Planning and Initiating Care in Nursing Practice - Case Study Example

Planning and Initiating Care in Nursing Practice Introduction: A nursing process comprises of steps of practice that are interrelated. These steps are designed to organize and prioritize patient care keeping in focus the patient's heath status and quality of life. Modern nursing involves many activities, of them perhaps the most important are concepts and skills related to basic sciences related to clinical care of the patient. In that sense, nursing as a profession is unique because it addresses the responses of the individuals and families to actual and potential health problems in a humanistic and holistic manner. Contemporary nursing requires that the nurse possesses knowledge and skills in a variety of areas. The changes in contemporary practice has made nursing practice more scientific and organized in the sense that the specific nursing is more of planned activity that derives from implementation of theory in practice, but it has expanded its role to include increased emphasis on health promotion and illness prevention as well as seeing and attending to the problems and concerns of the patients from a holistic perspective. In this work, the writer applies knowledge of pathophysiology to assess a patient in her clinical placement in Vascular Surgery, and applying nursing process develops a plan of care (Alfaro-Lefevre, 2006, p 50-60). The Client: The patient whose care would be discussed in this work was encountered in clinical placement in Vascular Surgery. For ethical reasons, the patient's identity would remain undisclosed. The patient's care was assigned to this nurse, and while delivering care, a care plan was developed for this patient taking into account the patient's condition as a whole, and the deduction of the care plan would be discussed here in a critical manner. The aspect of care that was dealt with was Hospital Associated Infection (HIA) and the related problems that might have arisen in this patient and the care plan developed to encounter these actual and potential problems in this patient. Nursing management is divided into two groups, independent and interdependent. Independent nursing actions are those that the nurse takes after analysis of the data pertaining to those aspects of the patient's health that are amenable to nursing interventions. Providing quality care for people at risk for or experiencing diseases or conditions that have a pathophysiologic basis, requires a systemic approach. This systemic approach based on the pathophysiology of the existing condition and potential complications of the prevailing condition is known as nursing process. The ability to plan and implement nursing care, monitor the patient's condition, and carry out treatments effectively requires a sound knowledge base, not only about people and the component factors that pertain to their health, but also about the pathophysiologic disorders per se (Katz, Peberdy, and Douglas, 2000, p. 171-203). The pathophysiology of a disease condition ultimately determines signs and symptoms of the disease and directs the management. Therefore, nursing assessment that is based on the knowledge of pathophysiologic mechanism underlying the disease process concerned is an important requirement for standards of practice. Pathophysiologic knowledge would enable recognition of the aetiology of the disease. Aetiology is the specific cause of the disease. Most people have multiple aetiology or causalities, meaning multiple factors are working and interacting together that lead to the manifestations of the disease. Pathophysiology is the study of the effect of the disease or pathology on body organs and systems and on total body functioning. When a disease occurs that changes the normal function of the organ or tissue concerned. Pathophysiology is the study of this alteration and its effects on the other functions of the body organs. This needs knowledge about the effects of the changes that causes the disease and on the compensatory or adaptive responses that an individual can have. This knowledge is necessary in nursing practice since this knowledge would facilitate the understanding of the patient responses. This would also help the nurse to monitor the patient's status, developing a care plan, looking for responses that are maladaptive, and for educating the patient about the disease. The knowledge of the signs and symptoms and medical therapies for common diseases facilitates monitoring for the presence and course of the disease, and depending on the assessment in monitoring, the nurse can support and educate