Experience at the Willows

Introduction

Carson McCuller once said “the closest thing to being cared for is to care for someone else,” a quote that relates to the profession of nursing (2015). Taking care of someone else takes compassion and kindness to others. It tests critical thinking and applying knowledge learned in school. As a nursing student, I am still learning how to become a professional nurse. A part of my nursing program is to go to clinical where knowledge learned in class is applied in real life.

Concepts like safety, communication, assessment and infection were all observed and performed in a nursing home community.

Safety: Interprofessional Communication & Medication Errors

The concept of safety is one of the first things I learned in school. As a nurse, it is our priority to keep our patients safe at all times. Easy to say, but it takes effort to implement. During clinical rotation, I have observed several safety measures performed by the health care providers (HCP). An example is the change of shift report from one Certified Nursing Assistant (CNA) to another.

According to Carins et. al., the exchange of information between two providers during shift report is a “time of risk and liability” since it affects patient care after the switch of HCP’s. End shift report is essential when it comes to noticing abnormal behaviors from patients that are not present from the last shift which may indicate many factors of illness. Another effective use of communication is the SBAR method which I used to report to my instructor about my patient and her possible care plan.

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In addition to the concept of safety, medication administration also has its own safety measures. When it comes to administering medications, medtech’s take responsibility on giving medications and does not delegate any medication administration to CNA’s or Unlicensed Assistive Personnel’s (UAP). Cheragi et. al., mentioned that medication errors are “considered as a global problem which increases mortality rates, length of hospital stay, and related costs” which makes it very important that the medtech implemented the 6R’s of medication (right: patient, medication, dose, route, time, documentation) before and after giving the medications (2013).

Another safety in medication administration that I have noticed is how the pharmacy delivers prepackaged medications (cut in the exact dose and medications needed in one administration is all in one container). This method reduces medication error because medications are already measured and giving the wrong dose is less likely. Promoting prevention medication error in healthcare is important because it contributes to HCP’s number one priority, which is safety.

Health care providers and patients work together to promote safety at Willows. In order for the HCP’s to safely transfer a patient from the wheelchair to a bed, they make sure that the wheelchair is locked, bed is in a comfortable position for them and asks for help if a patient is a two person lift. I also observed residents using non-skid socks to prevent fall injuries. Residents also use walkers to assist their gait when walking to avoid any risk for injury. Although it is considered restraint, HCP’s uses bed alarms, chair alarms and bed rails on patients who are unable to ambulate themselves and are fall risk as well. Overall, correct patient safety was implemented by the CNA’s and UAP’s during my clinical rotation.

Communication: HER, Documentation, Health Hx

Communication is essential in healthcare especially when caring for patients who are unable to voice out their concerns. During my clinical rotation, I have observed several communication tools and methods performed by HCP’s. When it comes to recording and viewing patient information, I noticed that Willows does not use electronic records. Rather, they use printed and written paper copies of patient interventions, treatments, diagnosis, and other health related information.

I, however, am not very fond of the paper method because it is less secure and more likely to violate Health Insurance Portability and Accountability Act (HIPAA). Even if the documents were stored in a safe room, it is easily accessible by anyone who enters the room. Compared to an electronic record, paper copies do not require a username and password to access the information. While retrieving or returning patient charts, I did not log it anywhere in paper, which then again questions who views patient’s information.

While reading the patient’s charts, I did notice that not everything is typed. Some of the documentation is written which made it a little harder to interpret, especially when you can’t read cursive. Paper copies are not as accurate as electronic records because it is not updated automatically when information is written. Stausberg mentioned that paper copies are less structured, less organized, and time consuming (2008). Even though my patient’s records were organized, going through every single one of the documents to find something specific was time consuming. Over all, each facility has their own preference on method of documentation; Willows uses the old method of ink and paper.

During my clinical rotation, I have witnessed very little documentation being done by HCP’s. American Nursing Association states that “clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice” which clearly shows how documentation affects nursing care (2010).

One documentation I have witnessed is during a fun activity with the residents. While playing Simon Says, one of the CNA’s was documenting which residents participated on the games. Another documentation I have witnessed is when the medtech gave a medication to a patient. After the administration, the medtech documented the time that the patient was given the medication. In addition, the medtech also documented that the patient refused one type of medication treatment and why. To sum up, proper documentation of resident daily activities, food and medicine intake, and overall health is helpful in comparing their status each day.

