The and the importance of the issue

purpose of this essay is to reflect a critical incident, I have encountered
during my post as a charge nurse in a private ward whilst using a model of
reflection. Firstly, the essay will brief about my professional role and
responsibility as a charge nurse in the clinical setting. Secondly, I will
illustrate the issue that I identified from the clinical practice and I will
highlight how the incident impact on me and the importance of the issue with
the evidence of statistical support from worldwide. Thirdly, the event is
discussed, followed by the process of reflection using chosen model. My essay
will include the importance of physical assessments and performing relevant
diagnostic tests to rule out the correct diagnosis. Finally, I will conclude by
explaining what I have learned from the experience and how it will change my
future actions.

          Nurses spend most of the time around
patients extending the care for efficient healing. Changes in nursing education
are designed to make nurses at all levels leaders in the field of nursing care
(Ralph & Taylor, 2011).

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          I am working as a charge nurse in a
private ward of a tertiary private hospital accommodating 100 beds. My main
responsibility is to supervise, guide the staffs as well as controlling the
work environment. Yet I serve as a member of interdisciplinary healthcare teams
in providing quality nursing care according to the nursing observation,
assessment, planning and implementation of care. Additionally, my
responsibilities as a charge nurse include closely monitoring patients; alert
physicians if any changes in patient status; and interact with patients and
family members often suffering from pain, stress, shock or grief. Furthermore,
I have to assess the patients’ progress in the clinical setting and determine
in collaboration with the doctors whether patients need to change their
medication or if further treatment is required in case it does not work well.

clinical incident is defined as an event or circumstances resulting from
healthcare which could have or lead to an unintended and/or unnecessary harm to
the patients (Davies, N. 2013). Thus, in this essay, I am going to explore the
critical incident of an unexpected death of an adult patient admitted with leg
pain. The patient was admitted with leg pain and died shortly afterward with no
indication of any other diseases or infections.

           The incident had the impact on me
due to the fact that as a charge nurse, I was involved with the patient who
died unexpectedly while he was admitted with leg pain. Furthermore
misdiagnosing from doctors, nurses and other healthcare providers can be very
critical for the patient’s life (Gilstrap C.M & White, Z. M. 2015). Sudden
death after short periods of leg pain is demonstrated as Deep Vein Thrombosis
(DVT) and Pulmonary Embolism (Wedro, B. 2015). Such a condition can raise
suspicion, especially in situations when health care providers failed to
conduct image scans for internal body organs to assist in determining the exact
cause of the disease. Most of the pain experienced in the legs accrues from
injuries in soft tissues, ligaments, tendons, muscles, joints, injuries, or overuse
(Patel, K. 2017). Patients admitted with leg pain could be suffering from any
disease. The degeneration of the leg pain into the sudden death of the patients
is subject to close examination to determine the possible causes one of which
is Deep Vein Thrombosis (DVT). Therefore, it is essential for nurses to
understand the manifestation of DVT and to diagnose correctly (Dinah, G. 2015).
Nurses are seen as the primary helpers to the doctors in any given medical
facility. Hence we should be the first caregivers to identify risks of Deep
Vein Thrombosis and to respond appropriately (Morrison, R. 2006). We are
therefore required to have adequate training to deal with all the medical
conditions that patients might have. Today nurses are better trained in the
skills of patient care. It allows us to make critical decisions that might at
times amount to saving our patients’ lives (Ericksen, K. 2017).

             Deep Vein Thrombosis (DVT) and
Pulmonary embolism (PE) are concerned issue for all nurses as the global
statistics reveal increased mortality rates followed by such incidents
(Blondin, M.M. 1996). Center for Disease Control places the number of people
affected by Deep Vein Thrombosis in the United States at an annual rate of
900,000 people. Up to 30% of all patients having the condition die within the
first month of diagnosis of the disease (Meyerhoefer et al., 2016). More than
100,000 people die of the disease every year. Additionally, in Europe, there
are 544,000 DVT related deaths every year. Up to 60 percent of Deep Vein
Thrombosis (DVT) cases occur during or after hospitalization, making it a
leading preventable cause of hospital death. The primary significance of the
matter lies in the fact that many patients are unaware until it is too late
(Sarah et al., 2012). The condition calls for research into how it can best be
detected before it becomes a danger to the patients’ lives.

