Firstly, this paper will present the factors leading to my client's admission to the clinical area in which I was placed. This will be followed by personal history and assessment of

University Degree Subjects allied to Medicine

Victoria Maline NRSRN 1008

Portfolio of Evidence to Demonstrate Care of a Client from Clinical Placement

The aim of this assignment is to produce a portfolio of evidence based on two nursing needs. A client from practice will be incorporated throughout in order to demonstrate an understanding of the relationship between the problems of the chosen client and the nursing care provided to alleviate them. Firstly, this paper will present the factors leading to my client’s admission to the clinical area in which I was placed. This will be followed by personal history and assessment of the client’s general condition during admission on the ward. It will be imperative for the purpose of this paper to demonstrate ability in using research based rationale for actions carried out by nursing staff and other members of the multi disciplinary team. Therefore, assessment, clinical decision making and selection of nursing interventions will be discussed by exploring evidence that informs these processes (Newton, 1991). In an attempt to justify why certain needs were selected for discussion, great emphasis will be placed on Roper, Logan and Tierney’s (RLT) (1996) activities of living model. Newton (1991) suggests nursing models represent the reality of nursing in ideal terms.

Literature gives weight to RLT model by explaining it is the most commonly used in general nursing care within British and European practice (Holland et al 2003; Tierney 1998). In conjunction with the identified needs, the physiological and psychological effects in relation to the needs will be explored.

In order to maintain confidentiality I have provided my client with a pseudonym (Nursing and Midwifery Council, 2002a).

Dave is a 43 year old gentleman who was presented to the Accident and Emergency Department (A&E) via emergency services with a suspected myocardial infarction (MI). An MI is sudden interruption of the supply of blood to the heart, usually resulting from obstruction of one of the two coronary arteries which originate in the aorta and supply blood to the myocardium which is heart muscle (Boyle and Senior 2002). Dave was conscious and complained of central chest pain, radiating down his arms and into his jaw. On admission it was noted he was short of breath, clammy, nauseous. The pain had begun three hours before when he was at home decorating. He explained the pain was ‘unbearable’ and persisted despite resting. Acute pain indicates that tissue damage is occurring and is a warning signal to that individual that action is required to stop further damage (Mcleane, 1999). Pain in unrelated areas during an MI is known as referred pain. Alexander et al (2000) explain how this is common as pain from deep somatic tissue can be felt in unrelated but predictable locations. Primarily, to relieve pain diamorphine had been injected intramuscularly by emergency services. Diamorphine is an opioid, a potent analgesic which relieves severe and persistent pain (Oxford Dictionary for Nurses, 1998). It would provide pain relief within 20 minutes of administration and last for 3-4 hours (Alexander et al). In addition to relieving pain the BNF (2005) describes how opioids confer a state of euphoria; therefore, this would help in relaxing Dave during routine tests. Whilst on A&E, Dave was administered reteplase and aspirin which are thrombolytic ‘clot busting’ drugs. They increase blood flow to the heart muscle to prevent further damage, assist healing and increase chances of avoiding death (NICE, 2005). A 12 lead electrocardiogram (ECG) was performed, recording the rhythm and electrical activity of the heart (BHF, 2004). Docherty (2003) suggests 12 lead ECG’s are one of the most useful tools used in evaluating a cardiac patient. On the basis of symptoms and review of the ECG a provisional diagnosis was made that he had suffered a myocardial infarction. According to the World Health Organisation criteria used for diagnosing definite MI is sometimes not available within the first 6 hours of symptoms (McKenna and Forfar, 2002). Therefore, a medical decision was made to transfer Dave to an acute cardiology ward where further investigations would take place. In order for a definite diagnosis, cardiac enzymes levels would be determined via a blood test. Cardiac enzymes are chemical substances contained within muscle cells and are released into circulating blood as a result of myocardial necrosis. The levels peak after 12 hours, therefore a valid result would be obtained after admission to the ward (BHF, 2004; Alexander et al, 2000).

