Student reflection on an episode of care
Within your reflection describe the episode of care and how you assessed, planned, delivered and evaluated person-centred care.
Mr A was received from the night staff during handover, patient was in bed and alert. I introduce myself and gain patient consent for all nursing interventions privacy and dignity provided. call bell within patient reach, safety check done bedside environment cleaned and de-cluttered. I also check the background history and the allergies of the patient before given the nursing needs to the patient. The patient was admitted to hospital due to syndrome with midline shift, patient was due for amlodipine, bisoprolol and clopidogrel. I flowed all the necessary medication management before administering of the medication and documentation. patient was breathing on room air.
During my shift Mr A, called for sara steady to use the toilet with assistance of one, I was able to transfer the patient to the sara steady to the toilet. The patient stool was type 6 large this was recorded on stool chart, after using the toilet I was given the opportunity to give the personal hygiene to Mr A. I was able to check skin and any pressure areas of Mr A. all the pressure areas of MR. A. All areas were intact and was able to turn himself. Mr A was on Level 7 diet and 0 fluid, Mr A had large amount of food eaten throughout my shift, all the food and fluid intake were recorded. Mr A vital sign was taken during my shift, and the news score was 3 it was notice Mr A Sp02 was 78% on the monitoring on the machine, Mr A was than advised to sit up as the position was not good. with the adjustment in position sp02 read 92% Mr A was within her target of 88.92% my supervisor was informed about the situation.
What did you do well?
In overall the patient was responsive and expressed back his needs, which were addressed, so overall I was able to interact with him successfully. As I had reviewed the patient ‘s medical history, knew what to expect from the patient medically, and was able to provide nursing care, I felt confident in my ability to take care of the patient.
What would you have done differently?
The patient appeared to be mentally sound and was aware of his needs and preferences. I could have encourag him to sit out more since he wasn’t sitting out much.
Describe how you have begun to work more independently in the provision of care and the decision making process.
Using the medical device Zimmer frame, sara steady and hoist for transfers and the information from the aforementioned episode of care, I was able to independently assist the patient on the sara steady. Since the patient’s previous position was obstructing, I was able to independently check the patient’s skin and also encourage the patient to sit up.
What learning from this episode of care could be transferred to other areas of practice?
To know what to do for a patient when providing care is something that may be learned from the episode of care and applied to other areas of care of practise. in addition, being proactive in learning about your patients’ medical histories and the reason(s) they were admitted could help you provide them with the proper care.
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
Applies knowledge of healthy lifestyle choices in relation to the person’s/persons’ physical health, mental health and well-being, e.g. smoking cessation.
Comments
This episode of care was well carried out. Important information was given to the patient for the patient to consent. Stella explained intervention as the process went on and gave a lot of encouragement for patient to sit out more.
Assessing needs and planning care
Accurately undertakes a comprehensive assessment and identifies need and plans care for a range of health needs.
Comments
Stella gathered all the information beforehand especially in the prescribed medications and was able to tell the patient what medication was given and what they are used for. Stella did her initial assessment by checking what the patient can do independently and carry out intervention appropriately
Providing and evaluating care
Demonstrates safe, compassionate, person-centred, evidence-based care that respects and maintains the person’s/persons’ dignity and human rights when managing a range of commonly encountered presentations, e.g. anxiety, pain, restlessness, confusion.
Comments
Stella was able to document all care given accurately and was able to verbally handover care to incoming staff under supervision
Improving safety and quality of care
Accurately undertakes risks assessments and demonstrates an understanding of local and national frameworks for managing and reporting risks.
Comments
Safety was met at all times. Stella ensured the patient bedside was decluttered and bed was working properly. The sera steady was checked prior to use on the patient (Last date of equipment checked was done).
Leading nursing care and working in teams
Uses effective communication skills to manage the care of a small group of people/individuals with complex care needs, demonstrating the ability to prioritise care recognising when and whom to refer/delegate to as appropriate.
Comments
Even though Stella was doing her episode of care she was able to involve the HCA to help check patient skin which demonstrate calling for help where help is needed and also teamwork
