Case Studies On The Importance Of Oral Care

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13th Feb 2020 Nursing Case Study Reference this

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This submission is going to focus on the nursing care that I gave in one placement simulation and two consecutive shifts on placement, placing emphasis on oral care, medication management and communication. It will outline the fundamental aspects of clinical nursing skills that have taken place in my setting. This will also highlight the learning process taken place and how it helped me to enhance my knowledge, and ethical values in order to deliver quality and safety of care. Using other sources of current literature, I will use a reflective model to discuss how I have achieved the necessary level of learning outcome. By utilising this model I hope to demonstrate my knowledge and understanding in relation to these skills as well as identifying areas with scope for learning. Reflection is the process of reviewing an experience in order to describe analyse, evaluate and so inform learning about practice (Reid 1993). Gibbs (1988) model of reflection will be used as a framework, because it focuses on different aspects of an experience and allows revisiting the event fully. By contemplating it thus, I am able to appreciate it and guided to where future development work is required. For confidentiality purposes the patient’s real names will not be used and will be referred to patients as B and R. This is in line with the (NMC, 2008) requirements to maintain confidentiality at all times. A diary is supported in this assignment as an appendix within the time of the process. The reflective model I have chosen to use as guidance is Gibbs (1988). The care of a patient’s mouth forms an important component of assisting hygiene needs and yet is a nursing skill which is not always afforded the attention it fully deserves (Evans, 2001) Description I was part of a placement simulation group which went to the multi-skills laboratory to practice delivering and receiving oral hygiene. I was assigned a colleague to brush his teeth using a toothbrush and paste. I put on gloves to prevent contamination (NICE 2003). Seeking his consent, I undertook a brief visual assessment of his mouth’s health. I then put him in a comfortable position so that he could tolerate the wash. Thereafter, I cleaned all-round the mouth, gums and tongue. I finished off by helping him to rinse his mouth with mouthwash. I treated my partner as though he was physically unable to hold the brush himself to scrub his own teeth, but he was able to communicate with me and was able to assist me in terms of spitting and gargling with water at the end of the procedure. Feelings When first informed that I was expected to undertake this task I felt anxious and concerned. I was aware that I had not brushed anyone’s teeth outside of my family before and that the mouth is an intimate and personal part of the body which is not usually exposed to anyone other than myself or the dentist. I was concerned about how my partner (whom I did not know well at that stage) would react to me examining his mouth. Writers have described such intimate physical assessments as creating a potentially intrusive situation (Lewis 2006, Sturdy 2007) which might cause the patient to feel uncertain and inadequate. I was also concerned that my own anxiety was shared by my partner who also appeared embarrassed and awkward at the time. This anxiety was increased when during the procedure my partner began to cough as though distressed. This caused me to feel hesitant about continuing- a situation recognised by Millon (1994) as a common response for carers to such an experience, although I persevered with his cooperation. When the task was completed I felt comfortable with my performance overall. Evaluation What was good about the experience was that, despite being aware that this role is often delegated to health care assistants (Kelly et al 2010), I was able to deliver a fundamental component of essential nursing care (Essence of Care 2003) quite effectively. The experience helped me to appreciate that oral care provides any nurse with an ideal opportunity to undertake a thorough physical, emotional and cognitive assessment of a patient (DOH, 2001). I was satisfied delivering this aspect of care without harming the patient as no injuries were sustained (having I checked his mouth prior to and after cleansing). Also, I was pleased to have an opportunity to improve my communication skills through the delivery of this skill and to understand the impact that this might have on the development of a therapeutic relationship with future patients. From my colleague’s reaction and feedback, I understood how feedback is an important learning tool. Despite my discomfort during the undertaking of this task, the experience highlighted the potentially complex problems I might have to solve in the provision of care needs to patients for whom I may not have had contact with before. Analysis Administration of this clinical skill involved undertaking an assessment of my colleague’s mouth before delivering any care in order to help determine the most appropriate means of delivering oral care. Malkin (2009) asserts that this is a critical component of the procedure and was one I was keen not to overlook. The World Health Organisation (WHO 2010) describes a healthy mouth as being free of chronic mouth and facial pain and in the situation described; this is the condition I