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Clinical Situation Utilizing The Johns Model Of Structured Reflection Assessment Answer

    ASSESSMENT GUIDELINES 

    When caring for patients, nurses often complete an 8-hour shift plan for all patients in their care for that shift. Please (construct) and submit your plan of care for your patient in the appendix (this is not counted towards the word count) and use this to base your critical reflection on. Please consider one of the patients we cared for in class, Mr. Casey, Mr. Khoury, Mrs. Graham, Mrs. Carlino or Mr. Kumar. Please make it clear which patient you are reflecting on. You may also consider Mrs. Thomas or Mr. Harvey but your reflection would only be based on your planned actions, not your practical actions so you would be better served to reflect on tasks you actually physically involved yourself in during a practice lab or practical class.

    Your task for Assessment Three (3) is to use John's Reflective Model to reflect on your plan of care for each patient, identify strengths in your clinical reasoning, limitations in your critical thinking, and an action plan for how you will address your future learning to improve the areas where you did not perform as well as you wish.

    John's reflective model requires you to address the following:

    Description

    • Describe what you did, how you feel that you performed, what information you used to develop your plan of care (this may be formal research or it may be personal experience such as working on a ward, or it may be that there was very little thought applied at all - note all of this here).

    Reflection

    •  Did you have clear goals for each patient? What were you trying to achieve for each patient? Would your plan of care achieve these goals? Would you have caused any harm to your patient by doing things that should not have been done? Would you have caused harm by omitting care that should have been done? 
    • Did you consider the legal and ethical implications of your actions? • Did you consider the specific individual needs of this patient, or were you developing your plan of care based on routine things that should be done for everyone regardless of what the patient needs or wants? 
    • Was your plan of care evidence-based - did it align with current clinical policies and guidelines? If there are no policies and guidelines around what you did, then consider what the evidence says in terms of what you did and the associated outcomes of patients here. 
    • Would your plan of care for this patient affect anyone else (other staff, other patients, family members, public health resources), and is this impact reasonable to provide care for this patient?
    • In developing your plan of care did you use high-quality evidence to inform your clinical decision making (i.e. clinical guidelines, policies, systematic reviews of high-quality evidence), or did you use lower quality evidence such as individual studies in journals or textbooks? Or was your evidence from dangerously low-quality sources other resources written for average consumers, not health professionals? Would you be happy to have your nursing plan of care developed from these sources?
    • Influencing factors

    Thinking about areas in your care plan which you did well, or which you did not do well, what were the factors that influenced these decisions? Consider internal factors (personal thoughts, limitations, confidence, and knowledge) and external factors (time, peers, and resources available).

    Did you use past experiences to help you, did you use EBP? Was time an influencing factor for you in developing the plan of care? What else influenced your decision-making processes.

    Would these influencing factors play a role in the enhancement or hindrance of patient care in a real-life clinical setting?

    • Improvement

    What could you have done better for these patients in developing this plan of care? How will you improve the patient's outcomes?

    What would the consequences be of your suggested improvements and do the benefits outweigh any potential risks (eg. Is it too expensive with very little evidence-based improved outcome?.

    • Learning

    What will change because of your experience in writing these care plans?

    What have you noticed is an area that you would like to improve your knowledge and skill-based on what you have reflected on? 

    How will you go about improving this? This should address 3 clear, specific, and measurable action plans (SMART goals). 

    o Do not write 'read hospital policy' as there are thousands, identify which exact policy you will read and reference it. The same goes for books, chapters, youtube videos, conferences, in-services. Do not write that you will vaguely attend these - these must be ones already scheduled/attended which you can reference. 

    o It must be an action that specifically addresses your ability to critically think, clinical reason and improve care for medical surgical patients 

    o It may be something you should already know but has been highlighted in this assessment as an area of weakness (such as medication administration errors), however, it should not be something you are already expected to know and this assessment has not highlighted any limitations in that area.

