Knowledge Required for Decision Making in Adult Nursing - Assignment Example

Running Head: Knowledge required for decision making in Adult Nursing Knowledge required for decision making in Adult Nursing of the [Name of the institution] Knowledge required for decision making in Adult Nursing Introduction The aim οf this assignment is to demonstrate an understanding οf the relationship between two problems οf a patient and the care planned to alleviate these problems. A further purpose is to develop an understanding οf implementing a holistic approach to planning care and to evaluate its effectiveness. I shall justify the selection οf problems, intervention the patient received, and relevant physiology and psychology. The details for this assignment come from a recent clinical placement on a surgical ward, which deals with Hepato-Biliary surgery. The patient will be referred to as Gill to ensure Nursing and Midwifery Council (2002) confidentiality guidelines are concurred. Description Gill is a 50-year-old insulin dependant Diabetic. She was admitted to the ward via Acute Medical Assessment Unit (AMAU). Gill was found on the floor after a fall, feeling drowsy, vague and confused and complaining οf abdo pain. After nursing hand-over, a multi-disciplinary team embarked on a strategy to assess, monitor and resolve Gills issues. Multi-disciplinary working is encouraged within the NHS Plan (2000) and is concerned with professional healthcare providers working together for the well-being οf the patient. (Castledine 1996) Gill was then admitted to the ward where a full nursing assessment took place and from here a plan οf care was prescribed and implemented. Further information was obtained from previous medical records. This revealed in 1998 Gill had a cerebral vascular accident (CVA) and recovered well. She was also diagnosed with alcohol liver disease (ALD) in April 2000 and diabetes 15 years ago. Gills observations on admission where taken so to provide a basis for any later comparisons. Her blood sugar glucose reading was 32.4 millimols per litre. The normal reading should be between 4-7 mmol/l before meals rising to no higher than 10 mmol/l two hours after meals (http://www.diabetes.org.uk/) A ward test urine was taken which showed glucose and protein were present. Gills assessment 1.Maintaining a safe environment - Gill had a nurse call bell and a patient identification wrist band. She was shown around the ward but increasing confusion and previous falls made it a priority to monitor Gill closely. 2. Communication - No problems. 3. Breathing - No problems. 4. Elimination - No problems. 5. Personal Cleansing and Dressing - No problems. 6. Controlling Body Temperature - No problems 7. Mobilising - Gill is normally independent but during admission co-ordination is impaired. 8. Working and Playing - No problems. 9. Expressing Sexuality - No problems. 10. Sleeping - Gill explains that she normally sleeps well but οf late she has quite drowsy. 11. Eating and drinking - Gill explained that she drinks a lot οf tea and cola throughout they day but is often left still trying to quench her thirst, her favourite foods are chocolate and sweets. She tries to eat regular meals but often has little appetite. 12. Mortality - No problems. Identification οf nursing problems After applying Roper et als (2002) model two nursing problems were identified. These will be the areas chosen for discussion: Eating and drinking with the long term aim οf controlling Gills diabetes. Maintaining a safe environment for Gill as her main reason for admission was falls and increasing confusion. After the identification οf issues a plan οf care was documented. This is a contract where goals are set. The goals should be patient centred, and the team should work in conjunction with the patient about what they want (Hogston 2002.) This then becomes meaningful to the patient rather than an unrelated series οf actions set by the nurse. (Mallik, Hall & Howard 1998.) Plan οf care: Maintaining a safe environment This was identified as a nursing problem as Gill may be unable to identify potential hazards due to her increasing confusion. Dimond (1999) states the function οf the nurse is to provide humanistic care required in order to maintain a good quality οf life. Gills confusion was apparent when spoken to; she would forget the topic οf conversation and discuss other matters. The presentation οf signs was reported to the medical team who instructed that 4 hourly neurological observations must be taken. These are defined as an evaluation οf an individuals nervous system (Mallet & Dougherty 2000.) This was documented on her observation chart. A Magnetic Resonance Imaging (MRI) brain scan was also needed. This is a diagnostic technique which enables the non-invasive diagnosis and treatment planning οf a wide range οf diseases (Ferran 1998). A referral was made for an urgent appointment. Through the assessment οf risk and the anticipation οf potential problems the nursing staff felt with regards to her mobility that Gill would benefit being encouraged to walk with assistance when able and that a referral to the physio and occupational therapy services was necessary. Plan οf care: Eating and drinking This was identified as a nursing problem as Gills diabetes was uncontrolled and potentially very dangerous. Gill was told that because οf her diabetes, she should avoid eating sweets and cakes and advised about being educated on her diet as the British Diabetic Association (1992) recommends that patients should be