Reflective Writing Using the John reflection model

Reflective Writing Using the John reflection model

Geriatric nursing is a unique area that requires critical thinking as one has to consider the comprehensive aspect of the patients (New Zealand Nurses Organization, 2014). In this paper, I am reflecting on the plan of care for two patients admitted to our facility within the same week. Reflective writing involves exploring the relationship between the nurse and the patient. In both cases, I will compare the guidelines in the management of their diagnosis with their plan of care. I will use the John reflection model to identify any shortcomings I might have had with the ultimate goal of learning and improving my nursing care in the management of other patients.

Description

The first case involves a 79-year-old lady by the name of Tran Thi Minh. She was admitted at 1200 hrs on 23/07/2020 from a nursing home where she resides. Patient vitals were monitored two hourly to check for any signs of deterioration. IV gentamicin, an antibiotic, was administered within the 2nd hour of admission. As she was hypotensive, the nurse in charge was informed, as is the protocol hospital policy for vitals in the yellow zone. Serum lactate levels were to be checked, and IV fluids administered according to these levels. The patient is a high fall risk and was put close to the nurses’ station for close observation. The patient was for two hourly toileting to prevent falls as well as early mobilization and involve a physiotherapist for mobilization of the patient. A dietitian was involved in the planning of the patient’s meals and assistance with feeding.  Skincare was done to prevent pressure ulcers.  Consider a gerontologist review due to the recent falls and check on the bone density—assistance with personal grooming, especially of the vulva area.

The Second patient, Noble Nicholas, was admitted at 0300 hrs on 30/7/2018. The patient was transferred from the emergency department (ED) with a possible diagnosis of Transient Ischemic Attack (TIA) with the possibility of cardiac involvement. I examined the patient for any physical injuries he might have had or any pressure injuries that might have been developing and performed a risk assessment test for pressure injuries. The patient started on the IV fluids at 60 MLS per hour as had been prescribed once we obtained an intravenous line. The patient was provided with oral care equipment, and he independently took care of his mouth care.  I made a referral to the speech therapist as the patient remained nil by mouth. There was a need to consider another route of administration of oral medication, including his hypertensive medications. I allowed patients to pass urine in the toilet, Random blood sugar levels measured at 10 mmol/ L to which the RMO was informed. We suggested the patient for an endocrinologist review due to the elevated HbA1c and the possibility of the patient having type II diabetes mellitus. The patient’s vitals were monitored half-hourly for the first one and a half-hourly then three hourly. The patient was put on room air with the respiratory rate observed to be below 30 breaths per minute and saturations at 90%. The nurse in charge was informed of the patient’s low blood pressure, which was within the yellow zone as per the Hospital’s policy. Gentamicin is started at 1400hrs, while all the other medications are planned at the write time. The patient was monitored for pain, which she does not report. Two hourly toileting is done due to a high risk of falls, and he was on IV fluid therapy. Early mobilization of the patient to prevent the patient from developing Deep Vein Thrombosis (DVT). An ECG was to be requested for the patient.

Reflection

In the first case, involving Minh, the goals were to for close monitoring to prevent further complications.  Another was the prevention of injuries from falls as the patient is prone to fractures from the previous history. The dietary intake was also considered to promote healing and adequate hydration. Another aim in the plan of care was to prevent deep vein thrombosis and re-infection.  The plan was comprehensive according to the patient’s needs (Doenges et al., 2010).

In the second case, the goals were to ensure that the patient was assessed on swallowing reflex before feeding to prevent aspiration. Repeating the CTB to confirm the diagnosis know which part of the brain has been affected (The National Stroke Foundation, 2016). Also, to ensure adequate patient ventilation considering he has COPD as well as to prevent further injuries from falls. It was upon the assessment and identifying the patient’s needs (Doenges et al., 2010).

Both plans were comprehensive according to the patients’ needs. The plans also looked at involving a team of different professionals besides the primary caregivers such as the gerontologist, a physiotherapist, an endocrinologist, and a dietician to ensure comprehensive patient care (New Zealand Nurses Organization, 2014). On review, plans were mainly based on evidence-based practice; however, some parts were based on a routine schedule. In retrospect, both plans failed to outline strict input-output monitoring clearly.

