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This hands, and said goodbye. So What

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This
essay is about a skill undertaken in clinical practice, the underpinning
evidence that supports its technique and necessity, and my introspective
analysis on my approach to the skill. The skill I chose was measuring
respiratory rates, number of breaths taken in a minute, during patient
observations. Through my reflective account, and research into literature, I
intend to have better understanding of its purpose, as well as evaluate my own
execution, and identify areas of success and improvement.

All
names used in this essay are pseudonyms, as to protect the identities of the
patients involved, in correspondence with the conduct of confidentiality
dictated by the Nursing and Midwifery Council (NMC, 2015).

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What
?

I
approached Connor, in freshly sanitized hands and new gloves, on the acute care
bay for his 1 hourly observations. He recognised the observation trolley as his
particular bay is for concentrated care; familiar with the procedure, he began
readying himself for the sphygmomanometer cuff. But as per The Code (NMC,
2015), I still made sure to ask if he was okay with me performing the routine
checks. Once consent was granted, I placed on the cuff and finger pulse
oximeter. I used the tympanic to take his temperature, and began running the
observation machine. As the cuff began to fill, Connor became relaxed and
talkative – which I find makes watching his chest rise and land very difficult.
I mentioned to him that the results will be more accurate if he fully relaxed.
This made him stop talking and look into his lap; his breathing was not
affected by talking or laughing, but he was not conscious of me measuring his
breaths either, so they were natural. I looked at my watch and counted breaths,
quickly glancing down again to check if the minute had passed. On the 60 second
mark, I removed all the paraphernalia, wrote all his results into his National
Early Warning Score (NEWS) sheet, threw my gloves into the clinical bin,
sanitized my hands, and said goodbye.

So
What ?

          Respiratory
rate is one of the first vital signs to falter when change in the patient’s
health is occurring. Although observation of pulse oximetry can also detect
decline in health, analysis of its results is not as widely understood; making
respiration observation paramount in detecting any change before it becomes
serious (Smith et al, 2011). Tachypnoea, abnormally rapid breathing, is one of
the most prevalent indicators of impending cardiac arrest in hospital settings.
Being aware of this change in respiration allows quick access to intensive
care, and ultimately prevents the catalyst that could result in organ failure
or even death. However, respiratory rate is the least measured of the vital signs
(Elliott, 2016). In a study of 41 British nurses through anonymous questionnaire,
most reported a lack of time (real or perceived) that inhibited them measuring
breaths for 30 seconds. Some did not believe respiration measurement was
important, or thought it was for particular patients (Philip et al, 2013). Education
into its importance is vital and time must be taken to observe respiration.

          To
ensure the reading is correct, however, it is best not to alert the patient
that you are measuring their breathing. It incurs demand characteristics. If I
had told Connor I needed him to stop speaking so that I could measure his
breathing, he would have tried to regulate his breathing in a way that would be
unnatural. I would not have an accurate image of his reflex breathing, but one
of the breathing he feels is good. Some nurses on my ward even suggested with shallower,
harder-to-see breaths, holding their hand for the pulse and bringing it to
their chest. This way, I would be able to feel the chest landing with each exhale
where I may not have been able to see it.

          A
regular respiratory rate is between 12-16 breaths per minute in an adult at
rest, but can be affected by respiratory issues such as Chronic Obstructive
Pulmonary Disorder (COPD) (University of Rochester, 2018). COPD includes bronchitis
and emphysema, and is effectively constant shortness of breath (COPD Foundation,
2018). It is important to be aware of the patient’s COPD status and always note
it on their NEWS paperwork, as it alters the analysis of the respiratory rate.
A rate that would read high for a patient without COPD, may be the regular rate
for a patient with. An important part of assessing vitals is being aware of the
patient’s baseline. Regular observations, especially frequent ones on
post-operative care wards, are to monitor change, not predominantly health. A
patient suffering chronic pain is likely to have a higher blood pressure than within
the regular range (Bruehl et al, 2005), and a person with an infection could
also have an abnormally high temperature as fevers inhibit the bacteria or virus’s
survival (Plaza et al, 2016). No person is admitted to hospital in perfect
health. Therefore, recognising each patient’s baseline in correspondence to their
diagnoses of new or pre-existing conditions is important. From there, you can
be aware of a COPD patient’s 20 breaths per minute, understand it is high, but
have explanation. When their next observation reads 25 breaths per minute, it will
be high enough to flag, because it is not only abnormal for a regular rate, it
is abnormal to them. Measuring respiratory rate fluctuation is in order to monitor
changes in the patient’s health. Therefore, it is extremely important that all
entries of rates are true. Vague guesstimates and false recordings can change
the image of the patient’s health. Writing a number similar to the previous
recording to save time might result in the patient’s tachypnoea being
discovered in the next reading, and viewed as an instant spike. It may have
been gradual but the second reading was false, and the diagnoses of what is
wrong will not have accurate symptoms to evaluate. Failure to record
information correctly, and falsifying data has resulted in a conduct and
competency hearing for a nurse before (NMC, 2017). It is extremely dangerous
and knowing the importance of the NEWS I would never make results up for any
reason.

          Breaths
are better counted over a minute than 30 seconds. Though some literature dictates
the rate at 30 seconds qualifies as a measurement 

x

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I'm Rick!

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