Patient Centered Nursing Care - Case Study Example

PATIENT CARE STUDY – A REFLECTIVE CASE STUDY ON PATIENT CENTERED NURSING CARE SUBMITTED BY PATIENT CARE STUDY – A REFLECTIVE CASE 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 (Suzanne et.al, 2004). 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 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 treatment options today (Kubler – Ross, 1969). Most of the patients want to discuss their treatment options and have a Right to refuse as per existing laws in UK. DESCRIPTION OF THE EVENT The patient in this case was admitted for an acute exacerbation of COPD with the complications Atelectasis, Anxiety and Cor pulmonale. Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), is a term used to describe progressive lung diseases, which include emphysema, chronic bronchitis and chronic asthma.  The common symptoms of COPD are progressive limitations of the airflow into and out of the lungs and shortness of breath. The primary treatment for acute massive Atelectasis was the removal of the underlying cause by surgery by a surgeon. Since the blockage could not be removed by coughing or by suctioning the airways it was removed by bronchoscopy and involved a pulmonologist. Antibiotics were given for the detected infection due to chronic Atelectasis as recommended by a Physician and Microbiologist. A low salt diet was recommended by a dietician .Diuretics were given to remove excess fluid from the body under the supervision of a urologist. An anxiolytic, buspirone, as recommended by a psychiatrist was found to be safe in reducing anxiety in this COPD patient instead of benzodiazepines, which affect lung function. The patient was assisted by a physiotherapist in regaining his mobility after the surgical intervention. A social worker assisted the patient in keeping updated on the latest developments around UK politics he was interested in. A speech therapist helped him to regain his normal speech. My role in the acute care included respiratory assessment and interventions. Respiratory assessment of the patient included level of dyspnea measured using a quantitative scale such as a visual analogue or numeric rating scale.Usual dyspnea was measured using a quantitative scale such as the Medical Research Council (MRC) Dyspnea Scale.The other assessments included Vital signs, Pulse oximetry , chest auscultation ,chest wall movement and shape/abnormalities, presence of peripheral edema, accessory muscle use , presence of cough and/or sputum, ability to complete a full sentence and the level of consciousness.By doing so, nurses were able to detect stable and unstable dyspnea and acute respiratory failure It was important for the nurses to remain with patients during episodes of acute respiratory distress.Medications included Bronchodilators ,Beta 2 Agonists ,Anticholinergics and Methylxanthines, Corticosteroids, Antibiotics, Psychotropics and Opioids . The patient had to be assessed for hypoxemia/hypoxia and administered appropriate oxygen therapy.Continuous Positive Airway Pressure Oxygen therapy is part of any respiratory intervention and requires absolute attention. Patient safety checks included circuit leaks; maintenance of positive pressure; adequate inspiratory airflow and not leaving the patient alone. Managing the therapy involved maintenance of the desired FIO2; level of positive airway pressure and time period for CPAP therapy, attaching CPAP machine medical air and oxygen gas lines to wall sources, preparation of humidification source, selection of prescribed FIO2 on oxygen blender, turning flow on to level above 25 litres / min., positioning of rubber securing band behind the patients head (Wunderink, 1992), centred on occiput, positioning of face mask over the patient, adjusting the level of positive expiratory pressure to prescribed level, adjusting inspiratory gas flow so that minimal fluctuations are present on pressure gauge, Observing and documenting respiratory rate; work of breathing and SpO2, increasing inspiratory flow if respiratory work is excessive or the patient complains of continuing dyspnoea, Maintaining continuous SpO2 monitoring with alarm function in place and maintaining humidification temperature at 36 degree C or at temperature tolerated by the patient. FEELINGS I found the intensive care or critical care nursing in a respiratory ward challenging due to the nature of life-threatening health situations, which demands complex assessments, high-intensity therapies and interventions and continuous vigilance. It was difficult to communicate to an old patient whose ‘hearing capacity was at a reasonably low level and whose perception had diminished due to aging (Phillips et al, 1993). Hence, non-verbal communications was an integral part in this nurse–patient communication. The non-verbal communication included patient-directed eye gaze, affirmative head nod, smiling, learning forward, touch and instrumental touch (Wilma, 1999). It was observed that these non-verbal communications had a tremendous impact on the patient’s well-being and comfort. The nurses had to eye gaze, head nod and smile to establish a good relationship. A caring touch was an important form of non-verbal but often effective communication. It was understood that the nurse should be able to perceive the expressions of the ill to provide maximum comfort. The nursing profession seems to have evolved from a state of care giving into