For this assignment I will be writing a reflective account which will identify a significant episode of care in which I had been involved with, by identifying the pathophysiology and the disease process for the chosen patient; this will be presented by giving a brief outline of the psychosocial influences of the illness for the patient and others who may have been involved with the care. I will also reflect upon this episode by using a reflective model and examining the nursing process, using a holistic perspective throughout the reflective framework.
Maintaining confidentiality is a key element, outlined in the Nursing Midwifery Council the Code (2008). The care for this patient was assessed using Roper Logan and Tierney, being the most used nursing models. It is described by (Newton. C, 1991, 15). “the concept is based on four components with the nature of the individual, the nature of health and illness the role of nursing in health and illness and also the nature of the environment” these all cover the 12 activities of daily living. With many of the twelve affecting the patient some were more ideal for the patient individually.
These will be assessed during the in-depth description of the patient. The client admitted onto the ward, a Male of 58 years of age, with a past medical history of diabetes, hypertension, a BMI of over 28. 4, which is recorded as overweight and also unstable angina, and also a patient who smokes 20 cigarettes daily. His family were keen visitors and always wanted to be involved with the care. This patient lived with their wife and was mobile. The client was admitted with unstable angina and this surrounded the care episode.
PATHOPHYSIOLOGY Firstly I will now discuss the pathophysiology of angina to give the reader an insight into the disease and reference it within the client and the episode of care. Looking at the cardiovascular system it comprises of the heart arteries, capillaries and veins. “This is what transports blood around your body, carrying oxygen, glucose and nutrients to the tissues”. (Brewer. S, 2010, 97). As described in the (Conway B, Fuat A. , 2007, volume 21) “The coronary arteries deliver oxygenated blood to the cardiac muscle”. Chronic Heart Disease occurs when atheroma which are fatty plaques develop in the coronary arteries. This process is called atherosclerosis. In time, the artery may become so narrow that it cannot deliver enough oxygenated blood when the demand is high, such as when exercising. ” “Angina pain is experienced as sensory neurones innervating the heart are richly endowed with an iron channel that is increased in the lactic acid concentration” Within (Margret. A, 2006. 15) pathopysiological description is provided describing angina as an “obstruction previously described as atheromas.
This providing insufficient oxygen delivery for local metabolic demand and this releases lactic acid as cells switch to anaerobic metabolism”. “Angina is the pain or discomfort experienced. Angina may also be brought on by emotional upset, cold and windy weather, extreme heat or after a heavy meal. MI occurs if there is plaque rupture and a thrombus develops, blocking the artery”. I assessed two main reflective models, which were Johns (1994) and Gibbs (1998) these both are described within common foundation studies in nursing (Jenny.
S, 2008, 59) “Johns model is linear in its nature whereas Gibbs’s model is always being described as a cycle. Despite their structural differences, Johns and Gibbs’s models are similar in character and have the same core components”. (A. Margaret, 2006, 1108) reflective accounts within the book are of Gibbs’s (1998) cycle which is described “I decided to analyse the incident using Gibbs, which provided cathartic experience” leading to myself choosing this certain model. The aim to Gibbs model is that reflection of the event can be assessed clearly in points.
By describing what had occurred and recalling the feelings that were felt at that time. After this comes the evaluation of the event in which I will consider what was good about the experience and what could be changed. I will throughout the assignment analyse the care given and provide a conclusion in which I will finally assess the whole situation by providing an action I will state what would be different if the situation was encountered again. DESCRIPTION The significant episode and its facts will now describe and explain my involvement with the patient, and maintaining confidentiality throughout.
The care episode for a male patient occurred on a cardiology ward during a night shift along with a nurse and a healthcare, caring for twenty patients. Before shift on the ward began, handover was given. During handover the nurse provided information regarding a patient showing signs of anxiousness and worry during the day shift. Upon hearing this I had taken note and was very keen on speaking to the patient, through a therapeutic relationship. Later on during the night shift this patient’s call bell sounded, the nurse and I on shift went to the answer of the client.
The patient described a pain radiating in his chest and said that it was their angina and asked the nurse “can I have my spray”. The nurse responded by asking the patient for consent if they could perform an ECG, The reason being that they could get a recording of the angina on the ECG for the on call doctor to asses.. The patient responded with an answer of “ok” but the patient did seem in uncomfortable pain. The on call doctor was also contacted to assess the results of the ECG and also assess the patient holistically.
As I could see the patient was in a lot of pain with a build up of anxiousness and worry which was already mentioned, this seemingly making the situation worse. The blood pressure and pulse was taken and the reading of 149/90mmHg which is showing hypertension, and 79 pulse which both would be regarded holistically as high for this patient, this may be due to the stress being caused. The ECG is a simple and effective electric recording of the heart rhythm which was taken with the patient still very anxious.
I decided that this was becoming very traumatic for the patient and felt that I needed to hold the patients hand by using a touch technique. The ECG was performed and did provide significant results for the doctor. The actual test of taking an ECG reading did provide some difficulties due to the patient’s pain and also the psychological pain as the patient was under extreme stress and worry at that time, as referred to before that. “Angina is the pain or discomfort experienced. Angina may also be brought on by emotional upset”.
