Maximising Health Using the Nursing Process In conclusion, this systematic cyclical approach to care has proved to be beneficial to Mrs Florence Nightingale

University Degree Subjects allied to Medicine

Maximising Health

To protect the resident’s identity, the resident will be called Mrs Florence Nightingale. Mrs Florence Nightingale has been selected to demonstrate how to maximize health using the nursing process. She is a 77 year’s old elderly resident in a private up-market nursing home in an EMI unit, who’s unable to self mobilize and is dependent upon a hoist for transferring. She is unable to verbally communicate, or feed her self. Due to her restricted mouth movement, difficulty with swallowing and fear of choking she is only fed in liquid form, which is thickened. She suffers from multiple disorders such as Alzheimer’s, CVA (stroke) and is doubly incontinent. Issues focusing on sustenance intake and surrounding issues will be explored in order to maximize the health of Mrs Florence Nightingale. Issues include psychological and social impacts of eating alone, ensuring adequate nutritional intake and adequate mouth care. Through the nursing process the patient’s perspective of health is identified in order maximize the patient’s health.

The nursing process is an organised, systematic and cyclical method of giving goal oriented, humanistic care to patients that’s both effective and efficient (Alfaro-LeFevre, R. 1994), it is often supported by nursing models such as Roper, Logan and Tierney model for nursing, based on activities of living and Maslow's Hierarchy of Human Needs etc. It consists of five sequential and interrelated steps - Assessment, Diagnosis, Planning, Implementation and Evaluation – during which you perform deliberate activities designed to maximize long-term results (Alfaro-LeFevre, R. 1994). In the UK the diagnosis stage of the process is omitted, although UK nurses determine a patient's needs or problems, they are not widely regarded as "diagnoses" (Wikipedia 2006).

This systematic approach to care is cyclical in nature and can end at any stage if the problem is solved. The nursing process not only focuses on ways to improve the patient's biological needs, but on psychological and social needs as well. Due to patient having no verbal communication skills, poor non-verbal transmission of facial expressions and poor body gestures (Holland, K et al 2003), it is unlikely the patient would be able to participate in the process. Also, the patient’s family will not be involved due to having very little to almost no contact with the patient. Therefore, to respect the autonomy of the patient, the senior nurse and other members of the multidisciplinary health team will be involved in all stages of the process.

The first step of the nursing process is assessment from which the care plan maybe devised. This is an organized and systematic process of data collection from a variety of sources. Data collection contains subjective and objective, current and historical patient information (Kozier, et al., 1998). It is through this, that Mrs Florence Nightingale’s person-centred care plan will be devised. During the assessment, you collect and examine information to get the necessary facts to determine your patient’s health status and to describe not only problems (needs) but also strengths and abilities (Alfaro-LeFevre, R. 1994). The assessment should ensure that modern standards and service models are incorporated (Department of Health 2004). To make the care plan meaningful, it is important to focus on the social, psychological, spiritual and to some extents environmental and politico-economic needs of the patient, rather than just focusing upon medical needs (Roper, N et al., 2002).

Through Mrs Florence Nightingale’s patient notes, examinations, observations, discussions with family, significant others and friend’s data are gathered so that a biography can be created. From the biography, the nurse is able identify what is important to Mrs Florence Nightingale. From her the patients biography it became clear that Mrs Florence Nightingale’s enjoyed social activities like interacting with other people, reading novels, listening to 50’s music, having her hair done, fingers nails painted, she was interested in fine dining and did not like male Dr’s and nurses (staff). Mrs Florence Nightingale’s regularly attended a dancing classes and bingo up until her stroke.

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Issues surrounding the event of Mrs Florence Nightingale’s death were discussed at the assessment stage. In order for the nurse to create a meaningful care plan the needs of the patient (Mrs Florence Nightingale) must be identified. It was important for Mrs Florence Nightingale to receive a visit from the local priest and have some one present by her side (ideally a family member or a loved one) before she passes away. An understanding of death, dying and bereavement is essential if nurses are to undertake care that is holistic and takes account of individual beliefs and religious practices (Holland, K et al., 2003). As people tend to live longer and may have a higher expectation on life. Although physically alive, the older person will be seen as less alive socially in the eyes of society or even family members. Those who are confined to nursing homes will sometime loose the will to live. Once hopelessness and helplessness prevails which can result in the rapid decline of the individual and subsequent death (Holland, K et al., 2003). According Maslow's Hierarchy of Human Needs it’s important to encourage that patient’s self-esteem (Wikipedia, 2006).

