The aim of this paper is to show the development attained within the following four areas: Professional/Ethical Practice; Care Delivery; Care Management and Personal/Professional Development. Through the use of case studies I will attempt to outline these developments from experiences gained whilst on placement. The names of the people referred to throughout this paper have been changed to maintain confidentiality, in accordance with the NMC Code of Conduct, Clause 5.

Care Management

The domain Care management will be addressed within this paper using a long term condition case study to highlight the development and learning of this student. The Long Term Medical Conditions Alliance (2002) defines the term long term condition as “a condition of prolonged duration that may affect any aspect of the person's life”.

A literature search was carried out using the terms care management and long term conditions and the results of which appeared to show that care management is an area of long term conditions that spans the Inter Professional Teams (IPT). From hospitals to primary care they all have input from the IPT and the focus appears to be increasing support for self care, strengthening primary care, responsive specialist care and management of vulnerable patients (DoH, 2004). The NSF for Long Term Conditions, as released by the DoH in March 2005, aims to bring about a structured and systematic approach to delivering treatment and care for people with long term conditions.

Personal/Professional Development

A literature search relating to personal and professional development gave rise to many results advocating reflection as the prime area for developing the nurse’s professional development. Gustafsson and Fagerberg (2004) suggest professional development starts when reflection begins. Williams (2001) suggests that reflection and the development of this ability should be inextricably linked to professional development.

Introduction to Case Study

The module four placement was based within a renal unit and was the first experience of a younger client group with needs that appeared to differ from the older adults whom I’d worked with on previous placements. The patients on the ward did not require help with their personal cleansing and feeding as those previously cared for. Consequently, I felt some confusion as to the skills required in the care of these apparently self caring patients.

Upon reflection I was still working and thinking in a task orientated way and to be exposed to an area where other nursing skills were required left me feeling a little unsettled. Douglas (1999) suggests that the task approach is often taken by student nurses as a “haven” that offers security.

During the first week I was encouraged to work closely with my mentor. This gave me the opportunity to orientate myself to the ward and to get an overview of the needs and requirements of the patients. This also provided me with the chance to observe how the nursing team worked on the ward.

The majority of the patients admitted to the ward were diagnosed with End Stage Renal Failure (ESRF) and were there for observation and help with their condition which included education and health promotion from the IPT. ESRF is the most advanced stage of Chronic Renal Failure (CRF) where there is complete or almost complete failure of the kidneys to perform to excrete wastes, concentrate urine, and regulate electrolytes and where the CRF can no longer be controlled by diet and medication. Dialysis is required to replace loss of function and prevent death from uraemia (McDonald, 1997, MedlinePlus, 2003).

Dialysis is a method of filtering toxins from the body when the kidneys are unable to do so. This can be carried out by two methods, which are: Peritoneal Dialysis (PD) and Haemodialysis.

In PD dialysis takes place within the peritoneal cavity. The peritoneal membrane is used as a filter to remove excess waste and water. A hypertonic dialysis solution is infused into the cavity. Excess waste and water pass from the blood into the dialysate and after a few hours the dialysate is drained and exchanged for fresh fluid. The catheter used to gain access to the cavity is inserted during an operation which is usually carried out under local anaesthetic (McDonald, 1997).

Haemodialysis is where blood is taken from the body to be cleaned in a filter known as a dialyser which acts like an artificial kidney. A dialyser works on the principle of blood flowing along one side of a semi-permeable membrane made of cellulose or a similar product, with the dialysate flowing along the other side. The dialysate contains a regulated amount of minerals normally present in the blood, but in renal failure they are present in excess. The membrane has microscopic sized holes which allow the excess fluid and substances in the blood pass through but prevent the larger protein and blood molecules from passing through.

Treatment is usually three times per week for approximately four hours each time. The blood is carried from the patient to the dialyser and returned through sterile PVC tubing which is connected to the patient in one of three ways: Arterio Venous Fistula (AVF), Synthetic Graft and Central Venous Catheter (CVC).

The AVF is where an artery is surgically joined to a vein under the skin. The vein enlarges and thickens eventually. Two needles are inserted to access it. One to remove blood and the other to return the blood after it has been pumped around the dialyser.

A Synthetic Graft is similar to the AVF but where the vein is attached to the artery an artificial tube is used instead. These are used when a suitable vein cannot be found, possibly due to vascular problems or old age. The AVF is preferable means of access as there are problems with the Synthetic Graft such as infection (McDonald, 1997).

A CVC is used to provide temporary access whilst the patient is waiting for an AVF to be created. A CVC is usually sited in the subclavian vein. The use of the subclavian vein for the CVC is not recommended for patients due to the risk of central vein stenosis which could impede the future success of the creation of an AVF (Thomas, 2002).

Case Study

Mrs Woods is a 28 year old lady who moved to London from France five years ago. Mrs Woods was diagnosed with ESRF six months prior to admission and was admitted to have an AVF created. As a result of her diagnosis Mrs Woods was commenced on dialysis. Initially she had been receiving dialysis via a CVC but did not feel happy with it as she felt it looked unattractive and felt very conscious about its appearance. In addition to ESRF Mrs Woods had been receiving treatment for hypertension which was diagnosed when she moved to London. According to Thomas (2002) ESRF is the result of a number of pathological conditions which includes hypertension.

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Hypertension is diagnosed when the systolic and diastolic blood pressure (BP) is greater than 140mmHg over 85mmHg (Riley, 2003). Long term hypertension is diagnosed when the average of three or more BP readings taken during rest, several days apart, exceed these measurements (Faithfull et al, 1996).

As we can see Mrs Woods suffers from two long term conditions which were being managed through medication. According to the NSF guidelines it is the role of the practitioners involved in the care of such patients to encourage them to develop skills to help manage their condition better on a day ...

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