In a stable condition and accompanied by his wife Dave was transferred to the ward. On arrival, nursing staff welcomed them as Dave was shown to his prepared bed space. Although anxious, Dave was alert and orientated to the ward and placed under the care of a cardiologist who was due for ward round that afternoon. The Department of Health (1999) suggests early medical intervention is the key to protecting patients, ensuring that the doctor and patient are aware of the nature and seriousness of the problem and the actions needed to address it. Dave’s wife was equally anxious and appeared very upset. Trained staff provided reassurance, however assessments had to be carried out on Dave who was priority in the initial plan of care. The BHF (2004b) describes that whirlwind activity can be frightening for relatives, but during testing and diagnosis, health professionals must focus their attention on the patient.

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The relevant admission documents were collected and the assessment procedure was explained to Dave. It was important to understand that hospitalization is a stressful time (Hinchliff et al, 2003), therefore, this was my first opportunity in attempting to build a therapeutic relationship with my client. Hinchliff et al (2003) suggests Nurses should aim to relax the patient using open friendly communication skills which will provide reassurance and treat Dave as an individual. This approach earns nurses trust, thus enabling the client to provide information for the purpose of assessment (Hinchliff et al, 2003). Alfaro-Lefevre (1998) suggests comprehensive data is collected in three phases, before you see the person, when you see the person and after you see the person. Initially, some information was transferred from A&E notes, such as personal history (see appendix 1). Dave resides in a house with his wife and two children. He is self employed as a butcher, jointly owning the business with his wife. Dave admits to smoking 20 cigarettes per day and drinking 20 units of alcohol per week. Research suggests that as a smoker Dave was 33 times more likely to have a heart attack than a non-smoker aged 45 years or under (Cook and Melby, 1999). Castledine (2004) suggests obtaining personal information and a detailed health history is the first stage in determining the health status of a client. Dave had a past medical history of hypertension that remains stable with treatment. His past family history indicated his father suffered hypertension and coronary heart disease consequently he died six months previously. The British Heart Foundation (2005a) suggests there are many heart conditions influenced by hereditary factors. However the National Service Framework for Coronary Heart Disease explains that genetic inheritance is an important consideration, however lifestyle changes can help to lower the risk (DoH, 2002). Skirton and Patch (2005) suggest nurses should know about genetic science because it is important to understand the prevention and management of some conditions. Therefore, it was important to retrieve this information and provide reassurance to Dave who appeared unsettled by the thought of following in his Fathers footsteps. At this point Dave was informed that a referral would be made to the cardiac rehabilitation nurse who would collaborate with him to provide advice relating to preventative measures in order to minimise future risks.

Dave underwent an initial assessment according to trust protocol. This assessment, based around the Activities of Living, also incorporated screening tools such as nutritional and Moving and handling scoring. Assessment is an important stage, as it guides a plan of care (Healy and Timmins, 2003). Aggleton and Chalmers (2000) suggest nursing assessments should be carried out as soon as possible. This is supported by the NMC (2002b) who explain that by law initial assessments are to be made within 24 hours of admission. Utilising the Roper, Logan and Tierney AL model will enable the identification of problems and allow the nurse to collaborate with the client in planning care in the form of realistic and achievable goals (Alfaro-Lefevre, 1998). It is ideal as Newton (1991) describes how it views a person as the focus of nursing, by incorporating the idea that nursing is concerned with helping people at all stages of their life span aiming to achieve their optimal level of health. Furthermore, this is achieved by helping them to solve, alleviate, cope with, or prevent problems relating to activities of living. Aggleton and Chalmers (2000) suggest health is affected by biological and psychosocial factors, however, they argue the RLT model appears physical, but a deeper assessment can indicate social factors. This claim is supported by Griffiths (1998) who agrees it is not the model adjusted, it can only appear this way if it is documented incorrectly by nurses.

