Assessment and Care Planning for the Adult in Hospital. This essay will include a case study of a patient I have nursed in practice.

by vhb1977 (student)

University Degree Subjects allied to Medicine

Assessment and Care Planning for the Adult in Hospital

Client Care Analysis

Introduction

According to the NHS Information Centre, Hospital Episode Statistics for England, (HES 2011) during the period of August 2010 to July 2011, over 14.8 million people were admitted to hospital and 5.3 million of these were emergency admissions. These statistics represent individual people who have their own needs, but share the common need for their healthcare professional to provide expert care to them during their time in hospital. Effective care planning and accurate, ongoing assessments of our patients and their needs is essential in achieving a positive experience for the patient and their continued recovery.

This essay will include a case study of a patient I have nursed in practice. I will make a holistic assessment of my patient’s needs. I will identify two of these needs and discuss these with regard to the care given, also discussing psychosocial, biological and patho-physiology of these issues. I will reflect on my own skills with regard to the care planning and delivery process and refer to relevant literature and the evidence base concerning assessment, care planning and delivery of appropriate care.

Main body

Castledine (2004) tells us that all nurses should carry out a patient assessment automatically as this is the first stage in ascertaining the health of the patient. A past medical history should be obtained and a physical assessment made as the information gained will enable the nurse to provide evidence based care tailored to the patient’s individual needs, both immediate and long-term.

The initial assessment interview with the patient not only allows the nurse to gather the required baseline information about the patient, but can also serve as the starting point for the establishment of a therapeutic relationship between the service user and their nurse ().

Assessment of a patient involves gathering as much information (data) as possible about the person and then using that information to form a plan of action with regard to the level of care, support and intervention that the patient will require (Hamilton & Price, 2007).

Van Dyke Hayes & Sparks Ralph (2009) point out that nurses use several ways of collecting information about their patient, such as observational skills, interviewing and conduction of physical examinations. An experienced nurse can usually assess a patient using these methods simultaneously.

A thorough patient assessment should include the collection of a past medical history (collection of subjective data). Collection of objective data via physical examination is also a vital part of patient assessment. Measurements of the patient’s weight, height, respiration, temperature and blood pressure are recorded. The extent of the physical examination the nurse will conduct is dependant on their experience and also the client’s needs (Wilson & Giddons, 2009).

Hamilton & Price (2007) remind us that the precise recording of our assessments is an important way to communicate a patient’s progress to other members of the heathcare team. Wilson & Giddons (2009) agree and stress that accurate documentation of a patient assessment is vital as other healthcare providers will also be using this information and if the data is incomplete or flawed then this will have a negative impact on the effectiveness of the whole healthcare team.

To ensure that patient care is organised in a simple and systematic way, a 4 stage nursing process is used. The 4 stages are: assessment, planning, implementation and evaluation. Once the cycle of all 4 stages has been completed, if necessary the nurse can start the process again with a re-assessment of the patient’s needs (Brooker & Nicol, 2003). The process of nursing care is supported by various models, one of which is the Roper, Logan & Tierney (2000) model, which is the main model used in nursing today.

The patient upon whom my care study is based is a 45 year old man who has been admitted to the ward for a right total hip replacement. To ensure compliance with the NMC Code 2008 and the regulations concerning patient confidentiality, the patient will be referred to as Chris.

Chris is divorced and lives with his new partner and her two teenage sons. His own son from his first marriage is 8 years old and lives with his mother but visits Chris at weekends and school holidays. Chris is a self employed mechanic, he had a motorbike accident at 23 years old which has since resulted in his right hip becoming severely arthritic. Over the last 18 months Chris’s pain has become unbearable, his mobility and quality of life has decreased to such an extent that he has been advised that a total hip replacement (THR) is the best solution to the problem. Chris has also been advised that due to his age and lifestyle, he may well require further surgery later in life to revise the procedure as currently hip replacements only last about 20 years (NHS, 2010). Chris’s main concern at the moment is that he is unable to work until he has recovered from the procedure and as he is self employed he is losing money.

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The first aspect of care I will explore with regard to nursing Chris is effective pain management. In 2010 The Australian and New Zealand College of Anaesthetists (ANZCA) described pain management as a “fundamental human right”. ANZCA furthered this statement by saying that pain management is fundamental to the ethical and client centred practice of modern medicine.

This is a preview of the whole essay

In 2007 the Chronic Pain Policy Coalition referred to pain as being the 5th vital sign. This is to remind nurses that if pain were monitored routinely and regularly alongside other vital signs such as blood pressure, temperature and respiration, they could prevent, manage and treat pain effectively without the patient being exposed to unnecessary suffering, stress and anxiety.

Smith-Miller et al (2009) say that a patient’s previous experience of coping with pain, their individual tolerance to pain and their expectation of pain all contribute to their reported pain levels. McCaffrey (2000) says that “pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does”.

