This assignment will use a holistic problem-solving approach to analyse how nursing skills and psychosocial theories can be steely utilised to deliver effective nursing care and effective assessment, planning and evaluation of care influences the patient experience. The importance of stroke management and the prevention of further reoccurrence will addressed and elaborate upon. The assignment will highlight the holistic role of nurses in nursing for a patient with stroke within the first 72 hours – the acute phase. In addition, the importance role of multi-disciplinary team and the effectiveness of communication role of the nurse will be viewed.
Overview of CVA
Jean was diagnosis with massive ischemic stroke which is inadequate blood flow to the part of the brain and consequently has suffered loss of mobility, permanent loss of movement and loss of communication. Ischemia stoke is a life-threatening event in which part of the brain does not receive enough oxygen due to a blood clot lodged in the cerebral artery, as a result the brain is deprived of oxygen, due to hypoperfusion, hypoxia, and eventual cell death secondary to a failure of energy production.
The blood clot may have formed in a thrombus to narrowed due atherosclerosis which is the hardening of the arteries causing a thrombotic stroke or the blot clot may have lodge in artery after travelling through bloodstream from another part of the body which will result in an embolic stroke. Deficits from stroke may involve weakness or paralysis, decreased sensation, decreased memory, decreased ability to think, speak, or eat (REF). Therefore a thorough understanding of stroke’s pathphysiology, presentation, investigation, current and future treatments and holistic management is crucial for nurses.
Brief account of CVA
It is important for nurses to understand the anatomy and physiology of normal brain function in order to understand why stroke/cerebral vascular accident occur. Brain tissue needs a constant supply of oxygen and nutrients to keep nerve cells and other parts of the tissue alive and functioning. The brain relies on a network of blood vessels to provide it with blood that is rich in oxygen. A stroke occurs when one of these blood vessels becomes damaged or blocked, preventing blood from reaching an area of the brain. When that part of the brain is cut off from its supply of oxygen for more than three to four minutes, it begins to die.
Cerebrovascular accident (CVA) is a disruption of blood circulation to the brain or commonly known as stroke. Stroke is a condition in which neurological deficits occur as a result of decreased blood flow to localized area of brain tissue. There are two kinds of strokes – ischemic and hemorrhagic. Ischemic is where clot forms in a blood vessel of the brain, preventing blood flow and oxygen while hemorrhagic is where a blood vessel in the brain ruptures, releasing blood. In both kinds of strokes, the longer the patient waits before getting medical attention, the more tissue in the brain that dies.
“Massive stroke” refers to a stroke in which many brain tissues have died, causing irreversible damage. A hemorrhagic stroke, or cerebral hemorrhagic, occurs when a blood vessel in the brain ruptures or bleeds. Like ischemic strokes, hemorrhagic strokes interrupt the brain’s blood supply because the bleeding vessel can no longer carry the blood to its target tissue. In addition, blood irritates brain tissue, disrupting the delicate chemical balance, and, if the bleeding continues, it can cause increased intracranial pressure which physically impinges on brain tissue and restricts blood flow into the brain. In this respect, hemorrhagic strokes are more dangerous than ischemic strokes. There are two types of hemorrhagic stroke: intracerebral hemorrhage, and subarachnoid hemorrhage (REF)
Intracerebral hemorrhage is bleeding directly into the brain tissue, forming a gradually enlarging hematoma (pooling of blood). It generally occurs in small arteries or arterioles and is commonly due to hypertension, trauma, bleeding disorders, angiopathy, illicit drug use for example amphetamines or cocaine, and vascular malformations. The hematoma enlarges until pressure from surrounding tissue limits its growth, or until it decompresses by emptying into the ventricular system and cerebrospinal fluid. A third of intracerebral bleed is into the brain’s ventricles.
