Complete an evidence based nursing care plan based on the nursing process.



DueDate-Sunday 1st November 2015 (Week 13)


Pass Mark-Notapplicable


Theassessmentshould becompleted in threeparts.Thefirst partrequiresthestudenttoreflectand identifya
situationthatdescribesanindividualpatient’sneedsaround theActivityofLiving-Maintaininga Safe Environment.Studentsareencouraged toreflectabouta clinicalexperience(itisnotessential tohave experienced thissituation first-hand;it maybeanaspectthatyou learned aboutfromyourfirstassessment,a classdiscussionor casestudy). Thereflectionisaboutwhat happened atthetimeand anysuggestionsthatmay improvethesituationif you werefacedwith itagain. Didthesituation affectonly you,youandthepatient,or
did italsoaffectthe patient’ssignificant othersand/or colleagues.Thesecondpartrequiresstudentsto complete
anevidence basednursingcareplanbasedonthenursing process.Thethirdpartis a conclusion aboutthe situationand howstudentsmayrespond iftheywereconfrontedwith thesamesituationagain.

Yourreflection mustbepresented withanintroduction(approx.1000words)ofthepatientandadescriptionof theincidentprovidinginformationaboutinfluences suchasculture,age, gender,ethnicity,religionor disability. Confidentialityis essentialand a pseudonymmust beused.
Asthispartoftheassessmentisareflectionstudentsmaywritein thefirstperson. Studentsshouldwriteabout howtheyfeelthesituationhasimpactedontheir personal learningwhilecaring for thepatient.What happened,howthis hasimpactedonyou?Doyouthinkthatyouorothersmayhavehandledthisincident differentlyif theyhad theknowledgeandskills?Thisrequiresidentifying strengths orweaknessesaboutthe situation. A descriptionofthesituationshouldbeprovided,followed byan analysis and reflection.
Togetyou startedthereisonetypeofreflectiveframeworkavailableintheassignmentresourcearea.Ifyou are

CompletedNursingCare Plan using thetemplateprovided in theresourcearea.Bulletpointsare notacceptable
in this section(approx.1500words)
Provideanevidence basedcareplan for thispatient
Thispartoftheassessmentisnota reflection. Information should besupportedwith relevantcontemporary evidencetosupportnursing interventionsand/or strategiesthatmightassistinfuturepractice.Usingthe
nursingprocess,studentsarerequiredto developa nursing careplanaboutthissituation identifyingappropriate goals and howtheywouldbeachieved. Studentsshould alsoprovidea rationaleforwhythegoalsare
important.Thisnursingcareplanmustbethe planofcarethatwouldbeinitiated if aRegisteredNursewere
looking afterthe patientagain nowthatthereisevidencetosupportthis.

Followingon fromthereflection andevidence based careplan,nowsuggesthowthishasimpactedonyour learningaboutMaintaininga SafeEnvironmentforyour patients.Where have you looked for evidenceto supportthecare you provide? How hasthisactivityassistedyouinprovidingfuturenursingcarefor patients?

NMIH107Essentialsof CareB
Assessment2: ReflectionEssayMarking Guide

Name ……………………………………………………………


Reflection. /35
Descriptionof theincident 0 1-3 3.5-4 5-6 7 7
Demonstratesresponsetokeyconcepts 0 1-3 3.5-4 5-6 7 7
Recognisesandexplores strengthsandweaknesses 0 1-3 3.5-4 5-6 7 7
Explorestheincident andreflects withadequatedepth 0 1-3 3.5-4 5-6 7 7
Demonstratesappropriategoalsetting 0 1-3 3.5-4 5-6 7 7
Content. /35
Ideasareadequately describedand correct 0 1-3 3.5-4 5-6 7 7
Ideasaresupportedbytherelevantliterature 0 1-3 3.5-4 5-6 7 7
Demonstrates knowledgeofthetopic 0 1-3 3.5-4 5-6 7 7
Information is comprehensiveandbalanced 0 1-3 3.5-4 5-6 7 7
StructureasrequiredforNursingProcess 0 1-3 3.5-4 5-6 7 7
Assignmentlogically developed






Introduction, bodyofwork, conclusion.
Adheres tothewordlimit.





Technicalterms explainedwherenecessary.






Itcatchesthereader’s attentionandpromotestheconveyingof information.





