Reflection On Experience Working In Accident And Emergency

Reflection On Experience Working In Accident And Emergency This fieldwork exercise was a visit to the Minors Department within Accident and Emergency (AE) for a large London National Health Service (NHS) hospital, to observe and interview an Emergency Nurse Practitioner (ENP) within the Department, and link their role in relation to primary health care (PHC). I had expected to learn further about the main connection between PHC and an acute care setting such as AE, assuming that it would be due to poor PHC management and issues with accessibility. These assumptions were based on some experience in AE as an Agency Nurse, along with colleagues, patients and media reports. 2.0 VISIT TO MINORS IN ACCIDENT EMERGENCY My fieldwork exercise began with covert observation in the AE waiting room, waiting for my fellow Nurse Practitioner (NP) student to arrive for a Saturday night shift. There were around 15 people and one child within the waiting room; a relatively calm environment, albeit for quiet restlessness, sighing, guarding and rocking, questioning companions as to when they would be seen, alongside comparing with others who had got in. Reception was a glass-shielded counter staffed by two personnel, informing patients registering, that there was a three hour wait. An electronic sign above reception welcomed patients, friends and relatives to the hospital, also informing them that we endeavour to see you in 4 hours; a reference to the Department of Healths (DoH) target, for patients to be discharged, admitted or transferred within four hours of presenting, in 98% of cases. The sign also requested for those with a minor illness, to attend the adjacent walk-in centre (WIC). Of note, aside from a clear focus on hygiene, was a sign notifying patients that treatment may not be free if not a United Kingdom (UK)/European Union citizen or resident. Such signage brings a principle of the Alma Ata declaration into question. The Alma Ata declaration arose following a joint World Health Organisation-UNICEF international conference, with a vision for healthcare for all people worldwide, with PHC at the heart (World Health Organisation, 2010). Although it can be argued that international guests are not paying into the NHS, and healthcare in the UK is not essentially free, given the National Insurance levy, the declaration views healthcare as a right for all, and not just those who are in a position to pay. On arrival, my fellow NP student showed me around AE. Within the adults section, the Department can be broken down to: Table 1: AE layout Department/Room Cubicles/Rooms Additional/Other Information Resuscitation 5 +1 paediatric cubicle Majors 16 Including 1 psychiatric cubicle Minors 12 Assessment/Triage 3 Clinical Decisions 10 Investigations and short term treatment (not more than 24-36 hours) Eye 1 Ear, Nose Throat 1 Plaster 1 X-Ray 1 Adjacent CT room being built next to Resuscitation The hospital is one of Londons major hospitals, opening in the 1700s in central London and developing into a main teaching hospital. With the increase in healthcare demands, more space was needed, and the hospital relocated to its present day location in the 1950s. In the 1970s, construction on the present hospital building began, and by the early 2000s, building and the final relocation of one of its hospitals was complete (Hospital website, 2009a). The AE Department is a 24 hour service, seeing around 100 000 patients per year, and of those, around 21% are admitted to hospital. Twenty two percent are children, to which a separate paediatric AE between the hours of 9am and 2am is available (Hospital website, 2009b). From April this year, the AE Department will become one of Londons four major trauma centres (MTC), and one of eight acute stroke centres (Healthcare for London, 2010). Preparations for this new designation were evident by the building of a computerised tomography scanner next door to Resuscitation, enabling suspected stroke patients to be scanned within two minutes of arriving. I spent most of my visit in Minors, a Department with 12 cubicles, which is staffed by two to three ENPs, one Senior House Officer, Registrar support, and a General Practitioner (GP) on Saturday and Sunday evenings. Despite having an adjacent WIC, this section of AE is dedicated to patients with minor injuries and illnesses. The most common presentations are due to infections (mostly ears, nose and throat, and urology), foreign bodies, wounds, fractures and head injuries. Numbers seen can vary, and around 150 patients had already been seen that day. There is a difference between days and nights, with days mostly seeing occupational injuries and GP referrals, with alcohol, drugs, domestic violence, assaults and foreign bodies featuring in the nights. In addition, weekends and evenings can see Minors taking on the role of an extended hours GP practice; supporting my hypothesis of poor PHC management and accessibility, as being a key cause of PHC in AE. The Department closes at 3am to reduce costs, but is sometimes too busy to do so. From next year, Minors will be a 24 hour service, with the aim for a Nurse-led service with Registrar support. This is to release medical staff for the new MTC, and in response to recommendations in Lord Darzis review on healthcare for London, discussed further in this assignment. The most surprising element of my visit, was to find out that ENPs are viewed and treated as junior doctors. This was mirrored by the consultation: history taking, examination, assessment, plan of care and documentation was that of seeing a medical doctor. While I was aware of the advanced and autonomous role of a NP, enabling diagnosing, prescribing and referring, I was taken back that NPs, certainly in this Department, have shifted from the nursing side of healthcare, and are now affiliated with medicine. The ENPs line management is a Registrar, who also supervises and signs off competencies. Any problems or concerns which need to be escalated, are dealt with by the Consultant. The AE Matron, and ultimately, the Director of Nursing are nowhere in the ENPs reporting line. The role of NP, reviews of urgent care, and PHC management are the topics I have chosen to base my discussion on. 3.0 DISCUSSION 3.1 Urgent care reviews The key review of urgent care in London is Lord Darzis Healthcare for London: A Framework for Action report. It was commissioned by NHS London in December 