In a practical sense the model can be incorporated as a framework to allow all the health professionals to coordinate and follow the same criteria of care (NMC, 2002; Wood, 2003; Nettina, 2001). This framework is most often shaped around the systematic approach to nursing. A systematic approach to patients, by which a nurse recognises the complex biopsychosocial needs of a patient. This is key to providing individualised care, based on the uniqueness of the person (NMC, 2002; Redfern, 1996). Individualised care then is provided throughout the systematic nursing process of:-
- Assessing
- Planning
- Implementing
- Evaluating .
Diagram One; The Roper, Logan and Tierney Model of Nursing (Roper et al, 1998).
Assessment of Mr X based on the activities of living (Roper, et al., 1998)
Maintaining a safe environment:
Mr X’s ability to maintain a safe environment is diminished and needs support in carryout this activity of living.
Actual/potential problems;
Potential for injury due to decreased psychological functioning.
Disorientation to time, place and person results in potential for reduced judgement/assessment of environmental dangers, for example flights of stairs.
Poor eyesight (registered blind) potential for reduced ability to perceive potential environmental hazards.
Tendency to wander increases risk of falling in unobserved areas.
Increased frailty and reduced gross and fine motor skills increase potential risk of inability to avoid hazards or navigate environment.
Communicating:
Mr X was able to express himself well. He could easily voice his concerns or communicate his desires or needs. Sometimes, however, Mr X could be incoherent and inappropriate in his speech and lacked context in some subject matter.
Actual/potential problems:
Anxiety due to confusion in context of chain of thought and reality orientation,
Frustration due to lack of affirmation or confirmation of contextually inappropriate questions that Mr X asks staff/other residents. For example “Where is my mother, I need her?”
Potential for becoming withdrawn and losing present level of communication skills.
Breathing:
On admission respiration rate were 12 breaths per minute. Rate, depth and rhythm appeared normal (Marieb, 1989). Mr X had no medical history of respiratory problems and was a non-smoker.
Actual/potential problems:
Risk of chest infections due to reduced mobility.
Risk of ineffective respiration reduced positional mobility in bed or when seated.
Eating and drinking:
Mr X enjoyed a normal diet and had a good appetite. He had no food allergies or particular dislikes. He had close fitting dentures and maintained good oral hygiene with minimal prompting. Mr X was 5 feet 10 inches tall and weighed 11 stone giving a body mass index of 22, which is considered healthy (Heath, 2000).
Actual/potential problems:
Potential risk of loss of appetite.
Risk of poor nutrition due to reduced fine motor skills required when eating.
Potential for compromise of skin integrity due to insufficient nutrition.
Eliminating:
On the whole Mr X maintains continence independently. However, he was prone to occasional accidents, in particular at night.
Actual/potential problems:
Potential for increase in severity and frequency of urinary incontinence.
Potential for increase in severity and frequency of faecal incontinence.
Potential to loss of dignity and privacy when being supported to carryout this activity of living.
Potential for compromised peri-anal hygiene due to loss of continence and reduced ability to independently attend to activities in this area.
Potential for compromise of skin integrity due to loss continence.
Personal cleansing and dressing:
Mr X requires one to one support and assistance to carryout this activity. Close assistance required for cleansing and hygiene activities. Enjoys being assisted with a bath once or twice a week. A minimal amount of prompting required to help select garments for the day. Physical support and guidance required when putting on and taking off clothes.
Actual/potential problems:
Potential of injury due to fall whilst putting on clothes.
Potential of loss of dignity and privacy whilst being assisted with this activity of living.
Potential of loss of individuality due to potential loss of freedom to choose own clothes.
Controlling body temperature:
Temperature on admission was 36.4 Centigrade which was within normal limits (Heath, 2000). He was capable of adjusting his bed clothing to regulate his temperature in bed. During the day he was able to ask for a blankets or such like. He did not appear to have any problems with this area. The unit had climate/temperature control systems operating the heating, which tended to keep the home at a comfortable temperature.
Actual/potential problem:
Risk of overheating in bed.
Risk of becoming too cold during the night.
Risk of not being able to communicate his feeling too hot or cold during the day.
Mobilisation:
Mr X was dependent on one to one support to mobilise. Attempts to walk without assistance, frequently wandering and falling.
Actual/potential problem:
Potential to falls/injury due to; - decreased psychological function, disorientation to place, time and person, poor eyesight, diminished spatial awareness and disorientation, tendency to wandering.
Reduced gross and fine motor skills reduced physical capacity to mobilise in coordinated and steady manner.
Risk of pressure sores, chest infections or deep venous thrombosis due to periods of immobility in bed or chair.
Risk of pressure sore indicated by actual Waterlow score of 16.
Working and playing:
Most of Mr X’s time was taken up with chatting to staff and other residents in the unit. He also enjoyed talking to visitors to the unit. He occasionally enjoyed watching television. He particularly enjoyed telling stories of his time in the Far East during his army days.
Actual/potential problem:
Potential for frustration due to not being understood by other resident.
Risk of becoming socially withdrawn due to deterioration of condition.
Expressing sexuality:
Mr X appeared not to have any concerns here. Had never been married and had no recent relationships. He did take an interest in his appearance and took a fair degree of pride in being smart- and in particular clean-shaven.
