Fundamental Aspects of Patient Care: an Introduction to Adult Nursing Practice - Essay Example

PATIENT CARE Introduction Undergraduate nurses have certain range of skills and knowledge being used in various health care setting. These skills involved the nursing process - patient assessment, health care planning, the process of evaluation, and the ability to provide the health care interventions needed by the patients. This can be achieved through the kind of students' clinical experiences in varied health care agencies such as acute-care hospitals, residential outpatient psychiatric facilities, extended-care facilities, and community-based health agencies which are integral part of a nursing education. Nurses recognize that psychomotor skills are significant but, performing without appropriate knowledge does not constitute nursing. The nursing knowledge about health and disease processes will be little use in the absence of appropriate nursing skills to execute. Similarly, The abilities to plan as well as to organise the clinical work are of little advantage to patients or clients if the valuable nurses' attitudes such as, caring and patience are not manifested; therefore, integration of the abilities, knowledge, skills as well as attitudes in nursing is very essential and is the key to understanding and performing competencies. This essay aims to reflect my experiences in relation to nursing practice during my clinical placement. It will demonstrate my knowledge, skills and ability to care for a patient being considered, who was nursed during the said placement. It also presents the needs identified based on the data gathered for further appropriate nursing interventions and discussed the entire process according to Roper, Logan and Tierney (2000) activities of living model. Most of all, it highlights the nursing process implemented to the patients to improve health outcome. Patient history and Bases for Patient Selection During one period of my clinical exposures, I had the opportunity to deliver health care with one patient who was known to have encountered problems on stroke. At that point in time, I found the case as one learning opportunity to look forward since I have only limited knowledge about stroke and limited clinical experiences in caring patients who have stroke. I believed that I had a learning opportunity to have handled the case on stroke, also termed as "brain attack". A research conducted by Wolfe, Tilling, Beech, Rudd, and the European BIOMED Study of Stroke Care Group (2000) revealed that, there are high mortality rates of stroke in areas of Central and Western Europe. An overall of about 4534 stroke events were known and the mean age of patients was 71.9 years. Thus, due to the aforementioned reason, I opted to focus in the said case. For the purpose of confidentiality, reiterated by the nursing and midwifery council (NMC 2008), the patient selected in this case shall be call "Mr B", a 68 years old widower, and retired teacher who was previously diagnosed of hypertension and during the time of admission, manifested the signs and symptoms of cardiovascular accident. According to the medical history, the patient was hospitalized due to a suspected Cerebrovascular accident (stroke) on the right side of the brain, which was thought have caused or resulted problems with his balance and coordination. Cerebrovascular accident or stroke (Schonbeck, 2002) is a brain injury which occurs if the blood flow to brain tissue is obstructed by a clogged or ruptured artery, then causing brain tissue to expire because of nutrient deficiency particularly oxygen. My patient (Mr. B) is 68 years of age, widow, now has retired from work and is obese. His height measures 5'11"; weight is 280 pounds; while the Body Mass Index (BMI) measures 39 (patient is considered obese when the BMI is over 30). Mr. B is obviously overweight too. The patient verbalized that he thinks he have an unhealthy lifestyle. The Nursing Process and Roper's Model of Activities of Living Understandably, nurses' role (Orlando, 1989) is to search for and meet the patient's abrupt need for help by using their intuitive perception, thoughts about the said perception, or the feeling from thoughts to see the sights with patients the significance of their behaviour. In carrying out this process, characteristics of the person must be a foremost consideration, with respect to prior as well as current level of development, and also the