Reflection On The Management Of Care

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This essay will present a reflective journal describing the different care requirements of patients from three different client groups undergoing surgery. I will describe the care of one of the client groups and subsequently compare and contrast the differences in their needs. This reflection will explore the strategies and skills for management used in the delivery of care to these individuals and demonstrate the team-working skills necessary for an effective working relationship in the clinical setting. I will show an appreciation and understanding of how to identify measures to protect and support wounds to provide optimum conditions for healing associated with current evidence-based practice. The modified version of Driscoll’s (2000) reflective framework will be used. The descriptive part of the journal can be found in Appendix1.These three client group will include the following: baby George 1 year old child., Helen 35 year old female and Damian 70 year old male. All names of the three clients groups mentioned are anonymous to maintain patient confidentiality (HPC, 2008)

SO WHAT

During the process of care to the above client groups I shared the team’s desire to realise the best possible outcome for all of the patients. Interdisciplinary patient care requires common values, a common vision, and an understanding of teamwork with the ultimate goal of serving three difference client’s group with wisdom (Ray, 1998).I also wanted to demonstrate recognition of the needs for Helen, Damian and George, and believe that they should be regarded as valued human beings who deserve the best care. Kumar and Hutton (1998) states that the responsibility of the theatre personnel lies in maintaining the safety comfort and welfare of the patient from the time he arrives in the theatre until the time he departs.

In theatre environment one of my role was to act as Helen, Damian and George advocate through their journey thus ensuring that their dignity and rights was in the forefront of preoperative care (Wicker and O’Neil 2006). Damian, George and Helen were of different age and had different surgery, according to their needs, their right to dignity, privacy and respect remained the same and the high standard of care delivered reflected that. In this situation George and other clients group privacy and dignity perioperative always been maintained and a warm blanket has be used to cover the child and other clients group until surgery commences (Woodhead et al. 2005).

As a student ODP, I was responsible for the delivery of high standard of care for three different client’s groups. The Health Professions Council (2008) states that registered practitioners must be able to work, where appropriate, in partnership with other professionals, support staff, client users and their relatives and carers. Whilst Helen was on the table I checked consent, wrist band and surgical side with the scrub practitioner, the surgeon and the rest of the team to ensure that right patient is presented for the correct procedure that all details and information are available, and that preoperative preparation is complete (Torrance and Serginson 1999). An agreed preoperative WHO checklist has been done by one of my colleagues to introduced ourselves and discuss our client so that we have a shared understanding of the patient condition and the operative challenge (or that it may be a straightforward procedure with no anticipated problems) (Wilson and Walker 2009).

Evidence based practice has become an important part of the quality required within the peri-operative environment. All theatre practitioners are required to keep their professional practice up to date and there is also an increasing expectation for the practitioner to develop research based practice and to keep informed with regards to relevant research findings (Hind and Wicker 2000).The knowledge and skills were very important aspects for effective working relationship in the theatre to maintain safety environment individually for each of the discussed group. Health professionals should strive to ensure quality and safety for those in our care (RCN, 2003).

For Helen and Damian I ensured the temperature was 22C and made sure that the warming device (Bear hugger) was placed over the top of their body to maintain and monitor their body temperature. Because of the potential morbidity associated with hypothermia and hyperthermia, it is important to monitor body temperature and to institute measures to maintain temperature as close to normal as possible (Townsend et al. 2004). However carried for George, I adjusted room temperature to 25C and warming device was also applied. Children have a higher surface area to body weight ratio compared with adults, and so they lose heat more rapidly. Neonates and preterm babies are particularly susceptible to hypothermia (Bingham et al. 2008).

Torrance and Serginson (1999) state that the theatre practitioner needs to be aware of and monitor safety with regard to: safety transfer and positioning of the patient, pressure relief, skin preparation, asepsis, diathermy, swabs, needles and instruments. Transfer of and positioning Helen, Damian and George for the orthopedic surgery onto the operating table was carried out by the theatre team with extreme care and with regard for any previous injuries or limitations of joint movement (Torrance & Serginson 1999). We were aware about the implications of inadequate movement in the above clients. Injuries can range from transient aches and pains and minor skin abrasions to paralysis and even loss of life (Beckett, 2010).Pressure reliving gels was provided to protected Helen and others clients aligned with pressure ulcers caused by long-term procedures. Unrelieved pressure on a specific area of the body will affect the blood supply to the skin and underlying tissues causing that area to become damaged (Hampton and Collins 2004).