the patient, and ultimately is able to carry out therapies that the patients cannot do themselves (Nowak and Handford, 1999, p. 101-137). The patient that would be discussed here is a 62-year-old male, obese, diabetic, with a history of intermittent claudication in the left leg. He is smoker, and his alcohol intake is 16 units per week with occasional binge drinking. Initial screening revealed peripheral vascular disease in the left femoral artery, left tibial artery, and left common peroneal artery, and left dorsalis pedis artery. This patient was admitted for peripheral revascularization. There was peripheral neuropathy associated with this disease, and the peripheral pulses were diminished. On admission, the blood glucose levels were erratic and well above the normal range. The main complaint the patient was admitted here for was a superficial ulceration in the left great toe of 1 cm x 1 cm dimension. As is evident from the records, this ulceration was not infected; the base of the ulcer was showing healthy granulation tissue, but the colour was grayish pink. The patient complained of no pain at the ulcer base, and there were no other evident signs of infection in the ulcer or in the area surrounding the ulcer. Sterile dressings and other measures to heal the ulcer has failed, and this was an area of concern for the general practitioner, and this is reason he was referred to the vascular surgery clinic. Due to his irregular dietary habit and uneducated nutritional choices and very irregular insulin regimen, the blood glucoses were uncontrolled and erratic, and this has been contemplated to be one of the important causes of his ulcer (Treat-Jacobson and Walsh, 2003, p. 5-14). Along with that, his diabetes, peripheral vascular disease, and sensory neuropathy have precipitated this ulceration and potentiated the progression of the disease. The most important concern perhaps is the predisposition to infection that the patient might acquire while in the hospital that may endanger his limb (Shilling, 2003, p. 66-68). Pathophysiology: Peripheral vascular disease refers to atherosclerotic and thromboembolic processes that affect the aorta, its visceral arterial branches, and the arteries of the lower extremities. Peripheral vascular disease always happens with atherosclerosis as the inciting pathologic process, and this is found more frequently among patients with known cardiovascular risk factors, specially older age, smoking, diabetes mellitus, or those with atherosclerosis in other vascular beds (Aronow, 2004, p. 172). Essentially, the process compromises the peripheral circulation, and atherosclerosis, indeed, is the most common cause. This patient had smoking, obesity, age, diabetes, hypertension, all positive as risk factors. The other risk factors that may be associated with the disease of such as patient and need to be ruled out are lipid disorders, elevated homocysteine levels, heredity, and stress. The management of peripheral arterial disease is important not only in terms of prevention or cure of the disease, but also in terms of prevention of complications in order to maintain quality of life and independence in the elderly. The term peripheral arterial disease is used to refer to atherosclerosis when it obstructs blood supply to the lower or upper extremities (Mousley, 2003, p. 73-74). In general symptomatic arterial disease is more common in men between the ages of 5o to 75 years with the incidence steadily increasing with age. This pathologic lesion develops in major bifurcations and in areas of acute angulations. In people with co-occurring diabetes, there is greater involvement of the smaller and more distal vessels. Upper extremity involvement is less common than lower extremity involvement. The presence of diabetes is associated with a two- to three-fold excess risk of intermittent claudication (Khattab, Ali, and Rawlings, 2005, p. 139-148). Many studies have revealed that atherosclerotic peripheral arterial disease and coronary artery disease is accelerated in diabetes, independent of other atherogenic risk factors mentioned above. The risk of stroke is 2.5-fold higher in patients with diabetes, and diabetes is also strongly associated with atherosclerosis of the extracranial internal carotid artery thereby imparting an additional risk of stroke. This patient had angiographically proven atherosclerotic lesions in multiple locations leading to vascular compromise. Atherosclerosis is a complex process happening in the tunica media of the arterial wall. This is essentially as result of metabolic derangements involving endothelial dysfunction, dyslipidaemia, platelet