future development (Ropert, 1996); independence/dependence continuum should be and twelve activities of living (AL's) representing individuals activities whether sick or well are to be incorporated which are as follows: Maintaining a safe environment; Breathing; Communicating; Mobilizing; Eating and drinking; Eliminating; Personal cleansing and dressing; Maintaining body temperature; Working and playing; Sleeping; Expressing sexuality and Dying. Nursing Assessment is the initial step of the nursing process. In this process, I have included the step by step or systematic and continuous data collection, validation (evaluation) as well as data that would be necessary for the next series of steps in nursing process. In the case of Mr. B, I have interviews him by beginning to ask about patient's history as basis of health care plan. Data that were collected are the: Patient's profile such as complete name, age, sex, date of birth, race or ethnicity, significant other's name, contact numbers, the vital status, medical history, previous hospital or clinic admitted, previous illness that caused the hospital admission and date of admission/hospitalization, which department was the patient admitted (Neurology ward, Rehabilitation stroke unit, Acute stroke unit, Neuro surgery Geriatric unit, Acute medical unit, Others), if medications such as Aspirin, Warfarin, Dipyridamole, Clopidogrel, Cholesterol lowering drugs, Unknown are/were previously taken; National Health Institute Stroke Scale (within 48 hours of admission, if available), and signs and symptoms. Most of these data were validated from the patient's families, health records and doctor/s. During the interview process, the seating position of the patient has been arranged to see to it that the patient was relaxed and comfortable in his environment that is - placing the chairs at right angles; about 3 feet away for easy data exchange; conversing at eye level; student nurse's name and status were introduced; and explaining to MR. B the purpose of the interview. The interview necessarily was terminated when Mr. B was uncomfortable and not able to provide answers to question. Moreover in this initial step, I ensured that subjective database was established by recording chief complaints of the patient or the perceived signs and symptoms. Mr. B and her granddaughter said they are not aware of his present illness is, during childhood common illness include colds, flu, measles and had fell on time a stair which resulted to mild injury of skin. He has been completely immunized, also, has taken aspirin in the past as ordered by his physician during the last hospitalization, when he was diagnosed of hypertension. I found out that Mr. B smokes at an average of 23 sticks of cigarette per day; gets tired to cook, most of the time takes instant or ready-made foods bought from grocery store and that include junk foods which were eaten while he watch television; he recalled that while he was younger, his friends enjoy and prepares food as he does; lately, he have been most of the time sedentary. Aside from that, Mr. B said that his parents were also overweight. One died of diabetes complications while the other one, his father, died of myocardial infarction. Patients blood pressure ranges from 140/90 - 190/110. In relation to the present illness, I have noted Mr. B's slight his left lower arms. He said he initially went home then later complained of a headache. Approximately 3 hours later, his granddaughter said, he was having "confusing speech" and so she takes him to the closest Emergency Department (ED). At first, I observed that patient is alert and oriented and recalled that he injured his skin at the lower right arm when rushing going home, followed by a severe chest pain. At ED, staff observed that he was having generalized seizure-like activity and vomiting. Before the event, no known alcohol or drug intake occurred. Mr. B also did not have migraines, seizure disorder, or connective tissue disorder. There was a family history of CVA on his father's side. Also, no considerable abnormality was recorded in his vital signs except for the patient's blood pressure and physical examination was significant for unequal pupils, with the right pupil larger than the left. Nursing Diagnosis Based on the assessment of practical health patterns, the human response patterns are identified as well as classified according to the statements of actual, the high risk and also