Reflection on Complex Nursing Care Plan
Student Name
Institution Affiliation
Author Note
Reflection on Complex Nursing Care Plan
Introduction
Self-reflection on complex nursing care is an important tool for developing practitioner knowledge because it improves the healthcare provider’s ability to handle challenging situations. The Johns Model of refection is a five-step cyclic paradigm of self-evaluation that allows professionals to participate in a personal transformative learning process of discerning the appropriate actions from incompetent choices in offering care (Finlayson, 2015). During my on-duty shifts, I provided care to two complex care patients, Nicolas Noble and Thi Minh Tran. Nicolas Noble suffered a Transient Ischemic Attack (TIA) while Thi Minh Tran had a risk of developing lymphedema. In this paper, I will use the Johns model to reflect on the care plan for handling the two patients to appraise and improve my clinical decision-making skills.
Description
The first plan of care for Nicolas was assessing the patient’s vital signs after every fifteen minutes for the first hour and hourly thereafter. The results were recorded in the patient’s obs chart. Medications, such as Ramipril and Aspirin, were administered through cannula intravenous fluids to lower the blood pressure and dissolve any blood clots. The patient remained NBM during this period until the referral of speech pathology assessment at 0900hrs. The care plan also monitored the patient’s ECG, sugar levels, and bowel activity. The care plan also included the administration of medication to prevent the development of COPD and renal impairment, which is common in TIA patients. Additionally, the patient received anticoagulant medication and hourly physiotherapy to reduce the risk of developing DVT.
Reflection
The goal for the care plan was to monitor and assess any TIA occurrences during the period of care or any changes in the patient’s vitals that could indicate either an increase or decrease in the risk of acute stroke. TIA is a condition of a minor stroke, where there is a restriction in the normal blood flow to the brain that causes changes in neurological functions (Veenith et al., 2010; MFMER, 2020). Immediate and periodic assessment of the patient’s vitals, renal function, and full blood count was crucial for mapping of the condition’s progress (National Stroke Foundation, 2007). The medical team carried out HbA1c blood tests to monitor the patient’s sugar levels and evaluate the diabetic risk factor of stroke (National Stroke Foundation, 2007). It was also essential to carry out an electrocardiogram (ECG) and echocardiography to determine the causes of cardiac emboli (Lindley, 2006; El-Fawal et al., 2019). However, it was important to keep the patient NBM until speech pathology to avoid any risks of choking from orally-consumed substances due to dysphagia (Daniels et al., 2015). Additionally, I decided to administer anticoagulant medication and physiotherapy because the patient had a high risk of developing blood clots in the legs due to his long hours of rest.
Influencing Factors
In my opinion, the care plan was effective in monitoring the condition and progress of the patient’s vitals. The interventions were crucial for determining the risk of acute stroke development. Conversely, the care plan did not focus on brain imaging that can determine the severity of damages resulting from the TIA. However, severity assessment would have been important only if the patient had distinct motor, verbal, or swallowing impairments, which was not the case. I also believe that the time consumed while running blood tests and ECG may have been too long. A patient with a high risk of exacerbation would be vulnerable if the care plan took a similar three hours to complete the assessment.
Improvement
Brain imaging procedures, such as CT scan and MRI, could have assessed the neurological damages to the brain. Ordering for brain imaging procedures would have helped the medical staff evaluate any lasting damages to Nicolas’ brain. However, such procedures would be very expensive. Besides, the result of the speech pathology was a good indicator of the absence of any permanent cerebral changes in the patient. Additionally, the care plan would be better if all the blood tests and vitals were taken concurrently during the first hour. Concurrent testing and monitoring would reduce the time taken in understanding and managing the condition.
Learning
I need to improve on the initial management efforts for arresting any exacerbating vital conditions. I believe that the medical team could have made better medical decisions if they understood the severity of Nicolas’ condition within the first hour of care. Improving this area of the care plan requires three actions. First, the medical team should run the various tests concurrently. Secondly, the medical team should increase the human resources available to run the necessary tests. Finally, the medical team should take measures to improve the coordination of nurses and the efficiency of initial management efforts.
Case 2
Description
Thi Minh Tran was hypotensive and in CR zone from suspected lymphedema. In the first hour, I assessed the patient’s vitals and recorded the observation on the obs chart. I then referred a dietician to review the patient’s nutritional status. The medical team later assessed the patient’s fall history, chest X-ray, and blood culture. The team continued monitoring his vitals and maintaining his body fluids intake for the next couple of hours. Serum lactate test was carried out to evaluate the risk of septic shock (Rhodes et al., 2017). Also, delirium assessment was carried out to evaluate the neurological condition of the patient. The medical team administered several medications to manage the condition, including IV antibiotics, anticoagulants, and magnesium sulphate.
Reflection
The goal of the care was to arrest and prevent the acute deterioration of his condition. The patient had suffered acute deterioration in health for four hours before experiencing no change in the last twenty hours. I administered antibiotics through IV to manage any sepsis based on the recommendations of clinical guidelines (Burkett et al., 2018). It was important to keep a record of his vitals, which would alert the medical teams of any deterioration in health. The assessment of the chest x-ray and the blood cultures were necessary to determine the patient’s full septic condition. The patient was encouraged to take in a lot of fluid to prevent dehydration and UTI development. I administered Magnesium Sulphate to prevent the patient from suffering any seizures due to delirium.
