Student Nurse

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    For the purpose of this essay I will give a descriptive account of what implementation means within the Roper, Logan and Tierney (1986) nursing process. I will describe what implementation involves for the nurse and will be focusing on one aspect of the holistic care given to my patient whilst on placement. The procedure that I have chosen to describe during this essay is the care of a man with a colostomy. A pseudonym of John will be used to protect the patient's identity and confidentiality, which is in line with the Nursing and Midwifery Council Code of Conduct guidelines (2004). John's surgery has resulted in him having a colostomy for the elimination of faeces and a colostomy bag for the collection of faeces. The aspect of care I will be focusing on will be the cleansing of the stoma site and the procedure of changing the stoma bag appliance. I will give a step by step account of the clinical procedure and will include how I managed the care that was given, and the difficulties that were experienced. I will conclude by discussing the patient's response to the care and I will reflect on the care I carried out. A brief patient profile has been included in the appendices for the benefit of the reader. Tortora & Grabowski (2003), define colostomy as a diversion of the faecal stream through the opening in the colon, creating a surgical stoma (artificial opening or substitute anus) that is affixed to the exterior of the abdominal wall.

    Implementation is the third stage in the nursing process and follows the assessment and planning of patient care. Implementation occurs when the nurse intervenes to solve the actual or potential problems the patient/client may experience. The nurse plans and carries out the interventions by drawing upon a range of knowledge and skills accumulated whilst nursing and through valid evidence based practice (Holland et al, 2004). This will certainly include knowledge gained during the assessment and planning stage of patient care. The nurse implementing any intervention is responsible for obtaining any relevant knowledge and having the clinical competency to perform the intervention (Potter & Perry, 1995). This is also a requirement of the Nurses Professional Code of Conduct (NMC, 2004).

    Implementation of the care plan (see appendix 2 for John's care plan) can take place once the nurse has selected the most appropriate actions. In trying to achieve the goals that have been previously negotiated with the patient, nurses may use a variety of actions related to the particular activities of living in which the patient is experiencing difficulties (Aggleton & Chalmers, 1986). In the case of my patient, intervention will occur in order to ensure effective communication to help facilitate learning and independence. The Roper, Logan and Tierney model (1986), states that many nursing actions are likely to involve three key elements. 1). The prevention of certain situations arising, 2). The comforting of a patient both physically and mentally. 3). Help to reduce the dependence of the patient. These three nursing actions help to encourage the individual to seek responsibility for self care and prepare the patient with coping strategies after hospital discharge (Aggleton & Chalmers, 1986).

    John is 66 years old and was admitted to the hospital for bowel surgery following the diagnosis of a cancerous tumour. This surgery has resulted in John having the lower part of the sigmoid colon removed. This procedure is medically known as a sigmoid 'end' colostomy (Mallet and Dougherty, 2003). This means that John now has a permanent stoma site on the left side of his abdomen. Three days postoperatively, I was asked to start the process of educating John to care for his own stoma. From the assessment and planning of care I had learnt that John was very anxious of how the stoma looked and how he and his wife would come to accept his new body image. I also learnt that he wanted to carry out all his personal hygiene independently and get back to normal as soon as possible. A care plan was written to identify problems/needs, prevent any complications and educate John to help him regain his independence concerning his colostomy (see appendix 2).

    After observing and participating in the cleansing of the stoma and changing of the stoma bag several times under the supervision of my mentor, I felt competent enough to carry this procedure out independently. I had built up a good rapport with this patient and understood that he was worried about the appearance, smell and discriminatory factors of his new body image. I understood that this patient would have to be treated with sensitivity. Elcoat (1986), states that the patient may need encouragement and support to enable him to look at his stoma for the first time. This can be a traumatic experience (Black, 2000) and the nurse should be sensitive to the patient's feelings. It is vital that the nurse does not show any sign of revulsion by word or gesture when dealing with the stoma as the patient will be scrutinizing their responses closely. Any sign of distaste, however small, will be used by the patient to reinforce his fears of being unacceptable (Potter & Perry, 1995).

    Before collecting the equipment for changing the stoma bag, I asked John for his consent, which is in line with the Nursing and Midwifery Professional Code of Conduct (NMC, 2004). This is important as it makes the patient feel he has a part to play in his care and helps to promote patient autonomy. Asking for consent also allows him the right to refuse the intervention or ask for someone else to carry out the nursing activity if he so wishes.

    To prepare for the procedure I collected the necessary items for the change of the stoma appliance (appendix 5). By preparing and checking that you have all the correct equipment before starting the procedure, it ensures that nothing is forgotten and the nursing activity is not interrupted part way through. Preparation is also a very important factor in the prevention of cross infection and health and safety issues such as MRSA. As John had only had the colostomy operation 3 days ago, he is still not very familiar with the procedure. Before starting the nursing activity the procedure was explained to John so he had a good idea of what it entailed. I asked him if he would like me to explain things as I went through the process. He said that would be helpful but wasn't sure if he would remember everything. I reassured him that it would take time and not to worry about asking for help.