the possible problems and wellness diagnoses (Carpenito, 1993). It shall be emphasized that this requires data analysis to recognize the patient/client's strengths as well as well as health problems that independent nursing interventions could resolve. Activities under these include: (1) interpreting and analyzing client data; (2) identifying client strengths as well as health problems; (3) the formulation and validation of nursing diagnoses; finally (4) developing a prioritized list in relation to nursing diagnoses. By and large, the diagnosis of CVA is not difficult. The symptoms naturally begin abruptly and are at the region of the brain which is afflicted by blockage or haemorrhage. The internal carotid artery supply strokes frequently generate unilateral numbness or weakness, or both. Other than that, there are possible signs of cortical dysfunction like aphasia, agnosia, apraxia and visual field defects. Recall that Mr. B's granddaughter explained that, the patient confusing speech. Vertebrobasilar distribution strokes can also be the cause for bilateral or unilateral sensorimotor deficits, together with signs and symptoms more definite for brainstem or cerebellar dysfunction: diplopia, disequilibrium, vertigo, ataxia, and cranial nerve palsies. Due to the posterior circulation which also supplies regions of the internal capsule, thalamus, and temporal and occipital lobes through the posterior cerebral artery, the CVA in this distribution may manifest with some blend of memory disturbance, sensorimotor symptoms, and the homonymous visual field impairment (Zweifler, 2003). Patients who acquire intracranial hemorrhage (ICH) be likely to exhibit an easily progressive neurologic turn down over the initial hours. Again, they complain of acute headache as well as exhibit vomiting or in the early hour impairment of consciousness. When the hemorrhage is widespread, impaired consciousness is manifested at initial examination, and the acute seizure activity could also occur (par 2). If patients encountering seizures can occur with focal neurologic deficits, particularly in the immediate postictal period while there is unilateral weakness (eg, Todd paralysis) or other manifestations also commonly associated with stroke (par 3). Patients suffering from CVA usually encountered problem with their mobility. Mobilisation is the mechanism by which part of the body capable of movement ( A-Z health encyclopedia 1999). During the assessment, mobility of Mr. B's was greatly affected, he was rushed to the hospital by relatives using their family car and not by an ambulance and the proper body position ideal to transport the patient to the hospital was not followed. During the assessment the mobility has decreased primarily due to the illness. He preferred to stay in bed and the entire body is not well functioning. Planning At this stage, patient's goals to promote health and wellness must be specified to prevent recurrence of the illness as well as its clinical manifestations and subsequently resolve the problems which were identified in the nursing diagnoses, as well as related nursing interventions.The goals to enhance the health of Mr. B include the following: (1) To provide and sound environment for the patient and keep him safe; (2) Monitor his airways and improve respiratory and cardiovascular functions; (3) Enable patient to communicate normally; (4) Increase mobility; (5) Regulate the balance of electrolytes ion the body as well as other essential nutrients; (6) Facilitate appropriate elimination; (7) Promote proper personal hygiene and environmental sanitation; (8) Regulate body temperature to optimum level; (9) Encourage Mr. B to cooperate in the health care teams medical and nursing interventions; (10) Keep the patient in an environment that will put him into good sleep; and (11) Allow the patient to express himself and communicate to him therapeutically. Implementation To implement the health care plan in accordance to Roper's Model of Activities of Living, I have provided my patient with and sound environment and keep him safe. Initially he was given 5mg of Nitroglycerine. Mr. B's was slowly laid on bed by placing the patient's head on the bed in a horizontal position with chest until head part slightly rose. Proper monitoring of Mr. B's airways was also done to facilitate ease in breathing. I asked the patient from time to time if he there is difficulty in breathing and in swallowing. I have also