Critical Incident

Rich & Parker 2001 defines critical incidents as snapshots of something that happens to a patient, their family or healthcare professional. It may be something positive, or it could be a situation where someone has suffered in some way. Reflecting on critical incidents will allow me to explore and analyse incidents and how it has affects me and what I hope to do with these effects in the course of my training towards becoming a registered practitioner. It also gives me the opportunity of changing my way of thinking or practice, as I learn valuable lessons when I reflect on an incident. This helps me to develop self-awareness and skills in critical thinking and problem solving (Rich & Parker 2001). On the other hand, Johns 2003 defines reflection as â€Å" being mindful of self, either within or after an experience, as if a window through which the practioners can view and focus self within the context of a particular experience, in order to confront, understand and move towards resolving contradiction between one’s vision and actual practice†. I will be using the Beckwith model of reflection which states clearly that reflection is a tool to deal with challenges that will influence the speed and amplitude of one’s development, to explore these effects in other to understand and learn from this incident, with the hope of improving my practice (Beckwith & Beckwith 2007). The incident I will be reflecting upon occurred while attending a clinical placement in the critical care unit at my placement hospital which for the purpose of this essay will be referred to as X Hospital. Critical Care is the multi-professional healthcare specialty that cares for patients with acute, life-threatening illness or injury, (Sheppard & Wright 2005). Critical care can be provided wherever life is threatened. Critical care provided at the scene of an accident or in an ambulance is basic life support. Basic life support is the emergency treatment of any condition where the brain stops receiving adequate oxygen; it could be a cardiac or respiratory arrest, (Kumar). A cardiac arrest is one where there is no pulse and is unlikely the patient will recover with basic life support alone but advanced life support with a defibrillator is required. It is important to carry out basis life support until defibrillator arrives even after careful assessment one discovers it’s a cardiac arrest, as one usually leads to the other, (Kumar). The importance of recognizing, assessing and reacting to cardiorespiratory arrest is very important. Immediate response increases the chances of a successful outcome, (Davey and Ince). Shostek says critical care in a hospital setting is provided by multi-professional teams of highly experienced and professional personnel who use their unique expertise and ability to interpret important therapeutic information, manage highly sophisticated equipment and provide care that leads to the best outcome for the patient. Patients are usually admitted from the emergency room or surgical area where they are first given care and stabilized to CCU, (NHS Careers). The management of the critically ill patient ranges from eye care(Appendix 1), oral care(Appendix 2), infection control, health and safety issues, tissue viability among other vital issues like care bundles for this high risk group of patients who are dependent these care to maintain integrity and dignity according to trust policy. Suction pumps are also vital in the critical care setting as airway hygiene is impaired in critically ill patients as a result of depressed cough reflex and ineffective mucociliary clearance from sedation, high inspired oxygen concentrations, elevated endotracheal tube cuff pressure, and tracheal mucosal inflammation and damage, (X Hospital Policy). Due to this, care of intubated patients includes tracheal suctioning to facilitate the removal of airway secretions (suction therapy) is carried out on all unconscious patient, as it maintains airway patency and prevents pulmonary infection, (X Hospital Policy). A tube or catheter is passed down inside the endotracheal tube and attached to a suction pump, the size of the catheter must be chosen carefully using a simple formula of doubling the size of ET tube minus 2. One should be careful to suction on withdrawal using a suction pressure that is appropriate. Suction depth varies depending on the size of the trachea tube hence suction can be shallow, pre-measured and deep suctioning. Despite the importance of suctioning some complications like hypoxia, cardiac arrhythmias, hypotension, tracheal trauma, laryngospasm and bronchoconstriction are associated with it. Hence tracheal suctioning of intubated patients should be performed on a when needed basis defined by the quantity of secretions obtained, not at prescribed, set intervals, (X Hospital Policy). The incident I will be reflecting on is about a Twenty-Nine-year-old male admitted to the critical care unit with a closed head