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Patent-care study. Kirsty is a seventeen-year-old young lady who was diagnosed with Crohns Disease when she was thirteen years old.
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The aim of this patient care study is to discuss the care and nursing interventions that a particular patient received whilst staying on acute medical ward. Clause five of the Nursing and Midwifery Council’s Code of Professional Conduct (2002) states that “as a registered nurse or midwife you must protect confidential information” and if information is to be revealed the patient’s consent must be sought. The patient’s permission was obtained after an explanation of the purpose and proposed content of the care study, with a staff nurse present. For reasons of confidentiality, the patient will be referred to under the pseudonym of Kirsty. Kirsty is a seventeen-year-old young lady who was diagnosed with Crohn’s Disease when she was thirteen years old. She lives in a terraced house with her mother and is a hairdressing student. She was admitted to the ward from the Children’s Outpatient Department following a routine check-up, where she presented with right-sided abdominal pain and loose stools. She was diagnosed with a flare-up of Crohn’s Disease. Kirsty was chosen for the purpose of this care study because her strength of character was admired and a good relationship was established.
Kirsty was admitted to a twenty-six bedded acute medical ward, which is primarily gastrointestinal conditions, however medical outliers are admitted. There are three bays: one male, and two female, one called the Day Room (as it used to be the patient’s day room, but was opened as a bay as there was a bed shortage) and the second is called the Female Bay. There is a double side-room and two single side rooms, top of the ward and bottom. Kirsty was admitted to a bed in the female bay.
The ward is split to accommodate the Primary Nursing framework. Walsh (1997) suggests that primary nursing requires one nurse to be accountable for patient care delivery twenty-four hours a day (from, admission, through assessing, planning, implementing and evaluating patient care, through to discharge), and when the primary nurse is off duty, associate nurses continues the plan of care prescribed by the primary nurse. Characteristics of primary nursing according to Mead (1991, cited in Walsh, 1997) include accountability for the nursing care of the patient, patient-centred care, continuity of care, confirmation of a ward philosophy, changes in ward organization and skill mix, and patient and family participation in care planning. Each bay on the ward has at least one primary nurse (when staffing levels improve, it is the aim of the ward to have two primary nurses in each bay, each nurse allocated with their own patients) and the ward is split to accommodate the primary nursing framework: the double side room, the bottom side room and the Day Room is one allocation, the top side room and the male bay is another and the last one is the female bay.
As is characteristic with primary nursing the ward has a philosophy of care, which is displayed in the centre of the ward (Walsh, 1997). The aims of the ward are to promote the health, well-being and dignity of their patients, to educate patients in order to allow insight and encourage independence and responsibility, to work within a multi-disciplinary team framework to enable patients to reach their optimal potential, and when necessary assist patients to a peaceful death, to ensure honest, open communication and the understanding that this is a two-way process, to involve family and friends in the achievement of these goals within the framework of primary nursing and to promote a stimulating learning environment to enable appreciation and respect of patients needs, to act as advocates for patients and understand the theory underlying practice and to always ask why. This philosophy of care is inline with the characteristics of primary nursing (Walsh, 1997) and patient-centred care (Swankin, 2002).
There is a varied skill mix on the ward, from the senior sister to auxiliary nurse. Some of the nurses have specific interests such as nutrition or wounds; some of the nurses have come from abroad and are C grade, one of the nurses qualified only twelve months ago, whereas the other nurses have been qualified for a number of years. The same is true for the nursing auxiliaries, some are fairly new and others have a number of years experience and have trained or training to NVQ Level three in care. The ward team all bring a positive contribution to patient care whatever their level of skill and all are committed to the care of their patients and the ward philosophy and primary nursing.
The model of nursing used on the ward is an adaptation of the Roper, Logan and Tierney Activities of Living Model. The focal point of this model involves twelve activities of living: maintaining a safe environment; communicating; breathing; eating and drinking; eliminating; personal cleansing and dressing; controlling body temperature; mobilising; working and playing; expressing sexuality; sleeping; and dying (Aggleton and Chalmers, 2000). The model on the ward incorporated communication, diet, and sleep, mobility, hygiene, toilet, occupation and a section for activities of daily living prior to admission on the admission form. The activities the admission form does not cover can be incorporated into the patient care plan if there are problems or potential problems.
Kirsty was assessed on admission and the care plan devised with her and her mother. Kirsty’s baseline observations on admission were: temperature: 37.4 degrees Celsius, her pulse was 100 beats per minute and her blood pressure was 100 millimetres mercury systolic and seventy millimetres mercury diastolic. On admission Kirsty was very tired and in pain, she was pale, which is a characteristic of Crohn’s disease (Pullen, 1999), and quiet. Her mother was present at the admission and assisted with admission details because Kirsty was tired and in pain. Her activities of living on admission were no communication problems, normal diet usually but had experienced a poor appetite and had lost some weight over the three weeks prior to admission, usually a good sleeper but had not slept well prior to admission due to her abdominal pain, she was fully independent and mobile and independent with hygiene needs. Kirsty had eliminated loose stools for three weeks prior to admission and urinating small amounts although she felt like she wanted to burst. Kirsty’s presenting problem on admission was right-sided abdominal pain and looses stools, and was diagnosed as an exacerbation (flare up) of Crohn’s Disease.
