Category Archives: Reflections: Year 2

Reflection

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In my placement area, patients were on many types of medications and medications were mainly administered through PEG. I have had the experience of administrating through PEG at previous placement areas but my experience of PEG administration in this ward was in-depth. I understand that PEG administration is not just a skill, but a holistic process requiring empathy and precision. Reflecting on the procedure, one must consider the patients’ comfort, communicate effectively and maintain effective hygienic control methods. I will continue to read more on PEG management to gain understanding of potential risks or complications associated with the procedure.

Most of the patients had tracheostomy in place due to swallowing issues and not necessarily because they could not breathe. Patients with swallowing issues can easily aspirate which makes it crucial for the need of a tracheaostomy. For tracheaostomy patients, AIRVO 2 was used to improve comfort, optimise airway hydration and reduce secretion. AIRVO 2 is a humidification system mainly used in respiratory care, providing high-flow therapy to patients. Patients normally experience discomfort due to dry air passing through the tracheostomy tube so the AIRVO 2 delivers humidified air, reducing irritation and improving comfort. Humidification provided by AIRVO 2 helps thin and mobilises secretion, making it easier to clear.

I have gained knowledge about the C-reactive protein test (CRP). I understand the test is conducted to measure the level of CRP, a protein produced by the liver in response to inflammation. High levels of CRP may indicate inflammation in the body, however the test does not pinpoint the source of the inflammation. CRP levels rise in response to inflammation and helps identify underlying issues. The test helps track the progress of inflammatory conditions like infections, autoimmune diseases and chronic inflammatory disorders. CRP test guides treatment by aiding in monitoring the effectiveness of treatment for inflammatory conditions.

I understand that undertaking swab tests of your patient before surgery is crucial for infection prevention. Nasal, groin and wound cultures help identify potential infections that could pose risks during or after surgery. Addressing these infections beforehand reduces the chance of complications.

Most of the patients in my ward were non-verbal so could hardly express their feelings. For this reason, identifying bruises on patients was considered a safeguarding issue which needed to be investigated. Investigating bruises included identifying if the patient inflicted themselves with the bruise, if the bruise was caused by staff member or if bruise was caused by an accident. Investigating bruises on non-verbal patients is crucial as it may indicate potential abuse, neglect, or underlying health issues. Identifying the cause helps ensure patients safety, provides necessary medical care, and allows appropriate intervention or reporting if abuse is suspected. This is essential for the well-being and protection of vulnerable individuals who may not be able to communicate their experiences verbally. Bruises identified must be monitored for 14 days. Pictures must be taken and there must be proper documentation detailing how well bruise is healing.

Skills

 

I have gained skills in changing Percutaneous endoscopic gastrostomy (PEG). It is important to get the right catheter size for the patient and undertaking a pH testing. I am able to aspirate a small sample of the stomach content through the catheter for the pH during PEG change to verify proper placement in the stomach. I use the pH strips and pH is usually acidic around 2- 5.0 due to the acidic content (gastric juice) of the stomach. If pH is within range, it suggests correct placement. If the pH is alkaline or inconsistent with gastric pH, it may indicate incorrect placement. Proper placement is essential to ensure catheter functions as intended and to prevent complications. I have acquired skills in changing water in the PEG balloon which is part of the weekly maintenance recommendations for patients in the ward. This helps ensures balloon remains inflated properly , which is crucial for keeping the PEG tube securely in place. Regular maintenance helps prevent complications and ensures tube functions effectively. I will further like to gain skills in nutritional management for Patients on PEG feeding where I am able to document nutritional assessments, feeding regimes, tube patency check and adjustments to feeding schedule to optimise patients nutrition and hydration.

Brain injury patients may experience urinary retention or bladder dysfunction due to neurological deficit or immobility. Undertaking bladder scan on them helps assess the volume of urine in the bladder non-evasively, aiding in the determining the need for interventions like catheterisation. I have gained skills in the use of the bladder scanner machine. During the procedure, I perform all my infection control measures like wearing my PPE and performing my hand hygiene to minimise the spread of infection. I lay the patient comfortably on their back and apply a small amount of gel to the skin to ensure good contact between the scanner and the body. I then position the scanner to the lower abdomen, specifically the pubic bone to get a clearer view of the bladder. The scanner emits high frequency sound waves into the body which bounce off the bladder and surrounding tissues. The scanner then detects the returning echoes and uses them to create an image of the bladder on the monitor. The bladder scan machine analyses the image and calculates the volume of urine in the bladder based on the shape and size of the bladder on the monitor. The scan results determines if the bladder is adequately empty or if there is retention of urine. This helps guide further intervention or management like the need for catheterisation or fluid intake adjustment or medication.