Planning is the second phase of the nursing process. Once the strengths and problems are identified from the assessment process the nurse is ready to work with the patient (and significant others) to develop a plan of action. This second phase is broken down into four stages: setting priorities, establishing goals and determining nursing interventions, recording the plan of care (Alfaro-LeFevre, R. 1994). The nurse and patient (and significant) others should mutually categorise identified needs into high, medium or low priority. A goal should be patient-centered, realistic, clear, measurable, broad and timed (Kozier, et al., 1998). To meet these goals, the next stage needs to be completed, setting nursing interventions. These are essential to the evaluation phase of the nursing process. It is important to focus on the problems the patient feels are of highest priority unless they interfere with treatment. Communication skills are required in order to educate the patient (and significant others) regarding treatment they need, to enable them to make informed decisions regarding their care.

Nursing interventions are activities performed by the nurse to monitor the status of patient’s health; prevent, resolve, or control a problem; assist with activities of daily living (bathing, eating, drinking etc); promote optimum health and independence (Alfaro-LeFevre, R. 1994). Specific nursing interventions, as stipulated in the care plan, will ensure continuity of care. There are often various measures the nurse can pick to meet the same goal so it is important to set interventions with the patient. This will ensure autonomy, co-operation and empowerment of the patient. Nursing Interventions are a set of instructions by a member of the multi-disciplinary health care team such as the GP, tissue viability nurse, audiologist, diabetic specialist nurse, physiotherapist, and require implementation from the nurse. The interventions you plan should be designed to prevent resolve, or minimise the problem identified.

The goals and interventions are as follows: Each goal will precede the interventions.

The mouth prepares food for proper digestion, protects the upper respiratory and digestive tracts, and helps us talk. These functions require healthy teeth and gums, good sensation, and working salivary glands. If disease affects any of these parts, the consequences can be serious (AGS, 2005) Firstly, prevent oral infection/inflammation. Use a glycerine and thymol swab to clean Mrs Florence Nightingale mouth every morning and evening. Apply Lypsyl stick or Vaseline to lips every morning and evening to prevent dryness.
Ensure adequate nutritional intake. Set up the feed as per regime, allowing the agreed time between each feed. Document start time of feed and amount of each feed. Discontinue feed if vomiting and contact nutrition nurse. Monitor weight weekly.
The most common cause of dry mouth is a side effect of drugs that are commonly prescribed for older adults (AGS, 2005). Ensure adequate hydration. Give water, juice through beaker prior to starting feeding and when feeding has finished. Document the amount given and time given. Document signs of dehydration.
Prevent oesophageal reflux. Mrs Florence Nightingale should be sat upright throughout the giving of feed to prevent her from choking etc.
To develop Mrs Florence Nightingale swallowing abilities. Place 5-10 mls of custard/yoghurt on Mrs Florence Nightingale lips every lunchtime and allow tasting and swallowing, as directed by speech therapist. In relation to goal 2, it is paramount to adhere to infection control policies to minimise the risk of cross infection to the patients. If, area around mouth becomes infected, a reddening of the skin would indicate the infection. This is the body's way of maintaining its own safe environment. The reddening is a rush of blood, containing lots of white blood cells, to the site of infection to begin the fight against the infection (Roper et al 1996). There are methods the nurse can take to maintain a safe environment. Regarding Mrs Florence Nightingale these methods include ensuring all of the multidisciplinary team are fully trained and are up to date with the latest procedure, as well, using equipment properly and adhering to health and safety guidelines and legislation. Also by taking simple measures such as ensuring all hazards are dealt with, e.g. loose carpeting is secured.

These six goals are relating to biological aspects of having not being able to feed one self. However, it is important to look at the social and psychological aspects as well as the biological. It has been discovered that Mrs Florence Nightingale was quite a social person and enjoyed spending time with other people. As Mrs Florence Nightingale no longer eats a meal, she is missing out on the social aspect of spending time with other people eating meals. From a psychological aspect, she no longer has the satisfying feeling of being full or just having something tasty to eat. It is important for the nurse to counteract this and try and make up for this loss in someway. This is done through enabling Mrs Florence Nightingale, where possible, to spend time in the company of other people, be it staff, residents, visitors or members of the activity therapy team. Also, it is stressed that goal 5, to develop Mrs Florence Nightingale swallowing abilities, must be carried out daily so that Mrs Florence Nightingale can still experience the sensation of tasting food.

The planning of care also involves identifying what services are available to the patient. Mrs Florence Nightingale resides in a nursing home; this ensures that she has 24-hour access to registered nurses and a team of care staff. This is the first service available to her and members of this team will provide most aspects of her care. However, due to Mrs Florence Nightingale feeding issues, she does require specialist services. The National Service Framework (NSF) for older people states that people who are thought to have had a stroke should participate in a multidisciplinary programme of secondary prevention and rehabilitation (Depart of Health, 2001). This opens up a lot of services for Mrs Florence Nightingale. Rehabilitation services include physiotherapists, occupational therapists, and speech therapists etc. The particular services that were utilised for Mrs Florence Nightingale are the community speech therapy team and the dietician. They visit the home at regular intervals to assess Mrs Florence Nightingale progress. The staff in the nursing home provides all other aspects of care. Mrs Florence Nightingale does access other services including general practitioner, opticians, dentists and chiropodists. Occasionally she will attend music sessions that are supplied by the activity therapy team.

