for understanding and the advantages and disadvantages.

We discussed the Mental Capacity Act 2005 (MCA). It is a legal framework for acting and making decisions on behalf of adults who cannot make a particular decision for themselves. Mental capacity can be assessed in these two stages of the test. Firstly, does the person have an impairment of their mind or brain, whether as a result of an illness or external factors such as alcohol or drug use? Secondly, does the impairment mean the person can not make a specific decision when they need to? People can lack the capacity to make some decisions but can make others. Mental capacity can also fluctuate with time-someone may lack capacity at one point in time, but may be able to make the same decision later. The MCA says a person can not decide if not able to do one or more of the following: not understanding the information relevant to the decision, retaining that information for long enough to make the decision, using or weighing up that information as part of making the decision, and communicating their decision in any way. MCA assumes everyone can decide for themselves unless proven otherwise. The multi-disciplinary team also acts in the best interests of the patient when there is no advocate for him. The class later had group scenarios, which was later discussed among the whole class.

I learned about the different communication difficulties at work and how to deal with these challenges. I also learned about the importance of consent in healthcare. I learned about what MCA is and how and when to use it.

I can confidently deal with communication difficulties at work under supervision. I would seek consent with an explanation before any procedure. I would follow the MCA at work when needed, under supervision and support.

This is relevant to the NMC Code (2018), prioritises people and practices effectively. Patients’ interests should always be put first when caring for them. It is of great importance to communicate clearly and effectively. Communication should meet people’s language and communication needs.

 

 

REFLECTION ON CANNULATION

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On this day, I learned how to cannulate a patient and venipuncture. I would be reflecting on the cannulation. A cannula is a tiny, plastic tube put into a good vein. Cannulas are usually inserted in the back of your hand or someone’s arm. A patient would need a cannula for the following reasons: for medication, fluids, and blood products to be given intravenously, and to facilitate blood sampling. The following items are needed for cannulation: cannula, extension set, tourniquet, gauze, pre-filled saline flush, alcohol swab, and cannula dressing. Firstly, introduce yourself and confirm the patient’s identity before cannulating. Secondly, it is important to sought the patient’s consent and inform him about the procedure. The lecturer asked the class about the purpose of a cannula, and we gave the reasons. She demonstrated how cannulation is done in front of the whole class while we observed and asked questions. After decontaminating your hands, you put on your apron. Since consent and introduction are already done, you look for a visible vein with your bare hand before putting on gloves, while communicating with the patient every step of the way. After feeling for the vein, you clean it with an alcohol swab, then put the tourniquet 7-8cm above the inserted site; this should be tight enough to impede venous return. The cannula is inserted using an aseptic non-touch technique. The cannula is inserted at an angle of 45 degrees, with each finger positioned on each wing and one in the centre of the cannula for stability and to form a C shape. While the cannula was being put in the vein, the stylet was also being pulled at the same time. You then have to look for primary flashbacks and secondary flashbacks. After the stylet is removed completely, it has to go into the sharp bin. The cannula is then clamped and the tourniquet removed. The other cannula lumen is closed with a bang. The clamp is then released and the cannula is flashed with the pre-filled normal saline using the push and pause technique. The patient is informed of every step of the process to ensure he is okay. If the normal saline goes through without any problem then the cannula is positioned correctly and working without any problem. The cannula is clamped again. A cannula dressing is then applied to the cannula on the hand. The date and time is then documented on the dressing. After the whole class observed the lecturer demonstrate the insertion of cannula we then did it individually whiles they went round to observe. I did some practices of the insertion of the cannula while the lecture observed and assessed me.

I learned the equipment needed in the insertion of cannula. I have also acquired the knowledge of the reasons and importance of insertion of a cannula. I have learned the process to use in inserting a cannula in a patients hand.

I can insert a cannula in a patient hand when needed under supervision. This will equip me to do my cannulation and venipuncture on my patient when needed in the future instead of calling another nurse to come and do it for me.

This is relevant to the NMC code to preserve safety. As I have been trained I will be able to insert a cannula safely into a patient’s vein following the right process under supervision.