JR is a 56 yo man with h/o asthma, HTN and hyperlipidemia. He presents to the ER today with h/o shortness of breath for 45 minutes at rest. He reports that he was feeling well and in his usual state of health until about an hour ago, when he smelled something burning. 20 minutes later, he began to feel short of breath and was wheezing. He tried using his albuterol inhaler without success, so he proceeded to the ER. Upon arrival, he was tachycardic, tachypneic, wheezing, using accessory muscles and hypertensive. His last admission for an asthma attack was 2 months ago. He denies a recent cold or URI and says the albuterol usually helps him when he feels an attack coming on and tends to use it on a daily basis. He generally has wheezing and shortness of breath on a daily basis. JR reports poor sleep due to waking about 2 times a week for shortness of breath. He has 2 cats, which sleep next to him on his pillow and he lives in an apartment complex. JR does not smoke, but his neighbor smokes. JR is a carpenter by occupation. He monitors his peak flow once a week at home. He reports that his peak flow generally runs about 325 L/min and his personal best is 480 L/min. His current peak flow is 175 L/min.
Medication Prior to Admission:
Albuterol MDI 2 puffs BID-QID PRN
Salmeterol Diskus 1 inhalation QID
Ipratropium bromide MDI 2 puffs QID
Lovastatin 20 mg po HS
Lisinopril 10 mg po QD
Below Is A Sample From Our Expert Writers On A
Clinical Practice Occurrence Investigation.
Throughout this piece,
I will use Gibbs’ (1988) reflective cycle to critically explore and analyze an
incident that occurred within clinical practice that has had an impact on my
learning and development. The use of Gibbs’ cycle will facilitate reflection by
identifying feelings which could have influenced my practice, recognizing
strengths and weaknesses of my performance and exploring what impact this had
Reflection is an integral aspect of Nursing as it promotes ongoing professional
development by exploring the impact of personal practice on quality of care
delivery (Kiron et.al., 2017). The focus of this reflection
will be how communication was adapted when caring for a patient with Dementia.
This area of practice has been selected as the focus of this piece as
Handley et.al. (2017) highlight that an ageing population and
reduction in social care services have resulted in a higher prevalence of
patients with Dementia being treated in hospital. It is essential that
practitioners adapt their practice to facilitate effective communication as
this is one of the fundamental principles of delivering high quality care -
particularly for patients with diverse needs (Murphy and Maidens, 2016).
In concordance with the Nursing and Midwifery Council’s (NMC, 2015: The Code),
all of the names of the people involved have been changed and the location of
the placement has been omitted. The patients name has been changed to Margaret
and my mentors name has also been changed to Helen.
I received a handover
at the beginning of my shift and was informed that a new patient was due to be
admitted from the community following a fall with a suspected urinary tract
infection (UTI). Upon arrival, Margaret appeared confused and was not orientated
to space or time. She was verbally angry towards staff who were transferring
her and was visibly distressed. We were informed in the handover that seven
months ago, she had been diagnosed with Alzheimer’s Disease
and that they believed the current presentation of signs and symptoms of
Dementia were being worsened by a untreated UTI. To ensure all staff within the
multi-disciplinary team (MDT) were aware of Margaret’s condition, the
‘Butterfly Scheme’ was implemented whereby a logo was situated at her bed station
to identify that Margaret had Dementia. This is designed to highlight to other
staff that Margaret may need care adapting due to her condition.
Effectively communicating with patients is a fundamental part of the Nurses
role and Fakr-Movahedi et.al. (2016)
highlight that when there are barriers to communication, it is essential that
practitioners adapt and overcome this to ensure quality of care isn’t
diminished. How myself and Helen adapted communication will be one of the main
focus points of this piece as this was instrumental to delivering
Admittedly, I was
somewhat apprehensive when witnessing how disorientated Margaret was when she
was admitted onto the ward. I was aware that staffing on the ward that day had
been reduced due to sickness so was concerned that she would not receive care
in a timely or safe manner as she was visibly distressed upon admission and
would require additional support to meet her individual needs.
However, I was reassured by Helen’s calm approach and felt confident that I
could learn from her experience of nursing patients with Dementia before, as I
was aware she had a specialist interest in this area. I was also determined to
provide person-centered care for Margaret and was eager to learn different ways
of adapting communication to facilitate care delivery and meet her specific
A strength of this
incident was that throughout Margaret’s stay in hospital, staff were made aware
using the Butterfly Scheme on her name board that she was exhibiting signs of
Dementia and that communication and care may need to be adapted. This improved
awareness and communication between staff and it was visible to see that in
most cases, Margaret’s care was adapted to suit her needs because of this
Another strength of this situation was that Helen had a lot of experience and
skills already in adapting care for people with communication difficulties.
This meant that I was learning Nursing skills that were consistent with
evidence-based, best practice guidelines that would enhance care. I was
grateful to have the opportunity to observe how Helen interacted with Margaret
as I recognize that I learn effectively from a vicarious approach –
particularly as Helen was a role model for me within practice.
However, I did notice that at times due to staffing, communication appeared
rushed when on the ward round and this negatively impacted Margaret. Witnessing
the distress this caused her emphasized the importance of adapting
communication more so and also reminded me of the importance of using nonverbal
communication to convey warmth and empathy. When Helen and I communicated with
Margaret, we ensured that our nonverbal cues emulated Egan’s ‘SOLER’ principles
which are designed to convey active listening and open-ness. We found that
using non-verbal cues like maintaining eye contact and touch helped us convey
warmth and care to Margaret which also seemed to soothe and reassure her.
