Assessing Student Nurse in Planning Patient Care free essay sample

This assignment will focus on the holistic assessment and care plan of a patient who was cared for during practice placement. It aims to discuss how the care planning decisions were made and relate these decisions with the relevant literature. The setting was an emergency trauma and orthopaedic ward and the care plan was developed in order to meets the patient’s needs after 1 week admission. The care plan was compiled by the student nurse and his mentor and aimed to identify the patient’s needs and the necessary interventions to meet these needs. The Nursing and Midwifery Council (NMC) Code of Professional Conduct (2008) states that a person’s right to confidentiality must be respected, therefore pseudonyms will be used to refer to individuals and all personal information used within the care plan are fictitious. Also, consent was obtained from the people involved in this scenario. John Smith is fifty seven years old and was admitted after a fall and consequently left neck of femur fracture. He has undergone surgery to repair his fracture and was able to mobilize with full weight bearing a day after the procedure. However the post-op x-ray three days later has shown a crack fracture below the prosthesis and John was put on bed rest with 5lbs traction on his left leg for six weeks. John was born with cystic spina bifida, and has no motor sensation on his legs, however he was able to mobilise independently using elbow crutches before the surgery. In spina bifida, the spinal cord is damaged or not properly developed and as a result, there is always some paralysis and loss of sensation below the damaged region. The amount of disability depends very much on where the spina bifida is, and the amount of affected nerve tissue involved. Also, bladder and bowel problems occur in most people with spina bifida, as the nerves come from the bottom of the spinal cord, so are always below the lesion (ASBAH, 2010). John is expected to stay in the ward for at least another eight weeks and will be discharged home once he is able to mobilize again. The care plan was elaborated following the model developed by Roper, Logan, and Tierney in the 1970s, which is based on 12 activities of living and link the biological, social and psychological needs required for health (Kozier et at, 2008). This model is widely used on the ward and allows nursing staff to use a holistic approach when planning care. Alexander, Fawcett and Runciman (2007) say that with this model, nursing interventions are grounded in the prevention, resolution, and management of actual or potential problems related to the activities of living, which may be influenced by biological, psychological, socio-cultural, environmental, and politico-economic factors. The assessment using this model integrates the patient’s biographical and health data, thus providing information for both nurses beginning care and the Activities of Living data, which is focused on the patient’s abilities to carry out the activities of living and routines, along with current problems (Roper, Logan and Tierney, 1996). Together with the care plan, other nursing assessment tools were used to aid on the patient’s care. The Nutritional Screening and Prevention and Management of Pressure Ulcers was incorporated to John’s care plan and updated weekly. For the purpose of this assignment, two aspects of the care plan will be prioritised and the decisions made by the nurse when planning his care will be discussed in relation to theory. To identify and assess John’s needs it is necessary to adopt a person centred care approach when assessing him in order to deliver the appropriate care. Potter and Perry (2007) argue that assessment is vital to the nursing process, therefore this approach needs to be patient–centred and can be adapted in accordance with the patient’s needs. Ford and Mc Cormack (2000) argue that the person centred approach represents a development of healthcare services at which the needs of the patient overcome the needs of the professionals and organisations who meet these needs. Kozier et at (2008) consider nursing process as divided into assessment, diagnosis, planning, implementation and evaluation. Aggleton and Chalmers (2000) define nursing models as ways of representing the process, guiding nurses on what to assess and how to obtain information about the patient, as well as planning and delivering care. The development of John’s care plan was based on the Roper, Logan, and Tierney (1996) twelve activities of daily living. Walsh (1998) says that the use of models in nursing practice is a way to facilitate understanding as models are concerned with knowledge about nursing. Carper (1978) (cited in Basford and Slevin, 2003) identified four types of nursing knowledge: empirical, aesthetic, personal and ethical; which have been applied when on decision making process while elaborating the care plan. In order to make nursing decisions effectively it was crucial that actual and potential problems were identified. The model used assists nurses in identifying potential problems using the activities of living as reference. It is also possible to ascertain if these problems are a pattern in the patient’s life or if they are the actual/potential problem, and identify other factors that can influence the activities of life and have been identified before. On admission, John was assessed and his care needs defined following the fracture femur integrated care pathway which is a multidisciplinary document of care; the care plan used in this assignment was elaborated to meet his needs after the bed rest traction being implemented and incorporates data collected by an inter professional team. With the decision to use skin traction as treatment for John’s new fracture the