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1. Provide safe, appropriate and responsive quality nursing practice

2. Evaluate outcomes to inform practice

Case study of Mrs. Maraim Jones and her rehabilitation after stroke

Standard 1: Thinks critically and analyses nursing practice

Mrs. Maraim Jones is of 65 years old Muslim woman and has suffered a stroke while she was working in her garden along with her grandchild who was of 15 years. Following the stroke, she had faced a fall on her knees that had large skin tears as well as bruises in different parts of her body. She also was suffering from improper glucose balance in her body that was also giving her poor quality life. Following the stroke, she was shifted to the emergency ward where she was treated. However, she had suffered mild paralysis on the right side of her body and had speech impairment. She was having issues with the mobility and she needed assistance with her daily activities of life. Therefore, the doctor in charge advised for transferring the patient to the rehabilitation unit for further treatment so that she can overcome the different barriers that she was facing. In this rehabilitation unit, nursing professionals play one of the most important role in the multidisciplinary treatment as they act as the care coordinators, communicators, assessors and holders of meetings and discussions beside providing nursing care for the patient. In this assessment as well, the duties of the nursing professionals will be discussed which will be mainly based on the following of the four important standards of practice as allocated by the Nursing and midwifery board of Australia.

Nursing professionals need to use a variety of the thinking strategies as well as the best available evidences for making effective decisions (Standard of practice, Nursing and midwifery board of Australia 2016). This is much important in providing safe as well as quality nursing care that would be involving both the person centred approaches as well as the evidence based frameworks (Fisher 2017). This standard usually dictates the nurse in accessing, analysing as well as utilizing the best of the available evidences. These evidences should be such that it would include recent findings do that effective quality and safe practices can be ensured (Standard of practice, Nursing and midwifery board of Australia 2016). In case of the patient, it was seen that weakness, spasticity as well as incoordination were common (Wilson et al. 2018). In such scenario, the patient needs to be encouraged to undertake exercise sessions as researchers suggest that this is one of the most effective ways for the brain to rewire and to try to recover physical fitness (Saunders, Greig and Meid 2014). Studies also suggest that patients after stroke tend to lose their cardiorespiratory fitness even on the unaffected side but at the same time, patients are seen to complain that exercise brings very little output even when exercise regimes are taken in a disciplined manner (Bernhardt et al. 2015). Still researchers like Morris et al. (2015) are of the opinion that the exercises allow better recovery of activities of daily life and reduce the chances of occurrence of strokes again. Spasticity was also a common problem after stroke that also affected the patient that was giving her much pain and was limiting her movements (Livingston et al. 2016). Therefore, physiotherapists were assigned for her and a drug called baclofen was given to her (Creamer et al. 2017). Many studies also suggest botulinum toxin injections (Demetrios et al. 2016) and it was also discussed with the doctor for furthur assurance. Psychological issues were also seen in the patient and this aligns with the studies of many researchers who worked on the mental health of the patients after stroke (Alajbegovic et al. 2014). The studies say that major depression occurs in up to half of the stroke survivors (Robinson and Jorge 2015). However very few studies have worked on the interventions that can be applied to such patients although some of them have mentioned about the routine use of the antidepressant to be helpful (Mortensen 

