In this assignment, I focus on the patient Mr Omar Banerjee whom has had a stroke which was a transient ischemic attack and now suffers from left-sided weakness, dysphagia, speech problem and other physiological conditions. Omar is a Hindu and is in an acute stroke care unit. In this essay, I will be discussing the nursing models and processes which is affecting is health needs based on holistic assessment and also specific assessment tools that help to determine what Omar’s holistic needs are to deliver patient-centred care. Delivering effective holistic patient-centred care is vital for patient recovery.
Rush et al (1996) defined nursing process as an organised and systematic approach to nursing which aims to improve the standards of nursing care. It has a holistic and systematic solving approach and it also works well with patients and family. There are four nursing process; assessment, planning, implementation and evaluation. (Kelly,1996) Assessment is gathering information about the patient’s condition and about the patients past health problems. This helps identifies potential health problems that can link to cultural status. Holistic individual patient assessment is also carried out to meet the needs of the patients. Planning is where the nurse and the patients set goals and create an outcome, these goals can be short, intermediate or long term. All the decisions are mainly made by the patients and ‘No decision about me without me’ (DH,2012). Implementation uses nursing interventions and actions on the problem which were identified in the planning process (Kartz,1970). Evaluation is where it encourages nurses to determine the expected outcomes are achieved. Yura and Walsh (1967) highlighted the importance of evaluation when comparing the behaviours of people who are capable in their care and the goals which have already be set. This ensures that the nurses can monitor the effectiveness of meeting the health needs. These stages are followed by the nurses until the patients gets discharged.
Barbara and Barnum (1994) said that the nursing process offers a system for practice and adaptability. Werlay and Land (1998) found that the nursing process works with a variety of other systems which are already in healthcare. On the other hand, Benner (1984) said there was a limitation of the nursing process and constructed the model to explore clinical excellence.
The nursing models helps support delivering of optimum healthcare. The models have four components, the person, their environment, health and nursing. This model is defined by scientific and logically related to systematically constructed concepts which identify the essential parts of the nursing practice (Riehl and Roy, 1980). Orem’s self-care model (1995) highlights the summative evaluation. The nursing role is complementary of the patients and the nurses work alongside the doctors whom have different special interest. This model goes for an early discharge and increases the care in the community as it focuses on the role of self and independent care. The adaptation model (Roy’s, 1976) says that the theory in which human behaviour is adaptive and the levels will vary among individuals depending on the circumstances. In evaluation, the nurses will keep an eye on the patient’s adaptation level to whether the behaviour has become more effective.
Roper, Logan and Tierney’s model (1976) identified 16 activities of daily living which was later refined to 12 activities of daily living (ALs). This model explains that people can be better understood using the activities they carry out. ALs depends on the individuals social, cultural, maturity and economic circumstances. The 12 activities of daily living are maintaining a safe environment, communication, breathing, eating and drinking, elimination, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying. Health needs of Mr Omar the Roper et al (1996) is mostly widely used in the UK as is an appropriate framework to deliver individualised care. Ropers model says that each AL may not be needed for every patient. Newton (1991) argues that every AL should be looked at except death. Fraser (1990) criticised the model by stating that he couldn’t find any research which supported the model. Tierney (1998) said that the model represented the nursing process in a simplistic manner. Roper et al (1996) in the assessment nurses have to identify the nursing problems from other medical health problems as it influences the plan, action nurses take when delivering care. Planning care is to ensure the goals are realistic and achievable and both nurses and patients must work together. Goals are determined to how independent or dependant the patient is and is specified into AL. Both long and short-term AL goals can be talked about with Omar for his mobilisation. A care plan will be completed based on the goals which have been decided. Implementation, Roper’s ALs only has guideline on the appropriate action that can be taken such as preventing and comforting. Roper et al (1983) said that when possible nursing action should be organised around current ALs. Evaluation Roper et al said that the activities that are decided in the planning are the criteria that is to be used when evaluating the care delivered. In Omar’s case the progress meeting would set goals in communication, engaging in leisure and expressing his sexuality would be done by observation and through patient experiences indirectly from his wife Preeti. In the Francis Report (2013) there was a decline in standard of care and they recommended healthcare professionals to be more compassionate, caring which should remain to be a high priority of nurses. NMC (2008) emphasised on the fundamentals of care, the duty of candour, delegation and accountability, preservation of trust and safety to ensure that the patients have the highest standard of care.
