Developing Care Plans: Clinical Reasoning And Prioritization In Nursing Essay.

Activity 1: Collecting Cues During Handover

ACTIVITY 1 You are working on the morning shift on the ward, and receive a patient from ED. The ED nurse provides you with the following handover, using the ISBAR format. Further information about the ISBAR format can be found on page 7 of this module. Please click on the handover link in LEO within Module 3 section, titled: ‘Module 3 Activity 2 Verbal Handover’. Listen to this recording, and then please answer the following: 1. What further questions will you need to ask the nurse? 2. List specifically what further assessments you would complete when the patient arrives onto the ward 3. Upload the above answers to your e-Portfolio on LEO. This forms part of your assessment for this unit.

This activity demonstrates how you have started collecting cues during handover. After handover as graduate nurses you will most likely develop a care plan. The development of a care plan is a way of processing the information that you have collected during handover to ensure you adequately manage your time in relation to the care you think you will need to provide. It is important to acknowledge that this care plan can often change, as you need to reprioritise care, which is similar to the second activity we undertook in the “ward for a day” simulation. Whilst you start to process information you will also start to think about cues that you are missing and where you can gather this information.

Assessing the patient’s chart, communicating with the patient and their family or even increasing your patient assessment are some of the ways in which you will achieve this. During the phase of processing information you are also starting to work out what is relevant information as opposed to information that is irrelevant to the situation. The Clinical Reasoning Cycle can provide a framework for you structure your thought processes and ensure you can link the knowledge that you have obtained during your undergraduate degree to the clinical context in which you will be working as a graduate nurse.

ACTIVITY 1 You are working on the morning shift on the ward, and receive a patient from ED. The ED nurse provides you with the following handover, using the ISBAR format. Further information about the ISBAR format can be found on page 7 of this module. Please click on the handover link in LEO within Module 3 section, titled: ‘Module 3 Activity 2 Verbal Handover’.

Listen to this recording, and then please answer the following: 1. What further questions will you need to ask the nurse?

2. List specifically what further assessments you would complete when the patient arrives onto the ward

3. Upload the above answers to your e-Portfolio on LEO. This forms part of your assessment for this unit. ACTIVITY 2 To understand more about the Clinical Reasoning Cycle please read chapter 1 of the prescribed text. Whilst reading this chapter identify ways that you can incorporate the Clinical Reasoning Cycle into your clinical placement. Levett-Jones, T. (2013) Clinical Reasoning: Learning to think like a nurse, Frenchs Forests, NSW: Pearson.

Activity 2: Incorporating the Clinical Reasoning Cycle

Please read the article by Felton (2012). While you read the article take particular note of how important it is to take accurate vital obs, and how your thorough assessment can have a major impact on the patient’s prognosis. Felton, M. (2012). Recognising signs and symptoms of patient deterioration. Emergency Nurse, 20(8), 23-27. Activity 2 : continued 3 Development, implementation and evaluation of planned care based on assessment findings Once you have completed all your assessments, it is then time to re-evaluate a plan of care for your patient. Most nurses will have a patient load of 4 or more patients, and it is essential you learn how to prioritise your time effectively in order to provide safe and quality care. Things change quickly in healthcare environments, and you need to learn how to be flexible.

Therefore, the ability to prioritise and delegate are essential skills for nurses, and with time and experience you start to improve these skills. Student and graduate nurses can quickly feel overwhelmed and overloaded when they are required to care for a full patient load, and their time management may suffer as they learn how to juggle different tasks and responsibilities. Wentworth (2003, p. 438) also speaks of the “personal inadequacy” one feels when they cannot manage their time – from personal experience, most nurses can tell you that they certainly felt incompetent when they started their graduate years; as most want to do everything for their patients but can not understand why it is not possible.

