Nursing and Health Care within the Community - Essay Example

?Introduction The effectiveness and success of nursing and healthcare provision within the community is largely dependent on proper holistic assessment based on an appropriate conceptual theoretical framework. Holistic assessment enables a nurse to plan the necessary patient-centred, consultative and evidence-based intervention while also taking into consideration the matter of client/carer and self-care extent to ensure that the client receives the best care possible while away from the hospital. The client selected in the family case study provided is Michaela and a justification for utilisation of Orem’s model of assessment for Michaela will be provided. Planned intervention integrating referrals to multi-disciplinary teams and the patient’s own values will be developed based on the best evidence followed by evaluation of the planned care for Michaela. Assessment of Care and Planning using Orem’s Model Orem’s model was selected for the case of Michaela based on several considerations that make it the best conceptual framework to utilise in this case. Orem’s model is founded on the view that nursing is necessary just in the time when the patient’s care needs are beyond self capacity or ability hence the nurse intervenes by evaluating the patient’s ability and then educating, providing guidance while at the same time delivering care whose completeness is relative to the patient’s own ability (Orem, Renpenning & Taylor 2003, 339; Naji et al. 2009, p. 174). Central to Orem’s model is the concept of self-care which is especially being encouraged by the UK health policy as an effective means of improving the health (Department of Health 2005, p. 48). It has been observed that Orem’s model is exclusively the main self care framework that can be incorporated effectively in assessment of patients (Basavanthappa 2007, p. 24-25; Macduff and Sinclair 2008, p. 32; Sitzman 2011, p. 339). Wilson (2003, p. 68) recognises the crucial role that nurses bear in education of clients and their carers where present and attach importance to Orem’s model in ensuring that this is achieved. They also note that nurses are charged with the duty of providing information that influences the patients’ decisions and participation in self care both of which are achievable through Orem’s self care deficit theory of nursing. Orem’s model is thus quite applicable for Michaela as a means of establishing the extent to which she can take care of her health and then developing a care plan to intervene on her deficiencies alongside an evaluation of the entire process and its impact on her health. This model is also advantageous as it is based on self care which particularly applies to the patient’s situation as we can discern that she cannot access a proper carer as her husband is also sick and unable to work while the daughter is currently in school and has her own problems with regard to decisions on reproductive health. The objectives of applying Orem’s model in Michaela’s situation includes assessment of her health conditions according to the items in the model, identification of her needs and lastly demonstration of effective communication with her in order to provide patient focused care and intervention (Nursing Theories 2011). The first self care item on Orem’s model is the maintenance of sufficient intake of air for which the checklist includes dyspnoea, cough, cyanosis and smoking. Michaela admits to smoking 25-30 cigarettes a day alongside her husband Nicholas which is particularly heavy when taking into consideration that she is also asthmatic and recently experienced a cough that exacerbated the asthmatic condition and forced her to seek emergency help. Michaela’s current self care ability in terms of air intake is low since she experiences coughs, has asthma and is a heavy smoker. From this, it is inferred that the self care deficit calls for partial compensatory requisites. The next item in consideration is maintenance of sufficient intake of water. Michaela can independently take water as none of her problems interferes with this. The inability of the spouses to work however raises questions on the availability and adequacy of water intake in the long term but this is not identified as a major problem currently. The same applies to the next item; maintenance of a sufficient intake of food; a consideration in which long term problems can be pictured. The nutritionist in the team will be important in ascertaining the results of nutritional assessments that Michaela and the rest of the family are following the ideal nutritional requirements and where possible advise the family on improvements or corrections. The inference here is that education support will help in addressing any future self care deficit with regard to water and food. Michaela also faces no problems in the next item-elimination processes as she does not experience difficulties in voiding and eliminating. There is concern however regarding the maintenance of a balance between activity and rest as Michaela is unable to attend to work. It can be inferred that being asthmatic and especially when worsened by the cough she recently developed has left her unable to work thus skewing the balance of work and rest. It is inferred that she cannot adequately undertake self care with regard to balancing being active and rest/mobility and a partially compensatory design can address this self care deficit. Michaela does not experience major deficits in maintenance of a balance between solitude and social integration as should be exhibited by deficiencies in terms of environmental matters, interests, family, sensory deficits, spiritual needs and developmental needs. The spiritual perspective scale will be utilised