injury sustained in a motor vehicle accident. His young wife, parents and other family members faced real fears. Most of the family members had never been inside a critical care unit, and found the array of pumps, tubes, machines, monitors and lines, as well as the rush of staff members overwhelming. Just by looking at them and watching their reaction each time they come visiting was enough to tell me how scared and worried they were of their son’s illness and the environment they were in. I started to wonder what was going on in their minds and was drawn to them not only for this reason but because the patient and his family members were the youngest I ever saw in the unit. I was thinking to myself if they have asked questions or done any research about CCU they will most likely be thinking their son’s situation is hopeless. It is important to label and date all the lines as this helps to know what each is used for and how long it has been in situ for. Also care should be taken when moving patients to ensure the stay in place as it can be very uncomfortable and difficult to reinsert a cannula on a patient as most of them are oeadematous. As I was involved in the care of the patient I had to explain to the wife why her husband was connected to a ventilator and it use. A ventilator is an artificial breathing machine that moves oxygen-enriched air in and out of your lungs. If your lungs have failed and you cannot breathe on your own, you will need to be attached to a ventilator (See appendix 3). Being helped to breathe by a ventilator means that you will usually need to be sedated. Ventilators can offer different levels of breathing assistance. If you only need help breathing for a couple of days, it is likely you will have an endotracheal tube from the ventilator to your mouth or nose. The tube will usually be held in place behind your neck as was the case with my patient. However, if you need help with breathing for more than a few days, you may have a short operation called a tracheostomy. This replaces the tube in your mouth with a shorter tube that is placed directly into your trachea. As well as being more comfortable, a tracheostomy makes it easier to keep your lungs clean, and usually requires less sedation. There are two kinds of ventilators, negative pressure and positive pressure. Negative pressure ventilators are not commonly in use today. In my trust we have only the positive pressure ventilators. Mode of ventilation should be tailored to the needs of the patient. Understanding these settings is important as they may need to be changed quickly. Once my patient’s next of kin fully understood the treatment he was receiving I could see this young lady’s face soften a bit. I later learnt from my conversations with her that their 5years-old daughter, had been in the back seat with him when the accident occurred. She had not slept properly since the incident, expressing that she was afraid he would â€Å"never come home. † She has continually asked her mother and grand parents, â€Å"When is daddy coming back home? † The 5-year-old girl would not enter the parents’ bedroom at home and insisted that the light remain on and has refused to take her bath as her dad always gave her a bath each evening. From this conversation I concluded that this little girl needed to see, touch, smell and be with her dad to understand what had happened. I believe that she needs to be allowed to grieve and participate in the healing process surrounding her dad’s trauma. However, there were barriers, because our institution’s written policy was to not allow anyone under the age of 12 to visit patients even though the majority of published studies evaluating family member presence in surgery have shown the positive effect it has on family members irrespective of their age, (Kingsnorth et al 2010). Some of these benefits included removing the family’s doubt about the patient’s situation and allowing them to see that everything possible is being done in caring for that patient, reducing their anxiety and fear about what is happening to their loved one, maintaining the family need to be together even at this time. In addition, when and if death occurred, families have reported that their presence gave them a sense of closure and facilitated the grief process, (Kingsnorth et al 2010). With this information I spoke with my mentor and she agreed how awful it must be for her and promised to look into it. Three days after the accident, my mentor came to me and said they have come up with something that will help this young family and asked if I wanted to be involved with it, I said yes. We approached our patient’s family about scheduling an educational conference for the family. We agreed to include aunts, uncles, grandparents a young niece and two nephews. There were fears about how the children will handle the information but the adults were advised that, if the children exhibited fear or discomfort, they can be allowed to leave the