Investigating the nursing process and nursing care.

University Degree Subjects allied to Medicine

In this essay I will use the nursing process which is an individualised problem-solving approach to nursing care. It involves four stages: assessment (of the patient’s problems), planning (how to resolve them), implementation (of the plans), and evaluation (of their success). (Oxford Nurses Dictionary, Fifth edition, 2003 New York). I shall be focusing on one aspect of the nursing process, which will be implementation.

The implementation phase is when you put your care plan into action. Implementation encompasses all nursing interventions directed at solving the patient’s problems and meeting health care needs. While you co-ordinate implementation, you also seek help from the patient, the patient’s family, and other members of the health-care team.

(Lippencott, Williams and Wilkins, Medical-Surgical Nursing Made Incredibly Easy, 2004).

I have already used the process of planning to work out the solutions to my Patient’s needs. I referred to the workings of the SMART (Specific, measurable, achievable, realistic and time orientated) principle. (Hinchcliff, S, 2004) and the 12 activities of living by Roper, Logan and Tierney (Roper, N et al 2001) in order to help me achieve that.

Egan explains that ‘a helping model is like a map that helps you know what to do in your interactions with clients. At any given moment, it also helps you orient yourself, to understand ‘where you are’ with the client and what kind of intervention would be most useful’. (G.Egan, The Skilled Helper: A problem Management Approach to Helping 6th Edition).

I have used a pseudonym to comply with my patient’s confidentiality as stated in the NMC (Nursing and Midwifery council) guidelines (NMC Code of Conduct clause 5.1 2004).

My patient’s name will be changed to Rachel; she is 35-year-old lady who has been admitted to have a bilateral breast reduction. She has been admitted to a surgical ward within the local trust. Rachel is married with two children who are two and four. She lives with her husband and children in the local area, with her husband being her next of kin.

I have focused on one aspect of care that was highlighted from the planning process, which is Rachel’s post-operative care. The nurse in charge explained the hospital’s policies and procedures for when the patient is received back into the ward from recovery. This was to check the airway is patent and the patient is breathing adequately. (Botti, M. and Hunt, J. (2000) The routine of post anesthetic observations. Contemporary Nurse 3(2): 52-57.) The nurse explained that usually the patient is conscious before leaving the recovery room. Then I was told to record her temperature, pulse, blood pressure and oxygen saturation and compare the results with the patient’s pre-operative recordings. “One of the most significant nursing activities in relation to ‘prevention being the key’ is to keep observing patient/ client” (Kenworthy.N, Snowley.G, C.?Ask christy. Common Foundation Studies in Nursing, third edition 2002). The nurse told me to observe the wound and any drains that may be present. Such as a Redivac or a catheter. I was told that I will need to check, if an intravenous infusion is present, and that I should inform the nurse in charge of her care, so she can check the intravenous infusion is functioning according to medical staff instructions. The nurse explained to me how important it is to read the patient’s theatre notes to confirm the surgical procedure, which has been carried out and ascertain any instructions from the surgeon or anaesthetist. For example, positioning of the patient, oxygen therapy. I was explained that I will have to ensure that the patient is lying in the most comfortable position possible, and that the limbs are positioned in a manner, which will not endanger muscle and nerve tissue. The nurse informed me, she would administer analgesia as required by the patient and as prescribed by the medical staff on her drug chart, as explained in the NMC guidelines for the administration of medicines london 2004. I was instructed to record blood pressure, pulse, oxygen saturation and respiration rates until they were within normal range and stable. Also to encourage and assist patient with breathing exercises to promote lung expansion, and therefore prevent chest infection.

Simple nursing interventions, such as early mobilization and encouraging patients to do leg exercises while in bed, can help to reduce the risk of thrombus formation as well as urinary tract infections, pressure ulcers and constipation (Torrance C, Serginson E (2000) Surgical Nursing. London, Baillière Tindall.)

The nurse told me that the policy was also to allow graduated amounts of fluid unless contra-indicated (e.g. the presence of a naso-gastric tube), then gradually introduce solid food if there is no vomiting and if bowel sounds are present. Also to record the amount and time when the patient passes urine and when ...

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I was told to carry out these observations by my mentor. Some of these observations such as record blood pressure, pulse, and oxygen saturation and respiration rates should be carried out every fifteen minutes for an hour, then every half hour for four hours, then after that hourly for a certain period of time. The patient’s observations should be monitored for twenty-four hours closely. This does not always mean carrying out clinical measurement with special equipment although of course this is carried out a great deal. It means, literally, look at your patient frequently, and get used to how they appear and behave when they are stable and comfortable. Because we are then able to notice even the very slightest changes in the patient’s condition and these observations can be life saving.

