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Elderly Patient on Psychotic Unhappiness ward

In this assignment I am following a 'Critical Incident Analysis' with an incident taken from my stock portfolio that was came across whilst in practice placement. This type of analysis was initially used to analyse traveling missions by pilots, as a means of bringing up their performance (Flanagan, 1954), in more recent years Norman et al. (1992) and Perry (1997) referred to this kind of analysis to be an important and valid tool for use in nurse training, as it allows the student to choose and use an occurrence that made an impact on them, from their practice position that was either positive or negative, in order to analyse, think about and study from it, exhibiting their development as a specialist and a person whilst linking theory to apply and supporting them move from novice to expert, as reported by Benner (1984).

Model used for reflection

For the purpose of this assignment I've selected the Gibbs (1988) reflective construction model which can be an iterative model indicating it is cyclical in character, the six things included in this model are:

Describe the experience or experience in objective aspect.

Discuss and explore any emotions you were having during the experience.

Evaluate the knowledge: What really happened? That which was good about any of it? What was bad? What factors added to the event?

Analyse the experience: What can you study from it?

Conclusion: What would you have done in a different way? Whatever you wish you'd done? Wish you hadn't done?

Action Plan: What can you plan on doing in the foreseeable future?

(Bethann, 2004, p167)

This is also the model I take advantage of in my portfolio as along with critical incident evaluation, it centres on reflective practice, an important skill in medical practice allowing situations to be analysed at length, identifying areas of potential change, Jasper (2003) and reinforcing the need for certain procedures by highlighting their benefits. I also find the rational, straightforward structure of the framework allows the reflection to be written obviously, providing opportunities to look at situations from different perspectives.

The Critical Incident

Stages one and two of Gibbs model of reflection are covered here, where in fact the incident is referred to along with my thoughts at the time of the event.

I chose this specific event as it put me in an exceedingly challenging position where I needed to believe on my legs, it made me test my capabilities as a communicator and a nurse under stress, whilst highlighting the importance of a few of a lot more basic nursing techniques like non-verbal communication through touch, educating patients to help themselves, shopping for physical signals that can reveal a patient is in distress and exactly how working meticulously with a patient can earn their trust whilst accumulating the healing relationship

In order to keep carefully the patient and the practice positioning confidential, as suggested in the NMC Code of Professional Carry out (2002) and the N. M. C. guide for students (2002), the practice positioning is kept anonymous and the individual will be referred to as 'Tom'. The patient's consent was also obtained, as it's the patient's to choose whether or not they wish details to be written about them, highlighted by Johnston and Slowther (2003) also outlined in section - 3. 7 of the N. M. C Code of conduct (2002) with reference to patients who suffer from mental disease.

The patient, 'Tom' a 72 yr old man, was accepted to my practice location experiencing Psychotic depression and stress, my placement reaches a Psychiatric admissions ward, for patients over sixty five yrs. old.

On supporting Tom along with his 'activities of daily living' (A. D. L's), (Roper et al, 1980) after, increasing one Monday morning hours, It became visible when assisting Tom dress that his right arm was triggering him pain, in the area of his right shoulder, I relayed this to the nursing staff who explained Tom had dropped unobserved on the Fri night and have been seen by the physician who on assessment experienced no other investigations were needed.

On further debate about his arm and the semester, between myself and Tom, he eventually admitted to presenting also fallen on the Sunday night and had not told anyone about it, once I had fashioned described this to the nursing staff the Doctor was again consulted and felt that Tom should have an X-ray to eliminate any broken bones.

I followed Tom as an escort to the x-ray office where he became significantly agitated, troubled and was mumbling to himself with delusional content of conversation evident, concerning the N. H. S. which had not been known about, as Tom had only recently been admitted, he noticed 'they' (the N. H. S) were going to cause him, bodily injury (a persecutory delusion - Gamble & Brennan, 2003) credited to his 'doing them out of money' when he was younger, I did so my better to give regular reassurance that I'd not let anyone harm him, but when someone supports a delusional idea it could be very firmly maintained and difficult to dissuade from, in particular when they are in a state of high anxiety like Tom, as suggested in Stuart and Laraia (2001). I had been quite worried about how the problem was going and this I might be out of my depth as I did so not know Tom very well and felt a little awkward endeavoring to reassure somebody who was this distressed, sensing I got doing little if any best for him.

