In order to successfully use the nursing process to asses a patient and plan care a nursing model should be used. The model of nursing that is most familiar to nurses was originally developed by Roper in 1976 and was updated and added to in 1980, 1981 and 1983 by Roper, Logan and Tierney. The model has been used in a wide variety of nursing settings (Holland etal 2003). The model of nursing specifies 12 activities of daily living which are related to basic human needs and will be used to produce a care plan for Joyce. They are maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal hygiene, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying.
On admission, a full contact assessment is devised. The contact assessment is based around the 12 activities of daily living to ensure holistic care is achieved. When completing the contact assessment it is essential that effective communication is used. Robinson (2002) outlines that effective communication is an essential prerequisite for valuable nurse – patient relationships. Egan (1986) developed the acronym SOLER as a reminder of the behaviours, or physical tactics, which can be used by listeners to promote communication and improve their own reception of messages. The rules of this are face the other person squarely. Adapt an open posture. Lean towards the patient slightly. Maintain good eye contact and try to be relaxed while paying attention. This will demonstrate interest. It is also vital that appropriate questions are used during the assessment process. Tactful questioning using open, closed and leading questions enable the nurse to gain as much information from the patient as possible. Moonie etal (2000) illustrates that using the appropriate language also plays a key factor in effective verbal communication. The use of technical terms or medical jargon often leaves the patients feeling alienated. It also leaves the patient feeling disempowered which can consequently result as a barrier for the service user to collaborate with other professionals in the future. All these factors need to be taken into consideration when undertaking the initial assessment upon Joyce.
The 12 Activities of Daily Living
Maintaining a safe environment. On admission Joyce’s baseline observations were taken, all of which were in the normal range with exception of her temperature which was reading 37.6ºC. All staff around Joyce was fully aware of the infection control policies, Joyce was in a bay of four patients and regular hand washing and application of the alcohol gel was applied before and after coming into contact with her. Joyce was also promoted to cooperate with regular hand washing by showing where the sinks and alcohol gel were located. Joyce was fully able to recognise any dangerous or hazardous situations.
Communicating. Joyce was fully able to communicate verbally, none verbally and written. She has no speech problems and doesn’t require any aids for hearing. Her first language is English.
Breathing. On admission Joyce’s respiratory rate was 16 resps per minute and 99% O2 saturates on air, these are within normal limits and show no signs for concerns. However Joyce is a heavy smoker. NHS (2008) outlines that smoking increases the chance of lung cancer, chronic bronchitis, emphysema and other problems such as regular occurrence of chest infections. This may not be a problem for Joyce now but could possibly reduce her recovery time or lead to health complications in the future.
Eating and Drinking. Even though Joyce is overweight, she explained that she’s recently lost weight due to the worry and stress of being ill. She has no dietary requirements at present, but has outlined that when she has fully recovered from the operation she would like help and advice to loose weight.
Eliminating. Joyce is fully continent and no concerns expressed.
Personal cleansing and dressing. Joyce is self caring with her hygiene needs. Joyce takes pride in her appearance and often has a beauty routine both in the morning and night. She expressed that she doesn’t want this changed and would like facilities to acquire this. Joyce has brought into hospital her own nightwear and belongings.
Controlling body temperature. Joyce’s body temperature on admission is 37.6ºC. This is above the normal range. She is not particularly vulnerable to changes in temperature, the room temperature is set at a medium heat on the thermostat and the weather outside is cold, to which Joyce is wearing the appropriate clothing.
Mobilising. Joyce mobilises unaided, and mobilises independently. The waterlow risk assessment provides an indication whether a patient is at risk of developing a pressure sore. Meyler and Trenoweth (2007) describe that the waterlow pressure ulcer risk assessment/prevention policy tool is, by far, the most frequently used system in the U.K. and it is also the most easily understood and used by nurses dealing directly with patients. It is based on a scoring system and categorised into four risk levels. On admission Joyce scored a 6, resulting in her being at a low risk of developing a pressure sore. However Lammon etal (1995) illustrates that even at a low risk appropriate measures can still be undertaken. Therefore Joyce’s skin condition and reassessment of her waterlow score needs to assessed weekly. Furthermore Joyce should be educated how to relieve her own pressure areas and a appropriate moving and handling sheet should be completed.
Working and Playing. Joyce leads an active life and works part time as a kitchen assistant. She thoroughly enjoys her job and would like a full recovery as soon as possible. Her operation has added extra stress at work as she explains they are regularly short staffed and has the added pressure of a lack of wage.
