Pre-operative Admission and Assessment: A Reflection

Gibbs Reflective Cycle - a Reflective Account

This account uses Gibbs Model as its basis for reflection about pre-operative admission and assessment. By working around the cycle, it is possible to gain insight and develop practice: A Student experience:

This experience relates to a day surgery unit, where a gentleman is admitted for cataract surgery.

I always find it difficult to start this off. It still seems strange to be writing about something, which appears trivial and all in a day's work and then dissect it. I am going to be discussing this piece with my mentor, so I must remember not to put in the patient's name, not so easy when you think of him as Mr. H. (NMC 2002).

Description, What happened?

The patient was an elderly gentleman who was being admitted for a cataract operation, in the afternoon. I was fairly new to this day surgery unit having only worked two shifts, here, previously and was concerned about the number of people who were being admitted and my tasks to be completed for each of the patients, prior to their surgery. I was also unfamiliar with the unit geography and where to find equipment. I hadn't done this before, without someone in close proximity, to ensure that I had covered all the requirements and the documentation paperwork was not the same as I had used on other units.

Feelings, What was I feeling?

I was therefore feeling stressed, but also anxious to get everything done, due to the time pressures. I probably wasn't as empathetic as I should have been. My mind was not solely on the gentleman being admitted. I wanted to do this right and not have to repeat anything and also I knew that my mentor would have to overview my patient records before Mr. H went to have his operation.

More Description and a little evaluation:

The gentleman had not been in hospital before and had enjoyed good health, apart from his cataract. He was worried about being discharged home and also what he was expected to do, prior to the surgery. My concerns were with his vital signs and obtaining a urine specimen, to ensure that he was fit for the surgery. Just from writing this down I can see that we had different goals, mine to elicit the information as speedily as possible and complete the pre-op. checks, his to get his operation done and go home as soon as possible. I should have explained the process and then gone over his discharge plan, but I wasn't feeling very confident about the process and I was worried about the time.

Some analysis and more evaluation:

He was having a local anaesthetic. He did communicate his worries to me and I tried to reassure him that these operations were carried out every day. How trite that seems as I read it back to myself, now. It was quite a few years ago when I had to have a minor operation and I knew the 'system' (working as a nurse). I was young and quite able, but worrying about the outcome of the biopsy and the affect it could have on me and my family.

I knew from the admission documentation that the gentleman had a wife, who was disabled from a stroke. She was being cared for by a married daughter, while Mr. H was with us. I suppose too that he was worried about not being there to care for his wife. They had been married for 54 years. I haven't even lived that long! I can't imagine what experience I will have had by then, either.

I had felt impatient with him for taking time to undress and for the amount of time that he was in the bathroom. He was not physically disabled, but walking did seem to be something of a chore. Having taken the time now to re-think what happened, I can see that the area to be covered between the bed and the lavatory is quite a distance and as he put it: 'it's not quite like being at home'. That's true for me too, I have an 'en-suite' bathroom, at home, so can nip to the toilet quite quickly and privately. The lavatories in the unit are arranged in stalls and he may have found it difficult to urinate into the container. I also realised that his fingers were not as nimble as they were once and he probably found buttons difficult. I have replaced my father's fastenings on shirts with Velcro, which he can manage more easily. Why didn't I suggest that to him? Would he have found that insulting?

Conclusion, What could I have done differently?

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I had also forgotten, in my rush to continue, that older gentlemen have problems with their urinary system and can't always pass urine immediately. I had later found him looking very carefully at each bed and had realised with embarrassment that he couldn't actually see his bed label, because of his impaired vision. That was quite thoughtless, I could have identified it for him, as the bed in the corner, next to the sink. That's something to remember for the future, as I'm sure there are quite a few people attending for this type of operation.

The good thing for me was that the gentleman was compliant and carried out all the requests that I had made in order to 'process' him through the pre-op checks. He didn't ask me any awkward questions and was also very easy to talk to, willing to pass the time of day. I stumbled over some of the paperwork and I do know how important record keeping is (NMC 2002) and I have taken a blank pack with me to familiarise myself with it, before I have to use it again. It was lucky that the packs are pre-assembled and that I didn't have to find each of the different items from the stationery store, as that would have constrained my time even more.

It makes sense to me in terms of efficiency that the nurse who takes the patients to the eye theatre is not the same one who triages and admits them, but perhaps it would be better for the patients if it were? It can be confusing dealing with more than one person, especially when you may be feeling anxious about the operative procedure. I wonder how I would feel if I were partially sighted and were passed on like a parcel?

When trying to evaluate the care given during the admission and assessment process, I realised that the vital signs checks had become 'basic and routine' in my mind and I hadn't thought about 'maintaining patient safety'. (Roper et al.1981). Of course I had thought about it with regard to the gentleman finding his bed and walking around the unit, but more in terms of communication and mobility (of what I did not think about while attending him, explaining exactly where his bed was, but more importantly, the distances involved, when you have impaired sight). Any procedure carries with it risks to the patient and by taking these physiological measurements and testing Mr. H's urine, I was ensuring that he was 'fit for surgery', physiologically. But was he prepared mentally?

Reflective writing has several aspects to it:

1.      It enables people who are learning their craft to put their thoughts on paper and thereby improve their writing skills.

2.      It may improve the thinking process by ordering the thoughts about a particular aspect of care or an incident.

3.      It can enhance and sharpen clinical skills and problem solving.

4.      It may assist in changing attitudes towards peoples' abilities, cultures and feelings.

5.      If it is to be shared with others, it will enable other perspectives to be explored within a safe 'academic' environment.

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Limitations:

1.      The student may misinterpret information and stages in the decision making process.

2.      The student may never move beyond the descriptive/feelings phase and therefore not critically think about their practice.

3.      Students may not want to write honestly about something in case someone else is found to be 'at fault'.

4.      Mentors may not agree with the outcomes/conclusions that the student has identified and may wonder how or why their interpretation of the event is considered to be 'more appropriate'.

References:

Roper, N, Logan, W and Tierney, A. (1981) Learning to use the Nursing Process, Edinburgh, Churchill Livingstone.

Nursing and Midwifery Council (2002) An NMC guide for students of Nursing and Midwifery. London: NMC

Nursing and Midwifery Council (2002) Guidelines for records and record keeping. London: NMC

Please note: The above essays and dissertations were written by students and then submitted to us to display and help others. Thanks to all the students who have submitted their work to us.