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Seminar: Throughout module 6, we looked into the care of a trauma patient. This weeks seminar we began with looking at some statistics about the burden of trauma and other statistics around hospitalisations and demographics of trauma in Australia from 2022-2023. We then split in 2 groups discussing the differences and considerations between a trauma in an paediatric patient and a geriatric patient. My group was looking at paediatric traumas and and had conversations around their different vital signs, how care would need to be more family based, consent and pain scales in children. Before moving into the clinical lab we looked into the case study of Sam where we were asked what more would like to know Sam and his accident. Sam was a 75 year old male patient who had a fall from a ladder and was going to be our patient in our workshop today.

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As a soon to be new graduate nurse I understand the importance of delivering safe, person-centred, evidence-based care. Throughout my three years of study, I have gained clinical experience through my placements in acute, medical, surgical, paediatric and community settings each of which has shaped me. Additionally, my employment as a part time educator has strengthened my communication skills, particularly with children and families, allowing me to find my passion and goal of pursuing a nursing career in paediatrics. My clinical experiences have allowed a deeper understanding of my strengths and the qualities I hope to see in myself. This includes working collaboratively with others in my team, thinking critically and applying evidence based care to all my patients and always seeking feedback and incorporating reflection. I believe my strengths closely align with the NMBA Registered nurse standards for practice, particularly standards 1 through 3 of thinking critically and analysing practice, engaging in professional relationships, and maintaining capability for practice. (NMBA, 2016).

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On completion of my first six month rotation of my grad year, I will improve my confidence and competence in both written and verbal communication skills with colleagues, patients, and families. I will do this but consistently using the ISBAR framework to structure my handovers as well as seeking constructive feedback from colleagues on at least 5 different occasions. At the end of each week I will aim to reflect on my patient interactions and how I delivered education to them and their families and identify my strengths and weaknesses within this process, ensuring alignment with the NMBA standards. Through achieving this goal, it will allow me to think critically about my communication, promote positive therapeutic and professional relationships and actively maintain my capability of practice through feedback and reflection (ACSQHS, 2016). (NMBA, 2016).

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Description

During my recent placement in a neurosurgery ward, I was involved in the care of a 54 year old male. He was admitted following a collapse with a head knock and loss of consciousness, seizure activity and a short stint of CPR in his group home. He had a history of early onset Alzheimer’s and had a baseline GCS of 13-14. On admission to us, he presented with several facial fractures, brain bleeds, a large haematoma on his left eye and a GCS fluctuating between an 8 to a 10. His next of kin’s had all decided on primarily comfort measures with no surgical interventions, intubation or CPR. Oral medications such as sertraline, docusate-senna and other analgesics had been charted despite it being known whether or not this patient was able to swallow safely. Only the IV medications of levetiracetam and paracetamol were able to be safely administered. An NG tube was not an option due to his severe facial fractures and respecting the families wishes of providing comfort. As I was taking the lead on this patient, I decided it was not safe to attempt to administer these oral medications to the patient. Together with my nurse we sent a request for a speech pathologist review, however, a formal swallowing assessment was not able to be completed due to his neurological status. My nurse and I trialled this patient to have small sips of water out of a cup with and without a straw, with minimal success. This then prompted us to have further discussions with the doctors and other members of the multidisciplinary term to clarify a new plan for this patient.

Feelings

At first, as I was taking the lead on this patient, I felt overwhelmed and unsure of how to approach the situation. I was concerned about how I was meant to administer these oral medications that had been charted with informed consent of the patient while keeping him as comfortable as possible as per the families wishes. Although the medications had previously been withheld, I felt as though some of them, including the sertraline and analgesics were important for this patient to have for symptom management. I did however feel nervous having to discuss this with the doctors in order to create a new plan.

Evaluation

I felt satisfied in that between myself and my buddy nurse we prioritised patient safety through not administering the oral medications but also respecting the families wishes and patient’s autonomy by progressing to consulting with doctors to find other alternatives to these medications to be given. This collaboration of medical and allied health staff adhered to the NMBA professional standards and ensured that all decisions made were both informed and involved a holistic approach. For myself I recognise that I may not have contributed as confidently as I could have with the medical officers and that in future should assure myself of my decisions.

