“Conducting an assessment provides an opportunity to involve patients in their own care, to develop nurse/patient rapport, to establish the normal life pattern of the individual and to create a document which is not only available for all to see but which can provide a foundation for a plan of care” (Basford and Slevin, p.508)
The starting point for the Roper, Logan and Tierney model of nursing lies in the hierarchy of human needs identified by the psychologist Abraham Maslow (1954). This orders human needs from the most basic needs to the most sophisticated. The basic physical needs, i.e. air, food and warmth, are seen as fundamental because, if they are not met, there will be no motivation to meet higher-order needs (Faulkner 2000). The twelve activities of daily living used in the Roper, Logan and Tierney model are based on these human most basic needs for survival.
On being asked to assess Peter I spent some time reading through the past assessment which was carried out when he was previously admitted to the ward for a sigmoidoscopy. I spoke to the sister in charge who had very good knowledge of the patient and told me about his past history and gave me his past medical documentation. This prepared me for my patient and helped me to gather some of the subjective and objective data prior to the patient’s assessment interview. It also allowed me to ask questions about the surgical procedure that the patient had been elected for, which in turn helped me to relay any advice to my client. The information on the past medical documentation indicated to me that Peter would have no trouble understanding the assessment/pre operation interview and would have a reasonable understanding of the procedure due to his intellectual background. If little or no information was known of the patient’s socio-economic and ethnic background, the nurse would have to assess the patient’s ability to understand whilst carrying out the interview and adjust accordingly. For example, if the nurse detects a language barrier, or the patient is finding it hard to hear, she can then adapt communication suitably, by speaking slowly and clearly avoiding medical terms and jargon (McCann. J, 2002).
The information was then confirmed by the patient during assessment on admission.
On approaching Peter, I noticed that he looked slightly older than I had expected for his age, he also looked under nourished and had a pale complexion. When I first met Peter he was sitting on the edge of his bed, looking tense and nervous, waiting for someone to greet him. Patient assessment begins when the nurse meets a patient or client for the first time using visual observations and information gathered from your senses such as sight, hearing, touch and smell (Hinchliff, Norman and Schober, 2003).
Firstly I wanted to put him at ease as I could see from his body language that he was very tense and needed reassurance. I approached him smiling and introduced myself to him, explaining that I was a student nurse and that I would be a part of his care team under the supervision of the sister in charge during his stay. I then helped to orientate him to the ward by showing Peter where the facilities were, such as the bathroom, toilets, dayroom and nurses station. I also showed him his locker, how to work the radio and TV and the bell to call a nurse. Orientation to the ward helps to alleviate stress in patients (Faulkner 2000). I explained to Peter that I had an assessment form to fill out and would like to ask him some questions. After giving him a brief idea of how long it would take and what it entailed I proceeded to carry out the assessment with the patients permission to do so. Gaining permission from the patient or client follows the guidelines illustrated in the Nurses Code of Conduct (NMC, 2000).
I pulled the curtain around the bed to protect the patient’s privacy but taking into account that we still could be heard. Protecting the privacy and dignity of the patient is in line with the Nurses Code of Conduct (NMC, 2000). I sat in a chair alongside the bed to make it clear that I had time listen to any concerns, carry out the assessment and reassure him and answer any questions that I was capable of. During assessment I was aware of using interpersonal skills which centre on active listening and using appropriate verbal and non verbal strategies which help to facilitate the transmission of information from one person to another. These strategies include the use of touch, facial expressions, gestures and the use of open and closed questions (Basford and Slevin, 2003).
First of all Peter’s nursing assessment was updated and completed using a assessment form based on Roper, Logan and Tierney’s 12 activities of daily living (ALs). The questions on the form do not directly correspond with some of the 12 ALs; however they do cover all of their criteria. Each AL specifies a relatively distinct type of human behaviour related to meeting a particular need. Some ALs have a biological basis. Those linked to eating, drinking and breathing are like this. Others are more socially and more culturally determined: ALs relating to personal dress, cleanliness, work/play and sexuality are more of this kind (Aggleton and Chalmers, 2000). By assessing the patient on the activities of daily living it allows the nurse to inspect the data and identify the patient’s needs or problems.
A full copy of the form that this assessment has been taken from can be found in appendix two.
Social Profile
Peter is married with three daughters; he is a retired environmental health officer and lives with his wife and lives near to his family and circle of friends. He owns his own property which is a bungalow. His wife and daughter plan to care for Peter when he is discharged from hospital.
Comfort and Safety
When questioning Peter about his comfort and safety the form prompted me to ask about any allergies. Peter informed me that he is allergic to aspirin. He is suffering constantly from a dull pain in his abdomen and often feels nauseous. He is currently taking codeine to manage his pain. He has been suffering from arthritis in his left shoulder and both hands for the past few years.
Sleeping
He has a restless sleep of about 5-6 hours per night. When asking him why he had trouble sleeping he explained to me that his constant worrying, pain and nausea kept him awake.
Personal Care
All personal care is undertaken by himself. Peter told me that he wears dentures.
Communication/mood
Wife and daughter say Peter is a relaxed person but he has recently become anxious about his health and spends a lot of time worrying about how he will cope after the operation.