2006, in order to fulfil Londons healthcare needs over the next 5 to 10 years. The report acknowledged that many patients presenting to AE for minor illnesses and injuries would be better looked after in polyclinics or urgent care centres (UCC) with longer opening hours. Patients presenting to AE is not optimal due to the waiting period and being seen by junior doctors rather than GPs, who more suited to these complaints along with managing long-term health conditions (Healthcare for London, 2007a). The report proposes UCC with diagnostic equipment, where patients will have access to a Nurse or GP, recommending 24 hour access if based in AE (ie. Minors), or to be open on weekends and afterhours for those not hospital based (Healthcare for London, 2007a). A co-located UCC within AE can be important, in diverting urgent care away from attending AE/MTCs (Healthcare for London, 2007b). However, the ENP reported problems recruiting fellow ENPs with appropriate qualifications and experience, and was unsure whether Minors would be a Nurse-led 24 hour UCC, to coincide with the transformation of the main part of AE into a MTC in April. The Darzi report received criticism, largely directed at cost cuttings, cashing in on privatisation, the demotion of acute hospital services, the question of elderly care, and that future predictions on PHC and AE usage was an understatement. There is also criticism that recommendations have been made without practicalities, including polyclinic staffing, failings and costs of minor injuries units, and the future of healthcare staff (London Health Emergency, 2007). The ENP reported a poor skills mix at the adjacent WIC, such as not being able to read x-rays or suture, with patients being referred on to Minors. Alongside the question of resources being doubled up, such referring on leads to disjointed care and greater waiting lengths to be treated. It could also be confusing for patients to know where the best place to attend is, especially having been diverted from AE to the WIC on the advice of the Reception sign, only to end back up in AE. Clarity and streamlining of services is needed to improve patient experience. The Royal College of Nursing (RCN) survey found that Emergency Nurses were under huge strain to meet the DoHs four hour target, termed as unrealistic (RCN, 2010: website). The survey also reported that the majority of respondents felt that patients with various and complicated needs, have had their care rushed to meet targets, and 59% of respondents feeling the responsibility lying solely within Nurses (RCN, 2010). Yet the ENP I spoke to was happy with the target, which gave momentum if a patient needed to be seen by a Registrar and had been waiting over an hour, this would then be escalated to a Consultant. On questioning, the ENP felt that the target was realistic, practical and they had the resources. 3.2 Primary health care management and accessibility London has the most AE attendances and admissions than anywhere else in England, and many of the 83% of patients not admitted could be treated elsewhere, with 40% of complaints able to be resolved through PHC. However, access to PHC services in London after hours is inadequate; a main thought behind AE attendance. AE patients are more likely to be fulltime workers and may take reassurance in knowing that they will be seen in four hours, rather than a wait of up to (or longer than) 48 hours to see their GP (Healthcare for London, 2007b). According to the ENP, patients report issues making GP appointments and that AE is quicker than seeing their GP, as the main reasons for presenting with PHC matters. The Healthcare Commissions (HCC, now the Care Quality Commission) review on urgent care in England, found that more than 50% of patients have problems calling their GP surgery, and a quarter of patients found GP hours were not convenient, and avoided going (HCC, 2008). Incentives for GP surgeries to provide afterhours care was a recommendation by The Royal College of General Practitioner (RCGP) in their review on urgent care (RCGP, 2007). Yet, the HCCs review found that where GP services provide afterhours care, less than half had organised a phone diversion with local GPs, to divert afterhours calls to their services. The majority of patients attending afterhours GP services are seen within two hours after an initial telephone assessment (HCC, 2008). This is not only faster than attending AE, but a more appropriate use of resources. The review found that many people are not aware of healthcare services other than their own GP and AE, or they might be unsure of using them. There were also examples of patients being referred to services that were not accessible. Work needs to be done to increase both patients and healthcare professionals understanding of alternative healthcare services, and when to use them (HCC, 2008). This is a view shared by the RCGP, along with GP practices implementing systems to deal with urgent care and GP training (RCGP, 2007). The ENP expressed frustrations with GPs making inappropriate referrals to AE, rather than to Specialists, generally noting the practice of defensive medicine. Despite referring back to the GP on discharge, patients were bouncing back for simple things, such as to have their dressings attended to. The ENP rarely had time to speak with GPs, but when they did, it was mostly to phone to question why they had referred. In respect to patients, the ENP felt that they were either not taking responsibility for their health or there was poor self management, possibly due to poor or no patient education, such as not taking analgesia and attending AE to request. The RCGP also note the need for improved patient education and self management promotion in their review (RCGP, 2007). The ENP was also very critical of NHS Direct, Englands telephone advice line for healthcare. They felt that the service was inadequate, as it was not possible to make an assessment over the phone, and defensively referring to AE. Yet half of callers to NHS Direct were given advice on self management at home (NHS Direct, 2010). 3.3 The role of the Nurse Practitioner 4.0 SUMMARY This fieldwork exercise has been a valuable experience. It has demonstrated the impact PHC has on AE, an already stretched resource, exacerbated by poor PHC management and accessibility. For these reasons, I will bear in mind my present practice and on qualification as a NP, to make seamless and appropriate referrals.