The GTN was soon administered and relieved the patient’s pain near enough automatically. The patient was assessed at 5 minute intervals and later 15 minute intervals to make sure that the observations were at a normal standard with the blood pressure being previously high. The Patient was also assessed throughout the night. The blood pressure did reduce to a normal rate. The one thing the Patient asked was “that we should not say to his wife and family that the angina episode had occurred” because it would worry them even more.
I explained that with the clients consent I would not disclose information about the angina attack. The patient state “I feel a burden is off me and that I know that the worry of coming into hospital may have brought on my angina”. THOUGHTS AND FEELINGS I do feel that seeing the patient in pain was uncomfortable as a nurse and also as a human. Pain is a universal part of human experience and is defined as an emotional and sensory experience resulting from actual or potential damage (Merskey and Bogduk 1994). During this experience the patient was in considerable pain and this affected me.
My own thoughts were to provide the patient with the GTN spray straight away to relieve the patient but I knew as a nurse that the process of an ECG, observations were needed before any pain can be relieved. My thoughts and feelings were compromised and made me feel uncomfortable. The psychological effect of seeing a patient in pain is difficult as a nurse and the only way I could show this was through empathy which is described as “ the capacity to understand another person’s feelings or perception of a situation… hrough empathy the nurse is able to understand and accept the feelings and thoughts of the client. ” Sympathy being different from empathy which derives from “sharing the feeling” (White. L, 2005, 116). EVALUATION In evaluation I can take positive and negative elements of the episode of care. This being in relation to the planning and the implementation. The main objective was to relieve the patient of pain as discussed, before pain as an “emotional sensory experience” (Merskey and Bogduk 1994) I feels that this definition epitomises my feelings during the episode.
So the patient not being in pain anymore was a relief to me and I felt the needs of that individual had been met holistically. The whole is greater than the sum of its parts”. ‘Instead of reducing the person into functional parts, the individual is considered as a ‘whole’. (Patterson,1998, p. 667) as described in holistic nursing handbook. I believe that this is a necessity in any care that it is individualised to that persons needs. The ECG and observations were to be taken before delivering the when required drug.
Glycerol trinitrate spray which is a nitrate as described in the BNF September (2009, 111) “Sublingual glycerol trintrate is one of the most effective drugs for providing rapid symptomatic relief of angina,” (Phalem. T, 2006, 21) “An ECG is to record the electrical activity of a large mass of atrial and ventricular cells as specific waveforms and complexes”. The patient was in pain but using the therapeutic relationship and ensuring consent was given using the (NMC the Code, 2008, 3) “You must ensure that you gain consent before you begin any treatment or care.
You must respect and support people’s rights to accept or decline treatment and care. You must uphold people’s rights to be fully involved in decisions about their care”. All these were addressed during the care of the client. The care given to the patient had a psychological element to it as I was able to talk to the patient and find what was causing them distress and anxiousness within the hospital setting. “Communication is therapeutic. Building relationships is the cornerstone of nursing work, particularly with patients with learning disabilities; communication is a prerequisite to that process.
It can also be life-saving” (Collins. S, 2009). This being a prime example where anxiousness and stress can cause angina, so by just talking to the patient and reassuring them, using a therapeutic relationship can help and prevent. “The resting ECG which is a simple test was taken to evaluate angina pectoris”. (Jackson. G, 2000, 42). So by me taking this ECG it can help evaluate the angina when compared to previous. This can be through the on call Doctor identifying changes within the ECG in relation to “ST depression or T wave inversion, but previous infarction may be identified”.
Showing that these results can be valuable with the further diagnosis of this patient. When evaluating the implementation of care given, I found elements which were negative. When I reviewed the care given, the patient being in pain was distressing. The patient was already worried and this didn’t seem to help. Even though I talked to the patient in a therapeutic way and delivered care in the highest standard I felt the need to build upon this situation. The patient also asked for the family not to be told was discussed with the doctor.
The patient not wanting myself and the team to discuss with relatives, would show that confidentiality in regards to the NMC the code (2008), could not be broken. ANALYSIS As I pointed out before “the whole is greater than the sum of its parts”. ‘Instead of reducing the person into functional parts, the individual is considered as a ‘whole’. (Patterson, 1998). I believes Holistic care is an important element with any patient, (A. Josephine, 2006, 1108) it is described as the principles of “holistic care should be adhered to and a process of continuous assessment, planning.
Intervention and evaluation followed”. This encompassing the nursing process as described in the nursing process (H. Yura, 1988, 25 ) “the nursing process is the glue that binds all nursing actions into a holistic unit. While assessing I came to the conclusion that the care was holistic as it was significant to that patient with regards to the outcomes and how the patient was cared for using techniques such as a therapeutic relationship to talk to the patient and help them understand the reason behind the care being given.