found my partners mouth to be in. I was therefore happy to proceed with cleaning his teeth as instructed. I selected to use a soft bristled toothbrush and toothpaste. The use of these adjuncts are described by many writers as being the most appropriate in terms of removing plaque and preventing trauma to the gums (Holman et al 2005,McCauliffe 2007).Despite this it has been identified that they are also most often not selected by nurses who appear uncertain about most effective evidence based practice ( McAuliffe 2007). Conclusion Clearly, mouth care is important and that, nurses have a role in assessing and maintaining it (Malkin, 2009).The task identified the role of the nurse in providing encouragement to the patient whilst delivering oral care. His weakness created a sense of dependency upon me and necessitated the utilisation of good communications skills on my part to complete the task properly. It has raised my awareness the effects of nursing interventions on others within my practice. Action Plan At the moment, I read more books a day than practice. My aim is to be proactive in the future by promptly opening up through total participation and doing more practices by brushing my teeth on regular basis. I would consider brushing others also and allowing them to brush mine in order to become familiar with areas that are often not well attended to. Keeping up to date with evidence based principles of practice will be maintained through the scrutiny of journals that refer to this aspect of care. I will take care to remember my feelings when providing and receiving oral hygiene before delivering it to patients in the future. Recognising the potential for embarrassment and awkwardness I will ensure that I treat the patient with sensitivity and discretion at all times. Administration of medicines is a key element of nursing care (Audit commission, 2002,). Therefore, one is accountable for the administration of medicines. Description I shadowed my mentor during the process of dispensing medication and knew that my role as a student nurse, each registered nurse is accountable for his/her practice. As a student it is important to seek consent from the patient before any care is given which I did. I went to the treatment room with my mentor and prepared for medication for morning. During the process of medication there are important nursing protocol steps to follow. Firstly, I checked order, assessing client, label medication, provide information to the client, check the medication when dispensing and record in the patients prescription chart. Patient R was present and I offered him a cup of water along with the Clozapine 300mg in another cup. Before I came in contact with the patient, I read their notes and the medication they are on. This gave me the baseline whether the patients comply with medication and the reason why they do not comply. Feelings The routine for prescribing medication may be different in various clinical settings. Although I have participated dispensing medication, I felt nervous and did not want my patient to see this as a weakness. (Butler, 1991,) warns us that when our self-talk is negative, we are carrying around toxic environment for ourselves everywhere we go. My mentor took the role to encourage me by assuring that I was doing fine, talking me throughout the procedures of medication management. I had brief knowledge about medication and this gave the opportunity for my mentor to question my knowledge about the right dose, time, route, right patient and right drug. My role as a Nurse is to record and report deterioration improvement and takes appropriate action for his treatment to care. Patient R felt that he did not need medication because he is not mentally ill. This was a barrier because he had no insight and it leads him to deteriorate with compliance. Evaluation This practice includes preparing, checking and administering medications, updating knowledge of medications, monitoring the effectiveness of treatment, reporting adverse drug reactions and teaching patients about the drugs that they receive (NMC, 2008). The (NICE, 2008,) guidelines state principles for the administration of medicines that treatment and care should take into account patients’ needs and preferences and patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. The staff discussed his presentation to healthcare professionals in the Muti-disciplinary team (MTD) if they could change his medication time and dose as he presents lack of motivation and sedation. People with schizophrenia should have the opportunity to make informed decisions, including advance decisions and advance statements, about their care and treatment, in partnership with their healthcare professionals.