Subarachnoid hemorrhage is bleeding into the cerebrospinal fluid of the subarachniod space surrounding the brain. The two most common causes of subarachnoid hemorrhage are rupture of aneurysm ( a bulge in a blood vessel that bursts usually near the brain) from the base of the brain and bleeding from vascular formations near the pial surface. Bleeding into the cerebralspinal fluid from a ruptured aneurysm occurs very quickly, causing rapidly increased intracranial pressure. The bleeding usually only lasts a few seconds but rebleeding is common. Death or deep coma ensues if the bleeding continues. Hemorrhage from other sources is less abrupt and may continue for a longer period of time.
This type of stoke is caused mostly by hypertension which is increased systolic and diastolic blood pressure which is associated with damage to all blood vessels, including the cerebral vessels. There are other factors which may contributes to hemorrhagic cerebral vascular accident include ruptured intracranial aneurysms, embolic cerebral vascular accident, brain tumours, anticoagulant therapy and (REF).
Other risk factors for stroke involve age and sex. The risk of stroke increases with increasing age, doubling for each decade after age 55. Women are more likely to have a stroke than men. This is because strokes mostly happen in the older ages. Woman have longer life expectancy that men, which them longer lives that lead to old age and therefore experience stroke. However, men who were stricken by stroke at their early age increase their risk due to their drinking and eating habits as well as smoking, of which both reflect their lifestyle. On the other hand, Heredity blacks, Asians, and Hispanics all have higher rates of stroke than do whites, related partly to higher blood pressure, but researchers still haven’t known the association of these particular populations which having stroke more frequently.
People with a family history of stroke are at greater risk., predisposing diseases or other medical conditions, and lifestyle choices. Stroke risk is increased for people with heart disease (especially atrial fibrillation), prior stroke, or Transient Ischemic Attack (TIA). Risk of stroke increases tenfold for someone with one or more TIAs. This is because TIA’s are often caused by a clotting in a persons blood vessel or artery which may develop slowly or rapidly. According to the Office of Communications and Public Liaison (2007), TIA’s are tell-tale signs of a more serious stroke caused by high blood pressure, cigarette smoking, heart disease, carotid artery disease, diabetes, and heavy use of alcohol.
Occurrence of TIA’s should be immediately consulted to the doctor since this can occur once, multiple times, or precede a permanent stroke. According to MedicineNet Inc. (2002), TIA’s can damage body parts such as:
“a clot to the eye (which) can cause temporary visual loss, involves the carotid artery that produce problems with movement or sensation on one side of the body, paralysis of the arm, leg, and face, all on one side, double vision, dizziness (vertigo) and loss of speech, understanding, and balance.”
Stroke risk also increases with obesity, high blood cholesterol level, or high red blood cell count, diabetes and lifestyle choices such as cigarette smoking (especially if combined with the use of oral contraceptives), low level of physical activity, alcohol consumption above two drinks per day, or use of cocaine or intravenous drugs.
Stroke and diabetes
Diabetes mellitus is a metabolic disorder, specifically affecting carbohydrate metabolism. It is a disease characterised by persistent hyperglacemia also refer to as high glucose blood sugar. People with diabetes are at increased risk of stroke because diabetes adversely affects the arteries, predisposing them to atherosclerosis or hardening of the arteries (REF). Multiple studies have shown that people with diabetes are at greater risk for stroke compared to non-diabetics regardless of the number of risk factors they have. Overall, the risk of cardiovascular disease like stroke is two and a half times higher in men and women with diabetes compared to people without diabetes.
According to a study carried out in Sweden by Sundquist, Johansson & Sundquist (2006), it was found that young to middle-aged persons with type 1 diabetes had a considerably higher risk of developing premature stroke than those without type 1 diabetes. Therefore it is important that nurses and other physicians should be aware that young to middle-aged persons with type 1 diabetes need specific attention to reduce the risk of premature stroke. In addition, middled-aged persons is twice as prone to stroke than those who already have a heart attack.
In this case, diabetics should be very very careful with their health and diet for the risk is much more dangerous in the second stroke attack. It will eventually lead to death. National Diabetes Information Clearinghouse (2005) explained the connection between diabetes, heart disease, and stroke which says that:
“High blood glucose levels over time can lead to increased deposits of fatty materials on the insides of the blood vessel walls. These deposits may affect blood flow, increasing the chance of clogging and hardening of blood vessels (atherosclerosis).”