Expressing Sexuality. Joyce has been married to her husband for over 40 years and has a large extended family. She has expressed that she has never been separated from her husband and would like him to visit as much as possible.
Sleeping. Joyce takes no medication to aid her sleeping and explains that she has a ‘good night’s kip’ most nights. She has not suffered any sleep deprivation before coming into hospital.
Dying. Joyce did not feel comfortable discussing death.
Kindlen (2003) reports that gallstones can sometimes cause flu like symptoms such as a high temperature. Joyce’s baseline temperature on admission is 37.6ºC. This is slightly above the normal range. The writer has chosen the goal of care is to control Joyce’s body temperature. The cause of the temperature could be for several reasons; disturbance of body tissues, malignancy or surgery but in relation to Joyce it could be a sign that gallstones are causing an infection to develop in her gallbladder. It is therefore highlighted that Joyce already has a slightly raised temperature has the potential problems of developing pyrexia.
Planning is the second phase of the nursing process. In this phase, the nurse develops a plan to assist the patient to meet needs identified in the assessment process. Excellent communication skills are needed here to educate the patient regarding treatment they need, to enable them to make informed decisions regarding their care. Walsh etal states that 'it is the nurse's responsibility to communicate effectively with the patient to bring about optimum nursing care' (2002). Mutual priority setting with the patient serves two purposes. Firstly it involves the patients in the planning of their own care. Secondly, it enhances the relationship between nurse and patient. After this has been achieved, the nurse needs to establish Joyce’s care goals. A nursing goal can be defined as 'a statement of what the nursing intervention is intended to achieve' (Yura and Walsh 1978). Alfaro (2002) clarifies that goals should be simple, measurable, achievable, realistic and time scaled. To meet these goals it is essential that the nursing interventions are also planned.
The writer would like Joyce’s temperature to return within normal range within 12 hours. Therefore the goal for Joyce is:
Record temperature hourly, then when stable for six hours reduce observations to four times daily.
A nursing intervention can be described as 'specific activities which the nurse plans and implements in order to help the patient to achieve a goal' (Atkinson and Murray 1990). 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. Interventions are a set of instructions for the staff to follow when delivering care to the patient. They must be specific to combat misinterpretation.
In order to reach the goal outlined for Joyce, nursing interventions also need to be planned to reach this goal.
- Commence fan therapy until temperature is reduced to below 37ºC
- Provide Joyce with iced water to drink. Monitor fluid balance hourly due to the risk of dehydration.
- If fan therapy shows no sign of reduction in temperature after 2 hours, issue an antipyretic such as paracetamol.
- Encourage Joyce to reduce bedding and wear loose cotton clothing.
- Promote regular mouth care as Dougherty and Lister (2004) reports that oral mucous membranes dry easily from dehydration.
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. Diamond (2008) clarifies that legal and ethical issues may also 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, then the appropriate treatment cannot be performed and as a result the care cannot be delivered. 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 isn't just as simple as obtaining 'the green light' to give treatment. Seeking consent gives the patient autonomy of care. Autonomy can be defined as 'the capacity to think, decide and act on the basis of such thought and decision freely and independently, without hindrance' (Crisp 1990). Therefore any treatment given to Joyce should be verified and given full informed consent before hand. Even something so small as removing bedding should be explained why and the potential benefits should be outlined. Even if the intervention could be presumed as ‘obvious’ it is important not to be judgemental and an explanation is still offered.
Other factors that may influence delivery of care include government and local trust initiatives. Government initiatives include the National Service Framework 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. This gives guidance on how certain procedures should be carried out and also ensures that each 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.
One part of implementation is record keeping. NMC (2002) specifies that record keeping is an integral and legal issue in nursing practice. McHale and Tingle (2007) insists that good record keeping is a mark of a skilled and safe practitioner. It is important to remember that records should not include any abbreviations, jargon or meaningless phrases and clearly written in terms other staff can understand. Nicole etal (2004) verifies that each practitioner’s contribution is of equal importance and an individual should use their professional judgement to decide what information is relevant and what should be recorded. In relation to Joyce’s care it is essential that her notes are kept in a timely manner and if something significant happens, it should be recorded as soon as possible. No slang or jargon should be used, additionally the notes should be clear, specific and non judgemental. In addition if written by a student nurse, the notes should always be co-signed.