When Rachel was brought back to the ward from recovery, I came to meet her in her room. I greeted Rachel and asked her how she was feeling, and whether she was nauseous or in any pain. “Pain is what the patient says it is, existing when he says it does”. (M.McCaffery, Nursing the patient in pain, 1983)

I needed to find this out for her post operative chart. Rachel then replied that she wasn’t in any pain and not feeling nauseous. I then asked Rachel if she was comfortable or needed anything, Rachel replied that she was fine but feeling a little tired.

“Individuals are primarily social beings and a major part of living involves communicating with other people in one way or another” (Roper et al applying the model in practice 1996).

I then went on to assess her level of consciousness and discovered that Rachel was still slightly drowsy which was not abnormal as she had just returned from theatre. I recorded the results clearly and in such a manner that the text can not be erased. I also recognized that I should not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements. As stated by the NMC (Nursing and Midwifery Council, Guidelines for records and record keeping, London 2005)

Then Rachel gave consent for me to conduct her observations I started by taking her blood pressure. Blood pressure is always undertaken on admission so we have a normal range for the individual patient and thereafter if required and according to the patient’s care plan. This is an important clinical measurement of cardiovascular function and one that denotes critical changes or potential changes in a patient’s condition. Post operatively, it is important to check and record frequently.

Blood pressure is the force extended by the blood as it flows through the blood vessels. It is arterial blood pressure, which is normally recorded. Blood pressure increases with age, weight gain, stress & anxiety. Normal range is considered to be from 100/60 to 140/90 mm Hg. The term hypotension is used when the blood pressure is lower than the normal range. The term hypertension is used when the systolic or diastolic blood pressure is elevated above the normal range. The correct size of cuff must be used to ensure accurate recordings. (Mallett, J. and Dougherty, L. (2000) Observations. Manual of Clinical Nursing Procedures Oxford: Blackwell Science. Ch.28 pp 402-432)

After making sure that the bladder inside the cuff was covering at least 80%of the circumference of the upper arm (Nicol.M, Bavin, C, Bedford-Turner.S, Cronin.P, Rawlings-Anderson, Essential Nursing Skills, Second Edition Mosby london.2004). I informed Rachel that the cuff was about to inflate, and asked her if she could keep her arm straight and relax. Rachel’s blood pressure 120/80 the first number is the systolic pressure taken just after the ventricles contract: the second number is the diastolic pressure, taken when the ventricles relax, (Smart.T, Human Body, Dorling kindersley limited London 2001)

During the time whilst taking Rachel’s blood pressure I decided to take her pulse oximetry. This as a sophisticated and painless test. In which a small sensor is placed on the patient's finger or earlobe, for measuring the proportion of oxygenated haemoglobin (oxyhaemoglobin) in the patient's blood. It works by measuring the amount of specific types of light that are absorbed by body tissue. An Alternative term is called an Oxygen Saturation Test.

(2000-2006 HealthCentersOnline, Inc.)
Rachel’s oxygen level in her blood was 98%, which is within her normal range. I recorded this and her blood pressure results on her observation chart.

I then informed Rachel that I was about to take her temperature and received her consent. Checking the temperature regularly is very important because an increased temperature maybe a sign that the patient could have an infection, or may have an allergic reaction to the medication she may have been given. Sites for recording body temperature include the axilla, rectum and ear. For each patient, the site for temperature measurement should be consistent. The normal range of body temperature is between 36°C and 37.5°C. (Anon. (2001) Essential skills: a monthly collectable guide to core clinical procedures. Observation and monitoring. 13. Recording temperature. 15(38): insert-12.)

In order to take her temperature I used a Tympanic and inserted the probe into the outer ear, adjacent to but not touching the tympanic membrane.