Equipment was selected appropriate to the age and individual requirements of each client. George compared with others groups of client required appropriately sized equipment which was used of all times, e.g.: diathermy plates, arm boards, specific pediatric table attachments for positioning (Woodhead et al. 2005). I made sure that sterile field consisting the scrub team, trolleys and the draped patient was maintained. Packets were opened and sterile items passed to the scrub practitioner in a manner that did not compromise the sterile field. As I was circulating I noticed that asepsis (or aseptic technique) was important and it involved all the practical measures taken to avoid ingress microbes to a susceptible site (such as instrumentation, theatre ventilation, and non touch technique), or to kill or remove them from that site (such as skin antisepsis and wound cleansing) (Quick and Thomas 2000). Aseptic technique was used during all invasive procedures for Helen,

Damian and George in preventing surgical site infection from microbial contamination.

During all groups of client operations the scrub practitioner used non-touch technique by passing sharp instruments such as blades or sutures on receiver so that the operating surgeon may lift them as opposed to passing by hand (Pirie, 2010). Instruments were placed in the neutral zone by the scrub person and then picked up by the surgeon or the assistant, and vice versa (Gruendemann and Magnum 2001).

Once Helen’s operation was completed, I handed the necessary wound dressings to the scrub nurse. This also forms a part of the circulating role. It is therefore important that the scrub person or surgeon ensures that the correct dressings were requested to optimise wound healing. Bentley (2004) suggests that effective wound management and use of appropriate dressings should be based on an understanding of the healing process. Wound healing consists of four phases that overlap; these are inflammatory, destructive, proliferation and maturation (Nazarko, 2002).

The steps in the wound repair process include inflammation around the site of injury, angiogenesis and the development of granulation tissue, repair of the connective tissue and epithelium and ultimately remodelling that leads to a healed wound (Gunnewitch and Dunford 2004).

The roles of surgical dressings are primarily to stem bleeding, absorb exudates and provide mechanical and bacterial protection for the newly formed tissues (Aindow and Butcher 2005). As Dealey (1994) highlights, the surgeon is responsible for inflicting the wound, although the bulk of the responsibility for ensuring that the wound heals without complications falls with the nurse. Lay-Flurrie (2004) urges that theatre practitioner should have a good knowledge of the dressing properties characteristics and an idea of what

is to be achieved. The use of an inappropriate dressing may result in damage to the friable and delicate tissue underneath (Lay-Flurrie, 2004).

During this surgery I also learnt that the needs of each individual client’s wound at any particular time after the surgery need to be prioritized as it may differ while it progresses through the healing process. The hospital where I was on placement used two main types of dressings for postoperative wound management, these fall under the following categories, fabrics and films. (Aindow and Butcher 2005).The wound dressing used for Helen’s right shoulder arthroscopy was Mepore (fabric) for a dry small incision compared with Damian’s total hip replacement; the surgeon used Opsite (film) for larger incision. Mepore incorporates pads to absorb the exudates produced by newly formed wounds. However while they form an effective barrier when dry, they can facilitate bacterial ingress when wet (Aindow and Butcher 2005).Opsite provides a barrier which prevents the contamination of the wound with extrinsic bacteria, including MRSA. As the wound is visible, dressing removal is unnecessary to inspect the wound. This further minimizes trauma and the risk of accidental wound contamination (Aindow and Butcher 2005). Ennis and Meneses (2000) state that, many chronic wounds such as pressure ulcers, take months and sometimes years to heal, becoming stuck in the inflammatory and proliferate phase of wound healing.

