Nursing Care Plan - Essay Example

Care Planning Introduction Nursing care plan is a patient-centred and customized tool for specific for nursing care delivery. It is linked with the assessment process of the patient and hence is connected to the pathophysiological process of the client's disease. This is derived through the nursing process approach to make clinical judgments and decisions. Although with the advent of managed care, the traditional columnar nursing care plans have been replaced by clinical pathways and standards of care, it is still regarded as an important tool in the nursing clinical practice and nursing education since it has practical utility in care delivery of any patient due mainly to its pathophysiological correlations (Vizoso et al., 2008). A written nursing care plan indicates the critical thinking of the nurse in terms of care that considers all aspects of the pathophysiology of the condition which they are caring for. This plan is derived through the nursing process which is considered to be a deliberate approach of care through problem solving in order to meet the healthcare and nursing needs of the patient. It has been advised that the care planning must occur through assessment to arrive at a nursing diagnosis and then planning of care and its implementation. The different phases of nursing assessment are cyclic and continuous in that it systematically collects data to determine the health status of the client in order to identify the actual and potential health problems through analysis of the collected information. The assessment is important analytic step to establish the specific database on which the specific care is planned, implemented, and evaluated (Lee, 2005). In this assignment, the case of Ms. X will be taken to analyze the details of her pathophysiological condition and develop her nursing care plan through SMART objectives and goal setting, the assessment and planning and a critical reflection on her care. This case has been taken from the unit of placement of this nurse which is medical-surgical ward. For the reasons of confidentiality, the identity of Ms. X has been kept undisclosed (Fullbrook, 2007). A nursing process was used to plan and implement her care. Her care had many components, and out of all these, two aspects of her problems will be critically examined in a greater detail to delineate the process of application of nursing care plan in her treatment. The purpose obviously is to identify the problems of the client and analyse and correlate them to the pathophysiological process and hence care delivered can be evaluated top justify the process and outcomes. It is also important to note that development of a care plan is the result of a process where nursing assessment leads to a nursing diagnosis, which can be defined by identification of actual or potential health problems that may be planned to be intervened through nursing actions leading to their amenability. The care planning would thus develop the goals and a time frame in which the resolution of the pathophysiological problems may occur through nursing actions (Cameron et al., 2008). The client is a 76-year-old elderly frail woman with history of hypertension and diabetes mellitus who was staying at home. On the date of the incident, she lost consciousness in the bathroom and fell down. The home members discovered her and found that she cannot stand or walk. On closer view, they found her voice to be slurred and paralysed on the left side. She was immediately rushed to the hospital where she was triaged in the Accident and Emergency and was diagnosed by the attending emergency physician to have suffered a cerebrovascular accident with left sided hemiplegia. She was admitted to the Medicine-Surgery unit where I was assigned her care. In this assignment two of her health-related problems will be discussed closely with analysis of the steps that I took to demonstrate the process of care planning and implementation. These two problems are stroke and probability of pressure ulcer. Goals and SMART Criteria Stroke is a condition where the due to a cerebral vascular accident, a specific area of the brain ceases to function, and as a result, the most common manifestation is paralysis of one half of the body. In case of Ms. X, the left half of the body was paralytic. This condition has led to a situation where there would be many problems, the most prominent of which would be impaired mobility and self-care deficits. Due to her frailty and stroke, she will have a risk of impaired skin integrity. The care plan will thus base on her nursing assessment and the goals of nursing care planning will be to achieve improvement in her mobility as the medical condition will allow at the end of the care and to achieve intact skin integrity without ulceration at the end of the care. The SMART analysis of both of these problems cannot specify a time, since the time period for stroke recovery is unpredictable in elderly individuals. The impaired mobility has happened due to stroke, and thus the mobility would improve on its own although supportive medical treatment will be provided. The care planning thus involves issues with her bed and transfer mobilities and nursing care to help her with activities related to self care. The goal is to help her achieve self support as the care advances. Both the improvement in mobility and