Most graduate nurses think that no one else feels this way and often feel judged as inept when they hand over to the next shift nurse. It takes a while, but you will finally learn that nursing is a 24/7 job, and you are not expected to do EVERY thing for your patients. You can leave tasks for the next shift if it does not compromise the care you provide. Initially, novice nurses will need help with prioritising their work, and Siviter (2013) has created the ABCD system to help with organising and prioritising your nursing

tasks: A - Absolutely must get done • Tasks that must be done at a certain time. Eg. medications, dressings, medical rounds

• You will be interrupted to do a particular task if it is not done soon

• Waiting will cause a patient avoidable distress. Eg. Administering analgesia

• A risk or hazard is present

• Documentation and paperwork. B - Better sooner than later

• Can wait, but not too long

• Must be done today or on this shift. Eg. ADLs

• C - Can wait until later

• Things that do not have any time frame attached. Eg. Changing During clinical placement choose a patient that is of interest to you. Perhaps a patient that you found challenging in terms of linking the theory together. Fill in the Clinical Reasoning Cycle Worksheet that can be found on the LEO page to assist with your understanding of that patient’s condition and how the Clinical Reasoning Cycle can be of benefit to you. Upload the worksheet to your e-Portfolio on LEO.

Activity 3: Prioritization and Delegation in Nursing

This forms part of your assessment for this unit. 4 linen

• Getting things that will be needed later in the day. D - Do not worry about it

• These are tasks that are beneficial, but if left undone will not affect patients or their care.

• These things should get done, but no one will be hurt if they are not. Once you assess your patient and ascertain what they need and the tasks you need to complete, rate them as either A, B, C or D. Do all the A tasks first, then B etc, and where possible combine tasks to increase efficiency. Sometimes (if not all the time), your plans will change, and this may mean that you will need to reprioritise. The doctor may have decided that Mr. Smith in bed 2 is ready for discharge this morning, and you will find that completing his discharge paperwork and education has now become your main priority.

It is normal to realise that sometimes you cannot do everything, even when you have prioritised. In this case, ensure you ask for help and delegate where possible. It is difficult for students to delegate, as you feel you are the most junior member, but you need to be able to speak up and ask for help. At the end of the day, your priority is your patients, and you need to ensure they receive the best care. To be able to develop professional nursing practice, you need to learn how to prioritise and manage your time. With practice and experience, this will become second nature but in the meantime, remember to practice, practice, practice! ACTIVITY 3 You have been allocated 4 patients this afternoon shift commencing at 1300hrs.

You have received handover for the following patients: Bed 1: A 45 year old female presented to ED with a haemothorax, and had an ICC inserted. She arrived on the ward at 1230hrs. She has an IVC in-situ in her left antecubital, and currently has 100ml/hr of NaCl 0.9% running. She has a morphine PCA which she is using appropriately, and it has kept her settled and pain-free. She is on 3 doses of prophylactic cephazolin 8 hourly, and she has received a dose in ED at 1200 hrs. There is an IDC in-situ, which is draining 35ml/hr, the urine appears cloudy. She will require a CXR in the morning, physio assessment, as well as a pain review by the medical team. Diet and fluids as tolerated. Bed 2: A 23 year old male has been admitted with suspected cholecystectomy, and has been placed on the evening emergency theatre list.

He is complaining of severe abdominal pain with a numerical pain score of 8/10. He has been fasting for 8 hours since he came to the ward this morning. He has no IV inserted, and has been prescribed PRN oral paracetamol and oxycodone for pain. Bed 3: A 17 year old male who is Day 4 following a laparoscopic appendectomy with perforation, and is ready to be discharged home. He has been on PRN paracetamol and oxycodone, and has been prescribed amoxicillin and lactulose for use at home. His parents will pick him up at 1700hrs, once 5 they have finished work. Bed 4: Dirty bed. A new patient is to come up from ED in 1 hour with abdominal pain of unknown origin. She has no relevant past medical history, and has been booked in for an abdominal ultrasound at 1600 hrs. She is fasting and has not yet been prescribed any analgesia.

