On this first week, I had the opportunity to participate in unit contents as a INC 6 group. Working as an Endorsed Enrolled Nurse over the years have enabled me to continue provide holistic and patient-centred care. I really liked the idea of being involved in three distinct learning experiences.

A seminar- where we will explore the concepts of the module

A clinical skills lab session- where we will practice clinical skills

A simulation suite session- where we can act as an RN and involve in the scenario

In the seminar, we participated in the discussion of unit overview, addressing unit learning requirements, covered the subject matter, shared our expectations, discussed our queries and strategies to deal with upcoming challenges. Our discussion included how our theoretical knowledge and clinical skills should reflect as well as guided by the Nursing and Midwifery Board of Australia's Registered Nurses standards of practice. We also got an absolute great opportunity to get to know each other by approaching someone we didn’t know before and involving in interactions. This idea really suits my learning style since I needed to fully understand the concept in a friendly environment.

In the clinical lab session, we were introduced to the UCH clinical areas and participated in groups to enhance our clinical skills in administering antibiotics, accessing pain levels, and administering scheduled 8 pain medications. Standard 3 of the Nursing and Midwifery Board of Australia emphasises on maintaining capability of practice for Registered Nurses where as Standard 6 emphasises on providing comprehensive safe, quality practice that are responsive to the nursing needs of the people. I maintained my capability of practice to promote comprehensive safe and quality nursing practice by identifying prescription error, finding correct administering techniques, adhering to seven rights of medications check and following safety protocols. As a nurse, we have huge responsibility to maintain patients' safety and giving wrong medication may have serious outcome. I thought of the responsibilities that I would be carrying while administering medications to patient and asked myself several questions such as "Do you know what medication is it?", "what does it do to body?", "Does it have any administering requirements?", "why are you giving this medication?", "can there be possible side effects?", "is the medication chart correct?" and so on. These questions made me look for the answers that me as someone handing those medication should be competent to know. 

• I will adhere to this standard by practising my clinical skills in accordance with relevant policies, guidelines, standards, regulations, and legislation to ensure delivery of comprehensively safe practice. 

• I will research about medications, possible interactions, mechanism of action, correct administering route, and possible side effects utilising resources such as MIMS, AHM handbook, do not rush to crush booklet. 

• I will immediately report error to the team leader and respective medical officer, seek guidance, and follow the medication safety policy of respective organisation. 

• I will complete my eLearnings required for medication administration, administration for intravenous medications and do revision as needed to build and know my scope of practice. 

• I will develop my competency in administering medications under the supervision of Clinical Development Nurse (CDN) or task supervisor. 

• I will be working on improving myself everyday through study, research and will approach for help if i struggle at any point during administration of medication. 

• Hyperglycemia

• Ketosis

• Acidosis

• Dehydration

• Electrolyte Imbalances (Sodium, Potassium, Magnesium and Phosphate)

Interventions:

• Biochemistry

• ABG/VBG

• ECG

• Urine analysis

• BGL/ketones

  
  

Link between one symptom (Hyperglycemia) and one intervention (Urine analysis):

Hyperglycemia is a common symptom of diabetes which can lead to serious complications if left untreated. Urinalysis assesses glucose and ketones in the urine. Urine analysis examines the physical, chemical, and microscopic properties of urine, plays a crucial role in detecting elevated levels of glucose in the urine like glucosuria. Glucosuria indicates that excess glucose is spilling into the urine due to the kidneys' inability to reabsorb all filtered glucose, typically occurring in cases of uncontrolled diabetes or other medical conditions affecting glucose metabolism. By identifying glucosuria, urine analysis provides important insights into the presence of hyperglycemia, guiding healthcare providers in the assessment and management of diabetes and its associated complications. Urine analysis helps to ensure timely intervention and effective management of hyperglycemia and related conditions.

Daily life with Diabetes care post discharge:

Post discharge diabetes care is vital to maintain good health and prevent possible complications.

Overview of what daily life with diabetes care looks like post-discharge:

• Blood Sugar Level (BGL) monitoring: Regular BGL check is crucial for diabetes management as recommended by their healthcare provider and adjustment is needed accordingly.