self-care can be measured, and it is achievable. This is relevant to her clinical condition, but due to the inherent nature of her condition no time-frame can be assigned. This means care should be ongoing until her discharge and total recovery. The same is applicable for her risk of pressure ulceration due to chances of failure of skin integrity. Due to her risk of loss of skin integrity, based on her condition of stroke, measures will be taken to improve her skin circulation and skin health so her skin does not break at pressure points while in care. The integrity of the skin can be assessed and measured through objective means, and this can surely achieve the objective of healthy skin without pressure ulceration at the end of the care. Given the relevance to her baseline condition, although this is achievable, no fixed time frame can be assigned to it, meaning it would be an ongoing planned nursing care (Sulch and Kalra, 2000). Pathophysiology Diagnosis 1: Impaired physical mobility leading to impairment of ability to perform activities of self-care. The goal of the care would be that the client will verbalise understanding of the situation and the care regimen, would demonstrate behaviours that would cause resumption of activities of daily living, would participate in the activities of daily living and other desired activities, and would maintain or increase strength and function of the affected or compensatory body parts. The diagnostic parameters for this problem are limitation of independent and purposeful movement of her left sided extremities. S: Improved cerebral function with stabilized or resolving neurological deficits M: At least 4/5 power and senses A: Activities of daily living needs met by self or help R: Demonstrating coping with the situation in a positive manner T: Within a period of 6 weeks Pathophysiological Correlation Stroke These as the assessment suggests have resulted from her stroke. Stroke is otherwise named as cerebrovascular accident leading to onset of dysfunction in the neurologic system. This is caused by disruption of blood supply to the brain. The compromise in blood supply usually results in temporary or permanent loss of function of the central neurologic functions leading to specific manifestations related to the area of involvement. A stroke, or cerebrovascular accident, is defined by this abrupt onset of a neurologic deficit that is attributable to a focal vascular cause. Thus, the definition of stroke is clinical, and laboratory studies including brain imaging are used to support the diagnosis. The clinical manifestations of stroke are highly variable because of the complex anatomy of the brain and its vasculature. Neurologic symptoms are manifest within seconds because neurons lack glycogen, so energy failure is rapid. If the cessation of flow lasts for more than a few minutes, infarction or death of brain tissue results. Stroke has occurred if the neurologic signs and symptoms last for >24 h. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction. In an ischemic brain attack, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. At this point, neurons can no longer maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH level. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate to fuel the depolarization processes. Thus, the membrane pumps that maintain electrolyte balances begin to fail and the cells cease to function (Hickey, 2004). A stroke is a lesion of the upper motor neurons and results in loss of voluntary control over motor movements. Because the upper motor neurons cross, a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. The most common motor dysfunction is hemiplegia or paralysis of one side of the body due to a lesion of the opposite side of the brain. Hemiparesis, or weakness of one side of the body, is another sign. In the early stage of stroke, the initial clinical features may be flaccid paralysis and loss of or decrease in the deep tendon reflexes. When these deep reflexes reappear usually by 48 hours, increased tone is observed along with spasticity or abnormal increase in muscle tone of the extremities on the affected side. It is to be remembered that a thrombotic cerebrovascular accident is characterised by slow evolution of symptoms due to compromise of the circulation in any artery in the carotid arterial systems, most commonly intracranially. In this case the stroke evolves until the stabilisation of the symptoms. The embolic event means a blood clot appearing elsewhere in the circulatory system is carried to the cerebral circulation and due to the blockage of the circulation in the recipient area of brain tissue, the infarct is localised in area distal to the artery involved. Ruptured aneurysm, hypertension, arteriovenous malformations, or other bleeding disorders will cause bleeding within the brain substance leading to death and loss of function of the tissue. The motor centres within the brain that cause voluntary contraction of the appropriate groups of muscles would not function, leading to paralysis. This will compromise transfers, movements, and activities of daily living. Nursing care in such situations holds very important ground since not only mobilities for self-care need to be fostered through care, and inability to move may pose the risks for pressure ulceration (Spahn, 2007). Gibbs Model of Reflection to State the Account of