Systematic approaches to client care

University Degree Subjects allied to Medicine

Zoe Hannah S0808427

Systematic Approach to Client Care

The aim of this assignment is to show the importance of a collaborative, inclusive approach to care and issues related to the context of care within a health care setting. For the purpose of this essay I will be conducting a case study. A case study is a unit of activity in the real world which exists in the here and now, and it is only possible to study in its context. It can be a study of an individual, a group, an institution and a community or multiples of each, for example a case study of many different hospitals or professions (Gillham, 2000). According to (Yin, 2003) case study research is an essential research method as it is appropriate when researchers need to study a topic in depth, and when it is critical to include complex details of a variety of conditions and have to rely on multiple sources of evidence.

As I am conducting my case study based on approach to client care, I need to seek consent from the client whom I wish to study. Informed consent is vital before individuals can take part in a research study (World Medical Association Declaration of Helsinki 1997). The Data Protection Act (1998) states that organizations have a duty of confidentiality towards their clients and any personal information held by an organization should not be shared or distributed without prior consent from the individual concerned, for example health records. It is the client’s decision to partake in any research, to gain this we must make it possible for them to give informed consent. It is important to let the client know that withholding consent will have no impact on their existing care or their future care, some people may feel obligated to consent in fear that they will face repercussions (Wilson et al. 2000). It is important to let the client know how and why their information is being shared to respect their right to confidentiality (Nursing and Midwifery Council, 2008). For the purpose of this assignment I gained consent form the client that I wish to study. From the evidence that I gather for this case study I hope to identify and plan to meet care needs based on an assessment of a client whilst providing evidence that shows that I recognise the importance of providing and maintaining accurate records.

The client that I will be basing this case study on was admitted on to the ward where I was on placement with exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Along with this he also suffers from Alcoholic Liver Disease (ALD), hypertension and is a non-insulin dependant diabetic (NIDD). For the purpose of this case study I will refer to the client as Paul in order to preserve his anonymity. Paul is 63 years old; he has been a smoker all his adult life, forty to sixty cigarettes a day. He has a history of recent alcohol excess, which he says is due to depression as a result of retiring from work in his early fifties due to health concerns, in particular COPD. I gained full consent from Paul to use his medical notes for this case study upon admission to the ward environment.

Each health organisation provides a Philosophy of Care. A Philosophy of Care statement is a core document that gives focus and direction to an organisation and provides a common basis for its decision-making (The Children’s Guardian, 2003). The aim of a philosophy of care is to create and inform a mission and it’s principles to ensure the guidance of the provision and implementation of care and the way in which we work together as part of a MDT. The Northumbria Healthcare Trust, NHS (2006) suggests that being part of a multidisciplinary team is a key aspect of client care. There is an emphasis on maintaining the quality of life experienced by the patient regardless of prognosis and preserving autonomy by addressing the physical, social and cultural needs of the client. The most effective way to do this is by working alongside and in conjunction with ward and community based colleagues, in the assessment, treatment and monitoring of patients. This will be provided in both formal and informal settings. To provide a competent and reliable philosophy of care you need to be able to work collaboratively within your team. Collaboration between health professionals is essential in ensuring quality care (Chaboyer and Pattinson, 2001). Collaborative care is a versatile organisational intervention, which could include a number of components, for example the introduction of a new role to aide the care of a client, the introduction of mechanisms to manage closer liaisons between primary care clinicians and other health specialists around individual patient care and the introduction of mechanisms to collect and share information on the progress of individual clients (Bower, et al. 2006). I relation to my client Paul, a multidisciplinary team was put into practice and implemented into his care pathway.

To ensure that Paul gets the optimum care, his care plan should include and be accessible to other health professions such as physiotherapists and smoking cessation nurses, and others relevant to Paul’s care, to gain from their expertise. This is often referred to as a multidisciplinary team (MDT). An MDT is a group of health professionals from diverse disciplines who cater to a clients individual needs to provide optimum assessment and care. An MDT programme of care for patients should be individually tailored and designed with the most relevant disciplines as part of the team to optimise each patient’s physical and social performance and autonomy (Man et al. 2004).

