Principles And Methods Of Nursing Care - Case Study Example

Principles And Methods Of Nursing Care Introduction Nursing knowledge seeks to derive and acquire a set of rules through explanatory theories leading to production of critical analysis and thinking skills through which the professional nurse generate integrative understanding about the care she is required to deliver to any patient (Fawcett and Alligood, 2005). The main forms of knowledge that the nurses need to employ in practice are personal practice knowledge, knowledge of medical theoretical knowledge, knowledge about procedures that they need to participate, knowledge on the culture of the ward, and knowledge about how to reflect on the care provided to consolidate the experience and seek more knowledge. However, the academic or theoretical knowledge would also involve seeking evidence from research to inform, guide, and modify practice. Jenny and Loagn (1992) indicated that nurses' knowledge also include the knowledge about their patients whom they care, since they tend to identify and know the holistic dimensions of the person they care, different from their knowledge about their diseases. Melesis (2007) indicated that based on this knowledge, the nurses are concerned with their care which involves "hygiene, rest, exercise, sleep, nutrition, relief from pain, rehabilitation, and safety in the context of a patient’s daily life, state of health or illness, and their environment (Melesis, 2007). It has been argued that the current care systems based on holistic approach tends to change the delivery of care by the nurses, and these would require new knowledge and ways of knowing. The traditional models of nursing knowledge and medical-model learning may be inadequate to suffice the needs of these clients. Sullivan-Marx (2006) has indicated continuous development and progress of nursing knowledge through experience from care scenarios (Youngblut and Brooten, 2001). This led to the concept that insight into the nursing practice would need evidence based on research, which can guide knowledge and practice in a different dimension since these may provide goals for assessment and planning care (Sullivan-Marx 2006). It is now a competency standard for the nurses to employ evidence-based practice and reflective practice. As has been described by Burns and Grove (2005), evidence-based practice is an important aspect of current nursing practice and competence since there is a need of research-based evidence to be incorporated in practice and to replicate the outcomes of quality nursing care (Burns and Grove 2005). Therefore, the best evidence base for practice in case of nursing would develop from integration of research evidence with practice knowledge. Polit and Beck has defined evidence-based practice to be "making clinical decisions on the basis of the best possible evidence. Usually, the best evidence comes from rigorous research but EBP also uses other sources of credible information” (Polit & Beck, 2004, p. 673). Client Scenario The focus of this assignment is on the assessment and care planning of an elderly client who was nursed and cared for by me in the hospital where I had a placement as a student nurse. This patient was admitted due to chronic obstructive pulmonary disease (COPD). Case The patient was a 67-year-old lady with severe COPD. A recent exacerbation resulted in a prolonged hospital admission. She was breathless at rest, had a persistent cough and appeared to have some ankle oedema. The identity of the patient will remain undisclosed due to ethical need for confidentiality. The NMC Code of Conduct (2009) in its article 8 indicates the importance on the part of nurses to respect the confidentiality of the client, which is also legislated (NMC, 2009). However, for this assignment, she will be called Ms. Jenny, which would obviously be a pseudonym. The medical history of the patient is that of a long suffering with cycles of exacerbations and remissions, which has been accompanied with history of hypertension, complicating congestive heart failure, and diabetes mellitus. The social history of the patient indicates she had been a smoker, lives alone, with one son staying in the United States with his family. The patient has complicated lung disease, which has characteristic exacerbations and remissions. The patient presented with restlessness, agitation, dyspnoea, disorientation, and confusion. When asked she also complained of headache and dizziness. She had rapid rate of breathing with evident use of accessory muscles of respiration. According to Roper, Logan and Tierney (1990) an individual and person is a whole, which stands in sharp contrast with the fragmented and systemic view of human body as per the medical model. In this model of nursing, nursing is defined by a process of care through which the individual is helped to prevent, solve, alleviate, or cope with problems associated with activities of daily living. This is embodied particularly in COPD where the patients usually suffer from serious activity limitations. Nursing in such situations deploy all measures to allow optimum level of independence in each activity of living to