Care of the adult in hospital setting

University Degree Subjects allied to Medicine

9794245

In this assignment a patient assessment was carried out, which demonstrates the use of a named nursing model. In this case the nursing model is the Roper, Logan and Tierney. This model is an assessment of the activities of daily living.

Interpersonal skills used in the assessment process are discussed and their effectiveness evaluated. A patient assessment was carried out using a nursing model, one actual or potential problem highlighted by the model was identified, and the strategies set out to deal with this problem will then be discussed. Before the patient assessment was carried out, it was ensured that consent was obtained from the patient prior to their inclusion in the assignment.

Throughout the assessment and the following assignment confidentiality is maintained to a high standard by following the NMC code of conduct, ‘you must respect people’s right to confidentiality’ (NMC 2008).

The data protection act (1998) was followed throughout. For the purpose of this assignment all information regarding the trust, hospital, ward and members of the multi disciplinary team were altered and the patient was referred to as Mr. Raymond Wilson to ensure the patients rights to confidentiality.

The assessment was carried out on an eighty eight year old man who was admitted to an elderly orthopaedic trauma ward following a fall. The diagnosis was a suspected fractured neck of femur. The assessment took place in a busy ward; the patient was located in a six bedded bay. The curtains were pulled around the patient bed to try and maintain privacy and patient confidentiality.

The nursing model used in this patient assessment (Appendix 1) was based on the theories of Roper, Logan and Tierney (1996). It assesses patient activities of daily living in a twelve point plan. This includes points such as maintaining a safe environment, communication, breathing, eating and drinking.

The first interpersonal skill that was looked at before starting the assessment was the environment. The environment is a key part in communication and the wrong environment can hinder the overall outcome of the assessment. The environment in this assessment was a bed in a six bedded bay. As the information required from the patient is confidential the curtains were pulled around. Raymond was in his chair with the table in front of him and I sat on the bed next to him. I feel that the environment in this assessment could have been more effective. The first factor that I would like to have changed would be the actual room.

As the assessment involved confidential information I felt that the six bedded bay was not private enough and other patients could easily over hear what was being said. However there was nowhere else available to do the assessment. Ideally I would have gone to a private room where the patient would feel that anything said would have been truly confidential.

Also Raymond had a table in front of him while the assessment was taking place and this was a barrier between me and the patient. This may have hindered the assessment because the table may have given the patient something to hide behind stopping him from being fully open. During social interaction with others a certain distance is kept from them this is called proximity (Williams, D 1997). Nurses usually maintain what is known as social or consultative proximity, which is between 1.2 meters to 3.6 meters away from their patients. However sometimes it is acceptable for a nurse to be closer to their patient when they are providing treatment to them or giving a diagnosis. When sitting next to a patient, the closeness of the nurse to the patient can symbolize rank or the relationship between patient and nurse

There are two types of communication skills used when assessing a patient verbal and non-verbal. Verbal communication is the spoken word and although it is the most obvious form of communication it represents only a small amount of how humans communicate with one another. Non-verbal communication skills or what is often referred to as body language, is how we communicate without using speech. This style of communication has a tendency to be viewed as more accurate or honest than verbal communication (Stein-Parbury, J 2000).Throughout a human’s life time the use of non-verbal skills goes full circle from using non-verbal skills as babies to when senses such as sight and hearing start to deteriorate in later life Both forms of communication were used during in the assessment. I have looked at each one and evaluated how they were used.

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Body posture is the position of the body and limbs, such as the placement of the head, arms, legs and the position of the body in relation to the person, whether it is leant forward, backward or sideways. Body posture can be seen as open or closed. An open body position is perceived as more welcoming (Williams D 1997). When a person sits quite close to someone or has their legs pointing in the direction of the person this is seen as an open body position. Whereas if they sit with their arms and legs crossed and their body ...

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When patients answer questions that are of an awkward nature they may show most of their emotions through their body language. In this assessment Raymond started off quite relaxed, he had his knees together and his arms on his lap. The body language displayed here showed that Raymond was open. As the assessment progressed and the questions developed into a more private nature he began to make his body language more closed and protective.