    I made sure that John was in a comfortable position and that he was able to see what I was doing. This allows the patient to come to terms with his altered body image and learn how to care for the stoma himself through observation (Elcoat, 1986). A protective pad was placed onto John's clothing to protect them from fluid and faeces. This avoids the necessity for renewing clothing or bedclothes and the demoralization of the patient as a result of soiling.

    To remove the appliance I carefully peeled the adhesive securing the current bag from the skin with one hand while exerting gentle pressure on the skin with the other. It is important to be gentle when removing the used appliance to prevent trauma to the skin or stoma (Mallet & Dougherty, 2002). Then, with a damp tissue I removed excess faeces from the stoma and surrounding peristomal skin. The faecal material from a colostomy is very irritating to the peristomal skin and if not removed immediately, the area will break down (Faulkner, 2000).

    The stoma needs to be assessed frequently for soreness, ulceration or ischaemic changes to the stoma itself (Mallet and Dougherty, 2002). Dullness and a change of colour to blue-black indicates a reduced blood supply and should be reported immediately, as should a stoma that either becomes much longer or seems to disappear below the skin surface (Potter & Perry, 1995). According to Leahy and Kizilay, (1998), a healthy stoma with a good blood supply is dark pink (similar to the inside of the mouth) and shiny. After surgery the stoma may be enlarged, but as healing progresses the size of the stoma should decrease (Elcoat, 1986). After assessing John's stoma to be healthy I proceeded to wash and dry the skin and stoma gently but thoroughly. Mallet and Dougherty (2002), state that this helps to promote cleanliness, prevent skin irritation and allow the appliance to attach more securely to the skin.

    Before applying the clean appliance I made sure that the flange (the part where a hole is cut to fit the size of the stoma, so the stoma can sit inside the bag) was cut to the correct size. The flange should be slightly larger (3mm) than the stoma itself. This prevents restriction of the stoma if oedema occurs (Leahy & Kizilay, 1998). After successfully fitting the clean appliance I checked that John was positioned comfortably on the bed and that the appliance felt secure. The used stoma appliance was emptied in the sluice and rinsed with water. This is done because faecal material in waste bags is a potential source of infection (Mallet and Dougherty, 2002). The empty bag, disposable gloves, plastic apron and soiled tissues were then placed in the appropriate yellow disposable bag and tied up securely, ready to be taken away for incineration. Hands were washed thoroughly using a surgical soap, to prevent infection by contaminated hands (Mallet and Dougherty, 2002). The wards written procedure for a colostomy bag change was followed (appendix 6).

    Throughout the nursing activity I was aware of my non verbal behaviour as well as verbal behaviour. Egan (2002), states that patients read cues from your non verbal behaviour that indicates your interest in them, thus being attentive to the patient can invite them to trust you and open up. A non verbal skill that can be used to tune into patients can be summarised in the acronym SOLER. S - Face the client Squarely, O - Adopt an Open position, L - Lean towards the patient if appropriate, E - maintain good Eye contact, and R try to be relatively Relaxed or natural in these behaviours (Egan, 2002).

    A post operation sheet was filled in (appendix 3) to monitor progress of healing and to record output, consistency and colour of the faeces. The record was countersigned by a qualified nurse which is in line with the Nursing and Midwifery Professional Code of Conduct (NMC, 2004). It is important for the nurse to document care given to a patient, as it may be used as a legal document if the patient is involved in litigation with the hospital. The record must accurately reflect a patient's stay in hospital in terms of problems identified, actions taken and outcomes (Faulkner, 2000). When the patient is ready to start the discharge plan (see 'Stoma Ladder', appendix 4) each successful step taken by the patient will be recorded by the nurse as the patient needs to achieve all eight steps of self care before they are ready to go home.

    Before discharge it is important that the patient has been referred to the community stoma nurse for continuing support. The stoma care nurse will liaise with the ward staff in regard to the date of the patients discharge. The patient and patient's carer should be given details of any support groups available, contact number for the stoma care nurse should be given along with written information on changing the appliance. This will help to allay the patients' fears that they may have forgotten everything by the time they reach home. Patients also need to know how to order a supply of appliances and should be given a sufficient supply to go home with to last them until their own supplies are obtained (Black, 2000).

    Whilst caring for John I was eager to support him and help alleviate the obvious trauma he was going through. I felt that I interacted with him effectively as his response to me was very positive. He shared his fears and anxieties with me and let me help educate him, I felt honoured that I was playing a part in helping him to regain his independence. This experience has shown me the different aspects the effect an altered body image can have on a patient. When implementing a patient's care it is important to consider their needs in a holistic manner so as to gain their co operation in working to achieve the desired outcome. Planning, education and emotional support are clearly the key factors when delivering effective care. Preparing all the necessary equipment before the nursing activity allowed me to carry out the procedure smoothly and helped me to avoid any interruption to the delivery of care. As I progress throughout my nursing career I hope to further expand my intrapersonal skills as well as clinical skills that are required to become a competent registered nurse.

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    last updated 16/08/05

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