The Plan of Care by Identification of Problems during the Assessment and the Diagnosis - Case Study Example

Medical Case Study Name of the Student Name of the University The purpose of this assignment first and most critical aspect of this paper is to give a detailed description of the age, physical and psychosocial history of the client in question. The patient is Mrs.Spiros, an 86 year old Greek lady residing with her daughter. Mrs.Spiros has Emphysema and has been admitted into the medical ward with a chest infection. Emphysema is a long-term, progressive disease of the lung that causes shortness of breath. Emphysema destroys the lung tissues that are necessary to support the physical shape and function of the lung. The following sections of this paper will discuss the nursing care planned for Mrs.Spiros, pre-operative investigations if any, inpatient care and the discharge referrals required. It will also analyze and explain how care that is to be provided will fit in with the competency standards given by the Australian Nursing and Midwifery Council. Once a patient and her problems have been assessed, care should be planned, if possible in consultation with the patient to ensure that the care suits his or her needs (Faulkner, 1996, p147). The plan of care is followed by identification of problems during assessment and the diagnosis. The plan of care also has a rationale following it for validation. Following the nursing diagnosis, the diagnosis with the highest priority is the beginning point for the nursing care plan. Other nursing diagnosis follows this in order of priority (Crisp, & Taylor, 2005, p. 327). Emphysema destroys the alveoli and the bronchioles which are very important structures for the lungs to function effectively. Emphysema also decreases the number of alveoli in the lungs, thereby restricting the amount of air drawn into the lungs. The fewer and bigger the alveoli, the less effectively they perform. Emphysema is known as an obstructive lung disease because the destruction of lung tissue around the smaller airways, namely the bronchioles makes the airways unable to hold their shape properly when one exhales (eMedical Health, 2009). Mrs.Spiros is often very breathless and extremely anxious due to shortness of breath caused by her emphysema. She is referred to the Respiratory Rehabilitation programme in order to learn to manage her shortness of breath. Mrs.Spiros is a Greek Orthodox and is a regular attendee at her church. Due to her admittance in the healthcare ward she misses her church attendance and is very anxious because of that. Furthermore, her daughter is exhausted from caring for her and seeing to her needs in coping with this condition and requires help when Mrs.Spiros gets discharged from the healthcare ward. Both parties do not have enough knowledge on how to cope with the Emphysema and the resultant shortness of breath. Respiratory Rehabilitation is a comprehensive approach to manage patients with respiratory impairments. Hill (2000-p.450) has defined it as, “a multidimensional continuum of services directed to persons with pulmonary disease and their families usually by an interdisciplinary team of specialists with the goal of achieving and maintaining the individual’s maximum level of independence and functioning within a community.” Most patients referred to respiratory rehabilitation have chronic obstructive pulmonary disease usually known as (COPD). Since Emphysema is a (COPD), Mrs.Spiros was referred to this programme in order to enable her and her daughter to cope with the effects of it. The primary goal of respiratory rehabilitation is to maximize independent functioning and to enhance health-related quality of life. Respiratory rehabilitation includes any intervention consisting of systematic exercise therapy, education and/or psychological support provided to patients with limitations caused by COPD (Lacasse, Guyatt & Goldstein, 1997). The following care plan for Mrs.Spiros will encompass six different dimensions ensuring holistic care. This plan of care has some of its principles based on the Essentials of Care (EOC) program put forth by the New South Wales Department of Health. (NSW Health, Online). The EOC program focuses on patient experience and on what patients and their families value about effective and relevant care. Its primary focus and aim is to develop clinical environments that empower patients, their families and health care professionals to work towards coping with health issues and to challenge problems that compromise the creation of effective environments. The plan care for Mrs.Spiros ensures holistic nursing care. Holistic nursing practice takes a full approach to nursing that addresses both the medical and psychological concerns of patients. It is defined as, “all nursing practice that has healing the whole person as its goal.” (American Holistic Nurses’ Association, 1998). It embraces all nursing practices that heal the person as a whole taking different aspects into consideration. Practicing holistic nature requires health care practitioners to integrate self care, responsibility, spirituality and reflection in their lives (American Holistic Nurses' Association, Quinn & Frisch, 2000). The plan of care provided for Mrs.Spiros taken on a holistic approach addressing both the physical as well as psychological dimensions. Moreover, the Commonwealth states and territories are working together to implement a range of activities that develop age-friendly practices that improve care for older people in healthcare wards. Improved assessment, correct identification and improved and active management of older people’s health needs is an important aim of these activities (Australian Government Department of Health and Aging, 2005). In that context the first important dimension and one with the greatest priority in the care plan is the physical dimension of Mrs.Spiros. During the assessment stage of the physical dimension of Mrs.Spiros it was found that there were high levels of shortness of breath, reduced mobility and fatigue. The diagnosis shows that there is ineffective airway clearance due to infection and mucous production. There