The nurse gathered a lot of David’s biographical details from her previous plan of care and his medical records, many of the core care plans were also completed in the office prior to returning to David to complete the A.D.L’s assessment sheet. The core care plans contain current problems and potential problems, each with the appropriate evidence based practice to support them, this enables the patient to make further informed decisions regarding their care (Pearson, Vaughan, and Fitzgerald, 2005).
Roper et al specify that the plan of care should be client centered and the gathering of information should be gathered from the patient (primary source) if viable and their relatives (secondary source) if required/present. Collecting biographical data from other sources is usually discouraged, unless for example the patient is unconscious.
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Any data collected must be in accordance with the professional code and kept confidential (Data Protection Act, 1988).
The A.D.L’s initial assessment sheet was completed at David’s bedside; David was able to offer information in regards to the 12 A.D.L’s and extra information was also gathered, such as skin assessment and a pain assessment. The R.L.T model collects information about prior routines and also if any alterations have occurred due to the patient’s present condition. David stated his occupation and his enthusiasm for playing rugby on a weekend to help him relax, this was noted down in the previous A.D.L of working and playing, but nothing was wrote in the changes due to admission/present condition section. This part of the care plan appeared to collect both objective and subjective data and allowed the nurse to establish baselines that David identified with, and also uses a pain chart that David could use to interpret his pain on a scale of 1 to 10 (Beverage, Mayer, Schaeffer and Thompson, 2005).
The objective data collected related to David’s fractured femur and allowed baselines for swelling and basic post operative checks, this data was collected through observation. The subjective data was what pain and
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discomfort David was experiencing and was not visible to others. Collection of both subjective and objective data can also help to discover coping strategies used by the patient (Roper et al, 2000).
David’s dependence/independence was considered under the A.D.L of mobility due to him only been part weight bearing and a referral was then made to the wards physiotherapist. Nevertheless the nurse did not address that David needed assistance with his personal cleansing and dressing, and completed the box for the A.D.L as ‘no problems’. Roper et al indicate that all A.D.L’s do not have to be utilized but the box should be left blank (Roper et al, 2000).
The nurse prioritized David’s problems that were identified throughout the initial assessment; however David was not involved in this process. The nurse stated the problem with the most priority was the fractured femur and associated possible problems. In comparison David’s financial and personal anxieties were not included in the plan of care.
The assessment was written in accordance with the Nursing and Midwifery Council guidelines for records and record keeping, the information recorded was factual, accurate, consistent and written clearly in a non-erasable pen (NMC, 2002).
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Planning is described as “The stage of the nursing process in which an individual care plan is produced” (Oxford dictionary of nursing, 2003, p376), at this stage the patient’s problems are stated, the goal set and nursing intervention set.
The planning of David’s care was established and discussed with him. The nurse used the blank evaluation/reassessment sheets to individualize the planning of care to be received by David. The use of the blank sheets in conjunction with the core care plan sheets permitted a client centered plan of care to be achieved, this was because David was involved in the goal setting process. (Pearson et al, 2005).
During the planning stage the nurse used the information gathered to create a nursing diagnosis in relation to David’s problems. The nurse wrote individualized needs statements for David’s remaining problems not included in the core care plans, the objective and subjective data was used to create baselines for his pain level, swelling of the affected limb, and also later his mobility level also had goals set by David and the physiotherapist (Hogston and Simpson, 2002).
David’s medical conditions were identified through using the R.L.T model; however the nurse neglected to take the factors influencing activities of daily living into account. If the nurse had used the model,
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other problems would have been identified. It was obvious that David appeared worried, but the nurse neglected to ask him if he had any worries other than his fracture, if the nurse would have addressed external factors such as politicoeconomic and sociocultural they would have been able to address his worries which were not being able to work and play rugby.
Roper et al (2000) describe how goals that are set should be achievable in relation to the patient’s personal circumstances; otherwise the patient may loose sight of the goal. The goals must also be set with the patient.
The nurse wrote the goals with David present but did not involve him in the goal setting; this may have been due to the ward provisionally deciding upon a discharge date when they were admitted. The ward did this following research into the duration of stay in hospital following common fractures. The goals written for David conformed to the acronym MACROS, this is that the goals set were; Measurable and observable, Achievable and time limited, Client centered, Realistic, Outcome written and Short (Hogston and Simpson, 2002).
