Community Setting in an Attempt to Justify the Nursing Care from Psychological and Social Aspects - Essay Example

Case Scenario- Discussing And Justifying The Care Given To The Patient Within A Community Setting, Taking Into Account Of The Physical, Psychological, And Social Aspects Of Nursing Care Introduction: Like all other healthcare providers throughout the developed world, the population seeking healthcare in the United Kingdom is ageing progressively, and care of the aged population has its own special requirements. Delivery of care sometimes becomes discriminatory, and it is accentuated by failure to provide care with dignity and respect. To be able to do this, the organization should pave the way of individualized needs assessment of the older people, and it demands a special care mode that is easily accessible by the target population. Care delivery in the community setting by nurses may be a way to alleviate all the problems associated with aged care since that can adequately take into account the physical, psychological, and social aspects of the care. While analysing the following case scenario, there will be a discussion about the care to this patient in the community setting in an attempt to justify the nursing care from physical, psychological, and social aspects. Case Scenario: Sarah Wilkins (the name is a pseudonym for confidentiality issues), aged 68, is visited by the district nurses on alternate days for dressings to a grade 3 pressure ulcer (European Pressure Ulcer Advisory Panel [EPUAP] grading system). The ulcer has a sloughy base, has moderate exudates, and the surrounding skin is macerated. She has a diagnosis of rheumatoid arthritis (RA), which has affected her shoulders, knees, wrists and hands. She is in pain most of the time, and this is sometimes severe. Sarah also suffers with urge incontinence, which means she has to change herself several times a day. She appears embarrassed about discussing the issue. Her mobility is restricted and she has had two falls in the past month with no serious injury. Her appetite is poor, her diet limited, she has a body mass index (BMI) of 16 and an Hb of 8.6. She is struggling to cope and currently has a care package with Health and Social care. Sarah’s husband Harold is 65, and he works long hours in the family’s sales business. He does not always engage too well with health professionals or his wife’s carers and seems to avoid contact with them. He seems quite abrupt on times and very reluctant to speak with the district nurses. Sarah worked part-time for the family business until 4 years ago, when her health forced her to retire. They have one daughter who lives in Ireland. Sarah is suffering from rheumatoid arthritis, which is an autoimmune disease that causes chronic ongoing inflammation of the joints, often multiple. Along with that, it causes progressive destruction of the joints leading to functional disability in the form of restricted mobility, pain symptoms, and other effects from the disease. These people are lifelong sufferers and in constant need of medical treatment and supervision. They have to depend on many drugs for controlling the disease flare-up, and restricted mobility gradually make them dependent on others even for activities of daily life (Pincus T., 1995). The national service frameworks for older people has laid out implementation of such a care plan to ensure appropriate professional knowledge, expertise, and behaviour on the part of the community care nurses in all care settings where profession goes outside the boundaries of the hospital walls into the community to ensure that people are involved in their own care under guidance by these nurses (Haight, B. et al., 1994). An effective and planned health and social care service for the aged, specially with a disabling disease, such as, rheumatoid arthritis can deal with the components of the disease satisfactorily. It should be an all-encompassing care executed in order to assure standards of care, extend access to services within easy reach, develop care plans in order to promote independence, help older people to stay healthy despite disabling diseases, and establish a care network by liaison with other providers to link between health and social services (Davies, S., Slack, R., and Laker, S., 1999). The nursing care plan must take into account the age of the patient, the chronicity of RA, and the changing environment of delivery of healthcare, that is, community care. The nurse plays the role of an educator to the patient and the family and to the community to build awareness about the disease (Symmons, D.P.M., Barrett, E.M., Bankhead, C.R., Scott, D.G.I., and Silman, A.J., 1994). Sarah can be taught to know about RA and about how to stay healthy. This can be adopting a healthier lifestyle through appropriate diet and exercise. The patient can be informed about how to seek and access help when symptoms of arthritis develop. These may prevent long-term disability. The nurse in this setting will involve the patient in care planning and decision making. To improve the patient care, the nurse must have high level of knowledge of rheumatoid arthritis. She must be skilled in treating different aspects of the disease (Lorig, K.R., Mazonson, P.D. and Holman, H.R., 1993). Sarah, for instance, will know whom to depend on when there is a problem. The nurse has a unique role to collaborate between different levels of care with emphasis that both patient and carers jointly make the decision. Evidence-based practice should be brought into force where practice should be continually evaluated by the caregivers themselves to achieve the best suitable form of care for a particular patient. The nurse in this scenario needs to be sensitive to the varying types and grades of disabilities in different patients. The arthritis needs long-term management by shared care between the nurse in the community and the secondary