seen by a dietician. The diabetes specialist nurse can also provide advice for managing diabetes in the clinical setting. She agreed to this and the necessary referrals where made. It was documented that Gill should be given a special diet menu card and should be encouraged to eat as she often did not eat regular meals. Gill was advised that her blood sugar glucose would be monitored four times daily before meals. A fluid balance and food chart were also commenced so that input could be monitored. Physiology and Psychological Effects Mobility is defined as the ability to move about freely (Ismeurt et al 1991) It is vital for activities such as avoiding danger or finding food (Courtenay 2002.) Movement is also a basic human need. Maslow (1968) discusses human needs in his hierarchy οf needs (Underwood 2003.) This hierarchy οf needs progresses from survival needs such as food and shelter to psychological needs such as self-actualisation. To meet our needs we develop skills necessary to survive such as walking, dressing and eating. Mobility is therefore central to performing all aspects οf daily living. Gill was admitted after a series οf falls which are common incidents among hospitalised patients (Gaebler, 1993). Falls are defined as an event which results in the patient or a body part οf the patient coming to rest inadvertently on the ground (Kellogg International Work Group 1987). Therefore it was a priority to ensure a safe environment was maintained as nurses have a direct role in ensuring the implementation οf safe care for their clients (Weaver and Hall 1998.) Also the NMC (2002) guidelines state you must work to promote health care environments that are conductive to safe practice. Gill is an independent diabetic (Type 1 Diabetes) which is one the types classified by the World Health Organisation (WHO 1995.) Simpson (2002) describes diabetes as the inadequate production or utilisation οf insulin. Insulin Dependant Diabetes Mellitus (IDDM) is thought to develop when someone has a predisposition to the disease combined with environmental triggers (McIntyre & Strachan 2000.) Type 1 diabetes occurs when insulin secretion is totally (or almost totally) absent and as a result lifelong treatment with insulin is required (Watkins et al 1996.) The pancreas is a very important organ in relation to diabetes. It is a gland which combines exocrine and endocrine functions. The endocrine function is concerned with the secretion and manufacture οf hormones: insulin and glucagon. Insulin is an anabolic hormone (McIntyre & Strachan 2000) and is released in response to a rising blood glucose level. Glucagon is a catabolic hormone (McIntyre & Strachan 2000) and is secreted in response to a falling blood glucose level. The effects οf lack οf insulin (McIntyre & Strachan 2000) include: Hyperglycaemia: Glucose is unable to enter cells it accumulates in the blood, causing abnormally high blood glucose readings Glycosuria: Glucose appears in the urine as the kidneys cant reabsorb it. Polyuria: Glucose is lost in the urine and large volumes οf water are lost as well Polydipsia: Patient drinks more in response to severe thirst due to dehydration. The cause for diabetes remains unknown. It has been found that diet plays a central role in the management οf diabetes (BDA 1997.) Unfortunately type 1 diabetes can not be cured simply by dieting however does makes lowered demands on the insulin supply. An important part οf any condition or hospital admission is the patients psychological state οf mind. Carter & Green (2002) discuss that nursing has integrated holistic perspectives and to perceive the patient as a whole and not as components is an important ideal and can help the nurse to be more receptive to the patients self image and self esteem. Self-image is defined as our own assessment οf our social worth. (Price 1990) Therefore self image and the patients perception οf themselves effects communication and is important part οf holism. Jasper (2002) defines holism as a philosophy addressing the person as an irreducible whole. It involves taking into account ones physical, emotional, intellectual, spiritual and sociocultural background. The nurses focus is on prevention and well-being and on helping individuals to take responsibility for their own health (Kenworthy, Snowly and Gilling 2002.) Nursing Care It was hard to determine the psychological effect on Gill. What had been noticed was it was hard to motivate her. The student spent time with Gill and found she felt restricted and wanted her independence back. A view from Rogers (1991) supports the belief that a patients major problem is that they are somehow prevented from being themselves. She reported feeling controlled, child-like having to be escorted to the toilet and a burden to the nurses and her family and when doing so became upset. Although what Gill said was often confused she was able to express her feelings. She felt deprived because she was unable to have normal foods such as chocolate and disliked being watched at meal times. Whilst Gill talked, the student listened and felt that giving Gill time to express herself enabled the formation οf a therapeutic relationship. Hogg and Vaughan (2002) suggests that a relationship between a nurse and a patient needs to contain elements οf empathy, warmth, understanding and unconditional positive regard. These communication skills were shown to develop Gills trust and in doing so I could appropriately respond to her needs. The student has found that reassuring patients, providing