is intolerance towards activity due to fatigue and shortness of breath (SOB). There is a significant deficit of self care, also caused by shortness of breath (SOB). The plan of care is to take a chest x-ray sputum culture, white cell count, to specify the accurate antibiotics to resolve the chest infection. The patient will be referred to respiratory rehabilitation to decrease SOB. Assistance will be provided to the patient for self care and equipment will be provided at home for free mobility. The rationale for this plan of care is that the blood test, x-ray helps determine the extent of infection and this in-turn will help the healthcare professional to prescribe the relevant antibiotics to reduce the infection. The respiratory rehabilitation will ensure that the patient copes with breathing difficulties through exercise and therapy provided. Assistance with self care ensures patient hygiene and the equipment ensures a certain level of independence with respect to mobility. The plan of care for the physical dimension of the patient is related to Competency 5.1 and 7.2 of the Australian Nursing and Midwifery Council (2006). According to Competency 5.1, “Uses a relevant evidence-based assessment framework to collect data about the physical socio-cultural and mental health of the individual/group”, assessment is approached and organized in a structured way, using all the available evidence sources. Assessment is carried out after collecting physiological, psychological, spiritual, socio-economic and cultural variables of the patient. It understands the role and importance of research-based accurate evidence. Appropriate assessment tools and strategies are used to collect data. According to competency 7.2, “nursing care is provided according to the documented treatment or care plan.”(2006,8-6) Under this competency nursing practice is consistent with the pre-made plan of care and a wide array of relevant strategies are used to facilitate the individual’s achievement of short and long-term goals. The second dimension to be dealt with is the Mental and Emotional dimension. In the assessment stage it was found that the patient had high levels of anxiety and depression. It was also found that fear played a major role in the patient’s mental state. The diagnosis shows that shortness of breath (SOB) and fatigue is causing fear. Lack of knowledge regarding the condition and medical decisions made is the cause for extreme anxiety. Furthermore, self care deficit, activity intolerance and restricted or dependent mobility is the primary cause for depression. The plan of care for this dimension is to educate the person on the expected plan of care, encourage her involvement in the decision making process and refer the patient to a social worker or counselor to aid her to deal with anxiety, depression and fear. The rational (ANMC, p 4, 7) behind this care plan is that, educating the patient regarding her condition and the options available to her, helps her get involved and aids her in making an informed decision regarding the kind of care and treatment options. The appointment of a social worker or counselor will help her deal with the stress, anxiety and depression thereby reducing it to a great extent. The competency standards related to this care plan include Competency 9.4 and 3.2.(2006, p 4, 7). Under Competency 9.4 “Assists and supports individuals/groups to make informed health care decisions.” enables and encourages individual decision making. It respects and supports individual decisions through communication with other members of the interdisciplinary team and arranges for consultation to aid individuals to make informed decisions. Competency 3.2, “Uses best available evidence, nursing expertise and respect for the values and beliefs of individuals/groups in the provision of nursing care.”( 2006, p 4). This standard ensures that nursing uses relevant literature and research to improve practice, recognizes that judgments and decisions are important components of nursing care and that nursing expertise varies with education, experience and context. The third dimension that needs a plan of care is the Social dimension. The assessment of social dimensions shows that both the patient and her daughter feel alienated in the hospital environment and both are victims of extreme fear and anxiety. The same fear and anxiety was also seen in the home environment of the daughter’s house. It was also found that the daughter was exhausted and stressed from caring for her mother and will be needing help when the patient is discharged. The diagnosis showed ineffective coping by the patient and the daughter in the daughter’s home. A lack of external social support was also seen in the assessment nursing diagnosis. The plan of care for this dimension is to educate them on how to deal with the problems they are facing. The intervention of community agencies will help both the daughter and mother to cope with the difficulties caused by the medical condition. A representative from the Greek community agency will help the patient and daughter to cope in the social environments and keep the daughter from getting exhausted and stressed. The competency standard related to care plan of this social dimension is Competency 7.5. According to competency 7.5,(2006 p 6), nursing practice “must delegate aspects of care to others depending on their scope and practice.” Nursing must delegate aspects of care based on the role, functions, capabilities and learning needs. It must also monitor care that has been delegated to others and provide help and clarification. It must also recognize one’s accountability and responsibility when delegating to others. Hence delegating the social issues of the Mrs.Spiros to a community agency will aid the patient and her family. The next most important dimension is the Cultural and Spiritual dimension. It was found in the assessment, that Mrs.Spiros is Greek orthodox and misses church attendance. Anxiety and depression also played significant roles in this assessment. The nursing diagnosis found that due to her admittance in the healthcare ward, she was unable to attend church on a regular basis and as a result of this there were considerable levels of depression and anxiety. The plan of care for this dimension is to encourage the daughter of Mrs.Spiros or the social worker involved to request the church priest to visit her in the healthcare ward frequently. Referring to Greek respite care is also a part of the care plan. Requesting the priest to come to the healthcare ward will alleviate the depression and anxiety that Mrs.Spiros is undergoing. Greek respite care will give take away some of the stress that her daughter is going through. The patient will also feel at home with respite care she is familiar with. The competency standard relevant to this is competency 2.3.