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The aim of this care analysis is to explore the process of assessment and care planning of a patient who has been admitted into hospital.
From the assessment 2 keys areas of care will be identified and explored further.
The author will present the factors that lead to the patient being admitted, followed by an assessment of their general health status at this time.
The author will present the factors that lead to the admission into hospital, followed by a brief account of the client??™s personal history and an assessment of their general health status at this time. The care that this assignment is based on is over a period of 10 days.
Throughout the essay a demonstration of using research based rational for all nursing care will be used.
(1)The author will attempt to explore the evidence and theories that underpins the nursing interventions and how they contributed to the care of this client.
(2)This will be achieved through a holistic assessment of the patient on admission to hospital. The nursing model that this will be based against is Roper, Logan & Tierney as this is the model that the trust follows.
(3)In conjunction with the 2 identified care needs, the patients physiological, psychological and sociological needs will be explored.
(4) In order to plan and deliver nursing care effectively the 4 step nursing process, assess plan, implement and evaluate will be followed in conjunction with the nursing model, Ropers activities of daily living.
(5) Finally I will reflect on my own inter-professional communication skills in relation to the assessment, care planning and the delivery of care.
In accordance with the Nursing and Midwifery Council (NMC) names of individuals and Trusts organisations have been changed in order to maintain confidentiality. (NMC, 2008)
As stated in the NMC, this patients health needs were dealt with in a professional manner at all times. In accordance with the NMC, guidelines for record keeping, (2008) all information that was obtained from Jane??™s assessment was clearly written, factual and accurate
Jane is a 55 year old lady who was first admitted 3 weeks previous via A&E, breathing and swallowing difficulties. Once in the A&E department it transpires that Jane has also been suffering from reduced mobility, muscle weakness, difficulties swallowing, confusion, and long periods of not being able to eat.
After the emergency team and intensive care team have assessed and stabilised Jane??™s condition she was transferred to Neuroscience critical care unit (NCCU) as she needed continuous observation, treatment and more specialised care. (The intensive care society, 2009)
After further emergency test and scans Jane was found to have an ovarian neoplasia, which is an abnormal proliferation of cells that may present as a lump or tumour.
The symptoms that Jane had been experiencing and contributed to her admission were found to be from a rare disorder called Paraneoplastic syndrome.
Paraneoplastic syndrome is triggered by an abnormal immune system response to a cancerous neoplasm. It is thought that the cancer fighting anti bodies or T-Cells, mistakenly attack the normal cells in the nervous system. This disorder affects mainly middle aged to older people who are suffering with lung, ovarian, lymphatic, or breast cancer.
Neurologic symptoms generally develop over days or weeks and usually occur prior to the tumor being discovered. There are a number of symptoms which may include difficulty in walking, swallowing, loss of muscle tone, loss of fine motor coordination and slurred speech, to name but a few.(National institute for neurological disorders and stroke, 2010) (NINDS) With Jane she presented with quite advanced Neurological symptoms on admission.
On medical advice Jane underwent a laparoscopic oophorectomy. This is a surgical procedure which removes both ovaries via an incision through the abdomen.(need ref) Following this surgery Jane underwent a course chemotherapy, which will be repeated.
Nearly 2 weeks after her initial admission doctor felt that Jane was now in a stable condition to be transferred to the neurological ward. From here she would receive further treatment to help with rehabilitation.
Prior to the admission to the neurological ward NCCU had faxed over the transfer letter, this would have given only a brief description of the patient??™s current medical condition. Therefore when a verbal hand over is required. This will ensure the receiving nurse is fully aware of the patient??™s current condition, on-going treatment and any possible changes or complications. (World health organisation, 2007) (WHO)
Once on the ward and in a stable and comfortable condition Jane is orientated to the ward, pointing out where the nursing station is, showing her how to use the call bell and is also introduced to the staff that will be looking after her for that shift. This initial introduction is a good way of opening communication between Jane and the nurse. As suggested by Peplau (1952) this may also be a starting point of assessment for the nurse, as the assessment process is likely to occur during orientation. (Hinchliff et al, 2008)
Once jane had sellted onto the ward the nurse explained that an assessment would need to be done in order to formulate a care plan specific the her current condition at this time.
As patients are only admitted to NCCU because of the severity of their illness, the care plan that would have been put in place would be to deal with Janes critical condition at that time. They would have been consentrating on stabalising her, and putting plans into place to accomplish this.
