DESCRIPTIONEvery individual needs to improve, not because they are wrong or not good enough, but they can be even better. Reflective learning is as same as this example because rewinding of a past incident could really help us to understand, mold and reconstruct a better outcome. So, it has been acknowledged that critical reflection is a continuous passive learning experience from past events or day-to-day life events to improve clinical effectiveness and to mature professionally. Reflective writing is evidence of an in-depth understanding of former knowledge with experiences. I used Stevenson’s framework (1994) to incorporate my experiences into words. Mr. X, 77years, who came as a new admission at 6:30 am with perineal pain and a lump in his perineum was waiting for further treatment order. It was a morning shift for me and I along with the preceptor took the hand over of patients. As usual, I finished up with observations first. I came to know that he was a new admission and nothing per oral was prescribed, as he was for a USG. I along with the preceptor went to give medications to the patient and gave him a clonidine patch 100mcg and diclofenac tablet, but he refused to take diclofenac, as he has heartburn if he takes it on an empty stomach. So, we did not administer the diclofenac tablet and planned to administer it later when the patient starts eating. I took permission from the preceptor and went to do an admission assessment. During my assessment, I found that he is a known case of positive MRSA. I informed this to the preceptor and she did not know anything regarding this. As he was a frequent flyer being admitted to the hospital, we checked his old reports in the system. And I also enquired with the charge manager about this. Thus, we arrived at the conclusion that he is positive for MRSA, as his reports from the recent test done in September 2019 denoted that he was positive for the same. Suddenly we arranged a single isolation room for him and with contact precautions to be followed. The signage board indicating contact precaution was kept for alerting others and linen disposal skip and a trolley with all the personal protective equipment (PPE) were kept outside the room. I made sure that the observation machine, bed, cardiac table, and his belongings were shifted from the old room and the previous room was terminally cleaned. I oriented him to the room, gave him information about using the call bell, and gave him the hospital gown. He was reviewed by the consultant and his current plan was for pain management. I talked with the senior consultant and arranged a pain team to come and meet him for his pain management. As per the consultant order, he could eat, so we gave him a sandwich, coffee and a piece of cake. Since he had food I administered his pending medication diclofenac as well as the new medications which were added by the consultant. (omeprazole, gabapentin, Panadol. (PRN)) after taking precautions in the presence of the preceptor. Then I reassessed the patient for his pain to know whether the medication and patch are effective before the pain team comes. After my assessment, I got to know that he was allergic to penicillin, codeine, and antibiotic (do not know the name). He also has lesions and bruises on both legs and hands due to nitrous oxide burns which he had in the past. His EWS(early warning score) was 0. The pain assessment score was 7/10 and it reduced with the help of the clonidine patch to 6/10. The pain team was still to review him. He was prescribed with opioids, for now, to relieve pain and was awaiting USG. During my handover, his pain has settled down and he was found settled and the pain tolerable. I ensure that the isolation process has explained during shift hand over to protect the other people including visitors.ANALYZEWhat was the role in the situation? Did I feel comfortable or uncomfortable? Why?I’m a CAP candidate who acted as a problem-finder in this situation. Since I was doing the paperwork (admission assessment form), I was able to understand that he is positive for MRSA. I felt uncomfortable because I realized that an MRSA patient has to be isolated. As far as I know, it is contact isolation and it spread through direct contact with the infected person. This can also be transferred by touching the objects used by the person who is infected. The MRSA bacteria can stay up to two weeks on the surface of the body. The patient has to be isolated to make sure that others are not harmed.References:SJ Van Hal, Z Jennings, D Stark, D Marriott, J Harkness,2009.MRSA Detection: comparison of two molecular methods with two selective MRSA agars.European Journal of Clinical Microbiology and Infectious diseases 28(1),47-53.What actions did I take? How did I and others act? Was it appropriate?As soon as I came to know that I’m dealing with an MRSA positive patient, I informed it to the preceptor and charge nurse manager, they were able to find out the old reports of the patient and confirm it. By that time I arranged a single isolation room with all the arrangements. I have made sure that personal protective equipment and disposal of linen area is properly maintained, And, all the personal articles of the patient as well as the used items (cardiac table, jug, glass, iv pole)from the old room, has been shifted to the single isolated room and terminal cleaning has done for the old room. I also kept a signage precaution board in front of the room to alert others. I also ensure that he has not used the common toilet. I think I was appropriate in my action because an MRSA positive person can spread the infection to all the individuals who all are coming in direct contact with them if I did not find out if he was MRSA positive. (This may include laboratory technician, nurses, receptionist, HCA, doctors students, visitors, kitchen).References:Yanhong Qiao, Fang Dong, Wenqi Song, Lijuan Wang, Yonghong Yang, Xuzhuang Shen, 2013. Hospital and Community-associated Methicillin Resistant Staphlococcus Aureus: a 6-year surveillance study of invasive infections in Chinese children.Acta Paediatrica 102(11), 1081-1086.How could I have improved the situation for myself and the others involved including the patient? What can I change in the future? The patient has come from the emergency department and I couldn’t find any of the assessment forms in his file, it would have been misplaced