its maximum potential. This theory and model also acknowledges the role of environment in health and illness. All these point to a holistic model of care where all angles of health of the person is attempted to be cared for in order to reach maximum activity in the client's environment. All these factors should be revisited in terms of COPD, where a large proportion of the hospitalised patients under nursing care suffer from this disorder, and this assignment of client care analysis will be based upon this. The nurses are required to address all the parameters, namely, physiological and psychosocial needs arising out of this condition. The nursing knowledge on COPD refers to a condition with a "spectrum of pulmonary diseases (chronic bronchitis, emphysema, and asthma) most often associated with cigarette smoking” (Janssens et al, 2000, p. 378). It is true the primary problem is acute exacerbation or chronic progression of previously existing lung disease, resulting in CO2 retention. This hypercapnia occurs because damage to the lung parenchyma and/or airway obstruction limits the amount of CO2 removed by the lungs. The other part of this physiologic alteration is hypoxemia, which occurs as a consequence of hypercapnia. In addition, damage to the lung parenchyma and/or airway obstruction limits the amount of oxygen that enters the pulmonary capillary blood. While the symptom management can be done adequately by pharmacological means, but it becomes often clinically evident that these patients attempt to self-control the dyspnoea through purse-lipped breathing, and quite often they fail. The frustration from this failure associated with agony of suffering and anxiety further aggravate the dyspnoea leading to increased distress (Jang & Choi, 2001). Applying the previously cited Ropar et al. (1990) model, the increased effort of breathing leading to additional burden on the respiratory system would lead to further deterioration, poor exercise tolerance, and fatigue, which compromise the activities of the patient. Thus definition of dyspnoea according to this model would include aberrations of both pathophysiological and psychosocial nature which predominantly would be fatigue, anxiety, decreased functioning, activity intolerance, compromising activities of daily living. Nursing interventions thus would mean focus into the holistic nature of these symptoms (Carrieri-Kohlman et al., 2001). Assessment Tools Assessment has been defined as an important aspect of nursing process that investigates relevant and precise information about a patient's clinical condition to arrive at a nursing diagnosis. Crow et al. (1995) has defined this to be a process with domain-specific knowledge in order to strategise care based on the patient needs determined through some principles, concepts, or procedural rules. In case of Ms. Jenny, the framework for holistic care is needed, and thus the core principles and procedural rules of those will be followed to decide and synthesise the collected information for adequate judgment of the problems requiring necessary action plans and actions. There are different models and tools available to facilitate clinical assessments. Competency in clinical assessment can only be achieved through suitable training, practice and experience (Meurier, 1998). In the United Kingdom training and education for clinical assessment is unfortunately ad hoc. Evidently, the nursing assessment would involve a process through which a comprehensive assessment of Ms. Jenny's health status will be made in order to estimate the level of care needs where nursing intervention would be required. The current nursing practice would also include identification of evidence to support the care decision making. Nursing assessment is not an isolated tool, rather it is the nursing component of the multidisciplinary assessment of the care needs. This means it would serve as the tool to develop nursing care plans centred on Ms. Jenny’s care needs so the best possible nursing practice can be facilitated in her care within the context of contemporary standards of practice. As it is clear, this would link to the framework of outcome definition of the care, and in Ms. Jenny’s case, since she is suffering from a chronic illness and is old (Wilkin and Jolley 1979), as recommended by RCN, should be promoted by the concept of holistic care with the aim to help Ms. Jenny lead as independent life as possible (Royal College of Nursing 2003). Since I was following the Roper, I used Roper assessment tools, where my academic knowledge, experience of work, and present findings from examination of the patient will be used to accomplish this where findings will be rationalised to knowledge to come to a conclusion, decision, and planning for care. Nursing Assessment Nursing knowledge in this area led to a detailed assessment of this patient. I noted her distress and experience of dyspnoea. Her increased rate of breathing, sweating, and retraction of intercostal muscles, all indicated her increased work of breathing. This was evident from her evident fatigue, anxiety, and frustration. This indicated deterioration of her psychosocial parameters along with