During implementation of Joyce’s care, there are other nursing interventions that are needed to be considered.
- Joyce should be monitored for any signs and symptoms of infection. Any new or worsening symptoms should be reported to medical staff.
- Samples could be obtained, if suggested, for example MSU or blood cultures.
- Observe for any changes of colour in the appearance of the skin
- A safe environment should be maintained by ensuring Joyce’s call bell is within her reach and she knows how to use it.
- Ensure Joyce and her family – with her consent, are fully informed about the plan of her care and know to inform the nursing staff if they develop any new or worsening symptoms.
- If Joyce’s pyrexia increases and she begins to rigor, bedding and clothing should not be removed as Hilton (2004) explains that this will increase shivering and discomfort for the patient.
Now that the care plan has been implemented, the final stage of the nursing process is entered, evaluation. Evaluation has similar characteristics to assessment. Aggleton and Chalmers (1986) describe that 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 patients' family/friends, the health care team and the patients' 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. Maybe the goal isn't realistic or measurable. If this is apparent, Parsley and Corrigan (1999) insists that 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 goal mentioned in this care plan was initially evaluated every hour and within 2 hours Joyce’s temperature had reduced to 36.3ºC. After one hour of fan therapy and the removal of Joyce’s bedding, her temperature hadn’t decreased, however with an antipyretic Joyce’s temperature decreased into the normal range. The goal was found to be successful in maximising the health of Joyce and the goal was neither changed nor removed. If this hadn’t of been successful other interventions would have needed to be carried out as previously outlined which consequently would result in the goal being modified. Throughout the five days Joyce was present on the ward, she has maintained a normal temperature, showing no signs of infection or dehydration. Also, her other observations have remained within acceptable limits, sustaining no problems. Through discussions with Joyce’s next of kin and the multi-disciplinary team, it was agreed that the care plan was successful and should remain unchanged.
In conclusion, this systematic approach to care has proved to be beneficial to the patient. The care delivered to Joyce in this circumstance has achieved its aim as it has maximised her health.
The reflective model I have chosen to use is Gibbs model (Gibbs 1988). Gibbs model of reflection incorporates the following: description, feelings, evaluation, analysis, conclusion and an action plan.
The clinical skill I chose to plan care within this essay is the controlling of body temperature. I have chosen this as within my placement experience it was a common reoccurring problem with numerous patients. I therefore researched the topic of pyrexia and my knowledge within this area developed.
Joyce was admitted to the ward to have an operation to remove her gallbladder. On admission, after doing her baseline observations, it was discovered that she was suffering from pyrexia. Through the use of the nursing process, I was able to plan and implement nursing interventions that enabled Joyce’s temperature to decrease within a normal range.
I was aware of being under the supervision of two qualified nurses and this made me feel very nervous and self conscious about planning Joyce’s care. Once my mentor questioned my practice, concerning pyrexia, I became even more aware of feeling nervous and under pressure. The patient was present and I did not want the patient to feel that I did not know what I was doing. I thought that as I had been observed carrying out this standard procedure on many other occasions then my practice must have been seen to be correct. I was also concerned that the practice of the qualified nurses was so inconsistent, which led me to evaluate the whole process.
The Royal Marsden (Richardson 2008) advocates the guidelines of nursing action in compliance with pyrexia as discussed in my plan of care for Joyce. Therefore my practice was within the trust protocol. This experience made me think about my attitude towards literature and how it is applied in practice. Through evaluation of the event in question I have become more aware of different practices concerning reducing body temperature. I am aware that many practices are used within my placement are, but as I develop professionally I am developing my own skills and will plan care as appropriate to the patient using the protocol rather than consulting the protocol immediately. There is no clear evidence in controlling body temperature which intervention should be implemented first within this area but I will use the literature which is available to justify my actions, and therefore give evidence based care.
In conclusion, Joyce’s temperature was back within normal limits in a short period of time, safely and effectively. I am aware that all nurses do not use evidence in the same way and may use different methods but as long as my practice is safe and evidence based then I can practice safely. My future practice will depend on the area in which I am working and I aim to find out the trust protocol concerning clinical procedures before I commence any procedure. Furthermore, if possible the patient should ask which type of intervention they would prefer first and their opinions and views should be respected.
Within my action plan my aim is to research further into the controlling of body temperature, not only raised temperature but lowered temperature too. I am also planning to have a discussion with the qualified nurses on the subject of fever management in children and the elderly.
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