Nursing practice: Case study

This essay is a reflection which explores one’s own experience as an adult student the relevance of reflection in healthcare using the Driscoll’s (2007) Driscoll model of reflection approaches reflection from 3 angles asking What?, So What?, Now What questions. The what question describes the event which the reflector has experienced and end leads to the so what question which helps the reflector to purposefully reflect on selected aspects of his experience during the event, enabling the reflector to discover what learning arose from the experience leading to the Now what question, leading to proposed actions to implement the learning experience in clinical practice three stages of model of reflection “What? So What? Now What? Was selected to structure the student nurse reflection.


Reflection is a mental process involving thinking, feeling, imagining and learning about the past experience and asking what might have happened differently and if this could affect present and future actions (Rolfe, 2011). Since reflection helps in shaping present and future thinking and action, its importance in healthcare cannot be overemphasized. Through reflection on own experience, a health care professional is able to identify key strengths in his/her actions as well as any weaknesses.  Ultimately, reflection provides a window through which a practitioner can view his/ her performance within his own lived experience (John, 2000). The reflection will focus on pressure ulcer risk management, Risk management can be defined as the culture, processes and structures that are directed towards the effective management of potential opportunities and adverse effect.  (Standard Australia and New Zealand 2009).

communication skills in Nursing practice

The evaluation will adopt a self-reflection approach to evaluate the effectiveness of the student nurse communication skills (Bramhall 2014) when in interacting with the patient.  The Nursing and Midwifery Code (NMC) of professional practice: prioritizing people; practicing effectively; preserving safety and promoting professionalism and trust. Mr. Duffy is used in this assignment to protect the patient’s right of privacy as a requirement of the NMC (2015) code of professional practice. (Diamond 2005)

Mr. Duffy : Nursing practice case study

Mr. Duffy was 85 year old gentleman admitted to the ward presenting  with a history of a large deep smelly ulcerated grade 4 sacral pressure, (query neglect), reduced mobility and double incontinent. Mr. Duffy lives on his own with no package of care, hence the neglect according to Northway and Jenkins (2013) detecting neglect is a problem and proving neglect is often not single event. Mr. Duffy condition warranted risk management procedures.

Pressure ulcers

Pressure ulcers are areas of localized tissue destruction caused by the compression of soft tissue over a bony prominence and an external surface for a prolonged period of time. (WOCN 2003, Alexander et al. 2006). Banks (1992) also suggested A pressure ulcer is an area of localised damage to the skin and may involve underlying structures. Blood cannot circulate causing a lack of oxygen and nutrients to the tissue cells. Likewise the lymphatic system cannot function properly to remove waste products. This risk assessment tool was first launched in 1988. It is a popular risk assessment tool in the UK as it has been well marketed by the author, Judy Waterloo. It is aimed at physically ill people in an acute care environment. The tool is a scoring system which covers 10 risk factors. It was revised in 2005 and includes a more comprehensive overview of the patients’ nutritional status.


Negotiating involves asking for permission before proceeding to give care. During initial interaction with Mr. Duffy, I introduced myself and my mentor to Mr. Duffy if he was happy for I to proceed to assess his wound in which he agreed to. The student nurse under close supervision by her mentor assessed Mr. Duffy by using the trusts Waterloo pressure ulcer risk assessment tool,  assessment of the wound and other pressure area were carried out this includes measuring the size of the pressure ulcer, the depth, exudates, location and appearance. A wound swab and photograph of the ulcer was taken as a baseline reference and medical guide of the effect of treatment.  An incident form was filled in line with the trust policy that stipulates the need for any patients admitted with pressure ulcers.

Nursing care

To meet the identified aspect of care which was management of Mr. Duffy’s wound preventative measures were taken to avoid further breakdown. These were pressure relief mattress (nimbus) ordered on arrival to the ward, referrals to the dietician and the tissue viability nurse. These duties were carried out by the student nurse under close supervision of her mentor. Mr. Duffy’s consented for referrals to be made to social services to assess and provide the necessary support and services she needed.


Food chart  and oral intake plan was put in place by the dietician and it was the duty of the student nurse to ensure that Mr. Duffy was encourage to eat and drink the recommended supplements so that his actual nutritional intake can be monitored. A nutrition assessment tool was used to assess Mr. Duffy, this is done because it has proven that nutrition intake is one of the factors influencing wound healing (Myles, 2006, Harding et al. 2000).  According to Bridel (2003) the screening tool detects malnutrition by measuring the patient’s body mass which include weight, height and body mass index, which indicated that Mr Duffy was slightly underweight.  Nutritional screening tool provide healthcare professional guidance on how to manage and treat malnutrition.
It is also imperative that the Mr Duffy nutritional status is assessed objectively and regularly and recorded in the patient’s care plan.

Factors contributing to pressure ulcers

It has been cited that protein calories malnutrition is a major factor in the development of pressure ulcers because it reduces the body’s ability to heal and repair itself (Breslow et al 1991). Ribu and Whal (2004) state ulceration causes psychological distress, fear and anxiety.  They therefore urge nurses not to ignore the psychological needs of patients suffering from ulcers.  By involving these specialties, it enabled the nurse to comply with the philosophy of care which states that nursing care should be promoted by good communication and relationships between staff and all members of the multi-disciplinary team.
Reduced mobility, the body owns defense mechanism against pressure injury to shift frequently throughout the day and night, which reduces individual’s ability to move the physiotherapist also has a key role to play in assisting Mr Duffy to mobilize.


Roper et al (2003) also suggests that a systematic assessment process in the holistic manner can give clear configuration for nurses to work around which reflects a problem solving approach and also incorporates the nursing process. It is important that evidence- based practice is maintained when implementing care to prevent and treat pressure ulcer development. It is fair to suggest that this was evident throughout Mr Duffy’s care delivery.  DiCenso et al (1998) argue that in practicing evidence-based nursing a nurse has to decide whether the evidence is relevant for that particular patient.
Under supervision of my mentor I dressed the wound on a daily basis according to the tissue viability nurse’s recommendation that is irrigating with saline then applying aquacell Ag as a primary dressing and maintain adhesive as a secondary dressing, carefully assessing the tissue within the wound boundary, color and condition of the surrounding skin as well as the size, depth, shape and width of the wound to assess for signs of infection (Roper et al, 1996).

Prevention measures

Reflecting on the scenario and the actions taken by me, the student nurse believes that I have demonstrated competency in preserving safety as a health professional by utilizing communication skills effectively. Given the effectiveness of the skills exhibited by the student nurse in preserving safety, I will continue to utilize these skills should any similar case of this nature present in the future. Pressure ulcers range from being little more than areas of discolored skin, to superficial ulcers, to deep purulent cavities extending to muscle and bone. (DoH,1993) These guidelines provide a framework to support decision making with the purpose of promoting best practice in the prevention of pressure ulcers based on current research. The NMC Code of Professional Conduct (2015) states that nurses have a responsibility to identify patients at risk.


In conclusion having carrying out an extensive research that enabled me to put theory into practice and reflect on practice during compiling this essay has helped me to understand the importance of risks assessment, that when caring for patients with pressure ulcer holistic and patient centered approach should be adopted with referrals to members of the multidisciplinary team as required by standard practice. In addition it has highlighted the importance of the risk assessment tools in assessing, planning and implementing care. This enable the student nurse to determine the underlying etiology for successful management. It also shows the importance of involving the patient in his treatment . It as well shows the importance of close collaboration between the members to achieve the goals for Mr. Duffy’s care delivery.

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