• Medication Management: Individuals with diabetes may need to take oral hypoglycemic agents or insulin to manage their BGL. Adherence to strict medication regimen is necessary post discharge.

• Diet management: Following a correct balanced diet that includes introducing nutrient-rich foods, limit intake of sugars and carbohydrates is essential for managing diabetes.

• Physical Activity: Regular exercise helps to improve insulin sensitivity, control blood sugar levels, and maintain overall health.

• Monitoring for Symptoms: Patient education on monitoring for symptoms of hypo and hyperglycemia and take appropriate action if symptoms occur.

• Foot Care: Diabetic patients need to inspect daily for any wounds, cuts, blisters or any signs of inspection and practice foot hygiene as they are at increased risk of foot problems due to poor circulation and nerve damage.

• Regular Medical Check-ups: Individuals with diabetes should monitoring blood sugar levels, monitor for complications, assess overall health and adjustment to treatment plans as needed.

• Emotional Support: Addressing emotional or psychological concerns is crucial as living with diabetes can be challenging.

• Education: Education regarding self-management is necessary for individuals to effectively manage their condition.

My immediate reflection for my future practice were:

• I will double-check policy to independently verify medications, charts, and procedures before administration to add a layer of safety and reduces the risk of errors.

• I will foster open communication to speak up about my potential errors to aware others.

• I will stay updated on best practices, guidelines, and protocols related to medication administration and patient safety.

• I will participate in medication administration training and educate myself to enhance my knowledge and skills.

• I will take time to reflect on today's experience and near-misses to prevent similar incidents in the future and identify areas for improvement.

Insulin infusions are considered high-risk medications that require careful monitoring, double checking, and dosing according to hourly BGL. As it needs to be closely monitored and considered high risk there is an insulin infusion policy which I got to read when I was in placement at The Canberra Hospital and nurses should adhere to this policy for a successful safe insulin infusion. This is in compliance with NMBA standards 6.1 and 6.5, which require safe practices that follow relevant guidelines and standards.

• Collaboration and interactions during these sessions built my knowledge through shared views and perspectives.
• Exposure to different kind of learning experiences developed boarder perspective of the unit. 

In week 2 of seminar, we discussed the case study of a 17 years old Avery who identifies themselves as a non-binary individual. We explored various health information of DKA, its symptoms, rationale, and prompt interventions for its management. We talked about role of electrolytes including potassium, magnesium, phosphate and sodium in context of DKA. We worked in a group to identify importance of various diagnostic test such as ABG/VBG, ECG, BGL/Ketones, urine analysis and biochemistry in accessing Hyperglycemia, acidosis, ketosis, dehydration and electrolyte imbalances. Our discussion also addressed psychological heath of Avery, collaborations with multidisciplinary teams, health awareness and post discharge management.

Clinical lab session:

In week 2 of our clinical lab session, I practised clinical skills based on the Avery case study. Case was focused on rehydration and commencement of insulin. As per case requirement, Avery was prescribed Actrapid 50 iu in 50 mls and 1L of Normal Saline. We worked in a group, introduced ourselves to patient, patient identification checked, attended bed site safety check and conducted A-G assessment. We started IV therapy for dehydration at the rate of 160 mls/hr and administered insulin infusion at the rate of 5.4 units/hour. We practiced these clinical skills guided by the policy of insulin therapy and subsequent IV fluid therapy from Canberra Hospital and Health Services. The biggest challenge that I found during my clinical practice was using pronouns "they/them". Growing up in a conservative society where "they/them" are specifically used for addressing plural pronoun, I was unconsciously making mistakes and might have appeared disrespectful by not using gender-neutral pronoun. I immediately took responsibility of my actions, apologised sincerely to Avery, and corrected myself. This reflects my understanding of NMBA standard 2.2 which states The RN communicates effectively and is respectful of a person’s dignity, culture, values, beliefs and rights. According to Standard 5 of NMBA, RNs are responsible for the planning and communication of nursing practice so I corrected pronouns on all documents, developed a plan to include the "they/them" pronoun in the handover, and incorporated this subject into her individualised care plan.