as an assessment tool to confirm spiritual stability in terms of Michaela’s perceptions as to the extent to which she holds spiritual views and engages in related practices as administered by Dunkinn and Dunn (2009, p. 25). Efforts from the social worker in the team will also be used to confirm most of the parameters for this section. In terms of prevention of hazards to her well-being, she does not adequately undertake self care as her smoking and contracting a cold is bound to contribute to acute asthma attacks. An educative supportive approach is however enough self care deficit intervention to manage this. The last item for assessment on the Orem’s model is promotion of normalcy which can be examined through a patient’s self concept, socio-cultural background, family, attitudes towards life, individualisation, interests in life, values, goals and motivation and developmental aspects. The perceived stress scale is the assessment tool of choice in establishing Michaela’s perception of her life as being stressful in terms of unpredictability especially financially and inability to be in control of issues (Peters 2007). This was important in measuring the self care ability of Michaela in regards to self normalcy. The social worker will also give more insight into the exact nature of disturbance of normalcy in the patient. Michaela and her husband emigrated from Poland to England in search of a better life and hence it can be inferred that they do not hail from a stable socioeconomic background which should be worsened by the fact that both are currently unable to work due to sickness. Her health problems and the financial plight of the family have distanced her daughter who can be seen making quite important decisions on her own indicating a breakdown of Michaela’s family relations. Her developmental state can be deduced to be anxious especially due to the husband’s health and inability to work. Like her husband, she also does not know the avenues to be followed by the husband to access benefits. It is thus inferred that Michaela’s self care in terms of promoting normalcy is wanting and a partially compensatory approach is necessary to address this. The four areas of deficiency of universal self care aspects identified are maintenance of sufficient intake of air, maintenance of a balance between work and rest, prevention of hazards to life and finally promotion of normalcy. The priority will be given to address issues of air intake, balance between work and rest and promotion of normalcy because the three are more important while considering the fact that compensating for deficits in the first item also solves the problem of hazards. This is because they are both related to the issue of smoking and cold. The Care Plan The nursing care plan will be based on the diagnosis according to the extent of the three needs: the prescriptive operations, the implementation of the control operations and finally the evaluation of the effectiveness hence the regulatory operations. The objective of the care plan is to apply Orem’s theoretical framework in solution of the already identified problems in self care and then determine the extent to which the interventions put in place are successful. A. Self care deficit area: Air It is inferred that Michaela’s ability to do this is inadequate and the nursing diagnosis made is that there is inability to maintain the ideal intake of air resulting from Michaela’s health condition and knowledge deficit. The desired outcome and goal is to achieve adequate air intake at all times and the intended design of the nursing system is partial compensatory. The tools for undertaking this step will include teaching, guidance, providing support and demonstration alongside a developmental environment. The actual implementation of this step will be first through mutual planning and setting of the objectives with Michaela. The risk factors that trigger asthma will be explained to Michaela, including animal protein, pollen, mould, extreme weather, drugs, fumes and sprays, emotions and smoking with particular weight resting on the last two (NHS 2010). Michaela will be asked to identify the risk factors that apply specifically to her situation. She will be made to understand that her heavy smoking and coughing aggravates it. Several strategies through which Michaela can improve self care will also be provided. This will be mainly centred on avoiding asthma triggers including reducing smoking and taking a great deal of care in cold weather alongside eating healthy and exercising regularly (NHS 2010). The clinical officer in the team will be requested to examine Michaela and come up with an asthma regimen that will specifically suit the patient through cooperation with the pharmacist. This will be to ensure that Michaela’s acute attacks are dealt with so as to enable her focus on managing her care in terms of avoiding the risk factors associated with asthma. The social worker in the team will be instrumental in convincing Michaela about the health impacts of smoking and helping her through the process of gradually quitting the habit through provision of professional guidance to ensure that Michaela succeeds. The evaluation for this will be through analysing whether Michaela clearly understands and can avoid the risk factors that worsen asthma whether she knows and avoids conditions that predispose her to catching a cold, whether she agrees to it and takes steps to eventually quit smoking. The conclusion on the evaluation will be based on whether the deficits in self care in terms of sufficient air intake are decreased. B. Self care deficit area: Activity and rest The assessment shows that Michaela is currently unable to work due to her acute asthma attacks that even necessitated a visit