SOLUTION: Aabish Ali is a 19year old student studying physiotherapy. She was diagnosed with Asthma as a child and has taken inhalers daily since then which keep it under control. Her peak flow is 500 L/min. She is currently having some occurrence of waking up and tightness in her chest overnight which she has attributed to anxiety and stress over her upcoming exams.

Scenario

Aabish Ali is a 19year old student studying physiotherapy. She was diagnosed with Asthma as a child and has taken inhalers daily since then which keep it under control. Her peak flow is 500 L/min. She is currently having some occurrence of waking up and tightness in her chest overnight which she has attributed to anxiety and stress over her upcoming exams.

Last night Aabish was found collapsed in the street by a passer-by who called an ambulance. The paramedics stated that Aabish had an audible wheeze when they were assessing her prior to bringing her to hospital. Aabish’s family have been informed of her admission to hospital and they are on their way.

Aabish is very upset. She is struggling to breathe and is unable to talk in full sentences. Her observations in A&E are:

Bp: 88/63mmHg

HR: 115bpm

RR: 28bpm, using accessory muscles

Sp02: 88% on room air

Chest auscultation: Wheeze

Temp: 36°C

Urine Output: Unsure when last passed urine

ACVPU – C GCS: E3 V4 M6

BSL: 4.5mmol/L

CRT: 4 seconds, peripherally cool to touch

Guidance for working through the scenario

Use the principles of ABCDE assessment and NEWS 2 scoring to establish the acute condition of Aabish and to assess if she is at risk of deteriorating.
Analyse the assessment data and related pathophysiology to plan the next steps of Aabish’s in terms of medical or surgical interventions and involvement of the multi-disciplinary team. Explain any abnormal signs and symptoms. Link the abnormal signs and symptoms to Aabish’s diagnosis and the underlying pathophysiology and/or compensatory mechanisms.
Identify and discuss the ethical-legal principles that apply to the clinical assessment of Aabish. Consider and discuss any capacity issues with reference to legal and ethical frameworks. Analyse the rationale as to why these principles should be applied. Discuss how you will utilise communication strategies and the ethico-legal principles that apply Aabish.
Examine the efficacy of strategies you might use to communicate with the multi-disciplinary team, families, carers.
Examine your clinical assessment of Aabish and your interpretation of the assessment data and using the evidence base, consider the actions you might take. Discuss the relevant interventions, treatment, including further investigations that Aabish requires. Using guidelines and evidence-based literature provide a rationale for each intervention, management and evaluation of care.

You are required to submit a 2,500 word structured critically reflective report based on a formative simulated activity which addresses all the points to consider.

Using the information in the patient scenario and your reflection on your communication within the simulation your brief will examine your knowledge and skills necessary to assess and deliver safe and effective care when a person is acutely ill, with reference to the patient’s underlying pathophysiology, relevant clinical guidance, and legal/ethical frameworks. It will appraise your ability to recognise people who are acutely ill and at risk of deteriorating, undertake timely structured assessments, interpret clinical data, and use situational judgement to escalate findings, prioritise care needs and to plan, deliver and evaluate evidence-based, person-centred care as part of the interdisciplinary team. Your brief must address all the Points to Considers.

Points to Consider 1: Apply a structured assessment approach to recognise the acutely ill person or when a person’s condition is at risk of deterioration. This means you should use the principles of ABCDE assessment to establish the acute condition of the person or to assess if they are at risk of deteriorating. Identify normal and abnormal signs and symptoms.

Points to Consider 2: Interpret assessment data in relation to pathophysiology and commonly encountered health conditions and use situational judgement to escalate findings and prioritise. This means, explain any abnormal signs/symptoms. Link the abnormal signs and symptoms to the patient’s diagnosis and the underlying pathophysiology and/or compensatory mechanisms. With reference to evidence based literature, you should analyse the assessment data to plan the next steps of their care in terms of medical or surgical interventions and involvement of the multi-disciplinary team.

Points to Consider 4: Examine the effectiveness of strategies used to communicate and work in partnership with people, families, carers and members of the interdisciplinary team. This means you assess how successful your communication with colleagues, patient, MDT etc With reference to evidence based literature you should evaluate any strategies used.

Points to Consider 5: Apply ethical-legal principles to the care of the acutely ill person. This means that you should discuss capacity issues with reference to legal and ethical frameworks. Identify the ethical-legal principles that applied to the clinical assessment scenario and analyse the rationale as to why these principles should be applied. Discuss how you will utilise communication strategies and the ethico-legal principles that apply to the care of an acutely ill person.

