Caring Practice Document Exemplar


CaringPractice: Document Exemplar

CaringPractice: Document Exemplar

Thepurpose of caring practice is to promote comfort, healing, andprevent unnecessary suffering of the patient and members of thefamily. The three domains of the Harris Health Nursing PracticeModels (NPPM) include the knowledge structure, care delivery system,and professional environment. The application of a systematicknowledge structure facilitates a professional level of practice thatis characterized by evidence-based decisions (Harris Health NPPM2014). The health care professionals strive to provide a healingenvironment for the patients and their respective families. The keydomains of the professional environment at the Harris Health Systeminclude shared governance, professional development, differentiatedpractice, and professional acculturation. The care delivery systemreflects the nurse’s accountability and authority for makingclinical decisions and obtaining targeted outcomes. It promotesconsistent, continuous, efficient, and accountable nursing care(Harris Health, NPPM 2014). The practice model enables the nurses toprovide a standardized care for the patients and families. This careis patient-centered and relationship-based. The relationship-basedcare helps the nurses to know the patients as well as their familymembers. The relationship that is established between nurses andpatients facilitates the development of a scenario in which thespecific needs of each patient are addressed.

A30 weeks’ gestational age babywas admitted to the Neonatal Intensive Care Unit (NICU) forrespiratory distress syndrome and prematurity. The baby was placed onbubble CPAP, PEEP 6, and FIO2 23-25 %. The bubble CPAP refers to adelivery system that is made up of a humidified gas source, a tubethat is submerged in a bottle of water, and an interface that playsthe role of connecting the CPAP circuit to the airway of the infantthrough the short nasal prongs. The gas creates bubbles that producesmall airway pressure oscillations as it exits the tube. Animprovement in the process of gas exchange and the functioning of thelungs are observed when these oscillations reach the neonate’slungs (Hanlon, 2014). The UVC line is inserted in order to facilitatethe total parenteral nutrition (TPN) as well as the medication. Thebaby tolerated bubble CPAP 6 and FIO2 weaned to 21%. I was assignedas the primary nurse for the 7p-7a shift.

Themother came when I was positioning the baby in the Dandle Roo. TheDandle Roo refers to a system that is based on a three-dimensiontechnology. It was designed by the NICU professionals. It is used tosupport the neurodevelopment of the ill and preterm infants. TheDandle Roo system is considered as the first three-dimensionalstructure that is used to support the spine, prone, and side lyingpositions in one device (Dandle Lion Medical). I introduced myself,arranged a private place, and offered the mother a recliner. Iexplained the infant’s condition briefly.I then called the doctor to give details of the medical condition ofthe baby. The doctor clarified her questions and explained in detailabout the immaturity ofthe lungsand the digestive system. In order to alleviate her anxiety, Iexplained to her about the cardiac monitor, alarm setting, bubbleCPAP set up, umbilical line, TPN, and feeding by the orogastric tube.I encouraged her to touch the baby and explained to her about thesignificance of breastfeeding and pumping. I then taught her how topump, store, and transport breast milk as she was separated from thebaby. I offered her the breast pump that she used to get milk at thebedside. According to Woten &amp Hurst (2016) a positive birthexperience and touching, seeing, and the provision of care to theinfant facilitates post-natal attachment. The mother- infantattachment is affected negatively by the birth of a premature infant,followed by its hospitalization in the neonatal ICU (2016, p. 1). Ialso explained to her, as the baby is premature the condition maychange at any time. The mother was happy when she left the NICU forthe first day.

Duringthe consecutive visits, I updated the mother about the infant’scondition. I taught her about several issues, including thesignificance of protected sleep, pain assessment as well asmanagement, positioning of the baby, feeding, and skin care. For thefamily centered care, I involved and assisted the mother to dokangaroo care, change the diaper, and position the baby. I explainedto her about the importance of providing a quiet environment topromote the baby’s rest and sleep. The mother of the baby haddeveloped confidence in me within a period of one week, which wasconfirmed by her own words. She said, “I feel like you are takingcare of my baby the way I want it to be in my absence.I am going to refer Ben taub hospital to my family and friends forthe excellent care”.