activation, thrombosis, oxidative stress, vascular smooth muscle activation, altered matrix metabolism, remodeling, and genetic factors (Khattab, Ali, and Rawlings, 2005, p. 139-148). Over all, there is a factor of superimposed inflammatory reaction on all the stages of the pathophysiology. In patients with diabetes this spectrum of vascular disease may take two forms. In the first, there is a non-occlusive microcirculatory dysfunction involving the capillaries and arterioles of the organs, such as, kidneys, retina, and peripheral nerves. The second type involves the larger vessels and is termed as macroangiopathy. This is morphologically similar to that developing in the nondiabetic individuals and comprises of identical atherosclerotic lesions encountered in the coronary and peripheral arterial circulation. It is evident that this patient did not become ill of this magnitude in a single day. It has gradually advanced stage by stage since the process of atherosclerosis is a staged procedure in individuals. To start with dietary irregularities related to lifestyle factors produces dyslipidaemia in a genetically predisposed individual. Surplus low-density lipoprotein starts accumulating in the layer between tunica media and tunica intima of the arterial wall, and this stage is known as lesion initiation (Milani and Lavie, 2007, p. 351-358). With ongoing metabolic insult more aggravated by the diabetes mellitus, this accumulated LDL would transform into a fatty streak which appears as a minor elevation in the arterial lumen. Fatty streaks would initiate an inflammatory process in the location of the abnormal fat deposition and would stimulate the fibrous mesenchymal cells to proliferate. This would encase the fatty streak in a fibrous capsule with fibrous bands running through it, and this pathophysiologic phase is known as fibroproliferative stage. This would lead to endothelial dysfunction that combined with inflammatory reaction and mechanical luminal compromise would reduce the blood flow distal to the area of the occlusion. The tissue which is supposed to be supplied by this artery would suffer ischemia, and the neural connection would also be affected as a result of microvasculopathy of diabetes. Acute reduction of arterial supply leading to tissue ischemia would lead to intermittent claudication, and chronic ischaemia with sensory neuropathy of diabetes mellitus would lead to dearth of blood supply. An ischemic tissue is a great place for bacteria to proliferate on the background of diabetes mellitus, where tissues are more prone to be infected easily if there is a breach in the primary barrier of the tissue (Sieggreen, 2006, p. 23-5). With such pathophysiologic background, the assessment process would particularly need to be designed such that all pathophysiologic factors involved are identified in this patient in order to frame a care plan that takes care of all the factors involved (Ambler, 2006, p. 132-144). Clinical signs of peripheral arterial disease happen due to blood's inability to circulate freely to the extremity. Symptoms would, therefore, depend upon the extent of the disease and the presence of collateral circulation. The patient stated that his intermittent claudication was experienced as a cramping and burning pain in the left leg that would relieve with rest to begin with. With advancement of disease over a period of 2 years, this pain was replaced by a continuous pain at rest with a sensation of burning and numbness in the left great toe. The patient stated that he noted hair loss in that toe, his nails were thickened, and the skin appeared dry, although he denied any discoloration. Over a period of time while he was continuing with alcohol, smoking, a very irregular diet, and his baseline uncontrolled diabetes mellitus, things were not fine. He attended his GP very irregularly, until one fine morning, he noticed a mild skin abrasion at the left big toe. This brought him to his GP back, and after 1 week of trial dressing and strict glucose control, the patient was referred to the vascular surgery unit, where he was examined and investigated. On my examination, a general examination revealed the patient to be hypertensive. A careful and thorough vascular examination revealed diminished volume and tension of pulses in the left lower extremity including femoral, popliteal, peroneal, posterior tibial arteries, and dorsalis pedis arteries on the left. This indicated that the patient perhaps would be having multi-level disease involving the left femoral branches. Investigations proved him to be having multi-level disease, and ankle-brachial