Roper et al specify that the plan of care should be patient centred and the gathering of information should be taken from the patient primarily and the relatives if required. Unless the patient is unconscious it is not recommended information is collected anywhere else. All data collected must be in compliance with the NMC Professional Code (2008) and kept confidential (Data Protection Act 1988).
The ADL assessment was completed at Lee’s bedside; this is to ensure a comfortable and private surrounding in order to collect information. Further information was also gathered, such as skin assessment, M.U.S.T tool and pain assessment. The RLT model collects information about prior routine and changes that may have occurred due to the patient’s present condition. Lee stated he enjoyed playing tennis on the weekend to help him relax and also enjoys cooking. Due to his fractured leg strenuous physical activity like playing tennis will be a problem for lee to continue for some time. This part of the care plan collect both subjective and objective data allowing the nurse to establish baselines that Lee identified, and the use of a pain chart that Lee can interpret his pain (Beverage et al 2005).
The objective data collected related to Lee’s fractured hip and allowed baseline for swelling, skin irritation and basic post operative checks, this data was collected through observation. The subjective data was what pain, discomfort and how Lee was feeling and was not visible to others. Collection of both subjective and objective data can also help to discover coping strategies used by the patient (Roper et al, 2000).
Lee’s nutrition and independence/dependence was considered under the A.D.L of mobility and eating and drinking to him having loss his appetite and loss of weight. He was referred to the dietician and physiotherapist. The physio decided lee did need assistance in his mobility and the dietician prescribed a high calorie supplement drink to increase his calorie intake. The nurse prioritised Lee’s problems that were identified through the initial assessment; however Lee was not involved in this process. The nurse stated the problem mostly lied with his fractured femur and his colostomy bag as not caring for the colostomy appropriately can lead to the surrounding skin becoming damaged. In comparison Lee’s financial and personal anxieties were not included in the plan of care.
The assessment was written in accordance with the Nursing and Midwifery Council guidelines for records and record keeping, the information recorded was factual, accurate, consistent and written clearly (NMC, 2008).
Planning is described as “The stage of the nursing process in which an individual care plan is produced” (Oxford dictionary of nursing, 2003, p376), at this stage the patient’s problems are stated, the goal set and nursing intervention set. The planning of Lee’s care was established and discussed with him. The nurse used blank sheets in conjunction with the core care plan sheets as this permitted a client centered plan of care to be achieved, this was because Lee was involved in the goal setting process. (Pearson et al, 2005). During the planning stage the nurse used the information gathered to create a nursing diagnosis in relation to Lee’s problems. The nurse wrote individualized needs statements for Lee’s remaining problems not included in the core care plans, the objective and subjective data was used to create baselines for his pain level, swelling of the affected area, and also later his mobility level also had goals set by Lee and the physiotherapist (Hogston and Simpson, 2002).
Roper et al (2000) describe how goals that are set should be achievable in relation to the patient’s personal circumstances; otherwise the patient may lose sight of the goal. The goals must also be set with the patient. The goals written for Lee conformed to the acronym MACROS, this is that the goals set were; Measurable and observable, Achievable and time limited, Client centered, Realistic, Outcome written and Short (Hogston and Simpson, 2002). The goals were also written in client centered manner. They stated Lee’s name in the goals statements and also written using language he could understand, medical terminology was kept to a minimum and no abbreviations were used.
The goal set between the nurse and Lee for the A.D.L of mobility incorporated a short and long term goal, in relation to walking certain distances with the support of the physiotherapist and cleaning and changing his bag with the support of the stoma nurse whilst minimizing pain and discomfort (Aggleton and Chalmers, 2000). Once a goal has been established with the participation of the patient, the next process is to state the nursing intervention in relation with each specific goal. The nursing intervention should indicate who is going to provide the treatment, what treatment or assistance is required, where the treatment will take place, why the intervention is required, when the goal should be achieved. An adequately written goal statement should enable any member of the nursing team to be capable of looking in the patient’s plan of care and be able to follow a set of ‘directions’ to provide an ongoing standard of nursing intervention. This is especially significant for the care of specific treatments such as pin site care and dressings for skin grafts (Richards and Edwards, 2003). The ward worked as part of a multi disciplinary team (MDT), this included the nursing staff, specialized stoma nurse, physiotherapist and occupational therapists. The central plan of care included a goal for pain reduction whilst undertaking training in maintaining his colostomy; the nursing staff observed and recorded any variations in condition daily. The physiotherapists used their own plan of care for Lee’s mobility and commented on his development following each visit. The government encourages the use of a collaborative plan of care for many disciplines but this was not used with this patient (Foster and Harrison, 2000).
Implementation is described as “The stage of the nursing process in which the patient’s individual care plan is utilized and executed, in collaboration with other members of the health care team” (Oxford dictionary of nursing, 2003, p241).