sectors involving multidisciplinary teams (Nolan, M. and Nolan, J., 1999). The nurse’s management in the community setting aims to control the symptoms of joint pain as a result of inflammation. The nurse as the primary caregiver will prescribe medications to control symptoms of joint pain and inflammation to minimize loss of function, to keep the patient mobile and independent, to reduce progression of joint damage, to deal with extra-articular complications, to advice on proper medication management, to ascertain the roles of exercise and independence, to provide emotional and social support, and to educate patients and family (Edmunds, M. 1996). Since there is evidence that secondary prevention of disability is beneficial, the nurse, apart from delivering these cares in the community, can arrange for early referral to the specialist service, can prescribe early the anti-inflammatory and anti-rheumatic drugs, and can advocate and access the multidisciplinary hospital-based care where indicated at the earliest (Bernard, M., 2000). At the same time, she is in a position to generate awareness about the problems with anti- inflammatory agents in the elderly. In case of Sarah, there would be a process for educating Sarah about the adverse effects of gastrointestinal upsets, and the nurse should co-prescribe gastroprotective medications. The nurse really can play pivotal roles in disability management by educating the patient and the carers about the disease, can highlight roles of physiotherapy and occupational therapy and can suggest various aids, appliances, and footwear to improve function. Exercise programmes, splints, mobility devices can be prescribed by the nurse. In some cares, secondary or tertiary care is necessary, and the nurse can refer the patient to orthopaedic surgeon for that reason (Twinn, S. and Roberts, B., 1996). As in this case, Sarah is attended for pressure sore dressing, extra-articular complications that can be taken due care of in the community setting can be cared for by the nurse. The key to care in such situations is to care about the patient as a person who is sick and in pain. The nurse must express her caring attitude by expression of warmth and interest. She must know how to respond to the patient’s feelings (Henley, A. and Schott, S., 1999). The pain should be assessed and a clinical gradation of the severity pain done so that response to the medications administered can be recorded and used as a guide for future pain management. While prescribing pain medications, it is important to consider the side effects of those, and a thorough patient education about pain medications and their side effects is undertaken. The nurse in charge of prescribing must have advanced knowledge about the medications, and most providers recommend a pharmacology course of the nurses over the top of basic nursing qualifications as requirement. The patients with RA are vulnerable since they are often exposed to polypharmacy due to pain and disease, and most of the disease modifying agents in RA needs clinical and pathological monitoring for morbidity-producing side effects (Emery, P., 1995). This is a comprehensive service comprising of primary, community, and acute hospital services. These are shaped by the needs assessment done by community nurses and based on preferences or choices of the individual, family, and other caregivers. In Sarah’s case, there is a poor eventual outcome with pain, restricted mobility, and disease along with complications like pressure sores. Practice nurses, hence, need to team up with general practice in the locality. The nurse needs to participate in the shared care scheme with the rheumatology unit such that the rheumatologist works as a multidisciplinary team member with the specialist nurse, physiotherapist, and occupational therapist (Jones, M., Hall, C. and Howard, D., 1998). With Sarah participating in the planning and implementation in her treatment, specially when she has minimal to less family support, the nurse can ensure the treatment happening in the community setting (Ebrahim, S., 1996). Pain for Sarah is not just a symptom; it is a multifaceted and complicated phenomenon that includes not only pain of RA, but also psychological pains resulting from isolation, abandonment, and loss of concern from the family, and loss of role. The nurse here has responsibility to provide psychological support and if feasible guide an occupational therapy so occupation can provide an engagement and activity that provides a sense of competence and worthiness. Since this framework of social care encompasses all community care environments, the role of the community nurses can be related to other roles. This appears to be successful mode of delivery of care as is apparent from the Macmillan nurses who specialize in cancer nursing in the community. They provide palliative support and information to the people with cancer. They help patients to take their own informed decisions about their care. They can manage pain and provide psychological support to the patient groups (Skilbeck, J. et al., 2002). The role of these nurses in the community is not exactly identical to those of the hospice nurses. Hospice nurses perform many conventional nursing duties, such as, observing, assessing, and recording symptoms, but still they work in close association with the physicians. They provide emotional support to the patient, but never take clinical decisions (Olthuis, G., Leget, C., and Dekkers, W., 2007). As a result, Sarah who lives with a long-term condition with considerable restricted mobility and pain, needs routine quality care from health and social care teams, primarily by the community care nurses. The nurse has the opportunity to be the care coordinator, to be the clinical caregiver, and to be the manager of the personalised care for Sarah. However, that is possible when the nurse is a caregiver in the community