The assessment task for this module requires you to write about a client/patient in whose care you have participated during a period in hospital.
Contents
Assessment Task 2
Appendix I 14
Appendix II 15
References 16
Bibliography 16
Assessment Task
The assessment task for this module requires you to write about a client/patient in whose care you have participated during a period in hospital. It must focus on the client/patient's lived experience of the altered health status that preceded their admission to hospital as well as discussing the role of the registered nurse in meeting some or all of their health needs in an acute care setting.
Submission Date - 28th February 2005
The Ward and Trust will not be mentioned by name in accordance with the NMC Code of Professional Conduct (2002).
The client that will be named in this assignment has been given a pseudonym Paula Money, to protect her identity in accordance with the section 5 of the NMC Code of Professional Conduct (2002).
This assignment will focus on a chronic illness and the patient/clients lived experience of this. The Roper, Logan and Tierney's model will be used to discuss the health needs of the client as it identifies and groups nursing activities in relation to the process of living (Roper et al 2001).
The patient observed for this study had chronic obstructive pulmonary disease (COPD). It is the term used to describe conditions such as emphysema, chronic bronchitis, chronic airway obstruction, and irreversible asthma. (Unison Healthcare, 2003) The causes of this disease can be exposure to industrial pollutants or inherited genes, but is most common in those that smoke or have a past history of smoking. The disease results in debilitating breathlessness, decreased exercise tolerance, poor nutritional intake and often-social isolation. It is characterised by exacerbation's that can be triggered by viruses, atmospheric pollutants, and air temperature. The most important help, which patients with COPD who smoke can receive from nurses, is how to give up smoking. (NICE 2004)
The patient, Paula Money, is a 63-year-old lady who had been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) 10 years ago. She has had several hospitalisations and has been admitted this time with exacerbation and end stage COPD and will remain in hospital until this acute attack passes, for approximately 10 to 14 days. She has been diagnosed as terminal and it has now been agreed with her and her family that she will not be resuscitated if she were to have a cardiac or respiratory arrest during her stay in hospital.
Paula worked all her working life in the public house trade. She had become a smoker at the age of 16 and had continued to smoke around 10 to 15 cigarettes a day. These are measured in pack years as 27. Bourke (1998) states that the total dose of tobacco inhaled is important to establish pack years.
Her exercise tolerance had reduced gradually over time, and now she was only able to walk 15 metres before becoming breathless and was just able to get dressed in the morning.
Paula had always been fairly fit and healthy and never suffered with any major health problems until a period of illness led to her being diagnosed with COPD caused by her long term smoking. Smoking is the single greatest cause of preventable illness and premature death in the UK and is responsible for 23 per cent of all male deaths and 12 per cent of all female deaths. (Health Development Agency (HDA) 2004).
Paula is divorced with 3 grown up children, and her health has now deteriorated to the point where she is housebound and unable to work. Her children have now become her full time carers.
Eleven years ago Paula had been suffering with recurrent colds and coughs and initially put it down to 'over-doing' it. The cough got progressively more productive and chronic and she consulted her GP who prescribed antibiotics. As these did not clear the cough up a further course of antibiotics was prescribed. Again, these did not work but at that stage she decided that the cough would eventually go on its own and proceeded to carry on with her daily living. Her exercise tolerance at this stage was reduced to around 50 metres before she was breathless and requiring a rest.
There was no marked change in her condition for about 8 or 9 months until she woke one morning feeling very lethargic, breathless, and unable to get out of bed. Her breathing had become very shallow and she felt that she was unable to 'catch her breath'. She called her GP who arranged an ambulance to take her into hospital.
Paula was admitted and put on oxygen. This worried her as, up until that point, she had thought she had just had a flu type virus, which she could not get rid of.
She was asked whether she smoked, which she confirmed, and was then told, before any investigation, that it was thought to be COPD - or Emphysema as it was called then.
