Nursing Care: Theories and Practice - Essay Example

Nursing Care: Theories and Practice Introduction Patients, with their various health complaints and diseases expect to receive the utmost quality ofcare in the hospital setting, with nurses being one of the primary caregivers for patients (Nursing and Midwifery Council, 2008). Various principles and values support the delivery of health services by various health professionals (Department of Health, 2013). However, these principles and values are not always sufficient to ensure the quality of care for patients, or in some cases there may sometimes be gaps in the delivery of health services for patients (Cook, et.al., 2000). This essay shall critically evaluate the care provided to a patient suffering from cardiovascular disease, specifically coronary artery disease (left coronary artery) caused by atherosclerosis, being cared for in the hospital setting. It shall assess the different theories and clinical aspects in care planning, evaluating the patient’s history, his disease, also evaluating the nursing theories and processes which are relevant to the case Evidence-based practice is an important addition to the current medical practice especially as it includes studies carried out in the clinical setting, using variables relevant to patients and to practitioners. The results which are made available through evidence-based research can provide guidance for the practice, especially for specific patients who may have different needs. This type of practice also distances itself from textbook clinical care which often applies a one-size-fits all type of care. This study shall also apply nursing processes, models, and evidence-based approaches to the management of patient needs. The recommendations for the practice would also be presented based on the elements of this study. The literature search would mostly include a Google search as well as a search of the following databases: Cochrane Collaboration, MedPlus, and EMBASE. In order to ensure compliance with the ethical elements of research, the informed consent of the patient being studied in this essay shall be secured. His anonymity shall be ensured with an assumed name assigned to him for purposes of this research (Data Protection Act, 1998). It is important to protect the anonymity of patients because it is an essential part of the trust and rapport which can be sufficiently secured during their hospital stay. Patient History Patient Anthony is 64 years old, male, recently admitted to the emergency room for elevated blood pressure (180/110 mmHg), angina (chest pain/chest tightening), and dizziness. The emergency room attending physician at that time immediately ordered Clonidine to be administered to him in order to decrease his blood pressure. Clonidine HCl (Catapres) was the preferred drug to immediately decrease his blood pressure because the patient’s wife said he was allergic to Norvasc. Clonidine proved effective during previous times when his blood pressure increased (Morris and Rymer, 2007). Clonidine works well in dilating the blood vessels and immediately reducing the patient’s blood pressure (Morris and Rymer, 2007). Norvasc also takes longer to decrease the patient’s blood pressure which under these circumstances would not prove beneficial for the patient (More, 2011). The better option is therefore Clonidine. A history of hypertension makes a patient at risk for related cardiovascular diseases (Weng, et.al., 2013). His blood pressure decreased to 150/100 mmHg, but the chest pain was still persistent. His diagnostic tests revealed extensive atherosclerosis in his left coronary aorta. He was recommended for angioplasty. He was admitted to the surgery unit for pre-operative processes. Anthony could not move independently, because he felt weak and dizzy. We assisted him in getting out of bed and into the wheelchair for his tests, and from the bed to the bathroom to relieve himself. The laboratory tests took almost a day to complete and for the results to be released. Based on the results, Anthony was relatively healthy enough for the upcoming angioplasty. He was scheduled for angioplasty the following day. After the successful angioplasty, he was put into the Coronary Care Unit for strict monitoring. There were no notable in the CCU, Anthony was stable. After two days in the CCU, he was moved to a regular room for further management. Coronary artery disease According to the National Heart, Lung, and Blood Institute (NHLBI, 2014), coronary artery disease (CAD) is a disease observed when plaque accumulates on the walls of the coronary arteries. This is a serious condition as the arteries provide oxygen to the heart. As the plaque would build up in the arteries, the health issue is known as atherosclerosis and the accumulation may take many years before any actual symptoms on the patient are noticed (NHLBI, 2014). With time, the plaque would harden or in some instances may rupture. With the plaque gradually building up, the passage of the blood also becomes narrower, decreasing the flow of blood into the heart. In instances