To be able to do a holistic assessment of Omar based on his numerous health problems, I am using Rogan et al (1996) model of 12 ALs due to its implementation of the activities and how it would definite health benefits. Morton et al (2013) defined holistic assessment as a ‘process of gathering and discussing information on the patient’s health needs. The patient’s well-being is whether its physical, emotional, spiritual, mental, social and environmental which is all used for the care plan. Omar’s holistic assessment is based on the Roper et al model framework, discuss his health problems gathering information with his wife regarding to Omar’s safety in hospital and his after care, speech problems which affects his ability to communicate. Omar’s breathing is stable however he needs attention when eating and drinking as he has dysphagia. He is at risk of incontinence in elimination because of his mobility issues he needs help with dressing and personal cleaning. He also requires assistance and support as he has left-sided weakness which was mentioned by Preeti and his body temperature is normal. Omar would benefit from undergoing meditation and relaxation therapy, looking at work and play he used to be a solicitor. Expressing sexuality, due to Omar’s cultural background he doesn’t like sharing personal feelings. When he sleeps he needs monitoring as he gets anxious. Roper (1996) said that the ALs also have biological basis for example, eating, drinking, breathing and socially and culturally determined which would be personal dressing, cleaning and expressing sexuality. There are a range of nursing needs which are identified after the assessment process which were risk of falling due to physical left-side weakness, speech therapy and helping Omar to express his needs, he needs assistance to eat and drink and he is incontinent due to his mobility. As cleansing and dressing are personal so would require the wife to help and to minimise exposure to other carers. Omar’s body temperature is on normal range and requires no monitoring. Work and his personal interests were discussed and identified his spiritual interest. Omar was uncertain when discussing sexuality due to cultural ethos. Omar’s wife is having sleeping difficulty due to anxiety from Omar’s stroke, the patient isn’t having ant sleeping difficulty. The nursing needs which were identified there are five top categories which are his safety needs, communication therapies, health and hygiene, nutritional needs and metabolic functioning of physiological system for healthy living. Aspirin and satin are the drugs which are prescribed to Omar. The two-nursing prioritised for Mr Omar are nutritional needs due to dysphagia and mobility needs as he has left-sided weakness.
Omar stroke caused physiological impact on his health which has affected his body image and his lifestyle and activities of daily living. Due to his stroke, it is restricting him from normal lifestyle and work and can potentially develop stress and depression from the feeling of hopelessness and sadness (Stroke Association, 2015). Another thing that would affect Omar’s social life would be his mobility issues as he would be restricted which can potentially mean that he could withdrawal from all social activities. Omar would benefit from going to counselling and social support services to help his psycho-social needs. Watson (1998) Omar is Indian from a Hindu background, he has spiritual beliefs and cultural needs that include fasting and dietary plan as he is a vegetarian and choices in personal care which enables individualised patient-centre care.
Nursing diagnosis is where you have to make a decisive decision looking at the patients’ needs (George,1995). The diagnosis depends on the medical diagnosis as they consider the person as a whole not just the illness and looks into nursing interventions (Christenson and Kenney 1995). Nursing assessment is both objective and subjective collection of data from the patient in order to identify their strengths and problems. Omar has two nursing needs; nutritional needs and mobility needs. I choose nutritional needs because he has dysphagia which means he finds food and fluid difficult to swallow and with a lack of food it can lead to malnutrition and dehydration and also weight loss. NICE (2005) guidelines say that it would be recommended to carry out nutritional screening. The assessment tool which would be used will be MUST as it nationally recognised and it is a reliable nutritional tool. Lewis (2009) compared three malnutrition tools, patient generated subjective global assessment (PG-SGA) which is recommend by American and Australian Dietician Association, the malnutrition Universal Screening tool which is used in the UK and the Mooreland Screening tool which is used in regional cancer centre. The findings of his study showed a variation between the different tools. MUST and the Mooreland score had a significant correlation and PG-SGA had a higher rate. Evidence says that MUST is easy to use (Stratton et al, 2004). Pearson et al (1999) said that there is a higher inter-observer reliability in PG-SGA and the Mooreland score hasn’t been tested for inter –observer reliability.