After he previously his x-ray and I was supporting him to get dressed in the x-ray cubicle the Radiologist came in and advised us that Tom's shoulder was shattered and that people would have to go around to casualty to be seen by a Doctor there.

This media made Tom's level of panic escalate considerably and he began to truly have a anxiety attack in the cubicle, probably a 'situationally predisposed worry invasion', which occurs on contact with a situational cue or trigger (DSM-4) Tom experienced become quite pale and commenced to perspire profusely, along with his deep breathing becoming very shallow and immediate to the point that he was panting, I found it quite distressing to see Tom in this condition.

I acquired never came across someone quite as panicked as this and I felt quite worried. I thought contacting out for someone to help might only panic him more, so I decided to try some deep breathing exercises to relax and quiet him down first, then if that did not work I would seek help. I recognized from reading Tom's records that he didn't have a center condition or other health problem that could have been causing these symptoms and it turned out recorded that Tom suffered from anxiety attacks, although I had been still watchful for just about any change in his symptoms that may indicate an alternative solution medical reason behind his condition.

Initially I sat beside Tom with my arm around him, asking him to adopt slow profound breaths, but with his level of worry and no attention contact recommended he was not concentrating on me, therefore i knelt down on to the floor before him had taken his hands, spoke to him delicately but strongly using his name and with direct eye contact received him to give attention to that which we were doing.

I discussed his symptoms were due to his panic attack and the breathing exercises we were doing would help relax him, relax him down and make him feel better. Tom began to comply and started with my instructions, breathing in little by little through his nasal area possessing it for an instant then inhaling out slowly but surely through his mouth area.

In a relatively short time his breathing commenced returning to normal and he began to relax, permitting us to be on to the casualty division to see about his make. Inside the casualty division Tom still required reassurance not only verbally but also with touch as he asked me to hold his hand, getting home the importance of the simple yet significant form of non-verbal communication and despite requiring another brief group of relaxation sucking in the casualty cubicle Tom was notably calmer.

I experienced privileged that he had put his trust in me and that we had shifted further in our therapeutic marriage, as while holding out in casualty Tom who acquired rarely spoken to anyone aside from myself, began speaking about how scared he previously been and talked about a few of his delusional values, which helped me empathise with how terrified he will need to have been. I got also in a position to discuss what Tom told me with the experienced nurses on return to the ward offering a deeper perception into his condition.

Critical Discourse of the Incident

For this portion of the Critical Occurrence Analysis phases three and four of Gibbs reflective construction are protected, allowing me to check out what was bad and the good about the incident along with contributing factors (Gibbs 1988), I am going to discuss, evaluate and reflect after three key issues: Anxiety attacks, the relaxation technique of Deep breathing and Touch remedy, that were encountered during the incident and that I believed were of significant importance.

Panic attacks

I believed this issue was important to the critical occurrence as it is a condition closely associated with anxiety which a great number of mental health patients experience often along with their main examination but mostly alongside depression such as Tom's circumstance, Clayton (1990) and Merikangas et al (1996) mentioned that comorbidity between panic and unhappiness is the one strongest kind of anxiety-mood comorbidity within both treatment and in everyone. Panic attacks are often talked about and appearance in patient records but this critical event brought home for me how absolutely terrifying and totally debilitating the anxiety attack was for Tom and exactly how distressing it could be to witness a patient in this condition.

Anxiety is a standard healthy a reaction to the stresses of each day life as suggested by Trevor Powel (2001) and even necessary for us to perform at our best as 'Yerkes-Dodson's Legislation (1908)' explains, illustrated in the graph below. Here levels of anxiety are referred to as 'arousal' and a direct correlation to performance is shown, it explains to us that if we have low levels of 'arousal' then our performance becomes lowered (stress, as presented by Seyle (1956)), at medium levels our performance levels peak (eustress as referred to by Seyle (1956)) and when our 'arousal' levels become high our performance levels and subsequent ability to function drop again (leading to stress) as seen in Tom's situation.

(Yerkes & Dodson 1908)

Peplau (1963) identified anxiousness in four levels:

Mild anxiousness- everyday routine stress.

Moderate stress and anxiety- Immediate concerns focused on, with narrowed perceptual field, although able to function when necessary.

Severe nervousness- Greatly reduced perceptual with difficulty focusing on anything except what's causing stress.

Panic- Person seems terror, dread as is unable to reason with the 'hazard' causing stress blown out of most proportion, so that it is extremely difficult to talk or function, with little if any control over themselves - leading to anxiety attack.