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The goals were also written in client centered manner. They stated David’s name in the goals statements and also written using language he could understand, medical terminology was kept to a minimum and no abbreviations were used.
The goal set between the nurse and David for the A.D.L of mobility incorporated a short and long term goal, in relation to walking certain distances with the support of physiotherapy whilst minimizing pain and discomfort (Aggleton and Chalmers, 2000).
In some of David’s care goals it stated to some degree which assistance was required in relation to mobilizing, it stated he was part weight bearing and no weight was to be positioned on his right leg. The nurse did not document how to assist David to stand or which side he should get out of his bed. The nursing intervention was not explicit in detail and therefore would not allow different members of the nursing team to provide the same assistance and treatment during his stay in hospital.
Once a goal has been established with the participation of the patient, the next process is to state the nursing intervention in relation with each specific goal. The nursing intervention should indicate who is going to provide the treatment, what treatment or assistance is required, where the treatment will take place, why the intervention is required, when the goal
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should be achieved. An adequately written goal statement should enable any member of the nursing team to be capable of looking in the patient’s plan of care and be able to follow a set of ‘directions’ to provide an ongoing standard of nursing intervention. This is especially significant for the care of specific treatments such as pin site care and dressings for skin grafts (Richards and Edwards, 2003).
The ward worked as part of a multi disciplinary team (MDT), this included the nursing staff, physiotherapists and occupational therapists. The central plan of care included a goal for pain reduction whilst undertaking physiotherapy; the nursing staff observed and recorded any variations in condition daily. The physiotherapists used their own plan of care for David’s mobility and commented on his development following each visit. The government encourages the use of a collaborative plan of care for many disciplines but this was not used with this patient (Foster and Harrison, 2000).
Implementation is described as “The stage of the nursing process in which the patient’s individual care plan is utilized and executed, in collaboration with other members of the health care team” (Oxford dictionary of nursing, 2003, p241).
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The physiotherapist initially assessed David and it was determined that he should receive daily assistance from them to help him regain optimum mobility with his recently nailed fracture, the nursing team prescribed analgesia to help with associated pain as expressed in James nursing intervention regarding his reduced mobility. The physiotherapists then provided additional information into David’s main plan of care; the information added included how to assist David to mobilize without resulting in complications, and also passive exercises. David’s progress was added to his plan of care and nursing interventions received were also recorded.
The care provided in the implementation stage relates to the nursing intervention stated in the patient’s individual goals. The care provided reflects on the experience and skills of the nurse and also evidence based practice, if the nursing intervention has been documented explicitly the nursing team can deliver optimum care (Holland et al, 2004).
The 12 A.D.L’s if used appropriately can provide a holistic overview of the patient, in spite of this David’s plan of care personal cleansing and dressing were not addressed correctly, in David’s normal activity of living the nurse recorded that “David was independent with his hygiene
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needs” and this changed to “minimal assistance required” due to admission/present condition. The nurse failed to collect information as to David’s preference of bathing and this did not take into account David’s personal preferences and therefore removed part of his individuality (Aggleton and Chalmers, 2000).
The nursing team should encourage the patient to carry out desirable activities. Pearson et al (2005) describes preventing activities help the patient be more aware of what can impair normal living, comforting activities to provide physical, psychological and social comfort and seeking activities to encourage the patient to pursue new knowledge and self education.
Evaluation is described as “The final stage of the nursing process, in which the effects of nursing interventions are compared with the goals or objectives set in the care plan” (Oxford dictionary of nursing, 2003, p166).
The nurse evaluated David’s treatment on the day of his discharge; this essentially consisted of a signature on every goal. The nurse did not take time to be certain the goals had been achieved and did not involve David in the evaluation of his treatment. The nurse who evaluated David’s
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treatment was not the same nurse who had set the goals with David’s involvement, due to David not been involved in the evaluation it did not permit him the opportunity to state if he felt the treatment and care received had been satisfactory and if he felt he had accomplished the set goals.