However, in a literature review by Mankovsky and Ziegler (2004) it was stated that there is convincing evidence suggesting that diabetes mellitus represent a strong independent risk factor of stroke even though the contribution of hyperglycaemia to increase stroke is not proven but it was proven by Tuomiletho et. al (1996) that people with diabetes who have a stroke often fare worse than non-diabetics as they have higher hospital stay, long term stroke mortality and pronounced residual neurological deficits, severe disability and prolonged hospital stay after stroke compared to patients without diabetes.
Signs & symptoms
The symptoms of stroke depend on the type of stroke and the area of the brain affected. Ischemic strokes usually only affect regional areas of the brain perfused by the blocked artery while hemorrhagic strokes can affect local areas, but often can also cause more global symptoms due to bleeding and increased intracranial pressure. Depending on the severity of the stroke, patients can experience a loss of consciousness, cognitive deficits, speech dysfunction, limb weakness, hemiplegia, vertigo, lower cranial nerve dysfunction, gaze deviation, ataxia, hemianopia, and aphasia among others. Among others, sudden weakness or numbness of your face, arm, or leg on one side of your body, sudden confusion, trouble talking, or trouble understanding, sudden dizziness, loss of balance, or trouble walking, sudden trouble seeing out of one or both eyes or sudden double vision and sudden severe headache may mean that you have had a stroke.
Stroke Impacts and Complications
Strokes are deadly or fatal. Aside from the high cost of hospitalization, medicines and caregivers, it will cause loss of work, enjoyability and quality of lifestyle and loss of independence. During these attacks, the weakness or numbness of your face, arm, or leg on one side of your body will have an impact in the patients muscles resulting to difficulty in swallowing. The abnormal swallowing then affects the way the patient talks which is characterized by slurred speech. If not taken well care of, the swallowed food or saliva will instead go down into the wind pipe which will develop into pneumonia making the patient more fragile.
During an acute ischemic stroke the brain stem may have a very clog vein and blood flows very slowly which puts the patient in a state of comatose. This is the state of unconsciousness, where the patient cannot awaken nor fail to respond to any interactions around and towards him. He is a vegetative state that he cannot react even to pain. Malik and Hess (2002) described coma due to ischemic stroke as:
“Large middle cerebral artery infarction with brain herniation, brainstem stroke involving bilateral rostral pons or midbrain and “Top of the basilar” syndrome with bilateral infarction of thalami and rostral midbrain.”
They further described coma as Coma results from one of two pathophysiologic mechanisms: a diffuse insult to both cerebral hemispheres or a focal lesion involving the ascending reticular activating system (ARAS) located in the upper pons, midbrain, and diencephalon. A lesion in one cerebral hemisphere will not produce coma; bihemispheric dysfunction is required. In most studies of comatose patients, the “big three” causes of coma are stroke, cranial trauma, and drug intoxication. Many stroke patients are left with permanent problems such as hemiplegia (weakness on one side of the body), aphasia (difficulty or the inability to speak), or incontinence of the bowel and/or bladder. A significant number of persons become unconscious and die following a major stroke. (MedicineNet, 2002)
During the stage of healing, a stroke patient constantly lays in bed and prolonged immobility which will sometimes develop pressure sores. Pressure sores are breakdown of the skin, called decubitus ulcers. This happens when the skin that is constantly pressured cuts off the flow of blood to that area, blocking oxygen and vital nutrients from maintaining healthy tissue. When the tissue becomes starved to too long a period of time it begin to die and a pressure sore starts to form. Pressure Sore is serious and therefore, should not be ignored before it gets worst and goes down into the bones. With this pain and abnormalities appearing in the patients body, he will not only be sick physically but also emotionally. These patients are very prone to depression.
Communication with patient
After the trauma of stroke getting the right information is vital for the best recovery. And some of that information can quite literally help patient to with psychological effect of stroke and save save life (). Moreover, Nurses in the Untied Kingdom have a professional responsibility to ensure that patients in there are given information about their condition and understand the risks and implications of any intervention required. Nurses also have a responsibility to gain the consent of patients for whom they are a duty of care (NMC 2002).