Analysis

This scenario reinforces the importance of critical thinking within nursing practice (Standard 1). Instead of following the medication chart without questions,  I assessed the patients swallowing ability, recognised the risks of aspiration and weighed up those risks against the benefits of the medications. Evidenced by the WA country health service, dysphagia following neurological trauma increases morbidity and mortality meaning that an early screening/assessment of swallowing is essential in situations similar to this one, (WACHS, 2023). Collaborating with speech pathologists and doctors embodied standard 2 showing how professional relationships are vital in providing safe care. By identifying my own lack of confidence when advocating for my patient, I recognised an area I need to improve upon in order to build my capability of practice through both reflection and development of my skills (standard 3). Through analysing this scenario it shows how reflection on challenging experiences can allow for immense growth as a nurse. (NMBA, 2016)

Conclusion

Through this scenario and reflecting upon it, I have solidified my understanding that safe and effective nursing care requires critical thinking of interventions that are both supporting the patient clinically and their expressed wishes. Professional communication and collaboration is a vital part in creating care plans and altering care in the best interest of the patient. I acknowledged my need to improve in my confidence when advocating for patients and therefore am maintaining the capability of my practice.

Action Plan

In future practice I will apply critical thinking when administering medications, looking particularly closely at the safety of routes. This could be done by looking to the Australian medication safety standard, (Australian Commission on safety and quality in health care, 2018). I will also aim to advocate for my patients with confidence as well as asking for feedback in order to improve my practice. I believe that this scenario and reflecting upon it has shown how my practice can adhere to the NMBA standards, particularly the first 3, and how I can improve in future.

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I have not used any GenAI tools/services in the preparation of this assessment. I understand that providing false or misleading information in this GenAI Acknowledgement Statement may constitute a breach of the University of Canberra (Student Conduct) Rules 2023.

I confirm that I have not used GenAI in the preparation of this assessment for any purpose other than what I have acknowledged above and I have cited and referenced any GenAI content in my assessment submission, applying the relevant referencing style. I understand that providing false or misleading information in this GenAI Acknowledgement Statement may constitute a breach of the University of Canberra (Student Conduct) Rules 2023.

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Australian Commission on safety and quality in health care. (2016). Communication at clinical handover. https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/communication-clinical-handover

Australian Commission on safety and quality in health care. (2018). Medication safety standard. https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard

Department of Health and Aged Care. (2022, November 16). National framework for advance care planning documents. Australian Government Department of Health and Aged Care. https://www.health.gov.au/resources/publications/national-framework-for-advance-care-planning-documents?language=en

Gibbs, G (1998). Learning by doing: A guide to teaching and learning methods. Oxford: Further Education Unit, Oxford Polytechnic.

Nursing and Midwifery Board Australia. (2016). Registered nurse standards for practice. https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

WA Country Health Service. (2023, November 20). Adult Dysphagia Screening and Assessment - Clinical Practice Standard. https://www.wacountry.health.wa.gov.au/~/media/WACHS/Documents/About-us/Policies/Adult-

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Seminar: Through the seminar in week 2 we went into detail around diabetic ketoacidosis, a topic we have previously covered in other classes. As a class we reviewed the pathophysiology of DKA and revised our understanding of the role of that potassium, sodium and other electrolytes play in the context of DKA. We then ended the seminar with discussing health promotion for patients with DKA and how this would change in the context of differencing health literacy. Despite remembering a lot of previously learnt content on DKA this refresher was definitely needed for me in order to solidify my knowledge on the condition.

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For week 3 of INC 6 I was on week one of my first block of placement this semester. I was placed in the neurosurgical ward at Canberra Hospital which I was very excited about. It was a 28 bed unit specialising in neurosurgery, oral maxillofacial surgery and trauma. Within the ward there were 2 rooms of 4 beds used for high acuity patients recovering from intracranial and spinal surgeries, trauma and traumatic brain injuries. For week 1 I was primarily on side 1 of the ward which focused on the patients recovering from traumatic injuries.

Positive takeaways:

I really enjoyed this week of placement as I was able to complete and improve in a lot of areas from a clinical perspective in a ward of which I had very little experience in. I gained extensive exposure to wound care on patients with extensive stab injuries and from motor vehicle accidents. This broadened my understanding in wound assessments, infection control and the importance of analgesia before some wound dressing changes. I was also able to observe the complex care required for tracheostomy patients including suctioning, deflation and inflation of cuffs and communication support.