It was discovered that when carrying out the AL assessment that some problems were interrelated with several activities of living (see appendix 2). Chest pain was interrelated with mobility, pain and discomfort and anxiety. Pain is difficult to observe and usually needs verbal clues in order for it to be reliable (Alexander et al, 2000). However, using the trusts numeric pain scale as a tool and obtaining a verbal description from Dave the degree of pain he suffered was documented. Pain scales have demonstrated reliability and validity, and are considered sensitive measures in pain intensity (De Walters et al, 2003). It was clearly identified that chest pain and further potential chest pain was an obvious need and Dave was openly anxious about the severity of the pain he experienced. Anxiety featured in communicating, fears and anxieties and pain, it also became an issue when discussing how Dave’s safe environment would be maintained. Advice was provided which informed he would be commenced on up to five days bed rest as trust policy indicates. This was supported by Dave’s moving and handling profile, which assessed my client’s level of dependence along with his mobility status. Given that this was day one of the regime for MI patients it is incorporated within the trust protocol that Dave would be nursed in bed, thus making him fully dependant. Thomson (1997) supports this policy by promoting bed rest as it is effective in improving oxygenation, therefore enhancing healing and relieving pain. This became an area of concern for Dave as he was anxious about coping with being confined to his bed/chair for this period, even more so on learning that commode privileges would be required for two of these days. Senior staff urged that under no circumstances must activity take place. However, The Department of Health highlights patient choice in ‘Building on the Best’ (2003a) therefore, it was important for Dave to understand the consequence of infringing this advice and the possibility of negative consequences on his current condition. Following promotion of this issue and persuasion from his wife Dave fully agreed to co-operate with this decision. In support of this situation, Martin (2004) suggests choice is only real when the patient understands what they are choosing between. Johnson (2004) suggests service users should receive all information relating to how their care will be given in order to allow them to make an informed decision. This approach helped when prioritising Dave’s care and incorporated a partnership between Dave and myself. This is supported by Johnson (2004, p135) who further states “it is always important to remember who the customer is in this process”.

Discussion will take place in relation to care plans implemented for pain and anxiety. The importance of this selection became apparent on analysing the AL assessment and finding these needs were identified in other categories as well as their own. With reference to pain in cardiac patients, MIMS handbook of pain management (2004, pp64) suggests “relief of pain minimises the stress response and improves prognosis for the patient”. Therefore this distinguishes a link between these problems and provides justification for the selection.

According to the Nursing and Midwifery Council (2002b) the record keeping and documentation involved with care plans should demonstrate:

A full description of assessment, care planned and care given
Appropriate information relating to the patient at any given time and what was done in response to their needs
Duty of care has been understood and all reasonable steps have been taken to care for the client
A record of any arrangement for continuing care

Care planning requires the skill of problem solving and decision making in collaboration with the patient and subsequently involving members of the multi disciplinary team (Atkinson and Murray, 1983). Care plans will be acknowledged by various member of the MDT therefore, laws and standards mandate that they be specific, clear and legible in order to allow easy access to information relating to Dave’s care (Alfaro-Lefevre, 1998). In order to maintain patient autonomy Dave was encouraged to be involved in his care, thus allowing goals to be agreed with him.

In order to foster a collaborative relationship with my client it was important to promote an open discussion as this would be useful in explaining each problem to Dave and determining how problems are related to each other (Alexander et al, 2000). Using a collaborative approach, priorities were set according to how Dave felt about each problem.