The roles of each person within the episode were important as they all had their part to play within the event. The episode of care included the patient, the nurse on shift, myself and also the on call doctor. I decided to discuss with the patient the episode of care, the patient commented on this and thanked me specifically about how I reacted to Him (the client). “Thank you for helping me, the way you helped me calm down and talked to me on the same level”. This is what self awareness is about. Other authors make eference to the concepts of this type of relationship saying that “patients themselves value therapeutic relationships which offer respect, trust and care and it seems that such relationships may in themselves prove to be healing in the broadest sense. ”(Mitchel & Cormack 1998 p50). After the episode of care, I decided to report to the nurse with an idea of using Roper, Logan and Tierney suggesting that a care plan may be useful for activities of daily living with the patient communication. The reason being I felt that the problem of anxiety caused by the terminology and the surroundings was not helping the patient’s situation.
I wanted the patient to have a full explanation and understanding, to be able to express his own worries and anxieties. Communication can include a whole variety of barriers as described in nursing models in action (Newton. C, 1991, 15) “subjective feelings, attitudes, anxieties and pain are all communicated, verbally or non-verbally, consciously or sub-consciously. So pain as a problem is included under communication”. Identifying some legal issues that are relevant to the patients care are always important.
The legal issue related to the patient is “confidentiality” making reference the Data Protection Act 1998 (DPA, 1998) and how this may shape or determine the patient’ experience. “DPA 1998 is an Act of Parliament, which defines the UK law on the processing of data on identifiable living people” (HSCO 1998). This also encompasses the (NMC The Code 2008) when referring to confidentiality “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. ” This comes into reference when the patient asked me not to disclose information about the episode of care. I made sure that the right documentation of the incident and what was said was in the patient notes and that it would be handed over to other staff. Clinical evidence of risk of angina which was the reason the patient was admitted summarized in (Fleming. M 2005, 21) shows a parallel between the patient and also research. Risk factors for CHD are age, sex, ethnicity and family history. When focusing on the psychosocial impact of angina I came across the idea of personality, stress and psychosocial factors including risk factors, aetiology and also epidemiology. Within the written text of Angina Pectoris in clinical practice (P. Scholfield, 1999, 7) “hostility, mental strain at work, negative life events and lack of social activities independently increase the risk of myocardial infarction” this is a psychosocial factor which can relate to the patient where research can provide the basis for health promotion.
I talked to the patient, after the episode occurred on a one to one, I assessed the episode themselves drawing on the ideas of “how the nurse and I was caring and helped him during that night”. I made clear that the episode can be prevented and the patient agreed that changes need to be made in the fact that he described it as a “wake up call”. I started providing health promotion using evidence based practice. The Patient agreed and believed that this is the best option so even though the episode of care occurred at an earlier date objectives were still coming from it.
I did provide information for smoking cessation as described in angina pectoris in clinical practice (P. Scholfield, 1999, 7) it described “there is no doubt that smoking particularly cigarette smoking, is associated with an increased risk of myocardial infarction”. Care for patients can always be improved upon when considering influences for example with this client using the (National service framework 2000) “People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events”.
In the essence of this episode the nurses and myself made sure this was possible, this is by using a systematic approach as referred to in the above reference “assessing and investigating people suspected of suffering from angina . providing and documenting the delivery of appropriate advice and treatment, and also offering regular reviews to people at high risk of CHD. ” This care was produced in reference to government guidelines and used to improve on the care of this patient during this episode. Conclusion I will now briefly summarise the episode of care drawing out the main points.
I believe the care given was of a standard which adhered with national service frameworks, with research and with the code of conduct using a professional standard. This is identified by the use of the (Nursing and Midwifery the Code 2008). Consent and confidentiality were a valid point, with this certain episode of care as well as adhering to the code itself. The care was given using the nursing process. Which as described “consists of continuous assessment, planning, Intervention and evaluation and these were used during the care”. A, Margret, 2006, 1108). This was used to assess the patient and their symptoms and how they are psychologically. The pain the patient was feeling and the observations were key in the care of this patient to help with the relief of the pain and also the patient being assessed correctly and to help with further diagnosis using the ECG machine.
“Acknowledgment of my own limitations and abilities were key” in accordance with the (NMC the Code 2008) “You must recognise and work within the limits of your competence. By doing this I and the team provided the patient with comfort and care in the best way. ACTION PLAN The care given was of a high standard but recommendations and improvement are always in the best interest for the care of the patient and clients and also the nursing staff. I think the care of this patient was individualised but the idea of talking to the patient does sometimes get over seen. “National benchmarks for communication require that communication needs are assessed and appropriate methods are used to enable patients and carers to communicate effectively.
Information that is accessible, acceptable and accurate, and that meets patients’ and clients’ needs, should be shared actively and consistently. Staff should communicate effectively with each other to ensure continuity, safety and quality of Health care for all” (DH 2010a), with communication between patients and staff alike. The care in this episode has shown me the need for communication and the need for a good relationship with the patient with this being as important as the medical needs and both can be very similar.