Introduction (approx. 250 words)

A brief overview of the scope of the structured brief (what do you intend to do), identification and rationale for using a structure ABCDE approach.
Provide a short overview of the scenario you participated in within the simulation, the patient’s diagnosis, including relevant pathophysiology.
Include the aspects of the clinical assessment you are going to address, providing rationale for the assessment model
Identify the ethical-legal principles that will applied to your patient scenario.
Identify which reflective tool you are going to use (if you decide to use one)

Main body(approx. 2000 words)

Identify normal and abnormal physiological signs within the patient scenario. Explain how these signs relate to the patient’s diagnosis and underlying pathophysiology and/or compensatory mechanisms.
Analyse assessment data to determine next steps in the care of the patient and the involvement of the multi-disciplinary team.
Examine your clinical assessment of the patient and interpretation of the assessment data. Discuss and provide a rationale for any interventions, treatment and further investigations that the patient requires.
Examine the efficacy of any strategies you used to communicate with the patient, the multi-disciplinary team or any significant others e.g. next of kin, carer in your simulation. Discuss what communication strategies there are.
Identify the ethical-legal principles that applied to the clinical assessment scenario and analyse the rationale as to why these principles should be applied. Discuss how you will utilise communication strategies and the ethical-legal principles that apply to the care of an acutely ill person.
Provide a brief overall evaluation of your ABCDE assessment on the patient scenario

Conclusion (approx. 250 words)

Provide an overall conclusion that refers to the evidence and effectively concludes your discussion and arguments. Briefly discuss the importance of assessment, intervention and escalating findings. Briefly summarise the importance of using a systematic approach to prioritise care needs and to plan, deliver and evaluate evidence-based, person-centred care as part of the interdisciplinary team.

This task requires you to use evidence based literature and relevant clinical guidelines/ reports such as those produced by NICE, the UK Sepsis Trust, BTS, JBDS etc. You are advised to use approximately 20-25 different references.

Task Exemplars

The following are examples (from child and learning disability) demonstrating how they met the assessment brief and Points to Considers. You will see in the examples how they support their analysis with strong evidence-based resources and relate it back to the scenario or clinical practice. We have also included examples of how they met the requirement of ‘reflection’ in a reflective brief. You will notice the use of ‘I’ in a reflective brief**

These exemplars are for guidance use only and do not represent the only way to address the assessment brief.

Child Nursing

This reflective brief is based upon an A-E assessment that I undertook on Joshua, a three-month-old boy who was taken to the accident and emergency department by his 17-year-old mother, Alesha. I will be using Gibb’s reflective cycle to give an in-depth study of the experience discussed throughout this brief. This will allow me to “describe the situation, analyse my feelings and consider whether I should act in the same way again” (Smith and Roberts, 2011, p. 225). I will discuss Joshua’s care plan, during his hospitalisation and post-discharge, while appraising the evidence-based tools used to support this. These include the situation, background, assessment and recommendation communication tool(SBAR) (Stonehouse, 2018), and the Paediatric Early Warning Score (PEWs)chart (Royal College of Nursing, 2017).I will explore how effective communication is a significant aspect in delivering a family-centred approach to Joshua’s care (Webb, 2011, p. 253). I will expatiate on communication techniques between the professionals and Joshua’s mother. Ultimately, I will reflect upon Alesha’s capacity to consent and the potential safeguarding issues that may arise.

Learning Disability

Reflecting on experiences within nursing practices is an integral part of the profession as it supports assessment, planning, implementation and evaluation of individual’s care ensuring best care (Kenny, 2017). This is because reflection enables a nurse to reconsider the experience and gain an insight into their practice to improve their actions or the quality of care given to people in their care. It should also be noted that reflection is relevant to The Code, Nursing and Midwifery Council (NMC,2018) as part of the theme to practice effectively demands nurses to act on feedback to enhance their practice. Hence the need to regularly reflect on care provided to identify areas for improvement for individual’s care and continuous learning to seek improvement. The reflective report will be outlined on the framework of the What? Model of Structured Reflection, Driscoll (1994, cited in Driscoll, 2007). Although a variety of frameworks have prominence in their use in supporting reflective writing the above framework is typified using three simple questions that allows critical thinking and learning to be extracted out from an experience and areas needing improvements identified. The reflective report will use three guiding questions to set the experience in context and unearth the knowledge that facilitated my actions and decisions that led to nursing needs and care plan for an individual. I will begin by setting the situation into context with a description of the initial assessment and examine my feelings and through the experience supporting the individual and their family. I will reflect on the influences and meaning of the situation through the expected knowledge, theory and evidence-based practices to help make sense of the situation. I will evaluate the experience and develop an action plan on the identified nursing needs for nursing care.