          To find the literature for this
essay, I reviewed databases such as Google Scholar, PubMed, Nursing Journals
Articles, Science Direct and I was able to get free access to
some of the articles in full, some abstracts and conclusions.  Mainly literature reviews, case studies,
nursing reflective essays, nursing journal articles and surveys were selected.
I tried to analyze the recent literature, however, some articles were chosen
when the relevant articles were found with the following keywords: unexpected
deaths, diseases associated with leg pain, Deep Vein Thrombosis, Pulmonary
Embolism and Gibbs Reflective Cycle.

          Refection allows me to look at an
experience and how it makes me feel and react, asking what is good and bad, and
what can be learned (Sellman, D. & Snelling, P. 2010). Reflective practice
is very important because it is an active and deliberate process to critically
examine the practice, where an individual is challenged to undertake the
process of self-inquiry (Duffy, A. 2008).

          There are various reflective models
written by multiple theorists. Though the best model for analyzing this and
many other nursing situations is the Gibbs Model of reflection which is shown
in figure (appendix 1).  It was
introduced by Graham Gibbs in his 1988 book “Learning by Doing” and is the best
place to find a diagnosis and solutions for today’s problems (West et al.,
2014). The questions are essential for forming a firm foundation for
understanding the chosen issue. Additionally, the model can be used because it
is more understandable and will reflect more clearly on this critical incident.
Furthermore, this model is efficient in the way it gives me the time to express
myself in such a way and provides others the chance to place the matter into
perspective (Wulfson, E. 2014). In this reflective process, six steps of Gibb’s
cycle will be illustrated.

           The process of description allows me
to draw an illustration of the event. The fatal incident happened while I was
taking care of a male patient, I will refer as Mr. X. The actual name of the
patient is replaced with another name as to retain confidentiality (Dimond, B.
2005). Mr. X was a 56-year-old married man admitted to the private ward under
Orthopaedic consultant with a provisional diagnosis of the muscle injury. He
was treated with anti-inflammatory analgesics and physical rehabilitation.
Magnetic resonance imaging (MRI) was conducted for him. No prior signs of Deep
Vein Thrombosis isolated. The incident took place while I was on morning duty.
I came for duty at 8 am. While receiving the hand over from night duty staff
around 8:30 am, we were in the patient’s room. When we entered Mr. X’s room, we
observed that he was sweating excessively and he started complaining of sudden
shortness of breath, sudden chest pain, and dizziness. At that time he was
alone in the room and his wife went home to get something. We checked his vital
signs and noted his heart rate was 186 bpm. As a charge nurse, I alerted his
status to the Medical Officer on duty, according to hospital policy and
transferred the patient to the Intensive Care Unit (ICU) immediately. Then I
called and informed the situation to Mr. X’s wife. Emergency treatment was
given to the patient in ICU. His condition was explained to his wife by the
doctors. He passed away around 10 am on the same day, which was the 5th day of
admission. Cause of death was stated as Cardiac Arrest and sudden death due to
Pulmonary Embolism.

        In this paragraph, I will discuss my
feelings that took place when the incident happened. Initially, I was shocked
and saddened by the incident that the patient died unexpectedly.  Later I felt regret as it impaired my right
as a charge nurse that I failed to request a doctor to conduct relevant
diagnostic tests or refer to another doctor for a second opinion. I was deeply
saddened that I missed making the decision of assessing him and performing
diagnostic tests for DVT. Earlier diagnostic tests would have helped the doctor
to diagnose him earlier and which might have saved his life. I felt overwhelmed
and discussed this with my supervisor and with the consulting doctor. Also, I
was concerned for his wife who lost her husband unexpectedly.

          My role as a charge nurse enabled me
to evaluate the incident and to identify what was positive and negative about
the experience. I believe the positive thing about the incident is that it was
an experience for me to learn from. I provided an accurate description to my
supervisor and the consultant doctor which could help in the future practice.
Furthermore, the incident taught me the importance of relevant assessments and
diagnostic tests in order to avoid the fatal complications especially patients
associated with leg pain. (Wallis, M. & Autar, R. 2001). On the other hand,
the experience was really difficult and challenging for me as I felt
disappointed for missing out the proper physical assessment and diagnostic
tests which could have been helpful in making the correct diagnosis for Mr. X.
As nurses, we were taught the associated signs and symptoms of DVT,
complications and the importance of early diagnosis of DVT. Accordingly, as a
nurse, if I receive a patient with leg pain I should do a proper physical
assessment for DVT and request the doctor to do further diagnostic tests to detect
DVT. I thought if we were able to make the correct diagnosis earlier, we could
have saved Mr. X’s life.