Negatives:

Some aspects of this week of placement that I struggled with included the patient load. Nurses were allocated up to 5 patients of which I was taking a patient load of up to 4 myself by the end of the week. I struggled with the high dependency of these patients with tracheas and found time management something that I struggled with a lot. Despite me mostly being able to get all of my tasks completed in a shift, I would often feel that I hadn't had enough time to properly engage with the patients throughout.

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For my second week of this placement I was in the same ward but in one of the 4 bed HDU pods. The patients in this pod were those recovering from traumatic brain or spinal injuries or from subarachnoid haemorrhages. The pods required 2 nurses with a 2:1 patient ratio who would team nurse for the shift. My main responsibilities throughout this week included regular neurological observations including GCS, spinal observations and keeping SAH protocols in place.

Positive takeaways: As this was my first placement in a neurological specialty, I gained significant confidence in conducting and understanding both neurological and spinal observations. Working with SAH and following the protocols also allowed me to feel confident in identifying signs of deterioration, particularly around blood pressure, pupillary changes and GCS decreases. I really enjoyed the lower ratio within the pods as I felt i was able to build extremely strong therapeutic relationships with not only the patients over the week, but also there family members. For me, this week reinforced the importance of consistent assessments and monitoring as well as attention to detail and precision.

Negatives: Although a higher acuity area, due to lower nurse to patient ratio I did find it challenging to maintain focus and find other things to do during slower periods throughout the shift, especially on evening shifts. There were often days when patients were stable when it was only monitoring of the patients which I did find could be quite repetitive.

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Seminar: The module 1 week 1 seminar was more of an overview of our semester as opposed to a specific topic of content. During this one hour seminar we looked at how our INC classes were split up into seminar, workshop and simulation and how they were going to run. We looked into our assessment items over the semester and completed an icebreaker as a class to get to know one another better. I felt that this was a great introduction to the unit this semester.

Workshop: This workshop was a revision on clinical skills we have previously been taught. Over the hour, within our groups of 3 we focused on a general A-G assessment along with administration of an S8 drugs and providing fluid therapy to our patient. This was a really great recap in order to ease ourselves back into the semester.

Simulation: We did not partake in a physical simulation throughout this class but instead we discussed what the simulations were going to look like, our past experiences with simulation and what we needed to get the most out of them. As a class we discussed how previously some simulations had been so daunting due to the debriefs after. It had observed previously that they had been talking about the things that the volunteers in the simulation had done wrong making them feel targetted. We discussed how our debriefs will be split into positives from the sim and things that we ourselves would've found challenging in the sim. This made me fell a lot more safe and open minded within the simulation environment.

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Seminar: In module 3, week 5 we were learning about caring for a paediatric patient and their family following a burn injury. Throughout the seminar we looked into a case about a nurse's child who tipped over a cup of boiling water from the bench over her head. We discussed the extent of her injuries, the treatment, the recovery process and how this impacted the patient and her family. We discussed in our small groups how we thought that we would apply first aid and react if we were a mum in the same situation. I found the content throughout this class quite confronting especially looking at the injuries of the young child and how it affected her quality of life.

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Seminar: Within the seminar this week, we looked into the management and recognition clinical deterioration in patients. We discussed as a class why early recognition of deterioration is so important along with certain diagnoses that have an increased risk for deterioration such as sepsis and cardiac arrhythmia's. We also discussed factors that contribute to our ability to recognise this deterioration along with essential factors in doing so.

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Workshop: This workshop also differed from previous clinical labs with discussions around a series of videos as opposed to hands on clinical skills. We were looking at de-escalation techniques and watched a series of exemplar videos of both non-effective and effective techniques. We began by discussing the aggression cycle, what each stage could look like and how we would effectively handle the situation. We then watched 4 videos, 2 being scenarios that were not handled well and 2 where the nurse/medical professional was using effective de-escalation techniques to avoid or get a patient down from the crisis point of the aggression cycle. The session emphasised the importance of specifically standard 4.1, conducting holistic and comprehensive assessments (NMBA, 2017). Recognising the agression cycle and having the ability to identify early behavioural cues demonstrates assessing not just physical health but also changing emotional and behavioural states. This falls closely with standard 4.2, of using a range of assessment techniques as through watching the videos and discussions I feel that I am able to interpret both verbal and non-verbal signs of agression (NMBA, 2017).

