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Monday, May 4, 2020

Critical Incident Pressure Area Near Miss free essay sample

Some key information missing in introduction conclusion. 3-5 Detailed and focused introduction conclusion. 6-8 Well developed introduction conclusion. 9-10 Very well developed comprehensive introduction conclusion. BODY0-2 Description of event lacked some major detail. 3-5 Descriptions of event mostly clear, but some detail lacking. -8 Clear description of event. 9-10 Very clear and succinct description of event. 0-4 Relevant legal and/ or ethical issues only briefly / not described. Critical analyses of issues poorly / not attempted. Arguments not/ inadequately supported by appropriate literature. 6-10 Relevant legal and/ or ethical issues described. Critical analyses of issues attempted. Arguments supported by appropriate literature. 12-16 Relevant legal and/ or ethical issues well described. Sound critical analyses of issues evident. Arguments well supported by appropriate literature. 18-20 Relevant legal and/ or ethical issues comprehensively described. In-depth critical analyses of issues evident Arguments well developed and thoroughly supported strengthened by appropriate literature. 0-4 Relevant ANMC or ACORN Competencies or standards only briefly / not described. Critical analyses poorly / not attempted. Arguments not/ inadequately supported by appropriate literature. 6-10 Relevant ANMC or ACORN Competencies or standards described. Critical analyses attempted. Arguments supported by appropriate literature. 12-16 Relevant ANMC or ACORN Competencies or standards well described. Sound critical analyses evident. Arguments well supported by appropriate literature. 18-20 Relevant ANMC or ACORN Competencies or standards comprehensively described. In-depth critical analyses evident. Arguments well developed and thoroughly supported strengthened by appropriate literature. 0-4 Recommendations not included/ only briefly described/not supported. 6-10 Recommendations included however more support or description needed. 12-16 Sound, relevant recommendations described. 18-20 Very clear description well argued support of relevant recommendations. Some (5-6) grammatical spelling errors. 6-8 Followed academic presentation requirements. Few (2-4) grammatical spelling errors. 9-10 Good structure and adherence of academic presentation requirements. No grammatical or spelling errors. Total: /100 /30% INTRODUCTION. In this assignment on critical analysis I will present a clinical incident and discuss and analyse a critical incident in detail utilising a critical incident tool (CIT). This incident I have chosen occurred during an operative procedure. I will discuss the incident as I proceed through the steps outlined in the critical analysis tool. I will present a brief overview of the incident before commencing my analysis. I will discuss the importance of a critical analysis and why they are important to nursing practice. I will also discuss the incident in terms of standards, guidelines and legislation. I will outline 4 recommendations for improvement to my practice. I will finish with a conclusion and a look forward to the future of pressure injury care in Australia. Incident The patient was a 12 year old male child undergoing and emergency open reduction and internal fixation of a right wrist fracture. The child was positioned in the supine position. The procedure was a difficult fixation and done by a registrar so was somewhat longer that the usual time taken to undertake this procedure. No names will be used to protect patient confidentiality. Due to the positioning the patient sustained a near miss pressure injury. The near miss and resultant tissue injury was not discovered until the procedure was completed. I will discuss this incident in full as I proceed through the critical analysis. Critical Analysis The purpose of undertaking this assignment is to look at this incident in more detail, and delve into the nursing obligations and duties owed to our patients. It has encouraged me to think more globally and think the issue through in depth. I have found I have had to consider the foundations that underpin my nursing practice. Critical analysis utilises a framework or a methodology to formally process and incident or significant event. The event does not have to be â€Å"critical† or even have a significant adverse outcome to be viewed as a critical incident. I have included the following definitions in relation to performing a critical analysis and what it hopes to achieve for the practitioner. Schluter, 2007), â€Å"The CIT is a practical methodology that allows researchers to understand complexities of the nursing role and function, and the interactions between nurses and other clinicians. † (p113). This is expanded in definition by (McClure ND) who defined reflective practice learning experience as follows, â€Å"To maximise learning through critical reflection we need to contextually locate ourselves within the experienc e and explore available theory, knowledge and experience to understand the experience in different ways. † (para 7). A critical incident is an event that is usually remembered by the participant as important or used as a learning tool for the purpose of reflection. (Daly, Speedman, Jackson,. 2010). The Australia Nursing Midwifery Council (ANMC) states the following about critical thinking and analysis, â€Å"This relates to self – appraisal, professional development, and the value of evidence and research for practice. Reflecting on practice, feelings and beliefs and the consequences of these for individuals/groups is an important professional benchmark. † (p. 2). Also under the ANMC competencies nurses have a duty of care to their patients to that complies within the current legislation governing nursing practice. I am using the following incident analysis from (Services, 2009) which is heavily based on work by Crisp, Green Lister and Dutton (2005) . 