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 Mary based on documents which made her personal file.
Both myself and my mentor introduced ourselves to Mary who was sitting at her bed
side in a cubicle. In an attempt to establish a therapeutic relationship with my client I
firstly orientated her with new surroundings such as visiting times, lounge, dining
areas. Involvement and relationship with another is both necessary for the enactment
of orientation and development of the therapeutic relationship (Glasser, 1965, cited by
Perry et al, 1991). Using an informal manner I went through each part of the
assessment. I used skills in 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. 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 has recently been introduced.
DoH (2002a) states that “single assessment will provide better and more efficient
access to cares services. It will minimise 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 individualised data, it then must be interpreted. The needs
identified were specifically related to mobility and pain, both of which affect 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.
CARE PLANNING
This stage of the nursing process is to develop a plan of care and determine what
approach should be used to help with identified problems. During the planning phase,
the nurse applies the skill of problem solving and decision making. Setting priorities,
writing goals and planning nursing actions also make up this phase (Atkinson et al,
1983). The ward held a care plan file, which held care plans for a range of different
problems. These could be used as a guide and had to be individualised relating to each
specific client and their needs. On reflection, I felt this was a good idea, particularly
for myself as a student to refer to, however it could present an opportunity for care
plans to become less individualised should they be used incorrectly, which
consequently, could have an adverse effect and defeat its objective. Archibald (2000)
explains that Nursing models have been used to provide systematic care delivery
stemming from a desire to organise care coherently, enabling the plan of care to be
used and continued by others. He goes on to suggest that since the introduction of
models, nursing practice has become more patient centred and holistic. Daws (1998)
agrees that the nursing care plans play a vital role in promoting a holistic and
individualised approach to care delivery and providing an essential tool for
documenting needs and preferences. With reference to Mary, goals were set to
increase mobility, increase confidence in mobilising and to reduce pain caused by
osteoarthritis. Due to the nature of this ward care plans usually determine discharge
outcomes. Targets are set for a maximum rehabilitation period of 28 days. Reasons for
this are due to the fact that patients are not acutely ill and need very little medical
attention. Instead, they have a great deal of input from physiotherapists, occupational
therapists who work closely with clients both individually and in small groups.
Newton (1996 p.29) states “Goals of Nursing care must be realistic and achievable
and reflect the patients goals for living, so they must be set in close partnership with
the patient and based on assessment of the individuals AL’s and on the nursing
knowledge associated with them”. The care plan is initially implemented by nursing
staff who will also take into account client centred outcomes. The easy care (single
assessment) document allows the client to say what they would like to achieve. All
key players will acknowledge care plans at some point, therefore they must have easy
access to the information they need, laws and standards mandate that care plans be
specific, clear and legible (Alfaro-LeFevre, 1998). In order to keep Mary involved in
her care, goals were agreed with her. This is to ensure patient autonomy but also to
give Mary a clear picture of what will be expected of her during her rehabilitation
period. It was established that the goal set for pain was highly prioritised and so
analgesia was reviewed by a doctor. This ensured Mary could proceed concentrating
on client centred outcomes.
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” . Hand over
was a good source of information used in order to find whether the care being given is
right for the patient. The ward used 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. Sometimes nurses do not have enough time to read charts and look up
common problems during their shift. When you have time to prepare for the shift, you
feel more confident, more competent and can begin giving care in a timely fashion
(Alfero-LeFevre, 1998). With reference to Mary care was continued to be monitored
and assessed, this mostly happened via handovers but also from every patient
encounter. I would see this as an opportunity to assess both physical and mental
health, I found that myself as a student could make a valuable contribution to the care
being given. All care was documented and signed and Mary’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 Mary and her family. DoH highlights this within the essence of care
document (benchmarks for record keeping) (2001, p.3) stating that “patients are able
to access all their current records if and when they choose to in a format that meets
their needs”. It is safe to say that the stages in the nursing process are not in complete
isolation from each other, 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.
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. 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. Mary was kept updated of this information
which can only be implemented on her consent.
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. In Mary’s case this was her care plans.
Therefore the questions would be asked: Is the client in pain? How well does the
client mobilise? Is the client confident in mobilising alone? This phase also involved
re-assessing Mary in relation to AL’s, and so by using the Roper, Logan and Tierney
(1996) model, a staff nurse updated this information by explaining the process to my
client and asking her views on each topic relating to AL’s. Tierney (1998) suggests
that this particular model is positively balanced, and has been one of the most popular
in the United Kingdom". Wimpenny (2001) agrees stating "It is certainly the best
known and most widely used model in this country“. Generally the model had worked
well as a basis for Mary’s care planning, and proved in the evaluation stage that
progress was made and the model was excellent in relation to most physical and social
aspects of care. It was documented and handed over that my client had appeared to
have progressed in all that was set. Newton (1991, p.181) confirms this by stating
“Value is also placed on observablee behaviour as an indication of the need for
nursing and the basis of evaluation of the effects of nursing”. On reflection, I found
that the care plans were maintained well. The intervention of therapy staff and their
role in meeting the specific goals was a key factor in Mary’s progression. At this point
and in order to encourage a timely discharge my client and her family were informed
of a home visit. This would prove to the MDT whether her progression in hospital
reflected on her own living environment, therefore determining an expected discharge
date and which services/equipment if any are needed to ensure the discharge is safe.
Archibald (2000) believes evaluation should take place in collaboration with the
patient and family. This happened on the unit via progress reports or case conference
which were organised by members of the MDT in a private setting and family were
welcomed to be involved on consent of the client. 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 and the only risks identified were eliviated by equipment provided by
occupational therapy. After a discharge date was set the nurse made appropriate
arrangements for transport via an ambulance and liaised with a family member in
order ensure a safe arrival at home.
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 individualised care plan.
To care for a person holistically requires ongoing assessments – utilizing knowledge,
attitudes and skills. Improving assessments and patient involvement in care is
highlighted in the essence of care document (DoH, 2001b). The fact that the MDT
were based within the same unit allowed a more timely advantage for both patient and
staff , allowed maximum communication to all concerned and worked well in relation
to discharge planning. 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. Mary 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 utilising it appropriately in order to care for the client
in a holistic way.
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