This is a reflective essay that will be focusing on my experience and feeling on how I related with a patient who was complaining of severe pain in the surgical ward during my posting there. I will be using the Gibbs (1998) reflective cycle as a guide on this essay. The Gibbs (1998) Reflective Cycle which is one of the most popular models of reflections consists of six steps: Description which describes as a matter of fact the situation and what happened during the incident. For my case the management of this patient who was admitted and was being managed pre-operatively for intestinal obstruction; secondly, feelings which is the description or the analysis of what my thoughts and feeling were at the time of this incident. Thirdly, the evaluation of my experience: this is about what was good and bad about my experience. Fourthly the analysis of my experience about what I can make out of the situation. Conclusion is the sixth step and it is about what else I could have done and what could I not have done. The final step is the action plan. The action plan will be about what I will do if this situation arose again or what I will do differently bearing in mind my experience from the steps above (Jasper 2003).
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Reflective practice writing is a way of expressing and explaining one’s own and others stories crafting and shaping to and understanding and development and it enables practice development because the outcomes of reflection are taken back into practice, improving and developing (Bolton 2005). Reflection “is a way of learning from your direct experiences, rather than from the second-hand experiences of others” (Cottrel 2003, p6). There are several other models of reflective practice. In addition to the Gibbs (1998) models, there are the Johns’ model of reflection (1995); Kolb’s Learning Cycle (1984) and the Atkins and Murphy’s model of reflection (1994).
During my placement at the acute surgical ward, I came across a patient who I will name Mr Jones (not real name). This is due to confidentiality. According to the NMC (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives article 5, 6 and 7, it states that ” You must respect people’s right to confidentiality; You must ensure people are informed about how and why information is shared by those who will be providing their care; You must disclose information if you believe someone may be at risk of harm, in line with the law of the country in which you are practising” (NMC 2008, p2). When I arrived at the ward on the 8th of October, the senior nurse briefed us about the cases on the ward. I learnt that Mr Jones was admitted into the surgical ward with severe abdominal pain and he has been diagnosed with small intestinal obstruction and is being managed pre-operative for surgical intervention. While attending to the patients in the ward under the supervision of my mentor (NMC 2008), Mr Jones called out to me that he is in severe pain. Walking up to him, I noticed the agony and pain he was in. Once he had my attention he was screaming and berating me that he is in terrible pain and that he need more pain killers. I approached Mr Jones and introduced myself with the aim of building an initial and good rapport with him and to establish a nurse-patient relationship (Holland et al 2008). I was so petrified with the signs and the way he communicated with me in such a way that really expressed he was in severe pain. I assured Mr Jones that I will have a word with a qualified nurse and will be back. I walked up to my mentor and ask that Mr Jones would need some pain killers as he is in severe pain.
I was very surprise when my mentor said to me “okay, where is Mr Jones drug chart”? And to my utmost surprise, instead of getting a cocktail of pain killers for Mr Jones, she was asking several questions. How do you know that he is in such severe pain as you have just described to me? Have you asked him with the trust policy of pain scale? What type of pain killers has been given to Mr Jones and for how long ago were these given to him? She went on and on and I felt embarrassed and at same time very eager to correct my mistakes. I was unable to answer any of the questions she has asked. I guess I must have been overwhelmed with sympathy rather than empathy for the patient. I went to bring Mr Jones’ drug chart and my mentor explained to me that from his drug chart recordings, he is on oral morphine 10mg 4 hourly and the last dosage was given in just an hour ago. He would need a doctor to review to see whether he might need another route and dosage of the analgesic she explain to me.
My first feeling was that this patient could be in severe pain and there is need to administer some form of strong analgesics. Pain according to the International Association for the Study of Pain is, “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP 1979). Pain may not be totally objective but subjective according to Braun et al (2003), they went on to further point out that included in pain are emotional as well as personal experiences. Pain could be divided simply into acute and chronic pain based on its duration (Shipton 1999). Acute pain is of short or limited duration usually associated with traumatic tissue injuries, whereas chronic pain is a pain or discomfort persisting for about 3 to 6 months and may persist beyond the healing period (Sinatra et al 2009; Ready and Edwards, 1992) and pain could progress from acute to chronic (Blyth et al, 2003). There is a psychological aspect to pain. According to Eccleston (2001), pain can be influenced among other things by culture, previous pain experience, mood, ability to cope or even belief. He concluded that pain is multifactorial and as such individuals should be treated differently. One of the underpinning principles of the Roper-Logan-Tierney model of nursing is the individualisation of nursing care and nursing practice (Roper et al 2000). My mentor showed me that Mr Jones is on 10mg oral morphine four hourly and that he may need a new review by the doctor so as to reassess his pain. I went to inform Mr Jones of this. On getting to him, I introduced myself with the aim of continuing our initial good rapport and also to obtain consent. According to the RCN “Informed consent is an ongoing agreement by a person to receive treatment, undergo procedures or participate in research, after risks, benefits and alternatives have been adequately explained to them” (RCN 2005, p5). Also, it has long been documented that information reduces anxiety (Byshee 1988 cited in Hughes 2005). I informed him that he will need a reassessment by the doctor in order to change his pain killer or if there is need to increase the dose and that the doctor has been notified of this. To my surprise, this seemed to calm him down a little as I explained and listened empathically to him. In a study carried out by Matthewson at the elderly care unit at New Cross Hospital in Wolverhampton, she concluded that nursing is the art of caring and as such we must listen empathically to what patients and service users want so we can give them the care that they deserve (Matthewson 2002).