Actual/potential problem:
Potential loss of sense of identity due to diminished capacity to attend to aspects of this area of concern.
Potential loss of privacy.
Dying:
Mr X had some insight into his condition but did not verbalise any concerns of his feels towards death directly. However, he did sometimes make statements that would indicate that he was sad about his situation.
Actual/potential problem:
Potential for depression due to progression of condition.
Potential for feelings of grief from loss of self due to dementia and subsequent loss of memories.
Specific Care Plan:
Pressure area care is the activity involved with minimising the risks of pressure sores developing. Pressure sores are areas of skin ulceration as a result of pressure in combination with other variables (Collier, 1996). The assessment of these variables can be quantified more objectively by using one of the pressure area risk assessment tools available, for example Waterlow, Norton and Braden (Heath, 2000).
Risk assessment scales have been devised to help assess these various factors in a systematic way. The risk assessment tool of choice in the unit was the Waterlow. See diagram 2.
Waterlow Scale Diagram 2 (Waterlow,1985).
The Waterlow scale has nine sub-sections; build/weight for height, skin type, sex/age, continence, mobility, appetite, neurological, special risks and major surgery or trauma. Ranges of numbers are used to calculate the level of risk for patients. The advantage of dividing the range into four groups; not at risk, at risk, high risk and very high risk allows a matching allocation of appropriate, cost effective preventative aids and nursing interventions (Waterlow, 1995; Maylor & Roberts 1999). Although it has been argued that most experienced nurses have the clinical judgement required to carry out risk assessment without a tool, risk scores help to support clinical decisions (Maylor & Roberts, 1999; Rycroft-Malone & McInnes 2000).
On admission to the unit Mr X scored 16 on the Waterlow scale. Although he had no breaks in his skin it was felt that the high risk score of 16 reflected concerns for him in this area voiced by his sister. By allowing consultation, with Mr X and his sister, during the assessment and planning process, interventions and goals could be agreed on a consensual and collaborative basis.
As implementation of the care plan occurs, there is evaluation of Mr X’s response to nursing interventions. The Waterlow scale is designed to be regularly reviewed in this way (Heath, 2000).
The Care Plan
Intervention One.
Problem: Actual: Mr X tends to lay in one position for long periods.
Actual: Mr X tends to fall asleep whilst seated in one position.
Potential: Increase in Waterlow scoring.
Potential: Developing pressure sores.
Goals: Long term- Minimise risk of pressure sores.
Short term- Ensure patient comfort.
Nursing action:
Reassure Mr X. Gain consent to carryout nursing interventions.
Inform Mr X of nursing interventions and relevance to his well-being.
Encourage activity, for example, changing position
2 hourly checks/repositioning.
Use pressure reducing mattress at night and pressure reducing seat mat
during the day.
Rationale:
Provision of information can be an effective coping strategy (Van Der Molen, 2000).
Frequency of re-positioning should be determined by results of regular skin inspections and not simply a ritualistic schedule (Rycroft_Malone & McInnes, 2000).
Pressure reducing equipment reduces pressure by redistribution over a greater surface area and to provide patient comfort (Rithalia & Kenny, 2000).
Intervention Two.
Problem: Actual: Waterlow score of 16. This represents high risk.
Goals: Long term- Minimise risk of pressure sores.
Short term- Ensure patient comfort.
Nursing action:
Reassure Mr X. Gain consent to carryout nursing interventions.
Assess risk to pressure areas daily using the Waterlow scale.
Rationale:
Risk assessment scoring in only useful if it is carried out regularly (Deeks, 1996).
Problem: Potential: Breakdown of skin integrity.
Potential: Increase in Waterlow scoring.
Potential: Developing pressure sores.
Goals: Long term- Maintain integrity of skin. Maintain pressure sore free
state.
Short term- Ensure patient comfort.
Nursing Action: Ensure that skin is clean and dry.
Observe pressure area for changes, for example, redness.
Assess skin integrity during personal cleansing and dressing
assistance Assess risk to pressure areas daily using the
Waterlow scale
Rationale: Friction to the skin is increased with moisture such as sweat (Alexander et al, 2000). Non-blanchable erythema of intact skin is the first stage of classification of pressure sores (NHS On-Line 2003)
Intervention Three
Conclusion
Summarising and on reflection the student realised that nurses are in a key position to make a difference when people are in their care. Facilitating processes to maximise an individual’s quality of life. Central to increasing their and their family’s satisfaction is the careful use of nursing assessment and care planning models. Roper, Logan and Tierney’s model of nursing lends itself to this individualising process. Reflecting further, the process of carrying out the care plan emphasised to the student the importance of the nurse/patient relationship. This is no better illustrated by the fact that the student favoured using a subject with whom they had a good rapport. Future action based on this reflection may involve focusing on communication skills and rapport building as an integrated part of the care planning process.
Dealing with pressure area care represents a challenge to nurses to become aware of the coping strategies, interventions and best practice available. Whilst remembering that these activities are only as effective as the assessments that underpin them. This challenge to nurses is emphasised further when one considers that on the whole the development of pressure sores is completely avoidable (Deeks, 1996). It is hoped it has been shown here that, with the proper use of nursing models, assessments and careplanning, the modern nurse is equipped with both the skills and the tools to meet that challenge.
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