when such blockage is seen, it can cause chest pain (angina), and when the blockage is not managed, a heart attack may occur (NHLBI, 2014). Associated symptoms of a heart attack from a coronary artery disease may also include pain in the shoulders, arms, the neck, and the jaws (NHLBI, 2014). In some instances, the angina may be mistaken for indigestion. Where there is failure to restore the blood flow to any part of the heart or organ due to the blockage, ischemia or cell death occurs as oxygen is needed for the cells to survive. CAD can also make it more difficult for the heart to pump out blood to the rest of the body and can cause heart failure and arrhythmias (NHLBI, 2014). Coronary artery disease is one of the leading causes of death in the world. In the UK alone, an average of 74,000 deaths has been attributed to CAD, 1 in 5 men and 1 in 8 women dying from the disease (National Health Services, 2014). On a yearly scale, about 3.8 million men and 3.4 million women die from coronary artery disease (WHO, 2004) and by 2020, this disease will likely be responsible for about 11.1 million worldwide deaths (Mathers and Loncar, 2006). According to the American Heart Association (2009), every 26 seconds, someone suffers from a coronary event with one dying every minute in the US. In Europe, about 1 in 5 and 1 in 7 European women perish from the disease (Steg, 2009). These numbers further provide a grim picture for the disease, mostly in terms of its highly unfavourable outcome for patient diagnosed with the disease. Nursing theories Various authors (Master, 2012; Colley, 2003) discuss how nursing theories have been established in order to provide a foundation for the nursing clinical practice. These theories helped provide legitimacy and credibility to the practice as it presented a means of specifically defining and identifying the clinical nursing practice. The model for self-care includes self-care and nursing care (Timmins and Horan, 2007). This is also a rich and dynamic theory, but regardless of its complexities, the model highlights the importance of individual right and ability towards self-care. In cases where there are deficits in self-care, nurses can assist fill in such gaps (Masters, 2011). This self-care model is used in order to fill in gaps in self-care, and as a result, nursing care can be managed appropriately including the patient’s ability to manage his needs (Pickens, 2012). In reviewing the application of Orem’s self-care theory, literature does not sufficiently provide guidance on current applications in coronary care (Timmins and Horan, 2007). This may be attributed to the fact that nursing models seek to understand nursing activity, and not nursing care. This self-care theory can be applied to develop education program, including models of care for patients after their angioplasty, and also to improve as well as to support self-care among patients. According to Jaarsma, et.al., (2000), current cardiac nursing practices support some congruence with the model and support its application across coronary care settings. While the reaction to Jaarsma, et.al., (2000) has been relatively slow, it is important for practitioners to consider its use and to promote its empirical assessment to ensure quality care and to distance itself from the medical-based theories which have been dominant in some areas of practice. Only under these conditions can better development of knowledge base for coronary care develop (Horan, et.al., 2004). The other model applicable in this case is Virginia Henderson’s Need Theory. In this theory, it is important to increase the independence of the patient in order to help reduce hospital stay and reduce return hospital visits (Henderson, 1991). Henderson also highlighted the importance of helping patients gain their independence in order to help them return to their normal daily activities. According to Henderson, there are 14 components of human needs with the nurse have various roles in ensuring such needs. These roles include the substantive role or doing for the patient; the supplementary role or helping the person; and the complementary role or working with the patient. Henderson believes that nursing is a unique role which ultimately seeks to assist the patient, whether he is well or sick, in carrying out the activities which are relevant to his recover or continued well-being, ensuring that he would carry out these tasks even without assistance (Henderson, 1991). There is however a failure in the conceptual link between physiological and other human qualities. There is also no concept of the holistic qualities of the human being (Fitzpatrick and Kazer, 2011). Where there is an assumption made that the 14 components prioritized, the link of such relations for the components are however unclear. There are also limited related factors including the influence of nursing care (Fitzpatrick and Kazer, 2011). RLT theory Another theory is the Roper–Logan–Tierney model of nursing which was first introduced by Nancy Roper in 1976 and mostly used in the UK (Roper, 2000). This model is generally