Fact Essay
INTRODUCTION
The purpose of this essay is to carry out an assessment of a patient and present a plan of care of three specific problems that the patient has encountered. The model chosen to guide the care plan is the Roper, Logan and Tierney’s Model of Nursing (Roper et al 2000). This will enable me to develop my skills in assessment, problem-solving and planning care.
The essay will begin by introducing the patient and outlining the rationale for choice. Following this, I will identify and discuss the care required through all stages of the nursing process (Roper et al 2000). I will discuss this in relation to assessment of three patient needs. I plan to show an understanding of holistic care and how it is used in each stage of the nursing process.
Pseudonyms will be used in accordance with the Nursing and Midwifery Council (2004) which states that “you must guard against all breaches of confidentiality by protecting information from improper disclosure at all times.
CHOSEN PATIENT AND RATIONALE FOR CHOICE
Jane is 81 years old, widow who lives alone in a bungalow, married for 54 years and has 2 daughters, one of which lives abroad and the other locally. She stated she has had a good life with many memories and had travelled to several countries with her late husband. She had enjoyed going to dance halls and outdoor bowling. Jane suffers with osteoarthritis which is a degenerative disorder in bone and cartilage (Hinchliff et al, 1998). She had fallen at home and was presented at the Accident and Emergency department. After a short stay on Medical Assessment ward, she was transferred to the unit for rehabilitation following her fall she developed urinary tract infection, with catheter in situ and reduce mobility. More than 300,000 pensioners each year require hospital treatment because of falls-related injury (Alexander 2000).
The rationale for choosing Jane was because I was involved in her care. I also wanted to emphasize on the function of nursing, which is to assist the individual to prevent, alleviate or cope positively with problems (actual and potential) related to activities of living (Roper et al 2000).
IDENTIFICATION AND ANALYSIS OF THE ROPER-LOGAN TIERNEY MODEL OF NURSING
The ward uses the roper, Logan, Tierney (2000) model as its theoretical framework for assessment. The model is applicable to the lifespan of a person from infancy to old age and contains the idea that actual and potential problems can place a person anywhere along a continuum from total dependency to independence. This idea promotes the goal of nursing to advance the patient from a state of dependence to independence to one of optimum (Dougherty and Lister 2004).
Roper et al (2000) identify the nursing process as a four stage dynamic, cyclical and continual process and the four stages are, assessing, planning, implementing and evaluating. The twelve integral and interdependent activities which form the core of the model of living are, maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilizing, working and playing, expressing sexuality, sleeping and dying. (Roper et al 2000).the five main groups of factors influencing the activities of living are biological, psychological, socio-cultural, environmental and political-economic factors (Roper et al 2000). These factors were considered throughout Jane’s assessment.
Roper et al (2000) suggest that assessment may on some occasions focus on certain activities of living relevant to a particular patient and setting. However, Newton (1991) argues that every activity of living should be considered when assessing a patient with the exception of dying and it may be the one thing the patient fears. For the purpose of this essay I have focused on maintaining safe environment, eating and drinking and elimination.
ASSESSMENT
Assessment is the first stage of the nursing process and it marks the beginning of a nurse-patient relationship. Assessment is an ongoing process When activities of living is used as the criteria for assessment, data is collected, reviewing objective and subjective data about the patient and identifying actual and potential problems which are amenable to nursing intervention (Newton, 1991). Because activities of living are complex and interrelated (Roper et al, 2000) it is difficult to consider each one independently.
Assessing Jane involved careful judgment under supervision, about a cluster of signs and symptoms before problem identification and diagnosis (Roper et al 2000). It helped to ascertain her needs and potential needs. Information collected from assessment was used to plan interventions and thus to achieve appropriate outcomes. We documented and recorded the relevant areas assessed to act as a baseline for re-assessment and evaluation of the patient. Assessment was also used as an instrument for safety, continuity and quality of patient care and it should be done continuously throughout the hospital stay as this will help provide continuity and quality care (Roper et al 2000). Assessment allowed me to make my own judgment in order to provide the correct care thus fulfilling legal and professional obligation, (Alexander et al 2000).
I participated in her admission process. As per trust policy I collected the relevant data collection documents and produced Jane’s folder ensuring each document was in the correct order. My mentor and I referred to the client’s case notes which contained past medical history, investigations and doctors notes etc. We transferred information from recent documents, such as full name, date of birth, address and next of kin. Under supervision of my mentor I was instructed to gather Information by assessing Jane based on documents which made her personal file.
I used skills of observation, open ended questions and listening in an attempt to retrieve as much information possible, particularly in Activities of Living. This helped to build a composite picture of my client and allowed her to introduce new facts that might be pertinent. It developed a therapeutic relationship with Jane (Nicol et al 2003). The questions posed by assessing in the individuality component of the model (such as how, how often, why and when) furnished information not only about the way in which the person carried out each activity of living but also the knowledge and beliefs she held about it (Newton, 1991).