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Simulation: For this weeks simulation we continued on with Sam. The sim started with the two nurses and a student nurse entering Sam's bedspace to conduct an A-G assessment following the handover from Sam's nurse who had just gone on break. Sam's vital signs were shown on the monitor next to his bedspace. Almost immediately the patient stated that he felt nauseous and was going to vomit. One nurse got a vomit bag for Sam while the other continued on the primary assessment. As they were doing this we could see Sam's vitals changing with his SpO2 and BP dropping and his HR and RR increasing, showing signs of deterioration for Sam. Sam then became unresponsive leading for the nurses to call a MET call and his vital signs began to further deteriorate. Oxygen therapy of nasal prongs at 3L was applied and the A-G assessment was continued until the simulation came to an end. Throughout this simulation I believe that the volunteer nurses showed adherence to standard 6, in providing safe and responsive nursing practice as they attempted to follow an A-G structure and intervened with oxygen when the signs of deterioration indicated to so, both following the trauma process approach (NMBA, 2016). As a class some positives from the simulation that we came up with included the clinical intervention of oxygen therapy given Sam's low SpO2 levels and high RR rate. We also said that they did a good job at introducing themselves to the patient and his family as well as keeping the family calm and explaining to them what was happening throughout. Some aspects that we identified as challenging were the ability to maintain a full A-G when things are constantly changing and new priorities of care for the patient are constantly coming up. We also discusses the difficulty of having 3 different nurses in the room and knowing which person was doing which job. Overall this was a high intensity simulation that I personally would have found difficult to participate in but learnt a lot from breaking it down as a class.

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Simulation: For this sim a 'shadow box' approach was used which is where we observed a video of a specific semi-scripted encounter being managed by a professional which in this case was a registered nurse. The recorded sim involved a registered nurse and a student nurse responding to a patient having a mental health episode who was initially admitted with an exacerbation of asthma. The believed episode of psychosis required the nurses to safely de-escelate and manage the situation that had reached a crisis point where a code black was required to be called. Calling a code black adheres closely with NMBA standard 5.3 of modifying plans to fit with outcomes as calling a code black when de-escelation isn't working effectively prioritises immediate safety in collaboration with the healthcare team. Class discussions of the video included voluntary/involuntary patient management as per the Mental Health Act, the criteria for when a code black should be called and looking at the de-escalation techniques that were used and their effectiveness (Mental Health Act, 2015). These conversations also re-inforced the importance of legal and organisational protocols and policies being in place like the mental health act, as per standard 6.5 (NMBA, 2017).

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Standard 4 (comprehensively conducts assessments): Throughout this week of placement I was able to conduct comprehensive assessments on varying wounds and tracheostomy sites. This included measuring of wounds as well as non-touch technique wound dressings. It also included suctioning of the trache, looking for any increased respiratory rates or increased work of breathing and looking for dislodgement.

Standard 5 (develops a plan for nursing practice): Each day on the ward, especially throughout my first week of placement I would use a shift planner. I would write down all of the patients I had and what I needed to complete for each of them along with their goals of care with times next to each task. This included duties such as medications, observations, ADL's and risk assessments. I felt that these shift planners not only allowed me to manage my time more effectively, but also gave me a sense of accomplishment in ticking tasks off once they had been completed.

Standard 7.1 (evaluates and monitors progress towards the expected goals and outcomes): Prior to my first day of placement I created 3 SMART goals to complete over the course of the 2 weeks. These goals involved improving on ward specific skills such as neurological and spinal observations. It also included goals focusing on building my confidence and taking adequate patient loads. These SMART goals allowed me to monitor my progress throughout placement with a timely and achievable outcome that I am aiming to reach. I will continue to use SMART goal setting in my future practice.

(NMBA, 2016).

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Paediatric burns patient - using Lund and Browder framework.

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Workshop: In the workshop today there were 3 main clinical skills that we covered in our groups. Following on from the case study in our seminar we were instructed to administer analgesia via mucosal atomisation device which was a new concept for me. We then had to calculate the total body surface area of burns on the child using Lund and Browder framework and the fluid requirements for the patient using the Parklands formula. I felt as though these assessments adhered closely with standard 4, particularly 4.2 of using a range of assessment techniques to collect accurate information (NMBA, 2016). Within my group of 3 we struggled the most with the TBSA percentage. We estimated the areas covered by burns to be a much higher percentage that it was said to have been. We put this down to the scale of the images and the patient as they were not completely to scale and had been misinterpreted by us in certain areas. Understanding and acknowledging these errors in estimation reflects my group and I's active learning approach and growth in systematic assessment tools for future practice. I will continue to use these assessment tool frameworks in my future practice in order to strengthen my evidenced based clinical decision making and to avoid errors and misinterpretation.