Tom's anxiety level was obviously at the 'stress' level which can't be allowed to continue indefinitely as being in an anxiety attck status is not compatible with living, as defined by Stuart and Laraia (2001), who imagine if prolonged can lead to total exhaustion or in extreme cases even death.

Panic attacks have an effect on between 3 and 5 percent of the population at some point in their lives (Lynch E, 2005). The findings of your American study completed this year exhibited that people affected by panic attacks account for around 25% of those participating casualty departments or G. P's. (Ham, P. et al, 2005) often having difficulty inhaling and exhaling properly as found with Tom, with most people suffering from panic attacks, proclaiming hyperventilation as being one of their main symptoms (Holt and Andrews, 1989), or with patients thinking they are experiencing a coronary attack.

Tom's anxiety attack was mainly noticeable by the physical symptoms he viewed, described previously, physiological symptoms often being the one visible symptoms of a panic attack as identified by Stuart and Laraia (2001).

In this example, although Tom's Psychotic Depressive disorder was the likely reason for his anxiousness with the ensuing anxiety attack, I felt wanting to deescalate his stress and anxiety levels, by getting the anxiety attack and hyperventilation in order was my main goal, there would have been no point in me seeking to cope with his delusional values at this time as this takes time and experience, of which I needed neither, plus Tom's worry levels were so high it was difficult for him to concentrate. Therefore it looked logical to focus on something it was perhaps possible to improve.

I hoped that using the deep breathing technique would achieve success in helping come back Tom's body systems to normal which would stop the hyperventilating making Tom feel a lot better and recognized that respiration techniques could be extremely effective but didn't want to put Tom at any risk by doing so, I had to produce a judgment call about how precisely I would handle the problem and made the decision I would try and offer with it using the deep breathing exercise.

Relaxation Techniques - Deep breathing

The next topic I am going to cover is Leisure Techniques and the technique of Deep Breathing in particular, Personally i think it is important to hide this matter as it was a key factor in the outcome of the event as by guiding Tom through the respiration technique, enabled him to control his breathing resulting in his panic attack and hyperventilating coming to a finish.

Tom's physical symptoms suggested that he was hyperventilating or 'overbreathing', the mental health handbook (Trevor Powell, 2001) instructs us this is a standard response to danger by our anatomies to bring more oxygen to the muscles, planning us for 'Fight or Airline flight', but if the extra O2 is not needed by the muscles, i. e. the situation is only an imagined danger such as Tom's case, the normal degree of gases in the blood and lungs becomes out of balance, scheduled to breathing in to much oxygen (O2) and moving out too much skin tightening and (CO2), this causes the blood to become alkaline which brings on many of the unpleasant symptoms Tom was experiencing.

There are several means of overcoming hyperventilation, possibly the most commonly described, is inhaling into a paper bag to facilitate the breathing back of the skin tightening and being breathed away, as discussed in the Nursing Times article, Facts: Panic Attacks (2003), which also acknowledges the importance of handling the patients respiration, Stuart and Laraia (2001) also concur that rest techniques are a recognized therapeutic treatment in the treatment of anxiety.

Since I had developed no paper handbag with me at night, I decided to use the three level deep breathing technique to retrain Tom's breathing which, Risser and Murphy (2005) recognize, improves panic symptoms and associated disability, this type of respiration which is often used in pilates helped to slow down and control Tom's respiration which also ended him hyperventilating, it is carried out by:

Inhaling slowly and deeply through your nostril.

When you've used a full breathing, hold it for a moment and then

Exhale slowly but surely through the nose or mouth area, depending on your inclination.

This action although dissimilar to the paper tote technique brings about the same desired result, regarding 'Deep Breathing' carbon dioxide is not being re-breathed however the rate it is expelled by has been slowed down along with holding it a little longer in the lungs which results in the levels of carbon dioxide in the blood rising, fixing the acid solution/alkaline balance in the blood, which relieved Tom's upsetting symptoms, having his breathing rate back to normal and making him feel calmer.

At enough time of the occurrence I really hoped that the breathing technique would be successful although I was not entirely sure whether to trust my intuition and give it a try. On reflection I was very impressed at how effective such a simple technique could be and was glad not only for Tom's sake but also my own that I acquired decided to give it a try, as it offered me more confidence in my skills as a nurse even though at that time I was undergoing it, although outwardly quiet, I had thought quite anxious.