Omar has mobility issues due to his left-sided weakness which means he has difficulty in going to toilet, walking, dressing and cleansing. This increases the risk of Omar of developing more pressure scores as he already has one on his sacrum which needs treatment and monitoring. Waterlow risk assessment tool would be used and can help find out his risk to use preventive nursing care intervention. Cochrane (2014) define pressure ulcers as localised injuries to the skin or the underlying tissue. Pressure ulcers occur in people who have limited mobility. To identify the risk of pressure ulcers nurses, use a risk assessment tool such as Waterlow, Braden and the pressure sore risk assessment scale. Risk assessment is used as the first step to prevent pressure ulcers, using these tools correctly will determine Omar’s risk of pressure ulcer development.
The Waterlow pressure ulcer risk assessment was devised by Judy Waterlow (1987). Judy didn’t feel that the Norton Scale didn’t consider nutritional issues. The Norton and Braden scale compared to the Waterlow scale looks at more risk factors. The score range goes from 4 to 40. 10+ score =at risk, 15+high risk and 20+=very high risk. Bell (2005) said that the Waterlow scale that it encourages staff to prevent and the management pressure ulcer. However, the Waterlow scale has been criticised for its lack of research (Edward, 1995). Braden Scale was founded by an American research in 1980. (Bergstrom et al, 1987) the Braden scale looks at pressure and the tissue tolerance which can result in pressure ulcers, the range of the score is between 6 to 23. The lowers score means there is a higher risk and when the individual is at risk it is 16 to 18. Capoianco and McDonald (1996) criticised this tools due to the staff unable to define the meanings of parameters e.g. mobility. When assessing Omar’s pressure ulcers, I would have used the Waterlow assessment tool because it is widely used and recognised across the UK and it is a very easy and simplistic for staff to use. They staff would also use clinical judgement to identify the risk of the pressure ulcer.
Reflecting on my placement I have acquired more clinical knowledge which I can use for Omar’s care to ensure his nursing care plan is effective and deliver the individualised patient-centred care. One of the things I learnt was the importance of gaining patient consent (informed consent, DOH, 2005) which we have to gain consent before we do any treatment or action. I will deliver care to Omar by treating him with his dignity and privacy, following the NMC professional code of conduct. While I was in practice I worked in pre-op care which involves patient assessment processes. Patients can be distressed when they go to the hospital, I learnt that nurses can use a therapeutic communication style to calm patients down. This is the type of the communication that I will use on Omar because this will make him less anxious and ask about what he does and his hobbies to try and engage in a conversation with him. This will allow a nurse-patient rapport (Brenda,2011). Omar has a nasogastric tube feeding because he has dysphagia and this helps Omar for short/medium term nutritional support. In addition, I also learned from risk of infections and cross contamination for infection control and the health and safety regulation (HSE Act,1974). Before and after any personal care I would wash my hands and wear personal protective equipment. Another clinical skill I learned was monitoring blood pressure all of these skills developed my confidence and will use these skills throughout my nursing career.
In this assignment and all of the placement experiences I have learned about the focus on importance of individualised patient-centred care. Nurses have to follow the nursing process and all of the models to deliver effective patient care and following the NMC codes, NICE guidelines and 6Cs. The holistic approach within the patient assessment is importance as it tell us the needs of the patients such as their psycho-social, cultural needs and physiological needs. With Omar’s he will have the best individualised care and support under the framework of stroke nursing care which helps with his holistic needs.