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Simulation: The simulation for this module again followed on from the previous seminar and workshop with 4 year old Yasmin, one day post a burn injury. The 2 volunteers entered the simulation following Yasmin's father pressing the call bell asking for help with his distressed daughter. Yasmin was clearly in a lot of pain and had recently been given paracetamol and oxycodone with no further analgesia charted. The positives we discussed from the simulation included the empathetic conversations had with both Yasmin and her family. It was also noticed that the nurses involved the family in their child's care and escalated care by discussing with a doctor/team leader whether more analgesia could be charted. Some aspects of the simulation that were discussed as being more challenging included the difficulty in completing an accurate pain assessment in a child who isn't able to explicitly communicate her pain with staff. I think that knowing how to manage the child's pain and comfort her without immediate pharmacological interventions was also a challenging aspect of this simulation, as well as managing the needs of both the patient and her family.

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Standard 4 (comprehensively conducts assessments): I performed regular spinal and neurological observations across this week of placement, becoming increasingly confident in detecting subtle changes indicating deterioration.

Standard 5 (develops a plan for nursing practice): Care planning involving SAH protocols, strict fluid balance charts and restrictions and ongoing neurological monitoring were all essential components of providing care within the pods

Standard 6.2 (scope of practice): Adhering to standard 6.2, staying within my scope of practice is a standard that I am always following closely throughout all of my placements and will continue to do so once I graduate. If unsure if a skill is within my scope or not I talk to my CLN, team leader and looks through both my Universities and hospitals policies. Scope of practice is in place to protect both myself and consumers.

(NMBA, 2016)

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In order to enhance my ability to respond to a patient who is clinically deteriorating I will continue to work on strengthening my structured primary assessments, specifically a thorough A-G assessment. This ensures that in the event of deterioration I am collecting relevant and accurate data to inform the next steps of practice in a timely manner, linking closely to standard 4.2. In the event of a MET call on one of my patients or a serious deterioration I will ensure that I stay within my scope of practice and respond proactively, taking lead where I can in order to build my confidence in emergency interventions such as CPR and airway management, aligning with standards 6.1 and 6.2. I am going to always be using my critical thinking skills and the assessment data that I have collected from my patients in order to recognise any early waring signs and potential complications which will allow me to develop more effective care plans (standard 5.1).

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Seminar: Module 7, week 9 was our last seminar for this unit. Throughout the seminar this week we went into detail about our upcoming clinical VIVA assessment in 2 weeks time. We were given an example scenario along with 3 different exemplar answers to different parts of the assessment which we as a class attempted to mark on the rubric. As the VIVA is an assessment that I think a lot of students including myself are quite nervous for I found this seminar extremely beneficial. Through the examples and discussions I now know that I need to have a deep understanding behind the pathophysiology of my condition and well as medications and how they interact. I need to ensure I am interconnecting everything with evidence from the case scenario and taking into consideration all parts of a person-centred holistic care approach.

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Emergency Nurses Association. (2019). Trauma nursing core course provider manual (8th ed.). Emergency Nurses Association.

Lund, C. C., & Browder, N. C. (1944). The estimation of areas of burns. Surgery, Gynecology & Obstetrics, 79, 352–358.

Mehta, M., & Tudor, G. J. (2020). Parkland formula role in treatment of severe burn – Case report. Liječnički vjesnik, 142(1-2). https://doi.org/10.26800/lv-142-1-2-7

Mental Health Act 2015 (ACT) (Austl.).

Nursing and Midwifery Board of Australia. (2017). Registered nurse standards for practice. Nursing and Midwifery Board - AHPRA. https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

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In my future clinical practice as a registered nurse I will draw upon information from this module in order to confidently contribute to the management of patients with DKA. I will incorporate application of standard 6.5 ensure that I am applying the clinical interventions in an appropriate order, such as administering fluids prior to insulin and always using safety mechanisms like the drug library on pumps when administering high risk medications such as insulin. Additionally to meet standards 5.1 and 5.1 I am going to continue to tailor how I provide health education to the patient's individual health literacy levels using clear, general language and checking for understanding throughout. This will ensure that health education is both accessible and effective. Lastly in relation to standards 7.1 and 7.3 I am going to reflect on outcomes and feedback within my practice to monitor whether or not my goals have been met. This is in relation to both my clinical skills and patient communication strategies when providing education. These strategies along with adhering to the standards mentioned throughout my reflection will allow me to provide culturally safe, person-centred evidenced-based care.