She remained in hospital for 10 days while the hospital undertook a series of tests, which included: Serial domiciliary peakflow measurements - to exclude asthma; CT scan of the thorax- to investigate symptoms that seem disproportionate to the spirometric impairment; Echocardiogram (ECG) - To assess cardiac status if features of cor pulmonale; Pulse oximetry - To assess need for oxygen therapy; Sputum culture - To identify organisms if sputum is persistently present and purulent.
The diagnosis was confirmed as COPD. Paula was prescribed a short course of high strength corticosteroids and was also prescribed bronchodilator inhalers, which ...
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She remained in hospital for 10 days while the hospital undertook a series of tests, which included: Serial domiciliary peakflow measurements - to exclude asthma; CT scan of the thorax- to investigate symptoms that seem disproportionate to the spirometric impairment; Echocardiogram (ECG) - To assess cardiac status if features of cor pulmonale; Pulse oximetry - To assess need for oxygen therapy; Sputum culture - To identify organisms if sputum is persistently present and purulent.
The diagnosis was confirmed as COPD. Paula was prescribed a short course of high strength corticosteroids and was also prescribed bronchodilator inhalers, which she was advised she would need to take when her shortness of breath became a problem. Paula was also advised to keep a food diary and to keep a note of everything that she ate so that this could be monitored at her outpatient's appointment a fortnight later. The diary would help to identify any dietary changes needed and would help the dietician to establish a diet based around foods that Paula enjoyed.
Following her discharge from hospital Paula gave up smoking with help from the smoking cessation nurse and she continues to remain a non-smoker. She sold her public house with the intention of finding other less strenuous work in a healthier environment but before she managed to get the chance to look for another job was again hospitalised. She said that she still wanted to work again as she had always been an active, busy person and had felt apprehensive at having to give the pub up to find a new career. Due to her deteriorating health and subsequent hospitalisations however Paula has not worked since.
Paula has been admitted to hospital 4 times since the original diagnosis. With the deteriorating nature of COPD it is expected that the number of Paula's admissions will generally increase in frequency as her condition deteriorates. Acute exacerbations of chronic obstructive pulmonary disease (COPD) are one of the most common causes of hospital admission for respiratory problems in the UK (Roberts et al 2001).
The initial admission to hospital ensured that Paula was diagnosed properly and was given the right drugs and support to help her continue with her daily living as independently as she was prior to diagnosis.
Her second admission was an acute exacerbation and at this point tests were done to establish whether further complications such as pneumonia had taken hold. The results indicated that she had got an acute chest infection and this was treated with strong antibiotics. Paula was prescribed with a short course of Prednisolone (a corticosteroid) to speed up the recovery time of her infection and further steroidal inhalers and modified release tablets to help with her breathing. On discharge, as she was mobilising more slowly and with increased shortness of breath, Paula was prescribed with home oxygen. The physiotherapists also provided her with a frame, which allowed her to mobilise more easily around her house.
At this time Paula was becoming more dependent on her family and was beginning to feel socially isolated and depressed. It was increasingly more difficult for her to visit her friends or do the activities she used to enjoy like walking holidays and nights out with friends in bars (due to the smoky atmosphere). She accepted the disease as now part of her, but felt angry and resented that it had stopped her doing the things that she once took for granted.
Paula's third admission was as an emergency case after she collapsed at home with breathing problems. She had been becoming progressively more tired and breathless with any exertion and, to try to help this, she had been increasing her use of home oxygen. With her increased tiredness she had found it more difficult to eat and she had begun to lose weight. She was advised that she would need O2 therapy 24 hours a day and that she would need more assistance with daily living, including help with getting up in the morning, with cooking and with cleaning. These were organised through social services while she was staying in hospital.
Her children had opted to become full time carers and set up a rota for her care prior to discharge and worked with social services to ensure everything was covered. A supply of oxygen was ordered and installed for Paula at home. Paula had felt particularly emotional before this with the increasing care needed for her to survive. She said she felt that she should not have to rely so heavily on her children. That it was not fair for them to have to go through the illness with her as they should be living their own lives.
Paula managed with the increased package of care from social services and her children for a few months before the current admission, when she was hospitalised due to dramatic weight loss and fatigue.