Sensory: Assessment of HEENT

Physical assessment of patients plays a role in determining patient’s needs and plan of care. The assessment of Head, Ears, Eyes, Neck, Trachea (HEENT) is essential to the residents to protect them from injuries. Since I was given different patients, I was able to assess HEENT and compare the findings. When inspecting the head, I check for hair pattern, distribution and texture and lesions on the scalp. Most of the residents presented hair loss at their age. Palpating the head, I feel for its general size and shape and if it’s is symmetric and smooth. I make sure that there is no tenderness during palpation and that the temporal artery is present. Assessing the eyes, I check for eyebrow and eyelash symmetry.

Looking at the eyeballs, I assess if they are moist, glossy and have a clear conjunctiva. Since I was assessing geriatrics, I was expecting one or two of the residents to have glaucoma since it is a common eye problem related to aging. I inspect the pupils’ size, shape and reactivity to light. Shining light on the eyes makes it constrict. Checking for corneal light reflex, I noticed one of the residents have slight strabismus since the light did not shine on the same spot on both of her eyes.

Looking at the residents eyes, I would say that most of their pupil size falls under 2-3 mm. A lot of the residents were wearing glasses which indicate that they have vision problems. Moving on with the ears, I inspect if they are symmetric, same color as the facial skin, roughly equal in size and shape. I did not notice any swelling or redness on the ears.

Some of the resident’s ears did have cerumen which may have impacted their hearing since some of them already have a difficulty in it. While in clinical, I did not see any resident using hearing aids. Inspecting the nose, I once again check for symmetry, checking if it is in the midline. There were no nasal abnormalities found. When it comes to their oral inspection, I noticed their oral mucosa and lips was dry and darker in color. Their teeth have decay and oral hygiene is clearly needed. Some residents even have food stuck in the sides of their mouth. This finding is related to the patient’s ability to open their mouth and do Activities of Daily Living (ADL) such as brushing their teeth.

No abnormalities were found in their trachea and lymph nodes. Over all, some physical findings during HEENT on the residents were normal signs of aging. Although it is common in geriatric population, it should be taken care of to prevent further damage to the body.

Infection: MRSA, C-Diff, UTI

Infection prevention is essential in any health care setting, especially in places where patients are in high risk of susceptibility. Since Willows takes care of the older adult population, extra precaution should be taken. Working in a memory care facility, it is important for the HCP’s to know how to prevent the spread of infection.

According to Rowe, Urinary Tract Infection (UTI) is the infection of the urinary system that may involve the upper and lower urinary tract (2013). UTI is one of the most commonly diagnosed infections in older adults. UTI may be asymptomatic to older adults, therefore harder to detect early. Rowe mentioned that UTI is the “most frequently diagnosed infection in long term care residents, accounting for over a third of all nursing home associated infections’ which is why it is very important to prevent it before it occurs. While on clinical, I helped female residents wipe their perineal area from front to back, one way to prevent (UTI). After breakfast, I also helped change a resident’s brief and clean their perineal area, to again, prevent any infection. When a resident tells me that they need to use the restroom, I assist them and try not to delay their urge to urinate since this can lead to UTI. Good fluid intake and avoiding bladder irritants like caffeine is also helpful in preventing urinary infection.

Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (Cdiff) are another type of infection but rarely found in nursing homes. Since both can be transmitted through contact, hand washing with soap and water is important. Another way to prevent MRSA and Cdiff is using gloves when in contact with patients that has the infection. I would also recommend to the charge nurse to send the patient to the hospital where they can be monitored properly. Since MRSA and Cdiff are very contagious, residents who carry this infection should not stay at the nursing home because it can be transmitted easily to another susceptible host. Over all, MRSA and Cdiff are infections that are very contagious and may lead to death in older adults.

During my time at Willows, I did notice several infection controls that is not being implemented. The first one is handwashing. Before meals, residents do not wash their hands. Some residents are eating with their dirty hands which are a risk for infection, especially when after using the restroom. I also noticed that not every UAP that feeds the resident wears gloves. There was also a lack of hygiene supplies, specifically wipes and soaps. It is hard to implement infection prevention if you do not have the tools for it. I also noticed that HCP’s go out in the kitchen with the gloves that they used to clean a patient. Gloves should be off when you leave a patient’s room. To sum up, further learning about infection control is needed for the staff of Willows of Winchester.

Summary

Briefly, hands on experience during clinical was helpful in applying my knowledge on the basic concept of safety, communication, assessment and infection prevention. The importance of safety is the number one priority for the residents. Communicating with other health care providers is important to prevent errors in treating the residents and implementing their care plan. A vital part of assessing patients is to determine their risk for injury and prevent it by giving their eyeglasses if they have a vision problem or their hearing aids if they have difficulty in hearing. Infection prevention is needed to reduce the chance of the residents to become more immunocompromised. To sum up, learning about different concepts and performing them during clinicals gave me an insight on what I will be doing as a nurse.