conference room. At the conference, I sat with the children at the table and provided them with crayons and paper. Drinks and cookies were available. I was glad the atmosphere was gentle, quiet, comfortable and conducive to learning. We began the session by discussing definitions of grief, mourning, loss and coping. The adults agreed that this was the first trauma in the family and were giving the children explanations such as â€Å"God may take him† and â€Å"Dad may never wake up. †It was now time to listen to the children. They were asked to talk about a time when they had been sick. We went over what each part of the anatomy did and how they worked together. The children were asked to draw picture of what they understand of the discussion, drew pictures of lungs, a heart, a brain and a rib cage. When the patient’s daughter drew her Dad, she placed wires and tubes in his organs. At this stage I could see that the little girl now understands what had happened to her Dad. The adults who previously did not fully understand the injury to their son appreciated the education. The patient’s young wife had her eyes full of tears but I saw relief on her face regardless. As the clinical picture becomes clearer, the little girl asked if she could see her dad. All agreed this might be beneficial. Now we were confronted with the hospital policy prohibiting children in the critical care unit. The sisters spoke among themselves. I was praying silently that they can make an exception here. It is believed that every patient should be treated as an individual and critical care involves the care of family members as well (Kingsnorth et al 2010). I was glad when the sister came back and asked the patient’s wife to take her daughter to the ICU door, while all the staffs were informed of the plan. The decision was to allow the young daughter to see her dad and hospital policy was explained again, they all understood and were evidently glad like I was. The daughter entered the unit with wide eyes and stood at her dad’s bedside, where she was told about every tube and its purpose. The little girl took her dad’s hand and cried, as did the entire staff. Except for the hum of ventilators, the unit was quiet as the little girl held hands with her father, stroked his hair, sang him a song and said goodnight with prayers. I savored this moment as I realized it was an important journey in the little girl’s life. As a student I concluded that surely there can be nothing superior to this type of care giving. Through out the lecture I couldn’t help but think that God forbid if this was me or my family member I would hope for a care team as nice and understanding as these ones looking after my family. I imagined if these were my children I sure would want them to understand what is happening and to be able to confront it if they want to and what better way to do this. Following the visit, we were told how the little girl had become more agreeable at home. She says â€Å"I have to keep things in order until Dad comes home. † Making a difference is what care exemplifies, particularly when the art of humanity in a technologically driven healthcare system is advocated, (NHS Careers). I truly agree with this statement. For me the critical environment was a different setting and honestly I believe there can be no other like it. It is a very emotional setting that requires strong willed people yet competent in their jobs as well as having a heart full of love to care for their patient and family members. This is an experience that will stay with me throughout my career and influence me in a positive way as I can clearly understand that delivering quality care goes beyond what is done for the patient but for family members around as well. In my trust eye care is recognized as a basic nursing care procedure required by critically ill patients to prevent complications such as eye infections or injury. This care involves regular eye assessment on each patient in the ward to ensure that all patients receive individualized evidence based eye care which ranges from no action required to hydration treatment with and sterile water to a more complex treatment prescribed by a doctor. If hydration or cleaned care is taken to wipe from the nasal corner outwards starting with the lower lids using a different wipe or gauze each time. If there is an infection the non-infected eye should be cleaned first. Sometimes a bacteria barrier cream may be applied if the doctors deem it necessary, (X Hospital Trust Policy). Appendix 2- Oral Care Similarly, all critical ill patients who are intubated receive individualized evidence based mouth care. All orally intubated patients will have moisture, integrity and cleanliness of all oral surfaces. Intubated patient are especially vulnerable to complications if inadequate oral care is practiced. Also there are many factors that pose as barriers to carrying out effective oral care such as: difficulty to access oral cavity, changes