Influencing Factors
The care plan did well in monitoring the patient’s neurological, cardiovascular, and septic status. Antibiotics medications were administered to arrest and prevent the exacerbation of the sepsis. Also, the plan carried out serum lactate test, which is one of the diagnostic tests for sepsis. The care could be better if the medical team undertook other diagnostic tests for sepsis, such as evaluation of levels of procalcitonin, lymphocytopenia, thrombocytopenia, and neutrophil to lymphocyte ratio (White et al., 2015). However, management of sepsis is a time-sensitive process because any delays could reduce the chances of patient survival. Therefore, the care plan resulted in carrying out the serum lactate test alone, which is the most effective test for diagnosing sepsis.
Improvements
The care plan could have been better if it carried out more blood test. Other tests could unveil underlying conditions that need treatment. However, carrying out more blood test in a time-effective manner needs more resources and better coordination among the medical team.
Learning
Writing the care plan has highlighted the importance of extensive and timely testing of various indicators of sepsis, such as procalcitonin and neutrophil to lymphocyte ratio. Therefore, I need to gain more knowledge of the testing criteria for diagnosing sepsis. I also need to improve on the number of tests and the timeliness of handling lymphedema patients in the future.
References
Burkett, E., Macdonald, S., Carpenter, C., Arendts, G., Hullick, C., Nagaraj, G., & Osborn, T. (2018). Sepsis in the older person: The ravages of time and bacteria. Emergency Medicine Australasia, 30(2), 249-258. https://doi.org/10.1111/1742-6723.12949
Daniels, S., Pathak, S., Stach, C., Mohr, T., Morgan, R., & Anderson, J. (2015). Speech Pathology Reliability for Stroke Swallowing Screening Items. Dysphagia, 30(5), 565-570. https://doi.org/10.1007/s00455-015-9638-x
El-Fawal, B., Badry, R., Abbas, W., & Ibrahim, A. (2019). Stress hyperglycemia and electrolytes disturbance in patients with acute cerebrovascular stroke. The Egyptian Journal Of Neurology, Psychiatry And Neurosurgery, 55(1). https://doi.org/10.1186/s41983-019-0137-0
Finlayson, A. (2015). Reflective practice: has it really changed over time?. Reflective Practice, 16(6), 717-730. https://doi.org/10.1080/14623943.2015.1095723
Lee, S., & An, W. (2016). New clinical criteria for septic shock: serum lactate level as a new emerging vital sign. Journal Of Thoracic Disease, 8(7), 1388-1390. https://doi.org/10.21037/jtd.2016.05.55
Leung, E., Hamilton-Bruce, M., Price, C., & Koblar, S. (2012). Transient Ischaemic Attack (TIA) Knowledge in General Practice: a cross-sectional study of Western Adelaide general practitioners. BMC Research Notes, 5(1). https://doi.org/10.1186/1756-0500-5-278
Lindley, R. (2006). Patients With Transient Ischemic Attack Do Not Need To Be Admitted to Hospital for Urgent Evaluation and Treatment. Stroke, 37(4), 1139-1140. https://doi.org/10.1161/01.str.0000209329.67467.a0
MFMER. (2020). Transient ischemic attack (TIA) – symptoms and causes. Mayo Clinic. Retrieved 17 May 2020, from https://www.mayoclinic.org/diseases-conditions/transient-ischemic-attack/symptoms-causes/syc-20355679.
National Stroke Foundation. (2007). Clinical Guidelines for Acute Stroke Management. National Stroke Foundation. Retrieved 17 May 2020, from http://centlib.lums.ac.ir/parameters/lums/modules/cdk/upload/content/portal_content/File/libarary/gadline/Acute%20Stroke%20Management.pdf.
NHS. (2019). Lymphoedema. nhs.uk. Retrieved 18 May 2020, from https://www.nhs.uk/conditions/lymphoedema/.
Rhodes, A., Evans, L., Alhazzani, W., Levy, M., Antonelli, M., & Ferrer, R. et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Medicine, 43(3), 304-377. https://doi.org/10.1007/s00134-017-4683-6
Veenith, T., Din, A., Eaton, D., & Burnstein, R. (2010). Perioperative care of a patient with stroke. International Archives Of Medicine, 3(1), 33. https://doi.org/10.1186/1755-7682-3-33
White, R., Jeffrey, S., Elstone, A., & Cutting, K. (2015). Sepsis and chronic wounds: the extent of the issue and what should we be aware of. Wounds UK, 11(4), 8-14. Retrieved 18 May 2020, from https://www.researchgate.net/profile/Richard_White3/publication/288841993_Sepsis_and_chronic_wounds_The_extent_of_the_issue_and_what_we_should_we_be_aware_of/links/568a4c3608ae1975839d7384/Sepsis-and-chronic-wounds-The-extent-of-the-issue-and-what-we-should-we-be-aware-of.pdf.