Care for Each Goal The Gibbs Model of Reflection will be used to present the account of care planning for each of these goals separately. Gibbs model of critical reflection is essentially reflection on thoughts related to actions in different situations. This passes through the processes of exploration of feelings, evaluation of experiences, analysis of the actions, reaching a conclusion, and putting together an action plan based on these conclusions. This can be a very important tool for nursing care planning when pathophysiological aspects of the patient's condition is considered for attaining a particular nursing care goal (Burbridge and Kiernan, 2005). When Ms. X. was admitted, the initial assessment involved assessment of her condition in terms of the care goal pertaining to her compromise in physical mobility. When her care was assigned, she had crossed the acute phase, and it was immediately evident that she has crossed the acute stage. A total neurological assessment was performed including her mental status. Other parameters of her neurological functions are remotely relevant to the current nursing goal of assistance to her self-care deficits in relation to her activities of daily living. These functions were assessment of mental status, sensation and perception, swallowing, nutritional status (Redfern et al., 2006), activity tolerance, and bowel and bladder functions. However, she was paralysed on the left side of her body, leading to impairment of her motor control in terms of movements of her upper and lower extremities on the left side. Obviously, her functions of activities of daily living were compromised, and with the stabilisation and improvement through care, it was expected that she will have improvement over time. Therefore, there would be an ongoing nursing assessment focusing on her existing impairment of functions related to daily activities. These were important since evidence indicates that following stroke, the patients' most important concerns are related to the quality of life, and the impaired functional status should be an important goal for nursing care. Although care must begin on the day of the stroke, the care process to achieve the goal was intensified following stabilisation of the pathophysiological process. It is also important that the care must focus on the whole person rather than the pathophysiological compartmentalisation of her list of problems. The major goal here would be improved mobility and achievement of self care. As things went on, it was understood that nursing has very important roles to play in Ms. X's recovery. In order to do that, the nursing diagnosis was self-care deficits in bathing, dressing, and toileting due to impaired physical mobility due to hemiplegia. The examination revealed paralysis of the left side with unequal hand grasps and diminished deep tendon reflexes. Along with that, she had loss of ability to execute purposeful motor acts, even though she had partial physical ability and willingness to do so. The priority of care was evidently assisting the patient for activities of daily living and assist her to gain independence in these activities, so during the care she gains improvements over her baseline levels at presentation. The rehabilitation is a time consuming process, but the goal was to make her reach a state where she can meet her self-care needs on her own and if not at all possible, she can meet these by assistance from others (Turner-Stokes et al., 2000). Apart from assisting her in her self cares, she was taught to use the unaffected right side for her activities of daily living and not to neglect it. Her care environment was adjusted to her needs, such as, through adjustment of bed rails, food trays, and call lights. The family was encouraged to provide clothing that would have a larger size, front closure system with Velcro tapes, and the patient was taught how to dress while sitting, since this would maintain her balance. It was also ascertained that her personal care items such as urinal and commode were nearby, and she was assisted her in transfers and other activities as needed with encouragement to do as much as possible on her own. However, while reflecting it is now recognised that sometimes there was failure to remain aware that activities of daily living require anticipatory and reactive postural adjustments, and this automatic coordination was affected in case of Ms. X., and this nurse failed to take anticipatory measures to avoid that failure. It was very encouraging to observe that Ms. X had clear goals in relation to her functional abilities, and observing the recovery, she was helped to set realistic short and long-term goals with her active participation. This was accomplished through new tasks added daily with her progress. An instrument named functional independence measure was used to assess her improvement which was combined with the neuromonitoring flow sheet during her care (Kwan et al., 2004). It must be acknowledged that due to inexperience in stroke care, this nurse had to adjust these goals and actual accomplishments in improvement in ADLs several times during her care with me. Pressure Ulceration This patient is exposed to the risk of pressure ulceration due to impaired physical mobility related to hemiplegia, loss of balance and coordination, and spasticity as a result of brain injury. There are evident