index also confirmed this finding. In terms of his diabetes, his blood sugars were in the range of 200s on my encounter, and I was maintaining his blood sugars by monitoring and administration of insulin as per the instruction of diabetologist. This was an example of collaborative care, since the overall control was judged by the diabetologist as per my report. This patient was treated with a femoropopliteal bypass by the open method and was transferred to intensive care for stabilization (Carpenito-Moyet, 2004, p. 785-802). The patient was susceptible to infection due to his uncontrolled diabetes, and the ischemic tissue along with a breach of the skin predisposed him to healthcare associated infection. This patient will evidently be exposed to hospital flora or organisms that in this particular patient may lead to serious infection. Exposure in such patients may frequently lead to colonization of the breached area of skin ulceration, and through that portal, bacteria and other pathogens can rapidly colonize the area or other areas. The most common mechanism of such colonization and spread of organisms are linked to the carriage through the contaminated hands of the healthcare professionals, and wound infection is a common form of such infections. This person is elderly, and this person with his background history of smoking may have ineffective coughing predisposing him to aspiration pneumonia (Donaldson and Donaldson, 2003, p. 83-88). This patient's loss of natural barrier of skin and diabetes and age leading to impaired immunity compounded with deficiency of blood supply will create a perfect stage for infections such as cellulitis on the base of this trophic diabetic ulceration. This being an elderly person would have age-related decline in immune function, which decreased his antibody response and cell-mediated immunity. This person's protein-calorie malnutrition is also another factor that would precipitate a HAI. Diabetes as a comorbid illness is particularly known to facilitate such infections. The other exposure risks in this patient is vascular procedure with access to the vessels, intravenous catheters, urinary catheters, and poor hand hygiene techniques. The care plan would involve meticulous consideration of the above factors (Donaldson and Donaldson, 2003, p. 83-121). The nursing care plan, therefore, would include meticulous hand hygiene of the personnel, and I advocated the strict use of it and would highlight its necessity in the multidisciplinary team meetings, and all would agree to follow this principle. The placement of intravenous device, urinary catheters, bed hygiene, all was strictly sterile techniques, and these were implemented to prevent contact transmission. The wound care was meticulous, and I implemented special precautions to avoid pressure sores, and the patient was repositioned every 2 hours. The plan of the wound care was drawn from the visit and assessment of the tissue viability nurse. She came to the ward to check his wound and to assess the tissue viability, mainly to exclude any presence of gangrenous changes. I was present, and she advised me regarding the wound care and wound dressing. This was another example of interdisciplinary collaborative care. Most importantly, a diet was drawn for the patient after discussion with him that would take care of his protein requirements and diabetic control. Repeated monitoring of bedside glucose guided the sliding insulin scale that maintained his blood sugars within normal range so the chances of infection would be less (Koelen and Van Den Ban, 2004, p. 38-49). The optimal patient outcomes in terms of infection would be white blood cell count in the optimal range, absence of signs and symptoms of infection, vital signs in the expected range, and absence of fever. This could be achieved through increased knowledge of infection control practices. As long as vascular complications of diabetes are there, even outside the hospital, the patient needs to deploy certain practices that would keep him clean of infections (Hogston and Marjoram, 2007, p. 13-16). Diet and nutrition obviously is a very important parameter to control in this patient. Dietary control is important in control of his diabetes. As has been discussed earlier, the starting point of atherosclerosis is dyslipidaemia where excess LDL gets deposited in the arterial wall to cause local vascular narrowing. His smoking, alcohol, dietary habits, and diabetes mellitus with inappropriate glucose control had roles to play. On collaboration with the patient, it revealed that the patient although informed about these risks, hardly understands