Importance of critical thinking and evidence-based practice in nursing care

and Anderson  2015). There are also evidences suggesting cognitive behavioral therapy to be one of the mainstay treatments (Kootker et al. 2017). Pain was also another complication that was seen in the patient resulting from contractures, spasticity, subluxation of the shoulder as well as the excessive strain that was taken by the unaffected side (Gillen 2015). Studies suggested that careful evaluation of the cause of pain as well as treatment of the reversible factors and then using the analgesia (Harrison and Fielf 2015). Therefore, following these studies steps were taken. Moreover, studies also state that painkillers should be given regularly than in times when pain becomes unbearable (Harrison and Fielf 2015). Therefore, such studies were followed and accordingly interventions were prepared from some of the best evidence based practices. Moreover, such standard also showed that it is important for every individual to undertake reflective practices (Cashin et al. 2015). Therefore, the healthcare professionals need to reflect on the experiences, knowledge actions as well as the feelings and beliefs (Standard of practice, Nursing and midwifery board of Australia 2016). Researchers are of the opinion that such practice helps in developing confidence and helps in shaping the best effective care ensuring development of expertise of the professional in the field (Cashin et al. 2017). I followed all the ethical frameworks when she was taking decisions. I practiced beneficence that instructs her to provide the safest care to the patient as well as non-maleficence that instructs the professional to provide care that will not cause any suffering and pain to the patient. (Grace and DRN 2017). Informed consent was taken by me from her in every of the interventions that were taken from her and she was made the centre of all decisions. In this way, the standard was maintained (Nagle et al. 2017). Not only that, following the standard one, the I also made accurate, comprehensive and timely documentation of the assessments that she conducted every day of the patients. Researchers are of the opinion that documentation is extremely important as it helps in maintaining a record of the patient’s health that become useful in different types of purposes (Petkovšek-Gregorin and Skela-Savi? 2015).  It can be used for helping to evaluate the betterment of the patient, health, circulate among the team members of the multidisciplinary team so that everyone becomes aware of the patient’s condition (Petkovšek-Gregorin and Skela-Savi? 2015). It is also helpful to prevent any form of legal obligation (Scanlon et al. 2016). It also acts as guidance when the patient revisits the centre for any kind of treatment. All the important legislations were followed along with important regulations, policies and guidelines for making the decisions as per the instruction of the standard.

Challenges faced by the patient - spasticity, mobility issues, psychological issues, pain

Standard 2: Engages in therapeutic and professional relationships

The nursing professionals should ensure that they are engaging in the effective therapeutic as well as professional relationships with the patient and the family members. Such relationships should be based on the mutual trust and respect while interacting with the patient so that the patient experiences high level of satisfaction (Standard of practice, Nursing and midwifery board of Australia 2016). While treating the patient, I made sure that I successfully establish, sustain and thereby conclude relationships in particular approaches that helps in differentiating the boundaries between professional as well as personal relationships (Ossenberg et al. 2015). The patient and his family members were very satisfied with the care that the professionals were providing them and therefore out of gratitude they wanted to give gifts to the professionals however, it was strictly denied by the entire team as it was against the professional standards to accept gifts from service users (Thompson 2016). Moreover, I had also maintained the very important guidelines that come under the standard. The standard states that professionals should communicate effectively with the patient and she should respect the dignity, culture, rights, beliefs and values (Bromley 2018). I developed therapeutic communication with the patient that was both compassionate and empathetic. This helped in developing a bond of the patient with me where the patient developed a feeling that the professional was trying her best for helping her overcome the feelings and were having genuine feelings for the patient. She respected the culture, values and beliefs of the patient when the patient stated that no male members would be treating her. Accordingly, I made arrangements where the team only comprised of female members. I also instructed the concerned authority to provide her with halal meat so that her cultural preferences are respected. The standard expects the professionals to accept that patients are the experts in their own lives and they should also provide them support to the patient as well as to the family members regarding optimization of the health related decisions (Jacob, Duffiled and Jacob 2018). I had taken informed consent where she had described all the interventions to the patient in details along with their pros and cons. Accordingly, the patient was given the full freedom to take her own decision and be the central part of every decision-making activities. Researchers are of the opinion that such an action help in empowering the patient where they feel that their self-respect was not harmed and their dignity was maintained (Judkins et al. 2014). Moreover, I had also provided a list of the resources to the family member of the patient from where they could arrange for services after the patient be discharged home. This helps the family members largely as they were very anxious about how to take care of such a patient in their home (Bryce, Foley and Reeves 2017). This standard also expects the professionals to use “uses delegation, supervision, coordination, consultation and referrals in professional relationships to achieve improved health outcomes” (Standard of practice, Nursing and midwifery board of Australia 2016). I had taken active part in delegation where I communicated the important details of the patient to the other nurse when I was leaving my shift. Moreover, I also did my documentation in a way that helped the later nurse to completely understand her duty and the steps that needed to be done. Effective delegation ensured that no interventions were missed out and the other nurse followed all important care guidelines. I also took the responsibility of effective coordination and supervision not only among the different healthcare professionals but also among the different experts of the multidisciplinary team. Effective collaborative practices were conducted as per the standard. I played the role of care coordinators besides nursing professional and took the responsibility of arranging meeting, discussion among the members about the planning to be adopted feedback sessions, setting of appointments and for the therapy sessions of the patients and many others. It was also important for the team members to work together to bring out the best outcome of the patient (Philips et al. 2017). I ensured that all the team members worked accordingly to the planned schedules, maintained a transparent approach among the members, ensured a collaborative approach. They coordinated and communicated among themselves like the occupational therapists, physiotherapists, speech therapists, dieticians, diabetes educators and other nursing professionals (Cross, Brown and Sein 2018). All of them coordinated and coordinated together for effective health outcome on the patient. All of them shared knowledge and practices with each other that helped in development of culture of safety as well as learning from each other. This helped in developing and fostering a culture of safety in the organizational culture that helped in ensuring better care for the patient (Birks et al. 2016).