He started by folding his arms, this showed that he was putting a barrier between himself and me; this indicated that he was getting more nervous. He then crossed his legs and turned away from me. This was another display of closed body language and posture which further supports the earlier observations that he was becoming more uncomfortable and nervous closed. Not all types of communication are on a conscious level, we communicate on a subconscious and this is usually non-verbal (Sundeen J et al 1998).

Raymond was changing his posture and body language subconsciously because he was becoming nervous. I had started to notice that he was becoming nervous halfway through the assessment so addressed this by asking if he wanted to carry on or if there was anything he wanted to talk about. It was my hope that this would reassure him.

In this assessment touch was not used as a form of communication as it was not required, this was mainly an information gathering exercise. However touch is the most universally used form of non-verbal communication that indicates that you care. (Sundeen J et al 1998) Touch can be used effectively by health professionals when implemented in the right situation as most of nurse-client interactions use touch. For example when reassuring an anxious patient touch can show that you care. In this assessment touch could have been used to show that I cared but I didn’t think it would be appropriate as it can be an invasion of the patient’s personal space. Although touch wasn’t used as a form of communication in this assessment touch is used in most parts of nursing care and it is used to take patients observations. While carrying out observations messages via touch can be exchanged between nurse and patient. Touch can be a powerful form of communication and can be associated with the use of strong emotion. This type of communication is no longer as commonly used and is sometimes deliberately forgotten because of the changes to normal human nature and cultural differences (Williams D 1997).

One of the main ways of gathering information is to ask questions. There are several different types of questions that can be asked and are determined by the type of response that is required (Williams D 1997). Open questions and closed questions are the two main types of questions used. Open ended questions are perhaps the most effective for assessments because more detailed answers are gained from them and it encourages more interaction with the patient. This does not mean that closed question should not be used at all, it is determined by what answer is sort after. Closed questions are used to focus a patient in one direction and obtain a specific one word or short answer (Sundeen, J et al 1998). In comparison open ended questions allow the patient to direct the interaction and give more detailed answers. Open questions may threaten a patient’s trust if one is formed whereas closed questions maintain interpersonal safety by keeping the assessment on a less personal level.

Raymond’s assessment involved both open and closed questions. Closed question were used, to gather minimal information as they have limitations on what answers you can receive. I had to consider what type of questions I wanted to ask and whether I wanted a leading question or just a yes or no answer. To gather the basic information like name and address a closed question was used as I only wanted one word answers.

However open questions were used to gather in-depth information. Some of the questions I asked were not the correct type of question therefore I didn’t receive the answer I wanted. For example I wanted to know about Raymond’s eating habits, so I asked ‘do you have a good appetite’ he replied ‘yes’. Had I asked him a more open question, I may have received a more detailed answer.

From the patient assessment it was identified that the patient may be malnourished. In this trust the MUST ‘Malnutrition Universal Screening Tool’ (Appendix 2) is used to screen patients who potentially have nutritional problems.

The main objective of any health professional is to try to prevent and or detect problems early. By using a screening tool we can detect possible problems earlier which can hopefully prevent them from developing in to more serious problems later on. The MUST tool was designed to identify adults who are running a risk of becoming malnourished. Malnourished can refer to both over and under weight individuals. The MUST tool is good as it can reveal patients at either end of the scale. (Bapen 2003)

The MUST tool uses a five step process.

Step one is BMI, step two is a weight loss score, step three is an acute disease effect score, Step four is overall risk of malnutrition and step five is management guidelines. For each step a score is given. The scores are added up and this determines the risk factors for the adult (Bapen 2003).

In the first step information about nutritional measurements were gathered. This included weight, height and BMI (Body Mass Index). The body mass index is an assessment of the overall height and weight of an individual. A calculation of the weight in kilo grams is divided by the height squared. This gives a score between nine and forty six. The higher the number the more obese the individual is. If the height and weight are not available then the length of the fore arm can be used. The mid upper arm circumference can also be used to estimate the BMI of an individual. The MUST scores for step one is awarded as follows if the BMI is greater than 20 then the score is 0, if the BMI is between 18.5 to 20 is the score is 1 and if the BMI is lower than 18 then is score is 2. (Bapen 2003)

This assessment is good for looking at an individual’s overall height and weight at present but does not show if they are nutritionally at risk. This is due to the fact that a normal weight can often mask other underlying problems.In a report done by (Bapen 2006) on the MUST tool, it was found that Between 10% and 40% of hospital admission have an average BMI of with less than 18 and even more have an even greater MUST score. In patients aged 65 and over one in seven have a MUST score of medium to high risk.

