Carry out an assessment of a patient and present a plan of care of a specific problem that the patient has encountered.
INTRODUCTION
The purpose of this essay is to carry out an assessment of a patient and present a plan of care of a specific problem that the patient has encountered. The model chosen to guide the care plan is the Roper, Logan and Tierney's 'Elements of Nursing'. This will enable me to develop my skills in assessment, problem-solving and planning care.
I will describe and explain the nursing model and provide an rationale for my choice. An overview of the assessment process will be given followed by an introduction and history of the chosen patient. An assessment of the patient will be carried out using the model to identify any problems the patient may have or encounter. Then a plan of care will be detailed relating to a specific problem identified in the assessment. Finally, I will reflect on the process of carrying out a care plan and discuss the nurse/patient relationship.
NURSING MODEL
I have chosen Roper, Logan and Tierney's model, as it identifies and groups nursing activities in relation to the process of living. The model believes individuals carry out a series of daily activities that are fundamental to normal functioning. The philosophy of care is based on living, not illness. (Walsh 1999). The model views individuals holistically and shows awareness of cultural environmental, political and economical factors. (Roper et al 1996). It emphasises on prevention and helps patients with problems relating to activities of living. The model consists of two parts, 'A Model for Living' and 'A Model for Nursing'. The Model for Living has five interrelated elements, twelve activities of living lifespan, independence-dependence continuum, influencing factors and individuality. (Roper et al 2001).
The activities are based on the idea of basic human needs and can be used as the criteria for assessment. (Roper et al 1996). Lifespan influences the individual's behaviour in each activity of living, as each person has a lifespan from birth to death such as childhood and adolescence. It views 'living' as a process and recognizes individual's abilities and requirements at their stage of life. (Roper et al 2001). The dependence-independence continuum identifies the patient's status, as it is subject to change during illness and incapacity. Dependence is assessed at each activity acknowledging need for nursing intervention. (Roper et al 1996). The influencing factors, which are physical, psychological, sociocultural, and environmental, and politicoeconomic, provide a structure enabling a full account to be taken of the circumstances of the patient. (Walsh 1999).
The Model for Nursing contains the same elements as the Model for Living apart from individuality, where it is replaced with individual nursing. (Tierney 1998). The model will help me to provide systematic care and the knowledge gained by using the model will give me greater insight into problems affecting patients.
ASSESSMENT
Assessment describes the process of collecting and reviewing data, identifying the patient's actual and potential problems. It is the initial stage of the nursing process, followed by planning, implementation and evaluation and is a continuous and ongoing activity. (Murray and Atkinson 2000). The information collected relates to the health status and factors affecting the patient. This information can come from sources such as the patient, family, significant others, health care professionals and health records. (Heath 2000a).
The assessment enables nursing care to be planned and implemented, prioritising the patients problems. (Alfaro-Lefevre 2002). It requires to be reviewed frequently to reappraise problems as the patients condition changes. (Heath 2000b), (Rowe 1999).
Subjective and objective information are gathered during the assessment. Subjective information is reported from the patient concerning their thoughts and feelings. Objective information is observed and measured by the nurse such as temperature and pulse. (Alfaro-Lefevre 2002).
My preceptor and I discussed a suitable candidate, on which to carry out an assessment. Due to the ward having very few admissions, we decided ...
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The assessment enables nursing care to be planned and implemented, prioritising the patients problems. (Alfaro-Lefevre 2002). It requires to be reviewed frequently to reappraise problems as the patients condition changes. (Heath 2000b), (Rowe 1999).
Subjective and objective information are gathered during the assessment. Subjective information is reported from the patient concerning their thoughts and feelings. Objective information is observed and measured by the nurse such as temperature and pulse. (Alfaro-Lefevre 2002).
My preceptor and I discussed a suitable candidate, on which to carry out an assessment. Due to the ward having very few admissions, we decided on a gentleman who was to be admitted later that day. Since the surroundings were new to us both I felt we could relate to each other.
As required by the Nursing and Midwifery Council guidelines, a pseudonym of Albert will be used to protect his identity. (NMC 2002). I introduced myself to Albert in private, as a nursing student and explained the nature and purpose of my assignment. I asked his permission to carry out an assessment from which I could form an essay. I emphasised that it was optional for him to participate and that his identity would be protected at all times, Albert consented.
The Roper, Logan and Tierney model will be implemented to the assessment and relate to the lifespan, dependence-independence continuum, and influencing factors.