There have been many organizations that focus on the needs of the ill older adults. NHS organizations in England recognizes the importance of the NSF for Older People and the emerging practice and policies related to this, such as Intermediate Care, the single assessment process, the 1999 Health Act Flexibilities and has responded by re-focusing its activity to realign more closely with the local and national priorities. (Department of Health, 2005) Published in 2001, this NSF focuses on people who are over 50 and still active but who need to be able to maximize and maintain their health as well as people with age related needs who may have more complex social and medical problems. (Department of Health, 2005)
The Department of Health, Services and Social Safety applies palliative care services which aims to achieve the best quality of life possible for patients and their family through active identification, holistic assessment and appropriate management of problems, when progressive advanced disease is not responsive to curative treatment.
A stroke is an interruption of the blood supply to any part of the brain. This causes parts of the brain to die from lack of oxygen. A “massive” stroke would be where a large area of brain has died. Symptoms would depend on what area of the brain is affected but a massive stroke would be very damaging. Holistic care provides a comprehensive check up and caring for a person with illness. While it has been a practice to treat an illness separately, holistic approach can very well trace prevent or cure other related problems which also affects the health problem. Through holistic care plans, it gives the patient a sense of ownership of which, when educated, the patient will be well aware of the symptoms, cause and effect of a certain problem. The sense of ownership will encourage a patient to cure himself and prevent further damage to ones health.
Healthy communication with the patient and healthy environment keeps the patient’s mind active and stimulated. Here Nightingale stresses that communication should be soothing and a form of therapeutic aid to the patient’s suffering. How the nurses interact with the patient, may it be verbally or non-verbally also plays a role in the patient’s recovery. They were to give comfort and ease the patient’s suffering. She adds that there is a need for social awareness or social education on the disease of the patient, his family or the immediate people of that environment
Nurses are there to control the environment and give the patients their basic needs to aid patients in their healing process and achieving their former strength. Nurses are not only to be focused on controlling the environment for the patient, but also in disseminating helpful information about the important aspects of the disease to the patient, the family and immediate community. Within Nightingale’s nursing theory are the assumptions that are significant to applying the theory. First and foremost, Nightingale stresses on the need to understand that a disease is a reparative process. An inflicted goes through the natural healing process and those sufferings are indications of the body healing itself. The patient then needs energy to deal with this healing and an unhealthy environment will only bring him stress and lessen his much needed energy to recuperate.
Another is the need for a nurse to be sensible and highly observant of his patient. If a nurse has these abilities, then she will be more focused and effective in her goal of balancing the right and healthy environment for the patient. Nursing is a calling to those who have the determination to help. A sensible nurse would take the initiative to think ways of keeping the patient’s mind active and optimistic despite his sufferings. Nightingale also gives emphasis on the important fact that nursing is a practice apart from medicine. The nurse’s concentration is on the patient’s reparative process and not the disease itself.