1. Account of the incident The incident I am going to discuss did not get discovered until we were taking down the drapes and getting ready to transfer the patient onto the bed. During the procedure I was the scout nurse in the theatre. Once the drapes were removed, I noticed the child’s left foot was crossed on top of his right foot. This resulted in the calcaneal part of his heel came to rest on the top part of the bony section of his right foot. I could immediately see a round red area on the top of his right foot that resulted from pressure from his heel. This was a direct result of the pressure of his foot over the duration of the procedure. The procedure was a difficult fixation and done by a registrar so was somewhat longer that the usual time taken to undertake this procedure. Once I discovered the incident my focus was to assess the injury and treat it appropriately. I pressed the skin involved and the red area from the pressure was blanchable, but slow to respond. I think had the pressure from his upper foot had been applied any longer this would have developed into a stage one pressure area. I rubbed the affected area to help restore circulation and checked the heel of the foot that was resting on the top of the right foot. I gave the patient a warm blanket to help achieve normothermia, reported and documented the injury. I also completed a prime incident report. 2. Initial responses to the incident When I discovered the incident, I felt a sense of failure that I had not noticed the crossed leg under the drape. I felt I had let our patient down whilst caring for him in the operating room. I also felt my colleague was unmindful of the ramifications of what a pressure injury that develops into a stage one pressure ulcer would involve for this patient. I felt we owed a duty of care to the patient to administer appropriate treatment, timely intervention and report the injury to the surgeons. I had assumed everyone would be of the same mind in relation to this incident. 3. Issues and dilemmas highlighted by this incident Under the ANMC competencies there is an ethical nursing framework that exists to govern ethical nursing practice. One area of ethical consideration during this incident was when I pointed out the scrub nurse this injury to the patient. She stated to me that the positioning was correct at the beginning of the case, so there was nothing that we could do about the injury occurring. Under the ANMC framework to â€Å"maintain an effective process of care when confronted by differing values, beliefs and biases. † I myself did not witness the patient position prior the draping, so I can’t say I noted the patient’s position. The staff member was very senior to me and have a forceful personality. I felt quite uncomfortable during the time that we discussed the patient injury. I felt the person who was with me felt as if there was blame being allocated, which for me was not the case at all. I wanted to notify her of the patient’s injury as I would like to be if I were in the same position. I also felt she was being dismissive of the patient’s injury. I notified the surgeon and documented this in the nursing notes. I also communicated the injury with the recovery staff. Under civil legislation we owe the client a duty of care in all aspects of the care we provide. 4. Outcome The patient was very fortunate not to develop a stage one pressure injury. Due to the state of the tissues when I found them I have no doubt that another 20 minutes or less would have resulted in a pressure injury for this patient. This is why I have used it as a critical incident. It was such a close call for a patient who was so young with no other co morbidities. Had he not been well nourished and in good health, I am certain this would have resulted in a pressure injury. Due to this incident I have changed how I practice in the surgical setting in regard to monitoring and correcting patients positioning. I feel I am more vigilant in regard to positioning. As I have processed this incident through critical analysis and reflective practice I think I have come to terms with the incident a little better. I have gained a better understanding of my role in this incident, and have developed as a practitioner to help other patients so they are better positioned to decrease the likelihood of developing a pressure injury. I have also increased my knowledge base about pressure injuries significantly, and continue to learn about them in the peri-operative environment. I think this incident served as an excellent learning experience to help prevent similar injuries in others. 5. Learning A recent survey has been collected and published by AORN, (Steelman, Grayling Perkhounkova 2013) found during a survey of peri-operative nurses that preventing pressure injuries was the 5th most important priority safety issue they were concerned about. When they divided it into settings, hospital based nurses rated it as the third most important safety issue. They also found there was no purpose built valid tool to conduct risk assessments on patients in the peri-operative environment. They also found limited resources to help nurses prevent pressure injuries. (Mahan, P. 2006) defines a pressure ulcer (now known as pressure injury) as â€Å"any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually located over bony prominences and are graded or staged to classify the degree of tissue damage observed. † (p. . ). (Mahan, P 2006) stated in relation to pressure injuries, that â€Å"prompt and effective treatment can minimise the deleterious effects and speed recovery. † (p. 6) (Baron McFarlane 2009) identified that staff felt that pressure injuries were uncommon in the operative setting. However due to surgical techniques improving and becoming increasingly complex, op erating times were lengthening. They found that injuries could occur in a one to four hour time frame dependent of the patient’s condition. They also found due to specific environmental reasons the operative environment contributed to this risk. This was due to general anaesthesia, anaesthetic agents that decreased perfusional status and body temperature. When relaying incidents and other issues found postoperatively I will continue to maintain a calm, non judgmental response. I will be more forward when a staff members seems to find this confronting and discuss the issue with them at and appropriate time and find out why they reacted the way they did. I have found 4 recommendations for improvement that I can undertake to help prevent pressure injuries. 