I also noticed that Margaret became particularly distressed when she was asked
questions with medical jargon. Despite alerting all staff on the ward round of
Margaret’s condition, it was disappointing that not everyone adapted their
practice to make Margaret feel more comfortable and settled as the use of
medical terminology clearly exacerbated Margaret’s sense of unease.
Overall, communication was adapted to meet Margaret’s needs the majority of the
time. The use of nonverbal cues when conveying information certainly enhanced
the therapeutic relationship and reduced Margaret’s anxiety whilst staying on
the ward. However, observing others communicating with her, typically on the
ward round highlighted that the use of medical terminology was detrimental to
her care delivery and that this approach caused considerable distress.
As a nationwide
initiative, the Butterfly Scheme was implemented in accordance with the NHS
Improvement guidelines for Dementia assessment and improvement framework (2017)
and in this instance was recognized most of the time. Early recognition and
transparency amongst staff aware of the Butterfly Scheme meant that Margaret
was given more time to communicate by people who recognized her as experiencing
Dementia. In these instances, her care dramatically improved and she was more
involved in making decisions about her care and exhibited less anxiety and
stress. However, as not all staff recognized this scheme and didn’t adapt their
communication or practice to suit Margaret’s needs, this highlights the need
for further training with staff and improved communication on the ward. Fetherstonhaugh, Tarzia and Nay
(2013) emphasize that patients with dementia often report feeling excluded from
making decisions about their care which contradicts the vision outlined in the
NHS Constitution (Department of Health and Social Care, 2015) to provide safe
and inclusive care to all patients.
Bandura’s (1977) social learning theory, I identified early on that I learn
most effectively through vicarious reinforcement so it was an incredibly useful
experience to observe how Helen interacted with Margaret in practice. As I also
identify similar personality traits to Helen, I believe this strengthened my
learning as I noticed myself modelling my behavior on her practice that I had
witnessed. This is something I will ensure I remember for future placements as
a student but it is also an aspect of teaching I will be aware of when
mentoring staff in the future as my career progresses.
Using Egan’s (1975) ‘SOLER’ principles proved to be effective when conveying
information to Margaret as it complimented a warm approach that was used by
myself and Helen. Use of therapeutic touch put Margaret at ease and Stonehouse
(2017) highlights that this can be a very useful approach to enhance trust and
rapport in the therapeutic relationship – particularly for patients with
dementia as there sensory perception can be altered.
Macdonald (2016) highlights that use of medical jargon can impede the
therapeutic relationship which was observed in Margaret’s case. It is essential
that patients are involved in making choices about their care to promote
empowerment, dignity and respect (Truglio-Londrigan
and Slyer, 2018). Farrington (2011) states that the use of medical terminology
can intimidate a patient and prevent them from feeling included in care
provision; diminishing empowerment and reducing the quality of their care.
Whilst Helen and I ensured that our terminology was appropriate for Margaret’s
needs, not every member of staff did which caused her considerable distress at
times. Furthermore, as Margaret had dementia, it was essential that
communication was adapted to suit her needs as Ellis and Astell (2017)
emphasize that this will enhance quality of patient care and promote safety and
transparency between staff and patients by ensuring that staff continue to act
within her best interests.
To increase my
understanding of Dementia, I will complete online training to learn more about
the condition and what the best practice guidelines are when caring for someone
with dementia. I think this will benefit my practice by allowing me to become
more aware of how to deliver safe and effective, person-centered care for an
individual with complex needs. To ensure this can be achieved by my next
placement, I will complete the online training within the next four week and
submit the completed certification as proof of Continuing Professional
To further enhance my Nursing skills when caring for patients with Dementia, I
will shadow a Specialist Alzheimer’s Disease Nurse to learn more about the
condition and how best to adapt care to the individual needs of a patient. I
intend to complete this within three weeks of my next placement as this will
also contribute to my Continuous Assessment of Practice (CAP) document and help
me achieve one of the Specialist Nurse professional learning logs.
Using Gibbs’ (1988)
reflective cycle, I have explored my experience of adapting communication for a
patient admitted onto the ward with Dementia. It has been essential to evaluate
this incident as effective communication is a core principle of the Nurses
role. Furthermore, adapting communication to suit the patients’ needs is an
integral part of compassionate, person-centered care and can enhance the
individuals’ experience of receiving care.
Due to an ageing population, nurses are caring for more people with Dementia on
busy hospital wards. This piece has shown how essential it is that the approach
to care is adapted to the individuals’ need to reduce distress and enhance their
quality of care. Implementation of the butterfly scheme was helpful to a degree
in this particular scenario but I also recognize that not all staff adapted
their practice because of this. This piece has demonstrated the complexity of
delivering care for a person with a communication difficulty and highlights
that provision of care is largely influenced by personal attitudes and beliefs
towards care delivery.
This piece has
illustrated the importance of not using medical jargon when communicating with
patients, particularly those with Dementia as this could exacerbate confusion
and cause distress. It also highlighted how essential non-verbal communication
cues were when conveying information but also when reassuring the patient.
Overall, I feel as though my initial reluctance and apprehension of taking
responsibility for Margaret’s care provision soon diminished with the support
of Helen. I recognise from this experience that I
learn most effectively through vicarious learning and will be sure to replicate
this in future placements and later in my career when I become a mentor to
other staff. Reflecting on this experience has been incredibly valuable
to my learning as I have recognized areas of work that require development as
well as elements of practice I feel more confident in. I believe that this
incident demonstrates that I can practice safely and effectively, whilst
ensuring that the patient remains at the heart of care delivery and that their
care is enhanced through adapting practice to suit their needs.