Simulation session:

In the simulation suite, I observed scenario on diabetic education through a live feed. My classmates demonstrated outstanding presentation by remaining composed, validating Avery's concerns, providing reassurance and education on management of Diabetes post discharge. Effective teamwork was reflected in managing challenging emotional states and referring to Diabetic educators. This aligns with NMBA Standard 4.3, which states working in partnership to determine factors influencing the health and well-being of individuals and populations to establish priorities for action or referral. After watching scenario, we reflected on the case and our discussion involved diabetic education, referrals, multidisciplinary team, empathy, active listening and others. Discussion was very helpful in post reflection and provided opportunity to learn from everyone's insights.

• I will prioritise comprehensive and culturally sensitive assessments, ensure that questions and interactions are inclusive, and facilitate a safe space for patients to express themselves without fear of judgement and discrimination.

• I will use a range of assessment techniques to gather necessary health information and identify any psychological or emotional factors that may impact their well-being.

• I will collaborate with patient, their family and healthcare professionals to discussing any barriers to care due to their gender identity and work together to prioritise interventions or referrals.

• I will assess the resources available such as gender-affirming healthcare services and non- heterosexual support networks to provide high quality care that meets the unique needs of individuals in the planning and delivery of care.

Experience with infectious disease:

Exposure to various infectious diseases increased my awareness of the importance of infection control, antibiotics, and patient education. While looking for infectious disease patients, I referred to infection prevention and control policies, guidelines for implementing isolation precautions, antimicrobial stewardship policies and complied with occupational health and safety policies. I reviewed policy regarding required precautions for HIV, RSV, VRE, MRSA, and Tuberculosis. I worked under supervision of Registered Nurse in conducting comprehensive assessments by identifying individuals at risk of infection, assess their understanding of preventive measures, and evaluate patient's compliance with recommended precautions. I found the importance of effective communication between patient, infectious disease specialists, nurses, and pharmacists in managing complex infections. This aligns with standard 2 of NMBA practice in engaging in effective therapeutic and professional relationships to promote patient-centred care. It involves respectful communication maintaining person’s dignity, culture, values, beliefs and rights. I collaborated with interdisciplinary team, supported patients and families, and advocating for patients as required. I maintained my capability of practice by building my knowledge and skills in infection control, prevention, and management to provide safe and effective care to patients with infectious diseases.

Experience with Neurological disease:

I was saddened by witnessing impact of neurological disorders on patient's quality of life due to physical limitation, cognitive impairment, social isolation and emotional distress. I found the significance of personalised care plans, rehabilitation services, and ongoing support systems which caring for patients with neurological disorders. I did neurological assessment, observations, pain assessment, cognitive function assessment, skin integrity checks under supervision of my RN. I followed neurological care guidelines, medication management policies and patient safety policies while looking after patients with neurological disorder.

I was able to meet NMBA Standard 4.2 by developing competence in conducting neurological assessments and implementing evidence-based interventions. I established plan of care (Standard 5) by developing personalised care plans under the supervision of RN to address the unique needs and goals of patients with neurological diseases. I evaluate the outcomes of neurological assessments and interventions to determine their effectiveness in improving patient outcomes and adjusted the plan as needed reflecting my ability to maintain NMBA standard 7.

Experience in Stroke Ward:

My experience in stroke ward was very valuable as it helped me identify early signs of Stroke, take prompt actions and conduct necessary assessment. It saddened my heart seeing patient having stroke at such a young age and session with my CLN helped me guide that was not my weakness but human response and encouraged me to be more resilient. I was impressed by seeing role of stroke nurse, speech-therapists and other multidisciplinary teams. I observed nurses conducting Glasgow Coma Scale (GCS), National Institutes of Health Stroke Scale (NIHSS), nutritional, functional and psychosocial Assessment. I practised within my scope of practice during my stay in Stroke ward adhering to Standard 6 to deliver safe, appropriate and responsive care. For these assessments, I referred to stroke management policies, dysphagia Screening and Management Policies, fall Prevention Policies, medication Management Policies. I developed competence in conducting comprehensive assessments to identify stroke-related signs by maintaining Standard 3 and Standard 4 of NMBA practice. I develop individualized care plans(Standard 5) to optimize post stroke complications and facilitate recovery. I gained lots of knowledge about secondary prevention strategies and lifestyle modifications in reducing the risk of recurrent strokes emphasised the holistic approach to stroke management.