Additional measures to reduce the risk of infection should be taken; these include avoiding unnecessary exposure of the joint implant for Damian’s surgery. Therefore it should not be removed from packaging until required. Extensive handling of the implant should be avoided (Eppley, 1999, citied by Radford et al.2004). DOH (2003) state that, wound care has a large impact on the total drug budget and it is important that limited resources are used wisely and effectively. The primary purpose of wound cleansing is to remove organic and inorganic debris before the application of a wound dressing, thus maintaining an optimum environment at the wound site of healing (Morrison and Wilkie 2004).Blunt (2001) agrees that wounds should be cleaned to remove foreign bodies, such as debris, excess exudates, necrotic tissue or slough all of which could become a focus for infection.

NOW WHAT

While working as a member of the multidisciplinary team, the importance and value of teamwork has become apparent to me throughout my training and I have learnt how good communication, skills and working together ensures effective patient care for the three different client groups undergoing surgery.

I have been able to establish and maintain a safe working place by improved confidence which has led to an improvement in my competence.

I believe that I have become a valued member of the theatre team by anticipated with the scrub team by passing appropriate instruments, sutures and wounds dressing to protected Helen and other clients from the infection and covered to maintain them dignity.

It also demonstrated my ability to explore and critically analyze own responsibilities in the following area identify measures to protect and support wounds to provide optimum conditions for healing.

The experience described enabled me to reflect deeper on my ability to support different groups of patients and as a result my commitment to achieve the best patient outcome.

References:

1. Aindow, D.Butcher M. (2005) Tissue vability supplement. The British Journal of Nursing, 14 (19), p.

2. Beckett,A,E.(2010)Are we doing enough to prevent patient injury caused by positioning for surgery?[Online].Available at: http://findarticles.com/p/articles/mi_m0748/is_1_20/ai_n48711688

[Accessed: 11 March 2010].

3. Bingham, R. Lloyd-Thomas, A. Sury, M. (2008) Hatch & Sumner’s Textbook of paediatric anaesthesia. 3rd Edition .Oxford: Oxford University Press.

4. Blunt J. (2001) Wound cleansing :Ritualistic or research-based practise ? Nursing Standard, 16 (1), p.33-36.

5. Department Of Health (2003).Supplementary prescribing by nurses and pharmacists within the NHS in England. [Online]. Available at: http://www.doh.gov.uk [Accessed: 19 February 2010].

6. Driscoll, J. (2000) Practising clinical supervision. Edinburgh: Balliere Tindall

7. Ennis, W. Meneses, P. (2000)Wound healing at the local level: The stunned wound. [Online]. Available at:

http://www.ncbi.nlm.nih.gov/pubmed/10732639 [Accessed: 18 February 2010].

8. Gruendemann, B. Mangum, S. (2001) Infection prevention in surgical settings. Philadelphia: W.B Saunders.

9. Gunnewicht, B. and Dunford, C. (2004) Fundamental aspects of tissue viability nursing. Wiltshire:HA Healthcare.

10. Health Professions Council (2008) Operating Department Practitioners. Standards of proficiency. London: HPC.

11. Health Professions Council (2008) Standards of conduct ,performance and ethics.[Online].Available at: http://docs.google.com/www.hpc-uk.org/assets/documents/July2008.pdf+Standards+Of+Conduct+,Performance+and+Ethics.[Accessed:01 March 2010].

12. Hind, M., Wicker, P. (2000) Principles of perioperative practice. London: Churchill Livingstone.

13. Lay-Flurrie (2004)Wound management to encourage granulation and epithelialisation. Professional Nurse, 19 (11), p.26-28.

15. Meltzer, B. (2001) A guide to patient positioning. [Online]. Available at:

16. Morison, L, G. Wilkie, O, K. (2004) Chronic wound care:a problem-based learning approach.London: Mosby.

17. Nazarko, L. (2002) Nursing in care homes. 2nd ed. Oxford: Blackwell Science.

18. Pirie, S. (2010) Introduction to instruments. [Online].Available at:

http://findarticles.com/p/articles/mi_m0748/is_1_20/ai_n48711689/.

[Accessed: 1 march 2010].