Now that the care is planned we enter into the third stage of the nursing process, implementation. To implement a care plan the nurse should document the care plan so that it is a written piece of work available for members of the team to read. The primary component of this stage is the actual delivery of care to the patient. However, there are factors that may influence the delivery of care. In the case of Mrs Florence Nightingale this might be that there is not enough staff with the ability, skill and time to feed her. Also, with Mrs Florence Nightingale residing in a nursing home they may not be able to get the specialist staff in, including speech therapists and dieticians. Legal and ethical issues may affect the delivery of care. Patients need to give consent for any treatment they are to receive. This has implications if the patient does not give consent. The Nursing and Midwifery Council (NMC) state in section 3 of the code of conduct you must obtain consent before you give any treatment or care (2002). Without consent then the patients' rights are being violated regardless of whether the treatment is urgent. However, the issue of consent is not just as simple as obtaining the green light to give treatment. Seeking consent gives the patient autonomy of care. Autonomy is the capacity to think, decide and act on the basis of such thought and decision freely and independently, without hindrance. The patient needs to be informed about the treatment so that they can give consent that leads truly to autonomy. This principle raise two questions, what is sufficient information and how this concept can be applied to a patient who has limited autonomy.

The Department of Health, state that sufficient information is as much information as they reasonably need to make their decision, and in a form they understand (2001). This offers guidelines but still leaves the concept of informed consent a very subjective concept. Gillons definition of autonomy suggests that a person is autonomous if they have the ability to think and decide freely and independently. When patients have limited autonomy the issue of informed consent depends upon their competence. Welie and Welie define competence as being fit for the purpose (2001). Therefore, when patients are competent to give consent they have the skills necessary to make an autonomous decision about their health. Welie and Welie suggest that one of the skills necessary is for the patient to communicate and account for the decision (2001). If the patient lacks this skill they are considered incompetent to give informed consent. According to section 3.6 of the NMC's code of conduct, if a patient is considered incompetent to give consent then the patients known wishes should be taken into consideration and criteria for treatment must be that it is in their best interests (2002). Due to Mrs Florence Nightingale communication difficulties she was deemed incompetent to give informed consent.

Other factors that may influence delivery of care include government and local trust initiatives. Government initiatives include the NSF for older people. This was set up in 2001 by the Department of Health and it sets national standards for the care of all older people. Its main guiding principles are that all care should be client centred, care should be non-discriminatory, practice should be evidence based and it strongly promotes multi-professional collaboration to enhance the care of the patient (2001). This initiative was set up to improve the care of older people. Local trust initiatives include Principles of Care. This intends to standardise care given to all patients being cared for in a hospital or nursing home. This gives guidance on how certain procedures should be carried out and also ensures that each nursing home and ward uses the same assessment tools. This is intended to improve patient care by setting standards across the trust and ensuring that the care that is implemented is of a high standard.

Now that the care plan has been implemented, the final stage of the nursing process is entered, evaluation. Evaluation has similar characteristics to assessment. It is an ongoing and continuous process and also occurs at timed points in a formal setting. The initial stage of evaluation is to decide whether the patient has met the goals established during the planning stage. The goal is evaluated at the stipulated time and is done by gathering information about the patient regarding this goal. Information can be sought from the patient, the patient’s family, the health care team and the patient’s notes. If the goal has been met then it can be removed from the care plan. If the goal has not been met, the nurse has to establish a reason why. This is the secondary stage of evaluation. At this point the nurse will look closely at the goal. Maybe the goal isn't realistic or measurable. If this is apparent, then new appropriate goals will have to be set. The nursing interventions might not be successful in meeting the goal, if so, new interventions should be set. The patient might not be co-operating with the care plan, therefore not meeting the goals. This situation demands the division of new goals and interventions. The setting of new goals and interventions leads the nurse back to the beginning of the nursing process, and the whole cycle starts again.

It is at this evaluative stage that the nurse can look at the effectiveness of the care plan. The goals mentioned in this essay were evaluated three weeks after they were initially established. The goals were evaluated at three weeks because there were concerns about Mrs Florence Nightingale general health. All of the goals were found to be successful in maximising the health of Mrs Florence Nightingale and none of the goals were changed or removed. Throughout the three weeks Mrs Florence Nightingale has maintained adequate levels of nutrition and hydration, showing no signs of malnutrition or dehydration. Also, her mouth has remained in good health, sustaining no problems. Through discussions with Mrs Florence Nightingale multi-disciplinary care team, it was agreed that the care plan was successful and should remain unchanged.

In conclusion, this systematic cyclical approach to care has proved to be beneficial to the Mrs Florence Nightingale. The care delivered to Mrs Florence Nightingale has achieved its aim as it has maximised her health.

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