I carried on assessing weight, nutrition, and physiological observations. Due to the nature of the ward the new single assessment process had recently been introduced. DoH (2002a) states that “single assessment will provide better and more efficient access care services. It will minimize duplication of assessments by agencies and save older people from having to repeat their personal details and needs to a range of professionals. On gathering individualized data, it then must be interpreted. The needs Identified were maintaining a safe environment, eating and drinking and eliminating of which all affects AL’s. Strengths identified such as family support are also a valuable resource when proceeding through the next stage of the nursing process which is care planning.
MAINTAINING A SAFE ENVIRONMENT
Assessment/Nursing diagnosis
The body of a healthy person has a remarkable ability to counter assaults from the environment and infection in order to maintain a safe environment (Roper et al 2000). This ability can be reduced by illness. Through her notes and questioning her, unfortunately Jane could not maintain her own safe environment because she was not mobilizing on her own due to the fall and she was weak. Through observation, there was attachment of urinary catheter which restricted her movements (Roper et al 2000).
Care plan:
In order to keep Jane involved in her care, goals were agreed with her (Roper et al 2000). This is to ensure patient autonomy but also to give Jane a clear picture of what will be expected of her during her rehabilitation period. It was established that the goal set for maintaining safe environment was highly prioritized and so measures are to be taken to ensure this. This ensured Jane could proceed concentrating on client centered outcomes (Roper et al 2000). Maintaining a safe environment is an activity which is carried out almost without conscious effort. All the other activities of daily living, except dying, contribute towards maintaining a safe environment (Roper et al 2000). Jane was referred and seen by the physiotherapist.
Implementation:
The Oxford Dictionary for Nurses (1998, p.313) defines implementation as “the stage of the nursing process in which the patients individual care plan is utilized and executed, in collaboration with other members of the healthcare team”.
To help her maintain a safe environment I made sure her buzzer was within easy reach so that if she needed anything, she could always call for assistance and not attempt to do it herself. To help her maintain her own body temperature, I had to regulate the room temperature for her because temperature plays an important role in wound healing, (Taylor 2005). The physiotherapist comes in every day for session with Jane and encourages her to mobilize in other to avoid the complications. However Jane indicated that most of the time she did not understand what tell or want her to do.
Hand over was a good source of information used in order to find whether the care being given is right for the patient (Roper et al 2000). The ward uses pre written handover sheets which were kept updated by the ward clerk, this allowed more time to write important details in a short space of time. Verbal and written communication skill helped in the care delivery of Jane, as information was given and shared amongst health care professionals (Nicol et al 2003).
Evaluation:
This is the final stage in the nursing process, which occurs continuously while providing care. Evaluation refers to goals which were set, any reassessment and documentation relating to specific goals. It was documented and handed over that my client had appeared to have progressed in all that was set. Newton (1991) confirms this by stating Value is also placed on observablee behavior as an indication of the need for nursing and the basis of evaluation of the effects of nursing. On reflection, all the care plans were maintained well. The intervention of therapy staff and their role in meeting the specific goals was a key factor in Jane’s progression. Jane was able walk to the toilet with very minimal assistance.
EATING AND DRINKING
Assessment/Nursing diagnosis:
Nutrition plays a huge part in a person’s recovery from illness and wound healing (Taylor 2005). It was important for her to have a balanced diet. To assist Jane with the activity of eating and drinking I had to take into consideration the fact that she was diabetic. I had to assess the food offered to her to make sure it was not high in sugar content, using the guide that was provided by the dieticians. On observation, Jane had dentures in her mouth. During the assessment, her medical notes indicated that she has history of choking and reduced mobility. This will be taken into consideration in the care plan.
Care plan:
After assessment, a plan of care can be devised in partnership with the patient, family / significant others, dietician and medical colleagues to ensure the patients nutritional needs are met (Workman and Bennett 2003). The goal set for Jane is to prevent her from aspirating by providing her with soft meal and also refer her to the dietician and other health care professional and also to make sure that her diabetic regime is maintained as well as measuring her blood sugar levels as per required by the doctors or Diabetic Nurse. Jane is to be observed for signs and symptoms of hypoglycaemia and hyperglycaemia.
Implementation:
Because of Jane dentures, it was important to choose food which was easy to chew and swallow. I assisted her with the food because she was at risk of choking. Instead of using a teacup, a beaker with spout was used for drinks to reduce the risk of spillages or even scalds in the case of hot drinks. Patient sat up to aid swallowing (Nicol et al 2003). All oral intakes were recorded on the fluid balance chart and food chart.
To help evaluate her food intake, Jane was on a food chart recommended by the dietician allowing them to make decisions to prescribe any supplementary nutritional intake in the form of Ensure or Enlive drinks if she needed them. Nutritional status for client of any age reflects on general health and can affects the rate of recovery from procedures, surgery, or illness (Potter and Perry 1999).
