CRITICAL INCIDENT CRITICAL INCIDENT PRESENTATIONPRESENTATION

Presented by: Arthur Presented by: Arthur AquinoAquino

IntroductionIntroduction Description of the incidentDescription of the incident The impact of this incident to Mr. D The impact of this incident to Mr. D The bigger pictureThe bigger picture

PathophysiologyPathophysiology Issues that emerge from this incident will Issues that emerge from this incident will

be identified and analysedbe identified and analysed My position in relation to this incident will My position in relation to this incident will

be identified and the roles of the nurse will be identified and the roles of the nurse will be discussed.be discussed.

My recommendations will be identified and My recommendations will be identified and explored.explored.

ConclusionConclusion

The IncidentThe IncidentThe Tesio Catheter Insertion and the The Tesio Catheter Insertion and the

FistulaFistula

The meaningThe meaningImpact on Mr. DImpact on Mr. D

Mr. D was not ready physically, Mr. D was not ready physically, mentally, and emotionally to have the mentally, and emotionally to have the procedure done that day.procedure done that day.

Not included when the team had a Not included when the team had a meeting prior to the doctor’s round.meeting prior to the doctor’s round.

Mr. D was disempoweredMr. D was disempowered

Looking at the bigger pictureLooking at the bigger picturePathophysiologyPathophysiology

End stage renal failure End stage renal failure Kidneys are unable to perform Kidneys are unable to perform

excretory, regulatory and metabolic excretory, regulatory and metabolic functions. functions. (Brown & Edwards, 2005)(Brown & Edwards, 2005)

Mr. D’s blood test showed elevated Mr. D’s blood test showed elevated serum creatinine and ureaserum creatinine and urea

Clinical manifestations such as Clinical manifestations such as lethargy, SOB, slight peripheral lethargy, SOB, slight peripheral oedema, pruritus, and urine-like oedema, pruritus, and urine-like odour on his breathodour on his breath

Looking at the bigger pictureLooking at the bigger picturePathophysiologyPathophysiology

Mr. D comes for regular haemodialysis Mr. D comes for regular haemodialysis 3x/week but does not get the optimum 3x/week but does not get the optimum benefits of HD benefits of HD

Fistula needs repair because of venous Fistula needs repair because of venous stenosis or narrowing of the vesselstenosis or narrowing of the vessel

The tesio catheter insertion is The tesio catheter insertion is necessary as a temporary vascular necessary as a temporary vascular access while waiting for the fistula to be access while waiting for the fistula to be repaired or a creation of a new fistula.repaired or a creation of a new fistula.

Analysis/Reflection on the issues Analysis/Reflection on the issues that emerge from the incidentthat emerge from the incident

1.Power1.Power

Expert PowerExpert Power is defined as the ability to is defined as the ability to influence the decision making ability of influence the decision making ability of others through the possession of skills others through the possession of skills and knowledge that are useful to others and knowledge that are useful to others (Kubsch, as cited in Manojlovich,2007)(Kubsch, as cited in Manojlovich,2007)

Mr. D could be intimidated, scared, and Mr. D could be intimidated, scared, and shyshy

Power dimension in the patient-nurse Power dimension in the patient-nurse relationship is a barrier to patient active relationship is a barrier to patient active participation to his own care participation to his own care (Crumbie & Lawrence, 2002)(Crumbie & Lawrence, 2002)

1. Power1. Power Patient tend to be submissive to the Patient tend to be submissive to the

EXPERT KNOWLEDGEEXPERT KNOWLEDGE of the medical of the medical professionals and eventually AGREED to professionals and eventually AGREED to the health team’s planthe health team’s plan (Crumbie & Lawrence, 2002)(Crumbie & Lawrence, 2002)

Mr. D became vulnerable because of the Mr. D became vulnerable because of the chronic illness and limited knowledge to chronic illness and limited knowledge to his medical condition. He did not have his medical condition. He did not have much of a choice because he needed the much of a choice because he needed the procedure. procedure.