In a study by Burkhauser and Cawley 2007 on the other ways of measuring fatness and obesity found that the BMI index can misclassify individuals in to weight classifications. The BMI index is flawed because it does not distinguished fat from fat free body mass such as bone and muscle. The BMI index is more accurate when classifying men than it is women and is generally inaccurate when classifying African Americans as obese. For this tool to give a more accurate idea of a patient’s body composition this study shows that it should also include measurements of an individual’s percentage of body fat and total body fat. The implications of a wrong classification using the BMI can result in a patient not receiving the correct treatment.

The second step is an assessment of the individuals unplanned weight loss. Through questioning the patient an idea of how much weight has been unintentionally lost over the past 3-6 months can be gained this is turned in to a percentage of body weight lost which is then awarded a score.

Getting an accurate weight loss score can be difficult because many elderly people don’t keep an accurate record of their weight therefore don’t know if they have lost weight and may be embarrassed to admit to loosing weight because it shows that they may not be coping at home.

The third step looks at individuals who have an acute psychological or pathological condition, commonly patients that are in intensive care. If the individual is presumed or known to have had no nutritional intake for five days or more then 2 is added on to their MUST score. This identifies those at risk from developing malnutrition rather than those that are malnourished.

The fourth step is an overall look at the risk of the individual’s nutrition. The scores are added together to acquire the total nutritional risk factor of the individual. If the individual has a score of 0 then they are at a low risk of becoming malnourished, a score of 1 suggests that the individual is at a medium risk and a score of 2 or more indicates that they are at a high risk. (Bapen 2003)

The fifth step is the guideline for the management of malnourishment. If the individual has scored 0 then they require routine care and regular screening. The guidelines for repeating screening varies between clinical settings. In a hospital setting it is recommended that the individual is screened once a week. (Bapen 2003)

For an individual of medium risk it is recommended that they are observed. Their dietary intake for three days is documented and assessed and the screening is repeated weekly. If the individual’s condition improves, they should be reassessed, if the patients conditions deteriorates then it may become a cause for clinical concern.

For an individual at high risk, it is recommended that they are refereed to a dietician. A care plan should be set up and their nutritional intake monitored. An overall health assessment is to be maintained and constantly reassessed. Also any underlying conditions should be treated and help and advice should be given on eating, drinking and meal choices when necessary (trust guidelines 2004).

A study conducted by Kyle, Kossevsyky et al 2005 was aimed to test the sensitivity and specificity of the Must tool as well as the Nutritional Risk Index (NRI) and the Nutritional Risk Screening tool (NRS 2002) in comparison to then Subjective Global Assessment. (SGA). The overall idea was to see how the nutritional risk determined by these tools affected a patient’s length of stay (LOS). The conclusion of this study was that NRS 2002 had a higher sensitivity and specificity than the must tool. However the score difference between the two studies was just 1%, with the NRS 2002 scoring 62% and the MUST tool scoring 61 %. In specificity terms the MUST tool scored lower than the NRS 2002 by 23%, which is a significant difference. This suggests that the authors of this article found that the MUST lacked specificity. Although it was one of the better scores for sensitivity 61% leaves a large margin for improvement.

As one of the most recent screening tools developed by BAPEN it has perhaps not undergone as many reviews and changes as other well established tools like the Subjective Global Assessment questionnaire, which the authors of this study identify as an accurate nutritional assessment tool which works as a successful global predictor of complications associated with severely malnourished patients. However it has its disadvantages in comparison to the MUST tool in that it does not assess mild malnutrition only chronic or established malnutrition. When malnutrition reaches this level of severity it is quite often easily observed and simply confirmed by the use of the SGA tool.

Early observations which need to be a part of the screening tools can be as simple as how well the patient’s clothes, rings, and dentures fit. (Holmes S 1999) Also simple questions such as what food the patient likes and dislikes and whether they are able to buy and cook food for themselves should be included as they can affect a personal nutritional state.