Attitudes and values

 

I understand the emotional impact of PEG administration to patients and their care givers. Patients undergoing PEG administration may go through physical discomfort, emotional distress, or frustration. I always remain patient and understanding towards their needs and show compassion which tends to alleviate their anxiety and foster trust. I keep myself updated about PEG care protocols to boost my confidence with the procedure and stay attuned to patients needs to provide compassionate and effective healthcare. I have demonstrated professionalism and competence in performing PEG administration procedures and have always provided safe, effective and compassionate care. I have demonstrated competence and attentiveness through my provision of care which has fostered trust and instilled confidence in my patients. It has become essential for me to always maintain my patients privacy and dignity by respecting their personal space, ensuring confidentiality, and preserving their autonomy. During procedures or discussions, I close curtains or doors. I only share patients relevant information with health professional involved in their care. Communication is crucial when providing patient care. I explain procedures thoroughly to patients and obtain informed consent before proceeding. I validate patients feelings and concerns, and offer support as needed.

Reflection

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My placement area is a neuro disability hospital which provides rehabilitation and long-term care to people with complex neurological disability caused by damage to the brain or other parts of the nervous system. Most of the patients have had traumatic injury to the brain and nervous system which have led to a variety of consequences depending on the severity and location of the injury. Most of the common outcomes included cognitive impairments, memory loss, changes in personality, motor skill deficit, and emotional challenges.

I gained knowledge into some of the complex conditions patients suffered from. Conditions included multiple sclerosis, schizophrenia, epilepsy and seizures, and stroke. I understand that Multiple sclerosis is a chronic autoimmune disease which attacks the protective covering of the nerves fibre (myelitis) which leads to communication problems between patients brain and the rest of their body. Schizophrenia is characterised by emotional and cognitive symptoms which impact patients memory and executive functions. Stroke occurs when there is a disruption in blood supply to the brain either due to a blockage (ischaemic stroke) or bleeding (hemorrhagic stroke). Epilepsy is characterised by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain which affects cognitive function and overall quality of life.

I noticed most of these patients with brain injury had respiratory problems. This is due to the intricate connection between the brain and the respiratory system. Brain injuries affecting the central nervous system can disrupt the neural signals that coordinate breathing muscles which can result in irregular breathing patterns or difficulty in maintaining proper respiratory function. In such cases patients required respiratory support to maintain adequate oxygenation. Again, swallowing difficulties is common after certain types of brain injury, which leads to an increased risk of aspiration. Reduced mobility and impaired cough reflex, often associated with brain injuries increases the risk of developing pneumonia, and respiratory infection.

I acquired knowledge about the different medication types administered to patients with these conditions. I understand reason for administration of some particular drugs and the side effects they have on patients. The common medication used included antipsychotic medications, seizure medications like levitiracetam and clonazepam. Respiratory medications like carbocisteine, which helps loosen secretions was commonly used. Baclofen was a common medication administered and I understand it helps reduce pain of muscle spasm.

I gained in-depth knowledge in the management and care of Percutaneous endoscopic gastrostomy (PEG). PEG is the only method used to provide medication and nutrition to the patients, as most of them had difficulty eating so were mostly NIL by mouth. I understand that PEG feeding is a vital means to ensure adequate nutrition and hydration to patients as it helps maintain their nutritional status while they work on rehabilitation and recovery. Patients received a multidisciplinary approach to care, involving neurologists, rehabilitation specialists and respiratory therapists. Their care involved ongoing assessments and early interventions in managing their respiratory problems associated with brain injuries.

Monitoring bowel movement especially for neuro-disability patients is crucial for their overall well being. Regular monitoring helps detect early signs of complications such as constipation, diarrhoea or bowel obstruction. Brain injury patients have increased risk of developing abdominal distension, which can lead to discomfort and pain. Constipation in brain injury patients may lead to retention which can be dangerous as it can lead to cardiac arrest. Severe constipation may trigger a vegal response to stimulate the vomit reflex, leading to vomiting. I understand vomiting is dangerous for brain injury patients as they have reduced consciousness levels and impaired swallowing reflexes which increases their risk of aspirating.