This being my first encounter of meeting a patient with acute pain, I have so much to learn and gain especially about acute pain management. Having ask several questions and establish a good patient-nurse relationship (Holland et al 2008), I was involved in most of management of Mr Jones. Monitoring vital signs and recording them accurately. I learnt according to Mr Jones past medical history that he was first admitted in to the hospital in September 2009 for hernia repair and discharged home. He is now being treated for small intestinal obstruction which is one of the side effects of adhesions which could result from hernia repair (Ryan et al 2004). I asked the qualified nurse series of question and she informed me that caring for patients with intestinal obstruction require great deal of nursing skills. Patients suffering from small intestinal obstruction do have not only physical needs but also psychological and nurses should be aware of the fact that patients react differently to the fact that they are acutely ill (Hughes 2005). The ward sister informed me that some of the important factors to look out for when managing a patient with bowel obstruction are the presentation symptoms and vital signs such as pain, dehydration and fluid and electrolyte imbalance and nausea and vomiting. According to Anderson (2003) vital signs need to be monitored closely for changes by nurses and respond quickly and appropriately.
After re-assessment by the resident doctor that responded to the summon, Mr Jones morphine was increased to 20mg, 4 hourly in titrated doses so as to minimize the effect of euphoria and unwanted effects. Also the route of administration was changed so as to quicken the onset of action. According to McQuay and Moore (1999) it is sometimes advisable to change the route of administration if the patient is still complaining of pain as oral and trans-dermal route may delay the onset in acute pain. All strong opioids require careful titration from an expert practitioner it is better to begin with a small dose and increase gradually in conjunction with careful assessment of its effectiveness (Hanks et al 2001).
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Despite the fact that Mr Jones has had a surgery to repair his hernia a year earlier and is about to undergo another one shortly, he was in very good spirit. The whole process from when I came into the ward and Mr Jones called out to me that he is in severe pain till now has all been eventful and educating at same time. Mr Jones was given morphine to manage his acute pain. Several preparations are available in the pre-operative period for pain management. These include intramuscular analgesics and opiates such as morphine (Hughes 2005). Morphine was used as a drug of choice in the management of Mr Jones acute pre operative pain. Though it has several advantages that are well suited for small intestinal obstruction management like its effect on slowing down the motility of the gut (Rodney 2010) which in the case of small intestinal obstruction is good, it causes nausea and vomiting as some of its side effect due to its direct action and stimulation of the chemoreceptor trigger zone of the brain (Daniels 2008). Though anti-emetics were prescribed to counter the effect of nausea and vomiting, their effect was not profound and this caused some delay in the operative process.
Under the supervision of my mentor, I actively participated in the monitoring of Mr Jones vital signs. In addition to recording the temperature, I was involved in the monitoring of the fluid and electrolyte balance. Fluid balance was monitored hourly as one of the senior sisters explain to me the importance of a maintaining its balance. Haemodynamic stability is crucial as hypovolaemia can occur quickly because of the obstruction, fluid levels can rise quickly due to decreased gut movement causing the bowel to distend and losing its functionality of absorbing water and minerals thereby leading to fluid and electrolyte imbalance (Torrance and Serginson 2004).
I feel that the whole process involved in the management of Mr Jones pre-operative acute pain went smoothly. Being my first placement in the surgical ward I asked several questions and mentor and senior nurses were on hand to explain and in some instances demonstrate this out. But what else could I have done or what could I have done differently? Well, from the first time I went to meet the patient and then relaying the patient concern to my mentor, I should have looked at the patient’s drug chart rather than being overwhelmed by self pity. All documentation with regard to the patients’ management is on the patients’ record and it is vital that I look at this. Effectual documentation according to Porter and Perry (2009) within a patient’s medical record is an imperative and fundamental aspect in the practice of nursing. To minimize the risk of errors in the management of a patient, there is the need for accurate documentation of all drug activities in the patients drug chart (Youm 2002). As I have come to realize, pain may not be totally objective but subjective and included in this are elements of emotion as well as personal experience (Braun et al 2003). Rating scale are the most commonly used method of accessing acute pain and its relief. The World Health Organisation (WHO 1996) modified analgesic ladder to control pain in that the simple principle is that the beginning of pharmacological intervention begins on the first step of the ladder and proceeds upward. Opioids are used extensively in the management of pain and believed capable of relieving severe pain more effectively than non steroid anti-inflammatory drugs (NSAIDs) (McQuay and Moore 1999).
My action plan should a situation such as this arose again will be significantly different. I will continue to reflect and study how acute pain is managed and the role of the nurse in such management and most especially to ensure I look at documentation for patients. Effective pain management is fundamental to quality care, good pain control speeds recovery. To increase the effectiveness of nursing interventions and to improve the management of pain, the use of pain assessment tools for acute pain has to be followed such as verbal description scales(VDS) which are based on numerically ranked words such as none mild, moderate severe and very severe for assessing both pain intensity and response to analgesia. Numerical Rating Scales (NRS) this is easily used as a verbal scale of 0-10 indicating no pain on one extremity of the line and 10 indicating severe pain at the other extremity (Hammer and Davies 1998). Uncontrolled pain can lead to increased anxiety, fear, sleeplessness and muscle tension which further exacerbate pain (Dougherty and Lister (2008). Perkins and Kehlet (2000) suggested that poorly controlled acute pain may lead to the development of chronic pain. I also learnt that there is a psychological aspect to pain. My nurse-patient relationship really helped in this area. According to Holland et al (2008) each patient should be regarded as unique in a nurse-patient relationship and that individuality should be taken into account when undertaking nursing care (Holland et al 2008 p11). Another aspect of nursing care that helped was effective communication which is an essential prerequisite for effective nurse-patient relationship (Robinson 2002). By talking to patient in an open, honest way about their pain made them feel more relaxed and in control which help them to cope better. I hope to increase my nurse-patient relationship and how to deal with acute cases. This will be a goal I will be aiming at in my next placement though discussion with my mentor and further research.
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