Critical Analysis of Patient Care Utilising John’s Model of Structured Reflection

Topics: Sepsis, Liver, Systemic inflammatory response syndrome Pages: 22 (5707 words) Published: April 26, 2011

The aim of this assignment is to reflect on the management of a patient with multiple organ dysfunction syndrome (MODS). Reflective practice is associated with learning from experience, (Johns & Freshwater 1998) and viewed as an important strategy for health professionals who embrace life long learning (Department of Health 2000). Engaging in reflective practice is associated with the improvement of the quality of care, stimulating personal and professional growth and closing the gap between theory and practice (Benner 1984; Johns & Freshwater 1998).

Central to Johns’ idea of reflective practice is the goal of accessing, understanding and learning through direct experience. It is this that enables the practitioner to take “congruent action towards developing increased effectiveness within the context of what is understood as desirable practice.” (Johns 1995, p 226).

The model for reflection that will be employed will be John’s model, this model uses Carper’s (1978) four patterns of knowing; aesthetics, personal, ethics and empirics adding a fifth pattern ‘reflexivity’. This reflective essay will critically evaluate the management of Mr. Cox during his 30 day stay as a patient in the Intensive Care Unit (ITU).

A pseudonym has been used to protect the identity of the patient in accordance with the Nursing and Midwifery Council (NMC 2002).

Past medical history
Alcohol abuse (1 bottle of whisky and approximately 10 cans beer per day); Liver failure; Cardiomyopathy; Heavy smoker (23-30 cigarettes a day).

Mr Cox a 61 year old gentleman was admitted to hospital following a 2 day history of malaena and generalised weakness. (He had no previous history of Gastrointestinal (GI) bleed).He was diagnosed with decompensated Alcoholic Liver Disease due to his deranged Liver function tests, jaundice and oesophageal and duodenal varacies.

Mr Cox’s condition deteriorated and he was transferred to ITU following an upper GI bleed of approximately 500 mls as well as evidence of acute coronary syndrome (ACS) (his blood results were troponin +ve, with ischaemic changes to his ECG) and increasing hallucinations and confusion. He was promptly intubated following a rapid deterioration of his GCS and was fluid resuscitated with gelofusin, 8 units of blood and 2 units of Fresh frozen plasma. He required Noradrenaline to maintain an adequate blood pressure and Amiodarone to control his fast atrial fibrillation (AF).

An Endoscopy revealed a bleeding duodenal ulcer (DU) which was injected with 10mls of adrenaline and diathermied, it was noted that Mr Cox still remained at high risk for further bleeding. On presentation to ITU he was pale, tachycardic with cool peripheries.

Mr Cox became increasingly unwell and on his third day of admission he had began to show signs of severe sepsis, initially the source of infection was unknown, but with further investigation a perforated bowel was identified, and as a result he was taken to theatre for a laperotomy .In theatre a duodenal perforation was discovered with 3 litres of gross peritoneal soiling, which mainly consisted of nasogastric feed and pus. A Foley catheter was inserted for drainage in the perforation and his abdomen was left open, so further washouts could be performed. A jejunostomy tube was inserted in theatre at this stage for feeding.

Two days following surgery Mr Cox had a further GI bleed from his oesophagus and abdominal drain. The surgical team felt he was too unstable for further surgical intervention at this stage as well as there being limited surgical options.

There was evidence of continuing septic episodes over the next few weeks, with persistent pyrexia, increasing inflammatory markers as well as an increased requirement of Noradrenaline. Escherichia coli, Staphylococcus aureus and Candida albicans were grown from blood cultures.

Renal replacement therapy (CVVHDF) was required intermittently as he developed acute renal...
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