The first nursing priority was to implement a care plan for chest pain (see appendix 3). McCaffery and Beebe (1989) suggest pain is what the patient says it is. This is supported by The British Pain Society (2005) who explain that the only person who can really say how painful something is the person themselves. Although Dave was pain free at the time of assessment he feared further, potential chest pain. The ward doctor had reviewed Dave’s current condition and discussed analgesia with him. Analgesia was indicated via a prescription chart which informed the name of medication, dosage, frequency and route. Paracetamol and Diamorphine were prescribed, making them available should Dave require them. Davies and McVicar (2000) describe the influence diamorphine has on the pain pathways by suggesting it inhibits synapses in the ascending pathway thus closes the pain ‘gate’ in the brain and spinal cord. This refers to The Gate Control Theory, which devised by Melzac and Wall in 1965, proposes that pain is a function of the balance between the information travelling into the spinal cord through large nerve fibres and information travelling into the spinal cord through small nerve fibres. Large nerve fibres carry non-nociceptive information and small nerve fibres carry nociceptive information. Therefore, if the relative amount of activity is greater in large nerve fibres, there should be little or no pain. However, if there is more activity in small nerve fibres, then there will be pain (Alexander et al, 2000). Dave was also prescribed Glycerol Trinitrate (GTN) spray, a nitrate, self administered to increase blood supply to the heart muscle (BHF, 2005b) and is effective in relieving chest pain (BCPA, 2005). . Instruction was given by the pharmacist to ensure this was used correctly. Instruction within the care plan expressed necessity in administering analgesia and monitoring its effects. Bradbury and Jenkinson (1996) suggest patients could suffer unnecessary pain if effects of pain relief are not evaluated by nurses. Furthermore, if this instruction was not carried out, then staff would not be in a position to detect any adverse side effects, therefore, it would be unacceptable to decide whether analgesia needs to be reviewed by the medical team (Bradbury and Jenkinson, 1996). It was important for Dave to notify a member of staff if he experienced chest pain, regardless of its intensity on a pain scale. Therefore, he was orientated to the nurse call ‘buzzer’ system, advised to keep it within reach and reassured that it is answered promptly by staff. In the event of chest pain, trust policy indicates that an ECG is requested and performed therefore, the care plan instructed that verbal and non-verbal signs of pain should be acted on by involving the expertise of other members of the MDT, clear instruction followed to ensure communication between nurse, Dave and the MDT was documented. It would be crucial to observe for signs associated with ischemic pain such at shortness of breath, nausea and vomiting (Alexander et al). Observations were made via a Modified Early Warning System (MEWS) chart. This involved measuring Dave’s blood pressure, temperature, respirations, oxygen saturations and fluid input/output, and using a scoring system to determine any deterioration.

A care plan was initiated for the problem of anxiety (see appendix 4). Its expected outcome was to relieve stress and anxiety. Focusing on psychological needs Jenkins and Rogers (1995) suggest patients who have suffered an MI are subjected to a barrage of experiences, some creating anxiety and stress. Planning care for anxiety in an MI patient is equally important for physiological needs as The British Heart Foundation (2004) explains how anxiety causes tension, frustration and increases heart rate. The physiological changes induced by anxiety can cause an increased respiratory rate and sweating which could reduce body temperature (Hinchliff et al, 1999). As a result of these changes, the increased demand for oxygen might lead to chest pain or even death in a patient with MI who has a damaged myocardium (Thornton and Hallas, 1999).

Although agreeing that anxiety was a problem, Dave admitted to feeling quite embarrassed of feeling scared. Physiological aspects of stress and anxiety include ‘fight’ and ‘flight’ hormones which are due to the body’s response to fear and are released as a result of the hormone adrenaline being secreted (Boyle and Senior, 2002). With relation to the heart, adrenalin responds by increasing blood pressure and output, and could have the effect of hypertension and chest pain (Boyle and Senior, 2002). Therefore, the care plan involved intense therapeutic measures to ensure everyone involved with Dave’s care observed for signs of anxiousness. It was discussed with Dave for him to express his fears, and even though this had been achieved by him, instruction for staff was to maintain encouragement in expression, maintain privacy and dignity, discuss feelings and avoid unnecessary distractions when communicating with him. On discussing long term goals, Dave elaborated on issues such as worrying about his business and was concerned about how his family would deal with his current situation. I listened to Dave and positively reassured him that a referral would be made to join a cardiac rehabilitation group post discharge. Run by specialist cardiac nurses and physiotherapists, the group utilises a regime in order for clients to achieve their optimal levels of health again. The NSF for coronary heart disease (2002) encourages multidisciplinary rehabilitation programmes, which are tailored to the needs of individuals to provide psychological support, improve the success of lifestyle changes and help people back to as normal a life as possible.

