This assignment will discuss and analyse the nursing care given to an 85 year old female patient, during a four week hospital practice placement. In order to fully comply with the Nursing and Midwifery Council (NMC) Code of Conduct (2008), full consent has been verbally granted by the patient to utilise personal clinical information for the purpose of this case study. To ensure patient anonymity, throughout this assignment the patient will be referred to as Rose (Swift).
Chapelhow et al (2005) states, in order for a novice to become an expert practitioner there are several enablers which are fundamental to the nursing care that Rose received. These are: communication, assessment, managing risk, documentation, decision making and managing uncertainty. For the purpose of this assignment, the enablers of assessment and communication in relation to the care that Rose received will be discussed.
Rose Swift is a retired teacher, a widower and is a mother of two sons. Rose was admitted to the accident and emergency department (A&E) via ambulance following an unexplained fall at home. Upon admission to A&E, Roses’ medical notes stated Rose had recently been diagnosed with Dry Macular degeneration, which is an age related chronic eye disease, causing loss of vision in the centre field (Samuel, 2008, Watkinson, 2010). After a short stay in a general medical ward for treatment of a urinary tract infection, Rose was transferred to an intermediate care ward for further rehabilitation, before being discharged home with a care package. Prior to admisson Rose lived alone, was independantly mobile with a stick and would cook her own meals.
The Royal Marsden (2011), regards initial nursing assessments as a step to providing an individualised patient centered nursing care plan. By conducting nursing assessments, key information is obtained to aid the improvement of Roses’ health and develop a plan of care, which will ultimatly enable Rose to establish control of her own health (The Royal College of Nursing (RCN), 2004). However, as cited by Chapelhowe et al (2005) nursing assessments are far from static. As part of the nursing assessment process, a set of individualised outcomes are agreed, in collaboration with the nurse, Rose and the multidisiplinary team. These outcomes are continously evaulated by the nurse, in order to moniter Roses’ progress and where nessescary clincal judgement will be used to adjust these outcomes to suit the needs of Rose (Estes & Ellen, 2013).
For a successful assessment to take place, it is argued a sufficient baseline knowledge is required by the nurse (Peate, 2012). In contrast however Chapelhowe, et al (2005) argue that base line knowledge alone is not enough. Irrespective of how knowledgeable a nurse maybe, without effective communication and interpersonal skills, the care the nurse provides to Rose will be limited as Roses’ individual needs may not be met. It is therefore considered that a combination of the two is thus required (NMC, 2010).
Throughout Roses’ hospital journey, there are several assessments that took place. During Roses’ initial admission to A&E, the nurse conducted a systematic `mini’ assessment to obtain a rapid outline of Rose from both a visual and physical point of view (The Royal Marsden NHS Foundation Trust, 2011). As the resusitation council (2005) points out, inital nursing assessments in acute settings enable preservation of life, by providing fast intervention where required, using the Airways, Breathing and Circulation (ABC) algorithm. By asking Rose questions and obtaining qualitive information, the nurse established that Rose was breathing, had a clear airway and brain perfusion as well as establishing vital background information to aid diagnosis (Fawcett & Rhynas, 2012). In addition, the nurse was also able to quickly access Roses neurologial state using the Modifed Glasgow Coma Scale (MGCS) (Jennett & Teasdale, 1977).
When a patient such a Rose sustains a head injury, the National insititute of Health and Care Excellence (NICE) (National Insitiute for Health and Care Excellence, 2014) recommends the use of MGCS. According to Pillay (2013), MGCS provides a tangible way of noting the concious state of Rose, it is a widely recognised and accepted standarised practical assessment tool, designed for ease of use (Jennett & Teasdale, 1977) which has been used for many years at both a national and international level. When used repeatedly, MGCS can indicate the progression of a brain injury (Teasdale, et al., 2014), this in turn can aid decision making (Nursing Times, 2014). Recently however, there has been some criticism against MGCS regarding the tools ease of use (Mattar, et al., 2013). McLernon (2014) questions if the MGCS tool is still fit for purpose, citing reduced reliability due to lack of clinical consistency and poor communication between professionals. It is therefore suggested that a remedy of a uniformed approach and concise communication between professionals is essential, to ensure safe theraputic practice.
Whilst conducting Roses’ MGCS assessment the nurse noted a reduced score on account of Rose presenting symptoms of delirium. Farne, et al., (2010) states new confusion in patients can often be caused by underlying medical conditions. By utalising this knowledge, this enabled the nurse to apply her professional decision making skills, in order to continue with further assesssments which included a set of observations.
Observations (also known as vital signs) enables the nurse to check Roses’ basic bodily functions such as temperature, pulse, respiration rate and blood pressure (The Royal Marsden NHS Foundation Trust, 2011). A fundamental part of the asessment process, observations allow the nurse to obtain a baseline figure in order to carry out a continous assessment and evaluation, and enable the nurse to establish the level of care that Rose requires (Wheatly, 2006). To identify the risk of Rose deteriorating further, as per Nursing and Midwifery Council (2008) guidelines, each quantitive result was charted correctly, concisely and legiblibly by the nurse and given a score using a modified early warning score (MEWS) (Department of Health, 2000). After combining all results, the nurse was then able to establish that Rose was scoring a MEWS for a raised temperature and increased pulse in addition to a reduced MGCS. By drawing on previous experience and knowledge, the nurse was able to evaluate the overall asssessment, to establish that the presenting symptoms could indicate Rose has some form of an infection. This could be the reason for the fall and delerium (Schroeder, 2010). To rule out a urinary tract infection, a urine dip stick test on a midstream urine sample was conducted. This test showed positive for leukocytes and nitrates, indicating a positive infection result (Little, et al., 2009).