self-care deficits compromising hygiene, toileting, and grooming. Over the top of that, there is disturbed sensory perception related to altered sensory perception, transmission, or integration (Daniel-Wichern et al., 2009). There may also be role played by incontinence related to flaccid bladder, detrusor instability, confusion, and difficulty in voicing the urge leading to soiling of the skin. These all may culminate into interrupted the risk of impaired skin integrity. Pathophysiologically, pressure ulcers may occur in all situations where the patients are subjected to sustained mechanical loads, and as a result our patient Ms. X. due to her condition of stroke leading her to a bedridden condition is particularly vulnerable to it. All nursing care planning in such patients must consider the risk of pressure ulceration and incorporate nursing measures to prevent them since these ulcers are painful, very difficult to treat once they occur, and may prolong the stay of the patient in the hospital with economic consequences. It has been suggested that pressure ulcers are pathophysiologically multifactorial with the main mechanism being immobility leading to sustained pressure on the skin, particularly at the pressure points where the pressure exceeds the capillary closure pressure of 32 mmHg. This pressure has been recognised to be critical in causation of skin ischaemia, and thus for a patient like Ms. X., the interface pressures at the contact areas between the skin and the supporting surfaces such as mattresses, there is fair chance that the pressures at contact points may exceed this threshold value leading to a degree of ischemia for a sufficient period of time leading to skin breakdown (Schoonhoven et al., 2006). SMART S The patient will not develop pressure ulcer in any part of skin M Daily inspection will reveal no pressure ulceration A Attainable through repositioning, skin care, exercises, bed adjustments, and monitoring of skin, specially at the pressure points. R Bed-bound situation due to baseline stroke and inability to move may lead to pressure ulceration and other relevant complications T No pressure ulceration during the care As evident from the pathophysiological correlations, the increased risk of skin ulceration can be minimised by nursing care interventions. Prevention of pressure ulceration is a nursing priority in case of stroke patients, and this can be accomplished through the knowledge of pathophysiology and frequent assessment of the skin, particularly with emphasis on the bony pressure points and pressure points in the dependent areas of the body. In the acute stage of the stroke, a specially designed air mattress, Waterlow air mattress was used (Baxter, 2008). Once the condition improved, this was changed. A regular turning and positioning schedule was followed to minimise pressure and to prevent breakdown of the skin. The patient was placed on a hydration schedule, and a balanced intake and output chart was used to prevent overhydration given her age. Evidence suggests this to be the most important nursing care step to prevent skin breakdown. During positioning, ample care was taken to minimise shear and friction to minimise damage (Baldelli and Paciella, 2008). A two-hourly schedule was used to clean and dry her skin, and while doing this all body parts were observed carefully for any warning signs such as redness. All healthy skin areas were personally massaged, and care was taken of feeding, since nutrition has been recognised to be an important factor in preventing skin breakdown. While a two-hourly turning schedule was followed, their implications in Ms. X's care were not known. When enquired about it, none in the ward could provide a satisfactory answer. Evidences were looked for which indicated that turning a patient from side to side on a regular schedule to relieve pressure areas and help clear lungs by mobilizing secretions. This also provides sensation of movement, awareness of position, and stimulation of senses of equilibrium, which may all be impaired in stroke (Johnston and Abraham, 2000). Extreme care was taken to maintain all extremities in positions of function and examination of the pressure points at each incidence of position change. The rehabilitation professionals were also involved in her care who assessed her and provided movement exercise scheduled. The range of motion exercises were learned from the rehabilitation professionals and these were executed on her extremities at least four times a day. Her transfers became important when she was able to move little more than her initial state at presentation. For pressure ulcer prevention, pressure reduction mattresses and kinetic turning frame were used. The kinetic turning frame was very useful in transfers. Daily inspection was continued over her bony prominences. Under stabilizing devices, the bony prominences were inspected very carefully, and a Waterlow risk assessment tool (Baxter, 2008) was used to determine risks on a daily basis. The skin was also kept clean, dry, and well lubricated. When she was able to move to a wheelchair, she was instructed to do weight shifts on the wheelchair every 15 minutes while the two hourly positioning schedule on bed continued. At intervals, she was also placed prone on bed. For all transfers a transfer board or a trapeze bar was used with care to avoid any shears (Wolverton et al., 