Manual of Nursing Diagnoses - Essay Example

?I. Most important goal for the patient – The patient will have increased mobility. Stroke patients often have impaired physical mobility. This is related to activity limitations which are associated with a decrease in motor functions and a decrease in spatial-perceptual impairment. It is also related to a loss of muscle tone, which is the result of periods of extremity flaccidity, as well as hypertonia of affected extremities. A fear of further injury also results in the patient being reluctant to move, and this also affects the patient's ability to be mobile after a stroke (Ulrich & Canale 2005, p. 230). Impaired mobility is related to a variety of factors, including activity intolerance, perceptual or cognitive impairment, musculoskeletal impairment, neuromuscular impairment, medical restrictions, prolonged bed rest, limited strength, pain or discomfort and depression or severe anxiety (Gulanick & Meyers 2003, p. 107). When the patient has impaired mobility, there is also risks which are associated with a lack of physical exercise – circulatory and respiratory problems and poor physical condition (Sparks & Taylor, 2005, p. 29). II. Why the patient needs to be at the centre - Stroke is a medical issue which is multifaceted. Cowman et al. (2010, p. 1) states that 50% of stroke victims will make a full recovery, 30% will make an incomplete recovery with no need for assistance with any functions, and 20% will make an incomplete recovery with a need for assistance with some functions. Horgan et al. (2011, p. 4) states that, despite the statistics which show that a good percentage of stroke patients have some disability upon being discharged from the hospital, follow up care is often lacking. According to Miller et al. (2010, p. 2403), care for a stroke patient should consider three factors: pathophysiological factors, the impact on the individual, and the individual's environmental and personal resources. Hartigan et al. (2011, p. 23) also emphasizes that the patient's perception of recovery is critical – the less the patient believes that he or she will recover, the less the patient is able to attain functional abilities. This means that social roles, as well as psychological, social and environmental needs must be addressed (Hartigan et al. 2011 p. 23). Moreover, there is ample indication that strokes do not just affect the patient, but the caregivers as well. Lutz & Young (2010, p. 152) state that caregivers of stroke patients suffer depression, isolation, a sense of being burdened, a decline in physical and mental health and decreased quality of life. However, Khan et al. (2012, p. 1) indicates that caregivers may not always be given the proper support. It is therefore crucial that the patient participate in his or her own recovery, in that it will alleviate the burden on the caregiver as well as give the patient a better outcome. That said, it is important that the perceived nursing behavior be conducive to this. The patient's perception of the nurse's behavior influences how active the patient will be in participating in his or her own recovery process (Larsson et al. 2011, p. 1). All of these factors must be considered in planning a nursing care program for a stroke survivor, because one of the goals must be to prevent readmission to the hospital, because hospital readmission results in higher mortality rates, greater disability levels and increased costs (Licthman et al. 2010, p. 2526). Therefore, it is important that Mr. Brown and his caregiver, his wife, be at the centre. Both need to understand what will be involved in Mr. Brown's recovery, and both need to understand the steps that will be needed to take. Because of the evidence that the burden on the caregiver is acute, and that the stroke patients' hope for recovery hinges partially upon social and environmental needs, and, additionally, the evidence suggests that patients must participate in their own care, the most important goal is to increase the mobility of the patient. This will ultimately not only be beneficial to the patient, but also to the caregiver, as it will alleviate the burden on the caregiver. III. One Short-Term Outcome – The patient will have an increased sense of balance. According to Swearingen (2004, p. 352), patients with mobility concerns will often have problems with balance because there is a tendency to lean toward the weaker or paralyzed side. Moreover, there is also an issue with falling, with often is the result of the patient not looking at this extremities and checking his position before moving. Because proper balance not only ensures that the patient will have fewer falls, but will also assist the patient in learning to walk at a quicker pace, it is important that the patient have an increased sense of balance. The patient indicates that he is frustrated at the pace with which he walks, and would like to be able to walk at a faster pace. Improving balance