The Responsibilities of Nursing Profession - Essay Example

Patient care study Introduction: The Nursing profession has evolved through time to establish a firm role in the medical domain based on strong ethical, moral and professional principles. The nursing practice has undergone a positive shift from that of a vocation to a professional status today. That is to say, nursing has a more active role to play in the health care delivery system than the past and nursing, as a profession is 'accountable' today. Many patients suffer only when they do not receive adequate care for the symptoms accompanying their serious illness. The care should not be confined to the physical aliment but also the psychological and spiritual needs. Thus, patient care should have a patient centered approach considering the patients as still active dignified individuals, who can plan, manage and create some meaning out of their end life situation. Understanding of these facts helps in better nursing care. The patients seem to know better (than the past) about health care and they demand more knowledge on their end of life options today. Most of the patients want to discuss their treatment options and have a Right to refuse as per existing laws in UK. Problems pertaining to 'End-of -life' care and care for the aged are on the rise especially when concepts of euthanasia and physician assisted death are trying to find legitimate positions in the society. The present case study is that of an eighty-year-old Mr.X in a care home in London. He is dependant on the staff for most of his daily activities. He has complaints of constant pain and it has been becoming increasingly difficult to move this man as his bones have become very contracted although he is being made to sit on his chair as often as possible. He is also encouraged to eat with the other residents in the dinning room in spite of his spine becoming so twisted that eating at the table is difficult. Patient X is a Retired School Master, widowed with 7 children all off whom visit him on a regular basis and although he is confused at times his Religion and faith are very important to him and still attends Mass every day in the care home. He has a medical history of Myocardial infarction, chronic heart failure, pacemaker, Paget's disease, depression and Type 2 diabetes. He is a classic example of an aged individual with multiple complications. Any further development in these complications will result in the patient being shifted to Intensive care with the possible outcome of death. Thus, it is an excellent case of a patient where managing patient care is vital rather than just assessment and interventions. The Nurse care for the case study should be based on Roper Logan and Tierney model of nursing (1980) which is a care model based on activities of daily living. Unlike Virginia Henderson (1966) model, which recognizes 14 activities, Roper model recognizes only 12 activities. This includes, maintaining a safe environment, communication, breathing, eating/drinking, elimination, washing/dressing, thermoregulation, mobility, work/play, sexual expressions, sleep and dying. Three problems in nurse care for Mr.X: 1.Chronic pain: Chronic pain of the bones is an unpleasant sensory and emotional experience in the patients with Paget's disease and Mr.X has been diagnosed with Paget's disease. Pain management in patients with Paget's disease helps in the improvement of quality of the patient care. Understanding pain needs specific communication skills based on perception. This is true because many of the terminally ill patients may not be able to verbally communicate their pain. Chronic pain is a pain, which lasts for more than six months. Chronic pain is further classified based on its etiology as 'non-malignant' and 'malignant pain'. Non - malignant is non-cancer related pain and malignant pain is cancer related. Chronic pain depresses, debilates and affects the quality of life (Cole, 2002) .A study by Green et.al (2002) on chronic pain management has revealed a need for further educational insights of physicians. A recent study of the experiences of nurses with chronic non-malignant men patients has given rise to three themes, namely 'Needing to be manly'; 'Struggling for relief from pain', and 'Needing human support' (Paulson et.al, 1999). Seventeen nurses and four physicians participated in the study in which a phenomenological method was used. The phenomenon confirmation of the theme 'needing to be manly' indicated that the nurses need to maintain a relationship with these men patients to make them feel respected. Confirmation of the theme, 'Struggling for relief from pain' indicated that the nurses should convince these men patients that they believe in their narratives of the pain. Conformation of the theme 'needing human support' meant that the nurses need to behave in a way that will convince the patients that they are really cared for by their care providers. Thus, studies proved that the patients needed a better support and assurance from the nurses to disclose their pain honestly. McCafferry and Pasero (McCaffery, 1999) list out misconceptions held by health care professionals towards people experiencing chronic pain. There is a misconception, according to McCaffery that 1."Because of the chronic nature of the pain, patients are less sensitive and better able to tolerate pain; 2.Pain for which there is no organic cause (known) is a symptom of psychological disturbance; 3. If the patient's pain occur or increases soon after a traumatic life event, the stress probably caused the pain. 4.If a patient is depressed, especially if there is no cause of the pain, the depression is causing his/her pain and the pain would subside if the depression could be treated; 5.Opioids are in appropriate for all patients with chronic non-malignant pain.6. People with chronic pain who have been taking opioids for months or years are addicted to narcotics; 7.When patients with chronic non-malignant pain are non-compliant, it is probably because they do not want to give up their pain (McCaffery, 1999). Studies indicate that the patients with chronic pain are keen to prove that the pain they experience is real when they interact with the nurses (Johansson et.al, 1999). The chronic pain patients also want to explain their pain in such a way that nurses will understand their pain (Price, 1996). These patients are in a need to feel that professionals do believe their pain (Seers, 1996). The perceptions of pain in chronic pain patients has been evaluated in a study which has shown that cognitive dysfunction does not influence pain prevalence but assessment of pain in demented patients is more difficult. 