2005). Reflections It was observed that with 2 weeks of such care, she did improve in her self-care activities, and she did not develop any pressure ulcers. However, it was evident that a planning enabled to customize her care, and the pathophysiological correlation and care planning based on evidence helped me to anticipate the next step as she progressed in her care pathway. I evaluated her care on a regular basis through her neurological examination on a daily basis and compared it with the neuromonitoring sheet entries that were recorded in previous assessment. A continuous adjustment and addition of new tasks for her to improve her functioning were done, and it was evident that she was able to achieve agreed upon goals. The clinical management during her admission also led to clinical improvement and rehabilitation was causing improvements in her neuromuscular functions which also facilitated her self-care activity adjustments and self-confidence. The preventative measures, mattress adjustments, care of her hypertension and diabetes and the nursing care to change positions, skin care, drying, maintenance of hygiene, pressure point cares, use of emollients, maintenance of limbs in positions of function, all caused prevention of pressure sores. I must agree that next time I am assigned care of similar patient, I will use this experience and find evidence base for care so I can execute appropriate care and speed up the process of her recovery (Law, 2003). Conclusion Stroke is associated with muscular paralysis, and this motor dysfunction compromises physical mobility. My patient, Ms. X had a stroke with difficulty in physical mobility which impaired her self-care abilities. Through a care planning approach, I devised a care plan which would assist in her self-care activities in the initial phase of care, and with improvement in her clinical condition, she was promoted to execute the care herself, and the goal was achieved in 3 weeks from her admission. There was considerable risk of developing pressure ulceration, and a care planning approach based on pathophysiology of pressure ulceration in immobilised patients and evidence base, preventative nursing care was delivered to prevent pressure ulcers, and at the end of the care at 3 weeks, when the patient was able to ambulate with assistance, she did not develop any pressure ulcers. References Baldelli, P. and Paciella, M., (2008). Creation and Implementation of a Pressure Ulcer Prevention Bundle Improves Patient Outcomes. American Journal of Medical Quality; 23: 136 - 142. Baxter, S., (2008). Assessing pressure ulcer risk in long-term care using the Waterlow scale. Nurs Older People; 20(7): 34-8; quiz 39. Burbridge, N. and Kiernan, S., (2005). Pressure ulcer benchmarking within a primary care setting. Br J Nurs; 14(6): S22-9. Cameron, JI., Tsoi, C., and Marsella, A., (2008). Optimizing Stroke Systems of Care by Enhancing Transitions Across Care Environments. Stroke; 39: 2637 - 2643. Daniel-Wichern, S., Dudel, H., Halfens, RJ., and Wilborn, D., (2009). Transfer of theory into practice in geriatric care: relation between pressure ulcer prevalence and guideline implementation. Pflege Z; 62(10): 612-6. Fullbrook, S., (2007). Regulatory codes of conduct and the common law. Part 2: confidentiality. Br J Nurs; 16(15): 946-7. Hickey, J.V. (2004). The clinical practice of neurologic and neurosurgical nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. p. 36-54 Johnston, G. and Abraham, C. (2000) 'Managing Awareness: Negotiating and Coping with a Terminal Illness', International Journal of Palliative Nursing. 6 (10), pp. 485-494. Kwan, J., Hand, P., Dennis, M., and Sandercock, P., (2004). Effects of introducing an integrated care pathway in an acute stroke unit Age Ageing; 33: 362 - 367. Law, J., (2003). Pressure ulcer prevention: education for nursing home staff. Br J Nurs; 12(9): 566-9. Lee, TT., (2005). Nursing diagnoses: factors affecting their use in charting standardized care plans. J Clin Nurs; 14(5): 640-7. Redfern, J., McKevitt, C., and Wolfe, CDA., (2006). Development of Complex Interventions in Stroke Care: A Systematic Review. Stroke; 37: 2410 - 2419. Schoonhoven, L., Grobbee, DE., Donders, ART., Algra, A., Grypdonck, MH., Bousema, MT., Schrijvers, AJP., Buskens, E., (2006). on behalf of the prePURSE Study Group Prediction of pressure ulcer development in hospitalized patients: a tool for risk assessment. Qual. Saf. Health Care; 15: 65 - 70. Spahn, JG., (2007). Develop A Seamless Individualized Pressure Ulcer Care Plan: Recognize-Understand-Solve. Home Health Care Management Practice; 19: 285 - 293. Sulch, D. and Kalra, K., (2000). Systematic review. Integrated care pathways in stroke management Age Ageing; 29: 349 - 352. Turner-Stokes, L., Williams, H., Abraham, R., and Duckett, S., (2000). Clinical standards for inpatient specialist rehabilitation services in the UK. Clinical Rehabilitation, May 2000; 14: 468 - 480. Vizoso, H., Lyskawa, M., and Couey, P., (2008). Standardized Nursing Care Plan: A Case Study on Developing a Tool for Clinical Research. West J Nurs Res; 30: 578 - 587. Wolverton, CL., Hobbs, LA., Beeson, T., Benjamin, M., Campbell, K., Forbes, C., Huff, N., Kieninger, M., Luebbehusen, M., Myers, M., and White, S., (2005), Nosocomial pressure ulcer rates in critical care: performance improvement project. J Nurs Care Qual; 20(1): 56-62. Read More