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In future clinical practice I will apply standard 4.2 in continuing to use assessment tools such as the Lund and Browder chart and the Parkland formula to ensure that my clinical decisions and interventions are based on accurate data that is evidenced. In order to be able to confidently recognise and understand the complexity of a paediatric pain assessment, especially in non-verbal and distressed children, I am going to aim to expand my knowledge in non-verbal pain cues and alternative communication methods for patients. This could include behavioural behaviours as well as looking at baseline provided by family members. This allows for me to provide more holistic care to my patients in line with standard 5.1 which focuses on tailoring care to best available evidence in order to meet the individual needs of the patient and their families.

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Key takeaways from this module and future strategies I am going to incorporate into my practice include strengthening my understanding and application of de-escelation strategies . I can do this by reviewing local clinical policies on the criteria of a code black as well as practising clear and therapeutic communication techniques with all of patients. Furthering on standard 6.5 with reviewing code black policies I will also ensure I am staying up to date and deepening my knowledge of all mental health legislation including the Mental Health Act. This will allow me to act within both ethical and legal parameters when caring for mental health patients particularly.

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In future practice when faced with a trauma specific patient I will continue to strengthen my understanding and actively use structured frameworks such as the trauma nursing process (TNP) as well as aiming to improve my clinical reasoning in acute settings (standards 4.2 and 5.1). This will including practicing not only my thorough primary assessments but also focused secondary assessments, in-depth pain assessments, and recognising potential red flags, including medication related complications. Another important part of treatment of patients, specifically higher acuity patients in trauma settings include prioritising and delegating skills where necessary as well as clarifying roles and incorporating shared decision making. This supports standards 6.3 and 6.4 ensuring that I can coordinate care when necessary in high pressure situations.

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I have not used any GenAI tools/services in the preparation of this assessment. I understand that providing false or misleading information in this GenAI Acknowledgement Statement may constitute a breach of the University of Canberra (Student Conduct) Rules 2023.

I confirm that I have not used GenAI in the preparation of this assessment for any purpose other than what I have acknowledged above and I have cited and referenced any GenAI content in my assessment submission, applying the relevant referencing style. I understand that providing false or misleading information in this GenAI Acknowledgement Statement may constitute a breach of the University of Canberra (Student Conduct) Rules 2023.

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The patients infusion order and calculation of insulin

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Workshop: Throughout the clinical skills lab during module 2 we were looking at fluid replacement and insulin infusions. Within my group of 3 over the hour we calculated how much insulin we were to give and how much fluids we needed to give this paediatric patient. We had discussions around the high risks of insulin and how when given through pumps it needs to be done through the drug library to avoid human error. Focusing closely on safe insulin administration links closely to standard 6.5 of providing safe . appropriate and responsive quality nursing practice (NMBA, 2016).We also had conversations around whether you would administer insulin or fluids first and decided that fluid replacement should be commenced before an insulin infusion to avoid too rapid of a decrease in BGL.

I felt that standard 7 of evaluating outcome to inform nursing practice was very prominent throughout this workshop, specifically 7.1; evaluates and monitors progress towards the expected goals and outcomes (NMBA, 2016). Our discussions and decision around administering fluids before insulin reflected on evidenced guidelines for DKA management in paediatric patients.

Overall I found this workshop a very positive learning experience. Although the clinical skills were quite basic, the understanding and discussions had around fluid replacement and insulin infusions in paediatric patients I found extremely beneficial to my learning and for my future practice.

Simulation: For this module, 2 of my peers volunteered to enter the simulation as the rest of us observed via a live stream set up. The simulation involved a young female adult who was struggling with the management of her newly diagnosed diabetes. The 2 student nurses had to provide extensive education and comfort to this patient, taking into consideration her health literacy and minimal understanding about the management of her diabetes. Overall, I thought that these 2 students did an amazing job in the simulation.

Some of the positives that we discussed as a class was the mirroring of body language to ensure the patient felt as comfortable as possible. The reassurance provided consistently throughout the scenario and the education of diabetes being explained in terms that match the subjects health literacy level.