- Department of Health. (2005) R&D annual reports by NHS organisations in England for 2005. Department of Health [online] Retrieved February 6, 2007 from:<http://www.nrr.nhs.uk/2005AnnualReports/ProgrammeSameID Records.asp?Code=5EY&Title=Older+Persons>
- Malik, K. and Hess, D. (2002). Evaluating the comatose patient: Rapid neurologic assessment is key to appropriate management. Post Graduate Medicine. Volume 3. Retrieved February 8, 2007 from http://www.postgradmed.com/issues/2002/02_02/malik.htm
- Mankovsky, B. and Ziegler, D. (2004) Stroke in Patients with Diabetes Mellitus. Institue of Endocrinology. Ukraine. Retrieved February 8, 2007 from http://www.strokesurvivors.ca/pdf/diabetes_stroke.pdf
- MedicineNet. (2002). Stroke. MedicineNet, Inc. Retrieved February 8, 2007 from http://www.medicinenet.com/stroke/page7.htm
- National Diabetes Information Clearinghouse. (2005). Diabetes, Heart Disease, and Stroke.NIH. Retrieved February 8, 2007 from http://diabetes.niddk.nih.gov/dm/pubs/stroke/#connection
- Nightingale, F. (1860). Notes on Nursing: What it is, and What it is not. A Celebration of Women Writers. [online] Retrieved February 5, 2007 from <http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html>
- Nursing and Midwifery Council (2002). Code of Professional Conduct. London, NMC Office of Communications and Public Liaison. (2007). NINDS Transient Ischemic Attack Information Page. National Institute of Neurological Disorders and Stroke. Retrieved February 8, 2007 from http://www.ninds.nih.gov/disorders/tia/tia.htm
- Sundquist, J. , Johansson, S.E., Sundquist, K. . (2006). Type 1 Diabetes as a Risk Factor for Stroke in Men and Women Aged 15-49: A Nationwide Study from Sweden. KAROLINSKA INSTITUTE . Retrieved February 8, 2007 from http://www.eurostroke.org/br_asp/br_oral_3.asp
- Tuomiletho, J, Hodge, AM, Dowse, GK, Gareeboo, H, Alberti, KGMM, Zimmet, PZ (1996) Incidence, increasing prevalence, and predictors of change in obesity and fat distribution over 5 years in the rapidly developing population of Mauritius Int J Obes 20,137-146
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Assessment and Care Planning: Holistic Assessment
rodrigo | December 22, 2016
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This essay deals with the holistic assessment of a patient who was admitted onto the medical ward where I undertook my placement. Firstly, the relevant life history of the patient will be briefly explained. Secondly, the Roper, Logan and Tierney model of nursing that was used to assess the care needs of the patient will be discussed, and then the assessment process will be analysed critically. Identified areas of need will be discussed in relation to the care given and with reference to psychological, social, and biological factors as well as patho-physiology. Furthermore, the role of inter-professional skills in relation to care planning and delivery will be analysed, and finally the care given to the patient will be evaluated.
Throughout this assignment, confidentiality will be maintained to a high standard by following the Nursing and Midwifery Council (NMC) Code of Conduct (2008). No information regarding the hospital or ward will be mentioned, in accordance with the Data Protection Act 1998. The pseudonym Kate will be used to maintain the confidentiality of the patient.
Kate, a lady aged 84, was admitted to a medical ward through the Accident and Emergency department. She was admitted with asthma and a chest infection. She presented with severe dyspnoea, wheezing, chest tightness and immobility. Kate is a patient known to suffer from chronic chest infections and asthma, with which she was diagnosed when she was young. She takes regular bronchodilators and corticosteroids in the form of inhalers and tablets. Kate lives on her own in a one bedroom flat. She has a daughter who lives one street away and visits her frequently. Her daughter stated that Kate has a very active social life; she enjoys going out for shopping using a shopping trolley.
Assessment of the Patient
In this ward, the Roper, Logan and Tierney model of nursing, which reflects on the twelve activities of living, is used as a base for assessing patients (Alabaster 2011). These activities are “maintaining safe environment, communication, breathing, eating and drinking, elimination, personal cleansing and dressing, controlling body temperature, mobility, working and playing, sexuality, sleeping, and dying” Holland (2008, p.9).
Elkin, Perry and Potter (2007) outlined nursing process as a systematic way to plan and deliver care to the patient. It involves four stages: assessment, planning, implementation and evaluation. Assessment is the first and most critical step of the nursing process, in which the nurse carries out a holistic assessment by collecting all the data about a patient (Alfaro-Lefevre 2010). The nurse uses physical assessment skills to obtain baseline data to manage patients’ problems and to help nurses in the evaluation of care. Data can be collected through observation, physical assessment and by interviewing the patient (Rennie 2009). A complete assessment produces both subjective and objective findings (Wilkinson 2006). Holland (2008) defines subjective data as information given by the patient. It is obtained from the health history and relates to sensations or symptoms, for example pain. Subjective data also includes biographical data such as the name of the patient, address, next of kin, religion etc. Holland defines objective data as observable data, and relates it to signs of the disease. Objective data is obtained from physical examination, for example of blood pressure or urine.