On this admission Paula's health was assessed holistically using Roper, Logan and Tierney's 12 Activities of Daily Living. Two of these activities have been further developed to discuss the nurse's role in enabling the patient to fulfil their life whilst they remain in hospital. See Appendix II for current admission details.
Health need 1: Mobility
As part of the holistic health assessment, nurses should ask their patients questions about the amount, type and frequency of the exercise they undertake.
With a good understanding of the specific benefits for conditions they can then make recommendations for lifestyle changes that are relevant to the patients in their care.
Prior to the current hospitalisation Paula said that she had been finding it increasingly difficult, because of her chronic breathlessness, to get around her house, even with the aid of her zimmer frame, and that the O2 masks and connections got in the way and also restricted her movement. Paula managed to exercise minimally and had resorted to exercising in the chair at home. The exercises had been given to her on a previous admission to hospital by the physiotherapists and, although they were aimed at increasing mobility, were still suitable for Paula's needs. They involved chest expansion exercises and stretching muscles that would otherwise become weak. She was reassured that this would be a benefit to her and the physiotherapists input would then begin the process of rehabilitation and to build her confidence.
In hospital Paula was attached to oxygen 24 hours a day and had regular nebulisers to loosen the mucus for her then to expectorate.
Paula felt dependent on the oxygen and became anxious when the mask was taken off for her to wash or get out of bed. This resulted in her having panic attacks /dyspnoea which then increased her requirement for oxygen to help overcome the symptoms of the attacks. Kozier et al (2000) explains that slow rhythmic breathing allows the patient to relax.
The nurse asked Paula to picture a peaceful scene whilst inhaling through the nose over a count of four and then exhaling through the mouth until the breathing was controlled, explaining that this was a good relaxation technique for her, to help with her breathing.
When the acute phase of her chest infection was over, Paula felt more comfortable leaving the mask off for longer periods of time and in coping with nasal speculum.
During the weeks that Paula was in hospital it was observed and documented in the nursing care plan that she was becoming less able to do things for herself. She complained of shortness of breath on any exertion, and washing and dressing was becoming almost impossible to do without causing her acute shortness of breath. She had started to become withdrawn and less willing to help herself with washing and getting dressed in the mornings. Her willingness to get out of bed was decreasing and because of this her mobility was suffering due to the muscle wastage with her lack of movement. Paula's confidence in her ability to move was now becoming worse and this lack of confidence increased her anxiety levels when movement was required in washing, dressing and toiletting.
The Registered Nurse talked with Paula about her decreasing mobility and tried to encourage and motivate her to get up. Paula said that everything was such hard work for her that she didn't feel like doing anything at all. She declined offers made to her about speaking to the counsellors, available to patients, about her depressed state of mind but she did however explain to her medical team about how she felt. As a result following this, a decision was made to treat her for a short period with anti-depressants. Gift and McCrone (2000) talk about anxiety and depression as being almost always present in end-stage disease and can effectively be treated with anti depressants.
The Registered Nurse also asked for some Physiotherapy input in her care to help with Paula's mobility. She was, initially, not able to get out of bed easily even with the physiotherapist help. Because of this Paula was given restricted physiotherapy, which consisted of daily chest physiotherapy for the expectoration of sputum from the bronchi to help her to breathe deeper.
Within 7 days of the anti depressants being prescribed, and with the daily physiotherapy, Paula was becoming more willing to do things for herself again. Although acutely short of breath, she was able to sit herself up in bed and eat small amounts at mealtimes, continuing with her own physiotherapy exercises.
When she started to recover from the acute chest infection Paula became keener to get up. She began asking for help to walk to use the toilet and shower in the mornings and was able to become more independent with her personal hygiene and eating. Edmund (2002) implies people can gain confidence and improve their activity levels, often enabling a return to former hobbies and interests.
The Registered nurse was encouraging her independence and ensured that only minimal input was given and only when asked. Collins Concise Dictionary (1989) defines independence as freedom from control in action or not being dependent on anything for function
Paula was on multiple tablets for the disease. These were mostly steroidal based, but some were to ensure the reduction of fluid retention that could exacerbate the symptoms of COPD.