Mobility
When showing Peter around the ward I could see that he was fully mobile, although the pain and general weakness from the tumour has slowed him down. Peter and his wife Carol told me that they are keen gardeners and sailors. Peter explained that his arthritis and illness has slowed him down.
Elimination
Prone to constipation and pain when opening bowels – he takes Fybogel for this. No problems with micturation.
Breathing
Peter’s respiration, pulse and BP were all within normal range when taking pre-operation observations (see appendix 3 for readings). It was already noted on Peter’s previous medical history that he had been a smoker for 20 years of his life.
Learning and Understanding
Patient is aware and has knowledge of his condition. He understands the operation and the outcome of a colostomy bag.
Nutrition
Generally enjoys food and eats a balanced diet, although nausea and abdomen pains often restrict his appetite.
Fears for the Future
Peter is very anxious about how is going to cope with the colostomy bag with regards to how it is going to change his life socially, physically and psychologically. He has expressed that he is also worried about the further spread of cancer. The Stoma Specialist Nurse reported to me that he had concerns about how the stoma would affect his physical relationship with his wife.
Dependency
He is a very independent character and does not want to become reliant on his family.
The contents of this assessment were gathered from previous notes, having conversations with Peter whilst preparing him for his procedure, from his wife and daughter and the sister in charge who has cared for him previously.
Through the assessment process we have learnt that Peter will have good family support when discharged. Important medical information has been bought to my attention, such as his allergy to aspirin and that he suffers from arthritis. His worries and anxiety towards his ability to cope and how the operation will affect his relationship with his wife and others were highlighted. Information gathered during the nursing assessment process gives health professionals the ability to plan the care of the patient effectively whilst being able to identify any problems with regards to the physical, psychological or social needs of the patient (Faulkner 1996).
Assessing my patient using the Roper, Tierney and Logan nursing model with a framework has helped me to build up a picture of the client, identifying his individual needs. Although I had a role to fulfil it gave me the ideal opportunity to get to know my patient whilst collecting objective and subjective data. I found that asking questions and giving explanations gave the patient confidence and seemed to put him at ease, it also made him realise that his safety was paramount. Using these assessment tools to measure, assess and evaluate the patient it provided the health team with valuable information about the client, enabling them to deliver the most appropriate care.
References
Aggleton, P. & Chalmers, H. 2000. Nursing Models and Nursing Practice, 2nd ed. Wales: Macmillan Press.
Basford, L. & slevin, O. 2003. Theory and Practice, an integrated approach to patient care, 2nd ed. Cheltenham: Nelson Thomes
Faulkner, A. 2000. Nursing, the Reflective Approach to Adult Nursing, 2nd ed. Cheltenham: Stanley Thornes Ltd.
Heath, H. 2000. The nurse’s role in assessing an older person. Elderly Care 12(1), 23-4
Hinchcliff, S, Norman, S, & Schober, J. 2003. Nursing Practice and Health Care, 4th ed. London: Arnold Publishers.
McCann, J. 2002. Assessment Made Easy, 2nd ed. Pennsyvania: Springhouse
Maslow, A. 1968. Towards a Psychology of Being, 2nd ed. New York: Van Nostrand Reingold.
Nursing and Midwifery Council. 2002. Code of Professional Conduct. London
Pearson, A, Vaughan, B & Fitzgerald, M. 2000. Nursing Models for Practice, 2nd ed. Oxford: Butterworth-Heinemann.
Roper, N., Logan, W. & Tierney, A. 1986. Learning to use the Process of Nursing, Edinburgh: Churchill Livingstone.
Walsh, M. 1998. Models and Critical Pathways in Clinical Nursing, Conceptual Frameworks for Care Planning, 2nd ed. London: Bailliere Tindall.
Patient Profile
Peter is 66 years old and has recently retired. He has worked locally for the past 20 years as an environmental health officer. Peter has 3 daughters and seven grandchildren. Peter and his wife have a good social life and are members of the rotary and sailing clubs, in which they like to take part in many social activities.
They live in a 3 bedroom bungalow, which backs onto the seafront, they take pride in their home, enjoying DIY and gardening, although they have recently employed a gardener to help with some of the heavier labour.
Peter’s GP had referred him for a bowel investigation at his local hospital after he found blood in his stools and described symptoms of abdominal pain, constipation, nausea and vomiting. Peter was then diagnosed with bowel cancer following a flexible sigmoidoscopy investigation at the hospital he was referred to.
Peter has suffered from arthiritis in his in his left shoulder and both hands for the past few years. He takes a non-steroidal anti-inflammatory medication to help alleviate the problem. Peter is allergic to aspirin. He is currently taking codeine to manage his abdominal pain. Peter smoked for twenty years of his life but has given up recently after attending a NHS run ‘Stop Smoking’ course.
Peter has been elected for bowel surgery following the diagnosis of a cancerous tumour. The operation will result in the patient having a part of his bowel removed after which the patient will require a colostomy bag for the elimination of faeces
Peter is worried about the cancer spreading further and is anxious to get the operation over and done with. He also has fears for the future on his relationship, social and physical.
Plans for care will include several visits from the stoma nurse to help Peter to cope with his stoma bag. It is also recommended that he sees a physiotherapist to ensure that he is able to carry out his own personal care independently, given that he suffers from arthritis.