Thebaby’s condition was improving gradually, but he vomited 3 timesduring the day on the 10thday of life. The vomiting was not associated with feeding. During myshift, the baby vomited one more time at approximately 2 hours afterfeeding. My assessment indicated that the baby’s abdomen wasdistended, suffered from mild erythema around theumbilicus,and no bowel sounds could be heard on auscultation. The baby alsodeveloped multiple episodes of apnea and bradycardia withdesaturations and hypotension. I informed the doctor about the changein the condition of the baby. The doctor assessed the baby andordered for an abdominal x-ray. The X-ray results revealed theexistence of some free air in the intestine. The Ben taub hospitaldoes not have a neonatal surgical team.Therefore, themedical team decided to transfer the baby to Texas Children’sHospital (TCH) for further management. I called the mother andbriefly explained the change in the condition of the baby and askedher to come to the unit to sign the Memorandum of Transfer (MOT). Inthis situation, I had to initiate and direct the doctors how to dothe MOT, as the Neo fellow and resident doctors were new to the NICU.My service was required because it was their first time to transfer ababy to another hospital.

Iarranged a private place and offered a recliner to the mother whenshe arrived at the NICU. She was very upset and sad and asked severalquestions regarding the condition of the baby. I explained to themother about the baby’s condition and the necessity of transferringhim to TCH. I called the fellow doctor to explain about the medicalfacts. From my previous experience, I knew that the sudden change inthe condition of the baby made her more upset. This resulted in achange in her behavior. I called the chaplain to talk to her. Sheremained upset and anxious, even after talking with the chaplain. Iinvolved the social service to inform her about the local supportgroup. I also invited the charge nurse to talk to her. I updated thefellow care provider regarding the behavior of the mother andrequested him to make an opportunity for her to talk to the attendingdoctor. The attending doctor also explained to the mother about thebaby’s condition over the phone. I enlightened her about severalways through which she could calm down, including meditation andprayer. I also gave her some handouts that provided tips for reducingstress and meditation. I explained to her about the kangaroo teamfrom Texas Children’s Hospital. The kangaroo team is a transportsquad that consists of a Neonatal nurse practitioner, respiratorytherapist, and RN from TCH.

Ihanded over the baby’s clothes, one ID band, umbilical cord, andfootprint sheet to the mother. I sat with her explaining these factsfor about half an hour. She said that she would practice meditationaccording to her cultural and spiritual heritage. When the kangarooteam arrived at the unit,I vividly explained about the mother’s reaction to change incondition of the baby. I requested them to allow her to go with them,which I believed could lessenher anxiety and worry. The team agreed to do so, in spite of the factthat this was not one of their established practices. The kangarooteam had a detailed discussion with the mother. The mother slowlybecame relaxed as evidenced by her soft words, touching the baby, andsmiling. She expressed gratitude to me for giving support during herdifficult times.

Iintegrated the caring practices inherent in the Neonatal IntensiveCare Unit (NICU) cultures that we value the most to reach the nursingmission of providing high quality care and the vision for optimalhealth outcomes in order to meet the caring needs of the baby.I incorporated the Neonatal Intensive Care Unit’s core measureswhile taking care of the baby.

Thefirst core measure was the provision of protected sleep. I assessedthe baby’s sleep-wake patterns and clustered all care activitieswhen the baby was awake. The NICU lights and sound were maintainedwithin the recommended range to provide the infant with uninterruptedperiods of sleep. The soft talk is one of the key practices that areobserved in the NICU where all people keep their voices at lowlevels. Another NICU culture is to attend to the cardiac monitor andventilator alarms without wasting time in order to prevent thedeleterious effects of noise on the babies. According to Caple &ampHurst (2016) a continuous infant’s exposure to excessive backgroundnoise can result in a decrease in peripheral oxygen saturation,physiologic requirement, slow weight gain, and a decline in theperfusion of vital brain tissues. It also leads to an interruption inthe normal sleep-wake patterns that are essential for the healing aswell as the development of the immune system. This exposure is alsoassociated with a prolonged stay in the NICU (Caple &amp Hurst,2016). I educated the family regarding the importance of providinguninterrupted sleep and avoiding excessive noise.