Upon the patients admission to the ward, I carried out a set of observations on Paul, to record blood pressure, temperature, respiratory rate, pulse and oxygen saturation levels. These observations were recorded on a Modified Early Warning Score (MEWS) chart. The NHS trust policy, Bournmouth and Christchurch Hospitals (2007) describes the MEWS chart as a measurement tool, routine observations are recorded on the MEWS chart in order to detect subtle changes in a patients physiology which will be reflected in a change of score should the patient be improving or deteriorating. The observation measurements are converted into a score, the higher the score, the more abnormal the vital signs are. If the score is three or more a doctor has to be consulted. When Paul was admitted he had a MEWS score of five due to high respiratory rate and hypertension. The on-call Doctor was called to assess Paul further. I also documented subjective data, such as how much pain Paul was in. This is subjective because it is how Paul himself assesses his pain levels, it is not something I am able to measure accurately myself. Paul’s appetite level is also something that only he can measure, as he knows what is normal for him as an individual.

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The nursing process is the assessment, planning, implementation and evaluation of patient/client care (Carpenito-Moyet, 2005). In relation to my case study the nursing process started upon admission to the ward setting. The nursing process includes regular observations, administering medications and therapies as directed and prescribed, maintaining a patients hydration levels, maintaining patency of any Intravenous (IV) access, using a holistic approach to nursing, adhering to the correct policies and procedures in relation to appropriate care pathways, adhering to the Code of Professional Conduct, liaising with other health professionals, families and relevant others and ensuring a safe and appropriate discharge ...

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As stated in my introduction, Paul was admitted to the ward with exacerbation of COPD. This condition is a term used to describe someone that suffers from chronic bronchitis and/or emphysema. Bronchitis is inflammation of the bronchi (the airways of the lungs) and emphysema is damage to the smaller airways and alveoli of the lungs. Exacerbation simply means an increase in the severity of a condition (NICE, 2004). The care pathway that I used in the ward environment was presented in a flow chart (Pathway for the Management of Acute Exacerbation of COPD. NHS Trust, 2008). The first stage was to assess the patient in relation to age, if they’re a smoker, and what symptoms they are presenting. If they are a smoker the care pathway suggests that a referral to a smoking cessation nurse should be arranged if appropriate. Paul agreed to an appointment with the smoking cessation nurse and was prescribed high strength nicotine patches; this was documented in his notes for the nursing team to facilitate treatment. By using a holistic approach to nursing I asked Paul if he would like me or the other nurses to intervene when we see him going off the ward for a cigarette, whilst he agreed that this might help, he suggested that we ask each time we see him going off the ward as he may feel differently later on, this meant that we were able to use health promotion and encourage Paul not to go for a cigarette but he still kept his autonomy by having the right to refuse the suggestion and advice. This conversation was also added to the notes to make sure all the health professionals knew the level of intervention. The next stage of the care pathway is investigatory procedures to assess the severity of the exacerbation of COPD. This includes thorax X-Rays, steroid trials and serial peak flows, these investigations can also rule out asthma. Upon completion of the investigatory stage treatment, as directed by the medical team, can commence. Paul was placed on oxygen therapy and ‘Salbutamol’ nebulisers to stabilize his COPD. The care pathway can also be used in a community setting, in this case it was not appropriate as Paul was not coping at home and had a degree of confusion along with an increased respiratory rate and low oxygen saturation levels in his blood. Because Paul is not coping at home and was unsteady on his feet due to his shortness of breath, I referred him to the physiotherapist and occupational therapist (OT) teams to assess him. Their findings were recorded in the patients shared notes and the appropriate actions were taken, for example to provide adaptations to Paul’s home and he was issued a Zimmer frame.