Before I use the Tympanic I had to check a few things to make sure I didn’t get an inaccurate reading. Such as wax in the ear, a cracked or dirty lens, and poor fitting in the ear and if the patient has been recently lying on the ear that is used, (Jevon.P, Using a Tympanic thermometer, Nursing Times 2001, 97(9): 43-44)

Next I took Rachel’s respiratory rate, which is thought to be the most sensitive indicatory of a patient’s physiological well being. This is logical because respiratory rate reflects not only respiratory function as in hypoxia or hypercapnia, but also cardiovascular status as in pulmonary oedema, and metabolic imbalance such as that seen in diabetic ketoacidosis (DKA). (Kenwood G, Hodgetts T, Castle N. Time to put the R back in TPR. Nursing Times. 2001; 97:32-33. )

Respiration is the exchange of oxygen and carbon dioxide between the cells of the body and the environment through rhythmic expansion and deflation of the lungs. Each respiration consists of an inhalation, exhalation and the pause, which follows. (Stevens, S. and Becker, K. L. (1988) How to perform picture-perfect respiratory assessment. 18(1): 57-63.)

When I assessed Rachel’s respiration, I had to ensure she was relaxed and unaware of the counting process, I then had to count the respiratory rate and observe the depth and pattern of respiration and count the number of respiration’s for at least 30 seconds. (Finesilver, C. (1992) Respiratory assessment. 55(2): 22-30)

I did this by asking Rachel whether I could take her pulse and counted her respirations for 60 seconds. Her respiratory rate was 14. Normal respiratory rates can vary according to age. The accepted normal range for healthy adults is 14 – 20 per minute. (Torrance, C. and Elley, K. (1997) Practical procedures for nurses. Respiration: technique and observation - 2... no. 4.2. 93(44): insert-Nov. Torrance, C. and Elley,)

I recorded the rest of Rachel’s results on her observation chart and informed the nurse in charge of Rachel’s care that her observation were in a normal range and showed her the chart just to double check my knowledge of this subject was accurate. The nurse in charge checked the results on the chart and informed me that my decision was correct and her observations were within normal range.

In conclusion with the help of nursing models I have used previously. I feel that I have implemented my patients care effectively and efficiently. The Roper, Logan and Tierney model (Roper, N et al 2001) which I used in my patients assessment, helped me break down my patients care to find out what my targets were, in order to treat her care holistically.

I then used the SMART principle (Hinchcliff, S, 2004) in the planning of Rachel’s care. It helped me turn the issues highlighted into more achievable and measurable goals. I feel that if I never used these models then Rachel’s care would not have been implemented properly.

I feel I have implemented Rachel’s care holistically to the best of my ability.

References

Oxford Nurses Dictionary, Fifth edition, 2003 New York

Lippencott, Williams and Wilkins, Medical-Surgical Nursing Made Incredibly Easy, 2004).

Hinchcliff, S, 2004

Roper, N et al 2001

G.Egan, The Skilled Helper: A problem Management Approach to Helping 6th Edition

Nursing and Midwifery council Code of Conduct clause 5.1 2004.

Kenworthy.N, Snowley.G, C.?Ask christy. Common Foundation Studies in Nursing, third edition 2002

Nursing and Midwifery Council, guidelines for the administration of medicines. London 2004

Botti, M. and Hunt, J. (2000) The routine of post anaesthetic observations. Contemporary Nurse 3(2): 52-57.

M.McCaffery, Nursing the patient in pain, 1983

Nursing and Midwifery Council, Guidelines for records and record keeping, London 2005

Torrance C, Serginson E (2000) Surgical Nursing. London, Baillière Tindall.

Roper et al applying the model in practice 1996

Mallett, J. and Dougherty, L. (2000) Observations. Manual of Clinical Nursing Procedures Oxford: Blackwell Science. Ch.28 pp 402-432

Nicol.M, Bavin, C, Bedford-Turner.S, Cronin.P, Rawlings-Anderson, Essential Nursing Skills, Second Edition Mosby london.2004

Smart.T, Human Body, Dorling kindersley limited London 2001

2000-2006 HealthCentersOnline, Inc.

(Anon. (2001) Essential skills: a monthly collectable guide to core clinical procedures. Observation and monitoring. 13. Recording temperature. 15(38): insert-12.)

Jevon.P, Using a Tympanic thermometer, Nursing Times 2001, 97(9): 43-44

(Kenwood G, Hodgetts T, Castle N. Time to put the R back in TPR. Nursing Times. 2001; 97:32-33. )

Stevens, S. and Becker, K. L. (1988) How to perform picture-perfect respiratory assessment. 18(1): 57-63.)

(Finesilver, C. (1992) Respiratory assessment. 55(2): 22-30)

Torrance, C. and Elley, K. (1997) Practical procedures for nurses. Respiration: technique and observation - 2... no. 4.2. 93(44): insert-Nov. Torrance, C. and Elley,)