based on the activities of daily living. The goal of the model is to assess the patient throughout his care. This model has also been used as a checklist for admission, assessing how a patient’s life has changed because of illness or hospital admission. Activities of living help ensure independence, mostly with the complete assessment, leading to interventions which lend more clarity and independence in activities which may be difficult for the individual to manage alone (Roper, 2000). This theory may not be fully understood, and may have a limited scope, but it provides essential elements which can be used in this article. Various weaknesses however have been noted in this model. For one it is not a medically oriented model and seems to be focused more on the patient’s activities of living. Miles and Fraser, 2003) has admitted that their model does not actually differentiate itself significantly from the medical practice. However, he also understands that this may be a strength for the model as it allows the nurses to work with medicine, and not be a separate practice. There is also limited research to support the validity of the model (Miles and Fraser, 2003). This model’s simplicity has allowed nurses to easily apply and understand its elements. The 12 activities of living have also been observable, easily describable and objectively assessed, providing a means for nurses to appropriately evaluate their patients. The model is systematic and logical, supporting team participation, thereby helping ensure primary and continued care. It is a clear and consistent model, supporting the holistic application to the nursing practice and recognizing nursing to be an independent health care function. It also presents a framework in guiding the nursing practice. Nursing process Nursing process includes a complicated and dynamic cycle which is crucial for the delivery of evidence-based care, using interventions like assessment, planning, implementation, as well as evaluation of care (Sinclair and Ferguson, 2009). This nursing process has become the standard practice in the global community. Discussions on the relevance of the practice have been presented in different studies (Castledine, 2003; Habermann and Uys, 2006). Its applicability in the clinical setting has been considered significant, but persistent issues emerging in the health care setting has led to questions in relation to the nursing process. The development of this nursing process is a rich and dynamic process, one which necessarily covers specific elements of nursing care, alongside nursing research and feedback. The nursing process provides nurses with a proper standard in problem solving using systematic care for the management of patient needs (Doenges, et.al., 2014). In general, the nursing process includes elements which help ensure independent nursing care, allowing for critical practice and multidisciplinary care to be an important part of the nursing practice. Registered nurses also perform essential functions in patient care which cover the assessment, planning, delivery, and evaluation of care while still applying evidence-based practice. As a result, studies support the use of the nursing process, especially as it is supported by the government provisions and it helps ensure patient-centered care (NMC, 2010). Issues on the inconsistent applications of the nursing process has however been observed (Castledine, 2003). In general, there are four stages in the nursing practice, but other practitioners have included diagnosis as part of the nursing process and taught to schools and related institutions (Peate, 2006). Diagnosis is said to be an essential aspect of the analysis of data assessed, allowing for the actual evaluation of issues even before care is planned (Peate, 2006). However, this additional stage or phase is not widely accepted, even in the UK. There are also not many studies to support its addition. Nevertheless, diagnosis as a part of the nursing process seems to be an important addition and the British educational system has not fully considered it into its practice (Hughes and Mitchell, 2008). In the actual practice however, nursing diagnosis has been included as a necessary part of the practice, mostly in the assessment process. Also, including diagnosis as a separate stage in the nursing process may actually present with more benefits for the clinical setting, further supporting independent nursing care. Assessment During the nursing assessment, there was a discussion with Anthony on the different processes involved in his care, explaining the procedures which would be taken, its risks, the necessary expectations for him, and the changes in his life arising from his recent hospital visit. In the process, his informed consent was gained on the different procedures and related care (NMC, 2008). Patient interviews and discussions which seek to gather information about the patient’s history, his feelings, and pain experience is very much important in order to help understand what the patient is feeling and what his needs are. The interview with Anthony