Some of the aspects we discusses that as individuals we would find difficult included what more to talk about or do with this patient. As the students were in simulation for around 10 minutes it was a very long time to keep providing education and find new things to explain that they hadn't already previously.

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preparation and administration of  IV 15% glucose 50ml.

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Workshop: For this weeks workshop we were looking after Maggie Thatcher. Maggie was brought into ED from an aged care facility after 48hrs of vomiting and diarrhoea. She had a medical history of T2DM, peripheral vascular disease and congestive cardiac failure, a topic I have been revising at home as part of my upcoming VIVA. The red flags that stood out from Maggie's initial A-G assessment included, that she was tachycardic and hypotensive with 50 below her usual systolic. She was drowsy with a GCS of 14, had limb weakness and decreased cap refill. Her temp was 37.5 with ongoing vomiting and diarrhoea and hadn't tolerated any fluids over the last 45 hours, her BGL was also 2.5. After discussing within our group we decided that Maggie was showing several signs of deterioration and we needed to get some IV fluids and IV glucose charted which we prepared and commenced for Maggie. We also discussed getting the medical officer to chart some ondansetron for Maggie due to her nausea. This initial assessment and then escalation of care for Maggie with fluids and glucose links closely to all of standard 6 in providing safe appropriate and specifically responsive nursing care to Maggie. Through using systematic assessments and a hollitic care approach as explained in standards 4.1 and 4.2, we were able to treat Maggie's nausea and vomitting with an antiemetic, hydrate her appropriately and increase her blood glucose levels.

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Introduction for each of the 4 patients.

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Simulation: for the simulation this week we did not partake in a physical simulation but instead worked within groups of 5 to prioritise the care of 4 patients as an RN in an aged care facility. We had 4 patients which included Mary, John, Rose and Paul who all had gastroenteritis. We were given updates on these patients every 10-15 minutes which marked every hour within the scenario.

Hour 1 - During the first hour we had prioritised John first. John was a diabetic with an elevated BGL of 12mmol/L and a temperature of 38.2. He had had 4 episodes of vomiting and diarrhoea and was lethargic and slow to respond. We were concerned with John's slightly elevated BGL, temperature and dehydration due to his poor urine output. Next we prioritised Rose. The red flags that stood out for Rose included her COPD diagnosis and recent use of her inhaler as well as her feeling short of breath. While more stable than John, these were noted as early warning signs for deterioration. Next was Mary who had all the common symptoms of gastro including temperature, vomiting and diarrhoea. At this point she was stable but we were slightly concerned about her dementia and confusing. Paul at this stage had mostly within normal limits vital signs with 3 episodes of diarrhoea and was stable.

Hour 2 - at hour 2 we still found John to be the priority due to his increasing temperature up to 39, his high RR and HR and his increasing BGL at 14mmol/L now. He also displayed worsening signs of dehydration. Next we stayed with Rose as her vital signs were also deterorating along with her shortness of breth and her risk for a COPD exacerbation was increasing. Mary now has a temperature in the high 38's and worsening vital signs. Her urine output was slightly decreased but not to nothing. Paul continued to remain stable with no new concerns or deterioration.

Hour 3 - In the last hour it became clear that John, Rose and Mary were all worsening still. John with a temp in the 40's now, tahcycardic and hypotensive as well as altered conscious state and very lethargic. We discussed that as our first priority we would be calling an abulance to send John straight to ED. We had conversations as a class to whether Rose or Mary would have been our next priority. I believe that it would have been Mary due to increasing confusing and extreme tachycardia and temperature, however, the conclusion was made that we would call and ambulance for both of them as well. Rose while still deteriorating with her shortness of breath and weakness still appeared to be more vitally stable and cognitive that Mary. Lastly Paul remained stable, recovering well.

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Some strategies I will focus on in future practice in order to further strengthen my ability to deliver safe and holistic, evidenced-based care include to deepen mu understanding on clinical reasoning as well as my prioritisation skils. Linking to standard 4.1, i will ensure when prioritising patient care that I am looking as the scenario as a whole, not only looking at how the patient is presenting now, but also how likely they are for fast and serious clinical deterioration. I will also adhere closely to standard 4.3 in working in partnership with other allied health professionals in order to determine all factors that could contribute to a patients health and wellbeing and a potential deterioration.