2. Depression: Depression is not just a 'down' feeling or a sign of weakness but an imbalance caused in neurotransmitters resulting in illness that has a profound effect on everyday life of Mr.X. This process of depression involves psychological and biological symptoms. The psychological symptoms include dejection, unhappy mood, anxiety, irritability, lack of interest in everyday life, withdrawal from outside world, slow mental activity, feeling of guilt, hypochondria, loss of libido, restlessness and thoughts of suicide. Biological symptoms sleeplessness, lack of appetite, constipation, fatigue and listlessness. 3.End-of Life decisions: Mr.X is an aged patient with cardiac complications One of the most difficult situations in nursing practice is that, despite the best efforts, some patients will die. Hence, it is legally and morally important to record the patient's wishes and end of life treatment options. In UK and most of the countries removing or denying treatment without consent from the patient is seen as clear murder (Dyer, 2006). There is no proxy consent for an adult in UK as in USA. Thus, no close relative of an adult can influence the treatment options in UK. Thus, the treatment options are decided on the best interests of the patient by medical professionals. In case of litigations on account of such medical decisions, the court will decide based on the findings whether the treatment was given in the best interests of the patient. The Bolam test is used to determine the best interest standards, which confirms if a responsible body of medical opinion, would affirm that the treatment was in the best interests. When a patient is temporarily incompetent, following an accident or medical event like being unconscious the healthcare professional should do only what is necessary in the circumstances. But, in case the patient when competent issues an advance refusal of treatment under certain circumstances, the doctors should abide by the same. A code of practice under the new Mental Capacity Act for doctors and others who deal with people who cannot take decisions for themselves was issued recently in draft for consultation. The draft code applies to England and Wales. It sets out how patient capacity should be evaluated and how these advance directives on treatment will function and how treatment modes should be decided. The act is expected to be in force from April 2007. Living wills are already binding on doctors even under common law (Dyer, 2006). The plan of care for Mr.X based on the above discussed problems: 1.Pain assessment: Pain assessment is vital before the start of the treatment for pain. Pain assessment aids the identification of the problems, overall understanding of the etiology, location, severity, frequency and duration of the pain. Pain assessment also helps to understand the associated debility, factors that enhances or relieves pain and the mode of treatment. Pain assessment is also useful to adjust the drug dosage and detect the possible side effects and aids patient controlled analgesia. Patient-controlled analgesia is a process where the patients can determine the pain relief process. For instance, the Opioid Therapy Documentation Kit, created by pain authority Elizabeth J. Narcessian provides tools to help nurses evaluate and select patients appropriate for opioid therapy for pain. (www.partnersagainstpain.com). The Kit includes forms to take a general medical history, to record an initial pain assessment, and to allow patients to perform ongoing assessment. The initial pain assessment is done on pain history with the following questionnaire; 1.When and how did your pain problem start 2. As far as you know, what is the cause of your pain 3. What doctors have you seen, when did you see them, what did they do and 4.What tests and studies have been done The next step involves probing the pain locations and the previous treatments. Pain location can be done by diagrammatic mode. The patient is shown four diagrammatic representations depicting human morphology and asked to shade the pain location /locations on the diagrams. Areas of severe pain are marked X. Evaluation of the previous treatments is done by using a series of numerical pain scales in which the numbers corresponding to the pain relief starting from 'no relief' to 'complete relief' is circled and marked for each of the treatment received. The patient is asked to mark the treatment mode if he is still receiving the treatment. This includes the history of pain medications and physiotherapy. This gives a clear idea on previous treatments and their effectiveness. The next step involves the description of the pain; details on the pain intensity and patterns; aggravating and relieving factors. To describe the pain, the patient is asked to describe the body sites where he experiences the pain and circle the words provided that best describe his pain such as aching, throbbing, stabbing, gnawing, intermittent, sharp, tender, burning, exhausting, tiring, continuous, penetrating, nagging, numb miserable, unbearable, shooting etc. The effect of pain on the physical and psychosocial functions is then evaluated using the 0-10 numerical scale. The lower end of the scale value indicates no interference and the higher end value indicates complete interference of the pain in activity. The current regimen, rescue doses needed and dosage adjustments are recorded. The side effects if any are also recorded with the remedial steps taken. The physical and psychosocial evaluation includes general activity, mood, walking ability; work routine, personal relations, sleep, enjoyment, concentration ability and appetite. This is done on the same 0-10 numerical pain intensity scale with 0 indicating no interference and 10 indicating complete interference. Pain management is dynamic and pain medications need to be altered accordingly. 