the evident physical findings. She was not able to talk. I assessed her breath sounds, which was demonstrating absent breath sounds. This indicated her inability to ventilate her lungs, and there could be atelactasis in her pulmonary parenchyma. There were fine crackles which indicated her ineffective airway clearance or even possibility of pulmonary oedema. I was immediately very concerned and felt the need for immediate intervention to oxygenate her so her symptoms are alleviated and her anxiety is lessened (O’Donnell and Parker, 2006). It has been evidenced in literature that alleviation of anxiety also reduces dyspnoea in patients with COPD. There was audible wheezing through her both lung fields, and this could be correlated with her narrowed airways and associated bronchospasm. The rhonchi and crackles indicated ineffective airway clearance (Nield, 2000). I evaluated her haemodynamic status, and I recorded all parameters since these would be necessary for future assessment of her condition including comparison. I was a student, and due to lack in academic learning, I found that I did not understand well the parameters indicative of hypoxaemia and hypercapnia. Later I came to know that her confusion, rapid shallow breathing, and paradoxical breathing associated with intercostal retraction all were due to her inability to maintain minute ventilation, which would be reflected by her vital capacity, minute ventilation, and other arterial blood gas parameters. I utilised this knowledge to assess her. I found from her symptoms that she was extremely hypoxaemic, and hence it was highly probable that her arterial blood gas levels would be compromised. A pulse oximetry revealed decreasing oxygen saturation, and I wondered what could be her carbon dioxide level. This could be measured by end-tidal carbon dioxide monitoring, and as expected this was elevated indicating carbon dioxide retention (Mahler et al., 2001). As a normal battery of examination, the physician ordered complete blood count, serum electrolytes, chest x-ray, electrocardiogram, and blood and sputum culture, since in most of the cases there may be associated complications such as congestive heart failure and associated infection respectively, which might have precipitated her acute exacerbation. While undertaking the data collection, it was decided that the data collection will happen through two assessment tools, one interview and another objective data collection tool that employs physical examination and documentation. I have presented my findings below. The interview tool will establish her holistic care needs and these will be acquired over time during the care process, and since my interview process would continue for over a period of one week, that would not be a valid tool to quickly assess her physical condition and the changes in her condition during this period. As expected, treatment in the inpatient unit would cause improvement in her condition, but use of interview to assess her holistic care needs would provide an opportunity to plan care appropriately. Nursing Diagnosis 1. Impaired Gas Exchange related to inadequate respiratory center activity or chest wall movement, airway obstruction, and/or fluid in lungs 2. Ineffective Airway Clearance related to increased or tenacious secretions. 3. Psychosocial stress and anxiety due to dyspnoea and lack of support system. Holistic Care Planning (Celli, 2008) 1. Administration of antibiotics, cardiac medications, and diuretics as ordered for underlying disorder. 2. Administration of oxygen to maintain Pao2 of 60 mm Hg or Sao2 > 90% using devices that provide increased oxygen concentrations such as aerosol mask, partial rebreathing mask, nonrebreathing mask. 3. Monitoring fluid balance by intake and output measurement, urine specific gravity, daily weight, and direct measurement of pulmonary capillary wedge pressure to detect presence of hypovolemia or hypervolemia. 4. Provision of measures to prevent atelectasis and promote chest expansion and secretion clearance, as ordered such as incentive spirometer, nebulization, head of bed elevated 30 degrees, turn frequently, out of bed. 5. Monitoring adequacy of alveolar ventilation by frequent measurement of respiratory rate, VC, inspiratory force, and ABG levels. 6. Recording and comparing monitored values with criteria indicating need for mechanical ventilation. 7. Performance of thorough systematic assessment, including mental status, vital signs, respiratory status, and cardiovascular status. 8. Documentation of patient's condition to provide a record for continuity of care. 9. Evaluation for signs of hypoxia when anxiety, restlessness, confusion, or aggression of new onset are noted. 10. Notification of physician when there are significant findings of hypoxia, cyanosis, circumoral pallor, rapid and shallow respirations, abnormal breath sounds, change in behavior or level of consciousness. 11. To alleviate her anxiety, explanation of her condition and the progressive nature of the disease. 12. Nutritional assessment and intervention as appropriate. Two Holistic Care Needs 1. Anxiety related to breathlessness and restlessness from inadequate oxygenation. 