Before assessment takes place, the nurse should explain when and why it will be carried out; allow adequate time; attend to the needs of the patient; consider confidentiality; ensure the environment is conducive; and consider the coping patterns of the patient (Jenkins 2008). The nurse should also introduce herself to help reduce anxiety and gain the patient’s confidence. During assessment, the nurse needs to use both verbal and non-verbal communication. Using non-verbal communication means that she should observe the patient, looking at the colour of the skin, the eyes, and taking note of odour and breathing. An accurate assessment enables nursing staff to prioritise a patient’s needs and to deal with the problem immediately it has been identified (Gordon 2008). Documentation is also very important in this process; all information collected has to be recorded either in the patient’s file or electronically (NMC, 2009b).
Carrying out the Assessment
Kate was allocated a bed within a four-bed female bay. Her daughter was with her at the bedside. Gordon (2008) stated that understanding that any admission to hospital can be frightening for patients and allowing them some time to get used to the environment is important for nursing staff. Kate’s daughter was asked if she could be present while the assessment was carried out, so that she could help with some information, and she agreed. Alfaro-Lefevre (2008) recommended that nursing assessments take place in a separate room, which respects confidentiality, and that the patient be free to participate in the assessment. Although there was a room available, Kate’s daughter said it was fine for the assessment to take place at the bedside because her mother was so restless and just wanted to be next to her. The curtains were pulled around the bed, though William and Wilkins argued that it ensures visual privacy only and not a barrier to sound. NMC (2009a) acknowledges this, along with the need to speak at an appropriate volume when asking for personal details to maintain confidentiality.
The assessment form that was used during Kate’s assessment addressed personal details and the twelve activities of living. A moving and handling assessment form was also completed because of her immobility. First, personal details such as name, age, address, nickname, religion, and housing status were recorded. Information was also recorded about any agency involved, along with next of kin and contact details, and details of the general practitioner. Holland (2008) stated that these details should be accurate and legible so that, in case of any concerns about the patient, the next of kin can be contacted easily. The name and age are also vital in order to correctly identify the patient to avoid mistakes. Knowing what type of a job the patient does or the type of the house she lives in helps to indicate how the patient is going to cope after discharge. Holland also insisted that religion should be known in case the patient would like to have some privacy during prayers, and this should be included in the care plan.
The second assessment to be done focused on physical assessment and the activities of living. Barrett, Wilson and Woollands (2009) suggested that when enquiring about the activities of living, two elements should be addressed: usual and current routines. Additionally, identifying a patient’s habits will help in care planning and setting goals. During physical assessment, when objective data was collected, Kate demonstrated laboured and audible breath sounds (wheezing) and breathlessness. Use of accessory muscles and nose flaring was also noted. She was agitated and anxious. Her vital signs were: blood pressure 110/70; pulse 102 beats /min; respirations 26/min; temperature 37.4 degrees Celsius; oxygen saturation 88%; peak flow 100 litres; weight 60kg; and body mass index 21. Taking and recording observations is very important and is the first procedure that student nurses learn to do. These observations are made in order to detect any signs of deterioration or progress in the patient’s condition (Field and Smith 2008). Carpenito-Moyet (2006) stated that it is important to take the first observations before any medical intervention, in order to assist in the diagnosis and to help assess the effects of treatment.
Kate’s initial assessment was carried out in a professional way, taking account of the patient’s particular circumstances, anxieties and wishes. After the baseline observations were taken, the twelve activities of living were analysed and Kate’s needs were identified. Among the needs identified, breathing and personal hygiene (cleansing) will be explored.
Identified Care Needs
Wilkinson (2006) states that a nursing diagnosis is an account about the patient’s current health situation. The normal breathing rate in a fit adult is 16-20 respirations/minute, but can go up to 30 due to pain, anxiety, pyrexia, sepsis, sleep and old age (Jenkins 2008). In old people, muscles become less efficient, resulting in increasing efforts to breathe, causing a high respiratory rate. On assessment, Kate’s problem was breathing that resulted in insufficient intake of air, due to asthma. She was wheezing, cyanosed, anxious and had shortness of breath.