Points to Consider 1 example: Apply a structured assessment approach to recognise the acutely ill person or when a person’s condition is at risk of deterioration.

Learning Disability *They are discussing which assessment tool they are going to use.*

Nursing models offer structure and systematic guide into decision making that aids the appropriate interventions for individuals during nursing care, stated by Yura and Walsh (1967, cited in Moulster et al.2019). Nursing models are fundamental to the nursing process, as they provide the guiding principles in enabling care therefor it is important that a chosen model for care is relevant to the nursing care being provided. As a result, the model that guided my action during the experience was the Moulster and Griffiths Model with its Person-centred Screen Tool (Moulster et al.2019). This model has combined elements of other models that draws on various strengths relevant to the needs of the individual, specifically enabling the identification of needs for individuals with learning disabilities compared to a variety of models.

Points to Consider 2 example: Interpret assessment data in relation to pathophysiology and commonly encountered health conditions and use situational judgement to escalate findings and prioritise.

Child *They are reflecting on the A-E assessment. Notice the use of reflection and analysis*

The final major concern I had during the simulation was that I forgot to consider undertaking a safeguarding assessment when assessing Exposure. This was alarming, as I did not immediately see the requirement of such an assessment in the context of the acute scenario. However, as the Department for Education (2018) asserts, safeguarding is a vital component of assessing children and young people in emergency settings and is a responsibility of all professionals involved in a child’s care at any point in time. This mistake enabled me to understand the detrimental impact that forgetting safeguarding assessments can do, as, if every professional Joshua is seen by does not undertake the assessment due to assuming that another individual will do/has done it, Joshua could be at significant risk for being harmed. As the Royal College of Nursing (RCN, 2019, p. 27) state, ‘every contact counts’ therefore I will aim to increase my knowledge of the crucial points at which a safeguarding assessment could be undertaken, and become more vigilant in assessing for signs of abuse and/or neglect in every day practice. However, my colleague and I did consider the importance of supporting Joshua’s mother during his stay at hospital, considering the fact that she is a young mother and was not expecting to have Joshua. Although her aunt is available to provide her with support, she may not be aware of the implications of Bronchiolitis and Pertussis and how she should take care of Joshua post-discharge Considering this, I recognised the value of health promotion as a component of Joshua’s care plan, as it could empower his mother to take more control over his health while building her confidence as a parent.

Learning Disability

Further to the above, The Code, (NMC, 2018) has relevance to my experience as it lays emphasis on prioritising people, a professional value theme that requires nurses to place the individual and their family at the centre of care. Therefore, completing a person-centred screen of the individual with the aid of the Person-centred Screening Tool (Moulster et al. 2019) during the initial assessment enabled data to gathered and disclose more about the individual’s background and goals. Alternatively, the approach to the experience was person-centred as the picture created out of the information gathered was personal to the individual, which suggested support to aid independence on maintaining personal care and stay in employment. There were also gaps identified that suggested activities to engage in more daily and essential health checks specific to his age and health condition. The implications of the experience on the individual and their family might help promote a healthy lifestyle and good well-being. As a student nurse, it serves as an evidence base learning to improve future experiences with other individuals in my care.

Points to Consider 3 example: Appraise evidence-based, person-centred nursing care and evaluation strategies for an acutely ill person.