included the RLT activities of living model. This model revealed that he was having difficulty in breathing, mobilising, sleeping, working, and he had significant fears of dying. He also felt weak and uncomfortable. These details represent the subjective information about Anthony (Timmins and Horan, 2007). Doctor’s orders in relation to his care indicated that his blood pressure would be monitored every 15 minutes, that he would be administered analgesia for his postoperative pain, and within the next 24 hours, he would be turned to his side in order to facilitate breathing and comfort. His vital signs were relatively normal, including his oxygen saturation and blood pressure (100/70). His pain was tolerable, at 5/10 on the Visual Analogue Scale (moderate). As soon as he was sufficiently recovered from his surgery, his BMI was taken, and he was interviewed about his diet and daily activities. He was obese, and his diet consisted of fatty foods and high sodium/high sugar content foods. He also did not exercise. He said that his activities generally consisted of walking around his house and playing with his grandchildren. Due to his rheumatoid arthritis which often caused swelling on his knees, his mobility and participation in exercise was further compromised. For CVD patients, assessing the patient’s BMI as well as their diet and exercise is very much important because it can help establish whether or not they need to lose weight or if they need to change their diet (Stampfer, et.al., 2000). In the physical evaluation of Anthony following his angioplasty, he felt sore in the chest area where his wound was located. A check of his wound a few days following the surgery showed no signs of bleeding or infection. The pain reliever was administered in order to relieve the patient’s pain. Anthony was a smoker when he was younger, from the age of 22 to 45 years old. He smoked about 10 sticks of cigarette a day. He also smoked marijuana during his teens. He is also an occasional drinker. When he was younger, from the age of 21 to 35 years, he drank about 10 bottles of beer in a week and 1 bottle of wine. He then reduced it to about 5 bottles of beer in a week when he was in his 40s. When he reached his 50s, he mostly drank wine, often finishing about a bottle of wine a week. Smoking and alcoholism are risk factors to atherosclerosis and coronary artery disease (Luo, et.al., 2013). Aside from his CDV, Anthony also had rheumatoid arthritis. He was suffering from a limp due to swelling on his ankles and knees. This added to his limited mobility. He was favouring his left side and had to use a cane in walking every time his arthritis would worsen. His right hand was also likely to swell at times, making it difficult to work or write. His vision was also impaired. He needed his eyes checked by an ophthalmologist because there appeared to be cataract formation on his left eye. He expressed that he could no longer see anything on his left eye and while using his cane, he would sometimes bump into chairs and tables. This caused him much frustration. This also made him at risk for falls. Based on the Berg Balance Test, he scored 27 points, which put him in the category of walking with assistance (Steffen, et.al., 2002). Without assistance, he would likely fall and injure himself. He is a candidate for possible cataract operation and with the corresponding diet and medications for his rheumatoid arthritis, it is possible to reduce his fall risk. There were several needs diagnosed based on subjective and objective data from Anthony. In relation to his recent angioplasty, he was in pain and discomfort. This pain is mostly related to his recent surgery. His difficulty in breathing is also associated with his recent angioplasty and his breathing was slowly eased in the hours following the surgery. During the assessment process for Anthony before the surgery, his unbalanced gait was observed. This was attributed to his rheumatoid arthritis. There is a need to secure the necessary precautions to ensure his safety against falls and fall injuries. There is also a need for him to lose weight. This would entail a diet plan and an exercise plan in order to reduce his weight and reduce his risk for further complications related to his coronary artery disease. Plan Anthony’s coronary artery disease was considered the priority health issue in this case. He had an angioplasty in order to manage the issue. However, since he is obese, he still carries the risk for a future heart attack. There is a need therefore to manage his weight, to decrease his BMI, and to reduce any further risks related to heart attacks, and possible death (Fonarow, et.al., 2001). The long-term goal is to reduce his BMI and reduce his risk for complications related to coronary artery disease. Within the short term period, the goal is to teach him about diet adjustments he has to make as well as the increase in his physical activity which he has to incorporate in his daily activities. There is a need to establish a daily diet plan in order to improve his eating habits and gradually reduce