The following assignment will aim to reflect upon the development of clinical skills throughout a three year interprofessional learning programme (IPLP). The skill focused upon in this assignment will be respiratory rate it will be analysed using an incident from practice where the assessment and management of a patient who is acutely unwell took place. The assignment will use Gibbs reflective cycle Jasper, M. (2003) to allow a structured focus and effective analysis of the development of this clinical skill. The following incident takes place on a twenty two bedded elective surgical orthopaedic ward.
To adhere to the Nursing and Midwifery Council the code: standards for conduct, performance and ethics for nurses and midwifes (2008) which states that all information must be kept confidential, therefore the patient depicted within this assignment shall be referred to as Vikki. Vikki is a sixty-eight year old woman who has had a total hip replacement athroplasty one day ago following a diagnosis of osteoarthritis several years ago. Prior to surgery Vikki's hip had caused severe disablement and had impacted greatly on her daily living activities. According to Adams and Hamblen (2001) a total hip replacement athroplasty is when the femoral head is excised and replaced with a metal prosthesis.
Description of Event:
It was a usual day on the ward; I was once again responsible for six post-operative patients under the supervision of my mentor. On observation Vikki seemed to be having difficulty in breathing and was sitting in an upright position looking very distressed. The second observation that I made was Vikki was tachypneaic. Vikki was using her accessory muscles to breathe and was complaining of a stabbing chest pain. I collected an electronic monitoring machine and started to record some of Vikki's other vital signs. Vikki's respiratory rate was 30, a pulse oximetry revealed an SpO2 of 86% on air which shows Vikki to be suffering with hypoxemia, Vikki's blood pressure reading was 94/48, Vikki was also tachycardic with a reading of 126 beats per minute.
I immediately put Vikki on 40% oxygen which had already been prescribed by the doctors to increase her oxygen saturations. I checked with my mentor the procedure to fast bleep the doctor; I quickly went to the phone and fast bleeped the doctor and relayed the basic information regarding the patient, their current condition and vital observations. He informed me that he would be up immediately and to complete the ECG prior to his arrival on the ward. After I had spoken to the doctor I informed my mentor about the situation and then returned back to Vikki to complete an ECG with assistance from my mentor.
When the doctor arrived on the ward he examined Vikki and took some blood to test urgently. He also ordered a portable chest x-ray. Once the results were back from the investigations the doctor ordered a spiral Computed Tomography (CT). The spiral CT confirmed that Vikki had suffered a massive pulmonary embolism (PE) and then underwent urgent treatment in the form of thrombolysis. Vikki's vital sign's had to be closely monitored afterwards to ensure a smooth recovery and to notice any early warnings of further deterioration. The treatment for Vikki's PE was successful and she survived the event. Once this incident had been concluded with a successful result my mentor and the doctor congratulated me on my quick thinking and efficiency under pressure.
Initially, my feeling on encountering this incident was fear for Vikki and how she must have been feeling. I did not feel panicked at the beginning of the incident I knew what I had to do, however I started to panic slightly when waiting for the doctor to arrive as it felt like an eternity, as my concern for Vikki's safety grew.
I felt happy with the outcome of the event and that Vikki survived. When I was congratulated for my reactions to the incident presented before me I felt successful and more confident that I will be able to handle emergency situations in future.
Evaluation and Analysis:
On evaluation, it is evident that there has been a development in clinical skills. During the first year of the IPLP the student would have noted the patient's respiratory rate noticed it was high using the Modified Early Warning Trigger (MEWT) and informed the nurse on duty without knowing what it meant or how else to act upon the data presented. This may have caused a delay in the necessary treatment for Vikki which could have been fatal. However, Evans and Tippins (2007) state that research suggests that health professionals often also fail to interpret or act upon the assessment data presented to them. This has also been noted within the consultation document Competencies for recognising and responding to acutely ill patients in hospital (Great Britain. Department of Health, 2008) who noted that recognition and response to patient deterioration by staff is delayed and sometimes even inappropriate. Consequently, the National Institute for Health and Clinical Excellence (2007) have created guidelines to assist health professionals on the early recognition and effective responses to the acute illness of adults in hospital settings.