The relevant referrals were made to specialist cardiac nurses who would assess Dave the following day to discuss physiological and psychological aspects of his current condition. A further referral was also made to the cardiac rehabilitation team at this point. According the NSF for coronary heart disease (2002) NHS trusts should put these agreed protocols in place prior to the patient leaving hospital. All aspects of the provision of care are a contribution in planning Dave’s discharge. The Department of Health (2003b) suggests in emergency admissions discharge planning begins as soon as possible. They also incorporate the idea that effective and timely discharges require the availability of appropriate care options to ensure that any rehabilitation, recuperation and ongoing health care needs are identified and met.

On reflection, this paper has demonstrated how the provision of care is based on a nursing model in order to provide guidance. However, when utilising it as a tool to make assessments, this model takes into account psychological as well as physiological needs. Therefore, correct application and promotion of client involvement ensures that this model meets individualised needs and consequently provides holistic care. I found that the care planned met the care given. Dave was appropriately informed of his present care and made aware of the care to follow, post discharge. This was achieved by following trust protocols for his condition and utilising research based rationale. In addition to this it was essential to work in partnership with Dave by gaining his opinions of each aspect of care, thus promoting his involvement in setting priorities and ensuring the goals set were achievable. This paper has allowed me as a learner to understand the importance of following guidance, but also understanding how the client thinks and feels about both physiological and psychological aspects of his experience.

References

Aggleton, P and Chalmers, H (2000) Nursing Models and Nursing Practice. 2nd Edition. Hampshire: Palgrave

Alexander, M F; Fawcett, J N and Runciman, P J (2000) Nursing Practice: Hospital and Home The Adult 2nd Edition. London: Churchill Livingstone

Alfaro-Lefevre, R (1998) Nursing Process: A Step by Step Guide. 4th Edition. Philadelphia: Lippincott-Raven Publishers

Atkinson, L and Murray, M (1983). Understanding the Nursing Process. 2nd Edition. New York: Macmillan

Boyle, M and Senior, K (2002). Human Biology 2nd Edition London: Harper Collins Publishers Ltd

Bradbury, M and Jenkinson, T (1996). ‘Factors Influencing Nurses Analgesia Decisions’. British Journal of Nursing. 5, 14, pp838-844

British Cardiac Patients Association (2005). Drugs –Nitrates (Online) Available at: Accessed on: 06/03/06

British Heart Foundation (2004a). Tests for Heart Conditions. London: BHF

British Heart Foundation (2004b) Caring for Someone with a Heart Problem. London: BHF

British Heart Foundation (2004c). Stress, Anxiety and Depression. (Online) Available at:

Accessed on 26/02/06

British Heart Foundation (2005a). What is the Link between Genes and Heart Disease? (Online) Available at:

Accessed: 28/02/06

British Heart Foundation (2005b) Treatment of Angina – Drugs (Online) Available at:

Accessed: 26/02/06

British National Formulary (2005). ‘Opioids’ Online: Available at: bnf.org/bnf/bnf/current/noframes/3491.htm

Accessed: 01/03/06

British Pain Society (2004). Understanding and Managing Pain: Information for Patients. (Online) Available at: Accessed: 01/03/06

Castledine. G (2004). ‘Patient Assessment: A Key Requirement for Nursing’. British Journal of Nursing. 13, 20, pp1233

Cook, N and Melby, V (1999) ‘Acute MI: Analysing Health Status and Setting Immediate Priorities’. British Journal of Nursing. 8, 3 pp150-158

Davies, J and McVicar, (2000). ‘Issues in Effective Pain Control: From Assessment to Management’. International Journal of Palliative Nursing. 6, 4, pp 162-169

Department of Health (1999). Supporting Doctors, Protecting Patients. (Online) Available at:

Accessed on 23/02/06

Department of Health (2002). National Service Framework for Coronary Heart Disease London: Department of Health