his weight and BMI. The second need is to improve his balance and reduce his fall risk (Zwick, et.al., 2000). In the long-term, the goal is to improve his vision through a cataract operation. The short-term goal is to teach him how to safely move from one place to another without injuring himself. By teaching him these safe techniques, he can reduce his risk for falls. Another need is to reduce the swelling from his rheumatoid arthritis. This can be managed through medications. Anti-inflammatories can reduce the swelling and pain relievers can reduce the pain (Firth, 2011). This would eventually help him improve his mobility and also help him lose weight. Implementation It was important to first discuss with Anthony about his diet and the need to improve it. A diet rich in saturated fat and sodium is a diet which can place a significant strain on the body, as they often lead to obesity (Steinberger, et.al., 2009). A healthy diet was therefore planned for Anthony. In order to make the diet plan more realistic for Anthony, he was given possible options in his meals. A high-fibre diet was planned, one which included wheat bread instead of white bread, oatmeal and fruits instead of a bacon breakfast, chicken breast instead of chicken legs, broiled instead of fried, cooked foods instead of processed foods, water instead of soda or fresh fruit juice instead of soda (Steinberger, et.al., 2009). A diet rich in vegetables was also suggested for Anthony, with recommendations for stir-fried vegetables, steamed vegetables, and brown rice, and fish instead of beef. Anthony was fond of eating beef and pork meat, and he said it would be difficult to eliminate it from his diet. It was recommended that he could still eat red meats, but he had to reduce his portions and reduce the frequency of intake of such meats. These changes in his diet represent a significant change in Anthony’s diet, but a change which is healthier, and more likely to reduce his weight and BMI (Taylor, et.al., 2001). Anthony was willing to make these diet changes. However, he admitted that he would have a difficult time adjusting. It was recommended that he would secure the assistance of a dietician in order to help plan and cook his food (Hartree, 2013). Anthony was more enthusiastic about gaining such assistance because he felt that he and his wife would not comply with the changes if they would be left to plan their diet. In the meantime, while in the hospital, the hospital meals for Anthony consisted of fruits and vegetables and other healthy foods (Hartree, 2013). Simple exercises were also planned with Anthony. He said that with his rheumatoid arthritis, he felt that he may not be able to participate in any activity (Steinberger, et.al., 2009). He said however that as soon as the swelling on his feet would subside, he said he is willing to participate in exercises, mostly walking. A daily plan of 30 minutes to 1 hour walk around the park with his wife was recommended. He agreed to such plan. He was also willing to make some adjustments in his daily activities. Since he was having difficulties in safely moving, an occupational therapist was recommended for him. Through the therapist various activities he could do in order to still maintain his independence (Steinberger, et.al., 2009). Mobility is not simply about encouraging patients to exercise or to move, it is also about considering the activities they could safely do based on their condition. In this case, the patient is elderly, and as such, there are activities they cannot safely conduct. There is a need to gain assistance from experts and specialists in order to understand proper interventions which would match the condition and the age of the patient. Anthony was on maintenance medications for his hypertension. A daily medication of an antihypertensive was indicated for him. Anthony’s limited mobility was addressed first with the administration of medications to reduce the swelling. A cataract operation was also recommended. His decreased mobility is a significant issue for Anthony because it is a set-back to his recovery. Some improvements in his mobility are however recommended including assisted walking from his bed to the bathroom and around his hospital room. These initial steps are important in order to reduce issues and complications which may arise due to poor mobility. These issues may include the development of pressure ulcers and constipation. The nurse can also assist him in walking the length of the hospital corridors in order to improve his mobility and initiate his way towards decreased weight (Bennie, et.al., 2003). Pressure ulcers are a major issue often seen among bed-ridden patient and in the case of Anthony, if he would stay in the hospital bed without any movements included in his treatment, he would likely develop pressure ulcers. He would also be constipated. Constipation is an issue also for patients who are bed-ridden. It is therefore important to prevent these complications for Anthony. Anthony also understood the continued risks on his health if he were to remain bed-ridden (Lindgren, et.al., 