Learning Disability *They are examining the assessment model they used. Notice their use of literature to support their discussion*

Nursing theory can be described as patterns that guides the thinking about, being and doing of nursing (Parker, 2005), in other words theory is what gives nursing a direction and discipline. The same is true of three theorists who shared the same person-cantered approach and focused their theories on the needs of the individual, defining the role of nursing to be the focus on the needs of the patient, (Abdellah,1960; Henderson, 1966; Orem, 2001; cited in Snowden, Donnell and Duffy 2010). On account of Virginia Henderson’s Need Theory (1966) its influence was drawn on Maslow’s Hierarchy of Human Needs (1954), which led to 14 Universal Human Needs (Snowden, Donnell and Duffy, 2010) Abdullah (1960) focused on 21 nursing problem which represented two sections, suggesting ten steps for identifying health needs and the other eleven for skills needed for diagnosis. Additionally, Orem’s (2001) Theory of Self-Care was maintaining life by focusing on the identification of limitation and the appropriate interventions to meet the needs of the individual. The same is true of the Moulster and Griffiths Nursing Model and its tools (Moulster et al. 2019) that influenced my experience during the assessment. The person-centred screening tool represents one of the stages within the assessment that enables data on the individual through a person-centred approach which may identify a self-care deficit (Orem, 2001) that may lead to interventions to aid personal care and maintain health as in the case of the individual in this report. More to the point, the model is attributed to four stages of assessment in obtaining a full overview of an individual’s needs. This includes the Health Equality Framework (Learning Disability Observatory, 2013) an outcome tool that measures the impact of determinants of health inequalities on the individual informed by the available data at the time of the assessment (see Appendix B for the individual’s score). Furthermore, the tool helps make sense of health concerns through its scoring system which is essential at the point of referrals and the order of prioritization in developing health action plan.

As stated, (McCormack, McCance and Klopper, 2017) a person-centred approach to practice facilitates the individual’s authenticity to be autonomous in decisions about their life and health. In this respect it is important to note, the Person-centred Screening Tool (Moulster et al. 2019) adopted through the assessment facilitated the personal relationship that enabled the individual to talk about family life and the most important person in their life. Furthermore, it gave the individual a sense of ownership to discuss his needs and relevant support to his care. As the individual was able give an insight and agreed to what might be beneficial to his support.

Points to Consider 4: Examine the effectiveness of strategies used to communicate and work in partnership with people, families, carers and members of the interdisciplinary team

Child *They were discussing SBAR communication tool and you can see how they have reflected on communication in their own clinical experience, but then relates it back to the patient scenario.*

The design of the SBAR communication tool allows professionals to narrow down information so that they have a focal point. According to the Royal College of Nursing (2019), miscommunication is one of the most common factors in patient’s dissatisfaction. Working in a clinical placement where things are fast paced, I can absolutely understand just how easy it is for miscommunication to arise. The nurses I have worked with in placement were very keen in showing me detailed interaction when it came to handover and transitioning patients to a different professional, a new ward or a different hospital. I admit it was difficult for me in the beginning to verbalise how my patient was doing when the nurses and doctors would ask. I didn’t know whether I was giving them inadequate information and it made feel incompetent. So I had to find something that worked for me- which was writing things down on a pocket sized notepad. They appraised the mini notebook that I carried with me and encouraged me to write things down and to be confident in double checking by asking questions. As a student nurse, communication through documentation has been embedded in my mind. Much like the A to E assessment, I’m fond of using SBAR as it is built like a formula. I can be rest assured that the next nurse will have all the relevant information they need to deliver the best care that they could. Having to memorise so much jargon in the hospital setting, this is helpful as it makes it so much more easier to attain. This then reduces errors and highlights the important things that need to be done by the next professional in charge of Ali’s care.

Learning Disability *They are explaining why communication tools are important.*

Establishing rapport with a patient at a first meeting is essential to developing a therapeutic relationship (Price, 2016). In addition, (O’Toole, 2008) further suggest developing a therapeutic relationship through mutual understanding enables positive relationship with individuals promoting respect, empathy and trust to enable health professionals obtain relevant information that informs decisions about care needs. Furthermore, developing a rapport with an individual and their support team as a professional also promotes communication, collaboration and shared understanding of the individual’s viewpoint (Norfolk et al. 2007). I developed a rapport with the individual during the assessment through acknowledging him first to signify my respect and value as an individual and allowed him to introduce his support or family for the assessment. I also used a Person-Centred Screen tool (Moulster et al. 2019) in capturing background information on various aspects of the individual’s life to familiarise myself with his aspirations and effectively maintain good communication and build a therapeutic relationship.

Points to Consider 5: Apply ethical-legal principles to the care of the acutely ill person.