Communication of assessment, planned care and evaluation of planned care – handover and documentation Central to the nurse’s role is the diagnosis, treatment, and evaluation of patient responses to actual &/or potential health problems (Campbell, Gilbert & Laustse, 2010). However, this is not done in isolation; but as a member of a team. The ability to communicate a patient’s condition, response to therapy, and plan of action is a foundation stone on which effective team-work is built. This communication can be between the nurse and other nurses, the patient, the patient’s family, and other members of the multidisciplinary team (Campbell et al., 2010). According to the Department of Human Services (2006), ineffective communication between staff is ranked as the second most common factor contributing to sentinel events in the Victorian healthcare setting.

Therefore different strategies for communication are necessary in order to facilitate effective communication depending on the setting, the issue, and the participants. The importance of effective clinical communication cannot be overstated, and if successful, can lead to:

• Improved safety.

• Improved quality of care and patient outcomes.

• Decreased length of patient stay.

• Improved patient and family satisfaction.

• Enhanced staff morale and job satisfaction (The Joint Commission, as cited in Department of Health, 2010, p. 5) This module will now explore two major forms of clinical communication – the verbal handover, and documentation of patient care. Now that you have received a handover, .

please complete the following tasks: 1. Assess your patient’s needs and decide what tasks or nursing care needs to be done

2. Draw up a shift planner with an hourly plan.

3. Prioritise these hourly tasks by rating it A, B, C or D – do the most important first.

6 Handover The practice of clinical handover at the change of shift can vary drastically between practitioners. While it may appear to be a simple task of “handing over” or “updating” the care of your patient, it is in fact a complex issue. There are a number of articles that identify ineffective handover as a source of adverse patient events – please read the articles which are linked below:

ACTIVITY 4 1. Scovell, S. (2010). Role of the nurse-to-nurse handover in patient care. Nursing Standard, 24(20), 35-39. Scovell (2010) identifies that handover assumes an almost religious significance in a nurse’s day before going on to describe the various roles that handover assumes in nursing culture. Therefore, apart from being a simple information sharing event, handover has a significant influence on the day-to-day, shift-to shift experience of nurses. 2. Street, M., Eustace, P., Livingston, P.M., Craike, M.J., Kent, B. & Patterson, D. (2011). Communication at the bedside to enhance patient care: A survey of nurses’ experience and perspective of handover. International Journal of Nursing Practice, 17, 133- 140.

According to Street et al. (2011), the primary purpose of handover is “to provide accurate, up-todate information about the patient’s care, treatment, use of services, current condition, and any anticipated changes in that condition” (p. 134). However dangers to effective handover include omission of vital information, inclusion of irrelevant &/or speculative information, and poor handover technique. Please read the Scovell and Street articles by clicking on the link. You may not look at handover the same way again after realising what a significant event it is. Take note of the practices you may have experienced already as a student and consider how these two articles can help you to be more effective when giving your own handover now and in the future.

Now that you have a better understanding of the importance of handover, you need to work out how to provide an effective handover to your colleague. Every facility will have their own processes, but you need to remember to incorporate the standards outlined above, and be SYSTEMATIC. There is a greater movement towards using the ISBAR clinical handover tool, which you would have learnt and practiced in previous units. This is an effective tool which ensures that your handover provides relevant and vital information, and is well organised. Remember, this is a guide only, and you will need to ensure you individualise this! I – Identify S – Situation B – Background A – Assessment R - Recommendation 7 Documentation Documentation includes end-of-shift progress notes, charting and any assessment findings.

