The purpose of this assignment is to ascertain a full picture of health; to assess and document the patients needs subjectively and objectively using suitable literature, and to further gain a comprehension of ways to promote health for an individual using an appropriate Model of Nursing. This assessment will also encapsulate The Nursing Process in order to gain a complete holistic understanding, a structured systematic provision of nursing care and to further enhance knowledge of an individual to implement the best individualised care. (Yura and Walsh, 1983) The Nursing Process addresses 4 domains; assessment, planning, implementation and evaluation. This is an ongoing process in order to provide care, identify patient needs, implement and evaluate to determine effectiveness of care. Additionally, this assessment will outline the 12 activities of daily living by Roper, Logan and Tierney (1980) through observation, interaction and communication.
It will aim to integrate 5 influencing factors such as; Biological, including an individuals’ physical ability, past and current infections, accidents and disability. Sociocultural; a persons’ faith, religious beliefs and values. Psychological; fears, stressors and emotional state. Environmental; type of housing and family background an individual resides. Politico-economic; particularly focused on factors relating to social policies, law and economical welfare. (Yura and Walsh, 1983)
In accordance with The Nursing and Midwifery Council (NMC) Code 2015 sections 4.2, 7.1, 10 – 10.6 and 14 reiterate the importance of record keeping. (NMC, 2015) It is fundamental that any documentation is correlated and collected with consent to the greatest accuracy. Within most, if not all facilities that provide care are a number of processes in place which gather information based on an individual, most of which come in the way of a care plan document. These documents are compiled with various multidisciplinary input therefore; it is essential that any healthcare practitioner has the competencies to ask relevant questions in relation to a patients’ care planning. This will promote good practice and corresponds with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 9 to document and plan thoroughly. (Legislation.gov.uk, 2014)
Due to the nature of this assessment it is subject to a number of confidentiality practices in alignment with NMC code (NMC, 2015), therefore it is appropriate that the patient remains anonymous however, an alias will be used within the context of this assignment.
In Northern Ireland the prevalence of Chronic Obstructive Pulmonary Disease (COPD) is on the increase with 39,965 people on the register in 2017 up 1435 people from 2016. (Ninis2.nisra.gov.uk, 2017) These statistics reiterates the seriousness of the disease and the importance of rehabilitation interventions. Within hospital and community environments there is a level of care in place to mediate symptoms such as pulmonary rehabilitation, chest physiotherapy and exercise. In participating with these interventions a patient can have an improved quality of life. (Mukundu and Matiti, 2015) In today’s media and literature proved a level of severity on this particular illness and provided rationale for the assessment of this patient.
Maureen is a 72-year-old lady who was admitted to hospital after a fall in her home. Maureen is retired but had worked most of her life in a well known clothing shop. She enjoys being active, going for walks with her dog and took part in church activities. Before admission she lived at home with her husband and during this time there was a care package in place. Maureen suffers from several illnesses such as chronic obstructive pulmonary disease (COPD) from excessive smoking, Acute kidney injury (AKI) from polypharmacy and alcohol consumption, Bipolar, anxiety, depression and early stages of dementia. Throughout life, Maureen has always been a sociable character enjoying a beverage with friends at the local pub. She is a popular person within her peer groups and community – she is well known. In the period of time she was in hospital she maintained a sense of humour and enjoys conversation, often these times were limited due the nature of bipolar and pain levels.
During clinical placement, introductory pleasantries are the basis of a patient / health care provider’s journey. It is appropriate to ensure that the person who is giving care understands and offers various methods of communication to gain a therapeutic relationship. Sale and Neale (2014) suggests that communication is essential for the basis of initiating, building and maintaining relationships. This process further highlighted the underpinnings of NMC 2015 guidance and the 6C’s identified by the Department of Health in 2012. (Cummings, 2012) The 6C’s consist of care, compassion, competence, communication, commitment and courage.
Throughout the phase of introductions Maureen was prominent as she was quite a verbal person, it would seem that she was more vocal when people were present. It was more apparent later as one of the characteristics of her illnesses.
Maureen orientated well to the ward and is conscious of her surroundings. The ward is well lit, maintained, signposted and clear from rubbish ensuring that there is sufficient room for patients to mobilise minimising confusion and risk of falls. As a result of this admission it was discovered that Maureen has been diagnosed postural hypotension, therefore has a risk of falls should she get up suddenly. The local trust policy introduced a falls prevention programme for patients who are over 65 and/or has risk of falls. (Publichealth.hscni.net, 2011)
Multidisciplinary input from physiotherapists denote that Maureen is independent at times, however she needs reassurance when mobilising. In addition, Maureen has 2L of continuous oxygen through nasal cannula which contributes to her anxiety due to fear of being “unable to breath” when mobilising to and from the ward, toilet or shower. A Study by Eisner et al (2010) suggests that patients are 15% more anxious whilst suffering from COPD due to dyspnoea. Maureen often found it difficult to make it to the toilet without having to overcome her fear of being unable to breathe and this took reassurance but sometimes led to some incontinence.
Maureen has no issues with her speech or hearing, her primary language is English and can be quite conversant provided that she is not anxious. Her communication can sometimes be misconstrued due to the nature of her bipolar whereby she would become more anxious and distressed when unaccompanied. Maureen needs reassurance at times to alleviate any confusion. McCarty, DM. (2013) suggests that in order to communicate appropriately one must provide a suitable environment that is free from distraction and that upholds confidentiality. Maureen was offered to discuss her health in an appropriate room, providing her with confidence and dignity that her personal information would not be shared improperly. In addition, Maureen found it beneficial at times having the company of other patients in her ward.