Paul has a history of excessive alcohol consumption; this excess has meant that he now suffers from Alcoholic Liver Disease (ALD). It is important to include this ailment as part of Paul’s care pathway in order to try and stabilise the condition and to assess the amount of damage to the liver. This being part of the care pathway will mean that all health professionals involved with Paul’s care will be kept informed. It is important to keep everyone involved to avoid complications, such as counteracting treatments or advice, for example Paul’s care could have been compromised had one profession given him advice on how he should restrict his movement but had this not been documented a different health professional could have also given him advice on his movement, whether the advice be conflicting or not. It would also be difficult to know if Paul was adhering to medical advice if the recommendations given to Paul were not communicated to other health professionals. According to Björvell (2000) the main benefit of the shared nursing notes is to improve the standard of structured communication between healthcare professionals to ensure the continuity of individually planned patient care. As part of Paul’s care pathway we stated that ‘investigations are to be carried out as directed by medical team.’ The Consultant recorded that because Paul has alcoholic liver disease, his hypertension can be an indication of cirrhosis of the liver. It was also recorded that Paul should have an investigatory Computed Tomography (CT) abdomen and an ultrasound to confirm prognosis. After the CT abdomen, it was recorded that Paul did have cirrhosis of the liver. Cirrhosis is the development of scar tissue within the liver from an underlying cause (Nursing Times, 2002). In this case the cause is ALD. Paul’s consultant then preformed an oesophagogastroduodenoscopy (OGD) to assess the level of damage to the liver and to rule out the possibility of oesophageal varices (Pugh, Murray-Lyon, 1973). To record the level of damage to the liver due to cirrhosis we use the Child-Pugh score (Child and Turcotte, 1964 and Pugh, 1973). The Child-Pugh score uses five variables to assess the severity of liver cirrhosis; this includes checking the severity of ascites and of encephalopathy, abnormality in the serum bilirubin, serum albumin and clotting times and a score of one to three is assigned to each variable. This provides a final score that can be used against the Child-Pugh Grade. The Grade uses classifications of A, B or C. with A being the least severe to C being the most severe level of cirrhosis. The grade is then used to determine what course of action is needed to stabilize the condition (Bhikha, 2009). Paul scored 9 on the Child-Pugh Grade which equates to the classification of B. Because Paul’s liver disease and liver cirrhosis was brought on by excessive alcohol consumption the first action directed by the consultant was alcohol detoxification and for Paul to stop drinking alcohol permanently. This was recorded in Paul’s notes to communicate the diagnosis and treatment to other members of the MDT. To help Paul stop drinking alcohol we referred him to Cumbria Community Drugs and Alcohol Service (CCDAS). The aim of CCDAS is to help people abstain from drugs and alcohol by providing assessment and treatment from those dependant on drugs and alcohol. They provide medical and psychological treatment along with health promotion to educate clients on the risks of continuing with their current lifestyle (CCDAS, 2008). This is based on a holistic approach to cater for each individuals needs to ensure the best recovery (Cumbria Partnership NHS Trust, 2008). CCDAS will also help Paul with the underlying cause for his need to drink alcohol, which he believes is depression due to early retirement.

Because Paul is a non-insulin diabetic, part of his care plan is to make sure his glucose levels are stable. This includes regular blood glucose measurements using a Glucometer and ensuring an appropriate dietary intake. We would use the Glucometer to test Paul’s Blood sugar (glucose) levels between three and five seven times per day depending on the degree of irregularity. When Paul was first admitted to the ward his glucose levels in his blood were low, he admitted he hadn’t eaten properly due to being ill. To raise these levels we gave Paul some toast and a ‘Lucozade’ drink. This raised the levels sufficiently. To ensure Paul had the right information on how to manage his diabetic diet we referred him to the dietician team that is based at the hospital in which the ward is contained. Due to the close proximity of the dietician team Paul could be seen and assessed by a dietician that same day. This increased the effectiveness of the advice, as it is possible that had Paul’s Glucose levels stayed stable he would have been less compliant with the advice given to him. As his glucose levels were low it can be argued that he was more inclined to listen, as there was a problem of low blood glucose levels to solve. According to an article in ‘Diabetologia’ (Brinkworth et al 2004) compliance to advice increases when a specialist provides the advice and information, in this case the specialist was a dietician. As being part of the multi-disciplinary team that is providing care for Paul, the dietician would provide an account of the assessment and outcome from the appointment with Paul in his medical notes to ensure that all other professionals that are part of the multi-disciplinary team are aware of any actions. In this case we were all informed that Paul has been placed on a fluid and diet chart to monitor daily intake and elimination. Sharing notes with all of the MDT is a form of collaboration; this implies interdependence and relies on mutual respect and understanding of the individual and complementary contribution each professional makes to achieve the desired care outcomes (Begley, 2003).