A patient’s experience of pain is modulated by not just physiological factors, but also psychological factors such as previous incidents, the patient’s culture and their fear and anxiety. This is confirmed by ANZCA (2010) who tell us that pain is an individual and subjective experience.

Tennant (2008) says that the following are key physical indicators that may relate to uncontrolled pain, although we should not expect every patient to display every one of these features: tachycardia, hypertension, dilated pupils, diaphoresis (excessive sweating), nausea and insomnia.

The local trust policy for adult post operative pain management in my area of practice was issued in June 2011 and was written taking into account NICE guidelines and other best practice guidance.

There are many pain assessment rating scales available, in adult nursing these are usually words or numbers, although visual analogue scales can also be used. My local trust chose to use a Numerical Rating Score (NRS) 0-10. NRS 0-3 indicates no pain or mild pain, 4-6 is classed as moderate pain and 7-10 is severe pain. Once the pain assessment has been carried out, the policy sets out a post operative pain management ladder which is based on the World Health Organisation’s (WHO) Analgesic Ladder. Any increase in or change in the pain reported by the patient initiates a medication review by the on duty prescriber. The nurse caring for the patient then gives the appropriate medication for the patient’s immediate needs. Provision is made to manage break-through pain for the patient and also for control of common post operative pain medication side effects, such as nausea and vomiting in the case of the prescription of morphine (BNF 2010).

As part of the anaesthetic procedure, before the general anaesthetic was given, Chris received a spinal anaesthetic. Dulin (2004), reports that the provision of spinal anaesthesia alongside a general anaesthetic has many benefits to the patient. These benefits include good post-operative analgesia, reduced blood loss during surgery and reduced incidence of post-operative deep vein thrombosis (DVT) and pulmonary embolism (PE).

When Chris came back to the ward after the operation, he was monitored every half hour initially and all his routine observations were normal with a pain score of 0. Chris had been given Fentanyl as a peri-operative analgesia and approximately 3 hours after coming back from recovery, Chris reported that the feeling was coming back into his legs and he was aware of some discomfort in the operation site which he rated as a 3 on the NRS.

I checked his drug chart and he had been prescribed Paracetamol and Diclofenac which were appropriate for his reported level of pain. My mentor and I administered this medication in line with the Nursing & Midwifery Council (NMC) Standards for Medicine Management (NMC, 2007).

When Chris’s partner and step-sons came to see him that evening, his routine observations were mainly normal, although he had become slightly tachycardic, he appeared to be happy and coping well. However when his visitors had gone home, Chris rang the call bell for assistance and said he needed additional analgesia. I asked him what score the pain was and he said it was 8. Until then Chris had reported a score of 3 or below for pain, however when the pain increased his family were with him and he didn’t want to worry them so he said nothing about it.

Peter and Watt-Watson (2002) tell us that nurses need to be aware that patient’s self reporting of pain can be influenced by many factors, including mood and medications and these can result in patients not reporting their pain accurately. Some patients do not report their pain as they are trying not to overburden already busy nurses. According to Apfelbaum et al (2003), many patients believe it is necessary to have pain after surgery and this is part of their experience. Wood (2008) reports that unfortunately, some nurses can appear to distrust patient’s reporting of their pain which may lead to patient’s reluctance to ask for analgesia when needed.

As a result of the delay in reporting increased pain, Chris’s pain became severe, instead of being mild and easily controlled. My mentor and I arranged for the Resident Medical Officer (RMO) to prescribe Oramorph as a rescue analgesia and then as needed (PRN) for break-through pain relief which was to be used in conjunction with his regular prescription of Paracetamol and Diclofenac.

My mentor and I discussed with Chris how important it was that he was truthful about his pain levels. We told him that the routine doses of Paracetamol and Diclofenac would control his pain well, but only if he took them regularly. We also explained that Oramorph was available for break-through pain control if needed and stressed that he should be honest and allow us to medicate the pain.

Chris was worried about taking opiate analgesia as he didn’t want to become dependant on it. McCaffery et al (2005) note that one of the misconceptions about management of pain is that patients suffering acute pain can easily become addicted to their medication. According to the British Pain Society (2010) the risk factors associated with acquired dependence on prescribed opiate medication include: current or past history of substance abuse, family member with history of substance abuse, and co-morbid psychiatric disorders.

None of these factors were relevant to Chris, and as his exposure to opiates was a short term solution to manage his acute post-surgical pain rather than a chronic long term condition, we explained that he was not in an ‘at risk’ client category for developing a dependence on opiate medication.

Once Chris had been reassured about the safety of his medications he was happy to take them as prescribed and felt he would be able to ask for more pain relief as required. After my mentor and I spent that time discussing Chris’s concerns he was able to control his pain comfortably for the remainder of his time on the ward. Chris did not require any further rescue analgesia as we were able to monitor and control any break-through pain efficiently.