    Answer

    INTRODUCTION

    Reflection is the essential pillar of the effective nursing care. It helps in better decision making and enhancing the knowledge. It is recommended by several researchers that reflective practices should be incorporated for widening the knowledge in nursing (Koshy et al., 2017). The aim of this essay is to describe a clinical situation utilizing the John’s model of structured reflection. The essay discusses the essential components of the case that I have cared. Various dimensions of the Johns reflective model are discussed with the means of this case including the description of the situation, reflection, factors influencing my decision and what I have learned from the situation so that I can take better informed decision if similar situation came in my clinical practices.

    JOHN’S REFLECTION MODEL:

    The reflective model was developed by the Chris John in the Burford Nursing Development unit during health early nineties. He developed the model for the guided reflection in the field of nursing for better patient care and outcomes (Graham et al., 2019). He uncovered the knowledge that can be used in the clinical situations, forming the framework of reflection, its factors and analyzing the learning from these situations. It consists of the five key components of the cycle where the focus is kept on the detailed understanding of reflection. These components of the reflective model are: description, reflection, factors influencing, could the situation be dealt in better way and the learning from the situation (Nicol & Dosser,2016).

    DESCRIPTION OF THE INCIDENCE

    Mr. Anthony Khoury was 67-year-old male presented during my posing in the Emergency department of the UTS Hospital. He was suffering from the pain in chest and shortness of breath. Symptoms begins to appear at the time of argue with his two sons. He was accompanied with his daughter. The symptoms continue to increase in intensity and attended the hospital on advice on his daughter. He was diagnosed with diabetes 12 years before. He has history of established peripheral vascular disease and symptomatic neuropathy. He had history of angina hypertension and hyperlipidemia. I had thoroughly assessed him for all the vital signs; monitored him for any red line changes in his vitals. The vitals were HR-125 BPM (AF), BP Sitting: 146/88 standing: 132/68, RR. 28, O2 - 91% RA this increased to 95% with O2 6L/min via the NRB, Temp. 36.5Oc, LOC Alert and orientated to person slightly confused with time and place GCS 14/15, Pain 4/10 focused left upper chest area – reduced with O2 administration, Airway Patent. He was also advised with all the required investigation including electrocardiogram. The started medications Atorvastatin, Frusemide 40mgs and Perindopril 5mg. he is on NS 0.9%. 250ml/hr.

    REFLECTION

    When I first experienced the situation where I have to assess the patient having pain in chest and unconsciousness, I got nervous. But even in that condition I acted best with my understanding and knowledge that I could. Although I have been dealing with patients before in the emergency department there were certain factors like significance of analyzing ECG, I was unaware of. I also felt that my understanding of patient prioritizing and triage within the emergency department was lacking which could have led to serious consequence for the patient (Van Bockstal & Maenhout,2019). Although I feel I have given my best in terms of patient monitoring and medication. But after releasing and understanding the importance of communication I feel that I could have made better nurse-patient relationship rather than just providing him the ordered medication.

    INFLUENCING FACTORS

    This step of the John’s Reflecting model includes the factors that might affects my decision at that moments of the time.  These factors could be internal as well as external factors (Jones et al., 2020). This includes the internal or the external factors that influenced my decision making for the Patient care.  My knowledge to deal with the patient was influenced by multiple factors. The courses I did and the knowledge attained in the field of the cardiology has helped me to care for the Mr. Anthony Khoury. Also, the immediate response to the patient was influenced by my understanding of the emergency medicine. My previous working with the emergency department and the learned clinical practices were also important factors. For example, I knew how to assess the patient, makes him feel comfortable and how to take the essential information. The order of my senior nurse present at the time of the patient admission and the physician helped me understand the medication to be provided to the patient at the regular interval. Factors that I felt has influenced my understanding of the situation and response were expansion of my knowledge and increase in my confidence level after being in the emergency department before and knowing how to monitor the cases of angina.