When Maureen was assessed it was noted that her respiration levels were heightened when she seemed distressed or anxious. As Maureen had a diagnosis of depression, it was hard to identify whether it was a level of anxiety or symptoms of depression. Unfortunately, anxiety is a common comorbidity of COPD and research has shown that the effects of this disease overlap with depression and is often difficult to identify. (Yohannes and Alexopoulos, 2014) With this in mind, interventions such as medicinal and psychological therapies input were in place to identify clearly if there is pre-existing depression and this allowed it to be managed appropriately. Maureen’s oxygen saturation levels were “normal for her” at around 89-90% and this was carried through as her baseline observations. Due to the nature of COPD she was prescribed continuous oxygen therapy of 2L through nasal cannula and nebulisers with a bronchodilator Salbutamol 5mg/2.5ml twice daily (BD). In relation to the oxygen therapy it was apparent that this caused some distress with Maureen as the mask size that was available was ill fitted. Although studies suggest this distress shown by Maureen is typical of patients using oxygen therapy and nebulisers. (Alhaddad et al. 2014)
Maureen enjoys sitting in the armchair beside the bed, reading “Woman’s Weekly” and a cup of tea on a regular basis. She likes to see around her and chat to other team members and patients in the vicinity. Unfortunately, this was only for short periods of time as her anxiety levels fluctuate and cause her distress, she would then request to go to bed again. Often Maureen would stay out longer when she was reassured by sitting beside her to talk and listen. Upon admission Maureen’s mobility was poor. Following her fall, her confidence levels had dropped and she required assistance mobilising to and from the toilet – ward areas. Her postural blood pressure was erratic, with readings of 84-90 systolic which presented Maureen with some levels of light-headedness. She was prescribed Fludrocortisone 50 micrograms once daily however; this was only a short term as it contraindicated with her mental stability. (Nice.org.uk, 2013) This stabilised Maureen’s blood pressure to her baseline observations of 125/70.
Maureen expressed that she enjoyed getting a wash each morning, her hair styled with her favourite hairspray “Silvikrin”. She preferred a loose fitting vest and top as she felt that anything tight would have restricted her breathing. Studies have concluded that constrictive clothing causes feelings of restriction and cause poor inhalation. (MacHose and Peper, 1991) Within the ward there was ample amount of bedding and ventilation for patients and Maureen preferred a light blanket, not only to keep her covered but to keep her cool enough in bed and free from feeling restricted.
Maureen had a selection of her favourite clothes to wear and often felt that she needed to dress appropriately during the day. Her husband visited daily and she liked to smell and look good for him. Maureen loved to have her nails painted at times, however this sometimes interfered with the oximeter. Studies have shown mixed readings for different types of nail polish and this could cause inaccurate readings. (Hakverdioğlu et al. 2014) Instead it was avoided by taking readings on the earlobe or toes. Maureen displayed levels of fatigue and tiredness which could be evident to restlessness at night. It was apparent that bipolar disorder and anxiety reached its peak during the night and staffing levels were lower at this time which prohibited the interaction that Maureen needed. Often she would try to catch attention of other patients within the ward interrupting them of their sleep. In addition, Maureen discovered that her COPD was exacerbated when she tried to lie down flat and this caused some unrest. She was prescribed Haloperidol 1.5mg as and when required (PRN) to manage this.
Maureen maintained a weight of 48kg and had a body mass index of 19.9 however, this was a drop in her original weight. Interventions such as the Malnutrition Universal Screening Tool (MUST) was used to identify levels of nutrition which indicated a 7.7% loss over three months thus Maureen was on supplementary foods such as Forticreme. (Bapen.org.uk, 2017) She was on a fluid balance chart in coincidence with her postural hypotension and this was to encourage and support fluid intake. Studies conclude that this method helps raise blood pressure. (Nice.org.uk, 2013) In addition to the MUST screening tool, Maureen’s weight exuded areas of bony prominences which were at risk of pressure ulcers. The standard across the local trust is that a Braden Scale must be implemented. This tool is used to carry out an assessment on mobility, activity, sensory perception, moisture of skin, nutrition, friction and shear. (Braden, 1980)
During the assessment Maureen displayed a strong faith, referring to God throughout each day, and discussed with other patients her religious stance. She often referred “being with God” and was content with this prospect. Research dictates that there is a coexistence of faith and contentment of dying. (Krause, 2015) This appeared to be relevant to Maureen. Notably, she enjoyed time with the minister of her parish when he came to visit. Maureen revealed a level of frustration and guilt for all the treatment she was receiving without physically paying for it and this was particularly relevant as she disclosed that if she were to die she would have very little to pass on to her husband.
The assessment process demonstrates the necessity of gaining an understanding of Maureen’s life. Developing therapeutic relationships that cannot be gained with a questionnaire or care plan, but by observing, talking and interacting using an appropriate Model of Nursing. These skills are fundamental within any health care professionals’ role which can be developed further by evidence based learning, growing interpersonal knowledge and improving communication skills. These skillsets are integrated through personal autonomy and experience. A study by Randi Skår suggests that to develop the principles of autonomy is by “the freedom to act within one’s professional knowledge base”. (Skår, 2009) Understanding Maureen’s background history played a role in enhancing her care. The Roper, Logan and Tierney model is the base foundation to build a picture of health and ways to promote it, considering her ethical, political, psychological, Biological and sociocultural statuses.