During my placement, I followed registered nurse standards of practice, nursing rights of medication administration and nursing code of conduct to ensure quality and comprehensive care for the consumers. I felt supported with the reassurance and kind words from Clinical Development Nurse (CDN) of the ward and my Clinical Liaison Nurse (CLN). My experience in this clinical settings expanded my clinical knowledge and skills as well as deepen understanding of holistic and collaborative approach essential in providing optimal patient care with infectious diseases, neurological disorders, and stroke-related complications.

To manage CAUTIs in my future practice, I will align with Standard 7 of NMBA practice. It emphasises on assessing and monitoring progress towards expected goals and outcomes, adjusting plans based on this evaluation, and communicating further priorities, goals, and outcomes to relevant stakeholders.

• I will regularly check for signs and symptoms of infections with urinary catheters, monitor patient's progress, and implement routine monitoring protocols within my scope of practice to assess the effectiveness of catheter care practices.

• I will establish clear goals related to the prevention and management of CAUTIs as well as collaborate with the healthcare team and patients to set individualized goals based on their specific needs and preferences.

• I will regularly review and evaluate the effectiveness of my catheter care practices in preventing CAUTIs and modify care plans as needed based on the findings, evidence-based practices and guidelines to enhance infection prevention strategies.

• I will effectively communicate with other nurses, physicians, and other healthcare team members, to ensure alignment of goals and priorities in CAUTI prevention and management.

• I will maintain accurate and comprehensive documentation of assessments, interventions, and outcomes related to catheter care and timely interventions.

On our fifth week seminar, we explored the care of a paediatric patient experiencing a burn injury. We discussed about the importance of giving adequate analgesia to facilitate assessment and patient's comfort during burn injury. I learnt about the integumentary system, first aid to burn, types of burn, body surface area (BSA) % calculations of a burn injury and paediatric pain assessment. This learning helped me recognise required patient care and nursing interventions for patient with burn injury.

Clinical lab session:

During clinical lab session, I had chance to prepare and administer Fentanyl inhaler and practice IV fluid resuscitation.

Administration of Analgesia- Intranasal Fentanyl:

We checked the medication chart for intranasal fentanyl administration and reviewed the RCH clinical practice guideline of Intranasal fentanyl administration. As per guideline, initial Fentanyl dose for paediatric patients with 18 kg is 27 mcg (1.5 mcg/kg) but charted dose was 30 mcg which needs to be clarified. We were able to reflect on Standard 1 of NMBA and 7 rights of medication administration, think critically and raise this issue to medical officer. I built a sense of trust and cooperation, checked readiness, explain the Procedure in playful way and gave constant reassurance before using MAD device to a paediatric patient.

IV fluid resuscitation:

I was shocked to see huge calculations we had to do for calculating BSA percentages using Parkland formula for burn injuries. I found myself sharpening my math skills and paying attention to detail to maintain accuracy during calculations. Estimating BSA % was crucial for us during clinical lab session to determine appropriate rehydration requirements because we don't want to overload patient with too much fluid. I was able to think critically by identifying the mistakes in prescription order and communicate with medical officer to clarify the wrong dose and maintain patient safety. I realised the importance of monitoring signs of fluid overload, electrolyte imbalance, or adverse reactions. Our team came up with plan to start fluid balance chart, which shows RNs are responsible for planning and communication of nursing practice(Standard 5). I documented all aspects of IV fluid resuscitation, including the clinical presentation, fluid calculations, fluids/medications administered, vital signs, urine output, and response to treatment. This will help me evaluate and monitor patient's progress towards the expected goals(Standard 7).

• To mitigate this type of nervousness situation, I plan to incorporate A-G assessment each time when I see a patient. I believe repetitive practice will assist me in remembering each categories effectively in my future practice.