Referencingasper Assessment Handbook

Thisassignmentis worth65%of thetotalassessmentforthissubject. / 100

COMMENTS LatePenalty(if applicable):

This reflective essay is about John Chan (Pseudonym used) as Nursing and Midwifery Board of Australia (NMBA) (2013a, p. 1) states that nurses should keep patients information obtained in a professional capacity as private and confidential. Mr. John was a sixty six years old patient born in China who was admitted from a nursing home in a medical unit in a Sydney based hospital for decreased loss of consciousness and acute renal failure on 10th of September. His recent medical history included cerebrovascular accident occurred in 2009, recurrent aspiration pneumonia, right sided hemiplegia and dysphagia. As a consequence of stroke, Mr. John had global aphasia and couldn’t speak or understand speech nor can he read and write. Due to dysphagia; difficulty in swallowing (Whiteing & Hunter 2008, p. 40), Mr. John was kept nil by mouth and a nutritional supplement was provided through Percutaneous Endoscopic Gastrostomy (PEG) at a rate of sixty five millilitres per hour starting from 0600hrs and finishing at 2100hrs to maintain his nutritional status. An intravenous cannula was in situ in median cubital vein, and an indwelling catheter was in situ to manage urinary incontinence and to monitor his output. Mr. John was bed bound, incontinent for faeces and was in full care. Mr. John had second stage pressure ulcer due to impaired mobility, loss of sensory perception and malnutrition.

The description of the incident will be based on the Gibbs’s (1998) reflective model which incorporates description, feelings, evaluation, analysis, conclusion and an action plan (Tregoning 2015, p. 69). During the second week of my clinical placement, I was asked to assist one of the staff working as an Assistant in Nursing (AIN) in order to change the diaper of Mr. John. Mr. John was new to me as he was not my regular patient, however I decided to assist the staff and we gathered necessary articles and went to the patient’s bedside. As we started, Mr. John was found to be lying in faeces everywhere and even his linens were all full of faeces. As I took off his incontinence pad, Mr. John was found to be having a dressing for pressure ulcer which was soiled with faeces on his sacrum. After cleaning him, the AIN that I was working with tried to put on a new diaper without even changing the soiled dressing which was ready to come out. I instantly questioned him whether we should inform to the nurse about his dressing and he mentioned that the nurse is busy updating her handover. Being a first year student nurse, I was not allowed to do dressing on my own as it was not in my scope of practice, I myself went to inform the nurse assigned to look after Mr Chan and let her know about his dressing. She came and assessed the condition of the patient’s wound and also identified that the area of pressure ulcer was increased. According to (Phillips 2012, p. 980), it was grade II pressure ulcer as evident by partial thickness loss of dermis, red-pink wound bed without slough. She applied a new dressing following an aseptic technique, filled out a wound chart and consulted to the wound care specialist. Later, the patient was repositioned and ensured that he was comfortable on his bed.

As I did not get to know much about Mr. John beforehand and his PEG tube and IDC were to be considered when providing personal care, I was feeling a bit nervous to work with the AIN by seeing the mess around. On the other hand, I felt sorry for the patient as he could not speak and appeared to be in faeces for long time which was really a bad experience for me. Moreover, the research (Hunter & Sarkar 2011, p. 519) suggests that pressure ulcers can be painful and also induce severe discomfort. Mr John was unable to express his pain but his facial expression was evident that he was going through pain which made me feel sad and helpless. Being empathetic to him, I was energised and motivated to make him feel comfortable and finally advocated for him, and managed to look after him which enhanced my level of confidence in providing an effective nursing care. I was so happy to see Mr. John waving his unaffected hand to me after he was left comfortable on his bed. The good thing about the experience was being able to speak up with the AIN and the nurse about the patient’s need around preventing infection and maintaining a safe environment.

A pressure ulcer is defined as “a localized injury to the skin and or underlying tissue usually over a bony prominences, as a result of pressure, or pressure in combination with shear” (Lewis 2008, p. 230). According to the literature (Sanford 2008, p. 1604), cerebrovascular disease refers to any disease process that impairs cerebral blood flow below a critical level to a specific reason of the brain causing neurological impairment.It is evident from the literature that patients with stroke are more susceptible to pressure ulcer due to various risk factors such as impaired mobility, poor nutrition, impaired perfusion, alteration in skin status and impaired sensory perception (Swann 2009, p. 416). Nurses should employ a validated risk assessment tools such as Braden and Norton scales to determine the patients at risk of developing pressure ulcer (Phillips 2008, p. 979). It is suggested that deficient communication between nurses and AINS has a significant impact on patient care (Sving et al. 2012, p. 1300). Nowadays most hospitals employ AINS to perform patient care, however they should be continuously supervised as nurses have higher level of education and duty of care (Athlin et al. 2010 cited in Sving et al. 2012, p. 1301). Based on the research (Moore & Geist 2015, p. 16), nurses must stay vigilant and act promptly to prevent and manage pressure ulcer, and acting as an advocate can help to keep our patients safe. As managing urinary and faecal incontinence is paramount to keep skin clean and dry in order to prevent incontinence associated skin damage and to prevent further deterioration of existing pressure ulcer (Benbow 2012, p. 32), I did regular assessment to determine whether the patient’s bowel was opened and changed patient’s position every second hourly after that incident during my clinical experience.