The evaluation process should not be used as part of the patient’s discharge procedure, but as an on going review of the effectiveness of nursing interventions for each specific goal. The evaluation of each goal should be reviewed at a time previously specified in the plan of care, this process should evaluate if the goals that were set was realistic and achievable and if the goals were achieved to a satisfying level (Hogston and Simpson, 2002). This process of evaluating allows the nurse to re-
assess the nursing intervention for each goal that had not attained the criteria set in conjunction with the patient (Holland et al, 2004).
The patient should if possible be involved with the evaluation of goals, this is essential if the goal was set in conjunction with the patient based upon subjective data, for example if analgesia had effectively reduced any pain or discomfort.
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In conclusion the Roper, Logan and Tierney activities of daily living model gives nurses a thorough framework to utilize to assess a patient. The model aims to encourage nurses to look beyond the medical problems a patient may present and to provide holistic care. It has been clear that the model can be extremely effective when performed by a nurse who is knowledgeable with the models philosophy.
The model has limitations if used by a nurse who does not fully understand how to gain a holistic representation of the patient’s previous and current abilities to perform the 12 A.D.L’s. It is commonplace for nurses to use the 12 A.D.L’s as a checklist type form and to write “no problems” or “no changes” if they are not competent with the model.
Many nurses are also not comfortable to discuss the A.D.L of dying with a patient; this is commonly completed as “not discussed” even when a patient has a short life expectancy. Roper, Logan and Tierney (2000) envisage that to die successfully you must first live successfully; with bearing on this the patient may wish to express their feelings, views and fears surrounding death.
The model when used correctly was client centered and involved the patient in the initial assessment and goal setting, this made the patients
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plan of care individual and permitted the patient to make informed decisions regarding the nursing interventions he would be receiving.
The rehabilitation ward also used Orem’s model, this may be the rationale behind some nurses not being comfortable with the Roper, Logan and Tierney model. The two models were used concurrently to provide holistic care and to also encourage the patient’s to be as independent and self-caring as their condition allowed. The incorporated models may have been successful due to good communication among staff and daily reports.
Many hospital settings commonly use pathways or core care plans due to the levels of documentation that the Roper, Logan and Tierney model requires when goal setting, the usage of pre determined actual and potential problems for specific conditions aid to create a comprehensive plan of care individualized by the usage of blank care sheets.
I found the model versatile and comprehensive, when used correctly the plan of care was individualized and client centered but when used inadequately just another part of the documentation process. If merely one model was used universally in hospitals there may be more comprehension of the philosophy and used more effectively.
REFERENCES
Aggleton, P., and Chalmers, H. (2000) Nursing Models and Nursing Practice. 2nd edition. Basingstoke: MacMillan Press
Beverage, D., Mayer, B., Schaeffer, L. and Thompson, G. (2005) Assessment Made Incredibly Easy. 3rd edition. Lippincott Williams & Wilkins
Foster, E., Harrison, M. (2000) Setting up collaborative care plans Nursing Standard 15 (6)
Hogston, R., and Simpson, P. (2002) Foundations of Nursing Practice. 2nd edition. Basingstoke: Palgrave McMillan
Holland, K., Jenkins, J., Soloman, J., and Whittam, S. (2004) Applying Roper, Logan & Tierney Model in Practice. London: Churchill Livingston
Nursing and Midwifery Council (NMC). (2004) Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: NMC
Nursing and Midwifery Council (NMC). (2002) Guidelines for Records and Record Keeping. London: NMC
Oxford Dictionary of Nursing. (2003) New York: Oxford University Press
Pearson, A., Vaughan, B., and FitzGerald, M. (2005) Nursing Models for Practice 3rd Edition. London: Butterworth Heinemann
Richards, A., Edwards, S. (2003) A Nurse’s Survival Guide To The Ward London:
Churchill Livingston
Roper, N., Logan, W., and Tierney, A. J. (2000) The Roper, Logan and Tierney Model of Nursing based on the activities of Living. Edinburgh: Churchill Livingston
Walsh, M. (2001) Models and Critical Pathways in Clinical Nursing. Conceptual Frameworks for Care Planning. Bailliere Tindall
STUDENT NUMBER – 200512861 FTUG
COHORT – JAN 06
TITLE – AN EXPLORATION OF A NEEDS ORIENTATED APPROACH TO CARE DELIVERY.
WORD COUNT - 3200
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