These drugs have varying side effects including weight gain, nausea, depression, and insomnia (BNF 2004) but without them Paula's ability to mobilise would be decreased further.
Health need 2: Nutrition
For a period prior to hospitalisation this time Paula had cooked with the help of her carers and had a varied diet and ate healthily, consuming plenty of slow release energy foods to maintain her throughout the day and to maintain her weight.
However, her increasing lack of mobility and tiredness and shortness of breath contributed to her reduced interest in and difficulty with eating and preparing food resulting in her losing weight.
Paula was admitted to hospital with a dramatic weight loss. On her admission she weighed approximately 60 KGs. She was extremely lethargic and had been predominantly been sleeping since arriving on the ward. She had little or no interest in eating and drinking and was becoming more malnourished. Within 10 days she had lost a further 2KGs due to her deteriorating condition.
The dramatic decrease in Paula's weight was a sign that her COPD was in its final stages (Edmund 2002). The weight loss made her weaker and less able to cope with the breathlessness, which occurred with any exertion, and this decreased her ability to mobilise.
The Registered Nurse reassessing Paula noted that her dietary intake was becoming increasingly poor, as, with Paula's decreased ability to chew and swallow, she was unable to absorb any nutrients from her food. She spoke with Paula about how she was feeling and why she no longer wanted to eat. Paula talked about food as though it was an enemy, she said that it had become very difficult for her to chew and swallow without her breathing becoming laboured.
The role of the registered nurse in this situation is to monitor all input and output over a rolling 24hour period so that a good knowledge and understanding of what is causing the prolonging of the condition is found.
In Paula's case, as she was depressed, and fatigued, she had become de-motivated to eat and unable to look after herself.
The registered nurse's role is to ensure that an increase in nutrition and balanced diet while in hospital was commenced and that her weight was monitored closely. It would also be necessary, as Paula was classed as end-stage COPD, for her to have a close liaison with the dieticians.
Where a patient is unable to maintain their own weight they need high protein, high calorie intake with food and fluid charts set up to monitor input and output of the patient and build up drinks offered in between meals to maintain calorie intake.
Many dieticians recommend that COPD patients limit carbohydrate intake to about 150 to 200 grams per day. Eating food high in carbohydrates produces carbon dioxide when the food is metabolised.
The nurse spoke to the dietician who was linked to the ward and, with the dietician's advice, a pureed diet was commenced which Paula could drink. When Paula's weight became more stable and her ability to eat had improved this was then adapted to a soft food diet.
In addition to her other difficulties with eating, Paula said that she didn't like to eat very much in case it made her constipated as this again made her breathing difficult.
The Registered Nurse reached was able to reach agreement, using concordance, by negotiating with Paula, so that she respected her wishes and beliefs, but also ensured that adequate nutritional intake was achieved. Concordance assures the patient of a proactive role in treatment decisions.
Increasing fibre in the diet improves bowel motility. If the patient becomes constipated this puts added pressure on breathing due to straining and therefore increases anxiety about eating.
Through talking to Paula about her diet, and with the advice from both the medical team and the dietician, senna and lactulose were prescribed to alleviate her fear of constipation and also to allow the nurses to monitor input/output (Mallett and Dougherty 2000).
Parenteral feeding was an option that was also discussed as part of the multi-disciplinary team. Paiva (2000) states the aim of this support would be to achieve weight gain, and to improve lung and respiratory muscle function enabling a faster recovery from the acute exacerbation. But, as an invasive procedure, it was decided that this would only be done as a last resort, as Paula was still able to eat small amounts.
This essay has discussed the clients lived experience of a chronic disease. The development from an initial irritating cough, 11 years ago, which could not be cleared, and which was coped with in a busy life style. Through the gradual increase in breathlessness and increasing frequency of hospitalisation to stabilise the condition so that Paula was able to continue with her activities of daily living. Paula's lifestyle has been discussed holistically and her health needs identified and related to the nursing role and to how the registered nurse could meet those needs.