         By analyzing the whole situation, I
understood there is much sense to be made. As a nurse, I have a responsibility
to maintain and promote the interests of individual patients (NMC 2004). This
responsibility includes ensuring that my knowledge and competence equivalent to
the task being carried out, especially when performing physical assessments for
the patients with leg pain. Payne, M. (2000) identifies that professional trustees
are at risk if a nurse has the insufficient knowledge required to perform
ethically, thus undermining their own authority. Even though I am a charge
nurse, I failed to develop the trust and relied more on the consulting doctor.
According to the hospital policy, nursing clinical decision making is not
widely approved unless it is a critical situation arises. It was a critical
situation where I should have made a proper clinical decision, such as perform
Electrocardiography (ECG) even without a doctor’s order. If the correct
diagnosis was made earlier, treatment could have been started and death of the
patient could have been avoided (Min, S. K. 2016). As in this incident,
I believed it was a critical situation where I should have made a proper

        In conclusion and reflection upon the
incident, it is clear that the selected course of action was not the best one.
I should have performed proper physical assessment and diagnostics test to rule
out Deep Vein Thrombosis. I should have performed Electrocardiography (ECG)
which could have established the diagnosis Pulmonary Embolism (Kurkciyan, I. 2017). Acting in the best interests of the patients should be very
important, even when this may take courage (Lachman, V.D. 2012).
Effective communication among patients, doctors, and nurses are essential in
preventing fatal outcomes in such cases (O’Daniel, M. 2008). I should have
asked Mr. X for more details of his medical and surgical history. I should have
requested my supervisor to develop the comprehensive education program about
Deep Vein Thrombosis, prevention, care including risk factors, signs and
symptoms of DVT and Pulmonary embolism, anticoagulants, and contraindications
to pharmacological and mechanical prophylaxes (Patel, K. 2017). It might
sometimes be hard for the doctor to determine the type of sickness a patient
suffers from by considering pain in the leg. As a nurse, I should have been a
critical thinker to make a decision to perform tests to clarify the correct

         An action plan is designed to help me be more
aware and I will know what to do if a similar situation arose again. It is
quite clear that I will be more careful in future to examine and treat the
patients with leg pain as it may be associated with Deep Vein Thrombosis
(Gilstrap C.M & White, Z. M. 2015). Most importantly, as a charge nurse, I
will make a decision in performing tests such as to assess for the Homan’s sign
to detect Deep Vein Thrombosis and to clarify the correct diagnosis (Dinah, G.
2015). I will perform a proper physical assessment and diagnostic tests for
patients with leg pain to rule out Deep Vein Thrombosis. I will not hesitate to
discuss the issue with the doctors if any such situation occurs in the future.
I will perform Electrocardiography (ECG) on all patients associated with leg
pain and if suspecting Deep Vein Thrombosis which will establish the diagnosis
of Pulmonary Embolism (Kurkciyan, I. 2017). I will develop and enhance knowledge
on the clinical nursing management of DVT (Wallis, M. 2001). I
will be proactive in making clinical decisions such as perform an ECG, cardiac
function test according to hospital policy (Lachman, V.D. 2012). If suspecting Deep
Vein Thrombosis, calculations of Well’s score and conducting D-Dimer blood test
might help to conclude the right diagnosis. (Modi, S.
2016).Majority of patients with Deep Vein Thrombosis lack the symptoms to
explain their condition. Therefore few clinical tests can be used to identify
the disease (Pai, M. 2017). The model of
Gibb’s cycle can be used to explore the patient’s descriptions to analyze
feelings, make evaluations and conclusions, and come up with practical
solutions to the issue. (Bourassa, M. G. & Tardif, C. 2015). I will also like to do more research on Deep Vein Thrombosis
and if the situation arises again, I know what I will do depending on the
evidenced-based practices.


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