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

Introduction

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).

Description
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

References: Adam, S, K., and Osborne, S. (2005). Critical care Nursing, Science and Practice. 2nd Ed. New York: Oxford University Press. Arroyo, V., Guevara, M., Gines, P. (2002). Hepatorenal syndrome in cirrhosis: pathogenesis and treatment. Gastroenterology 2002 May;122(6):1658-76. PMID 12016430. Benner, P. (1984) From Novice to Expert. Addison-Wesley, Menlo Park, California Beauchamp, T, L., and Childress, J, F BMA (British Medical Association) (2005). Right to live. New York: Educational Broadcasting Corporation Booth, M, G., Doherty, R., Fairgrieve, R., Kinsella, J Carper, B. (1978) ‘Fundamental ways of knowing in nursing.’ Advances in Nursing Science, 1; 1: 13-23 Choi, P,T,L., Yip, G., Quinonez, L, G Cook, D., Guyatt, G. (2001). Colloid use for fluid resuscitation: Evidence and spin. Ann Intern Med 2001; 135:205–208. Dellinger, P, R., Carlet, J, M., Masur, H., Gerlach, H., Calandra, T., Cohen, J. et al. (2004). Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock. Critical care medicine. 2004; Vol 32, No 3. Department of Health (2000). The NHS Plan. London: The Stationary Office Department of Health (2005) Elsurer, R., Sezer, S., Ozdemir, N, F., Akgul, A., Arat, Z., Haberal, M. (2006). Acute Renal Failure in Intensive Care Unit: which factors predict future dialysis dependency. J Nephrol. 2006; 19: 634-639. Fernandez, J., Navasa, M., Gomez, J. (2002). Bacterial infections in cirrhosis : epidemiological changes with invasive procedures and nofloxacin prophylaxis. Hepatology. 2002; 35: 140-8. Fisher, M. (2004). Ethical Issues in the Intensive Care unit. Current Opinion in Critical Care. 2004, 10:292-298. Foreman, M, G., Mannino, D, M., Moss, M. (2003). Cirrhosis as a Risk Factor for Sepsis and Death. Chest. 2003; 124: 1016-1020. Fry, S., and Johnstone, M, J. (2002). Ethics in Nursing Practice: A guide to ethical decision making. 2nd ed. Oxford: Blackwell Science, Ltd. Goulis, J., Armonis, A., Patch, D. (1998). Bacterial Infections is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology. 1998;27: 1207-12. Hinshaw L, B. (1996). Sepsis/septic shock: participation of the microcirculation: an abbreviated review. Crit Care Med 1996;24:1072–1078 Huonker, M., Schumacher, Y, O., Ochs, A., Sorichter, S., Keul, J., Rossle, M Hudak, C, M., Gallo, B, M., and Morton, P, G. (1998). Critical Care Nursing: A Holistic Approach. 7th ed. Philadelphia: Lippincott. Johns, C. (1995) Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing, 22; 226-234 Johns, C., and Freshwater, D Meltzer, L, S., and Huckabay, L, M. (2004). Critical Care Nurses’ Perceptions of Futile Care and Its Effect on Burnout. Am J Crit Care. 13; 3: 2002-208. Mims, C., Dockrell, H, M., Goering, R, V., Roitt, I., Wakelin, D., Zuckerman, M Morkerjee, R, P., Sen, S., Davies, N, A., Hodges, S, J., Williams, R., Jalan, R. (2003). Tumor Necrosis Factor  is an important mediator of portal and systemic haemodynamic derangements in alcoholic hepatitis. GUT. 2003; 52: 1182-1187. Montgomery, C.L. (1993) Healing through communication, the practice of caring. Sage Publications, London. Morse, J.M. (1991) ‘Negotiating commitment and involvement in the nurse-patient relationship.’ Journal of Advanced Nursing, 16: 455-468. NMC (Nursing and Midwifery Council. (2002). Code of Professional Conduct. NMC: London. Olafsson, B. (2003). Absence of Response: A Study of Nurses’ Experiences of Stress in the Workplace. Journal of nursing Management. 11: 351-358. Rivers, E., Nguyen, B., Havstad, S. (2001). Early goal-directed therapy in the treatment of sevre sepsis and septic shock. N Engl J Med. 2001; 345:1368-1377. Salmaan, K., Pharm, D., John, W., Delvin, P., Krista, A., et al. (2001). Recombinant Human Activated Protein C, Drotrecogin Alfa (Activated): A Novel Therapy for Severe Sepsis. Pharmacotherapy. 21(11): 1389-1402. Sass, D, A., and Shakil, A, O. (2005). Fulminant Hepatic Failure. Liver Transplantation. 11; 6; 594-605. Schierhout, G., Roberts, I. (1998). Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: A systematic review of randomized trials. BMJ 1998; 316:961–964 Schon, D.A Thalheimer, U., Triantos, C, K., Samonaskis, D, N., Patch, D., and Burroughs, A, K. (2005). Infection, coagulation, and variceal bleeding in cirrhosis. GUT. 2005; 54; 556-563. Urden, L., Stacy, K., and Lough, M. (2002). Thelan’s Critical Care Nursing: Diagnosis and Management. 4th ed. St Louise: Mosby Inc. Way, J., Black, A, L., and Randall Curtis, J Wong , F., Bernardi, M., Balk, R., Christman, B., Moreau, R. et al. (2005). Sepsis in cirrhosis: Report on the 7th meeting of the International ascites club. GUT. 2005; 54: 718-725. Young, J, D, (2004).The Heart and Circulation in Severe Sepsis. British Journal of Anaesthesia, 2004; 93: 1 114-120.