Fauquier Rehabilitation and Nursing Center (FHRNC) is a 113-bed center located in Warrenton, Virginia. As stated on their website “services included are physical occupational and speech rehabilitation; long term care and respite services”.
The average stay of patients is 25 days but can be longer depending on the needs of the patient. (retrieved from FH website, 2018)
Safety: Interprofessional, Communication, Medication Errors
Safety:
The Institute of Medicine (IOM) has stated that “the healthcare environment should be safe for all patients, in all of its processes, all of the time” (Giddens, 2017). Safety is largely influenced by the attitude of the healthcare professional. As stated “It is the collective and shared environmental scanning and vigilance by all team members that prevents errors” (Giddens, 2017) Interprofessional
It is the cooperation between nurses that can influence health care errors. According to Giddens 70% of healthcare errors occur due to the level of cooperation. (Giddens, 2017) Worked with two nurses the first clinical day. Both were very empathetic towards their patients and each other. Their working relationship appeared to be supportive. The first nurse was working a 16hour shift and had 12 patients for whom she was responsible. She was a recent nursing school graduate and has been with FHRNC for a few weeks. The second nurse has been with FHRNC a few months.Due to their work load they were not able to communicate as much as a new graduate may have needed.
When administering insulin to a patient, the second nurse was not around to have the dose verified leaving the female nurse to draw the dose and administer it without it being seen by another nurse- a safety violation related to insufficient inter-professional communication and or cooperation,
Communication
While being on the floor we witnessed a change in shift where the nurse whose shift was ending was reviewing and counting the narcotics present per patient and verifying that the numbers all were accounted for. This was efficiently done and the numbers were checked off. A good begin to the new shift and a good way to end the shift.
There was a question from a nurse relating to medication in a patient’s drawer. According to the nurse there were two of the same medication in the drawer with different prescriptions and the was not sure what to do. This may have been prevented if there was more communication between the healthcare provider and the nursing staff.
The second day of clinical worked with a nurse who imbued more confidence and made the shift more productive as there was less chaos and more focus. The SBAR witnessed was thorough. The time was taken to review each patient and questions were asked and answered when possible. Both nurses involved were focused and not distracted during this process.
Medication Errors
To reduce the risks of medication errors a system has been implemented that involves checking the medication three times prior to administering to the patient. checking the medication with the MAR at the bedside, verifying the patient using two identifiers and if needing to bring medication in a pre-measured dose to have it labeled properly. This was not how the medication being administered was handled.
The MAR stayed in the hallway in a fixed position. The nurse would check the MAR, get the medication, draw it up in a syringe or put the pills in a cup and take it to the patient in their room. There was no audible check of the medication at the MAR, before entering the room or at the bedside. Syringes and pills were not labeled after being prepared for the patient. Any assessing that was done in form of blood sugar determination was done at the bedside and then the nurse had to walk back to the MAR to record it. During the administering of the medication, with nurses involved, 26-32% of medication errors occur. The system observed at FRHNC was susceptible to medication errors.
Communication: Health History, EHR, Documentation Health History
To provide patient-centered care a thorough understanding of the patient’s chief complaint and relating factors is crucial. It is the responsibility of the nurse to gather the needed data to make an accurate nursing diagnoses and the consequent nursing goal, outcomes and related interventions. The first step to achieving this is to document a thorough health history “A comprehensive health history covers all health dimensions” (Potter, 2017). The components of a comprehensive health history are:
- Biographical information- name, DOB, gender, address, marital status, occupation, • healthcare insurance
- Chief complaint (CC)- reason for consulting the health care provider • Present history of illness (PHI)- use the following OLD CART to gather more specific data:O-onset, L-location, D- duration, C-causative factors, A- associative factors, R- relief, T- treatment thus far
- Past Medical History (PMH) including immunizations, relevant illness • Past Surgical History (PSH)
- Family History (FH)- including genetic and relevant illness such as cancer, hypertension, diabetes
- Cultural considerations- religious, spiritual, gender sensitivity, modesty (Potter, 2017).
At FRHNC we were presented with a summary of the patient’s records. The information presented was not complete depending on what was disclosed to the students. It was not always apparent what the chief complaint was. Some patients were long term so the PHI was not as succinct and their plan of care was more focused on addressing chronic illness such as hypertension, diabetes and renal failure. The past surgical history was often quite extensive due to their being older and having had more time to have medical issues. As most patients were geriatric there was no family history listed in the health history. FRHNC being a small facility in a rural community the population was rather homogeneous and there was not much cultural diversity.
EHR
The Electronic Health Record (EHR) has been implemented to reduce errors in medical practice and enhance communication between health care professionals by facilitating the sharing of patient information. The EHR also poses a risk for HIPAA violations as it is easy to access and share patient information. The EHR can assist the nurse in the assessment of the patient by ensuring that thorough information is documented. The EHR reduced the risk of misspelling and misinterpretation of handwriting as it is typed and the spelling can be checked.