It is essential that you document in a timely manner, and remember that unless it has been documented properly, it has NOT happened. We tend to fall into bad habits over time, such as writing vital signs on a piece of paper and transcribing it “later”, several hours on. Ask yourself this: If your patient was to arrest and a MET was called, and there was nothing charted for the last few hours, do you think that your crumpled up piece of paper with random numbers will hold up in court? When you complete your documentation, try to follow the standards of effective documentation, as outlined below:

Complete • Try and prevent interruptions – once you start, don’t stop until you are done Concise

• Include only relevant statements and avoid unnecessary repetition Accurate

• Use words which are considered. Facts and figures need to be accurate

• If you have not witnessed an event, ensure you communicate that. Eg. Mrs. Jones stated she had eaten breakfast in the hospital cafeteria this morning. Clear

• Short and familiar words are used to construct effective and understandable messages

• Avoid jargon, patronising or discriminatory language

• Don’t use abbreviations unless legally acceptable. Here is a list of acceptable abbreviations you can use.

• Please note that you still need to follow the policy and procedures of the facility when using abbreviations Timely

• Relay and document information in a timely manner – don’t delay!

• Remember – if it hasn’t been documented or charted, it has not been done! (VPSR, 2013) Summary To enable you to practice in a safe and professional manner you can try reflecting on the experience of your current placement in addition to the information presented in this module. Reflect on these activities in the context of your clinical experience.

Activity 1: Collecting Cues During Handover

The main purpose of the professional nursing practise is to direct and maintain safe and clinically competent environment for nursing practise. These nursing standards are important for the profession of nursing because they help to promote quality and safe clinical practise (Benner, Tanner & Chelsa, 2009).

Module 1

            Delegation can be considered as the multifaceted skill set which mainly begins with the proper understanding one’s state nurse practice act that in turn outlines the legal responsibilities of the nurse, authority as well as accountability of the patient care (De Vleigher et al., 2016). Registered nurses have the responsibility to conduct ongoing reviews of their practice along with special attention given to delegation.

Five important steps of delegation needs to be followed by every nursing professionals that include consideration of right task, right circumstances, right person, right directions and communication as well as right supervision and evaluation (Cagginello et al., 2014). In this case, several scenarios are provided where the registered nurses has to undertake proper delegation of the tasks so that patient safety and quality care can be ensured.

• The elderly postoperative patient would be my first priority. She had suffered a fall and had become unconscious. For this, I might need to make a met call as well as code blue for her mainly because she had facial surgery.
• The second priority would be to administer the antibiotics to the patient named Mrs. Chew. Her infusion had tissued as she had missed her antibiotics. I can also delegate the task to NUM as he can successfully handle the situation as well. Enrolled nurses cannot do this task, as they are not competent yet.
• I can delegate the task of providing preoperative medication to Mr Esposito. As it is not stated in the case about the medication that needs to be given to her, I can also delegate the task to Enrolled nurse.
• Smith’s visitor had fainted but since she is an outsider, professionals cannot treat her in the nursing ward. The AIN should stay with her where an ambulance can be called for her or she should be admitted to the ED where a doctor can attend her.
• I should not prioritize the block toilet scenario and should request the ward clerk to call for an emergency maintenance request.
• The medication error had occurred one-week age and it had not been addressed at that time. Therefore, since it is already late, therefore, I can handle this situation after i have attended all emergencies.

Module 2

1. The healthcare professionals who would be included in the team are the neurologist who is specialized in the neurological disorders. Occupational therapist would be required for helping the person with his mobility, function and independence. Social worker, psychologist as well as the counselor would be required. As his mobility is decreased he may suffer from social exclusion as well as depression and other mental issues. Therefore, the professionals can help him in these. A physiotherapist would be also helping to maintain physical activity as well as mobility.
2. The case manager would be leading the team. He would be interacting with all the members of the team and would assist people to access health and community services. He would be communicating important information in the team and ensure that there is proper bonding and smooth flow in the healthcare.
3. The role of the occupational therapist is mainly important. After the doctors and nurses have conducted their assessment and acre intervention, it becomes important for the patient to initiate and maintain the daily activities of living. Being independent empowers the patients ensuring better quality lives. The occupational therapists thereby help the patients to come back to normal life without whom the care would be half-hearted.