Some of the influencing factors in planning for both patients were good knowledge of both conditions as well as proper hospital protocols that guided decision making. Each patient had a unique previous chronic disease that made planning take into consideration their specific needs (Doenges et al., 2010).

Improvements

The plan failed to include patient education in both cases. The patients needed to learn about their conditions and the mode of treatment. In Minh’s case, she needed to learn how to prevent re-infection, while in Noble’s case, he needed to learn that he might have had kidney complications as well as type II diabetes.

Learning

I feel I did my best in the plan. However, the few areas identified would have made the plan better. Strict input-output monitoring was a crucial area. In patients with sepsis, control of urine output is an integral point of management as it helps to show the severity of the sepsis and whether the patient is deteriorating (Levy et al., 2018). It was essential to check the kidney function of the second patient because he is a known hypertensive patient, has mild chronic kidney disease, and might be having type II diabetes Mellitus, which are risk factors to renal disease (Lukela et al., 2016). I need to study the management of sepsis guidelines on urine output monitoring (Levy et al., 2018). I also need to read further on the management of hypertension complications on different body organs, including the kidneys (Lukela et al., 2016).

In retrospect, I should have emphasized on patient education. Patients need to understand what is ailing them for them to participate in their care. Incorporating the patient’s education in their care promotes their adherence in their care (Hess, 2009). Both patients must understand the reasons for early mobilization and the pressure area care (New Zealand Nurses Organization, 2014).

I need to keep myself up to date with different medications used in the management of both cases. In the management of sepsis, IV antibiotics prioritize care (Levy et al., 2018). However, some medications are contraindicated in cases of renal impairment, such as using pantoprazole. I also noticed there was a gap in the management of the geriatric patient. I have to update myself in geriatric nursing knowledge and skills (New Zealand Nurses Organization, 2014).

References

Doenges, M. E., Frances, M., Moorhouse, R. N., C., A., & Murr, R. N. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th Edition. Retrieved from https://taskurun.files.wordpress.com/2011/10/nursing-care-plan-guidelines-for-individualizing.pdf

Hess, C. T. (2009). Incorporating patient education into your plan of care. Nursing39(4), 62. https://doi.org/10.1097/01.nurse.0000348423.03172.42

Jennifer Reilly Lukela, R Van Harrison, Jimbo, M., Sy, A. Z., Greenberg, G., Ma, & Mhsa R Van Harrison. (2016). Guidelines for Clinical Care Ambulatory Chronic Kidney Disease Guideline Team Leader Ambulatory Clinical Guidelines Oversight Management of Chronic Kidney Disease. UMHS Chronic Kidney Disease Guideline. Retrieved from http://www.med.umich.edu/1info/FHP/practiceguides/kidney/CKD.pdf

Levy, M. M., Evans, L. E., & Rhodes, A. (2018). The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Medicine44(6), 925–928. https://doi.org/10.1007/s00134-018-5085-0

New Zealand Nurses Organization. (2014). Gerontology Nursing Knowledge and Skills Framework. Retrieved May 16, 2020, from www.nzno.org.nz website: https://www.nzno.org.nz/Portals/0/Files/Documents/Groups/Gerontology/20141201%20Knowledge%20and%20skills%20framework.pdf

The National Stroke Foundation. (2016). Update. Nursing Management (Springhouse)47(2), 1. https://doi.org/10.1097/01.numa.0000480697.42505.97

Wilson, S. (2014). Management of Sepsis in the Adult. Retrieved from https://lms.rn.com/getpdf.php/2057.pdf

Youngblut, J. M., & Brooten, D. (2001, December). Evidence-based Nursing Practice: Why Is It Important? Retrieved May 16, 2020, from ResearchGate website: https://www.researchgate.net/publication/11599213_Evidence-based_Nursing_Practice_Why_Is_It_Important

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