JSTA December 2010 - Australian Association of Stomal Therapy ...

Reflective essay
Katie Jane Bird
INTroducTIoN
This reflective essay will demonstrate my journey from a
beginning stomal therapist practitioner to an advanced
practitioner. It will provide different examples and experiences
that have been significant to my individual journey. The
Australian Nursing Federation Competency Standards for the
Advanced Registered Nurse 1 will be applied throughout by
the competency standard identified in bold and in brackets
following the related action. Each point of the competency
standard will be allocated a corresponding number, for example
competency one, point three will be 1.3.
reflecTIve exPerIeNce
I first met Mr Kat on the ward on a Sunday while I was the
clinical nurse in charge of the shift. He was transferred from ICU
day two post-emergency Hartman’s procedure for perforated
diverticulitis. I introduced myself to the patient and then the
ICU nurse handed over to me and showed me Mr Kat’s stoma.
The stoma was covered in a dark red blood clot so was not
visible (4.1, 4.6). On my questioning, the ICU nurse said she
thought the stoma had always looked like that but she could not
be sure (5.1, 6.7). The patient’s notes did not give any further
information (1.1, 1.3, 1.8, 1.9, 5.1). Blackley2 states a stoma should
be inspected as soon as possible after the operation to make
baseline observations. This includes ensuring the colour of the
stoma is bright to dark red to indicate adequate blood supply
(6.2). I decided to do a closer inspection myself (7.2). Mr Kat was
awake and alert so I explained my role as a clinical nurse for the
ward and a stomal therapist. I asked him if I could have a better
look at his stoma because of the clot and the need to check blood
supply (1.10). He was happy for me to proceed. I discovered the
clot would not be dislodged easily and I could still not view the
stoma (1.7, 8.1). I was not happy to continue to try and remove
the clot as I did not know where the blood had come from or
if I would disrupt something. I did not wish to do any harm
(1.6, 3.2, 3.3). I opted to ring the on-call surgical registrar for
advice; coincidently the patient was on her team (6.3, 6.6). The
registrar agreed it was important to view the stoma and together
we removed the clot to reveal a healthy, pink, moist stoma. I
informed Mr Kat of the end result and documented my actions
in the progress notes.
This was my first experience of dealing with an abnormality
in a postoperative stoma independently. I felt a sense of
accomplishment that day as I realised I was able to adapt
my practice and integrate the theory I had learned and prior
experiences to competently and confidently advocate for my
patient’s best interests (3.5).
Mr Kat’s recovery started well, he was receptive to learning about
his stoma and actively took part in his cares (6.6). Mr Kat chose a
two-piece appliance. I chose a base plate with slight convexity, as
his stoma was retracting, with a drainable bag until the output
thickened. Both of these measures were working well. I was still
doing most of the care with Mr Kat verbally instructing me as he
watched in a mirror (6.6). One morning while the doctors were
reviewing Mr Kat they came and got me to review Mr Kat’s
appliance as there was a leakage issue. I discovered that one of
the senior nurses had removed the appliance as some leakage
had occurred due to the faeces becoming more formed and
pancaking under the base plate. Instead of replacing both the
base plate and bag, she had placed just the bag directly over the
stoma. I had assumed that the senior nurses on the ward would
be familiar with a two-piece appliance. This incident showed I
was wrong and needed to do a teaching session with the staff
(9.1, 9.4, 9.5). I approached the nurse unit manager (NUM) of
the ward and explained that I would like to do an in-service
and the reason why. She agreed and we made an appropriate
time and I did it the following afternoon after the nurses had
handover (13.1, 13.2, 14.2). I chose this time so I would have as
many staff present as possible. There was a good mix of junior
and senior staff. I took along different stomal appliances and
showed them how they worked and let them have a play. I
asked that they share the information with staff who were not
present and reminded them to involve the patient with their
stomal care. I asked if they had ay questions and let them know
I was always available for support (11.2, 11.3, 15.1). The session
took approximately five minutes and I feel it was effective as a
repeat incident has not occurred again. Feedback from the staff
was positive (9.6). As Mr Kat had chosen his appliance I started
to prepare him for discharge from the stomal perspective. While
I was filling out the forms for him to join the Stoma Association,
I discovered he did not have a Medicare card or health insurance
and was waiting to apply for permanent residency. Mr Kat and
his wife were from South Africa. This was all unfamiliar ground
for me so I started to figure out what I could do and what
implications there were going to be for Mr Kat.
The first thing I did was ring the Stoma Association (5.1, 5.2,
5.3, 7.28.1). They told me Mr Kat would need to get his stomal
supplies directly from the company and pay for them himself.
I then rang the company of his appliance and they gave me
prices and a sales phone number for Mr Kat to call for ordering.
They also told me about a sample pack of the chosen appliance
that I could get for Mr Kat free of charge so I organised that. I
relayed all this information to Mr Kat and asked his permission
to contact the social worker, which he agreed to (6.6). I rang the
social worker who saw Mr Kat and his wife the next day and
throughout the rest of his hospital stay. I continued to liaise
with the social worker and in the process learnt much about
the finances of staying in hospital (5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7,
6.3, 8.1). Because Mr Kat ended up having an extended stay, I
continued to use the stomal department’s stock and organised
that on discharge I would give him additional stock to take
home (7.1). Because the appliance Mr Kat had chosen was
working so well and he was happy with it, it did not occur to me
that I should consider looking at a more cost-effective appliance.
When the stomal therapist nurse took over Mr Kat’s care she
did change his appliance purely for the reduction in cost. On
reflection it reminds me to think outside the box.
Journal of Stomal therapy australia – Volume 30 Number 4 17