According to the American Holistic Nurses Association (2001) a holistic nurse is an instrument of healing and a facilitator in the healing process. It is a nurses’ duty to honor the individual's subjective experience about health, health beliefs, and values. To achieve this they must liaise with therapeutic partners, individuals, families, and communities. Holistic nurses draw on nursing knowledge, theories, research, expertise, intuition, and evidence based practice. Holistic nursing practice encourages reflection of professional practice in various clinical settings and integrates knowledge of current professional standards, law, and regulations governing nursing practice. Research by Frisch (2001) states that practicing holistic nursing requires nurses to integrate self-care, self-responsibility, spirituality, and reflection in their lives. This may lead nurses’ to greater awareness of self, others and nature. This awareness may further enhance the nurse's understanding of all individuals and their relationships to the clients/patients and the community, and permits nurses to use this awareness to facilitate the healing process (Gadsby, 2007). In the case of caring for a patient, a holistic approach is important to understand why a certain treatment is being used and if an alternative would be better for that individual patient. Hunter (2009) suggests that a holistic approach to nursing can aid decisions on best treatment course, for example the use of non-invasive ventilation as opposed to pharmaceutical management. Being holistic means taking into account the patient’s psychologyical, physical, social and spiritual well being however Hunter, (2009) suggests that o be a holistic nurse it is important to be vigilant with patient assessments in order to avoid contradictions in treatments and to provide the best course of treatment for the individual patient, it is important to treat the patient and not the diagnosis.

Accurate record keeping is essential for all health professionals. Legislation such as the Human Rights Act (1998) and the Data Protection Act (1998) have increased application to medical records so it is important to follow the guidelines stated in the ‘Code of Professional Conduct’ set by the Nursing and Midwifery Council (NMC, 2008). The ‘Code of Professional Conduct’ states that the health care record for the client is an accurate account of treatment, care planning and delivery. It should provide clear evidence of the care planned, the decisions made, the care delivered and the information shared'. It should be written with the involvement of the patient or client wherever feasible and completed as soon as possible after an event has occurred. This code of practice is to protect both the client and the health professional from both legal issues and care and treatment issues (Wood, 2003). Accuracy in record keeping is stated in the Code of Professional Conduct. Colleagues rely on information in medical notes when they take over the care or are involved in the care in some other aspect. Health professionals should be able to be fully informed of a patients care through record keeping in order to provide seamless care for the patient (Wood, 2003). For example, Paul was transferred to a cottage hospital for rehabilitation. It was vital for Paul’s care that health professionals at the cottage hospital could rely on the nursing and medical notes that were provided by the MDT caring for Paul whilst on the ward. The factors that aid holistic nursing is looking at the patient or client’s individual physical, spiritual, psychological, environmental and social needs.

Upon evaluation of Paul’s care whilst on the ward, I found his care pathways(diabetes) and care plans to be appropriate, accurate and up to date. I was lucky enough for members of the MDT, that I was a part of, all placed a high importance of accurate record keeping and there was adequate input in the shared nursing notes. This made it possible to provide seamless care for Paul. I also found that staff reviewed Paul’s notes and care package regularly, for example there was an MDT meeting once a week with an advocate from each discipline attending. And after every consultation or treatment development with Paul, the outcome was documented.

In conclusion this essay has highlighted the importance of having a holistic approach to nursing, good record keeping, collaborative care and working as part of an MDT. The case study showed how these elements of nursing practice can be applied to a health care setting and why we need to apply them. The case study has also made it possible to show implications to practice if there are breaks in communication between members of the MDT, had outcomes of assessments not been documented it could have been difficult to understand what nursing care to provide for Paul, for example if the results of his blood glucose levels not been documented I would not have known what dietary advice to give Paul, such as advising him to have a sugary snack if his blood glucose levels were low. Good communication between members of the MDT is vital to ensure optimal and appropriate care is possible in all areas of care. From discussing this in my essay, I understand the importance and can implement this in future practice. I have also developed my understanding of holistic care, to implement this into future practice I will spend more time with patients in order to find out how their MDT treatment if affecting them and to see if they are adhering to medical advice, I have chosen this as an area of development as I have learned that knowing more about patients can give much more of an insight into how they are responding to treatments, coping with diagnosis and how their time in hospital could be made better. Paul had no complaints about his stay on the ward but by knowing more about him I knew why he drank excessive amounts of alcohol, his level of addiction to cigarettes and his level of commitment to stopping smoking and drinking alcohol. Whilst respecting Paul’s autonomy and right to refuse consent, treatment and health promotion.

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