  
  

• I will seek help from senior or experienced staffs if i struggle to provide reassurance to parents and deal with child.

  
  

• I will practice to become less hesitant and be transparent about my limitation regarding dosage of medications administered and my scope of practice.

My self learning this week have made me realise the importance of conducting comprehensive assessments that includes understanding of family dynamics, peer relationships, and past trauma. I realised complexity of understanding adolescent mental health, which requires nurses understanding of developmental psychology, social factors, and cultural influences.

After performing a compressive A to G evaluation, I became more concerned about Avery's respiratory rate of 9 and she was mildly sedated. I realised that Glasgow Coma Scale (GCS) should have been done straight away as to measure the patient's consciousness and the focused neurological examination to evaluate the patient's motor function, reflexes, pupillary response, and consciousness. Focused neurological assessment led me to find pinpoint pupils in Avery which along with other assessment indicated possible opioid overdose. This incident guided me to use variety of thinking strategies in making decisions, accurate assessment techniques and providing safe and quality nursing practice as illustrated in Standard 4.2 and standard 6.1 of NMBA nursing standards.

I initially considered administering Naloxone (an opioid-receptor antagonist) via intranasal route as effective option which guarantees therapeutic effects and drug absorption while being non-invasive. It is an effective alternative route as it is absorbed into circulation avoiding first pass metabolism which helps for rapid onset of action. Later, I came to realisation that Avery wasn't conscious to be able to inhale medication. While naloxone was being administered on one hand, I checked BGL as well considering her history of hypoglycaemic episodes. This aligns with the NMBA standard 4 and standard 1 of conducting assessments systematically and using critical thinking to make informed decisions for best patient outcomes.

• I will conduct thorough pain assessments using age-appropriate tools and techniques to collect information on the child's pain experience.

• I will incorporate evidence-based pharmacological and non-pharmacological pain management interventions tailored to the child's age, developmental stage, and individual needs.

• I will develop a holistic pain management plan that addresses the physical, emotional, and psychological aspects of pain. I will document all pain assessment findings, interventions implemented, and the child's response to treatment to facilitate ongoing evaluation and modification of the pain management plan.

• I will continuously evaluate the effectiveness of pain management interventions and modify the care plan as necessary based on the child's response to treatment and changing needs.

• I will collaborate with other healthcare professionals, including pain specialists, psychologists, and physical therapists, to optimise pain management outcomes and identify underlying cause.

• I will coordinate resources effectively, including pain medications, equipment for non-pharmacological pain management techniques, and access to specialised pain management services to provide comprehensive care.

• I will consider interventions based on pain level and use my critical thinking to administer either analgesics or non-pharmaceutical strategies(positioning, distraction, heat packs/cold packs). (Standard 6.1)

I analyzed the urgency of Ivory's health status from the nervousness of the student nurse, validated her response, took a quick ISBAR handover and started with my primary A-G assessment. However, we were able to link patient's situation to opioid overdose and provide timely intervention showing our capability of practice as illustrated in Standard 3.1 but we were frequently distracted with constant questions from the student nurse leading me to forget some assessments. I felt under stress of "what to do next?" as our interventions weren't giving positive outcome. At first, I was reluctant to request MET and was overwhelmed by thoughts of the challenges during the MET. But I reflected on understanding the MET call criteria is very important so the treatment is not delayed during critical moments.

I was able to demonstrate good teamwork with my colleague, show efforts trying to solve problem by using Hudson masks for decreased saturation and collaborated well with MET team in providing basic life support to Ivory. My interactions with student nurse and MET team aligns with the NMBA standard 6 of collaborating effectively within the healthcare team to optimise patient outcomes.

My take home strategies were:

• I will not hesitate to call for assistance or escalate care when needed, especially in situations where my interventions are not giving positive outcomes and the patient's condition is further deteriorating. It aligns with NMBA Standard 3.1 and 4.3 to respond in timely manner and to determine priorities for action.

• I will take time to reflect on my experience, identify areas for improvement and develop strategies for future practice which aligns with NMBA standard 5.3.