monitored if still connected with the electrocardiogram device, attached to the patient's system as I believe this is important so that Mr. B receive continuous cardiac monitoring. I have explain to Mr. B what are the procedures undertaken (such as collection of complete blood cell together with platelet count, partial thromboplastin time test, test for prothrombin time with international normalized ratio, etc.) so he would appreciate how significant it is to improve his health. To improve mobility of the patient, I have implemented appropriate range of motion to improve his blood circulation. To regulate the balance of electrolytes ion the body as well as other essential nutrients; my patient received intravenous hydration with normal saline which I closely monitored. He also has supplemental oxygen. Vital Signs taking are conducted to monitor patient's health status. He got fever for two days and was treated with antipyretics. In facilitating appropriate elimination process of Mr. B, careful maneuver was done practicing again the proper range of motion. I have also given him suitable bed bath on daily basis and ensuring privacy and dignity as well. Body secretion accumulates and the person is unable to maintain cleanliness. He was also assisted to promote independence. A Risk assessment was undertaken in order to maintain a safe environment. According to Migliozzi (2005) all health care personnel, irrespective of the setting, are responsible for maintaining a safe environment. I also examined some skin changes, check buttocks and bony prominences frequently for signs of redness and soreness and to ensure that pressure on the body is relieved regularly by repositioning her 4 hourly or earlier depending on the skin condition. Ensure the use of airflow mattress on his bed. One of the most important health indicators in the case of Mr. B is the Blood Pressure. Thus, it was carefully monitored, recorded and evaluated.I have successfully ensured that the blood pressure was maintained below 185/110 mm Hg. More importantly, I check patient if he got enough sleep and rest, if not I collaborated with my supervisors and Doctors and sick for advice to help him. On the other hand, I listen to him and allowed him to express himself and communicated with him therapeutically. Mr. B was cooperative as the health care plan was implemented. I have explained to him and to his granddaughter about the available short- and long-term clinical expectations on CVA. The symptoms of poststroke depression for example, were shared to them, since it was raised by her granddaughter. I have somehow shared about the available treatment of the disease, preventive measures of CVA, stroke symptoms and the use of emergency medical services was discussed with them as well. Evaluation Mr. B is comfortable and not irritated; He has slowly moved his extremities; appeared clean and felt clean as well; there were no signs of sores, unpleasant secretions and other marks on skin, as well as other parts of the body; He has his hair done by his daughter and nails by a chiropodist at regular intervals; His temperature came back to normal and the blood pressure is slowly going back to normal as well. Conclusion According to (Doh, 2001) older people who are thought to have had a stroke should participate in a multidisciplinary programme of secondary prevention and rehabilitation. This opens up a lot of services for Mr B. Rehabilitation services include physiotherapists, occupational therapists, and speech therapists, etc. The particular services that were utilised for Mr B is the community speech therapy team As well as the dietician. REFERENCES Alfo-LeFevre, R (1998) Applying Nursing process: A step-by step Guide 4th edition Philadelphia: Lippincott Child, K. and Higham, S. (2005) Assessing and meeting nutritional needs. In: Baillie, L. (eds). Developing Practical Nursing Skills. 2nd ed. Oxford: Arnold. Cronin P. and Anderson, K.R(2004) Knowledge for contemporary Nursing Practice. London: Mosby Department of Health (2003) The Essence of Care: patient-focused benchmarks for clinical governance. TSO, London. Dougherty, L. and Lister, S. (eds) (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6th (ed) Oxford: Blackwell Science. Downer, P. A. (2002) Nursing theory and nursing care. In: Kenworty, N., Snowley, G., Gilling, C. (eds) Common Foundation Studies in Nursing. 