In order to treat Roses’ symptoms the doctor prescribed antibiotics, providing treatment under the biomedical model. Considered a dualistic approach, this model treats the mind and body as separate entities. Fast acting in its approach it treats the immediate problem (Mehta, 2011). However, in order to provide truly effective care the biomedical model alone is simply not enough. It is considered by many professionals that a holistic viewpoint should be taken (The Royal Marsden NHS Foundation Trust, 2011). Id est, in addition to Roses’ physical requirements, consideration should also be given to her emotional and social needs (Chapelhowe, et al., 2005). The psychosocial model should therefore also be considered, in order to treat Rose from a holistic perspective (Chapelhowe, et al., 2005).
Given Roses’ confused state of mind, unsteady gait and MEWS score it was decided to admit Rose to a general medical ward. In order to assess Roses’ psychosocial and cultural needs, the Activities of Daily Living (ADL’s) model (Roper, et al., 2000) was used. ADL’s is a systematic framework, which recognises Roses individuality and beliefs. It considers twelve fundamental concepts and provides a continuum in recognition that dependency can change throughout time (Roper, et al., 2000). Kearney (2001) argues however, that the care Rose receives maybe jeopardised using this model, due to its inflexibility and complex structure. To alleviate this, The Royal Marsden (2011) therefore advises that the nurse should use a pragmatic approach, and use the ADL framework as a guideline for professional decision making. In Roses’ case the nurse was able to utilise the ADL framework to identify a change in care needs. Due to Roses confused state and unsteady gait, assistance would now be required with washing, dressing, mobilising and other essential care needs as defined by the Department of Health (2010) in the Essence of Care guidelines.
Effective communication is an essential skill which enables the expert nurse to build a therapeutic relationship with Rose (Chapelhowe, et al., 2005). According to Dwamena, et al., (2012), communication is considered to be a significant factor in the rapid recovery of Rose. Throughout Roses hospital journey there are many ways in which the nurse interacts with Rose. However, as cited by The Royal Marsden (2011), interpersonal communication skills are the most widely used medium in nursing and arguably the most important skill.
In order for interpersonal skills to be effective Arnold & Underman Boggs (2011), states the nurse must consider several elements such as, verbal and non-verbal exchanges of information, active listening and observation skills. As the initial assessment process is often the first interaction Rose may have with the ward staff, Rose maybe reluctant to share information (Perry Black, 2013). The Royal Marsden (2011), recognises this could be a potential barrier for the nurse to deliver effective care to Rose and key communication factors such as environmental and nurse time restraints maybe contributory to Roses’ unwillingness to share information. To aid the nurse in overcoming this issue, (Cotoi & Ilkiescu, 2013) suggests a trusting environment should be created. Trusting environments enable Rose to feel safe and supported and provide a platform where Rose will feel comfortable and confident in sharing information with the multi-disciplinary team (The Royal Marsden NHS Foundation Trust, 2011).
In order to assimilate meaningful information from Rose, the nurse utilised her communication skills effectively in a number of different ways. An example of this would be, during the initial assessment process. When Rose was admitted to the ward, in line with NMC (2010) Code of Conduct to ensure privacy and dignity is maintained, the assessment took place in a cubicle, with the door closed thus creating a quiet environment. The Royal Marsden (2011) states a quiet environment during assessments is essential to enable Rose to maintain optimum concentration and remain complicit in her responses. Past research has shown discrepancies can often occur between the nurses understanding and that of Rose during assessments (Lauri, et al., 1997). A quiet environment therefore enables the nurse to focus solely on Roses responses, to maintain a meaningful interaction and deliver effective individualised therapeutic care (The Royal Marsden NHS Foundation Trust, 2011).
To ensure effective non verbal communication takes place, body language should also be considered. White, et al., (2011) states body language can be a powerful means of sending a message to Rose, therefore a postive open posture should always be maintained. Throughout Roses hospital journey it was noted the nurse positivly adapted her body language to suit the needs of Rose. An example of this would be when conducting assessments the nurse sat facing Rose, kept an open posture and maintained regular eye contact. These interations are considered by Egan (2002), to be fundamental elements of non verbal exchanges, in order to achieve optimum levels of communication.
As specified by the nursing and midwifery Code of Conduct (2008) optimum communication is an essential nursing skill. To be proficient, the nurse should respect Roses right to be involved in the decisions of her care (NMC, 2010). During discharge planning the nurse demonstated the proficient use of communication, when a conflict occurred between Rose and her family. Acting as an advocate, the nurse conveyed the wishes of Rose to return to her home against her sons wishes. Xxx xxx states during discharge planning, conflict can often occur due to lack of communication. To remedy this, the nurse utalised her commuication skills by asking open ended questions to asscertain the reasons behind the familys anxieties. Questions that are open ended allow the answer given by the receiver to be expanded and explored xxxxx xxxx. However XXX XXX states questions alone are not enough. In order to gauge the true meaning of the answer, non verbal signals should also be observed xxx xxxx.
In conclusion in order to provide effective nursing care to Rose the nurse must ensure that a thourgh assessment is conducted. This cannot be fully completed however, without effective communication skills, concise documentation and decision making. Each enabler is therefore interlinked to provide individualised holistic nursing care to Rose. As a nurse, good communication is vital to build a positive theraputic relationship with Rose and to enhance the relationship there are a number of factors the nurse should be aware of such as enviroment and non verbal communication prompts. Good interpersonal skills are therefore an essential nursing skill to aid the recovery of Rose.
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