Having experienced this incident and having learned from the literatures, I feel that my competency around pressure ulcer management and care has enhanced. Nurses should work collaboratively with multidisciplinary teams to protect and promote the health and well being of patients. If this situation arises again, I would always raise questions if I feel the needs of a patient are not being met. I would communicate effectively to the interdisciplinary teams to provide a qualitative nursing care and to protect the interests and safety of patients. Most importantly, I will go through evidenced based literature around preventing and managing pressure ulcer to increase my level of expertise and I will perform pressure ulcer dressing whenever patient requires during my future clinical placement.

The nursing process is the systematic, person-centred and collaborative approach in order to structure the planning and delivery of nursing care (Holland 2008, p. 12). Assessment is the process of collecting and identifying patients potential or actual health problems and planning is the process of setting short term and long term goals for the problems identified (Holland 2008, p. 19). Interventions is the process of delivering specific nursing interventions to meet patient’s needs and evaluating is the process of judgement to determine the patient’s progress towards achievement of goals and the effectiveness of the interventions (Luxford 2012, p. 212). The nursing care plans for Mr John are developed based on these four stages.

Assess (including rationale) Plan Implement Evaluate
Patient requires wound dressing due to stage II pressure ulcer as wound dressing promote wound healing, prevent deterioration of the ulcer stage and protect wound from further contamination (Lewis 2008, p. 227). To maintain skin integrity with no further signs of pressure ulcer. Perform hand hygiene before and after caring for wounds to prevent transmission of infection (Phillips 2012, p. 991).

Administer prescribed analgesics as pressure ulcers are painful and induce severe discomfort (Hunter & Sarkar 2011, p. 519).

Use isotonic solutions or tap water to irrigate the wound by employing an aseptic technique for keeping the wound free from infection(Phillips 2012, p. 999).

Apply sterile gloves and clean the wound from inward to outward direction to avoid transferring organisms from the surrounding skin into the wound (Phillips 2012, p. 999).

Avoid repeated cleaning of the wound if it has little exudate and reveals healthy granulation tissue as unnecessary manipulation during dressing changes destroys granulation tissue (Phillips 2012, p. 999).

Use hydrocolloid dressings for clean wounds as these dressings produce a moist healing environment and protect the wound from bacterial contamination (Phillips 2012, p. 996).

Consider taking baseline and serial photographs to monitor pressure ulcer healing over time (Phillips 2008, p. 996).

Maintain appropriate documentation by mentioning the stage, size, location, amount of exudate, type of wound, presence of infection or pain (Lewis 2008, p. 216).

Make a referral to wound care specialist to review the condition of the wound (Phillips 2012, p. 996).

Patient shows signs of improvement as manifested by increased epithelialization.

Assess (Including rationale) Plan Implement Evaluate
Patient is at risk of pressure ulcer deterioration due to right sided hemiplegia. This is because a person’s ability to reposition himself and to relieve the pressure is hindered due to impaired mobility (Phillips 2012, p. 978). To avoid potential associated risks, promote healing and maintain skin integrity. Perform risk assessment for pressure ulcer by using a validated tool such as Braden scale as knowing the level of risk allows implementation of preventative measures (Phillips 2012, p. 978).

Reposition patient that are confined to bed every second hourly to relieve pressure and inspect skin for erythema over bony prominences while repositioning to detect any deviation (Hunter & Davies 2014, p. 473).

Employ manual handling aids such as lifters, slide sheets rather than dragging the person across or up in the bed to prevent friction which may cause blisters and abrasions (Swann 2009, p. 416).

Use specialised bed mattress to relieve pressure (Phillips 2012, p. 992).

Ensure the bed linens are smooth, firm and wrinkle free to prevent injury due to friction and shearing forces (Phillips 2012, p. 992).

Use positioning devices such as foam or pillows between bony prominences to prevent direct contact and to reduce pressure (Swann 2009, p. 416).

Use wedges or pillows or heel protectors to raise the heels completely off the bed (Phillips 2012, p. 994).

Consider using a skin moisturiser to hydrate dry skin (Phillips 2012, p. 992).

Patient has uniform moisturised skin and existing ulcer shows signs of healing.

Assess (Including rationale) Plan Implement Evaluate
Patient has risk of impaired wound healing related to decreased nutritional intake due to dysphagia. The research (Whiteing & Hunter 2008, p. 44) suggests that our body uses food for energy, growth and maintenance and tissue repair, and a decreased nutritional input may predispose patient to the development of pressure ulcers and contribute to wound healing. To achieve adequate nutritional status and to promote wound healing. Monitor and maintain the dietary supplement (PEG feed) as the patient is already ordered to have PEG feed at twenty millilitres per hour by dietitian. It is evident across literature that PEG feeding is considered appropriate to stroke patients who are at risk of malnutrition and require long term enteral feeding (Rowat 2015, p. 142).