3rd ed. Bailliere Tindall: Church Livingstone. National institute of clinical Excellence (2005) Stroke. Second edition Potter & Perry(1995) Fundamentals of Nursing, 6th Edition, Elsevier Health Green, S. and Jackson, P. (2006) Nutrition. In: Alexander, M. F., Fawcett, J. N., and Runciman P. J. (eds). Nursing Practice: Hospital and Home. 3rd ed. Philadelphia: Churchill Livingstone. Holland, K. (2003) An introduction to the Roper-Logan-Tierney model for nursing, based on Activities of Living. In: Holland, K., Jenkins, J., Solomon, J. and Whittam, S. (eds). Applying the Roper-Logan-Tierney Model in Practice. Edinburgh: Churchill Livingstone. Macfie, J. (2005) Ethic and Nutrition. In: Gibney, M. J., Elia, O. L. and Dowsett, J. (eds) The Nutrition Society Text book Series: Clinical Nutrition. Blackwell Science. Newmarch, C (2006) caring for the mechanically ventilated patient: part one. Nursing Standard. 20 (17), 55-64. Nicol, M., Brooker, C. and Meyer, J. (2003) Adult nursing: setting the scene. In: Brooker, C. and Nicol, M. (eds). Nursing Adults: The practice of caring. Edinburgh: Mosby. Nursing and Midwifery council. (2008) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: Nursing and Midwifery Council. Peto, R. (1998) Infection control. In; Malik, M., Hall, C. and Howard, D. (eds), Nursing Knowledge and Practice. London: Bailliere Tindall. Roper, N., Logan,W. W. and Tierney, A. J. (2000) The Roper, Logan and Tierney. Model of Nursing Based on Activities of Living. Edinburgh: Churchill Livingstone. Royal Collage of nursing (2004) Working Well Initiative: Good practice in infection control. London: RCN. Say, S. (2005) Eating and drinking: nutrient and fluid requirements for health. In: Peate, I. (ed) Compendium of Clinical Skills for Student Nurses. London: Whurr. Serra, A. M and Griggs, A, J. (2006) Disorders of the Ear, Nose and Throat. In: Alexander, M. F., Fawcett, J. N., and Runciman P. J. (eds). Nursing Practice: Hospital and Home. 3rd ed. Philadelphia: Churchill Livingstone. Martyn, K. (2003) Nutrition. In: Brooker, C. and Nicol, M. (eds), Nursing Adults: The practice of caring. Edinburgh: Mosby. Major, C. (2005) Meeting hygiene needs. In: Baillie, L. (eds). Developing Practical Nursing Skills. 2nd ed. Oxford: Arnold. Migliozzi, J. G. (2005) Minimizing heath-care-associated risk. In: Peate, I. (ed) Compendium of Clinical Skills for Student Nurses. London: Whurr. Roper, N., Logan, W., & Tierney, A. (1996). The Roper-Logan-Tierney Model: A model in nursing practice. In P. H. Walker (Ed.), Blueprint for use of nursing models: Education, research, practice, and administration (pp. 289-314). New York: National League for Nursing. Charles D. A. Wolfe, MD; Kate Tilling, MSc; Roger Beech, PhD; Anthony G. Rudd, FRCP for the European BIOMED Study of Stroke Care Group Department of Public Health Sciences, The Guy's, Kings College, and St Thomas' Hospital Medical and Dental School, Guy's Campus (C.D.A.W., K.T., R.B.), and Department of Care of the Elderly, St Thomas' Hospital (A.G.R.), London, England. Roper, N., Logan, W., & Tierney, A. (1983, May 25). A nursing model...why the nursing process is useful, when used in an explicit nursing framework. Nursing Mirror, 156(21), 17-19. Punton. S. (1983, March 2-8). The struggle for independence: How the Roper model of patient care was put into practice at Burford. Nursing Times 79(9), 29-32. Aggleton, P., & Chalmers. H. (1985, February 13-19). Models and theories: Roper's activities of daily living model. Nursing Times, 81(7), 59-61. Rhodes, K. (1990, May 23-29). Parkinson's disease: Using the Roper model. Nursing Times, 86(21), 36-39. 33 Bellman, L. M. (1996). Changing nursing practice through reflection on the Roper, Logan, and Tierney model. Journal of Advanced Nursing, 24(1), 129-138. Roper, N., Logan, W., & Tierney, A. (1996). The Roper-Logan-Tierney Model: A model in nursing practice. In P. H. Walker (Ed.), Blueprint for use of nursing models: Education, research, practice, and administration (pp. 289-314). New York: National League for Nursing. Tomey, A. M. (1998). The Elements of Nursing: A model for nursing based on a model of living. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorist and their work 4th ed., pp. 321-332). St. Louis: Mosby. Tierney, A. (1998). Nursing models: Extant or extinct Journal of Advanced Nursing, 28(1), 77-85. Reprint requests to Richard M. Zweifler, MD, Stroke Center, University of South Alabama College of Medicine, 2451 Fillingim Street, Mobile, AL 36617. Email: rzweifle@usouthal.edu Read More