1)Educate staff on what a pressure injury is and how to prevent them. This would also highlight patient risk factors, important co morbidities and the importance of patient positioning. There are two online options for this education. These had the added benefit of accruing CDE points, and all staff can undertake the education when they are able. https://members. nursingquality. org/NDNQIPressureUlcerTraining/https://members. nursingquality. org/NDNQIPressureUlcerTraining/ http://www. health. vic. gov. au/pressureulcers/education. htm 2) Use a patient positioning time out prior to draping involving all team members. This does not have to be formal, and is a quick and easy check prior to draping to ensure the patient is correctly positioned prior to draping. It is important to involve other staff members from all disciplines as pressure injuries occurs both in the anesthetic and surgical arena. This also incorporates all elements of the ACORN standard on peri-operative positioning. Advocate for the use of pressure relieving devices on all patients, regardless of age, co morbidities or skin condition. Even young well people are at risk of pressure injures. Conduct and document a baseline skin assessment, and continue to monitor the status of the patients skin, documenting any issues. The Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury suggest a number of tools for the use in children, and there is good evidence to support the use of three of the tools 3)Ensure patient is warm and all warming devices are used appropriately. Pressure injuries can result from heavy blankets. So I would ensure the patient has one warm blanket and a forced air warmer insitu. There is good evidence to link pressure injury prevention and normothermia. If the patient is normothermic the risk of pressure injury is decreased. (Fred, Ford, Wagner VanBrackle, 2012) As a result of this incident I am more aware of the Australian College of Operating Room Nurses Standard (ACORN) on Patient Positioning. (ACORN 2012-2013) states, â€Å"Safe positioning for, and during, surgery and in the immediate postoperative period minimizes the risk and prevents unnecessary surgical complications. † and also â€Å"The positioning shall not compromise the patients respiratory and cardiovascular function, or cause damage to the nervous, muscular and integumentary systems. Future learning needs. I believe I need to educate myself on patient positioning for all types of surgery. I also need to maintain currency in the latest evidence based practice on pressure injuries and pressure relieving devices. Due to the governments policy on pressure injuries and the financial penalties health care facilities face, I think all nursed will need to make this a priority learning goal. I also need to learn more about anaesthetic agents in greater detail. It was not until I undertook this assignment that I realised the uge impact they have on a patient and there risk of a pressure injury. (Walton-Greer, P. 2009) discusses the impact anaesthesia has on the patient in relation to pressure injury. Due to pain receptors being blocked, depression of the autonomic nervous system and the vasodilatory effect of the anaesthetic agents the all have a cumulative affect on the risk of developing a pressure injury. She also found that patients having a spinal or epidural anaesthetic were more at risk. I am also going to complete the pressure injury education components as per recommendation one in this assignment. As a department we need to explore a risk assessment tool for use in the theatre for patients who do not have one already completed. The health care facility uses the Waterlow scoring system. It is part of the ACORN standard S12 criteria 1. 3. This standard also states that nurses â€Å"demonstrate a competent knowledge of the aetiology of pressure sores’ and (ACORN) statement 3, states that nurses â€Å"appropriately use a risk assessment tool and preventive screening positioning techniques based on evidenced based research† (p. 3). CONCLUSION In conclusion I think that pressure injuries are a priority area for nursing care and active preventative measure should be instituted in all surgical patients. Nursing staff should work as a team to ensure the patient is positioned well, and given appropriate follow up care. It should become standard practice to conduct a skin assessment on admission to a hospital facility, and if one has not been done, it should be conducted if practicable by the theatre nurse. At the end of my conclusion I will include a look forward for what in will mean to hospitals if patients acquire a pressure injury in their care. I personally will conduct a patient positioning time out prior to draping to ensure the patient is correctly positioned and had the correct pressure relieving devices in place. I will also explore my future learning needs as outlined in my assignment. All issues surrounding patients need to be communicated clearly and in a calm and non judgmental way, they also need to be documented as per hospital policy. Looking Forward. The Australian government has instituted a policy where Health Care Facilities will be fined under a punitive system on each pressure injury that occurs in a facility. This money will be taken from the operative budget of the ward/ unit in which the pressure injury occurred. I personally think this will have a detrimental affect on health care. There are other models in which you a financially rewarded for preventing pressure injuries. Injuries need to be documented within 6 hours of admission or otherwise a financial penalty will result whether the injury occurred within the facility or not. This will be important to theatre nursing staff who are treating trauma patients and critically ill patients who are admitted to their unit after presentation to the hospital.

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