• I will establish open communication for a clear understanding of each team member's role to minimise distractions and improve coordination during critical situations. This aligns with NMBA Standard 6.4 which states to provide effective timely direction and supervision to ensure that delegated practice is safe and correct to ensure safe and coordinated care.

• I will develop a systematic plan to prioritise tasks and monitor the progress towards the expected goals as stated in NMBA standard 7.1 during critical situations to stay organised and focused, even in high-stress situations.

During this de-escalation process, the first clinician was able to immediately back off from the patient's zone, monitor the patient from safe distance and directed second nurse to initiate code BLACK to prevent any further harm to patient and get extra hand for staff's safety. This provides evidence and adherence to Standard 6 of delivering nursing care that is appropriate, safe, and responsive. It shows recognition of escalating situations, appropriate delegation of tasks for everyone's safety, and adherence to regulation protocol to prevent potential harm.

• I will prioritise effective communication skills such as active listening, good body language, and showing empathy from a safe distance and leaving the exit unblocked. This ensures safe nursing practice to de-escalate the tense situations.

• I will practice within my scope of practice by evaluating my capability and not placing myself in distressing situations if it has negative impact on me or patient outcomes. I will reflect on my emotions in challenging situations, such as managing highly agitated patients can have negative impact on myself.

• I will work collaboratively with other healthcare members to ensure a coordinated and safe approach to manage agitated patients and maintain safety of staffs.

• I will analyse the situation for potential risk to both patients and staffs so I can approach for timely interventions such as calling code BLACK or staff assistance in time.

We discussed about rapid assessment and intervention of life-threatening conditions in primary survey focusing highly on ABCD (Airway, Breathing, Circulation, Disability) where as a detailed assessment of the patient's injuries in secondary survey once life-threatening conditions have been addressed. As a new Registered Nurse, it can be distressful and overwhelming to witness rapid deterioration of patient. I learnt the importance of allocating roles, making plan through discussion and knowing your ABCD plan plays vital role in overcoming such stressful environment.

Take home points:

• Handover should be done precisely and formulate a plan when transitioning trauma patients from one place to another.

• If something changes in the primary survey and findings aren't in the normal range, the patient should be reviewed and addressed the troubleshoot.

• Keep the patient warm and don't give cold blood.

• PMHX: HTN, migraine, depression

• Meds: Propranolol - 30mg daily. Fluoxetine - 40mg daily. Aspirin - 100mg daily

  
  

In our clinical lab session, we did a primary survey on Steven where I prioritised A to D. 

A- airway patent, nil obstruction noted and speaking clearly in full sentences.

B- RR: 30, symmetrical rise and fall of chest, Sats: 92%

C- HR: 117, CR< 3 seconds, skin warm to touch.

D- Confused, GCS: 14, suspected spinal cord injury: spinal precautions implemented.

I was able to utilise above findings to develop a care plan for Steven provides evidence towards Standard 5. As I continued with my primary survey, I stopped at "Breathing", and started Steven on 2 L/min oxygen therapy via nasal prongs and continued monitoring his saturation. I started to get worried about his heart rate and recent onset of confusion. I continued to think about multiple possibilities causing abnormal findings on primary survey such as chances of internal bleeding as he hit his head, increased pain and others. I realised need of further assessment and investigations to identify potential underlying cause as well as communicating to healthcare team for early interventions.

When Steven reported pain in his neck and L) side of his chest, I performed pain assessment using PQRST mnemonic. I started to look for best appropriate analgesia for Steven and his medication chart increased multiple confusions in my mind. There were several factors to considerate while administering his pain medication such as level of his pain score indicating need of stronger opioid analgesia, his previous experience with morphine (any reactions, effectiveness, time when taken last) and his nausea making IV route more suitable than oral. I felt need of broad critical thinking mind when educator was explaining multiple perspective to be considered prior administering pain medication. As per Standard 5.1, Registered Nurses uses assessment data and best available evidence to develop a plan. I utilised the assessment findings, referred to previous notes and developed a plan to administer IV anti-emetic (Ondansetron) and IV fentanyl after 5 mins.