(2006 p 3). According to this competency standard, nursing must be practiced in a way that, “acknowledges the dignity, culture, values, beliefs and rights of individuals/groups.” This competency ensures respect to individuals irrespective of race, culture, religion, age, gender etc. Nursing practice according to this competency ensures that respect is given to individual beliefs and values and care is provided according to those beliefs and values. The next dimension is concerned with the Health Education Needs of the patient. The assessment shows difficulty in managing shortness of breath shortness of breath (SOB) and poor mobility in the home environment. The diagnosis shows a lack of knowledge regarding the management of shortness of breath shortness of breath (SOB) and the resultant limited mobility at home. The plan of care for this dimension is to educate both the patient and her daughter to cope with the difficulties caused by shortness of breath (SOB) and mobility restrictions. The other plan is to provide equipment to the patient to improve mobility at home. The competency standard associated with this is competency 7.7 and competency 9.4. Competency 7.7 says that nursing practice must aim to educate individuals to promote independence and control over their health.” This includes meeting specific educational requirements and provides formal and informal educational sessions to increase patients’ knowledge pool. Competency 9.4 states that patients must be assisted and support individuals to make well-informed decisions”. The final dimension is discharge and referral needs. There are several needs that the patient will have after discharge. The assessment shows that the patient will need assistance for mobility, equipments and respite care. “Respite care is temporary relief for primary caregivers from the ongoing responsibility of caring for a child or another care recipient.” (National Human Services Assembly, 2007). The care plan for this will be organising community nurse for self care, support, education and mobility. Equipment will be provided for mobility assistance and respite care will be given to ease the stress that the patient’s daughter goes through. The competency standard related to this context is competency 7.8. This standard ensures that nursing” uses health care resources effectively to promote optimal nursing care” (ANMC, (2006p.6) This is a case study on Mrs.Spiros, an 86 year old Greek lady residing with her daughter, and suffering from emphysema of the lungs. She has been admitted into the medical ward with a chest infection. On account of the illness but due to admittance into the ward, she feels anxious since she can’t attend church, to which she is a regular. She feels breathless quite often which has led her to being admitted to a Respiratory Rehabilitation programme to control her breathing patterns. Respiratory Rehabilitation, on account of being comprehensive and effective therapy has been expected to show positive effects on her and enable her to cope up with the condition in a better way. The care plan that is developed for Mrs.Spiros has been expected to meet her requirements in an effective manner, developed over six different dimensions ensuring holistic care. This plan of care has some of its principles based on the Essentials of Care (EOC) program put forth by the New South Wales Department of Health. This paper has dealt with all six interventions ensuring holistic nursing care for Mrs.Spiros. References American Holistic Nurses' Association, Quinn, J A & Frisch, N C. (2000). AHNA Standards of Holistic Nursing Practice: Guidelines for Caring and Healing. Jones & Bartlett Publishers, 2000. American Holistic Nurses’ Association. (1998). Description of Holistic Nursing. AHNA Website. Retrieved September 7, 2009. http://www.ahna.org/AboutUs/WhatisHolisticNursing/tabid/1165/Default.aspx Australian Nursery & Midwifery Council. (2006). National Competency Standards for the Registered Nurse. Retrieved September 7, 2009. http://www.anmc.org.au/professional_standards National Human Services Assembly. (2007). Strengthening Grandfamilies through Respite Care. Family Strengthening Policy Centre. Hill, N S (2000). Long-term mechanical ventilation: Volume 152 of Lung biology in health and disease. Informa Health Care, 2000. p. 450 E-Medicine Health (2009). Emphysema Overview. E-Medicine Health Website. Retrieved September 7, 2009. http://www.emedicinehealth.com/emphysema/article_em.htm New South Wales Government Department of Health (2009). Essentials of Care Program: Putting Patients at the Center. Initiatives and Projects. Retrieved September 7, 2009. http://www.health.nsw.gov.au/nursing/projects/eoc.asp Crisp J, Taylor C, . (2005). Potter & Perry's fundamentals of nursing. Elsevier Australia, 2005. p 327. Faulkner, A (1996). Nursing: The Reflective Approach to Adult Nursing Practice. Nelson Thornes, 1996. p 145 Australian Government Department of Health and Ageing. (2005). Annual Report 2004-05 From hospital to home: improving care outcomes for older people under the National Action Plan. Australian Government Department of Health and Ageing Website. Retrieved September 7, 2009. http://www.health.gov.au/internet/main/publishing.nsf/Content/health-mediarel-yr2005-jointcom-jc016.htm Lacasse, Y, Guyatt, G H & Goldstein, R S (1997). The Components of a Respiratory Rehabilitation Program. Chest Journals 111. p 1077-1088. American College of Chest Physicians. Read More