setting. This demands a new role that involves complexity of working in the community with due care and precautions about personal safety, remaining aware of the physical environment of the area of her visit. She should know how to get about that area safely and efficiently. She must ensure personal safety since she is essentially on her own. She must have the understanding that nurse attends the patient’s house only with invitation. A safe working environment at the patient’s home must be assessed by the nurse. She has the responsibility to assess the client’s safety in her home environment and advise her about the safety practices with respect to her choice and needs. The patient is in control of all decisions in the home or community environment (Watson, N.A., and Wilkinson, C., 2001). The patient decides health and well being, and the nurse simply negotiates care between the patient, family, family carers, and social support networks. With Sarah’s husband barely involved in her care, this might prove to be a really very difficult task. In contrast to the hospital setting, where decisions are made by professionals, the outcome of care and achievement of positive outcome is dependent on nurse’s ability to establish and maintain a relationship with her (Cowen, H., 1999). In the home environment, Sarah will undertake most of her own health maintenance, treatment, and care activities, and the nurse will contribute just a small part in the daily care experience of the patient. Most importantly, the nurse is required to make independent professional decisions regarding treatment delivery away from the professional colleagues, sometimes rapidly in less than ideal circumstances. The care management, as a result, consists less of conventional nursing care and more of social care. The community and the patient should be prepared to accept this nurse in their community as the primary caregiver for long-term crippling conditions. The operational details must be clarified so that there is an effective liaison between general practice, social service networks, relevant hospital consultants, and community nursing service. Health and social care professional should be ready to accept this new member in their team (Naidoo, J. and Wills, J., 2000).. In Sarah’s case, the nurse will promote health with her and the other family members. The family is not easily available, and Sarah is in constant suffering. The centrality of the client and informal carer from the family or society and their education on the specific disease process in important. The nurse thus first builds up a solid interpersonal relationship to promote health and education about disease, so the involved people can exercise informed choices. The nurse is supposed to document findings and keep all records up to date. For example while dressing the pressure sore, the shape, size, and quality of the ulcer is to be recorded. This record will help secondary care from a specialist (McCaughan, D., 2007). A record and its analysis may encourage the nurse to motivate herself and the patient to have more exercises, as exercises are known to ease mobility in RA. In the community setting, there are varied groups with chronic diseases with long- term suffering. Her care is directed to the needs of the individuals. It is never guided by the paying capability or age group of the patient, thus abolishing any discrimination in delivery of healthcare. Needs assessment plays a role to assess priority in the list of the nurse in the community. This also abolishes social isolation and promotes social inclusion, since the whole procedure depends on listening to older people, respecting them and their dignity, and allowing them to make their choices (Thomson,G.E.,1997). New roles, like district nurse is coming up. This role is unique in the sense that this is a leader role in the community level. These senior nurses lead teams of community nurses delivering care to home-bound patients. In case of Sarah, she is house bound due to disability and the pressure sore. The district nurse can pay visit at home, monitor the care, and decide on whether the patient needs a disability appliance and can keep a tab on the people who are discharged from the acute care setting to prevent further hospital admissions (Beynon, T., Richards, M.A., and Herns, M., 1999). Lastly, the home care setting may turn out to be dangerous for the patient and the nurse both due to violence and aggression within the community setting. The community nurse should be aware of such facts in the background of reluctant family members and should look for evidence of such. If suggested, she should waste no time to seek help since improper moving and handling of a frail individual like Sarah may further aggravate her already serious problems (Henry, O.E. and Henry, G.A., 1997). Conclusion: In this framework, the community nurse is exposed to uncertainty of changing situations, priorities, and services. With rapid change in priorities, she supposed to demonstrate rapidity and flexibility to the changing needs of the patient. She should be confident as a negotiating decision maker about the interventions, medications, health needs, exercise planning in the absence of other professional guidance. The main structural element in this process is negotiation with the patient and the family so that there is a healthy partnership among all stakeholders involved in care. She has the unique role of mentoring the care as a deliverer, advocate, and educator. Reference List Beynon, T., Richards, M.A., and Herns, M., (1999). Changing district nurse practice of palliativecare. Palliative Medicine; 13: pp. 514 - 515. Bernard, M., (2000). Promoting Health In Old Age. Buckingham: Open University press. Gastrell, P and Edwards, J. (2003). 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Nursing In Primary Care- A Handbook For Students. Basingstoke: Palgrave MacMillan. Read More