As nurses we should be are aware that by gaining the trust of our patients is an integral part of providing effective and appropriate nursing care. Robson (2002) states that by using effective communication, having an approachable friendly manner is not only an essential prerequisite for a nurse/patient relationship but also provides re-assurance and having an approachable friendly manner, this will help to build a therapeutic and trusting relationship between the nurse, patient and their family. (American journal of nursing, 2009)
The World health organisation defines assessment as ???A systematic or non-systematic way of gathering relevant information, analysing and making judgment on the basis of the available information.??? (WHO, 2010)
This can be applied to nursing; information that is retrieved from the assessment process is then used to make a judgment about that patient??™s health status, and whether or not they need nursing care or whether there is a need to refer to other mdt . This information may be objective or subjective. Information which is objective is based on the nurses own observations and measurement and can be verified by another person, whereas subjective is based on the patients feelings, values or beliefs. (Hinchliff, 2008)
The utilisation of a recognised framework is an integral part of assessing a patient in order to identify their needs. A nursing model or framework is used to guide the nurse in critical thinking and decisions making. (Nursing theory, 2010) Roper et al. (2003) provides a model for nursing based on the Activities of Living. This nursing process (framework) offers a clear structure for nurses to work to with a problem solving approach.
This nursing process consists of 4 phases and was used to analyse Jane??™s care needs, assess, plan, implement and evaluate (APIE). This systematic approach is used to plan and deliver care effectively. The process aims to identifying actual or potential healthcare problems and establish a plan to meet those needs and deliver specific nursing interventions. This assessment process is continues and is required to be reviewed frequently in order to foresee any problems or changes in the patient??™s condition. This is a cyclical process, and when followed correctly will result in competent nursing care (Kozier et al, 2008)
In order to implement the nursing process effectively a recognised framework must be used. Therefore, ???Roper, Logan and Tierney??™s model of nursing??? which is a nursing model based on 12 activities of daily living (ADL??™s) will be used in accordance to the trusts protocol.
Roper, Logan & Tierney??™s model of nursing was first introduced by Nancy Roper in 1970; this was further developed in 1980 by Roper, Logan & Tierney as ???The elements of nursing???. Since this time it has subsequently been added to and improved, and is now one of the most widely used models of nursing in the United Kingdom. (Roper et al, 2008) NEED TO REWRITE , INFO NOT RIGHT.
This model consists of 5 core concepts;
v The 12 ADL??™s; Maintaining a safe environment, communication, breathing, eating and drinking, eliminating, personal cleaning and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying.
v Dependence/independence continuum
v Factors that influence the ADL??™s,
v Individuality in living.
In order to asses Jane holistically all these areas need to be covered. According to Siviter (2004) in order to for-fill a holistic assessment the patient needs to be looked at as a whole person, this includes looking beyond the reasons for the patient??™s admission, it requires the nurse to seek out what is important to the patient and their family to aid in their recovery. The assessment should include their emotional, physiological, psychological and cultural needs.
As highlighted by Roper et al (2008) these factor can have an impact on the outcomes of the ADL??™s therefore the assessment should be unique to that individual, and therefore holistic. This is further emphasised by Mallett and Dougherty (2003) who agrees that these areas of assessment are necessary in order to identify or prevent any risks to the patient.
Because Jane had been transferred from within the same hospital some biographical data could be obtained from her previous assessment. Such as name, date of birth, reason for admission, current diagnoses.
Jane lives at home with her husband, she is a house wife and has 2 sons who are now grown up and moved out. Prior to Jane??™s onset of health problems she attended a ladies club twice a week, where they participate in fund raising, coffee mornings and such activities. She considered herself to be fairly fit for her age, with no past medical history. Both Jane and her husband enjoyed dancing and walking the dogs, until the last few weeks when Jane was been unable to attend any of these activities.
The planning stage is where the nurse uses their skills of problems solving and decision making to review all the collected information and formulate a plan of care in order to meet those identified needs. The assessment booklet which was used picked up on areas of care that needed to further educate Jane ow is the time to start the planning process.
Pain has been identified by Jane; particular when she was is receiving personal care. It is apparent that some of the ADL??™s are interlinked, such as mobility being linked to pain, Jane appears to be in more pain when she is being moved in bed or is being seen by the physio. Pain is defined by the International Association for the Study of Pain (IASP) as, ???an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage??? (www.iasp-pain.org).
Pain assessment needs to be carried out in order to identify what level of pain jane is experience.
Th results from the waterlows score indicates that Jane is at risk of pressure sores, this is d
It became apparent from the assessment that some of the ADL??™s were interlinked. The pain that Jane felt was linked to mobility. Being moved in bed to have her personal care attended to increased her pain, or when she was being seen by physio or ot??™s.
A waterlow score Which is a comprehensive tool is used to assess the risk of a patient developing a pressure sore. The patient is scored dependant on their age, skin, mobility, appetite, neurological status, medication. A score of 10+ is deemed a low risk, were as 13+ is a high risk and would need to have a treatments and preventative aids put in place. (Judy-Waterlow.co.uk, 2010)
Jane waterlow score was 14 meaning she would need to have equipment and aids put in place.
Assessment score from the waterlow chart inidcaup from the risk assessment section of pressure ulcers, highlighted that Jane is unable to turn herself sufficiently; therefore the need of a 4hourly turn chart is needs to be put in put in place.