Consciousness As Determined Th Essay examples -- essays research paper

Consciousness is understood in a variety of ways. In one belief, a person is conscious when awake, but unconscious when sleeping or comatose. Yet people also do things requiring perception and thought unconsciously even when they are awake. A person can be conscious of their physical surroundings, pain and even a wish or fantasy. In short a creature is conscious if it is aware of itself and that it is a physical and emotional being. Consciousness is a psychological condition defined by the English philosopher John Locke as "the perception of what passes in a man’s own mind".1 Consciousness is defined and perceived differently in many psychological view points. For instance the earlier views around the 19th century was diversely considered. Most perceived consciousness as a substance or "mental stuff" unlike an object from the physical world. Others deferred that the conscious mind was what separated man from lower forms of life. It is an attribute characterized by sensation and voluntary movement which described the difference between normal waking state of animals and men and their condition when asleep.2 Other descriptions included an analysis of consciousness as a form of relationship or act of the mind toward objects in nature, and a view that consciousness was a continuous field or stream of essentially mental "sense data." The method believed by most early writers in determining consciousness was introspection—looking within one’s own mind to discover the laws of it’s operation. This belief was limited when it was apparent when observationalists could not agree on observations. Obviously due to the differences in one’s own idea of introspection and the underlying views they possessed. The failure of introspection to reveal consistent laws led to the refection of all mental states as subjects of scientific study and thus psychology attached consciousness to its diversity. The term consciousness is most often used by philosophers and psychologists as meaning "attention to the contents or workings of one’s own mind." This notion had little significance for the ancients, but it was emphasized in the 17th century by John Locke and Rene Descartes. Contemporaries of ... ... physical framework of reality.6 Smythies presents that everyone has a private space in addition to the shared, public version. Each individual’s personal framework intersects with the familiar dimensions while remaining distinct from them, and it provides an arena for all conscious sensations that have spatial extension or location–objects discernible by sight or touch.7 To understand Smythies’ theory see Appendix A. In conclusion one can determine a variety of theories in the evolution of consciousness. As cited earlier, consciousness is viewed as being physical or material in some cases and yet in others it is viewed as a function of the inner mind or the minds eye. These theories have even been as radical as Smythies’ philosophy that the state of consciousness is a sort of physical plane. If we were to collaborate these theories to form a conclusive view point, individuals would possibly be able to understand consciousness and the workings of consciousness. Perhaps the mystery of consciousness is to remain a mystery. Possibly this mystery is the key to cognitive thinking. And perhaps the key to our personal evolution.