Albert is an 83 year-old widower and lives alone in a bungalow in the city. He stated he has had a good life with many memories; he had travelled to several countries in his time with the Royal Navy. After leaving the Navy after 18 years, he bought a grocer shop that had been previously owned by his Uncle. He had enjoyed going to dance halls and outdoor bowling. Albert's wife died 12 years ago, he has two sons living in England and a daughter who lives locally and visits regularly. There was no medical history relevant to his current admission.
Before admission to hospital, Albert stated he was independent and active; he regularly took his dog long for walks. Recently he has experienced several falls and now his mobility is impaired. He complained of nausea and feeling generally unwell. Albert decided to be admitted to hospital for investigations. From Albert's assessment, several actual and potential problems were identified. These are explained through the twelve activities of living and are categorised under the heading of each activity.
Maintaining a safe environment
Albert is unable to maintain a safe environment independently. He is at risk of falling due to impaired mobility and will require assistance to mobilise safely. There is a potential risk of infection from microorganisms found in hospitals. (Filetoth 2003).
Communicating
Albert was alert and orientated. He fully understood the reasons for his admission to hospital and asked many questions relating to his stay. He has no speech or hearing difficulties and wears glasses for reading.
Breathing
Albert's health records showed he had no previous respiratory problems. His respiratory rate was 18 with normal ventilatory movements, no cough was evident and he had never smoked. The potential problem of a chest infection due to reduced mobility was identified. Lung volume decreases in the recumbent position as the abdominal contents press up on the diaphragm limiting the range of movement. (Redfern and Ross 2001). This increases the risk of accumulation of secretions in the airways, which are a medium for bacterial growth. (Heath 2000a).
Eating and drinking
Albert has had a poor appetite; he felt nauseated and has lost interest in food in the last fortnight. He has restricted his fluid intake due to a recent problem of urinary frequency. Albert is 1.64m and weighs 48kg. His Body mass index is currently at 18, indicating he is underweight for his height. (Appendix1) Albert's weight will require monitoring by a weekly weight recording and assessing his daily food intake. (Redfern and Ross 2001). Due to insufficient food consumption Albert may be undernourished and at risk of pressure sores. (Redfern and Ross 2001). Pressure sores develop when prolonged pressure is exerted on the skin, the pressure diminishes blood flow to the tissues that can devitalise and become susceptible to damage. (Alexander et al 2001). There is a potential problem of dehydration, which can cause constipation due to inadequate fluids. (Woodrow 2002), (Madden 2000).
Elimination
Albert has a problem of urinary frequency and occasional incontinence. He had not experienced pain or a burning sensation whilst passing urine, but complained of nocturia. This is a term to describe passing urine during the night. (Chasens and Umlauf 2003). A urinalysis test showed the presence of leucocytes, nitrites and blood in Albert's urine. This indicates the presence of a urinary tract infection. (Heath 2000a), (Hope et al 1998). Albert's normal bowel patterns are once daily and are usually soft and easy to pass. Unusually for Albert his bowels have not opened for approximately seven days and has been straining to defecate, he feels constipated. This can be due to his impaired mobility and lack of fluid and dietary fibre consumption. (Madden 2000).
Personal cleansing and dressing
Albert's impaired mobility will reduce his ability in carrying out this activity safely and independently. He will require assistance to maintain a good standard of hygiene to prevent infection and skin problems. Albert's skin is dry and discoloured, but remains intact. A pressure sore risk tool, the Waterlow scale showed Albert to be of high risk at 15. (Appendix 2). Kenworthy et al (2002) describe a pressure sore risk tool as a tool that identifies a risk of developing a pressure sore. Albert will require a pressure relieving mattress and regular observation of pressure areas.
Controlling body temperature
Albert had a raised temperature of 37.8C, the normal adult temperature is between 36 C- 37.5C. (Redfern and Ross 2001).The raise in temperature can indicate the presence of infection. (Alexander et al 2001). Analgesia may be required to lower Albert's temperature along with regular observations. (Hope et al 1998).
Mobilising
Albert is normally independent and active, recently he has been experiencing falls and is unsteady whilst mobilising. He will require assistance of a nurse or a mobilator when mobilising and physiotherapy input. The use of a mobilator may cause a psychological problem by a loss of self-identity and self-worth. (Bourret et al 2002).There is a potential risk of the loss of joint motion known as joint contractures. When muscles are disused they shorten by fibrosis and joint fixations occur. (Larson 1999). Thrombo-embolism is a potential risk, as a slow or reduced flow of blood, due to reduced mobility, within the veins can lead to a deep vein thrombosis or a pulmonary embolism. (Seely et al 2002). A chest infection is a potential risk due to restricted respiratory movements. Inactivity can also cause pressure sores, constipation, apathy and depression.(Redfern and Ross 2001).
