University Hospital Case Study: Patient Care Plan Reflection Report

This report presents a comprehensive reflection on a patient care plan developed by a student during an 8-hour shift in a hospital ward. The report details the student's actions, including patient greetings, vital sign checks, medication reviews, and communication with other healthcare professionals. It also includes a reflection on the student's performance, highlighting effective communication, patient-centered care, and areas for improvement. The influencing factors, such as communication and time constraints, are discussed, along with proposed improvements like incorporating additional assessments and peer guidance. The report concludes with learning outcomes, emphasizing the importance of systematic information recording and peer support in providing optimal patient care. The student references various journal articles and books to support their reflection and demonstrate evidence-based practice.

Case Study Reflection

Contents
Description.......................................................................................................................................1
Reflection.........................................................................................................................................2
Influencing factors...........................................................................................................................3
Improvement....................................................................................................................................3
Learning...........................................................................................................................................4
REFERENCES................................................................................................................................5

Description
I developed the patient care plan on hourly basis for the effective description of condition
along with improvements. This is vital in nature to perform by everyone who provide their
service at ward. This will not only help each other staff members in different shifts to monitor
the health of patient but also aid the medical professional to make informed decision making for
further medication (Baker and et. al., 2016). These care plans further provide the opportunity to
staff members to gain information about the factors that are important for regular monitoring in
the patient because each different patient has their own specific medical requirement. I
performed the 8 hour’s shift that started on 13.30PM and ended on 20.30PM. There were number
of operations performed at the time of working through which gained lots of information. All
these further used by me in the development of care plan. The detailed description of the
procedure along with attained information is further defined.
I started with effective greeting of the patient along with mine own description. I asked the
name of patient and confirm the same by looking her arm band that it is the right patient or no
(McManus and et. al., 2015).
Then after, I started checking the vital signs charts of patient to identify that there any issue
is present in health according to the checking’s done by morning nurse (Tuinman and et. al.,
2017). I also checked the medication charts to consider that provided on time or not by the main
nurse.
Further, I checked fluid order form, O2, air and suction and Pt IV line for considering the
amount left in bag. There are numerous tests were done for monitoring BP, HR and RR. Talked
with patient to do GCS for monitoring the level of consciousness and ascertaining the
information when the last time she was opened her bowel and feeling the pain (Bender, 2016).
I checked that ECG was done by morning nurse or not and ask the patient to provide the
urine sample for testing. Further, I checked the order of medication, called dietitian as patient
was underweight, called physiotherapist to review patient due to high risk of fall as patient had
the history of fall around 3 weeks ago and numerous factures in past 5 years and called social
worker to ascertain the level of performance in her ADL’s (Kvale and et. al., 2016).
I also checked MSU result in EMR patient record, consideration of the time when the CXR
booked, checked blood culture result and commencement of fluid balance charts for monitoring
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input and output. In the time period of afternoon, I motivate the patient for some oral intake (Oh,
Uhm and Yoon, 2016).
After this, started to build care plan on EMR and checked the patient IVC site for ensuing
that still patent and redness of swelling (Braithwaite, Wears and Hollnagel, 2015). Completion of
the necessary aspects, I checked the patient on hourly basis, made the progress notes and ready
the patient for dinner and check the BSL before to the dinner. After the dinner, I made the
records on food chart and fluid chart and toileting the patient for further its recording and
charting.
Then after, the time comes up regarding the medication. I provided the medicines and asked
for any further help in personal stuff. In last, before the shift ends I checked her BP and HR
before to the administer metoprolol and handed over the all workings to night staff fir further
monitoring and caring of patient (Orbæk and et. al., 2015).
In accordance to the information attained and working at the time of shift, I ascertained that
my performance was good as able to gather lots of health related information along with proper
recording and charting (Tobian. and et. al., 2016). I also took all the measures that were
important in direction of person centred care along with directing the professionals in further
better treatment of patient.
I always tried to build better level of communication where all information was conveyed
timely along with asked for help in completion of person stuff (Carthon and et. al., 2015). The
positive and motivating behaviour was adopted by me where always asked the patient to focus
over proper food and fluid intake as these are important in the direction of recovery process.
Reflection
Yes, I always have the clear goals in respect to each patient because everyone has different
needs. I tried to provide effective care to each and every one in accordance to their comfort zone
so they can adjust in the atmosphere and respond accordingly (Tobiano and et. al., 2015).
The care built by me is effective in regard and fulfils the criterion the person centre
approach. All the necessary information was mentioned in plan in accordance to the health issues
exist within the patient (Casotto and et. al., 2017). During the process of care nothing was
happened that negatively impacts the health of patient. I built the care plans by adhering both