multidisciplinary rehabilitation process which would start just after the surgery has been put on hold and new care plan developed. John potential risk for developing pressure ulcer and his elimination needs will be discussed in depth in this assignment as they are considered the main problems, however, it is important to highlight that all problems identified within the care plan needs to be addressed. Skin integrity is an important subject when caring for patients who are at bed rest and with skin traction. According with Walsh and Crumbie (2007) skin breakdown is a commonly complication of skin traction and immobility. Although the surgical wound was healing nice, John was in risk of develop pressure sore while on traction due factor such as immobility and incontinence. The goal is to keep the skin integrity and avoid further complication. Brooker and Nicol (2003) say that pressure ulcers are preventable and an ongoing assessment and implementation of a holistic plan of prevention can reduce their frequency and distress they cause to patients. It is responsibility of nurses to identify patients that are at risk of developing pressure ulcers (Alexander, Fawcett and Runciman, 2007). The use of Waterlow Pressure Sore Prevention Tool as a complement to the assessment has aid in the assessment of activities of living such as eating, drinking, mobilizing and eliminating based on the patient’s actual condition, and therefore helping in the recognition of the risks of pressure ulcer development. John was identified as being at moderated risk of develop pressure ulcer and a pressure relief mattress was provided as it alternately applies and then removes pressure to areas of the body and is suitable for patients with medium to high risk of developing pressure ulcer. John was able to move himself in bed and the nurses have explained the importance of positioning. He was encouraged to move during day the at least once every 2 hours by a member of the nursing staff. Although John was able to maintain an adequate BMI and has good diet and fluid intake, the Malnutrition Universal Screening Tool (MUST) was incorporated to his care plan and so any weight loss could be monitored as weight loss reduces the subcutaneous fat, eliminating some of the padding between the skin and underlying bony prominences, increasing the susceptibility to pressure ulcers (Carpernito-Moyet, 2004). Skin inspection of back and bottom is necessary every time personal care was provided; also because John does not have lower motor sensation was a necessary regular check on his right heel and leg. Whiteing (2008) advises that skin traction should be removed at least daily for limb washing and skin inspection and pressure area care is essential every two hours. He also suggests that neurovascular assessment should be carried out regularly and that the patient will require general nursing care and physiotherapy to prevent deep vein thrombosis (DVT), chest infection, muscle wasting or foot drop. Elimination was a problem for John and the fact that he could be incontinent of faeces and urine at time also contributes to the risks of developing pressure sore. Constipation is a problem that John has encountered during his whole life due the spina bifida. At home it has been well controlled taking lactulose and senna tablets daily, however being immobile would make it even worse. Lack of exercise reduces peristalsis due to reduced muscle tone of the bowel and abdominal muscles, resulting in fluid absorption and constipation (Brooker and Nicol, 2003). Therefore the nurses should pay attention to the fluid and diet requirements of the patient. Walsh and Crumbie (2007) state that it is important to maintain the fluid intake goal of 2-3 litres daily, also the patient needs to be encouraged to eat a high fibre diet and fruits. The use of medication such as laxatives and osmotic agents also play an important role in the management of constipation on patients who are in the same situation as John. Immobility also can lead to urinary retention and infection (Walsh and Crumbie, 2007), consequently the optimum fluid intake would help to avoid these complications as good hydration reduces the blood coagulability, liquefies secretions, inhibits stone formation and promotes glomerular filtration of body wastes (Carpenito-Moyet, 2004). John has been seeing by the incontinence nursing team in community and finds easy to manage his urinary incontinence using conveen and pads as required. He is able to apply the conveen himself, so the nursing staff needs to make sure that the bag is emptied regularly. Also, it is necessary to ensure that John has clean and dry pads. Potter and Perry (2007) suggest that planning needs is to set priorities for the patient’s care. Goals need to be realistic and based on patient’s needs and resources in order to be achievable. Although care plans enhances the continuity of nursing care by listing specific nursing action to achieve the goals, very often some goals are not achievable in hospital setting due factors such as staff shortness and lack of resources. In conclusion, to write a holistic and realistic nursing care plan is a great commitment. Even though the care plan aims to cover a wide number of different aspects of care, it was felt that some areas can be missed or omitted. For sure it needs to involve the patient in a holistic way and be centred care but it is necessary to define realistic and achievable goals with the setting where the care plan is being applied. Although two problems have been discussed in depth within this assignment, a number of other potential problems have been indentified on John care plan which are directly or indirectly related with the problems discussed and failing in address these other problems clearly would affect the outcomes of the main problems.