will help with this ultimate goal. Moreover, if the patient has an increased sense of balance, he will also have less fear of falling (Swearingen 2004, p. 352). Sparks & Taylor (2005, p. 28) also state that it is important that the patient achieve proper body alignment at all times, in order “to avoid contractures and maintain optimal musculoskeletal balance and physiologic function.” Increasing Mr. Brown's sense of balance will hopefully ultimately increase his ability to walk, and increase his ability to exercise with weight-bearing exercises, which will ultimately build his muscles to the point where physical activity is easier for him. In the process, the burden on Mr. Brown's caregiver, his wife, will be decreased, because she will have less of a worry that Mr. Brown will fall. Therefore, there will also be less of a worry that Mr. Brown will have to return to the hospital as a result of a fall. IV. Activities related to the short-term outcome – Swearingen (2004, p. 352) has outlined a number of activities which should be taught to ensure that the patient has an increased sense of balance. The first thing that she suggests is that the patient learn to be conscious about where his extremities are and should also be taught to check his position before he moves. One concrete way of accomplishing this is to remind the patient to be conscious about lifting and extending his foot when he is ambulating. Swearingen also suggests that the patient be instructed to compensate for a lack of balance by leaning towards his stronger side. The reason for this, according to Swearingen, is that patients often lean towards their weaker or paralyzed side. Swearingen suggest that the patient be instructed and reminded to keep his body weight forward over his feet when he stands. Other Swearingen suggestions are that the nurse should encourage weight bearing on the patient's stronger side, and instruct the patient to use his stronger arm for support and pivot on the stronger side. The patient should also be taught to transfer towards the unaffected side, and to place his unaffected side closes to the chair or bed to which he is transferring. While the patient is transferring, he should be reminded that his affected leg should be under him and the foot flat on the ground. The person who is responsible for these activities will be the caregiver, therefore the caregiver must also be taught these activities. The caregiver and the patient will have reinforcement for these exercises by a demonstration that will be done between the nurse and the patient in the office. The expected output of these activities is that the patient will learn how to balance properly, and should have less of a risk for falls. The only resources which are necessary for these activities will be the time and attention of the caregiver. V. Evaluation of the short-term outcome – The patient will be assessed one month after he and his caregiver are given the instructions on increasing the patient's balance and lessening the patient's risk of falls. The caregiver and the patient will be privately interviewed with specific questions related to the instructions that was given to them about how to increase balance. The questions will concern how often the instructions and exercises are reinforced in the home, and how much the patient and the caregiver remembers about the specific instructions which were given. If the caregiver or the patient have difficulty remembering the instructions which were given, the instructions will be reinforced by reiterating them and demonstrating the proper way to carry out the instructions. The demonstration will be the same as what occurred in the earlier session – the nurse will review the steps that have been given, and will physically show the patient how to do the different exercises and activities. Before reiterating the exercises, however, the nurse will ask the patient and the caregiver to demonstrate how they carry out the exercises. This particular evaluation is important because it reinforces the instructions that were given, by testing the knowledge that the caregiver and the patient have on the instructions, as well as reinforcing information that perhaps they have forgotten or about which they were unclear. By again showing the patient and the caretaker the proper way to transfer, to weight bear, etc., this will remind them to continue with these exercises daily. Moreover, this evaluation is also important as it encourages the support of the significant other, who is also the caretaker in this scenario. Reinforcement of information and support of significant others are two ways to achieve the desired outcome of increased mobility, according to Ulrich & Canale (2001, p. 145). VI. One long-term outcome – The patient will be able to perform weight-bearing exercises. This is important because weight-bearing exercises will help the patient increase muscle tone. According to Ulrich & Canale (2001, p. 230), a loss