    IMPROVEMENT

    I think I have dealt with Mr. Anthony Khoury to best of my understanding and knowledge. But after learning better about the patient having myocardial infraction I think If I could change the direction of the care, I would certainly give keen observation to the changes in his ECG and take patient care for the best suitable interest for him, I would establish effective communication and spend some time to reassure regarding his mental worries (Kisely et al., 2015). I could have tried to help Mr. Anthony Khoury through more initiative in the situation where he needed reassurance and support. Also, after analyzing more regarding the situation I think I could have monitored him on timely manner. I should also have discussed the case with other nurses to understand the role of investigation like ECG in assessing the direction for his treatment and also other investigation like blood enzyme including Troponins to establish the diagnosis (Winchester & Pepine, 2015).

    LEARNING

    As a Nurse the insight that I gained and learned through caring for this patient is increase in my experience and way of caring for the patients in the emergency department. I have learned how each and every minute detail of the case is required for the quality patient care and best treatment outcomes. I have also learned that guidance of senior nurse and experts is also in recognizing best decision making and considering the facts. I should remain perceiving and alert in my way of dealing with the patient even within the stressful environment of the hospital like emergency department. Importance to the overall well-being of the patient rather than just dealing with the pharmacological aspect should be given. I should also now focus on the nursing interventional plan that includes the appropriate communication and counselling of the patient (Dithole, et al.,2017). All these are the essential component of the practical skills

    CONCLUSION

    As a Nurse, evaluating the case of Mr. Anthony Khoury and reflecting the situation under John’s reflection model has helped me to analyse the changes required within the scope of ethics, clinical practice, self-awareness and scientific knowledge along with moral. The learning from the reflection will help me caring for the patients through better choices and decisions in every aspect of my clinical practice.

    NURSING CARE PLAN:

    Name: Mr Anthony Khoury                                                         Date of admission: 10-01-21, 1000hrs                                                                                                         

                                                                                                            MRN 1134508

    Nursing Diagnosis: Pain in chest 

    Related to: Coronary artery occlusion                                       Medical Diagnosis: Myocardial infarction

    Nursing Assessment

    		Nursing outcomes:

    		Nursing intervention

    		Nursing Evaluation
    • Check for all vital signs
    • Evaluate the chest pain on a scale
    • Systemic examination
    • Observe vitals every 3 hourly
    • Evaluate blood troponin levels


    Pain in chestShortness of breathDecreased Urine outputFatiguePallorVitals:HR 125 BPM (AF)BP Sitting: 146/88 standing: 132/68RR. 28 BPM O2: 91Temp. 36.5oCGCS 14/15; Pain 4/10 Airway Patent


    • The patient will report decreased pain in the chest
    • Better blood troponin levels
    • The patient will maintain the normal cardiac output
    • Prevention of shock

    • Monitoring vital signs every 30 minutes
    • Assessment of pain in the chest after every hour once improvement is established evaluate the vitals every 3 hourly


    • Encourage for bed rest
    • Place him in fowler’s position
    • Administer oxygen
    • Administer the fluid therapy
    • Monitor urine output
    • Administer medication as advised
    		After 8 hours of nursing intervention the patient will:
    • free from pain
    • have stable or improved vital signs
    • Maintain posture of relaxed body 

    Time management sheet for nurses – Morning Shift

    timeKHOURY Anthony
    7:00am - 8:00am--
    8:00am - 9:00am---
    10:am – 11amSodium chloride 0.9% 250ml

    Handover notesAdmitted to ward for pain in chest with shortness of breath. History of diabetes with neuropathy. Patient not for resuscitation discussed with family. Confused, patient was given Atorvastatin, perindopril, Catheter inserted. Oxygen administered. Electrocardiogram advised, Sodium chloride 0.9% 250ml 
    11:00am – 12:00pmSeen by doctor, Sodium chloride 0.9% 250ml, vitals stable, Atorvastatin, perindopril, frusemide
    12:00pm – 1:00pmPt asleep
    1:00pm – 2:00pmSodium chloride 0.9% 250ml Atorvastatin, perindopril
    2:00pm : 3:00pmPt asleep
    Handover NotesPatient settled with no complaint of pain in chest, catheter on place resisting to take medication may require further counselling with very poor fluid intake.



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