emotional support and encouraging them to share their fears, enables nurses to offer the patient realistic feedback, reassurance and empathy (Carpenito 2000.) The social and psychological effects οf diabetes, confusion and impaired mobilty can be devastating for the patient, for example Gills hospitalisation meant she had lost her a sense οf normality and that her decreasing mobility posed a threat to her freedom and life after discharge. When Gill explained how she felt the student empathised and was able to feedback this information to the team. Gills neurological observations were monitored 4 hourly and recorded on her neurological assessment chart. The assessment was done to monitor her condition and assessed Gills level οf consciousness, limb co-ordination, pupilary activity, motor function, sensory function and vital signs (Mallet & Dougherty 2000.) Gills verbal response was often confused as she was often unable to answer questions such as the date. She responded to speech but was drowsy. Gills limb co-ordination was impaired which resulted in her suffering falls. Her eyes reacted satisfactorily to stimuli and her vital signs showed her respiration rate fluctuated between 16-24 breaths per minute. Timby (1989) states respiratory rates in female adulthood will be between 16-20 breaths per minute. Gills blood pressure, pulse and temperature fluctuated but were satisfactory. The results show that Gills neurological reactions were not as they should be needed further investigation. The results οf her MRI Brain scan revealed that Gill was in early stage dementia. Dementia is defined by Ferran (1998) as a chronicor persistent disorder οf behaviour and higher intellectual function due to organic brain disorder. This diagnosis explained her increasing confusion and was also identified as the most likely cause for her falls. This progressive brain dysfunction, leads to a increasing restriction οf daily activities (http://www.alzheimers.org.uk/.) Dementia not only affects patients but also those surrounding them, as most patients require care in the long-term and during the later stages οf dementia most people will become increasingly frail. They will also gradually become totally dependent on others for all their care and knowing what to expect can help everyone to prepare. The multi-disciplinary team recognised the benefit οf family centred care in producing a favourable outcome. Gills husbands participation was vital to her continuing care after discharge as he is her main career. He was involved using informal conversations and structured meetings which enabled decisions to be made, to anticipate problems upon discharge and their possible solutions. As Gills mobility was impaired the nurses had an important role in promoting her independence and enhancing her well being. To ensure Gills safety a chair was used to transport her. She was only encouraged to walk with staff when she felt able. When in bed, bed rails were used to ensure she did not fall out. The physio and occupational therapists visits also proved valuable to Gills care and maintaining her safety. Gill had something to look forward to as she enjoyed mobilising with the physiotherapist. The occupational therapist was also a welcomed input as they suggested a home visit to assess the suitability οf her home environment with a view to discharge. This filled Gill with hope and after this visit she was less home-sick and started to accept hospitalisation was temporary. During informal discussions Gill was provided with suitable health education structured to meet her needs as she had a very high blood glucose, known as hyperglycaemia. Nurses and dieticians were able to select appropriate leaflets concerning healthy eating and particular needs οf the diabetic. The dietician gave dietary advice to Gill and her husband. It was explained that Gills blood sugar would be better controlled if she ate regular meals, including a high carbohydrate food at each meal. These are preferable to simple sugar based foods as sugary foods are rapidly absorbed, which raises blood glucose levels (BDA 1992.) The dietician advised that it is not essential to eat specific diabetic food as they are expensive and often sugar free alternatives are available. The dietician also suggested that as Gill drank tea and cola, she would arrange for her to have skimmed milk and for diet cola to be available. The use οf the food/fluid charts continued as it indicated whether Gills diet was helping to regulate her blood sugar. These suggestions seemed agreeable to Gill however the student recognises that when translating theory into practice, not all patients are able to achieve these dietary guide lines, as patients presenting with diabetes have well established dietary likes and dislikes Gordan (1996.) The diabetic specialist nurse also visited Gill; explaining that her blood glucose would be monitored four times a day. This would be done before meals and last thing at night; and would be recorded on a chart by the nurse looking after her. Reading this chart would show if the insulin prescribed twice daily, along with a controlled diet, was regulating her blood glucose and preventing further hyperglycaemic attacks. The nurse presented Gill with a glucometer and taught Gill and her husband how to monitor blood sugar. User involvement has great importance as it ensures care is patient-centred, and they are more likely to comply with suggestions to improve their health and well-being (Binnie, Titchen, Lathlean 1999.) Compliance is also