Metcalf (2002) states that Crohn’s disease is a chronic inflammatory condition, which can affect the functions of the gastrointestinal system, from mouth to anus and presents with acute exacerbations (flare ups) and then followed by remissions where patients often feel well. The symptoms of Crohn’s disease vary according to the location extent and severity of the condition, however the most common are diarrhoea, abdominal pain, rectal bleeding, anorexia and weight loss (Metcalf, 2002).
Following Kirsty’s initial assessment on admission certain problems were identified and her care plan was initiated. Kirsty’s identified problems were sleep, nutrition, abdominal pain, and loose stools. Due to the word constraints of the care study, pain and nutrition will be discussed. The agreed goal for Kirsty’s problem of nutrition was to ensure adequate dietary and fluid intake and this was to be achieved by referring Kirsty to the dietician and offering Kirsty small, appetising meals and monitor dietary intake. The agreed goal for Kirsty’s problem of pain was to maintain comfort and monitor and this was to be achieved by monitoring occurrence and severity of her pain, offering analgesia as prescribed (0.5 – 1gramme of paracetomol every four to six hours) and monitor blood pressure, temperature, pulse and respirations every four hours.
McCaffery (1989 cited by Cunningham, 2001) states “pain is what the patients says it is and exists when the patient says it does”. In order maintain Kirsty’s comfort and monitor her pain it was important for the nurses to effectively assess Kirsty’s pain. Lawler (1997) maintains that good communication skills are important in assessing pain in patients. Cunningham (2001) advocates the use of a questioning technique. The patient should be asked where the pain is (remembering that the patient may have more than one site of pain or type of pain), is it there all of the time, what does it feel like, does anything ease or worsen the pain, does it radiate to other parts of the body, and how severe is it? Alongside this the nurse must observe the patient’s non-verbal communication and be aware of his or her own (Cunningham, 2001).
On the ward there is very little in the way of pain assessment. Paracetomol was offered on the drug rounds and unless Kirsty informed a nurse of her pain very little was in the way of assessment and monitoring. There are a variety of tools available that nurses can use with their communication skills in order to effectively assess pain (Lawler, 1997). The hospital trust where Kirsty was admitted had brought in a new ‘TPR/BP Assessment and Observation Chart’ to replace the old one that was used for all patients. The new chart was introduced to comply with The National Audit Commission Report “Anaesthesia under Examination” (1997) and the Working Party of the Commission on the Surgical Services “Pain after surgery” (1990) recommendations that acute pain experienced by patients in hospitals should be regularly assessed.
The new chart has three new parts that the nurse should assess and record onto the chart along with Temperature, pulse and respiration and blood pressure. One of the new parts is a pain score. The nurse should ask the patient if they have any pain, and is it at rest and/or on movement and should check the scores after pain relief has been administered and observe any side effects. The scoring system on the chart is on a scale of 0-3: 0 being no pain; 1 being mild (no pain at rest but mild pain on movement); 2 is moderate (intermittent pain at rest, moderate pain on movement); and 3 severe (continuous pain at rest, severe pain on movement). If the chart was used as it was intended, Kirsty’s occurrence and severity of pain and the effects of analgesia could be monitored and assessed four hourly (or as necessary) more effectively.
Kirsty’s pain was caused by underlying causes, due to Crohn’s disease. The underlying inflammation was treated with intravenous hydrocortisone. Hydrocortisone is an anti-inflammatory and was prescribed to reduce the inflammation. McNally (1996, cited in Metcalf, 2002) states that initial doses of hydrocortisone should be forty to sixty grammes a day, Kirsty was on forty. Shepherd (2000, cited in Metcalf, 2002) asserts that once remission has been achieved doses are reduced and then withdrawn. Once Kirsty went into remission her dose were reduced and withdrawn.
Kirsty’s second identified problem was nutritional intake.Cortis (1997, cited by Harris and Bond, 2002) advocates that nutrition is a vital part of nursing care. Nutritional assessment according to Harris and Bond (2002) should be integrated with the overall nursing assessment and the plan of care and implemented and evaluated and involves identifying and evaluating patient’s nutritional status using assessable techniques to quantify any impairment or risk, such as food record charts and risk assessment scores. Pullen (1999) argues that patient’s with Crohn’s disease can eat a normal diet without increasing pain or loose stools, unless the patient has fistulas, strictures or abscesses, in which case complications can occur. Pullen (1999) also argues that fats should be encouraged as fat gives flavour and can stimulate the taste buds and increase appetite. Part of Kirsty’s plan of care for nutrition was to monitor dietary intake, therefore the use of food record charts was implemented. Because Kirsty wished to be actively involved in her nursing care, Kirsty filled in the food record charts each time she had something to eat or drink.