A literature review by S.Green, R.Waton et al 2005 looked at reviews of screening tools and assessments from 1982 to 2002. They identified 71 nutritional assessment tools and reviewed 35 of theses and left out the tools which used biochemical measures. It suggests that not enough of the tools in use have gone through reliability, validity and acceptability testing as is needed. The review fears, that although it may help nursing staff to pay attention to the nutritional care of some of their patient. An untested tool may cause more the severe malnutrition to develop as a patient suffering malnutrition may not achieve a score that is the at risk category which means that no further action will be taken. This study identified that the MUST tool is not specific enough. Perhaps the poor categorization is an unseen disadvantage of this tool which indicates that more testing of this tool is needed.

In conclusion communication plays a large part in patient assessment. The way in which communication skills are used in an assessment can affect the outcome. If this assessment was to be carried out again then the first thing that would be changed is the environment that the assessment took place in as this was not a suitable environment as it was not private enough.

The use of the MUST tool is now standard practice in the hospital environment in the U.K. However it’s use can lead to patients at risk of malnutrition being overlooked and vice versa. This is mainly due to its lack of specificity. Its use of the BMI in the 5 step process to asses the patients well being brings another assessment which has already been recognised as flawed because it doesn’t differentiate between fat and fat free body mass. This makes the MUST tool unsuitable for certain body types and ethnicities making it not as universal as its title claims to be. Step 2 is also inaccurate as there is no record of the patient’s weight loss only an estimate made by the patient which can be exaggerated or under emphasised. The Must tool needs to use more questions and integrate it with observations of the patient. To make it more sensitive to the risk of malnutrition and more specific to the patient.

The implications for future nursing practice are that the MUST should not be used independently but more as a guide. Other factors including lifestyle, appearance and ethnic background need to be taken consideration when classifying a malnourished patient.

References

Bapen (2003), ‘MUST information booklet [online] Available at (Accessed 22/05/2008)

Burkhauser. V. and Crawley. J. (2008) ‘Beyond BMI: The value of more accurate measures of fatness and obesity in social science research,’ Journal of Health Economics March 2008, Pages 519-529 [online] Available at (Accessed: 20/08/2008)

Dougherty. L. and Lister. S. (2004) The Royal Marsden Hospital manual Of Clinical nursing Procedures (sixth edition) Blackwell Publishing Ltd

Ferri R (1994) Care planning for the older adult: Nursing diagnosis in long term care

W. B Saunders

Green, S. and Watson. R. (2005) Nutritional screening and assessment tools for use by nurses: literature review,’ volume 50, Issue 1, pages 69-83 [online] Avalible at (Accessed 17/08/2008)

Holmes.S. (1999) ‘Hospital related malnutrition’ Nursing times books.

Hunt, J (1986) Nursing care plans : the nursing process at work (second edition)

Chichester : Wiley

Kagan C, Evans J (1998) Professionals Interpersonal Skills for nurses Stanley Thornes (Publishers) Ltd Cheltenham

Kyle. U. and Kossovsky. M. et al (2006) ‘Comparison of tools for nutritional assessment and screening at hospital admission: A population study.’ Clinical nutrition volume 25, issue 3, June 2006, pages 409-417 [online] Available at (Accessed 17/08/2008)

Nursing and midwifery (2004) ‘NMC code of conduct’ [online] Available at (Accessed 22/03/2008)

Price, B (1990) Body image: nursing concepts and care . London : Prentice Hall International

Roper N, Logan W, Tierney (1996). The Elements of Nursing. A model based on a modal of living. (fourth edition) Churchill Livingstone

Stein-Parbury J, (2000) Patient and Person: Developing Interpersonal Skills in Nursing (second edition) Harcourt Publishers International London

Sudeen J et al (1998) nurse-client interaction: implementing the nursing process (sixth edition) Mosby Inc USA

Trust (2005) Nutritional guidelines (anonymised for confidentially purposes)

Williams D (1997) Communication skills in practice: a practical guide for health professionals Jessica Kingley Publishers Ltd Lon

Trust site accessed 22/05/2008 (anonymised for confidentially purposes)

Care of the adult in hospital setting

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Hunt, J (1986) Nursing care plans : the nursing process at work (second edition)

Chichester : Wiley

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