Child

An ethical and safeguarding consideration I plan to integrate with Ali’s family centred care would be analysing whether he and his sister Dee are Gillick competent, as well introducing social workers to the multidisciplinary team. As Ali is due for insulin injections for his treatment, he may find that he’d gladly do it himself. Gillick competency would help me as a professional to find balance in being inclusive to my patient’s wishes with the intent and responsibility of protecting them (NSPCC, 2021). Out in placement, I’ve met children and young adults who relish on being able to contribute to their own treatment. Children and young adolescents have the right to be involved in making decisions that would have an impact on them (Coughlin, 2018). If I was in their shoes, I would want to be highly involved too. Having a condition where they can’t necessarily dictate or have the upper hand on, I can empathise how having that small amount of control could make them feel uplifted. Once they are deemed capable and Gillick competent with commensurable decision making capacity, then they shall be the primary decision makers to their treatment (Coughlin, 2018)

Learning Disability

As a requirement, all health and social care workers have a duty of care to individuals in protecting their rights and choices in decision making during their care and treatment. Owing to that, capacity to consent to the above, are set out in accordance with the five principles of the Mental Capacity Act (2005) and clarifies that an adult cannot give consent for another adult unless appointed with Power of Attorney. However, a report finding into the Premature Death of People with Learning Disability identified (Heslop et al. 2013) significantly poor practice to the use of the Mental Capacity Act (2005) with delays and problems in diagnosis and treatment for individuals. Hence its recommendations for mandatory training for all health and social care workers to ensure safeguarding and protection of the rights of vulnerable adults seeking care and treatment. Adhering to the Mental Capacity Act, (2005) I assumed the individual had the capacity to consent and supported their ability to make an informed decision about the assessment leading to future interventions. The Code (NMC,2015) set out a legal responsibility to properly obtain an informed consent before any consultation leading to the individual receiving treatment. Therefore, I explained my reasons for the meeting and made sure they were aware and acknowledged my presence. I set a clear simple goal and expectation for the meeting and assured the individual of my support through the meeting. I used simple language, open questions to gather information, gauging his understanding at various stages of the meeting before continuing. More importantly prior to asking questions about his health, I gauge his understanding of the reasons for the assessment hence establishing his capacity to consent for the meeting and the assessment in other to receive care.

Reflection examples; Child *They have used a paragraph to reflect on the overall experience and apply it to clinical environment. You can see how they have applied a ‘reflective cycle’ to discuss what happened, how they felt, evaluated experience and action plan for future.*

On reflection this scenario has proven a useful learning experience. In real-life situations you may not necessarily have in depth knowledge of the situation or the time to prepare yourself and familiarise yourself with local policies and guidelines for specific illnesses/ailments. Highlighting the importance of having the basic knowledge of an A-E assessment and how to stabilise a patient with confidence. According to The Nursing and Midwifery Council (NMC) it is of the upmost importance that as both qualified and student nurses we do not act outside of our competencies (NMC, 2020). It is therefore important to know when you need to step back from a situation and allow someone more qualified than you to take over. However, due to the time we were given and prior knowledge I feel I was competent to make the decisions about care that I did and that they were the right ones. This was also confirmed by my partner I was working with who also had prior knowledge and competency. In the future, I will ensure that if time is available, I will read local policies and guidelines for specific illnesses. Preparation can be done before a specific placement area or before a shift with knowledge that specific illnesses or medications are on the ward. In cases where preparation is not possible (such as frontline emergencies) it will be crucial to allow someone with more experience or skill to take lead of the situation.

Learning Disability

I felt confident before the assessment because I believed I had the right framework, tools, and the knowledge to achieve the intended outcome. Partly because it was an initial assessment, and my aim was to build a rapport and access the background information to gain whole picture and knowledge about the individual for a holistic approach to his care. However, the set up for the assessment was not favourable due to the virtual platform, there were instances the communication was poor and could not hear the responses or gage the understanding of the questions put to the individual. Moreover, the individual made a good effort to stay engaged during the process and offered an insight into his needs and contributed to a meaningful engagement considering the situation. Nonetheless, the time limit and the environment for the assessment meant the quality of the data gained may not be enough to have foreseen the whole picture and therefore a fellow up assessment may be needed in future to enable an all-inclusive picture. Notwithstanding the above drawbacks, the data collected informed decisions through the assessment.

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The post Aabish Ali is a 19year old student studying physiotherapy. She was diagnosed with Asthma as a child and has taken inhalers daily since then which keep it under control. Her peak flow is 500 L/min. She is currently having some occurrence of waking up and tightness in her chest overnight which she has attributed to anxiety and stress over her upcoming exams. appeared first on Apax Researchers.