his nutritional problem. I carefully explained how pathophysiologically it is important to be concerned with his dietary practice and how mandatory it is for him to implement sound nutritional practices in his diet not only to maintain the expected outcome of the vascular surgery at the present situation but also to abate progression of disease in other areas of the body with increase in his age (Ewles and Simnett, 2003, p. 56-78). However, it was important to concentrate on the immediate goal of strict adherence to diet prescribed to maintain the blood sugars within acceptable range. Next in the list would be reduction of saturated fat content in the diet to reduce dietary cholesterol with the addition of fibres and vegetables in the regimen. Caloric intake needs to be reduced and maintained as guided by the sugar levels. He must stop alcohol or at least reduce the quantity of daily intake. I negotiated with the patient to set appropriate behavioural goals for this purpose, and to achieve a successful outcome, he was encouraged to participate in the goal-setting process where he played an active role to achieve a realistic goal. The S.M.A.R.T. criteria were applied to draw a goal. The specific dietary inclusions would be vegetables and fibers, reducing fat, increasing proteins, and limiting carbohydrates. The measurable criteria were eating five portions of fruit and vegetable a day. The goal was achievable in realistic since the patient agreed to reduce the fat and chocolate intake to half the current amount immediately; he would continue with 1/4th the portion size starting 4 weeks from now; and then he would abstain from all adverse factors then onwards to continue for life. This was relevant to the goal of treatment since the aim was to reduce carbohydrates and fat. This was time specific since the goals, short, mid, and long-term were set. This plan was set with the help of the dietician in the team who also encouraged light exercises for this patient, and the patient agreed (Hogston and Marjoram, 2007, p. 13-16). The next problem is regularity in treatment of diabetes to reach optimum blood sugar control. The pathophysiologic importance of diabetic control is very important in this patient. Normal glucose homeostasis, as evidence suggests, is dependent on several simultaneously operating variables, hormones, food intake, nutritional status, tissue sensitivity to insulin, and physical activity. While setting the goals and identifying the actions for planning for this patient, I expected an objective of attaining normal blood sugars in this individual and planned to ensure regularity of treatment. In collaboration with the diabetologist in charge the diabetes treatment was instituted, where I played an important part in monitoring blood sugars and in administering insulin therapy (Macdowall, Bonell, and Davies, 2006, p. 37-64). My short-term goal was to achieve immediate control of sugars to the normoglycaemic levels, and my long-term goal was to motivate the patient and alter his behaviour so achievement of normoglycaemia becomes easy with therapy. The effectiveness of nursing action would be met if these standards are met with the action. I used MACROS to set the goals. The measurable criteria were blood sugars within normal range. This is achievable since I could identify the basic problems in this patient. He had diets high in simple sugars and saturated fat that led to obesity, hyperglycaemia, and hyperlipidaemia. He consumes excess alcohol, and he is obese. Since he contracted for a dietary change, this would not be difficult. This was client-centered since the patient participated in the plan. This was realistic since change of behaviour occurs over a long period of time, and the goals were set in this fashion, and the outcomes were written, and he would never fail an insulin dose (Hogston and Marjoram, 2007, p. 13-16). The other problem was alcohol drinking. Alcohol adds to obesity. Similarly the care plan was decided by the patient. He was connected to the peer groups and was advised regarding how alcohol is actually causing his obesity to increase. Increased fat levels in the blood are increasing his obesity and diabetes both, and his atherosclerotic disease is increasing aggravating his vascular disease (Naidoo and Wills, 2000, p. 59-77). The care plan was set at a short-term of reducing the alcohol intake to alternate days over a period of 4 weeks followed by maintenance of this for a period of 8 weeks. Then the amount would be reduced to another half, and this would be maintained, ultimately to abstain totally (Hogston and Marjoram, 2007, p. 