during handing over or else the ED department did not complete the assessment then and there. I’m unaware of what exactly happened. In addition to this, the previous night duty staff had no idea regarding the MRSA and the patient arrived in the ward at 6:30 in the morning. It was her time to finish the duty and she would have been busy at that moment.I think this situation could be improved more by asking the patient regarding infections at the initial stage in the emergency department. If it would have been done earlier, this problem could be solved in the Emergency Department. It was a great learning for me that the admission assessment form has to be done as soon as the patient arrives at the ward or to any department. This actually saves not only me but also other health professionals.Definitely, I will change my view for a better future outcome by taking a proper handover, assessments and immediate questions that can be asked until I get a general idea about the patient. And I use standard precautions while I handle a new admission due to unknown and hidden factors of the patient’s condition.References: C Wenisch, H Laferi, M Szell, KH Smolle, A Grisold, G Bertha, R Krause,2006. A holistic approach to MRSA eradication in critically ill patients with MRSA pneumonia. Infection 34(3),148-154.Do I feel as if I have learned anything new about myself? Yes, I have learned to be more responsible and keen in observation. Teamwork may sort out this issue if the staff is busy.Making sure that the shift hand over should be more reliable, accurate and precise.Follow ISBAR- Identify, Situation, Background, Assessment, Recommendation.Reference: -Jason E Farley,2008. Epidemiology, clinical manifestations, and treatment options for skin and soft tissue infection caused by community-acquired Methicillin-Resistant Staphylococcus Aureus. Journal of the American Academy of Nurse Practitioners 20(2),85-92.Did I expect anything different to happen? What and Why?Yes, certainly, I really hope something better to happen. Earlier isolation of the patient could be done if the patient has been assessed from the Emergency Department or else as soon as admission came to the ward. The night duty staff from the ward also can act after she received him in the ward but this took hours to find out even though he is an old patient of the same hospital. If any of the areas have detected these, the morning staff could save the time as well as to avoid the spread of infection for those previous hours where the patient stayed and shared a common room where the post-operative patients are. And the patient has to be informed regarding the condition and spread of infection and explain that he may inform this or alert this whenever he seeks medical assistance. Except for these, I personally have an opinion for a swab test for each staff who looked after the patient from the emergency department till the discharge would give a proper idea regarding the frequency and speed of transference of this infection, this also helps us to treat if we have infected.Reference:• Leigh Haysom,Melanie Cross,Rebacca Anastasis,Elizabeth Moore,Stephen Hampton, 2018.Prevalence and Risk For Methicillin-Resistant Staphylococcus Aureus(MRSA) infections in custodial populations: A systematic Review. Journal of Correctional Health Care 24(2),197-213.• Anna Irene Vedel Sorensen,Thomas Rosendal,Stefan Widgren,Tariq Halasa,2018.mechanistic modelling of interventions against spread of livestock -associated methicillin-resisitant staphylococcus aureus(LA-MRSA)within a Danish farrow-to -finish pig herd.PLoS one13(7)e0200563.Has it changed my way of thinking in any way? Yes, I become more vigilant, alert and aware of receiving as well as handing over the patients. It has thrown a light that specific threats to be safely handed over to avoid harm and transfer the infection or any communicable disease during inter-department transfer.Reference: Sarah R Deeny,Colin J Worby, Olga Tosas Auguet,Ben S Cooper,Jonathan Edgeworth, Barry Cookson,Juile V Robotham,2015.Impact of muciporin resistance on the transmission and control of healthcare associated MRSA.Journal of Antimicrobial Chemotherapy70(12),3366-3378.What knowledge from my theory and research can I apply in this situation? Contact precautions to be taken for MRSA patient to avoid the transfer of infection. Contact precautions include clean hands when entering and leaving the room of the affected patient, wear gown and glove at door, doctors and staff must use patient-dedicated or disposable equipment, clean and disinfect shared equipment. In addition, cover the patient with a clean sheet while internal transfer to any department during a hospital stay.Reference: Karnin Bergstorm, Gorel Nyman, Stefan Widgren, Christopher Johnson, Ultrika Gronloud-Anderson,Ultrika Ransjo,2012.Infection prevention and control interventions in the first outbreak of methicillin-resistant staphylococcus aureus infections in an equine hospital in Sweden. Acta Veterinaria Scandinavica 54(1),14.What broader issues (eg. Ethical, political, or social) arise from this situation? What do I think about these? The endemic spread of infection may change the magnitude of public health and would have been an outbreak, unfortunately, it becomes the reason of an emerging cause of morbidity and mortality. Resistant infections require more costly second-and third-line treatments and are sometimes associated with extended hospital stays. In community most often cases are skin infections and in some cases, this may cause pneumonia and in extended cases, if untreated, sepsis and chances of the extreme response of the body to infection.Ethical issues point out the compromising nature in the medical ethics principles of autonomy and beneficence.Reference: • Beena Jha, J Sapkota, M Sharma, B Mishra, CP Bhatt,2018.screening of nasal carriage staphylococcus aureus and their antibiotic susceptibility pattern among the health care workers in a teritiary carehospital, Nepal.Journal of Kathmandu Medical College7(2),64-67.• AEV, A, IB, dos S, IMA, F, RF, B., LA. M., & JPM, S. (2015). Determination of lethal and sublethal doses of Acineto bacter baumannii and Methicillin Resistant Staphylococcus aureus (MRSA) in murine models using a reduced number of animals. Journal of Experimental and Applied Animal Sciences, 1(3),336-340.
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