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.

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.

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-

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.

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.

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.

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.

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).

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)

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

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.

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.

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.