Case study 4:

1. A number of issues had been identified from the case study. The main issue was that there was improper teamwork among the members. These might be mainly because they had poor team working skills. Moreover, there were also high rates of absenteeism in the team that might be because the working environment of team was not appropriate for effective teamwork. Effective team working requires development of proper bonds among the members for which work pressures are shared (Kalisch et al., 2015). Moreover, it also requires trust among the members. Therefore, blame games and high absenteeism were taking place, as the mentioned attributes were not present.
2. It is extremely important for me to first develop a proper bonding among the members and make them feel that the organization cares for them (Kalsich et al., 2015). Therefore, meeting sessions would be arranged where they will reveal their grievances so that I can work on them. There would be also meetings where the members would give each other constructive feedbacks so that they can overcome any ego problems and thereby develop bonding and emotional attachments. This would reduce their work burden and when they feel that organization care for them, the turnover would be reduced (Yi, 2016). Moreover, training on team working skills and development of communication skills would be ensured. These would help to resolve issues in the physiotherapy department.

Module 3

Patient Needs

Bed 1
Priority	Time	Justification
Priority 1: A	1230 hours	Urine sample test in order to detect the reason for cloudy urine. It can either be arising for dehydration or due to infection arising from catheter or other bacterial mediated urinary tract infection. Results of the test will help to take further steps in treatment (Foxman 2013)
Priority 2: B	20 hours	Administration of prophylactic cephazolin
Priority 3: C	1230	Checking the condition of ICC inserted upon arrival
Priority 3: D	Next morning	Review of pain, preparation for CXR and physio-assessment

Bed 2
Priority	Time	Justification
Priority 1: A		Introduction of IV at a rate of 100ml/hr of NaCl 0.9% running in order to maintain the electrolyte balance (Aitken, Chaboyer & Elliot, 2102)
Priority 2: B		Administration of oral paracetamol and oxycodone for pain
Priority 3: C		Tabulation of the vital parameters like blood pressure, heart rate, pulse rate, body temperature
Priority 4: D		Ultrasonography in order to detect the exact condition of the gal-balder for further progress in the surgery

Bed 3
Priority	Time	Justification
Priority 1: A		Preparation of the detailed discharge report via stating all the dosage and the time of administration of the antibiotics (Campbell, Gilbert & Laustsen, 2010)
Priority 2: B		Noting down the vital parameters before release
Priority 3: C		Explaining the parents the importance of the medication, the condition of their child and how they are going to care for their boy while at home
Priority 4: D		Educating patient about the requirement of the antibiotics and all other interventions prescribed by the doctors (Street et al., 2011; Scovell, 2010)

Bed 4
Priority	Time	Justification
Priority 1: A		Immediate cleaning of bed and maintenance of the hygiene (Jacox & Cole, 2012)
Priority 2: B		Preparing a team to address patients need 1. pain score 2. measurement of vital stats 3. additional requirement: electrolyte balance (Jacox & Cole, 2012)
Priority 3: C
Priority 4: D

Documentation: Reflection

During my role as a trainee in clinical practise setup, I came into an understanding that the effective documentation of the patient information in ordered manner (complete, concise, accurate, clear and timely) will help to assist the physicians at the time of emergency or when they visit the ward. This helps to prevent the necessary confusion. Once I had written patient vital parameters over a sheet of rough paper with no clear documentation. Then when my senior nurse came, I failed to give her proper brief as by the time she came I was lost and forgot what data is related to which parameter. It is my senior nurse who informed me about the importance of proper documentation and how it can be helpful. After that incident I always document the patient’s information on the basis of the desired documentation format (complete, concise, accurate, clear, and timely)

Module 4

The first thing that I will do is divide the duty of the NUM between two of the RN (me and the other nursing professional). This division of the duty of the NUM between two RN will help to decrease the workload on a single person and thereby helping to increase the quality of care and decrease medication errors (Keers et al., 2013).