Critical Thinking Question Essay

1. Explain the differences between bacterial meningitis, aseptic meningitis, fungal meningitis, and tubercular meningitis. Bacterial meningitis is a primary infection of the pia mater, arachnoid and subarachnoid space, ventricular system and the CSF of the brain. The subarachnoid space is accessed either by a systemic, bloodstream or direct extension infection. Common causes of bacterial meningitis after the neonatal period are Meningococcus (Neisseria meningitidis) and pneumococcus (Streptococcus pneumonia). For neonates, pneumococcus and gram-negative enteric bacilli are common agents. Aseptic meningitis (viral meningitis, nonpurulent meningitis, lymphocytic meningitis) is an inflammation which is thought to be localized to the meninges. The population at risk depends of the virus. A variety of symptoms are caused by a plethora of viruses such as enteroviral (most common), mumps, herpes simplex types 1 and 2,, St. Lus encephalitis virus, West Nile virus, California encephalitis virus, Venezuelan equine encephalitis, Colorado tick fever, lymphocytic choriomeningitis virus, Epstein-Barr virus, and influenza virus types A and B. Fungal meningitis is a chronic, much less common condition than bacterial or viral meningitis. It most frequently occurs in persons with impaired immune systems or those with altered normal flora. Development is insidious and usually occurs over days to weeks. Also associated with chronic meningitis are syphilis, tuberculosis and Lyme disease. Tubercular meningitis is the most common and most serious form of CNS tuberculosis, and is found mostly in those with acquired immunodeficiency syndrome (AIDS). Miliary tubercules form in the brain and meninges, later eroding in the pia mater with mycobacteria entering in the CSF producing a hypersensitivity reaction which causes purulent exudate to the basal meninges, cerebrum and spinal nerves. Vasculitis occurs causing cerebral ischemia and infarction. Symptoms include headache, low-grade fever, stiff neck, nausea and vomiting, irritability, difficulty sleeping and fatigue. These signs and symptoms lead to increase to confusion, stiff neck, significant behavioral changes, and seizures. Additionally, hydrocephalus and cranial nerve palsies or cerebral infarcts may occur. Early diagnosis and treatment with proper antituberculosis may cause a 90% recovery rate. 2. A neonate has a harsh, loud, systolic murmur shortly after birth. This is best heard at the left lower sternal border. The neonate is acyanotic and has no other symptoms. What type of congenital heart disorder does this infant have? Explain why the neonate is not cyanotic. When could the infant become cyanotic? These symptoms describe a ventricular septal defect (VSD). This type of defect is a left to right shunt of blood flow through the septum of the heart and symptoms depend on the size of the shunt. Because of the increase in blood from the right ventricle (RV) into the pulmonary artery (PA), the PA, left atrium (LA) and left ventricle (LV) become enlarged. A large VSD causes a large amount of pulmonary volume. Over time, the smooth muscle layer of the arteriolar wall thickens and a decrease in diameter of the pulmonary vessels occurs which causes resistance to the new blood flow. An increase in pulmonary vascular resistance causes a reverse shunting through the VSD causing cyanosis from deoxygenated blood flowing through systemic circulation. This phenomenon is termed Eisenmenger syndrome. 3. How does defective gastric secretion of intrinsic factor (IF) cause anemia? What is this type of anemia called, and how does a person get it? Intrinsic factor (IF) is a mucoprotein that is produced by the parietal cells. It is responsible for absorption of vitamin B12 in the ileum. Decreased amounts of IF causes a lack of absorption of B12 resulting in pernicious anemia. IF deficiency may be congenital or from adult onset gastric mucosal atrophy and parietal cell destruction. In older adults, failure to absorb IF is the cause of almost all vitamin B12 deficiencies. Congenital IF disorder is caused by an autosomal recessive inheritance pattern which is a genetic disorder. Gastric atrophy may be autoimmune and occurs along with type A chronic gastritis. 4. Discuss the pathophysiologic relationship between cirrhosis and portal hypertension. Cirrhosis is an inflammatory disease of the liver that disrupts its structure and function. Fibrous bands are formed causing nodular regeneration giving the liver a bumpy appearance. The liver is smaller or larger than normal and is hard when palpated. Parenchyma of the liver becomes distorted and the biliary channels become obstructed causing jaundice. Shunting is formed in new vascular channels bypassing blood from the liver. Obstruction in the portal veins also causes abnormal high blood pressure in the system from resistance of the blood flow from the obstruction. This is termed portal hypertension. Cirrhosis of the liver is the most common cause of portal hypertension.

A Visit to the Historical and Current Day Bermuda - 659 Words

Index.html: Sit back, relax and enjoy the warm ocean breeze. Welcome to Bermuda! Located only 640 miles west-northwest to North Carolina, Bermuda Is the place to be. Beautiful beaches, soft pink sand, historical sites that date back to the sixteen hundreds and friendly people are just some of the many things to experience whilst visiting Bermuda. History.html Bermuda was first discovered in 1505 by a Spanish navigator, Juan de Bermudez. He Named the island after him, hence the name Bermuda. He left and returned ten years later in 1515 and decided not to settle due to the bad weather. In 1609, a ship headed to Jamestown Virginia, got caught in a storm and then wrecked on the reefs of the Island. The crew of about 150, made its way to shore and was led by Sir. George Somers of England. They spent ten months on the island and built two ships, the Deliverance and the Patience. When completed, the crew would resume their journey to Jamestown Virginia. Somers returned to Bermuda to stock up on the roaming hogs, which would later be put on our currency, and died. His body was sent back to his hometown but his heart was buried on The Somers Isles. In 1612 Richard Moore, Bermuda’s first governor, and three others began construction on the Town of St. George. In 1620, the House of Assembly of Bermuda held its first session that introduced a representative government in which Bermuda became a self-Governing colony. This is just the start of Bermuda’s settlement. 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