of muscle tone contributes to impaired physical mobility. Another issue is that, if the patient has a loss of muscle tone, this will also lead to activity intolerance. The risks of activity intolerance, according to Ulrich & Canale (2001, p. 144) is that the patient will have a slower metabolic rate because of inactivity. He will also have a further deterioration of his muscle mass, tone and strength because of the lack of activity. His cardiac reserve will also decrease if he is inactive, because of decreased coronary blood flow, which is the result of a shortened diastolic filling time, a weakening of the myocardium and “increased cardiac workload resulting from the increased venous return in a recumbent position” (Ulrich & Canale 2001, p. 230). He may also have difficulty resting and sleeping if he experiences activity intolerance (Ulrich & Canale 2001, p. 230). Moreover, the patient himself indicates that he desires to be more ambulatory and be able to walk at a faster pace. He is frustrated with his inability to walk, and the fact that he walks slowly and needs assistance. If he is able to strengthen his muscles with weight-bearing exercises, then this will improve his ambulatory outcome and will also decrease the burden on his wife or other caregiver, in that his wife will no longer have to assist him with walking. The ultimate goal is that Mr. Brown may once again get back to his active life of golfing, socializing and traveling, if he is able to become strong enough to walk at a quicker pace and his muscles are not allowed to deteriorate. VII. Activities related to the long-term outcome – Since the ultimate goal is to get Mr. Brown strong enough to sustain weight-bearing exercises, the nurse must first assist him in strengthening his muscles without the weight-bearing exercises. This will help him become strong enough to eventually be able to participate with the weight-bearing exercises. To this end, the nurse will approach the problem with two prongs – nutrition and exercise. Nutrition is important because if the patient is not receiving proper nutrition, the patient is at risk for weakness and fatigue, which will necessarily impair the patient's strength (Ulrich & Canale, 2005, p. 132). To this end, the nurse will teach the patient and the caregiver the importance of serving the patient small, frequent meals, if the patient has a poor appetite or fatigues easily. Moreover, if getting the proper nutrients is a problem because of gastrointestinal problems, then gastrointestinal stimulants may be prescribed. The caregiver will also receive information on why it is important that she be present during meals, why fluid intake should be restricted during meals (to avoid feeling of fullness) and encourage her to allow adequate time for meals (Ulrich & Canale, 2005, p. 132). The outcome of this training is that the patient will get the proper nutrition to keep up his strength. The patient and the caregiver will also be trained on ROM exercises, which will be performed every 2 to 4 hours, and they should progress from passive to active. ROM exercises are important because they “prevent joint contractures and muscular atrophy” (Sparks & Taylor 2005, p. 30). The patient should also be taught to use a trapeze or another assistive device - Sparks & Taylor(2005, p. 30) states that this, too, helps improve muscle tone and it also helps increase the patient's self-esteem. Isometric exercises should also be taught – Sparks & Taylor (2005, p. 30) state that this kind of exercise increases muscle tone and joint mobility. The caregiver will assist this these activities, and no other resources will be necessary except a trapeze. The outcome of these exercises is that the patient will become stronger, which will allow him to perform weight-bearing exercises. VIII. Evaluation of the long-term outcome – The patient and the caregiver, at the initial meeting regarding the importance of increasing strength, will be given an evaluation. The patient will be evaluated by the nurse to find out his strength and ROM by performing exercises which will evaluate this. After one month, the patient will be evaluated by demonstrating the same exercises which he performed at the initial consultation. If the patient is performing the exercises properly, then he should have an increase in his ROM and strength. Moreover, Sparks & Taylor (2005, p. 30) suggest concrete ways of evaluating the progress that a patient makes towards increased mobility and strength. The patient is to demonstrate the isometric exercises that he is doing at home. The patient is also to explain the rationale for maintaining the activity level. The patient should also be required to recite at least five risk factors for activity intolerance. The patient should be asked to perform physically active exercises in the office, and the patient should not exhibit evidence of cardiovascular or respiratory complications before or after this activity is performed. A