Freeman (2002) explains that food record charts can form the foundation of nutritional assessment and help to identify future treatment plans and argues that food record charts can be useful tools in the assessment of patient’s nutritional intake. The aim of food record charts according to Freeman (2002) is to record the quantities of all the patient’s food and drink intake as accurately as possible and are useful in patient’s who for example have a Body Mass Index (BMI) below normal (20-25), have a history of recent unintentional weight loss, a poor or no appetite or physical problems (for example swallowing difficulties). Freeman (2002) states that although food record charts can be useful it is difficult to assess patient’s nutritional intake precisely and the reliability of what has been consumed and not consumed can also cause inaccuracies.
Freeman, (2002) argues that food record charts can be included in the plan of care and used alongside clinical judgment and Nutritional Risk Assessment Tools. Freeman (2002) also states that there are various screening tools available and are used in a range of settings. The risk score used on the ward is called the Lee Nutritional Risk Score and is very similar to the British Association for Parenteral and Enteral Nutrition (BAPEN) Tool (Sizer, 1996, cited in Harris and Bond, 2002). Kirsty’s nutritional score on admission was eight, which is satisfactory. However, when the dietician assessed Kirsty it was recommended that Kirsty should be encouraged to drink supplement drinks and complete the food record charts until her appetite returned to normal.
On the ward the patient care plans are updated and evaluated on a daily basis. When this was undertaken, Kirsty was consulted. She would be asked how she was, frequency and severity of her pain and loose stools, was her appetite improving, and so on, and the care plan was amended accordingly. Kirsty’s had a stool chart that she completed, in addition to her food record chart and TPR/BP Assessment and Observation chart and these were examined whilst updating her care plan. The stool chart documented the date, time, amount, consistency, colour, and odour, and whether there was any blood or mucous present, therefore the consistency and frequency of her stools could be monitored and assessed. Kirsty’s condition did improve during her stay on the ward. Her abdominal pain subsided, her loose stools started to form, her appetite improved and she began to sleep better. Kirsty’s condition was managed and she was in remission. Kirsty was discharged home after ten days on the ward.
Upon reflection the nursing care Kirsty received was very good. The staff was fully committed to her. The model of care used on the (activities of living) worked fairly well for Kirsty. However, I do not feel it is a holistic model of care and focuses largely on the biomedical model of health (Archibald, 2000). The primary nursing framework also worked well for Kirsty. Primary nursing is a positive approach to care as it is patient-centred, provides continuity of care and encourages patient and family participation (Mead, 1991, cited in Walsh, 1997). There are arguments (Ford and Walsh, 1994, cited in Walsh, 1997) that primary nursing is an empowering framework, for nurses and patients alike and is a transforming idea and there are arguments (Walsh, 1997) that nurses cannot be held responsible for care because they have insufficient power and influence in the health care system and deemed as a fashionable trend. Another framework may be implemented, such as team nursing. Team nursing involves a team of nurses who are responsible for the delivery of patient care to a group of patients and each team has an experienced qualified nurse as a team leader and patients are assigned to a team throughout their stay in hospital (Walsh, 1997). Within this framework, however it is still possible for divided, task-orientated care to happen (Walsh, 1997) therefore primary nursing is much more holistic, patient-centred framework for Kirsty (Mead, 1991, cited in Walsh, 1997).
The ward philosophy of care is very patient-centred and this reflects in the practice of all of the staff on the ward. They involve the patient and family in assessing, planning, implementing and evaluating care, they ensure honest and open communication with the patient and their family and educate patients and respect their hopes and limitations. The overall care Kirsty received was good. Good relationships were built up between Kirsty and the primary nurse and the associate nurses and myself. Kirsty was admired for her ability to live with this illness. Body image can be altered whilst living with Crohn’s disease, lack of body control and feeling dirty, having to use public toilets with explosive and noisy diarrhoea, physical appearance and so on (Metcalf, 2002). Kirsty always tried to put a brave face on despite the difficulties she faced.
Kirsty’s identified problem of nutrition was managed and achieved well by the nursing staff. Nutrition is a vital part of nursing care, whoever the patient as so many patient’s leave hospital malnourished (Malnutrition Advisory Group, 2000, cited by Harris and Bond, 2002) and is even more important for Kirsty as malnourishment is a problem for patients with Crohn’s Disease (Pullen, 1999). The implementation of food record charts and risk assessment scores for Kirsty was based on practice (Freeman, 2002). Kirsty’s appetite had improved during her time on the ward.
Kirsty’s second problem of pain could have been assessed better. The use of a pain assessment tool alongside good communication skills and clinical judgement would have been better for Kirsty (Lawler, 1997). When Kirsty’s blood pressure and temperature, pulse and respirations were taken an effective pain assessment should have been undertaken and recorded in order to effectively monitor occurrence and severity of Kirsty’s pain. However, Kirsty and her mother appeared to be happy with the nursing care Kirsty received. Kirsty was also pleased that she was chosen for the purposes of this care study. The primary nursing framework, the ward philosophy and the commitment of the nursing staff all contributes to effective care delivery and a positive learning environment for staff and patients. The nursing staff are fully committed to and strive for individualised, holistic patient-centred care, but like any other ward, short staffing levels can sometimes hinder this.
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