Thesecondly core measure was pain and stress assessment as well asmanagement. I assessed the pain in every 4 hours and before, during,and after all procedures. All these assessments were properlydocumented. According to Pasek &ampHuber“Painful procedures place a newborn at risk for brain damage.Moreover, brain damage and the generation of free radicals areassociated with hypoxia” (2012, p. 61). I used non-pharmacologicalmeasures (such as swaddling, offering pacifier, and theadministration of sucrose) prior to all painful procedures. According to Pasek &amp Huber (2012) the mechanism of action ofsucrose is achieved when the endogenous opioid system is activatedfollowing the release of beta endorphins through gustatory taste orpathways. I encouraged the mother to do skin-to-skin care (kangaroocare), which has a positive impact on the stress of the NICUenvironment for premature babies. I also involved and shared withthe parents regarding pain and stress management plan of care.

Thethird core measure was the developmental activities of daily living,including feeding,positioning,and skin care. I ensured proper postural support by placing the babyin Dandle Roo. Dandle Roo keeps the baby in flexion containment andalignment. According to Caple &amp Hurst (2016) the developmentalcare (DC) of the newborn should involve reading and responding to thebehavior of an infant in order to identify its needs. This isaccomplished by holding the infant, gently touching it, and placingit in a fetal position. The developmental care also involves thealteration of the surroundings through a decrease in light and thenoise levels in order to reduce the stimulation as well as theexposure to stimuli that are greater than what the premature brain ofthe infant can tolerate (2016). I provided pacifier for non-nutritivesucking during the gavage feeding. I educated and supported themother for breastfeeding and pumping in every two hours since she wasseparated from the baby. Finally, the skin integrity was assessed anddocumented in every 3 hours. The Aloe Vesta (skin care product thatis used in NICU in order to reduce the risk of the skin breakdown)was then applied after each diaper change.

Thefourth core measure was the family-centered care. The parents of thebaby had unrestricted access to their infant in the Neonatalintensive care unit. I assessed the mother’s emotional and physicalwell-being, the ability, and confidence in taking care of her baby.The parents were encouraged to participate in medical rounds (theteam includes neo fellow, resident, charge nurse, bedside nurse andrespiratory therapist) at 9 pm every day. I involved the motherduring the care giving activities, such as bathing, diapering, andfeeding. I encouraged the mother to do kangaroo care. I also involvedthe social services that allowed the mother to access resources andsupport that could assist her in the short and long term parentingneeds.

Thefifth core measure was the healing environment. A quiet environmentwas provided by dimming the lights and lowering noise levels. Iensured physical and auditory privacy for the mother during eachvisit by providing curtains around the baby’s bed and lessinterruption by the health care team. In the NICUnurse-doctor-respiratory therapist collaboration was always practicedto provide high quality comprehensive care to the infants. Ipracticed evidence-based policies, procedures,and resources to sustain the healing environment in the NICU. Icommunicated effectively and timely with the neonatal team, and thebaby’s mother to prevent any delay in treatment. Jean Watson’stheory of caring practice was very relevant in this context. Thetheory explains the interpersonal relationshipbetween two or more people. In addition, the theory holds that careshould be focused on the interpersonal relations.This is because the care moments are expressions ofthe interaction that can happen in a transpersonal manner. Theanalysis of the transpersonal care concept focuses on theestablishment of a relation that goes beyond caring for physiologicalnecessities, aiming at a higher level and resulting in thetransformationof both individuals (Santos et al.,2014). A loving, trusting, and caring relationship between themother and the health care team affected her positively.


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