to the local emergency unit. Michaela’s extent of self care in terms of balancing activity and rest is inadequate. The nursing diagnosis in this case is that Michaela leads a sedentary lifestyle which contributes to worsening of her condition and thus the desired outcome of the intervention is making Michaela develop into a physically active individual. The specific goal is to make Michaela adopt an exercise regimen that will improve her care ability in balancing rest and activity as she currently is unable to undertake many tasks. The objectives include setting aside time for exercise, identifying specific sustainable and appropriate exercises and teaching Michaela how to undertake these. The nursing system design in this case is partially compensatory and the main methods of helping includes explaining to Michaela how exercise is important in her case, developing a timetable for exercise with her and exploring the specific exercises she feels will suit her preference. Environmental support will be achieved through encouraging her husband and daughter to take part in the exercise programs alongside her. The physiotherapist’s evaluation of Michaela and members of her family will be important in establishing the extent of the exercises and the exertion and flexibility that their bodies can handle at the start of the regimen and possible changes as time goes by. A referral form will be filled by the nurse to enable Michaela access any equipment needed for the exercise program being instituted. Oldman, Brodie and Nmatsakanova (2003) provide quality evidence of an objective method for obtaining equipment loans for community-based health care dependent on a prioritisation system according to a patient’s clinical needs. Their study indicates that clinical prioritisation in referral forms improves provision of services by nurses, it is more equitable and eases decision making. The importance of the exercise program for her entire health improvement will be used to prioritise exercise equipment in the referral form. Evaluation of the intervention provided to enable Michaela improve her care for a balance between rest and activity will be through whether there was establishment of an effective and workable exercise schedule, the ability of Michaela to undertake the exercise procedures on her own, involvement of the rest of the family in the exercise regimen and Michaela’s ability to develop, achieve and sustain a balance between rest and activity. C. Self care deficit area: Promotion of normalcy The assessment reveals that Michaela faces challenges in maintaining her normalcy in terms of emotional stability and family relations. Michaela’s self care is inadequate according to the nursing diagnosis and the desired outcome is making her more emotionally stable. The specific objectives of this intervention is to enable Michaela overcome her anxiety resulting from the family’s health and their financial plight and enable her to develop stronger family ties especially with her daughter. The nursing design for the intervention is also partially compensatory. A number of support actions will be undertaken mainly involving referrals. The first of these will be through accessing psychological help for Michaela. A referral for professional services will be made through the social worker to avail the best possible psychological care for Michaela after informing her that this is the best course of action in case she is apprehensive to attend psychotherapy sessions. It has been shown that a psychopharmacological approach to treatment is a better and holistic avenue with sufficient evidence supporting its effectiveness (Murray 2006, p. 318; Hales et al. 2009, p. 393). Tyrer and Silk (2008, p. 569) also address effective treatments in psychiatry and identify the importance of integrating medical and psychological approaches in therapy. Further evidence to support the need to provide psychotherapy can be obtained from the concept of illness behaviour in which individuals may present illness based on their own perceptions of health, cases for which medical care may not be sufficient to deal with the situation (Wikman, Marklund, and Alexanderson 2005, p. 450-454). This supports the decision to involve psychological help to enable Michaela take charge and overcome her anxiety that could be contributing to aggravation of her asthmatic condition. Referral will also be made for possible benefits since it is clear that this is one source of concern for her and the husband. According to the UK parliamentary Health Committee (2006, p. 50) every patient suffering from cancer needs to be offered specialist advice at the time of diagnosis and throughout the key points of their treatment. The government states that referral mechanisms should be integrated into care pathways so as to give patients sufficient advice about their benefits. Rankin (2008, p. 125) observes that a practical solution to cases in which cancer patients do not have clear information on the accessible benefits is to provide a referral to a social worker in order to avail the relevant advice on benefits to the patients. This is particularly useful for the case of Michaela and her husband who have scant information on how they can access benefits for Nicholas. A referral form for benefits or allowances will be filled in consultation with Michaela and her husband and then handed over to the social worker to access a benefits advisor in order to establish the benefits Nicholas is entitled to. As a result Michaela’s worries will have been dealt with and she can now concentrate on her part in self care. Evaluation for this step will include determining whether Michaela and her family will be able to access the referral services. In terms of psychological help, attending