The EHR allows for amendments but no information can be removed from the EHR once entered. This too ensures patient safety as it is possible to retrace all actions done for and to the patient.
Documentation
“A fundamental skill of a nurse is accurate and timely documentation in the patient record”. (Giddens, 2017). As FRHNC has nurses, physical therapist, occupational therapists, CNA, LPN and physicians attending the patients it is crucial that information is documented as soon as it has been done to ensure that the safety of the patient is maintained. It is this access by more than one person at a time that also can lead to errors as the information may not be accurarate. The documentation needs to be medically accurate and use standard phrases that are familiar to all accessing the records. There are certain abbreviations that may not be used as they can lead to errors. As the documentation is facilitated and often done in a rapid fashion this leaves room for error. Vigilance and attention to detail is important when documenting.
Sensory: Assessment of HEENT
The HEENT assessment involved an inspection, palpation, and testing of sensory function of the Head, Ears, Eyes, Nose and Throat. It includes these five elements as well as the lymph nodes around the head, the neck and clavicular area. Prior to the review of systems, a comprehensive history is documented and if the chief complaint is related to the HEENT more in depth question may be asked to determine impact of past medical history and family history.
When assessing it is important to compare both sides such as both eyes, both ears, both nasal cavities as this is a good indicator if something is with normal range of abnormal.
The assessment and inspection of each element is as follows: • Head& Neck: Shape, Symmetry, Position, Abnormal findings, palpate lymph nodes, thyroid symmetry and whether enlarged.
- Ears: Shape, Symmetry, Pain when moving pinna, whisper hearing test, Rinne & Weber for conduction, inspection of tympanic membrane with otoscope. Note any exudate or excessive cerumen which could impact hearing.
- Eyes: orbital cavity shape, eyelids, conjunctivae, PERLA (pupils equal, reactive to light, accommodates) peripheral vision, extra ocular eye movement (EOM) by following finger in shape of + and X. Note any exudate or excessive tearing. With ophthalmoscope look at back of eye, optic nerve and any abnormalities.
- Nose: inspect for symmetry and placement. Deviated septum. Exudate – COCA (color, odor, consistency and amount) Palpate frontal and maxillary sinuses. With otoscope look inside nasal passages.
- Throat: inspect for any lumps, bumps, discoloration or other abnormalities. Have patient open mouth and inspect tongue- color, shape, size, texture, inspect uvula, tonsils and back of throat. (Jarvis, 2016)
While at FRNHC did not perform an assessment of HEENT.
Infection: MRSA, C-Diff, UTI
MRSA
MRSA is caused by the Methicillin-resistant-bacteria Staphylococcus Aureus. Risk factors for the infection with the MRSA bacteria are a hospital stay, residing at a long-term care facility or having an invasive medical device. MRSA most often present as skin infections which, if not treated, can lead to sepsis and death. It is spread by direct contact. A MRSA infection is characterized by redness, warmth, pain, swelling and pus. It can start as a small raised pustule that may be mistaken for acne or a spider’s bite. Hand hygiene is one of the most important ways to prevent the transmission of the bacteria.
Day one of our clinical experience prented with two patients who both were infected with MRSA. This was quite daunting as a first interaction with patients. It was challenging to have an interpersonal exchange that felt natural with the patients while one’s mouth and therefore part of facial expressions is hidden behind a mask. In addition to walking into a room in “full armor” makes ones feel very removed from the patient and concerned that the patient will perceive this as a rejection due to their infection. (Lewis, 2017) Both patients were very kind and cooperative.
When going into the room we have been taught to wear PPE consisting of mask, gloves and gowns. The attending nurse did not think this was necessary. To resolve this conflict the preceptor to accompanied us into the room. We followed her example and put on the full PPE.
The objective was to take vitals of the patients. To maintain the isolation a dedicated blood pressure cuff, pulse oximeter and stethoscope needed to be present in the room. This was not the case. When addressed the necessary equipment was provided and left in the room.
The trash receptacle was overflowing which was a safety hazard in overflow on to the floor which could cause a fall and spread of the bacteria. The tray that was used to bring the patient food was not disposable. The nurse, without gloves, removed the tray from the patient and put it on the catering trolley. The catering staff, with gloves tucked in her pocket, wheeled the trolley with MRSA room tray to the cafeteria where all staff would be exposed to the bacteria.
One of the patients had a low body temperature of 96.7 when assessed by oral method.
geriatric patients, hypothermia can be an indicator of septicemia. This patient has MRS. The concern regarding her care was that the treatment was not as aggressive as medically indicated as the family did not agree to a higher amputation.as possible due to the family not agreeing to more of her leg being amputated. The pulse ox measured 88% which could be a reason for her being incoherent and confused. This mental state had been corroborated by the attending nurse.