The second aspect of Chris’s care I will discuss is wound care. Martin (2010) defines a wound as “an injury to living tissue, breaking its continuity.” The local trust policy for wound care management in my area of practice was issued in October 2010. The policy includes a statement that promises all patients with a wound will receive appropriate wound care, based on current evidence based guidelines, from clinical staff that have been assessed as competent to provide it.

The majority of clean surgical wounds are sealed by primary closure. This means the wound edges are closed using sutures, staples or wound adhesives (Moore & Foster, 2002). Dealey (2005) states that wounds healing via primary closure will usually seal and begin to dry out within 24 - 48 hours. Healing should take place within 7 - 14 days. This should be considered during the regular assessment of wounds and used to determine whether the wound is healing correctly.

Dowsett & Alyello (2004) and Werdin et al (2008) advocate the use of the TIME (tissue, infection/inflammation, moisture balance and edge advancement) concept of wound assessment to identify the key barriers to healing. NICE (2001) tell us to identify factors that may delay healing as early as possible in order to maximise post-operative wound care. Accurate assessment of wounds is essential for effective wound management. The wound must be checked for any sign of infection, such as heat or inflammation and all subsequent findings documented (Burton 2006).

Vuolo (2006) accepts that many clinical areas develop their own wound assessment tools to suit their particular needs. My placement area uses a structured wound assessment tool form which enables nurses to systematically document all required information when assessing a patient’s wound. The assessment takes into consideration wound classification, type of surgery, location of wound, closure method used and any relevant past medical history. Photos may be taken of the wound at different stages of healing for the patient’s record with their consent.

Once all that information has been gathered, policy dictates that the nurse must refer to their wound matrix which is based on the TIME concept tool to select the most appropriate type of dressing for the wound, based on tissue type and the primary and/or secondary dressing recommended. Each time the wound is re-assessed any changes to the wound must be documented and treated as appropriate (NMC, 2009).

In Chris’s case, his wound was closed with internal soluble sutures and staples to close the skin. This was then covered with a large, transparent waterproof Opsite Post-Op dressing. Chris also had a surgical drain in situ to prevent haematoma formation or excess fluid build-up within the wound bed as these can lead to infection and irritation of the tissues (Walker, 2007). The surgeon had left instructions for the nursing team to remove the drain 48 hours post operatively.

A routine assessment of Chris’s wound was carried out soon after he came back to the ward. The wound was clean and dry, the skin was of normal temperature with no inflammation and no odour from the wound. The drain site was also normal, with no signs of any potential problems.

Transparent dressings should generally be changed on a weekly basis, unless the manufacturer recommends otherwise, or if the integrity of the dressing is compromised, such as being damp, loose or soiled (, , ).

As per the surgeon’s instruction, the drain was removed from Chris’s wound two days after surgery. This was done using an aseptic technique and sterile equipment to reduce risk of infection (Fraise & Bradley, 2009). Chris was advised to try some deep breathing exercises during the removal of the drain to try and focus his attention elsewhere and keep him relaxed so the pain of the procedure was minimised. Once the drain was removed, the drain site was covered with a sterile dressing and secured. In order to maintain an accurate record of drainage from the wound and enable us to evaluate the wound, the contents of the drainage bottle were measured and recorded in Chris’s wound assessment in his file (NMC, 2009).

We also changed the dressing on the main surgical wound as there was strikethrough evident. The wound was dry and not leaking blood or exudate upon the dressing change and therefore did not require cleaning before the new dressing was applied. If a wound is clean and with little exudate, repeated cleaning is contraindicated because it may result in new tissue being damaged (Doran-Williams et al, 2011). Blunt (2001) also believes that exudate contains nutrients and factors that may be beneficial to healing and so should not be removed from wounds routinely.

One of my roles when caring for Chris was to liaise with other members of the multi-disciplinary team (MDT), such as the surgeon, the RMO, the out-patient’s department and the physiotherapy team. The surgeon wanted to see Chris again 4 weeks post-operatively to check on his progress and I had to ensure Chris was aware of this and assist with arranging his follow-up appointment as an out-patient. The RMO was responsible for prescribing analgesia for Chris while he was an in-patient, and they were also required to prescribe medication for Chris to take home.

The physiotherapy team had to wait until the nursing team gave them approval to begin working with Chris after the surgery, and then they had to clear Chris as being fit for discharge before we could begin that process. In order for Chris to be cared for effectively and efficiently, it is vital that all relevant members of the MDT communicate clearly and quickly with each other. Chris needed us to communicate with the RMO with regard his analgesia, physiotherapist needed to communicate with us when they were happy for Chris to be discharged. Should the communication process fail, ultimately the patient suffers and this is unacceptable.

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SID: 0918117 Page of Module code DK130013S