the sessions set will be used to determine whether the approach is successful alongside its effectiveness in enabling Michaela overcome her anxiety and take charge of her family. Analysis of whether illness behaviour was a contributor to her worsening asthmatic condition will also be used to evaluate this approach. Access to services from the referrals made for benefits will also be used as a yardstick to evaluate this step besides observation of the effect of such a move in enabling Michaela to undertake her own self care in relation to normalcy through overcoming anxiety. The Multidisciplinary Team The team handling Michaela consists of a clinical officer, a nurse, a pharmacist and a physiotherapist besides forming part of a larger interdisciplinary team that consists of a nutritionist and a social worker. Ellingson (2002, P. 7) observes that multidisciplinary and interdisciplinary teams have maintained growth in popularity in all aspects of healthcare particularly where holistic assessments are necessary, a view also shared by Meyer et al. (2004, p. 25-27). Borrill et al. (2002, p. 3) undertook a study and found out that multidisciplinary teams especially those which are professionally diverse have elevated levels of innovation in provision of healthcare and that members of such teams suffer relatively lower stress levels. Effectiveness and quality of patient care is improved when multidisciplinary teams are in operation. This is evident in the case of Michaela where the team is diverse and through effective communication within the team and with Michaela and her family quality care will be availed. The data collected for all the items in Orem’s framework is reliable as nursing assessment tools, nutritional considerations and social perspectives are integrated to give a comprehensive assessment of Michaela and her family thus enabling the self care deficits to be addressed properly. Referrals are also far easier to undertake within the multidisciplinary team. Some challenges and setbacks however might arise especially in the case where communication is ineffective, lack of time for consultation and differences/conflicting observations. These are the things to address to ensure that Michaela receives the best possible care. Overall evaluation of the implemented self care deficit theory An in-depth appraisal of the effectiveness of the adopted Orem’s model in the case of Michaela can be undertaken through considerations of whether its objectives have been met. To begin with, the approach is able to assess the Michaela’s health conditions in entirety in terms of physical health, mental health and her social well-being through the methods itemised in Orem’s model. The assessment also results in achievement of the second objective i.e. the identification of the needs of Michaela in terms of her deficiencies in self care capacity. The fact that a successful assessment is undertaken and that Michaela’s needs are identified indicate that effective communication and interaction with the patient has occurred. The ultimate effectiveness of the interaction of the nurse, Michaela and her family will be demonstrated when the care plan is successfully implemented and the desired outcomes observed in Michaela in terms of improving self care. Another important yardstick for appraisal of this approach is the development of a care plan that is client-centred. This is demonstrated in all the interventions set for Michaela. In the first intervention, Michaela is enlightened on all the possible risk factors for an asthma attack and then let to identify the ones that are specific to her case. In the second intervention, she is involved in developing the exercise schedule and selection of the exercises that she prefers from the range given by the expert. The fact that evaluation is undertaken at each step is also an important pointer to overall effectiveness of the self care deficit approach to Michaela’s case. The importance of evaluation in Orem’s model cannot be overstated for the case of Michaela as it is the only way to determine whether valuable decrease in self care deficiency is achieved. Michaela is in a position of inadequate self care in terms of sufficient air intake which crucially impacts her general health; an evaluation to indicate that she understands the measures she could take to avoid aggravating her asthma and contracting colds besides taking the initiative to quit smoking is important in determining whether Michaela improves her own care in terms of air intake. In a similar fashion, evaluation for the effectiveness of the exercise program instituted has importance in establishing whether Michaela will be able to take charge of her balance between rest and activity which is currently inadequate. An evaluation of reduction in anxiety and family involvement also serve to indicate that Michaela is able to undertake self care for her normalcy. Evaluation of the instituted planned care is thus ultimately important in arriving at a conclusion about the success of implementing Orem’s self care deficit theory in the case of Michaela. References Basavanthappa, BT 2007, Nursing theories, India, Jitendar. Borrill, C, et al. 2002, Team-working and effectiveness in healthcare: Findings from the health care team effectiveness project, United Kingdom, viewed 23 September 2011, . Department of Health 2005, Supporting people with long term conditions: An NHS and social care model to support local innovation and integration, UK, Crown, viewed 23 September 2011, . Dunkin, J & Dunn, LL 2009, ‘Spiritual Perspectives and Health: A Random Survey in a Southern State’, Online Journal of Rural Nursing and Health Care, vol. 9, no. 2, pp. 25, viewed 23 September 2011, . 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