2004). He was willing to cooperate with other health professionals, including his nurse and therapist in order to avoid such complications. Evaluation The evaluation of the care was observed during the patient’s last day at the hospital, prior to his discharge, after a week’s stay in the hospital. The evaluation in this case covers the progress which was observed on the patient’s condition following the implementation of the different interventions. The extent to which the goals and expected outcomes were fulfilled through the interventions are reviewed in the evaluation process (Roberts, et.al., 2001). In evaluating the patient after a week’s interventions and prior to his discharge, it was determined that he lost about 2 kilos already. This can be attributed to his healthier hospital diet as well as the stress and anxiety caused by his hospitalization and health crisis. There were times during his stay when he did not have much appetite for eating, and for two days because of his angioplasty, he was on a nasogastric tube feeding. He however understood that it was time to make changes in his diet. He was already armed with a healthy diet plan which was recommended by the dietician. The swelling on his feet from his arthritis was almost eliminated after a week’s treatment. He was walking with assistance with reduced limping. His mobility was improved and he was actually eager to walk at the park with his wife the following day. Anthony was scheduled for a follow-up visit after three days. On his return visit, he was more energetic. His weight decreased by a pound. He reports that he had been walking at the park with his wife an hour each day. He admitted that it was difficult to make the changes in their diet, but it was a gradual change he was slowly adjusting with. Recommendations for future practice Nurses are one of the primary caregivers for patients and they are invaluable individuals in improving patient outcomes. They also help provide the patient with evidence-based care (Kitson, et.al., 2012). Poor nursing care can sometimes also translate to poor patient outcomes and vigilant quality care can help ensure better patient outcomes, including reduced hospitalization, and reduced hospital stay. It is important for nurses to also provide patient-centred care because each patient is different and each patient copes with disease in his own way which may be different with how other patients cope with theirs. There is no ‘one-size-fits-all’ treatment for patients. It is important for nurses to treat each patient as a new patient each time (Kitson, et.al., 2013). Even if a patient displays similar symptoms with a previous patient, the interventions which worked with the last patient may not necessarily apply to the new patient. In this case, while Anthony has coronary artery disease which is a common disease among older patients, interventions which work with other patients of the same condition may not necessarily also work with him (Kitson, et.al., 2013). It is important for the nurses to see Anthony as his own person, as an individual and unique patient, one who deserves personal, compassionate, and competent care. Conclusion The nursing practice has developed into a respected and advanced clinical practice. The days when the nurse was merely the assistant of the doctor is no longer the case. Now, nurses are independent health care professionals, and they are expected to make independent nursing decisions on patient care, as well as serve as a part of the multidisciplinary care team. Different theories have now been applied in the clinical practice, and these theories help provide a foundation for patient interventions. In the case of a patient with coronary artery disease, the nurse has roles related to his care, from the time he is admitted into the hospital, from the time he is discharged and during his follow-up visits. The nurse applies assessment tools to evaluate the patient’s condition, and to establish a possible diagnosis for his condition. Interventions related to nursing education and clinical care has been implemented following such assessment. These interventions relate include diet and lifestyle changes in order to promote weight loss and to prevent health complications arising from the coronary artery disease. The activities of daily living and the promotion of the patient’s independence was an important goal for the patient improved care. The plan of care for the patient was based on evidence-based practice, one which clearly supports the importance of patient-centred care, providing for interventions which would address individual patient concerns. The patient clearly needs interventions which would address his diet and his issues in mobility. Addressing each individual issue, using verifiable and practicable nursing interventions are likely to help promote improved patient outcomes. Word count: References American Heart Association, 2009. Heart Disease and Stroke Statistics–2009 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 119:e21-e181. 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