a profession with legal accountability. Continuity of caregivers where a single, continuous treatment team is responsible for patients in both inpatient and outpatient settings seem also to complement continuity of care with improved self-care skills. The nurse today seems to be a qualified responsible member of a medical team in which she plays a key role. Her neo responsibilities seems to 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. I feel that the nurses should develop skills to assess patient’s responses to the serious illness. Caring sensitive issues such as copd, hopes of survival, fears about their disease condition requires maturity and is not easy. This requires active self-introspection of the events, assessment of the events, psychological understanding of the patients and above all a genuine concern for the ill. EVALUATION The events in this case study can be classified into medical interventions and nurse –patient interactive interventions. The medical interventions went on as per prescribed medical norms in a typical COPD patient as described .The nurse –patient interactive interventions seems to need a reflective introspection. ANALYSIS Research studies pertaining to factors related to nurse interactions with elderly people have shown that the educational level of nurses influenced nurses interaction with elderly patients (Wilma MCM et.al, 1999). Most of the nurses were more directed in the physical care of the patients them the psychological interaction or restorative activity. Communication problems seem to erode Nurse commitment to care. Another critical issues of debate in nurse – patient relation ship with reference to patients is that the patient’s contribution is always neglected. Literature reviews point out that nurses are seen to be controlling and restricting the conversations with the patients. ‘Assumptions’ have been seen as an important factor, which formed the basis of nursing interventions without taking the views of the patients at all. Nurse-patient communication is not a series of isolated conversations, but a vital component of the care & comfort concept (Jarret, 1995). Studies have found that, a nurse patient conversation is usually duty oriented like giving instructions to the patients (Jarret, 1995). CONCLUSION Intimacy is an important aspect of nurse patient relationship with psychological, emotional and physical components. A literature review on this concept has drawn attention to the threat to intimacy due to the market led health care service (Williams A, 2001). A study on the patient’s experience in nurse patient communication has shown that nurse can interact with patients well when they use a patient centred approach, although the health care organizations do not seem to appreciate this approach (McCabe, 2004). ACTION PLAN Nursing interventions should be 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 (Baum, 2003). 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). The patient care in this case study should be based on Roper Logan and Tierney model which prescribes 12 elements of maintaining a safe environment, communication, breathing, eating/drinking, elimination, washing/dressing, thermoregulation, mobility, work/play, sexual expressions, sleep and dying to be taken into account to give a patient centered care. REFERENCE Armstrong, K.F, “Surgical Nursing”, Bailliere Tindall, Edinburgh.1986. Brunner & suddharth’s, Suzanne C. Smeltzer, Brenda.G, “Textbook of Medical Surgical Nursing”, 10th edn Lippincott U.S.A, 2004. Clare Dyer, “British Medical Journal”, 332:623, 18 March 2006. Henderson Martha L., ‘Promoting excellence, An university affiliated geriatric practice’, www.promoting excellence.org Hines J, ‘Communication problems of hearing – impaired patients’, Nurse Stand, Vol 14(19); 33-7, Jan 26, Feb 1, 2000. Jane Richardson, “Health promotion in Palliative care: the patients perception of therapeutic interaction with the Palliative nurse in the primary care setting”, Journal of Adv. Nurs. Vol 40 (4); 432, Nov 2002. Jarret Nicola et.al, ‘A selective review of the literature on nurse patients communication; has the patient contribution been neglected?’ Journal of Advanced Nursing, Vol 22(1), 72, July 1995. Kubler – Ross E, “On death and dying”, Macmillan New York, 1969. Laakkonen M.C et al, “Terminally ill elderly patients experience, Attitudes and needs: A Qualitative study,” The Journal of Death and Dying, Vol 49 (2), 2004. McCabe C, “Nurse-patient communication: an exploration of patient’s experiences,” Journal of clinical Nursing, Vol 13 (1), 41-49, Jan 2004. Neil H.Baum, “Support your decisions with Evidence based Medicine”, “Urology Times” Feb 1, 2003. Phillips CD et al, ‘Effects of cognitive impairment on the reliability of geriatric assessments in nursing homes’, J Am Geriatr Soc, Vol 41(2); 136-42, Feb 1993. Price B, Illness Career-a chronic illness experience, Journal of Advanced Nursing, 24, 2,275-79,1996. Roper N., Logan W.W. & Tierney A.J. (1980). The Elements of Nursing. Churchill Livingstone. Wilma M.C.M et.al, ‘Non Verbal behaviour in nurse elderly patient communication’, Journal of Advanced Nursing Vol 29: 808, Apr 1999. Wilma MCM et.al, “Factors related to nurse communication with elderly people”, Journal of Adv. Nurs. Vol 30 (5), Nov 1999. Williams Angela, ‘A literature review on the concept of intimacy in nursing’, Journal of Advanced Nursing, Vol 33(5), 660, March 2001. Read More