13-16). The action plan was very realistic and appropriate, and the planned care was explicitly stated and recorded. There are sufficient resources to meet this plan. There is sufficient rationale of such plan as is evident from the discussion of the pathophysiology of the disease that this patient is suffering from. The most pressing diagnosis at this point was diabetes, and that needs to be controlled immediately, and the action was concentrating on diabetic care. It should be followed by infection control and dietary measures. The last in the priority list is alcohol restriction. This action plan centres around the patient with his active participation, and the importance of the interdisciplinary care team is also nothing less (Murray and Atkinson, 2000, p.29-41). The care plan would meet the set goals of infection control, control of blood sugars and regular insulin treatment, nutritional measures to control diabetes and dyslipidaemia, and behavioural control of alcohol restriction that would reduce serum lipids and diabetes ultimately culminating in control of the patient's disease process. Reference Alfaro-Lefevre, R. 2006. Applying Nursing Process: a tool for critical thinking. 6th Edition. Philadelphia: Lippincott Williams and Wilkins. P 50-60. Ambler, P. A. 2006. Disease: a nursing process approach to excellent care. 4th Edition. Philadelphia. Lippincott Willliams and Wilkins. P. 132-144. Aronow, WS, 2004. Management of Peripheral Arterial Disease of the Lower Extremities in Elderly Patients. J. Gerontol. A Biol. Sci. Med. Sci.; 59: 172. Carpenito-Moyet, L.J. 2004. Nursing care plans and documentation: nursing diagnoses and collaborative problems. 4th Edition. Philadelphia: Lippincott Williams and Wilkins. p. 785-802. Donaldson, L. J., and Donaldson, R. J., 2003. Essential Public Health. 2nd Edition. Plymouth: Petroc Press. p. 83-121 Ewles, L., and Simnett, I., 2003. Promoting Health; a Practical Guide. 5th Edition. Edinburgh: Bailliere Tindall. p. 56-78 Hogston, R., and Marjoram, B. A., 2007. Foundations of Nursing Practice: leading the way. 3rd Edition. Basingstoke: Palgrave Macmillan. p. 12-16 Katz, J., Peberdy, A., and Douglas, J., 2000. Promoting Health; Knowledge and Practice. 2nd Edition. Basingstoke: The Open University in Association with Palgrave. P. 171-203. Khattab, AD, Ali, IS, and Rawlings, B, 2005. Peripheral arterial disease in diabetic patients selected from a primary care setting: Implications for nursing practice. J Vasc Nurs, Dec 2005; 23(4): 139-48. Koelen, M.N., and Van Den Ban, A. W., 2004. Health Education and Health Promotion. Wageningen: Wageningen Academic Publishers. p. 38-49. Macdowall, W. , Bonell, C., and Davies, M., 2006. Health Promotion Practice. Maidenhead: Open University Press. p. 37-64. Milani, RV and Lavie, CJ, 2007. The role of exercise training in peripheral arterial disease. Vascular Medicine; 12: 351 - 358. Mousley, M., 2003. Diabetes and its effect on wound healing and patient care. Nurs Times; 99(42): 70, 73-4. Murray, M.E. and Atkinson, L.D., 2000. Understanding the Nursing Process: in a changing care environment. 6th Edition. London: McGraw-Hill. p. 29-41. Naidoo. J., and Wills, J., 2000. Health Promotion; Foundations for Practice. 2nd Edition. Edinburgh: Bailliere Tindall. p. 59-77 Nowak, T.J., and Handford, A.G. , 1999. Essentials of Pathophysiology: concepts and applications for healthcare professionals. 2nd Edition. Boston: McGraw Hill. P. 101-137. Sieggreen, M., 2006. A contemporary approach to peripheral arterial disease. Nurse Pract; 31(7): 14-8, 23-5. Shilling, F., 2003. Foot care in patients with diabetes. Nurs Stand; 17(23): 61-4, 66-68. Treat-Jacobson, D and Walsh, ME, 2003. Treating patients with peripheral arterial disease and claudication. J Vasc Nurs; 21(1): 5-14 Appendix Care Plan A. Assessment 1. Detailed history and Physical Examination. 2. Dietary History and Dietary Preferences and Risk factor assessment 3. Vital Signs. 4. Examination of the Ulcer 5. Examination of the vascular territory. 6. Examination of the nervous system. 7. Recording of all the information in the chart accurately for records and comparison. Plan 1. Diet plan considering dyslipidaemia and hyperglycaemia. 2. Education on diet and its implication. 3. Appropriate posture. 4. Monitoring of glucose. 5. Insulin administration. 6. Medication administration 7. Dressing. 8. Exercise. Implementation. 1. Implementation of diet. 2. Implementation of dressing. 3. Infection control. 4. Insulin therapy. 5. Risk factor modification. 6. Monitoring of blood glucose and management. 7. Planning with goal setting. 8. Interdisciplinary care. Read More