Department of Health (2003a). Building on the Best: Choice, Responsiveness and Equity in the NHS. (Online) Available at:

Accessed on: 27/2/06

Department of Health (2003b). Discharge from Hospital: Pathway, Process and Practice. London: Department of Health

DeWalters, T; Popovitch, J and Faut-Callahan, M (2003). ‘An Evaluation of Clinical Tools to Measure Pain in Older People with Cognitive Impairment’. British Journal of Community Nursing. 8, 5, pp226-234

Docherty, B (2003). ‘12 Lead ECG Interpretation and Chest Pain Management: 1’. British Journal of Nursing. 12, 21, pp1248-1255

Griffiths, P (1998). ‘An investigation into the Description of Patients Problems by Nurses Using Two Different Needs-Based Nursing Models’. Journal of Advanced Nursing. 28, 5, pp969-977

Healy, P and Timmins, F (2003) ‘Using the Roper-Logan-Tierney Model in Neonatal Transport’. British Journal of Advanced Nursing. 28, 2, pp 792-798

Hinchliff, S, Montague, S and Watson, R (1999). Physiology for Nursing Practice 2nd Edition. London: Balliere Tindall

Hinchliff, S; Norman, S and Schober, J (2003) Nursing Practice and Healthcare. 4th Edition. London: Arnold

Holland, K; Jenkins, J; Soloman, J and Whittam, S (2003) Applying the Roper-Logan-Tierney Model in Practice. Edinburgh: Churchill Livingstone

Jenkins, D and Rogers, H (1995). ‘Transfer Anxiety in patients with Myocardial Infarction’. British Journal of Nursing. 4, 21, pp1248-1252

Johnson, N (2004) ‘Effective Care Plans: Keeping Service Users at the Core’. Nursing and Residential Care. 6, 3, pp135-136

Martin, J (2004). ‘Making Choice Happen’. Practice Nursing. 15, 4, pp161

McCaffery, M and Beebe, A (1989) Pain: Clinical Manual for Nursing Practice. CV Mosby: St Louis

MCKenna, C and Forfar, C (2002) ‘What is a Heart Attack’? British Medical Journal. 324 pp377-378

McLeane, G (1999). ‘Pain symptoms and effects’. Practice Nursing. pp 20 – 22

MIMS (2004). Handbook of Pain Management. London: Haymarket Medical Imprint

National Institute for Clinical Excellence (2005) Final Appraisal Determination: Drugs for early thrombolysis in the treatment of acute myocardial infarction. (Online) Available at: Accessed: 21/02/06

Newton, C (1991). The Roper-Logan-Tierney: Model in Action Basingstoke: Palgrave Macmillen

Nursing and Midwifery Council (2002a) Code of Professional Conduct. London: Nursing and Midwifery Council

Nursing and Midwifery Council (2002b). Guidelines for Records and Record Keeping. London: Nursing and Midwifery Council

Oxford Dictionary for Nurses (1998) Oxford: Oxford University Press

Roper, N; Logan, E and Tierney, J (1996). The Elements of Nursing: A Model for Nursing Based on a Model for Living. 4th Edition. London: Churchill Livingstone

Roper, N; Logan, W and Tierney, A (1996) The Elements of Nursing: Models for Nursing Based on a Model of Living. 4th Edition. New York: Churchill Livingstone

Skirton, H and Barnes, C (2005). ‘Obtaining and Communicating Information about Genetics’. Nursing Standard. 20, 7, pp50-53

Thompson, P (1997). Coronary Care Manual. New York: Churchill Livingstone

Thornton, E W and Hallas, C N (1999). ‘Affective Status Following Myocardial Infarction Can Predict Long-Term Heart Rate Variability and Blood Pressure Reactivity’. British Journal of Health Psychology. 4, 3, pp 231-245

Tierney, A (1998). ‘Nursing Models: ‘Extant or Extinct?’ Journal of Advanced Nursing. 28, 1 p77-85