Elevate the head of the bed at thirty to forty five degree to prevent aspiration, however prolonged elevation should be prevented as healing of existing pressure ulcer is interfered especially for the wound in sacral and buttocks region (Cox & Rasmussen 2014, p. 24).

Assess patient’s nutritional status regularly and refer to dietitian in order to determine the number of kilojoules and type of nutrients needed to meet nutritional requirement (Guenther 2008, p. 1030).

Provide high calorie and protein rich diet, and provide the recommended daily requirement of micronutrients to promote healing of pressure ulcers (Cox & Rasmussen 2014, p. 20).

Maintain adequate hydration as hydration plays a vital role in the maintenance and repair of skin integrity via oxygenation of both healthy and wounded tissues (Cox & Rasmussen 2014, p. 23).

Monitor patient’s weight at specified intervals to make adjustments as needed in kilojoule intake (Guenther 2008, p. 1030).

Monitor accurate documentation of patient intake and output to determine whether the input is proportional to output (Lewis 2008, p. 218). Patient has put on weight as manifested by increased Body Mass Index (BMI) and signs of wound healing shown as evidenced by increased epithelialisation.

Assess (Including rationale) Plan Implement Evaluate
Patient is at risk for wound infection associated with incontinence of faeces. The research (Cox & Rasmussen 2014, p. 24) suggests that stool is a contaminant which can have deleterious effects on wound healing and can lead to wound infection. To prevent infection in the pressure ulcer. Assess patient’s bowel movement frequently in order to prevent over exposure to moisture from faeces which consequently can prevent accumulation of bacteria thereby keeping away from infection (Phillips 2012, p. 978).

Gently cleanse the wound with warm water as promptly as possible after each episode of incontinence and provide a good perineal care to prevent skin breakdown and pressure ulcer development (Benbow 2012, p. 34).

Provide adequate skin protection by using topical barrier creams and consider using emollients to hydrate dry skin and reduce the risk of skin damage (Cox & Rasmussen 2014, p. 25).

Use high quality incontinence pads and employ a faecal management system to protect wound from further exposure and to establish a healing environment (Cox & Rasmussen 2014, p. 25).

Consider changing dressing if it is soiled as discussed in earlier care plan to prevent infection and promote wound healing (Benbow 2012, p. 34). Patient had no evidence of secondary infection such as redness, oedema or exudate.

In conclusion, pressure ulcers, which are caused by prolonged pressure usually over a bony prominences, are a great risk in maintaining a safe environment for patients. Reflecting the incident through the use of Gibbs’s model of reflection and formulating an evidenced based care plan has enhanced my knowledge and skills around managing and caring for patients at risk of having pressure ulcers as well as to prevent them. Having learned from the literatures, I know that pressure ulcers are preventable and nurses are the professional group that are primarily responsible for caring patients as they spend most of the time with patients as compared to other health professionals. Due to this, nurses should have adequate knowledge about anatomy and physiology of skin and the physiology of wound healing. Moreover, I discovered that a pressure ulcer risk assessment should be conducted for every patients during admission by using a validated risk assessment tool to determine patients at risk of having pressure ulcer and adequate prevention should be considered at an early stage in all patients. Most importantly, patients with stroke are highly susceptible of getting pressure ulcers due to their impaired mobility, faecal and urinary continence and impaired sensory function. Vigilant care is required to address patient’s risk factors for development of pressure ulcers. Wound care should be conducted to promote wound healing depending on the condition of pressure ulcers by using an aseptic technique, and faecal and urinary incontinence management should be employed in order to prevent infection and further deterioration of existing pressure ulcers. Most importantly, documentation of wound should be appropriate and should follow the wound parameters while documenting i.e, stage, size, location, amount of exudate, type of wound, presence of infection and pain. As I came across many literatures from science and nursing databases, books, google scholar and journals, this activity has developed my understanding of maintaining a safe environment for patients and I came to know that both internal and external environment should be considered while maintaining patient’s safety. More specifically, this activity has enabled me to have a broader understanding of pressure ulcer injury, risk factors, preventative measures and the management. Most importantly, this activity has assisted me to understand the effectiveness of collaborative approach of multidisciplinary teams and the importance of effective communication in providing a qualitative patient care. During my future nursing practice, I will always employ a holistic approach to assess patients’ needs and incorporate an evidence based practice into patients’ care so that patient care would be based on the best available evidence and patients’ quality of life would be enhanced.



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