Effective interventions - exercise sessions, baclofen for spasticity, antidepressant therapy, pain management

Standard 6: Provides safe, appropriate and responsive quality nursing practice

The nursing professionals are instructed for providing and delegating quality as well as ethical goal related actions (Standard of practice, Nursing and midwifery board of Australia 2016) . These actions would be based on the comprehensive as well as systematic assessment and even the best available evidence for the achievement planned and agreed outcomes. The registered nurses are expected to provide a comprehensive safe as well as quality practices for achieving agreed goals and outcomes that are responsive to the nursing needs of the people (Cashin et al. 2017). The nursing professionals need to practice within their scope of practice (Standard of practice, Nursing and midwifery board of Australia 2016). The nursing professionals are also advised to ensure that they are providing timely direction as well as supervision for ensuring that the delegated practice is not only safe but also correct (Standard of practice, Nursing and midwifery board of Australia 2016). After the patient was transferred from the emergency ward to the rehabilitation ward, it was very much important for me to recognize the needs and requirements of the patients. I needed to first take proper assessments with proper assessment tools that help them in recognizing the main needs of the patients. This could be exemplified with the help of the assessment tools that the professional had used (NO REFERRENCES COULD BE PROVIDED HERE AS IT IS THE EXAMPLE OF WORK THAT WAS CONDUCTED). For this specific patient, I had used the Glasgow comma scale as well fall assessment tools so that the capability of the patient in such arena can be ensured and accordingly interventions for development of their capabilities can be ensured (Thompson 2016). Researchers Lewis et al. (2016) are of the opinion that assessment is the first part of the nursing procedures that mainly forms the basis of the care plan. Lewis et al. (2016) have also stated that essential requirements of the accurate assessment us to view the patients holistically and thereby identity the real needs of the patients. The different types of assessments that the nursing professionals need to do to ensure about the health of the patient and understand the care needs are the test results, assessment of the physical, mental and the different neurological status. Vital signs, airway assessment as well as lung assessment, CNS and PNS assessment are the assessments that would also help in the understanding about the condition of the patient (Cross, Brown and Sein 2018). Knowing about the real needs of the patients is important following which the care priorities would be set. It is very important for me to know about the care needs so that the interventions provided are not only safe but also helps in covering all the requirements and needs of the patient and none of the needs are missed out. For this, I utilized the clinical reasoning skills which was proposed by the famous Tracy Levett Jones (Hunter and Arthur 2016) that help the professionals to take the proper assessments, utilize the results for understanding the pathophysiology and accordingly develop the care goals (Hunter and Arthur 2016). Following this, the professionals need to develop the care plan and then accordingly apply intervention for the problems. Through the effective assessment of Jebsen Taylor Hand Function Test, I found that the patient had motor deficits and had poor physical fitness. Through the assessment tools Jebsen Taylor Hand Function Test, it was also found that weakness, spasticity and even incoordination was found. For the psychological aspect, Beck depression inventory was also used and through this, it was understood that the patient was also suffering from depression as well (Ayton et al. 2017). The Glasgow comma scale initially helps in understanding the level of consciousness of the patients. The pain scale from 0 to 10 helped in stating how much pain the patient was suffering from which showed she was suffering from moderately to high pain. Accordingly safe comprehensive care plan was prepared in order to achieve the agreed goals as well as the outcomes that were responsive to the nursing needs of the 