This was a different experience for me taking into account how specialised it is. The focus was mainly on patients with brain injuries. With other experiences, I have always had patients I could easily communicate with to understand their needs and feelings. With this new experience most of the patients were cognitively impaired and non-verbal. In my first week, I found it hard just watching them and giving them care. I tried my best to communicate as much as I could by speaking gently with reassurance. Most of these patients do not show awareness or responsiveness but I continued treating them with respect and dignity during any care intervention I provided for them. I spoke to them as if they can hear and understand me.

Skills

 

I have gained skills in monitoring vital signs in brain injury patients which is crucial for assessing their overall health and detecting potential complications. Changes in blood pressure, heart rate, and temperature can indicate neurological distress or systemic issues. Timely identification of abnormalities in vital signs ensures prompt interventions, preventing further complications and optimising patients outcome. Most of the patients were always on oxygen saturation monitors to monitor their oxygen saturation levels. Monitoring oxygen saturation levels in brain injury patients is crucial because the brain requires a consistent and adequate supply of energy to function properly. Low oxygen levels (hypoxia) can worsen brain injury and hinder the healing process. I gain the skill of regularly monitoring patients oxygen levels, familiarising myself with their normal parameters so patients can receive appropriate interventions to maintain optimal oxygenation and support brain recovery.

I gained skills in the care of tracheostomy. Patients who had tracheostomy required daily care of their trachea’s. When giving care to tracheas, I ensure hand hygiene by washing hands thoroughly before and after handling the tracheostomy site or equipment. I have gain skills in cleaning around the tracheostomy site using a saline solution and sterile gauze. I avoid irritation by being gentle all the time. I have gained skills in suctioning the tracheostomy tube to clear secretions and maintain airway patency. When cleaning around the tracheostomy or suctioning, I ensure the tracheostomy tube is securely in place with no sign of displacement. It is important to check tracheostomy site for any redness, swelling, or unusual discharge. Providing adequate humidification prevents tracheostomy tubes and airways from drying out. I have gained skills in regularly monitoring patients breathing pattern for any signs of respiratory distress.

I gained skills in caring for PEG sites as most of the patients were on PEG feed. I always washed my hand thoroughly before handling any PEG site. I clean around PEG site with a sterile gauze soaked in water and pat it dry with gauze. Whiles cleaning around site, I avoid rubbing or causing any irritation. I monitor for infections by keeping my eye out for any signs of redness, swelling or discharge. I gained in-depth skill in the administration of medication and nutritional requirements through the PEG.

Tracheostomy management and care involves intricate procedures so it is crucial for me to stay current with best practices, acquire relevant training and collaborate with multidisciplinary team to feel confident about the procedure and provide comprehensive care. I will regularly update my knowledge on PEG feeding guidelines and seek ongoing training to improve my skill acquired in this procedure.

Attitudes and values

 

In all care interventions, I practised patient-centred care by prioritising patients needs, preferences, and safety of patients receiving PEG administration and tracheostomy care. I demonstrated empathy and understanding towards patients undergoing these procedures recognising the potential emotional and physical challenges. I maintained high level of clinical competence during administration procedures, including knowledge of relevant equipment, and infection control practices. Patients safety was one of my top most priority. I ensured PEG tube was correctly in place and ensured to avoid complications during and after procedure.

I uphold professional standards in practice and during care interventions, including reliability, accountability, and maintaining confidentiality. I continuously kept myself informed about current evidence-based practices and advancement in tracheostomy care and PEG administration to provide the best possible care. These attitudes and values collectively contributed to me being able to deliver a holistic and patient-centred care.

Most of the patients were PDoC (Prolonged disorders of consciousness) and as such required specialised care. The patient care was provided in their best interest as they were unable to consent to care. I was compassionate in providing holistic care, and involved patients family in decision-making and care planning. I collaborated with colleagues to ensure comprehensive support for patients. I collaborated well with team members and always asked relevant questions when in doubt. I listened attentively to my experienced colleagues, seek professional feedback, considered their perspective, and used their feedback constructively.