With reference to Jane’s care, her blood sugar levels were checked twice a day and care was continued to be monitored and assessed, this mostly happened via handovers. I saw this as an opportunity to continue assessment of both physical and mental health of my patient. All care was documented, signed and Jane’s assessment/care plan file was kept at the foot of the bed. All of the contents are legal documents and can be referred to by health professionals who participate in the care being given but can also be viewed by Jane and her family. Tasks were allocated to each member of the team on specific days at specific times. The patient was also kept well informed of their care via a board in her room which gave the days and times and activities to be held, but Jane hardly looked or read the information on the board. All input from therapy staff was documented by form of report and handed over to nurses on completion. Weekly MDT meetings were held, which allowed the team as a whole to discuss plans of care. At this point social workers are updated relating to their area of care and look into the possibility of services post discharge. Jane was kept updated of this information which can only be implemented on her consent.
Evaluation:
The evaluation of care was fully documented by the nurse and the MDT agreed that goals had been met. Therefore the plans were discontinued as it had been established how my client would manage at home.
ELIMINATING
Assessment /Nursing diagnosis:
Assessment of the usual elimination habits is vital in identifying the underlying problem and planning care appropriately. During assessment Jane had a urinal catheter in situ. From her medical note I noted that she has had a UTI in the past. I also observed that the urine in the catheter was concentrated which might indicate that the patient is drinking enough. According to Nicol et al (2003) concentrated urine is a sign of dehydration whilst a strong smell could be an indication of an infection. She was also constipated as she claimed that she had not passed stool for some days.
Care plan:
The care plan for Jane is for her to be encouraged on her increase in fluid intake at least 1500mls daily. The urinary catheter is to be checked and changed to avoid the occurrence of UTI, making sure the catheter area is clean and dry also a urinalysis is to be done to see if there is any indication of UTI. A fluid balanced chart and stool chart is to be added to her care plan. Embarrassment and anxiety can cause the individual to ignore the urge to defecate (Potter and Perry 2007). An increase in dietary fibre in Jane’s diet will enhance the absorption and retention of water in the stool. This will make the stool softer and pass easily. (Anderson 2003). Ensure Jane understands the importance of maintaining proper fluid and dietary consumption and activity. (Anderson 2003).
Implementation:
Jane’s catheter bag was emptied, measured and recorded in the fluid balance chart also assessed the colour and to check if it had a strong smell. Normal urine should have a nice straw colour and any other colour would give an indication of whether the urine was concentrated or not (Nicol et al 2003). Jane was prescribed enema by the doctor on which she passed stool and the result was recorded on the stool chart. Because of her dehydration she was encouraged to drink more fluids and this was observed, monitored and recorded on the fluid chart. A urinalysis test was carried out which provided immediate information concerning Jane’s kidney, urinary tract and liver as well as information concerning other systemic functions such as metabolism and endocrine function.
I found from observing care given that each stage overlaps the next. It is at this stage that clear direction is given about what is to be done for the client and by whom it should be done. Since the entire MDT was based in the same unit, the communication was excellent. This ensured a timely advantage for patients and for tasks to be delegated to the correct healthcare professional. Handovers were essential tools in this phase as information could be exchanged between nursing staff and the rest of the MDT, and further strengths and weaknesses could be highlighted, despite that there were communication breakdown at times. Jane benefited from the MDT as there was continuity of care and there was proper caring of the patient (Potter and Perry 2007).
Evaluation:
Jane’s short-term goal was achieved within 36 hours despite only a 1500mls increase in fluids. The long-term goal was achieved before discharge, as Jane’s usual bowel pattern had resumed. She fully comprehended the measures to be taken to prevent a recurrence and implemented them with encouragement.
Overall Conclusion
As both care giver and observer, I found that the care planned matched the care given. Collaboration between the Multidisciplinary Team and working closely with patient and family enabled outcomes to be achieved. This experience has taught me the importance of holistic care in relation to the nursing process and how an effective therapeutic relationship between patient and healthcare professional allows more information to be retrieved, thus creating a more precise and individualized care plan.
My client had commented how she enjoyed the 4 weeks on the ward. I think that the social aspect of the ward helped a great deal. Jane was encouraged by the whole team and maintained as much independence possible throughout her stay. I have benefited as a result of this placement, as it has taught me the importance of the nursing process. I have become more efficient in collecting information from the client and utilizing it appropriately in order to care for the client in a holistic way.
The skills gained whilst gathering the information during the assessment, for instance communication skills, will be invaluable to me throughout the rest of my training and beyond.
REFERENCES
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Roper, L. Logan, W and Tierney, A. (2000) Roper-Logan- Tierney Model of Nursing: based on activities for living. Churchill Livingstone. Edinburgh.
Taylor, H. (2005) Assessing the Nursing of Older Adults: a patient’s centred-approach. Radcliffe Publishers. Oxford.
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