19. Quick, C.Thomas, P. (2000) Principles of Surgical Management. Oxford: Oxford University Press.

20. Radford, M. County,B. Oakley, M. (2004) Advancing Perioperative Practice. Cheltenham: Nelson Thornes Ltd.

21. Ray, M, D. (1998) Shared borders: achieving the goals of interdisciplinary patient care. American Journal of Health-System Pharmacy, vol. 55, issue

13, p.1369-1374 AJHP [Online].Available at: http://www.ajhp.org/cgi/content/abstract /55/13/1369 [Accessed: 6 March 2010]

22. Royal College of Nursing (2003) Clinical Governance:an RCN resource quide.London:RCN.

23. Scott, E.Earl, C.Leaper, D.Massey, M.Mewburn, J.Williams, N (1999)

Understanding perioperative nursing. Nursing Standard, 13(49), p.49-54.

24. Torrance, C .Serginson, E. (1999) Surgical Nursing.12th Edition. London: Harcourt Brace and Company Limited.

25. Townsend, M, D. Beauchamp, D .Evers, M. Mattox, K. (2004) Sabiston textbook of surgery.the biological basis of modern surgical practice.17th Edition. Philadelphia: Elsevier Saunders 2004.

26. Wicker, P. O’Neil, J. (2006) Caring for the perioperative patient. Oxford: Blackwell Publishing.

27. Wilson, I. Walker, I. (2009) The WHO Surgical Safety Checklist: the evidence. The Association for Perioperative Practice,19 (10), p.362-364.

APPENDIX 1

WHAT

During my placement in the orthopaedic theatre, I took the role of the circulating person for the first operation on the list that day. Helen (pseudonym) was 35 years old woman, and was having right shoulder arthroscopic surgery.

Before Helen arrived in the theatre, I took great care to ensure the operating room had been cleaned and had all the equipment and instrumentation for the procedure available. I adjusted the temperature in the theatre to 22 c and humidity between 40-50% .Next I helped the scrub nurse with gowning and gloving. I followed aseptic technique and opened relevant sterile packs, pouring lotions and I did the first swab, instrument and needle count with the scrub person so it was recorded on the board.

When Helen arrived into the operating room on a trolley, I made sure there were enough members of staff to safely transfer the patient from the trolley onto the operating table using a pat slide ensuring that the patient’s dignity was maintained. The anaesthetist took responsibility for the patient’s head, neck and airway, and co-ordinated the team as the patient was turned. Helen was placed in the left lateral position with her arm placed in traction for better access to the shoulder joint. Before the transfer I ensured that the doors were closed and patient was not exposed unnecessarily and during the positioning of Helen my role included a final check, to make sure that patient was appropriately covered and ensured pressure reliving gels were placed under her left shoulder, buttock and heel.

Whilst Helen was being transferred from the trolley onto the operating table adequate padding was provided and body alignment was maintained. She was secured with a strap and the lower arm adjacent to the head. I checked the patient consent, patient’s wrist band and surgical side with the scrub practitioner the surgeon and the rest of the team. The WHO checklist was read out loudly by one of my colleagues to identify any problems and concerns from anaesthetic and surgical side (blood loss, ASA grade).Additionally, a pneumatic compression system (flowtron boots) was employed prophylactically against deep vein thrombosis, the diathermy plate electrode was attached and ”bear hugger” a patient warming device was positioned.

When draping was completed I adjusted the light and assisted with connecting the monitoring equipment, and positioning the diathermy machine and suction tubing around the operating table so that they did not compromise the sterile field .I ensured that electrical cables were secured. I completed the patient care plan, and filled out the pathology form for the specimen ensuring that the form bore the patient’s label containing details of the patient’s name, address, date of birth, NHS number and patient number.

During the surgery I anticipated the needs of the surgical team, especially carrying out the instructions given by the scrub person. I counted needles, blades, and instruments and compared the count with the board.One of the theatre practitioners measured and informed the surgeon and anaesthetist about blood and fluid loss recording it on the board. Under the direction of the scrub practitioners I collected the specimens into the specimen containers, labelled with the patient’s label which included the name of the specimen which was confirmed with the surgeon. I did the final count of the swabs, needles and blades and instruments then handed the surgeon the necessary wound dressing.

Once the wound was appropriately dressed all team helped to remove the patient drapes and transfer her to the supine (position lying on the back) on the trolley. Using a blanket I covered the patient. I signed the operations register with the scrub practitioner at the end of the operation.

When Helen had gone to the recovery, I started to clean and prepare the theatre for the next case.

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