1. Power1. PowerThe nurse should maintain the The nurse should maintain the

balance of powerbalance of power within the nurse- within the nurse-patient relationship by considering patient relationship by considering factors such as patient’s emotions, factors such as patient’s emotions, social support, health beliefs, social support, health beliefs, attitudes, lifestyle preference, attitudes, lifestyle preference, knowledge and understanding and knowledge and understanding and personalitypersonality (Crumbie & Lawrence, 2002)(Crumbie & Lawrence, 2002)

Effects of resolving power differentialEffects of resolving power differential Patient taking controlPatient taking control Patient becomes active participant of their carePatient becomes active participant of their care Involve in decision making processInvolve in decision making process Patients are consulted on an issue that Patients are consulted on an issue that

concerns about themconcerns about them(Obeid, 2000)(Obeid, 2000)

2. Advocacy2. AdvocacyAdvocacy means someone who Advocacy means someone who

intercedes on behalf of another intercedes on behalf of another (Bu & (Bu &

Jezewski, 2006)Jezewski, 2006)

Konhke's model of advocacy is Konhke's model of advocacy is focused onfocused onThe patient's right to self-determination The patient's right to self-determination

and this is achieved by informing the and this is achieved by informing the patients and then supporting the patients and then supporting the decisions they make.decisions they make.

(as cited in Bu & (as cited in Bu & Jezewski, 2006)Jezewski, 2006)

2. Advocacy2. AdvocacyAnother aspect of advocacy is Another aspect of advocacy is

preserving and representing patient’s preserving and representing patient’s values, benefits, and rightsvalues, benefits, and rights in a in a situation where patients are unable situation where patients are unable to help and represent themselves.to help and represent themselves.

(Bu & Jezewski, 2006)(Bu & Jezewski, 2006)

Based on this aspect of advocacy, the Based on this aspect of advocacy, the 33rdrd principle of the Code of Conductprinciple of the Code of Conduct issued by issued by the Nursing Council of New Zealand (2006) the Nursing Council of New Zealand (2006) states that the nurse respects the rights of states that the nurse respects the rights of patients by providing information to enable patients by providing information to enable patient to exercise informed choice and patient to exercise informed choice and consent to the delivery of nursing care.consent to the delivery of nursing care.

3. 3. Principle of BeneficencePrinciple of BeneficenceBeneficenceBeneficence refers to the concept of refers to the concept of

doing gooddoing good; performing the action ; performing the action and the outcome regarded as and the outcome regarded as worthwhile, now or in the future.worthwhile, now or in the future.

Beneficence, in a nurse-client Beneficence, in a nurse-client relationship, requires a relationship, requires a partnershippartnership with the patient and the result of that with the patient and the result of that partnership is viewed by the patient partnership is viewed by the patient as beneficial to their own as beneficial to their own interpretationinterpretation(New Zealand Nurses Organisation [NZNO], 2001)(New Zealand Nurses Organisation [NZNO], 2001)

My PositionMy Position

To be there with the patientTo be there with the patientTo identify patient’s concernsTo identify patient’s concernsTo facilitate informed consentTo facilitate informed consentTo support patient’s decisionTo support patient’s decision

Roles of the NurseRoles of the NurseProtector and client advocateProtector and client advocateCommunicatorCommunicator

Maintain therapeutic communicationMaintain therapeutic communicationHelp the patient learn about their Help the patient learn about their

illness, coping mechanisms (i.e. pain), illness, coping mechanisms (i.e. pain), and to assure the patient that and to assure the patient that someone is there to be with them to someone is there to be with them to ease their suffering or anxietyease their suffering or anxiety

(Arnold & Boggs, 2003)(Arnold & Boggs, 2003)

Roles of the NurseRoles of the NurseCritical decision makerCritical decision maker