The physiotherapist initially assessed Lee and it was determined that he should receive daily assistance from them to help him regain optimum mobility with his recently nailed fracture, the nursing team prescribed analgesia to help with associated pain as expressed in Lee’s nursing intervention regarding his reduced mobility. The physiotherapists then provided additional information into Lee’s main plan of care; the information added included how to assist Lee to mobilize without resulting in complications, and also passive exercises. Lee’s progress was added to his plan of care and nursing interventions received were also recorded.
The care provided in the implementation stage relates to the nursing intervention stated in the patient’s individual goals. The care provided reflects on the experience and skills of the nurse and also evidence based practice, if the nursing intervention has been documented explicitly the nursing team can deliver optimum care (Holland et al, 2004). The nursing team should encourage the patient to carry out desirable activities. Pearson et al (2005) describes preventing activities help the patient be more aware of what can impair normal living, comforting activities to provide physical, psychological and social comfort and seeking activities to encourage the patient to pursue new knowledge and self education.
Evaluation is described as “The final stage of the nursing process, in which the effects of nursing interventions are compared with the goals or objectives set in the care plan” (Oxford dictionary of nursing, 2003, p166).
In conclusion the Roper, Logan and Tierney activities of daily living model gives nurses a thorough framework to utilize to assess a patient. The model aims to encourage nurses to look beyond the medical problems a patient may present and to provide holistic care. It has been clear that the model can be extremely effective when performed by a nurse who is knowledgeable with the models philosophy.
The model has limitations if used by a nurse who does not fully understand how to gain a holistic representation of the patient’s previous and current abilities to perform the 12 A.D.L’s. It is commonplace for nurses to use the 12 A.D.L’s as a checklist type form and to write “no problems” or “no changes” if they are not competent with the model.
Many nurses are also not comfortable to discuss the A.D.L of dying with a patient; this is commonly completed as “not discussed” even when a patient has a short life expectancy. Roper, Logan and Tierney (2000) envisage that to die successfully you must first live successfully; with bearing on this the patient may wish to express their feelings, views and fears surrounding death.
The model when used correctly was client centered and involved the patient in the initial assessment and goal setting, this made the patients plan of care individual and permitted the patient to make informed decisions regarding the nursing interventions he would be receiving.
The rehabilitation ward also used Orem’s model, this may be the rationale behind some nurses not being comfortable with the Roper, Logan and Tierney model. The two models were used concurrently to provide holistic care and to also encourage the patient’s to be as independent and self-caring as their condition allowed. The incorporated models may have been successful due to good communication among staff and daily reports.
Many hospital settings commonly use pathways or core care plans due to the levels of documentation that the Roper, Logan and Tierney model requires when goal setting, the usage of pre determined actual and potential problems for specific conditions aid to create a comprehensive plan of care individualized by the usage of blank care sheets.
I found the model versatile and comprehensive, when used correctly the plan of care was individualized and client centered but when used inadequately just another part of the documentation process. If merely one model was used universally in hospitals there may be more comprehension of the philosophy and used more effectively.
References
Aggleton, P., and Chalmers, H. (2000) Nursing Models and Nursing Practice. 2nd edition. Basingstoke: MacMillan Press
Balzer-Riley, J.W. (2000) Communications in Nursing (4th Edition). London:Mosby
Beverage, D., Mayer, B., Schaeffer, L. and Thompson, G. (2005) Assessment Made Incredibly Easy. 3rd edition. Lippincott Williams & Wilkins
Foster, E., Harrison, M. (2000) Setting up collaborative care plans Nursing Standard 15 (6)
Hinchliff, S.M, Norman, S.E, and Schober, J.E. (1994) Nursing Practice and Health Care. London:Arnold
Hogston, R., and Simpson, P. (2002) Foundations of Nursing Practice. 2nd edition. Basingstoke: Palgrave McMillan
Holland, K., Jenkins, J., Soloman, J., and Whittam, S. (2004) Applying Roper, Logan & Tierney Model
in Practice. London: Churchill Livingston
Oxford Dictionary of Nursing. (2003) New York: Oxford University Press
Myers, C (ed) (1996) Stoma care Nursing: A patient centred approach. London:Arnold
Nursing and Midwifery Council (NMC). (2008) Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: NMC
Nursing and Midwifery Council (NMC). (2004) Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: NMC
Pearson, A., Vaughan, B., and FitzGerald, M. (2005) Nursing Models for Practice 3rd Edition. London: Butterworth Heinemann
Roper, N., Logan, W., and Tierney, A.J. (2000) The Roper , Logan and Tierney Model of Nursing based on the activities of daily Living. Edinburgh:Churchill Livingston