Touch Therapy

The final key issue I wish to identify from the critical event is the benefit of touch as a remedy, which I experienced was vital as a means of communicating with Tom during his panic attack along with presenting him reassurance that I was there for him, empathising along with his situation and assisting him concentrate on whatever we were looking to do.

There are several terms used to spell it out different types of touch found in nursing, some of which are: 'necessary touch' which addresses 'activity' and 'instrumental touch' that is mainly used when a procedure or job needs to be carried out on a patient instead of 'non-necessary touch' which is referred to as spontaneous and emotional physical contact between your nurse and patient, released by Routasalo (1996), 'expressive touch' comes under the 'non-necessary touch' umbrella with the same type of nurse patient contact, identified by McCann & McKenna (1993) which is comparable again to 'caring' and 'protective touch' highlighted by Estabrooks (1989) and lastly restorative touch, which can be an alternative therapy just like reiki, discussed by Meehan (1998).

Nesbitt-Blondis and Jackson (1982) concur that touch is most likely the most important of most non-verbal communications that people use in nursing and can be particularly useful in circumstances like Tom's panic attack where his capacity to comprehend and converse was diminished, when patients cannot talk verbally or understand verbal communication for reasons such as dementia, people that have learning or cognitive troubles and in panic attack situations like Tom's, touch can be an outstanding means of communication.

Unfortunately, McCann & McKenna (1993) reported that in the U. K. there is little use of expressive, non-necessary or caring touch by nurses. Many nurses see touch as just something that is employed when a procedure or task must be completed on a patient, but Tutton (1998) suggests that touch in nursing and the powerful expressions it conveys to patients are regretfully underutilised. Routasalo (1996) also shows that non-essential touch but not absolutely essential, can be hugely important and essential to the patient.

The benefits associated with this type of touch in medical are strengthened further by Moore & Gilbert (1995) who found patients interpreted the utilization of touch by nurses as a screen of love and attention which they greatly loved, with patients interviewed in Routasalo & Isola's (1996) study, describing touch by nurses as extremely comforting.

Davidhizar & Giger (1997) whilst acknowledging the important role that touch can play in the nurse patient marriage, also highlights that the value of touch is not valued by all health professionals or considered appropriate or appealing by some patients. Bearing this at heart as long as the correct manner of touching is utilized, and there is absolutely no way maybe it's seen as being inappropriate with the patient's personal and ethnical beliefs being considered, it is one of our most valuable communication medical tools.

The scope of physical contact carried out in a culture is governed by models of well-defined behavioural norms for whatever circumstances we find ourselves in (Pratt & Mason 1981). Jourard (1966) accepted that the occurrence of touching within our Western modern culture declines from child years onwards but Montagu (1986) found out that the need for touch didn't reduce with years. It is believed that the amount of touch common in years as a child can give back in situations of sickness or incapacity (Barnett 1972). This might mean that, the need for touch in condition might be more important than our ideas of 'proper' behaviour.

I thought the touch factor in this incident: my taking of Tom's hands to help him target, get his attention and communicate my empathy, was extremely important and was at fact the making point in the whole occurrence which allowed me to get Tom's trust and initiate the breathing technique which halted him hyperventilating. I feel that minus the touch element it could have been extremely difficult for me personally to 'reach' Tom and the results of the incident would have been very different.

Implications for Professional and Personal Development

In this final portion of the Critical Event Analysis, both final levels of Gibbs style of reflection (1988), five and six are covered, here we look at what was learned from the event, what might have been carried out in a different way or should not have been done, along with what was overlooked out concluding with an idea for future action.

I found in utilising the Gibbs (1998) representation tool, the impact the event made on my own and professional development was made much clearer.

Through undertaking this Critical Incident Analysis I have already been in a position to see what I've learned through representation, as the Department of Health (1999) states, reflective practice is necessary in order to further our ongoing personal and professional development and causes a greater knowledge of our very own needs. Referred to as a form of self discovery by Freshwater (2004) with a deeper understanding of the needs of the patient and better patent care highlighted by Davies (1995).

From this I feel the analysis made me look at my communication skills on a deeper level for although I feel that I am a natural communicator, and have had many years experience dealing with people suffering from dementia, I hadn't fully thought about the utilization of touch or the great importance it includes in conversing with patients.

Without the use of reflective practice I'd not have explored into the idea of touch so completely or really known its relevance and repercussions in my medical practice. Or accepted the significance touch performed in the successful deescalating of Tom's panic attack and hyperventilating in this critical incident. This Critical Event Examination has definitely taught me to have more faith in my own capabilities as a nurse but has also taught me I have more to learn as a communicator.

