Placement Practice I Discovered a Great Deal

¶ … placement practice I discovered a great deal about pressure ulcers that occur following perioperative care. I am normally community based and I treat patients that have been discharged from hospital that have developed pressure ulcers following an operation. During my complementary placement on a short stay ward I was involved in the care of patients through their perioperative period. I was amazed how quickly one patient developed a pressure ulcer. The experience and subsequent investigation produced several facts concerning the reasons why such ulcers develop, how to prevent them from occurring, treatment and the emotional, financial and physical hardships that having these ulcers produce in patients.

To evaluate my experience, I have chosen to use Driscoll's model of reflection. Driscoll's model was chosen because of the simple but reflective manner in which it concentrates on questions that are pertinent to the care of patients. The model is divided into three parts: What, So What and Now What. The "What" aspect of the evaluation requires returning to the situation and reflecting on the facts and feelings associated with the situation. The "So What" part of the reflection considers the context of the situation in terms of feelings and actions while the situation was occurring. The final part of the reflect ask "What Now" and focuses on modifying future outcomes. This aspect of the reflection will assist me in determining how I will handle these types of situations in the future as a medical professional. The answers to all of these questions are important and will assist me as a nurse in treating patients in the appropriate manner. Overall this type of reflection was chosen because of the simplicity with which it details and records how various situations in the medical field can be handled. Through the observations made I will be able to determine the steps I need to take in the future to be the best medical professional that I can.

What: Returning to the situation

What is the purpose of returning to this situation?

The purpose of returning to the situation involving Pressure ulcer risk during the Perioperative period is to examine the ways in which such ulcers can be avoided and how to treat these ulcers when they do occur. The presentation provided the opportunity to focus on the serious problems that occur during the perioperative care period. Overall the purpose of returning to this situation was to acquire the evidence base that can enhance my practice and reduce the negative impact pressure ulcers can have, for patients and the NHS.

What exactly occurred?

During placement practice a patient experienced a pressure ulcer on the sacrum following hip surgery. The patient was a bit depressed because she had to stay in the hospital for a longer time than she had anticipated. She was also expressive about how vulnerable she felt as a result of where the ulcer was located. This particular experience affected me because the patient's stay in the hospital was extended as a result of an ulcer that could have been prevented.

What did you see?

I saw the ulcer right above the buttocks and the discomfort that is caused the patient. Additionally the patient was devastated she needed to stay in hospital longer and was experiencing what should have been preventable pain and low self-esteem. Both the pain and low self-esteem caused by the ulcer really impacted that morale of the patient and it is likely that is also impacted her recovery.

What did you do?

I repeatedly made sure the patient was comfortable and re assuring her. I encouraged her to drink and eat and explained that this would help in the recovery of her operation and ulcer.

What was your reaction?

I was anxious to assist in helping the patient as it related to relieving the pain and finding and remedy for the ulcer so that the patient would be able to concentrate on regaining mobility after the hip transplant.

What did other people do? E.g. colleague, patient, relative

My colleagues went into action immediately to treat the pain and to position the patient in a manner that would assist in healing the ulcer. The family was concerned about the ability of the patient to recover from both the ulcer and the hip replacement. They were also concerned about the extended hospital stay because longer stays in the hospital during the perioperative period increases the risk of getting other hospital borne bacterial infections. These infections can be fatal and as such the family wanted the patient to have a short stay in the hospital.

What do you see as key aspects of this situation?

This situation indicates that greater care must be taken to prevent such ulcers from occurring. The research and my experience in this area indicate that while anyone can be vulnerable to developing pressure ulcers following surgery, there are several factors that can be addressed prior to surgery that will reduce the likelihood of developing an ulcer. This means that preventative measures are a key aspect of ensuring that patients will not experience this complication.

So What: Understanding the Context

What were you feeling at the time?

At the time I wanted to relieve the stress and the pain that the patient was experiencing as a result of both the operation and the ulcer. I was also somewhat upset that more hadn't been done to prevent the ulcer. I did my best to attend to the physical and emotional needs of the patient as she was really looking forward to having a shorter stay in the hospital but the ulcer prevented her from doing so. Additionally Even though I had not completed the assessments I did feel guilty that she had come in to hospital for a hip replacement and ended up developing a ulcer. Therefore I wanted to gain the knowledge, skills and understanding of what can be achieved to prevent ulcer development. this is why I choose the topic I did for the presentation, to raise awareness on how quickly ulcers can develop the affect they have on the patient and to raise the awareness of everyone to the importance of prevention. When I talked about ulcers on the ward not many staff seemed to be aware of the impact ulcers have on the patient. Everyone knows what an ulcer is but unfortunately a high number of patients still develop them.

What are your feelings now? Are there any differences and, if so, why?

I still a vbit of frustration in the manner in which the situation was handled by the medical staff and their inability or unwillingness to act soon so that the pressure ulcer did not develop. I also feel some relief for the patient because I was there to comfort her and reassure her that the ulcer would heal and she would be able to go home. I still feel some sadness for her because of how vulnerable she felt when having to get the ulcer dressed. As a medical professional I always want to help patients to maintain their dignity. In some ways I feel as though I was not fully able to do this with the patient. I also feel empowered in some ways because after researching this issue I know that in the future there are many steps that can be taken to ensure that many of my peri-operative patients do not get pressure ulcers. In addition if these ulcers do occur I will know how to address the issue with compassion and sensitive as it pertains to preserving the dignity of the patient.