(NICE, 2008,) This is the importance of communication working as a team within the MDT. Analysis Administrating drug medication is one of the most critical nursing responsibilities for both legal reason and safety patients. Hand washing was important protocol the infection control policy as hands are source of infection and hand washing would break the chain of infection. Patient R is on Clozapine. The use of this atypical antipsychotic licensed to people who are resistant to or intolerant of other antipsychotic drugs due to the potentially the use of adequate dose of two different antipsychotic agent. Clozapine can lower the number of white blood cells that help to fight infection (BNF, 2008,). Before initiating Clozapine, patients should have a history and physical examination. For example, if the patient has a history of cardiac illness, it is important that you have regular blood tests. The reason behind this is because, if white blood cells count falls below accepted lower limit are classified as “Red alerts” medication must be withdrawn, and any other prescriber in the future wishing to restart medication are aware of the patient’s haematological history. Once a week I would go with the Patient to the Clozapine clinic to have blood test done and to monitor his potential side effects of psychiatric drug treatment. Patient R was presenting various side effects sedation, drowsiness which makes him less motivated to get out of bed for his medication leaving him to forgetting the mornings. Conclusion… Not all non-compliant choose to reject medication; it may be because they forget to take them and this may be cognitive confusion. Intolerance of various side effects is the most common cause of clients discontinuing medication use (Taylor et al 1997). It is important to remember that the symptoms can fall into a number of different categories, so patient like to be told their diagnosis and what is wrong with them (Blenkiron, 1998,). This area was one of my weaknesses, and I asked my mentor the importance of the Clozapine clinic and how it is associated with regular blood monitoring. I learnt that in order to attend regular visits, all patients must have normal leucocytes and different counts. Action Plan… Communication Description On this occasion I was being observed and supervised by my mentor to work with a 45year old Caucasian man, with a diagnosis of paranoid schizophrenia and on section 37/41 of the Mental Health Act 1983. He has previously presented with chaotic behaviour, auditory hallucinations, delusions as well as violent and threatening behaviour. In the morning I would do my observation of the patient and make an assessment of how he presented himself to see if he had attended to his personal hygiene and activities of daily living. According to (Greenwood, et al 1999), patients who are in hospital satisfaction with information are found to be lacking. Feelings As a student nurse my role and responsibility by the (NMC, 2008,) is that you must respect and support people’s rights to accept or decline treatment and care. I observed that Patent R found it difficult to wake up and take his medication, which was a problem that staff nurses struggled with time to time. (Watson, 1995,) emphasise that caring communication is holistic, taking into account the entire person and demonstrating respect for the client’s ad people. Evaluation Listening is the most important communication skill in nursing. (NICE, 2004), emphasis that communication between healthcare professionals and patients is essential. I learnt that if patients are encouraged to have treatment choice, they need to have information about the recommendation given before committing themselves. This is why it is important that patients must be central to and include in their care. For the patients to be able to do this, it requires the nurse to use communication skills effectively, to develop therapeutic nurse-patient relationship in which the patient feels safe enough to disclose and discuss issues they find central to them and from jargon. Analysis During the shift I communicated with other members of the team on any significant events or any concerns with the patient. At the end of the shift I recorded what the patient had done for that day and I gave handover to the staff who were taking over the next shift. This was very important because it would ensure continuity of care and reduces any errors or omissions. A good example of effective communication links to medication is to give instructions and provide training involving analysis and synthesis of the learner’s experience. In reference to my patient (Gamble, 2004), illustrates when a person has mental health problem it can affect the individual cognitive process, their beliefs, perception and outward behavior. If Patient R discontinues Clozapine he will become psychotic again and create a turmoil leaving the community and his family members in distress. Conclusion……. I developed my knowledge by providing leaflets about Clozapine, encourage to attend to the clinic centre which they will explain the pros and cons of Clozapine. Action Plan…….. General Conclusion I identified that some patients felt uncomfortable with direct question so it was important to use (Bein and Miller 1992), Open ended question. The outcome if the client-nurse interaction depends on the nurses ability to engage the client in decision making and share the control and power in the relationship (Roberts, et al 1995,). I felt that their were barrier to communication as I felt that some of the staff’s attitudes made me feel as if I was not part of the team and sometimes lead to me no being able to give my views on issues regarding patients. Although I am aware that all nurses do not use evidence in the same way and may use different methods in clinical settings. I felt that working in partnership with the patient and other health professionals can enable time to build supportive and empathetic relationship as an essential part of care. (NICE, 2008,). The process of learning I went through is more complex than Gibbs suggests. It is not as cyclical as this model implies and I found myself jumping or combining some stages, before coming back. However, it has taken me out of my comfort zone, challenging my thinking.

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