2. Depression: The Hamilton Rating Scale for Depression, also known as the HAM-D, is a valid tool for use in assessing the symptoms of patients diagnosed with depression. The scale created by Max Hamilton (1960). It is a guide for physicians to assess the severity of a patient's depressive symptoms. The scale contains 21 items, Evaluation of the severity of depressive symptoms is typically based on the patient's scores on the first 17 items, with some items graded on a scale of 0 to 4 and others graded on a scale of 0 to 2. The four additional items are diurnal variation, derealization, paranoid symptoms, and obsessive/compulsive symptoms. The HAM-D scale is for use with patients already diagnosed with depression. The clinician uses the HAM-D scale to quantify results of an interview and its value depends entirely upon the skills of the clinician in eliciting the necessary information from the patient. Although it was primarily designed to measure the severity of depressive symptoms in patients with primary depressive illness, it has been used to assess depressive symptoms in other groups as well. The rating should ideally take place at a fixed time to avoid the influence of diurnal variation. It is usually done within 15-20 minutes at 2 weekly intervals (Jha, 2004). The Psychometric properties like reliability and validity of the scale has been examined explicitly since 1979. The Higher the score, the more severe the depression. While it is not possible to assign a specific level of depression to a specific HAM-D score, it is possible to classify the level of depression as follows based on score 10-13=mild; 13-17=mild to moderate and > 17 =moderate to severe. While the scale contains 21 variables, evaluation of the severity of depressive symptoms is based on the patient's score on the first 17 items (Hamilton, 1960). The Nursing care and interventions for Mr.X: Nursing interventions are based on evidence-based practice. Evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the case of individual patients (Sackett, 1996). Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003). Since, patient care in this case study is based on Roper Logan and Tierney model the 12 elements of maintaining a safe environment, communication, breathing, eating/drinking, elimination, washing/dressing, thermoregulation, mobility, work/play, sexual expressions, sleep and dying are taken into account in the care of Mr.X. Maintaining a safe environment: Maintaining a safe environment includes the nurse making sure that the electrical gadgets and equipments are safe for patient use and the side rails of the patient cot are intact. It is iportant to keep the ward free from animal/ insect intruders ,well lit and ventilated. Communication:The gender, age and health condition also influences the communication. For example, it is difficult to communicate to an old patient whose 'hearing capacity would be at a reasonably low level or whose perception has diminished due to aging. Non-verbal communications do occur in nurse-elderly patient communication. The non-verbal communication includes patient-directed eye gaze, affirmative head nod, smiling, learning forward, touch and instrumental touch (Wilma, 1999). If has been observed that these non-verbal communication have as tremendous impact on the patient's well-being and comfort. The nurses seem to eye gaze, head nod and smile to establish a good relationship. A caring touch is an important form of non-verbal but often effective communication. If should be understood that the nurse should be able to perceive the expressions of the terminally ill to provide maximum comfort. Breathing: People with cardiac complications or conditions that cause shallow breathing benefit from mechanical devices that assist breathing, such as continuous positive airway pressure, which delivers oxygen through a nose or face mask that prevent airways collapse, even at the end of a breath. Additional respiratory support is also provided with a mechanical ventilator during such episodes. Oxygen administration relieves symptoms and prolongs patient survival. Antibiotics are to given for any detected respiratory infections. Benzodiazepines are not recommended to relieve anxiety in such patients who have COPD because of aging. They decrease respiratory drive and compromise lung function. An anxiolytic, buspirone, have been found to be safe in reducing anxiety in this patient. Eating/drinking: A low salt diet is recommended and making him eat with everyone in the table will positively influence his other activities,reducing his depression and improving mobility. Thermoregulation:. Diuretics are given to remove excess fluid from the body.Further,calcium channel blockers, intravenous prostacyclin, or the oral medication bosentan are frequently used to treat pulmonary hypertension which if untreated will cause cor pulmonale due to fluid retension in lungs. Blood thinning anticoagulants have also been useful. Washing: Oral care includes brushing the patient's teeth, use of solutions and mouthwash to cleanse the mouth, and periodical suctioning of oral secretions apart from routine cleansing of the body. Conclusion: Continuity of caregivers where a single, continuous treatment team is responsible for patients in both inpatient and outpatient settings (Fuller Torrey 1986) seems also to complement continuity of care with improved cognitive function self-care skills .The nurse today is a qualified responsible member of a medical team in which she plays a key role. Her neo responsibilities include monitoring the physiological status after medications, establishing a communication bridge to establish patient's self care, caring based on intimacy and decision making rather than just following doctor's instructions, recording the legally important patient care documents like informed consent, advance directives and proxy directives based on the competency of the patient and physiological /psychological status. Nurses should develop skills to assess patient's responses to the serious illness. 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