2. Powerlessness, lack of social support, and stress related to inability to perform role responsibilities because of chronic illness. Holistic Care Needs The psychosocial assessment revealed that she was dependent on others for her activities of daily living. Apart from that prolonged disease and disability progression had their effects on her disease. Her physical mobility was limited. Although she was not employed, her limitations in activities of daily living were very frustrating for her. Due to her respiratory distress, I noted, she was not able to converse or maintain voice. She was feeling very fatigued, lonely, and deserted away from home. Her sleeplessness further aggravated this situation. Obviously her support system was deficient, most probably due to her neglectful relationship with other family members (Maurer et al., 2008). Therefore, the care needs can be summarised in the following manner, her psychosocial needs of anxiety alleviation will be taken care of by explaining the problem that she is suffering during the care. I will explain how anxiety is causing her to suffer more. Her family and other social needs cannot be alleviated by me, but I decided to rather reinforce her ability to perform activities of daily living, so she can manage her daily activities, which may let her feel that her quality of life has improved. Interprofessional collaboration with physical and occupational therapy will be sought explaining her physical condition, family situation, need to strengthen herself, need to conserve energy, and need to adjust the living condition. I also advised her that she must learn how exercises can improve her activity tolerance even accepting that her original clinical condition and its nature. Reflection Dyspnoea in COPD is a sensation of breathlessness, but it is associated with the themes of fear, helplessness arising out of the patients' experiences. There was fatigue and loss of vitality and preoccupation with the disease. For a holistic care delivery, attention to these factors is very important since they influence the outcome of care. The very factors of loss of vitality and suffering in isolation, all point to an empathic care that considers and acknowledges these points. Carrieri-Kohlman et al. (2001) indicated the role of exercise training in COPD patients to demonstrate that both shortness of breath and dyspnoea related anxiety decreases with exercise, and I specifically encouraged self-supported ambulation and exercise while engaged in her care. The other aspect is interprofessional care. In the hospital setting these patients are cared for by multidisciplinary teams, and being a student I could observe that interprofessional care coordination was extremely important in her case, since nursing care largely attends to monitoring of different parameters, recording them, and informing them to the appropriate healthcare professional so immediate intervention and appropriate support can be initiated (Carrieri-Kohlman et al., 2001). Her care was executed by a team of doctors comprising of medical specialist, chest physician, cardiologist, and endocrinologist. I also noticed that a respiratory therapist and a physiotherapist were also involved in her care. Although I was a student nurse involved in her care along with other nurses in the unit, I noticed that communication and collaboration was extremely important on my part while delivering the care during several occasions. For example, maintenance of her blood sugar and infection control were important for both the medical specialist and the chest physician, and they depended on the records of her findings during the care to assess improvement. I had to learn the breathing exercises from the respiratory therapist so I could educate Ms. Jenny as to how to improve her quality of breathing as her condition improved. To the medical team, I had to inform them about the relevant clinical information, so they can arrive at a decision focused on Ms. Jenny’s care. In short, among these individual professionals, I had to coordinate Ms. Jenny’s care. Conclusion Chronic obstructive pulmonary disease is a common nursing care scenario in hospital nursing. As a student nurse, while involved in the care of this client, I was able to connect between my limited clinical knowledge with the pathophysiology of the client condition. However, on reflection I was able to understand that appropriate nursing care of such condition must be based on holistic dimensions of this disease, such as psychosocial aspects of the suffering. A more effective nursing care is possible through application of knowledge about holistic model of care and biologic model of care as evident in this assignment, until further research change the evidence base to alter care processes. The knowledge indicated above is organised through the processes of nursing process, where the nursing diagnosis and care plan are delineated through a problem solving approach that helps them to execute care which involves observation, recording, analysis, intervention, and solution. Reference List Baker, C. F., & Scholz, J. A. (2002). 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