Professional relationships and therapeutic communication

people (Bryce, Foley and Reeves 2017). This standard also expects the professional to provide effective timely direction as well as supervision for ensuring that delegated practice is safe and correct (Ayton et al. 2017). Therefore, when the different members were acting in the tea and providing care, the professional has maintained strict supervision to ensure that the delegations that were carried on and safe. I worked according to the relevant polices, standards and guidelines so that legal obligations do not occur and also to prevent any chances of complaints from the patient as well as his family members. Another one of the most important aspect of this standard is that the professionals should use the appropriate procedures for identification and reporting of the potential and actual risk related system issues and where the practice may be below expected standards (Baldwin et al. 2017). I was working with the patient had followed this standard and had taken risk assessment hazards not only to realize the different risk that were associated with the patient but also with that of the professionals in the team. Some of the enrolled nurses were not being able to keep up with the treatment procedures and were missing out on their responsibilities and hence, they were sent for training to identify their knowledge gaps and thereby develop their skills and expertise.

Standard 7:  Evaluates outcomes to inform practice

The nursing professionals need to take the responsibilities for the evaluation of the practices that remain based on agreed priorities, goals, plans and outcomes and thereby revise the practices according to the needs accordingly (Standard of practice, Nursing and midwifery board of Australia 2016). The registered nurses need to evaluate and thereby monitor the progress towards the expected goals and the outcomes. After the planning and discussions that were done by the professionals of the team members in the clinical care, it was necessary to analyze that whether the professionals ultimately meet the planned goals. Therefore, I supervised the outcomes of the interventions and accordingly reassigned the responsibilities or discuss with the professionals due another intervention that would be fruitful (Martyn, Zanella and Wilkinson 2017). The professionals were seen to report about the outcomes in the documentation procedure that helped to evaluate about the recovery procedures of the patient and how well the patient was responding to the recovery procedures. Moreover, the care-coordinator also took a separate analysis to find out that the patient responds to all the applied interventions. The standard also showed the important of revision of the plan based on the evaluation (Standard of practice, Nursing and midwifery board of Australia 2016).  However, in the care of the patient, it was found that all the planned intervention was bringing out the positive outcomes on the patient and she was gradually recovering and coming to terms with normal lifestyle. Therefore, no revision of the plan was required as the response of the patient was quite satisfactory to the treatments (Martyn, Zanella and Wilkinson 2017). Moreover, the standard also instructs the professionals to determine and thereby document about the care of the patient. This standard also stated the importance of the communication of the different priorities, goals and outcomes with the relevant persons. As the care of the patient was continued, I held regular meetings. This meeting mainly encouraged discussions about the health conditions of the patient and constructive feedbacks from the different professionals of the teams. This helps every professional to develop an idea about the next steps in the treatment plan that they needed to take and accordingly next set of intervention and plans were introduced. All information were noted and documented for future activities.

Respect for culture, values, and beliefs of the patient


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Importance of informed consent and empowerment of the patient

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