C-Diff
Clostridium difficile is the bacteria which causes watery diarrhea and is referred to as c-diff. The infection occurs in older and/or immunocompromised patients. Often while hospitalized or, during stay at a long- term care facility. If a patient is on antibiotics, a c-diff infection can present within 5-10 days after the start of the medication. This timeframe is variable and can be from day one of antibiotic administration or 2 months later. The bacteria are spread by spores in the feces that are transferred by direct contact. A C-diff infection presents as watery diarrhea with bowel movements 10-15 times per day. Abdominal pain and cramping.
Complications of C-diff are toxic megacolon caused by gas accumulation due to the lack of bowel movements (ileus), which can rupture. Other complications are dehydration due to water loss with diarrhea, kidney failure (assessed by BUN/Creat values in blood). C-diff can be fatal.
The diagnosis is made using a fecal sample. The treatment for c-diff is antibiotics. Depending on the severity different medications will be used. For a mild infection, Flagyl is the antibiotic of choice. A severe c-diff infection is treated by vancomycin. This is an ototoxic/renal toxic antibiotic and is therefore a high alert antibiotic. To help normalize the bacterial flora a fecal transplant can be considered. (Lewis, 2017) While at FRHNC there were no patients with c-diff encountered.
UTI
A UTI is a urinary tract infection. The cause can be bacterial, viral or fungal. E. coli is the most frequent cause if bacterial and leads to a bladder infection (cystitis). Patients at risk are female due to urethra width and length, with a catheter abnormalities including obstruction of the urinary tract and immunocompromised. Being sexually active can lead to sexually transmitted infections (STI) such as herpes, gonorrhea, chlamydia and mycoplasma can cause UTIs. The diagnosis is made using a urine sample to detect the presence of white blood cells indicating an infection and red blood cells indicating irritation in the urinary tract causing bleeding. To choose the most effective antibiotic, it is best practice take a clean (mid-stream catch) urine sample for culturing prior to starting (empiric) antibiotic therapy. (Potter, 2017). The antibiotic used is trimethoprim/sulfamethoxazole, commercial names Bactrin or Septra. An anti-spasmodic, such as pyridium, can be administered as well to reduce the pain. If using Pyridium it is important to inform the patient that it will turn the urine orange.
UTIs can be prevented by ensuring adequate hydration to flush out the bacteria, proper perianal care by wiping front-to-back and emptying the bladder after sexual intercourse. Female patients need to be advised not to use irritating vaginal products that can affect the urethra.
(Lewis, 2017)
While at FRNHC cared for a patient with acute pyelonephritis. She did not have a urinary catheter. She was diagnosed with an E. coli infection. The UTI etiology was most likely improper perianal care. She was an obese woman with impaired mobility. Her oxygen saturation varied from 80-95% depending on movement. The impaired gas exchange was caused by cardiac myopathy. Due to the impaired cardiovascular system and resulting affected gas exchange, she was mostly bedridden. Being bedridden did not enhance her ability to urinate and could have caused urinary stasis which lead to the pyelonephritis.
When admitted she had been able to ambulate to the bathroom but a week after admittance she was not able to stand unassisted. (her condition was deteriorating). Her perianal area had impaired skin integrity and there was evidence of a pressure ulcer at the base of her spine. These factors contributed to the UTI (pyelonephritis) developing and persisting.
Reflection on Experience in Clinical Setting The time in this clinical setting was an enormous learning experience. Nursing skills were applied and fears were confronted. It was confronting to see choices made by nurses to the detriment of their patients and themselves. It was encouraging to realize that what is being taught is becoming second nature i.e. always be assessing, hand hygiene, patient identifiers, asking if need anything before leave room, ensuring call bell in place and accurate documentation.
The consequences of immobility were evident in most every patient encountered while at FRHNC. It was clear how nursing interventions are crucial to facilitate ambulation of patients to enhance their wellbeing as objectively assessed by vital signs, lack of infections and ability to carry out ADLs and IADLs. Patients who are not able to perform ADLs are often less communicative and receptive to help I found than patients who can still care for themselves. It was humbling to care for patients, who needed perianal care. I so respected their willingness to be vulnerable and let me help them. It was the greatest reward to help a bedfast patient with a bed bath and see the patient’s skin look fresh and have more color in her cheeks and see the relief in her face, the infusion of hope and renewed resilience.
References:
Fauquier Health Rehabilitation and Nursing Center Information Sourced from: https://www.fauquierhealth.org/our-services/senior-care/fauquier-health-rehabilitation-and-nursing-center Giddens, J. (2017) Concepts for Nursing Practice (2nd ed.) St Louis, MO: Mosby Elsevier, 445-447, 449, 450 Jarvis, C. Physical Examination & Health Assessment (7th ed.) St Louis, MO: Elsevier 252-383
Lewis, S.L., Bucher, L., Heitkemper, M.M., Harding, M.M., (2017) Medical-Surgical Nursing (10th ed.) St. Louis, MO: Mosby Elsevier, 216-217, 929-931, 1033-1036 Potter, P.A., Perry, A.G. and Stockert, P.A. (2017) Fundamentals of Nursing (9th ed.), St Louis, MO: Mosby, Elsevier, 214-220, 1112