Similarly with this issue of panic attacks which I was obviously familiar with and experienced some knowledge on, having been through the occurrence with Tom and then undertaking the reflection on the incident, allowed me to start to see the field of panic and anxiety disorders with a deeper understanding and much more from the patients viewpoint. Having witnessed the true distress and levels of impairment it can inflict will permit me to essentially empathise with patients like Tom going right through this kind of disorder while i come across them in my own future career.

The part of relaxation deep breathing was something I had developed used myself in yoga practice and does know of its profit in anxiety situations, but I hadn't expected to have to begin teaching it to a patient that day in the X-Ray cubicle. I got quite stunned when Tom experienced started out hyperventilating but after some consideration I will have perhaps saw it coming with his rising levels of nervousness after our introduction at the hospital, especially when i experienced read only that morning that he had a brief history of panic attacks. Again on reflection I could have asked the nursing staff the ultimate way to deal with it will the situation happen. I have discovered out of this that I possibly could have been better ready before escorting Tom by requesting questions and having an idea of action to use if necessary.

I have been worried about adding Tom vulnerable by trying the breathing approach with him when i stated earlier, as well as perhaps it was wrong of me to acquire tried it to begin with, but I had fashioned made a wisdom in an emergency situation, and I did so not make the decision lightly, being aware that help was near by should it be needed. I did not need to stress Tom further by phoning out, resulting in people rushing in to the cubicle and in conclusion felt the deep breathing exercise was well worth a try, but I would have called for help quickly if it didn't seem to be working.

On talking about the occurrence and my activities again on the ward, my coach also felt I needed made the right choice. This made me think about the undeniable fact that as a nurse there are times when it is up to you to make wisdom cell phone calls regarding patient care and attention and that it is important to remember that you will be accountable for your actions. To carry this level of responsibility needs a sound knowledge of practice and an capability to think calmly and clearly even under stress.

I was both relived and delighted that the breathing technique worked so well for Tom and noticed honoured that he made a decision to put his trust in me. As stated preceding, this prompted Tom to confide a few of his fears if you ask me, which revealed trust on Tom's part and fostered a deeper understanding of his condition on mine. This improvement of the therapeutic romantic relationship between Tom and I has extended during my positioning where I've worked quite meticulously with him and where I have educated him how to apply the breathing techniques when he seems calm making it easier for him to utilise in panic situations, which he is doing with good effect.

As a follow on out of this occurrence and after seeing the effectiveness of rest techniques doing his thing, at my practice location I asked my mentor if it would be possible to carry out some relaxation categories with carefully screened groups of patients who possessed stress and anxiety problems. My mentor and other medical staff thought this would be a good idea both for the advantage of the patients and for my personal and professional development. After researching the topic and finding appropriate music along with compiling a script, the communities were initiated with great success and are now regularly applied to the ward, which has given me some sense of achievements and helped build my assurance in my capabilities as a nurse.

Along with being very beneficial in analysing this specific incident the use of reflective examination has definitely better my practice in placement, and although I have used this style of reflection in my own portfolio for quite a while now, it offers made me re-examine the value keeping and utilizing a portfolio to further my professional and personal development. I also feel this helps me to advantage more from my location as I fully understand the idea behind reflection and make use of it positively as a tool rather than task I need to perform.

When using reflection now I am in a position to draw more information from my experience on positioning, while previously I had formed only skimmed the top of subjects when carrying out reflection. It has increased both my self consciousness and my potential to web page link theory and practice mutually. Overall, I can see obviously how representation is a useful tool in helping nurses to focus on their skills and behavior which consequently allows them to supply the best care possible for patients, as mentioned by Somerville (2004).

Action Plan

Preparing and utilising action designs is an important way of improving both our personal and professional development as nurses, whilst building on improved upon medical practice.

To be prepared for this kind of scenario in the future I have identified the following course of action:

Make sure I know and understand all relevant information regarding patients.

Have good communication with other participants of personnel about patients.

Have a plan of action thought out for any incidents that may happen.

Remain calm and consider actions carefully.

Empathise with the individual by trying to understand what it might be like to be in that situation.

Where possible help the patient to help themselves, i. e. by educating these to use breathing techniques so whenever a panic situation arises they are really in a better position to take control themselves.

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