Wilkinson (2006) explained that a goal statement is a quantifiable and noticeable criterion that can be used for evaluation. The goal statement in this case would be for Kate to maintain normal breathing and to increase air intake. The prescription of care for Kate depended on the assessment, which was achieved by monitoring her breathing rate, rhythm, pattern, and saturation levels. These were documented hourly, comparing the readings with initial readings to determine changes and to report any concerns. The other part of the plan was to give psychological care to Kate by involving her in her care and informing her about the progress, in order to reduce anxiety. Barrett, Wilson and Woollands (2012) stated that it is very important to give psychological care to patients who are dyspnoeic because they panic and become anxious.
Checking and recording of breathing rate and pattern is very important because it is the only good way to assess whether this patient is improving or deteriorating, and it can be a very helpful method for nurses to evaluate whether or not the patient is responding to treatment (Jamieson 2007). Mallon (2010) stated that, if the breathing rate is more than 20, it indicates the need for oxygen. Blows (2001), however, argued that this can happen even after doing exercise, not only in people with respiratory problems. Griffin and Potter (2006) stated that, respirations are normally quiet, and therefore if they are audible it indicates respiratory disease. Nurses needs to be aware of these sounds and what they mean, for example a wheezing sound indicates bronchiole constriction. Kate’s breathing was audible and the rate was also above normal and that is why breathing was prioritised as the first need.
Oxygen saturation level was also monitored with the use of a pulse oximeter. The normal saturation level is 95-99% (British National Formulary ((BNF)) 2011a). Nevertheless the doctor said that 90-95% was fine for Kate, considering her condition and her age. Kate was started on two litres of oxygen and she maintained her oxygen saturation between 90 and 94%. The peak expiratory flow was monitored and recorded to identify the obstructive pattern of breathing that takes place in asthma (Hilton, 2005). This is another method that is used to assess the effectiveness of the medication (inhalers) the asthmatic patient is taking, and this test should be carried out 20 minutes after medication is administered. It is the Trust’s policy to do hourly observations on patients who have had one, two or three abnormal readings, until readings return to normal. Kate was observed for any blueness in the lips and tongue and for oral mucosa as this could be a sign of cyanosis. All the prescribed nebulisers, inhalers, bronchodilators, corticosteroids, antibiotics and oxygen therapy were administered according to the doctor’s instructions. Bronchodilators are given to dilate the bronchioles constricted due to asthma, and corticosteroids reduce inflammation in the airway (BNF 2011b). Kate was also started on antibiotics to combat the infection because, on auscultation, the doctor found that the chest was not clear.
Kate was nursed in an upright position using pillows and a profiling bed in order to increase chest capacity and facilitate easy respiratory function by use of gravity (Brooker and Nicol, 2011). In this position, Kate was comfortable and calm while other vital signs were being checked. Pulse rate and blood pressure were also being checked and recorded because raised pulse can indicate an infection in the blood.
Due to breathlessness and loss of mobility it was difficulty for Kate to maintain her personal hygiene. Hygiene is the practice of cleanliness that is needed to maintain health, for example bathing, mouth washing and hair washing. The skin is the first line of defence, so it is vital to maintain personal cleansing to protect the inner organs against injuries and infection (Hemming 2010). Field and Smith (2008) stated that personal cleansing also stimulates the body, produces a sense of well-being, and enables nurses to assess the patient holistically. Personal hygiene is particularly important for the elderly because their skin becomes fragile and more prone to breaking down (Holloway and Jones 2005). Therefore this need was very important for Kate; she needed to maintain her hygiene as she used to, before she was ill.
The goal for meeting this need was to maintain personal hygiene and comfort. The care plan prescribed involved first gaining consent from Kate, explaining what was going to be done. Hemming (2010) recommended that identifying the patient’s usual habit is very important because each individual has different ideas about hygiene due to age, culture or religion. Identifying usual habits helps individuals to maintain their social life if things are done according to their wishes. Though Hemming said all human beings need personal hygiene, Holland (2008) argued that it is important to ask patients how they feel about being cleaned, especially in private areas. Kate indicated that she didn’t mind being assisted with washing and dressing. She preferred washing daily, shower and a hair wash once a week, and a mouth wash every morning and before going to bed.