more probable if the patient feels in personal control οf their care (Russell 1999). It was vital that Gills husband was aware οf this process because οf Gill increased confusion she may forget what she had been taught. This health education is an important component οf health promotion. It is aimed at the individual and can be approached in many ways. The nursing staff, dietician and diabetic nurse adopted a self-empowerment or humanistic approach (Mackintosh 1996) which focused on Gill with the goal οf improving her situation, they aimed to develop her motivation and self esteem, to re-establish healthy eating and help her to reach acceptance οf her diabetes. It has been found that teaching the client treatment measures can help decrease their fear and anxiety οf the unknown, and their sense οf control over the situation (Redman 1997) As a result οf the care planned and implemented Gills blood sugar level started to stabilise (reading fluctuated between 8-15 mmols per litre.) She started eating regular meals and the source for her increasing confusion and poor mobility was identified. After several weeks on the ward Gill returned home with a suitable care package which considered the need to ensure adequate nutrition at home, regulation οf her blood glucose level and minimising the risk οf further falls. I feel that because Gill and her husband were well informed about the purpose and goals οf treatment, and they could adhere to the information and advice they received. I was pleased that Gill and her husband were involved in the decision making process as it promoted empowerment and ensured they were not disregarded (Baumann 1998). I have found that to deliver holistic care required not only full understanding οf Gills illness but also her social, physiological and psychological needs so that care was individualised. After examining the aspects οf holistic care I know that although not every patient requires regular monitoring οf blood glucose or experiences increasing confusion the basic principles underpinning care are the same and all patients and families require effective communication. Conclusion When reflecting on Gills care I thought about what may have been done differently. Gill was on a surgical ward and although the care given by the staff was in the students opinion was well planned and implemented, I wonder if Gill had been on a designated diabetic ward would there have been greater advice and support available? I feel that Gill did not receive adequate support and information on was how dementia will affect her life. I think perhaps she should have been offered the opportunity to meet with a councillor because the feelings she expressed when we spoke suggested to me that she needed to talk. However when reflecting on Gills care I was pleased that I had been involved, that her identified problems were resolved and that she was able to return home. I have found that applying Roper et als (2002) theoretical framework gives a good foundation for delivering effective nursing care. I believe that effective care was achieved for Gill, through teamwork and good interpersonal skills from all the team. I have gained a better understating, οf how vital it is for the multidisciplinary team to work collaboratively in order to provide maximum patient care. This was beneficial for the Gill and her family, as it promoted the exchange οf information and continuity οf care. It is also beneficial in decision making and problem solving as it encourages involvement from various disciplines as well as the patient. In conclusion by speaking to other nurses, and furthering my knowledge on patient care, I have gained a better understanding on how to prioritise and identify actual and potential problems affecting my patients. References Baumann L (1998) Health and Physical Assessment, Mosby Binnie A, Titchen A & Lathlean J (1999) Freedom to Practice: Patient-centred Nursing, Butterworth Heinemann   British Diabetic Association (1992) BDA Nutrition Sub-committee Dietary Recommendations for Diabetes; An Update for the 1990s. London BDA British Diabetic Association (1997) Diabetes Care - What You Should Expect. London BDA Carpenito J (2003) Nursing Diagnosis: Application to Clinical Practice. 10th edition Lippincott Williams and Wilkins, Philadelphia Carter S & Green A (2002) IN Hogston and Simpson (2002) Chapter 7 Body Image p238-261 Foundations for nursing practice 2nd edition, Palgrave Macmillan, London Castledine G (1996) Encouraging Team Collaboration in Health Care. 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Roper N, Logan W & Tierney A (1996) The elements οf nursing: a model οf nursing based on a model οf living 4th edition. Churchill Livingstone, Edinburgh Russell G (1999) Essential Psychology for Nurses. Routledge, London Simpson (2002) IN Hogston R & Simpson P (2002) Foundations for nursing practice. 2nd edition Palgrave Macmillan, London Timby (1989) IN Mallet J & Dougherty L (2000) Clinical nursing procedures, 5th edition, Blackwell Science, Oxford Underwood M (2003) http://www.cultsock.ndirect.co.uk/ Accessed 23rd February 2004 Watkins et al (1996) IN Alexander M Fawcett J & Runciman P (2002) Chapter 5 p163 Nursing Practice Hospital and home: The Adult, 2nd edition, Churchill Livingstone, London Weaver C and Hall C (1998) IN Mallik.M, Hall C, Howard.D (1998) Chapter 1 Nursing Knowledge & practice - a decision making approach. Bailliere-Tindall, Edinburgh World Health Organisation Report (1998) Life in the 21st Century A vision for All. Genev Read More