Within the third year of study the student knows when observing respiratory rate that a great amount of knowledge can be gained about the patient through one minute's worth of observation. According to Jevon and Ewens (2007) respiratory rate can be the most useful sign to show that breathing has been compromised. However, Simpson (2006) states that respiratory rate is not a definitive diagnosis and further thorough and systematic respiratory assessment is needed. Jevon and Ewens (2007) also concur with this statement and themselves state that a look, listen and feel assessment to breathing is needed to detect signs of respiratory distress or inadequate ventilation.
Evidence for the healthy respiratory rate seems to be very standardised the Resuscitation Council UK (2008) state that the normal rate for a health adult is between twelve and twenty breaths per minute. Furthermore, Cretikos, Bellomo, Hillman, Chen, Finfer and Flabouris (2008) state that an adult with a respiratory rate of over twenty breaths per minute is probably unwell. An adult with a respiratory rate of over twenty-four breaths per minute is likely to be critically ill. Within the third year of training it is now acknowledged that these changes in rate signify problems within the health of a patient. However, it is not uncommon in the elderly for rate to increase above these normal parameters as gaseous exchange is impaired with age within the alveoli (Francis, 2006).
As a first year nursing student respiratory rate was counted for fifteen seconds and then multiplied by four. Within a systematic review The Joanna Briggs Institute (1999) found that a fifteen second count period compared to the full one minute count period when measuring respiratory rate found significant differences between the outcomes in rate. Now as a third year student a full one minute count is always completed to assess the patient's respiratory rate.
An article by Hogan (2006) states that in many cases respiratory rate is not completed by nursing staff when assessing patients and was recorded less than 50% of the time on general wards. This means that insufficient information is gathered to successfully complete the MEWT scoring system. As a first year student it was observed that respiratory rate was often omitted on the MEWT chart so occasionally the student also omitted the information. A further article by Butler-Williams, Cantrill and Maton (2005) shows that during their study nurses and other health care workers do not see respiratory rate as a vital sign so therefore often omit the information.
Through varying placements and theoretical knowledge gained the student now realises that respiratory rate is indeed a vital sign and now always completes a full one minute respiratory rate assessment on a patient. The National Patient Safety Agency (NSPA) (2007a) completed a report on the necessity for completing all assessment criteria on the MEWT chart especially respiratory rate to detect vital changes in health for the prevention of unnecessary deaths within hospitals. Another report by the NSPA (2007b), state that there were an unacceptable amount of deaths within the United Kingdom because of the insufficient monitoring of patients vital signs. These reports have reiterated the need for the recording of respiratory rate within the student's current and future practice.
Benner (2001) and the Dreyfus model of skill acquisition shows that in relation to the incident described above the student has progressed through the stages of one: beginner to the current stage of two: advanced beginner within the current training. However it is noted that to continue progressing through the stages according to Stuart (2007) the use continuous use of assessment of clinical practice and skills should be drawn upon to enhance learning and similar situations and incidents need to be experienced.
To conclude, it is evident that there has been a great development of clinical skills in relation the assessment and management of an acutely unwell patient. The student can now see the progression of skills throughout the IPLP and the necessity for a holistic assessment. There is an obvious link between the practice and theory elements of the course in relation to the assessment and management of the acutely ill patient.
On encountering this situation again I will proceed to do everything the same although a slight of time was lost confirming the procedure to fast bleep the doctor. Next time I will ensure that I know all the emergency and routine telephone procedures for all the hospitals. To ensure a more efficient assessment on next encountering a similar situation an ECG may need to be completed prior to contacting the doctor to provide a more holistic view of the patient's current situation. However, I have learnt that this is not a situation I am ready to deal with independently and should continue to request help from a more senior member of staff who can give me guidance on the patient, their condition and the management plan that needs to be implemented.