Appendix I
* 63 year old lady, divorced with 3 children
* Worked as a Public House Trade all her life
* Diagnosed 10yrs ago when hospitalised for the first time
o Gave up smoking (10 to 15 per day)
o Put pub on market and sold 18months later to get away from smoky atmosphere
* 5 years ago hospitalised again and discharged with better mobility with frame
o On O2 when discharged, increased steroids
* 3 years ago moved to a bungalow as stairs in the house were becoming too much to cope with
o Stopped working altogether and living solely on profit from the sale of the pub and house and benefits from the government
* 1 year ago hospitalised again and now on fulltime O2 with further decreased mobility due to the increased shortness of breath on any exertion.
o Family now full time carers
* Recent history of dramatic weight loss, decreased appetite, loss of mobility of more than a couple of steps with the frame and now hospitalised and diagnosed with end stage COPD, DNAR completed and agreed by both the patient and her family
Appendix II
PMH
Smoker 40+ Yrs 10-15 per day - ceased 10yrs ago
Diagnosed COPD 10 yrs ago
# L Ulna 30yrs ago
Presenting
Increased SOB
Restless
Dyspnoea
Dramatic weight loss (10 Kg 3/52)
Decreased mobility
Diagnosis
Exacerbation COPD
? Pneumothorax
Plan
Chest x-ray -? Chest drain
O2 no more than 4L (36%)
IV access
Antibiotics - Metronidazole and Ceferoxine IV qds
Nebs qds - salbutamol, Ipratropium bromide
Increase nutrition -? NG / Peg
References
Aggleton, P. H, Chalmers (2000). Nursing Models and Nursing Practice. 2nd Ed. Basingstoke: Palgrave.
BNF - 3 Respiratory System <http://www.bnf.org/bnf/bnf/current/openat/>
Bourke S, Brewis R (1998) Respiratory Medicine. Oxford, Blackwell Science
Collins Concise Dictionary (1989) Collins Concise Dictionary. London, Collins.
Edmund, C (2002) Respiratory Disease cited in Alexander, M et al (2002) Nursing Practice Hospital and Home. 2nd Ed. Edinburgh: Elsevier Science Limited.
Gift AG, McCrone SH (1993) Depression in patients with COPD. Heart and Lung. 22, 4, 289-297.
Health Development Agency (2004) The Smoking Epidemic in England. London, HDA.
Lorig K et al (2000) Living a Healthy Life with Chronic Conditions. London, Bull Publishing Company.
Mallett, J. L, Dougherty (Eds) (2000) Manual of Clinical Nursing Procedures. 5th Ed. Oxford: Blackwell Publishing Company.
Paiva S.A.R.; Campana A.O.; Godoy I. (2000). Nutrition Support for the Patient with Chronic Obstructive Pulmonary Disease. Nutrition in Clinical Care, February 2000, vol. 3, no. 1, pp. 44-50(7) Publisher: Blackwell Publishing
http://www.ics.ac.uk/publications_menu/PNguidelines%20in%20ICU%20final%202004.pdf February 2005.
Roper, N et al (1980) The Elements of Nursing. London: Churchill Livingstone
Unison Healthcare, 2003
Bibliography
Aggleton, P. H, Chalmers (2000). Nursing Models and Nursing Practice. 2nd Ed. Basingstoke: Palgrave.
Barnum, B (1998) Nursing Theory: Analysis, Application, Evaluation. 5th Ed. Philadelphia: Lippincott-Raven Publishers.
Edmund, C (2002) Respiratory Disease cited in Alexander, M et al (2002) Nursing Practice Hospital and Home. 2nd Ed. Edinburgh: Elsevier Science Limited.
Heath, H (Eds) (1995) Foundations in Nursing Theory and Practice. London: Times Mirror International Publishers Limited.
Mallett, J. L, Dougherty (Eds) (2000) Manual of Clinical Nursing Procedures. 5th Ed. Oxford: Blackwell Publishing Company
Niven, N (1994). Health Psychology: An Introduction for Nurses and Other Health Care Professionals. 2nd Ed. London: Churchill Livingstone
Emma Fovargue
PRDN Adult Nursing September 2003
Medical/Surgical Assignment NJ203
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