in mucosa and normal bacteria flora of the mouth, immunocompromise and medication, presence of endotracheal tubes, oral suctioning and therapeutic dehydration. Based on the above, assessment is carried out daily using the Eilers assessment guide. Whatever the outcome of this assessment oral care on all critically ill patients on a daily basis involves using a soft tooth brush and toothpaste every 12hours in a circular stroke away from the gums, cleaning the tongue and inside of the cheeks. A through rinse using a syringe and gentle suction to remove secretions thereby minimizing trauma to soft tissues in the mouth. Foam sticks and sterile water can be used in cases of extreme dryness as it’s is effective for moistening oral cavity. Soft paraffin can also be used to prevent lips from cracking. Dentures are usually removed and cared for till when patient needs it, (X Hospital Trust Policy). Appendix 3 – Understanding ventilators settings Tidal volume This is the lung volume representing the normal volume of air displaced between normal inspiration and expiration with no extra effort. Typical values are around 500ml or 7ml/kg. To avoid adverse effects of barotrauma and volutrauma it is recommended to use lower tidal volumes. An initial TV of 5-8 mL/kg of ideal body weight is generally indicated. The goal is to adjust the TV so that plateau pressures are less than 35 cm H2 O. Continuous mandatory ventilation (CMV) Breaths are delivered at preset intervals, regardless of patient effort. This mode is used most often in the paralyzed patient because it can increase the work of breathing if respiratory effort is present. CMV has given way to assist-control (A/C) mode. Many ventilators do not have a true CMV mode and offer A/C instead. Assist-control ventilation The ventilator delivers preset breaths in coordination with the respiratory effort of the patient. With each inspiratory effort, the ventilator delivers a full assisted tidal volume. Spontaneous breathing is not allowed. This mode is better tolerated than CMV in patients with intact respiratory effort. Intermittent mandatory ventilation With intermittent mandatory ventilation (IMV), breaths are delivered at a preset interval, and spontaneous breathing is allowed between ventilator-administered breaths. Spontaneous breathing occurs against the resistance of the airway tubing and ventilator valves, which may be formidable. This mode has given way to synchronous intermittent mandatory ventilation (SIMV). Synchronous intermittent mandatory ventilation The ventilator delivers preset breaths in coordination with the respiratory effort of the patient. Spontaneous breathing is allowed between breaths. These modes are beneficial for patients who require high minute ventilation. Full support reduces oxygen consumption and CO2 production of the respiratory muscles. A potential drawback of A/C ventilation in the patient with obstructive airway disease is worsening of air trapping and breath stacking. Pressure support ventilation For the spontaneously breathing patient, pressure support ventilation (PSV) has been advocated to limit barotrauma and to decrease the work of breathing. Pressure support differs from A/C and IMV in that a level of support pressure is set (not TV) to assist every spontaneous effort. Airway pressure support is maintained until the patient's inspiratory flow falls below a certain cutoff. PSV is frequently the mode of choice in patients whose respiratory failure is not severe and who have an adequate respiratory drive. It can result in improved patient comfort, reduced cardiovascular effects, reduced risk of barotrauma, and improved distribution of gas. CPAP is an acronym for â€Å"continuous positive airway pressure†, a variation of the PAP system. Respiratory rate A respiratory rate (RR) of 8-12 breaths per minute is recommended for patients not requiring hyperventilation for the treatment of toxic or metabolic acidosis, or intracranial injury. High rates allow less time for exhalation, increase mean airway pressure, and cause air trapping in patients with obstructive airway disease. The initial rate may be as low as 5-6 breaths per minute in asthmatic patients when using a permissive hypercapnia technique. Positive end-expiratory pressure Positive end-expiratory pressure (PEEP) is a term used in mechanical ventilation to denote an airway pressure that is kept above atmospheric pressure at the end of the expiratory cycle. The equivalent in a spontaneously breathing patient is CPAP. One obvious beneficial effect of PEEP is to shift lung water from the alveoli to the perivascular interstitial space. It does not decrease the total amount of extravascular lung water. This is of clear benefit in cases of cardiogenic as well as noncardiogenic pulmonary edema. An additional benefit of PEEP in cases of CHF is to decrease venous return to the right side of the heart by increasing intrathoracic pressure. 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