Working and playing
Albert is at risk of loneliness and anxiety as admission to hospital has altered his usual routine. Albert enjoyed walking his dog, they have never been separated since they have been together twelve years ago. Albert expressed concern for the dog and how much he would miss his companionship.
Expressing sexuality
Albert dressed appropriate to age and gender and was well groomed. Sexual activity was not discussed as Albert had stated that his wife was the only woman for him and he had no desire to meet anyone else.
Sleep
Albert has a regular sleep pattern of seven hours per night, and has never required night sedation. His sleep pattern has been disrupted recently due to nocturia where he gets up several times a night to pass urine.
Dying
Albert's condition did not indicate that death was imminent. However he clearly expressed that he has no fear in dying as he looks forward to the day he can see his wife again.
CARE PLAN
The focus for the care plan is constipation, which was identified in the activity of 'elimination'. I have chosen constipation as it has a significant impact on an individual's physical, psychological and social well being.(Ross 1998). Norton (1996) defines constipation as decreased or difficult evacuation of dry, hard faeces that are painful to pass. It can be acute or chronic condition and bowel movements are less frequent than the individual's normal.( Redfern and Ross 2001). Constipation is distressing, undignified and embarrassing; nurses approaching the subject require tact and sensitivity. (Whinney 1999), (Murray 1997).
Planning
The planning stage of the nursing process is setting realistic achievable goals and selecting nursing interventions to achieve these goals. (Alfaro-Lefevre 2002). Due to impaired mobility and an insufficient dietary fibre and fluid intake, Albert is suffering from constipation. Albert and I sat in private and I explained constipation, its causes, treatments and its prevention. Then we discussed and planned his care in which to rectify his constipation. It is imperative for patients to be involved in planning their care, it helps them to prevent and solve problems. It empowers them and compliance is more likely to be achieved. (Potter and Perry 2001).
Goals provide a focus for nursing interventions and determine the effectiveness of the interventions. (Heath 2000a). The short-term goals were for Albert's bowels to move in 48 hours without difficulty and to increase his fluid intake by 1500mls daily. The long-term goals were for Albert to exhibit regular patterns of bowel elimination before discharge and for him to recognise measures that will prevent a recurrence.
Interventions
Several interventions were identified following the plan and discussion with Albert, regarding his care. Albert will increase his physical activity, within his own limits, as activity stimulates peristalsis in the colon and increases muscle tone that facilitates voluntary contraction during defaecation.(Whinney 1999). Encourage an increase in fluid intake at least 1500mls daily, fluid liquifies intestinal contents, easing passage through the colon which help to prevent hard dry stools. (Whinney 1998). Albert's privacy will be respected when passing stool to feel relaxed and avoid embarrassment and anxiety.(Schaefer and Cheskin 1998). Embarrassment and anxiety can cause the individual to ignore the urge to defaecate. (Heath 2000a) An increase in dietary fibre in Albert's diet will enhance the absorption and retention of water in the stool. This will make the stool softer and pass easily. (Bottomley and Lewis 2003). Ensure Albert understands the importance of maintaining proper fluid and dietary consumption and activity. (Schaefer and Cheskin 1998).
EVALUATION
Albert's short-term goal was achieved within 36 hours despite only a 1000mls increase in fluids. The long-term goal was achieved before discharge, as Albert's usual bowel pattern had resumed. He fully comprehended the measures to be taken to prevent a recurrence and implemented them with encouragement.
CONCLUSION
Nursing models provide a framework to facilitate nurses in caring for patients effectively and consistently in the clinical setting. The 'Elements of Nursing' model guided me to collect relevant data in a systematic way, relating to the 'activities of living'. It enabled some measurement such as a baseline to determine what point the patient was on the dependence - independence continuum and identify actual and potential problems. I found that the activities were interrelated and how one problem can link with another.
The assessment process is the beginning point for all nursing interventions and is an essential component of the nursing process. Developing a relationship with the patient is essential, good interpersonal skills are required in order for the patient to disclose personal information. I felt I had began to build up a relationship with Albert, he appeared keen to gave me the information I required and was not afraid to show his vulnerabilities. Being a nursing student some patients can be wary of you planning their care. Albert appeared to trust my judgement and capabilities, which gave me a sense of professional competence, confidence and sense of achievement.
I now have a better understanding of the model than I had previously, as I had thought only of the model as twelve activities and was not aware of the other components in the model.
Having an increased knowledge of the model, I can confidently apply it to practice and plan/deliver care more effectively.