Reflection on outreach with the occupational therapist

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I shadowed the occupational therapist (OT) on one of his session to assess a patient in my placement ward. A 91 years old male who came into hospital presenting vomiting and unsteadiness on feet. The patient mobilised with a Zimmer frame with minimal supervision. Before the patient’s assessment began, the OT introduced himself and maintained privacy and dignity all through and gained his consent. The OT began his assessment by asking the patient a couple of questions(background assessment- basically to gain understanding of patients baseline, environment and how patient have been managing before admission). Patient reported that he was responsible for his day to day care as he cooked for himself, did his own laundry, shopping and manages his own. He reported that he only had a cleaner coming in once a week to help. Patient reported to be feeling a little bit wobbly walking. The OT assessed patient functionally by telling him to mobilise to the toilet(toilet transfer) and also getting in and out of bed(bed transfer) so he can observe him. This was aimed to determine how much help patient will require when discharged back home and in other to ensure safe discharge. The OT explained to the patient that this assessment is necessary to determine the need for a package of care. Patient was asked if he would like carers helping him with his shopping, laundry and some basic needs and he responded affirmatively, he reported that he does not know how he was going to manage when he returns home, hence will probably need help till he gets better on his feet. The OT explained to him that he can have up to a maximum of four visits a day but patient said he will only require three visits daily. OT also recommended red cross referral for shopping when patient reported that he was worried about how he is going to do his shopping, patient consented for OT to send a red cross referral. OT advised that patient will be issued a frame to assist him with his mobility and also community therapy referral will be sent aiming at progressing him back to his mobility baseline. Patient reported happy with OT for his help. OT gained patient’s consent to send referral for POC, patient consented for POC. OT advised that patient will be discharged as soon as POC is confirmed

Practice Supervisor’s comments:

 

Rita has shown thorough understanding for the need of an occupational therapy assessment for patients having problems with their mobility. She understands that these assessments ensures a personalised treatment for patients taking into account their exact needs with the aim of promoting their overall wellbeing.

CIWA assessment reflection

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A 52 years old male was admitted in my ward presenting acute confusion from GHB drug withdrawal, had a fall at home resulting in humeral fracture. Before rendering care to him, I introduced myself, gained consent and maintained privacy and dignity all through. The patient appeared agitated and unsettled when the shift started, and was assigned enhanced care where he had one to one care. Patient was presenting symptoms of confusion, hallucination and was sweaty and tremulous. Patient was on an hourly CIWA score to assess and manage his withdrawal symptoms. During the CIWA assessment, factors such as the patients anxiety, nausea and tremors were evaluated to guide treatments of his undergoing drug detoxification. Patient had a prescription of diazepam with a start dose of 10mg. In the morning he was administered with 10mg dosage of diazepam. Under supervision, on one of the hourly rounds of his CIWA assessments, I asked patient if he was aware of his environment. He seemed confused at that point as he was not sure of his environment. I asked patient if he knew the date and day, his response was negative as he gave me a wrong date and day. Patients mouth appeared dry so I offered him water but he seemed drowsy and unresponsive. The staff nurse and I started calling out his name loudly with no response. The emergency bell was immediately pressed to alert doctors and all staff members. Patient was put on a high flow oxygen 10L via non-rebreathe mask and he was saturating at 100%. I quickly observed his vital signs and monitored it. Patients vital were within range. I undertook patients blood glucose levels and it read 5.7mmol/L which was within patients range. Patient became responsive, alert and started talking. Patients observations were rechecked fifteen minutes after and were within range. Patient was assessed and reviewed by doctors and the DASS team. ECG was done and results reported to the doctor.

I understood the CIWA assessment tool as I was able to evaluate the patient by assessing the severity of GHB withdrawal symptoms. I learnt that a patient scoring between 0-8 meant minimal to no withdrawal, 9-15 meant mild withdrawal and close monitoring will be needed. Scoring between 16-21 meant moderate withdrawal and interventions and referral may be required. Scoring above 21 meant severe withdrawal and medical intervention will be needed. Understanding the scoring scale help to know what interventions to give patients in managing the addictions.

Practice Supervisor’s comments:

 

Rita understand the CIWAS tool and was able to alert as soon as the patient was not responding. She was able to manage the situation professionally as well as very proactive.

wound care

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During simulated placement, I had the opportunity to join the wound care session. Most area of wound care was covered in this session which included gaining knowledge of the different types of wounds, factors affecting wound healing, wound assessment, wound cleaning and wound dressing. There was a brief discussion about the skin, its layers and the function of each layer. I understand that the outer layer of the skin known as epidermis acts as a protective barrier and controls water loss to prevent dehydration. The middle layer known as the dermis is made up of connective tissues which is a semi-fluid substances consisting of collagen and elastic fibres. The subcutaneous tissues also known as the hypodermis is the lower layer of the skin and it functions to protect the body’s temperature.