routing check-up’s and person centred care aspects.
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The plan made by me is evidenced based where all recordings are present in chart and
documentary form. All these are aligned with the current policies of government and guidelines
adhered by the care setting. If there are no policies than as per the evidences, it would be clear
that completed work in respect to the care of patient is good in nature (Klemanski, Browning and
Kue, 2016)
This plan of care did not have any kind of impact to anyone else because done with using
effective working practices (Chera and et. al., 2015). This care plan will be improved if collect
information about some more aspects or perform some other special treatments like FBC and
measuring urine output due to risk of kidney injury from sepsis and dehydration, falls risk
assessment and falls prevention strategies (patient is high falls risk) and Serum lactate needs to
be checked (as per sepsis guidelines).
Influencing factors
The areas which went well during the period of care was effective communication and
coordination (Hewitt, Tower and Latimer, 2015). This help me in effective care along with
determining all information about the patient. The aspect that not happened good was lack of
peer guidance.
This would be the reason that some special areas are left which will be helpful in effective
formulation of care plan. Time was also the factor that restricts in taking of guidance. I used the
past experience that would be the reason that able to perform maximum working according to
care needs (Palmer and et. al., 2015).
Improvement
The additional aspects which will be performed by me for further improvement of care plan
includes FBC and measuring urine output due to risk of kidney injury from sepsis and
dehydration, falls risk assessment and falls prevention strategies (patient is high falls risk) and
Serum lactate needs to be checked (as per sepsis guidelines) (Rosen and et. al., 2018).
All these provide the opportunity to select the best strategies that help in performance of
regular functions without attracting any kind of risks. Also, help the medical professional in
providence of feasible medication accordingly (Hill, 2019).
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Learning
The aspect that will change in me due to the experience of writing care plan is mentioning of
all information in systematic form so these can be further used by the each and every one in
providence of better care (Rotenstein and et. al., 2016).
Also, I get the importance of peers support in improvement of knowledge and consideration
of the aspects which are important towards providing optimum care to patient. To grab or
develop this skill in me, I have to do the regular consultation with the peers and seniors. This will
help me to focus over the areas that are must in the direction of creating focused care strategies.
(Kemp, 2016)
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REFERENCES
Books and Journals
Baker, A. and et. al., 2016. Making the comprehensive shared care plan a reality. NEJM
catalyst. 2(3).
Bender, M., 2016. Clinical nurse leader integration into practice: developing theory to guide best
practice. Journal of Professional Nursing. 32(1). pp.32-40.
Braithwaite, J., Wears, R. L. and Hollnagel, E., 2015. Resilient health care: turning patient safety
on its head. International Journal for Quality in Health Care. 27(5). pp.418-420.
Carthon, J. M. B., Lasater, K. B., Sloane, D. M. and Kutney-Lee, A., 2015. The quality of
hospital work environments and missed nursing care is linked to heart failure
readmissions: a cross-sectional study of US hospitals. BMJ Qual Saf. 24(4). pp.255-263.
Casotto, V. and et. al., 2017. End-of-life place of care, health care settings, and health care
transitions among cancer patients: Impact of an integrated cancer palliative care
plan. Journal of pain and symptom management. 54(2). pp.167-175.
Chera, B.S. and et. al., 2015. Improving patient safety in clinical oncology: applying lessons
from normal accident theory. JAMA oncology. 1(7). pp.958-964.
Hewitt, J., Tower, M. and Latimer, S., 2015. An education intervention to improve nursing
students' understanding of medication safety. Nurse education in practice. 15(1). pp.17-
21.
Hill, L., 2019. Producing an effective care plan in advanced heart failure. European Heart
Journal Supplements, 21(Supplement_M), pp.M61-M63.
Kemp, D. J., 2016. Care plan redesign: improving service user experience of the Care
Programme Approach. Mental Health Nursing. 36(1). pp.18-19.
Klemanski, D. L., Browning, K. K. and Kue, J., 2016. Survivorship care plan preferences of
cancer survivors and health care providers: a systematic review and quality appraisal of
the evidence. Journal of Cancer Survivorship. 10(1). pp.71-86.
Kvale, E. A. and et. al., 2016. Patient‐centered support in the survivorship care transition:
outcomes from the Patient‐Owned Survivorship Care Plan Intervention. Cancer. 122(20).
pp.3232-3242.
McManus, M. and et. al., 2015. Incorporating the six core elements of health care transition into
a Medicaid managed care plan: lessons learned from a pilot project. Journal of pediatric
nursing. 30(5). pp.700-713.
Oh, H., Uhm, D. C. and Yoon, Y. J., 2016. Workplace bullying, job stress, intent to leave, and
nurses’ perceptions of patient safety in South Korean hospitals. Nursing research. 65(5).
pp.380-388.
Orbæk, J. and et. al., 2015. Patient safety and technology-driven medication–A qualitative study
on how graduate nursing students navigate through complex medication
administration. Nurse Education in Practice. 15(3). pp.203-211.
Palmer, S.C. and et. al., 2015. Outcomes and satisfaction after delivery of a breast cancer
survivorship care plan: results of a multicenter trial. Journal of oncology practice. 11(2).
pp.e222-e229.
Rosen, M. A. and et. al., 2018. Teamwork in healthcare: Key discoveries enabling safer, high-
quality care. American Psychologist. 73(4). p.433.
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Rotenstein, L. and et. al., 2016. The critical components of an electronic care plan tool for
primary care: an exploratory qualitative study. Journal of innovation in health
informatics. 23(2). pp.529-533.
Tobiano, G. and et. al., 2015. Nurses' views of patient participation in nursing care. Journal of
advanced nursing. 71(12). pp.2741-2752.
Tobiano, G. and et. al., 2016. Patients’ perceptions of participation in nursing care on medical
wards. Scandinavian Journal of Caring Sciences. 30(2). pp.260-270.
Tuinman, A. and et. al., 2017. Accuracy of documentation in the nursing care plan in long-term
institutional care. Geriatric nursing. 38(6). pp.578-583.
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