Kate was assisted with personal care 5-10 minutes after having her medication, especially the nebuliser. Individuals with asthma experience shortness of breath whenever they are physically active (Ritz, Rosenfield and Steptoe 2010). After having medication Kate was able to participate during personal hygiene. According to NMC guidelines on confidentiality (2009a), privacy and dignity should be maintained when giving care to patients. Therefore, whenever Kate was being assisted with personal care, it was ensured that the screens were closed and she was properly covered. Field and Smith (2008) suggested that assisting a patient with personal hygiene is the time that nurses can assess the patient holistically. Since Kate was immobile, it was very important to check her pressure areas for any redness. She was also checked for any pallor, jaundice, cyanosis or dry skin that needed attention. The care was always carried out according to her wishes.
The Role of Inter-Professional Skills
Considering Kate’s age and condition, she needed multi-professional teamwork. NMC (2008) encourages teamwork to maintain good quality care. Kate was referred to the respiratory nurse who is specialised in helping people with breathing problems. Since Kate was on oxygen since admission, the respiratory nurse taught her the importance of healthy breathing and taught her some breathing exercises to help wean her from oxygen. Kate was also referred to the physiotherapist who did breathing exercises with her. Kate was not able to walk without aid so she was also referred to the occupational therapy department to assess how she was going to manage at home, or if she required aids to help her manage the activities of living. Upon meeting together, all the multi-disciplinary team agreed that Kate needed a care package, as she could no longer live without care. She was referred to social services so that they could assess this aspect of Kate’s future.
After one week Kate was medically fit but could not go home because she was waiting for the care package to be ready. Her nurse shared information with the multi-disciplinary team in order to establish continuity of care for Kate. The team prepared for her discharge: the occupational therapy staff went to visit her home to check if there was enough space for her walking frame; social services arranged for a care package; and her nurses referred her to the district nurse to help her with her medication and make sure it did not run out.
Kate responded well to the medication she was prescribed; normal breathing was maintained, her respirations became normal, ranging from 18 to 20 respirations per minute, and her oxygen saturation ranged from 95% to 99%. Kate was able to wash and dress herself with minimal assistance. She was discharged on a continuous care package comprising care three times a day, and the district nurse helped her with the medication to control her asthma.
The model of the twelve activities of living was followed successfully on the whole. The nurse collected subjective and objective data, allowing a nursing diagnosis to be formulated, goals to be identified and a care plan to be constructed and implemented. Privacy is very important in carrying out assessments, and this was not achieved fully in Kate’s assessment. However, this lower level of privacy has to be balanced against causing anxiety to the patient. Kate’s daughter thought that the bedside assessment would be more comfortable for her mother, and therefore cause least anxiety. This was very important because of the effects of potential panic on breathing; therefore, this was the correct balance to strike.
A multi-disciplinary team was involved in meeting Kate’s care goals. This is a good example of the use of inter-professional skills, as a number of different departments were involved in creating and implementing the care plan. However, the system was not as efficient as it should have been: Kate spent unnecessary time in hospital after recovery because the care plan was not yet in place.
Assessment can also take a long time, especially with the elderly who are usually slow to respond. Therefore, more time is needed to be sure that the necessary progress has been achieved before taking further steps. However, poor staffing also affects performance in this area, an observation supported by the Royal College of Nursing (2012).
In conclusion, the assessment of this patient was completed successfully, and the deviation from best practice recommendations (the lower level of privacy) was justified by the clinical circumstances. Progress from assessment to care goals was good, and at this point an inter-disciplinary team was used successfully. However, the one flaw in this process was delays, caused partly by the difficulties of working across different departments, and partly, it seems, by staff shortages.
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Tags: Assessment and Care Planning: Holistic Assessment, essay deals with the holistic assessment of a patient who was admitted, onto the medical ward where I undertook my placement
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