Using critical thinking and problem Using critical thinking and problem solving skills, keeping in mind the solving skills, keeping in mind the patient remains the core of the entire patient remains the core of the entire processprocess (Rogers & Niven, 2003)(Rogers & Niven, 2003)

Makes decision in collaboration with Makes decision in collaboration with patient and familypatient and family (Crisp & (Crisp & Taylor, 2001)Taylor, 2001)

My RecommendationsMy Recommendations1. 1. Focus on patient-centred care by:Focus on patient-centred care by:

Valuing and acknowledging patient’s own Valuing and acknowledging patient’s own way of interpreting what is happening to way of interpreting what is happening to him. Take time to sit down with the patient him. Take time to sit down with the patient and ask his own views regarding his and ask his own views regarding his condition.condition.

Identifying verbal and non-verbal messages Identifying verbal and non-verbal messages from Mr. D during the doctor’s rounds.from Mr. D during the doctor’s rounds.

Sharing knowledge about patient’s medical Sharing knowledge about patient’s medical condition, resources, support groups condition, resources, support groups available to the patient and encourage the available to the patient and encourage the patient to share personal information patient to share personal information leading to a shared decision making.leading to a shared decision making.

My RecommendationsMy Recommendations2. 2. Informed ConsentInformed Consent

Ask surgeon to explain the procedure Ask surgeon to explain the procedure (risks and benefits), alternative (risks and benefits), alternative procedures as well as its risks and procedures as well as its risks and benefits, and the success rate.benefits, and the success rate.

Confirm if the patient has understood Confirm if the patient has understood what the surgeon has explained.what the surgeon has explained.

Ask if patient wants his family to be Ask if patient wants his family to be presentpresent

Provide leaflets containing patients rights Provide leaflets containing patients rights as stated in the Health and Disability as stated in the Health and Disability Consumers Rights and explain. Consumers Rights and explain. Right 7Right 7 = receive a service ONLY when = receive a service ONLY when

patient has made an informed choice and patient has made an informed choice and informed consent. Also, patient may refuse informed consent. Also, patient may refuse services and withdraw consent services and withdraw consent (Rogers & Niven, 2003)(Rogers & Niven, 2003)

My RecommendationsMy Recommendations3. 3. Preoperative AssessmentPreoperative Assessment

Knowing patient’s surgical history and Knowing patient’s surgical history and identify coping mechanisms to the identify coping mechanisms to the surgical procedure Assess patient’s surgical procedure Assess patient’s knowledge of the procedure (ask what knowledge of the procedure (ask what the patient know)the patient know)

Assess patient’s learning style (audio, Assess patient’s learning style (audio, visual, physical)visual, physical)

Preoperative TeachingPreoperative TeachingWhat they will hear, smell, and feel during What they will hear, smell, and feel during

the procedurethe procedureThe sequence of eventsThe sequence of eventsShow video or photos of the actual Show video or photos of the actual

procedureprocedureAssess the need for sedationAssess the need for sedation

My RecommendationsMy Recommendations

4. Involve the family4. Involve the familyTo facilitate meeting to address issues To facilitate meeting to address issues

that may affect the family’s ability to that may affect the family’s ability to support the patient.support the patient.

Family also provides key information Family also provides key information about the patient which is necessary to about the patient which is necessary to the delivery of nursing care that is the delivery of nursing care that is tailored to the needs of the patient.tailored to the needs of the patient.

ConclusionConclusion I have described the incident and its impact I have described the incident and its impact

on Mr. Don Mr. D Pathophysiology of ESRF is discussedPathophysiology of ESRF is discussed Issues on power, advocacy and beneficence Issues on power, advocacy and beneficence

are analysedare analysed My position as a Student Nurse is identified My position as a Student Nurse is identified

and the roles of the nurse are explained.and the roles of the nurse are explained. Recommendations focusing of patient Recommendations focusing of patient

centred approach, informed consent, centred approach, informed consent, preoperative assessment and family preoperative assessment and family involvement are explored.involvement are explored.