The total number of patients is 22 of them 8 are going to during my shift hence the remaining will be 14. All these 14 patients went to surgery during the morning and hence will have intravenous access. Moreover, as per the case study half of the total number of patients will require antibiotics that is 11 patients. I am assuming that all the 14 patients who returned from the surgery will require antibiotics. According to Keers et al. (2013), the rate of medication administration and dosage errors are high among the assistant nurses are nurses who are interns and this rate of error increases with the increase in pressure load.

Activity 2: Incorporating the Clinical Reasoning Cycle

Hence I will divide 7 patients under me and 7 patients under another registered nurse and will assign 1 AIN to each of the group of 7 patients to assist RNs. This will reduce the overall work-load and thus helping to increase the quality of care (Schwartz, 2002). Another AIN will be asked to meets other requirements of the patients including checking of the vital statistics. However, the entire work of the AIN will be done under the supervision of RN.

As a RN I will also perform task like patient education, counselling, wound care and infection control. All these fall under the scope of practice of RN (Nursing and Midwifery Board of Australia (NMBA), 2013). In the domain of patient education I will help the patient to understand why intra venous fluid transfusion and administration of antibiotic is important for their fast recovery. I will also take good care of the wound management while taking protective measures to control the hospital acquired infection. The AIN nurse working under RN will be asked to follow the routine hand hygiene in order to prevent spread of infection.

References

Aitken, L., Chaboyer, W. & Elliot. (2102). Scope of Critical care Practice. In ACCCN’s Critical Care Nursing 2nd Ed.  Elsevier, Sydney.

Benner, P., Tanner, C. & Chelsa, C. (2009). Expertise in practice; Caring, clinical judgement, and ethics 2nd Ed.  New York: Springer.

Cagginello, J., Blackborow, M., Porter, J., Disney, J., Andresen, K., & Tuck, C. (2014). Nursing Delegation to Unlicensed Assistive Personnel in the School Setting. Position Statement. Revised. National Association of School Nurses (NASN).

Campbell, L., Gilbert, M. & Laustsen, G. (2010). Clinical coach for nursing excellence. Imprint: Philadelphia, Pa.  

De Vliegher, K., Declercq, A., Aertgeerts, B., & Moons, P. (2016). Health care assistants in home nursing: The Holy Grail or the emperor’s new clothes? A qualitative study. Home Health Care Management & Practice, 28(1), 51-56.

Foxman, B. (2013). Urinary tract infection. In Women and Health (Second Edition) (pp. 553-564).

Jacox, L. & Cole. A. (2012). ISOBAR: Standardising nursing handover.  Retrieved 21 June, 2013, from:

Kaiser, J. A., & Westers, J. B. (2018). Nursing teamwork in a health system: A multisite study. Journal of nursing management.

Kalisch, B. J., Aebersold, M., McLaughlin, M., Tschannen, D., & Lane, S. (2015). An intervention to improve nursing teamwork using virtual simulation. Western journal of nursing research, 37(2), 164-179.

Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug safety, 36(11), 1045-1067.

Nursing and Midwifery Board of Australia (NMBA). (2013). Professional boundaries for nurses Retrieved from: 

Schwartz, L. (2002). Is there an advocate in the house? The role of health care professionals in patient advocacy. Journal of Medical Ethics, 28(1), 37-40.

Scovell, S. (2010). Role of the nurse-to-nurse handover in patient care. Nursing Standard, 24(20), 3539.  

Street, M., Eustace, P., Livingston, P.M., Craike, M.J., Kent, B. & Patterson, D. (2011). Communication at the bedside to enhance patient care: A survey of nurses’ experience and perspective of handover. International Journal of Nursing Practice, 17, 133-140. 

Yi, Y. J. (2016). Effects of team?building on communication and teamwork among nursing students. International nursing review, 63(1), 33-40.