I understand that during skin assessment some factors must be considered which include areas of dry and scaly skin, skin perfusion, size, location and duration of the wound, signs and symptoms of skin rashes, oedema and temperature. I gained knowledge about the four stages of wound healing which included homeostasis, inflammation, proliferation and maturation. I gained knowledge about the type of wounds which includes and not limited to surgical wounds, pressure ulcers, laceration, burns, traumatic wound leg ulcer and diabetic ulcer. TIMES is the acronym used during wound assessment where T stands for Tissue, I stands for Infection, M is for Moisture and E for Epidermal advancement. During wound assessment it is important to identify if there is dead or unhealthy tissue present and if wound is infected. Wounds will be painful , swollen or smelly if infected. It is important to know if wound is wet and if so, why? Consider surrounding skin to determine if there are any barriers to the wound healing or if edges are healthy.

Many factors can affect the process of wound healing which may include drugs, infection, obesity, nutritional status, or dressing. I gained in-depth knowledge in wound dressing and the types of dressing available. I understand that during wound dressing one must always think about comfort and minimise stress and trauma by covering the wound. Always provide a non-adherent primary contact layer as a base for other secondary dressings or bandages. Appropriate wound dressing is relevant to the NMC code as it directly relates to several key principles that underpin safe, effective and professional nursing practice. NMC code emphasises on prioritising people by putting their care and safety first. Proper wound dressing ensures that patients receive the best possible care to promote healing, prevent infection, and manage pain. This demonstrates a commitment to high standards of patient care and prioritises their wellbeing. Acquiring wound care knowledge will benefit me in my nursing practice as I will be able to use the best available evidence to provide care. I will keep myself informed about the latest advances in wound care, understanding different types of wounds and select and utilise the most suitable and appropriate wound dressing materials and techniques. By adhering to the principles of wound care, I will be able to align my practice with the NMC code, thereby delivering high-quality, safe, and effective care.

Speech and language therapy

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During the simulated placement, I had the opportunity to join the IPL workshop where there were discussions on speech and language therapy which included communication, consent and mental capacity. There were discussions surrounding the impact of communication difficulties on engagement with healthcare professionals and the barriers to communication that impact healthcare professionals’ relationship building, gaining consent and mental capacity. The workshop involved adult nursing students, mental health students and physiotherapy students. There was role play scenarios which enabled all the different fields involved to learn from each other.

I gained knowledge about different communication disorders which impairs one’s ability to receive, process and comprehend verbal, non-verbal and graphic symbols. I understand these disorders can arise from factors including neurological and developmental issues. The session explored the importance of gaining consent which I understand is crucial in healthcare. Gaining consent ensures respect for an individual’s autonomy and their right to make informed decisions about their health. Healthcare professionals must ensure that individuals are fully informed about the potential risks, benefits and implications of a procedure or treatment to empower them to make knowledgeable decisions. .By gaining consent, a person’s right is protected by ensuring they have control over what happens to them and preventing privacy breach. I understand that communication barrier can impede the process of gaining consent, creating barriers that may affect a person’s understanding and ability to make informed decisions. People with communication difficulties may find it hard to comprehend information which can lead to misinterpretation or misunderstanding the risk or benefits of a procedure or treatment. This can make it difficult for them to indicate their consent or refusal.

The session further discussed Mental capacity act which I understand is a law that provides a framework for making decisions on behalf of people who lack the capacity to make decisions for themselves. I understand capacity is decision-specific and time-specific, meaning an individual can have the capacity to make some decisions but not others, and their capacity can change overtime. Factors that are considered when assessing a person’s capacity include their understanding, retention, how they are able to use information and how best they can communicate their decisions either verbally or non-verbally. Decisions made on behalf of an individual who lacks capacity must be made in their best interest considering their feelings, beliefs and values.

My understanding and skills related to communication difficulties, consent and mental capacity will significantly enhance my nursing practice. It will enhance my patient-centred care skills. By recognising and adapting to communication difficulties, I can ensure that patients understand their treatment options and care plans which will foster a supportive environment where patients feel heard and valued. It will help me tailor communication approach to each patients needs to improve cooperation which can lead to accurate assessment and better outcomes. My understanding of informed consent will ensure I obtain valid consent, which is crucial for ethical practice. This will protect patients’ rights and uphold my professional integrity. Being proficient in understanding mental capacity will help me make appropriate decisions about patient care, ensuring that those who are unable to make decisions for themselves receive the best support and protection.

Understanding communication difficulties and gaining consent is a fundamental aspect of the nursing and midwifery council (NMC, 2018). NMC code 1.1 requires nurses to prioritise people and by gaining consent, a healthcare professional is respecting an individual’s dignity and their right to make decisions about their care. The NMC code 1.2 emphasises about involving individuals about decisions concerning them. It is important to recognise and address communication difficulties to better involve patients in their care.