What were the effects of what you did (or did not do)?

My efforts to reassure the patient that the situation would be resolved and she would get better seemed to affect her mood. OI wanted her to know that the medical staff was working to treat the ulcer. I also wanted her to know that she had an advocate and that I understood her feeling of vulnerability as a result of where the pressure ulcer was located. As an effect of my efforts I do believe that the patient was able to cope with the situation and not feel shame. Overall I think I did a good thing in regards to the patient's well-being and encouraging to get well so that she could return home and fully regain her strength.

What good emerged from the situation e.g. For self, others?

The good that emerged from this situation included my own personal ability to better understand how to treat preoperative ulcers. I also learned how to maintain my composure when treating people in distress. In addition, as a result of the experience I learned about the healing process and the extra financial burden that is placed on patients and their families when ulcers occur. I also learned that I have the ability and responsibility to educate others concerning ulcer prevention in patients.

What troubles you, if anything?

The primary issue that I find troubling is that an estimated 95% of pressure ulcers can be avoided (NICE, 2005) when the proper precautions are taken. Failure to take precautions complicates the ability of the patient to recover from surgery and completely heal in a timely manner. In fact some pressure ulcers can take up to two years to completely heal. Treating patients that have developed pressure ulcers costs the NHS from 1.3 million-3.2 million a year. Specialist equipment is required to nurse pressure ulcer patients for example an Airflow mattress, There are also costs associated with wound care and the time taken by the nurse to complete the dressing, there is also the added cost of medicines such as antibiotics.

What were your experiences in comparison to your colleagues?

Long time nurses knew how to treat the ulcer and remedy the situation once it occurred. However, I was concerned and taken aback that they did not do more in the area of perioperative care to ensure that a pressure ulcer did not develop in the first place. There should have been more of a concerted effort to ensure that the patient was being repositioned so that the ulcer did not occur. They seemed to be used to these ulcers developing and not as concerned about them occurring following an operation. Overall my reaction was to comfort the patient and reassure her that the ulcer would heal.

What are the main reasons for feeling differently from your colleagues?

The primary reason why I had a different reaction than my colleagues is probably associated with the fact that I am not as experienced with patients as the full time nurses. It is likely and understandable that they have grown accustomed to seeing patients in this predicament and as such their reactions to such conditions are different than the reaction that I experienced. I can imagine that if I was confronted with similar situations everyday for years, I would not have the same reaction. Over time people may become desensitized to seeing and experiencing certain situations that patients are in following surgery.

Now What

What are the implications for you?

This experience taught me the importance of carefully caring for patient during every stage of their treatment. This is the reason why I chose this issue for my presentation. I hope that through the facts given in the presentation those who saw this information will make better decisions when caring for patients. The implications for me include my awareness of this issue and how it affects patients and their ability to recover following surgery.

What needs to happen to alter the situation?

Throughout the nursing and health services professions there needs to be better training and more emphasis placed on avoiding pressure ulcers hat occur after operations. Nearly every case of pressure ulcers can be avoided if the proper actions are taken before and after surgery. This means the proper measure must be taken to understand what risk factors that a patient has before an operation even takes place. For instance patient that are diabetic or have mobility problems are more likely to experience pressure ulcers. With this understood these patients should be more carefully monitored and should be repositioned as frequently as possible to ensure that pressure ulcers do not occur.

What are you going to do about the situation?

Now that I understand more about pressure ulcers and the ways in which they can be prevented I plan to continue to education myself on the measures that should be taken to prevent pressure ulcers in perioperative patients. For instance before an operation even takes place the mobility, diabetic status and nutritional status of the patient need to be evaluated to determine what extra precautions need to be taken prior to the operation so that the development of pressure ulcers can be avoided. For instance, if medical personnel is aware that a patient about to undergo an operation is dehydrated or nutritionally deficient, steps need to be taken to remedy these issues prior to the operation taking place. Although this is not always possible as some operations are performed on an emergency basis, there are many occasions where operations are scheduled well in advance and these extra precautions can be taken. In addition I want to educate others in the medical profession concerning the steps that need to be taken during the preoperative and perioperative stages. Medical professionals need to understand that they are the first line of defense when it comes to preventing pressure ulcers.

What happens of you decide not to alter anything?

Patients will continue to go the hospital for routine operations and have the inconvenience of getting a pressure ulcer which will force them to stay in the hospital for an extended period of time. If I do not attempt to alter this situation patients will continue to endure the indignities associated with having to treat pressure alters. In addition the medical community will continue to perform in ways that are inconsistent with the desire to assist patients in getting well as soon as possible so that they can leave the hospital. Pressure ulcers will also continue to costs patients and insurance companies millions of dollars each year.

• What might you do differently if faced with a similar situation again?

Looking through the evidence highlighted I would take more care when completing assessment tools. Using such tools leaves a very wide scope on the vulnerability in each individual patient. Also when completing such forms there is a great of clinical judgment required to be aware of small signs to take extra care especially diet, mobility, dehydration. If addressing the situation again I would have pointed out the need for better assessment to my colleagues. However, I do believe that how I reacted to the situation is all I could have done at the time as it related to the situation she was in. I did what I could to comfort her and to encourage in physical health. In this regard there is not anything that I would have done differently.