functional mobilty scale should also indicate that muscle strength and joint ROM remain stable. These activities are appropriate because they test the patient's knowledge of the exercises that he is to perform every day, as well as assessing how well he is progressing in his range of motion and overall strength. This ensures that the patient is continuing these exercises. For the nutrition end of this program, the patient and the caregiver should answer questions regarding the patient's nutrition – when does he eat, how much does he eat, what does he eat, does he eat alone or with others, etc. The patient's weight should be noted to make sure that he has gained weight, if needed, or his weight has stabilized if he did not need to gain. This is important, because, as noted, the patient should have proper nutrition to keep up his strength and prepare him for the next step of doing weight-bearing exercises. IX. How to work collaboratively and support the interventions of others -Martin (2011) states that, because of the complex needs of stroke patients, an interdisciplinary approach must be taken with recovering stroke patients (Martin 2011). For instance, a team may consist of a speech therapist, a physiotherapist, a doctor and a nurse (Moule et al. 2011, p. 319). Moreover, because psychological concerns are often prominent in stroke patients, and such issues might have an impact upon functional outcomes (West et al. 2010, p. 1723), a psychologist might also be a part of the caregiving team. Another potential part of the interdisciplinary team might be a case manager who is assists the patient with such issues as recommending and carrying out strategies regarding the patient's insurance coverage, policy exclusions, coordinated treatment plans, alternative funding sources for medical benefits and covering alternative treatment plans (Newell 1996, pp. 17-18). Nurses need to work with the other team members, because a patient often has multiple issues that go along with the underlying main issue. In this case, if Mr. Brown is having issues with his speech, then he will have a speech therapist who can help him overcome these issues. If he is having issues with depression or grief, which may beset a stroke patient, then he can work with a psychologist who can help him with this issue. A psychologist may also help his caregiver overcome any issues that she might be feeling about helping Mr. Brown recover. She might also be feeling overwhelmed, depressed and confused, and a psychologist may assist her as well. Beyond this, a physiotherapist may assist the patient in retaining and building his strength and ambulation. A case manager will help Mr. Brown with any issues that he might have in financing the medical interventions that he is facing. The nurse should work with all of these caregivers by keeping in touch with them - finding out the progress that Mr. Brown is making in each of the areas; finding out what needs to be done, further, to help him in any areas where he still has weakness; and communicating anything which is noticed in his visits to the nurse. The team should have an integrated approach, in that each member of the team understands his role, and each member of the team also understands everybody else's role. Further, the team should put together a holistic plan which is carried out by each member of the team. The nurse should be instrumental in carrying out this plan, and evaluating how well the plan is working and creating interventions for any plan weaknesses. The nurse should also work with the case manager who is in charge of assisting Mr. Brown with financing – insurance, alternative financing, and the like. The nurse should have knowledge of this aspect, as well, so that, if Mr. Brown has questions, the nurse may answer them. In short, the nurse should be at the center of the care, and at the center of the interdisciplinary approach, and should have substantial input in the holistic plan that the caregivers create. Bibliography Cowman, S., Royston, M., Hickey, A., Horgan, F., McGee, H. & O'Neill, D. 2010, 'Stroke and nursing home care,' BMC Geriatrics, vol. 10, no. 4, pp. 1-6. Gordon, M 2009, Manual of nursing diagnoses, Jones & Bartlett Publishers, Sudbury, Mass. Gulanick, M. & Myers, J 2003, Nursing care plans, Mosby, London, UK. Hartigan, I., O'Connell, E., McCarthy, G. & Mahoney, D. 2011, 'First time stroke survivors' perception of their health status and their goals for recovery,' International Journal of Nursing and Midwifery, vol. 3, no. 1, pp. 22-29. 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Whittemore, R 2009, 'How can nursing intervention research reduce the research-practice gap?', Canadian Journal of Nursing Research, vol. 41, no. 1, pp. 7-15. West, R., Hill, K., Hewison, J., Knapp, P. & House, A 2010, 'Psychological disorders after stroke are an important influence on functional outcomes: A prospective cohort study,' Stroke, vol. 41, pp. 1723-1727. Read More