The Nursing Assessment and Nursing Plan - Essay Example

Task: Nursing Assessment and Care Plan Focused Upon an Adult Patient Cared For In the 2nd Year of the Programme IntroductionThis essay shall seek to determine the nursing assessment and nursing plan needs for the patient by the name of Mr. Tan. There are a number of theories that can be used to make a nursing assessment. However, for the case of this essay, the Roper, Logan and Tierney’s model (RL and T model) shall be used. The rationale for using this theory is that it has been fully detailed and explained to fit into the Mr. Tan situation. In addition to that, the pain assessment tool shall be used to justify the assessment. As such, Mr. Tan’s nursing needs which include his difficulty in mobility (immobility) that was caused by the number of amputations that he has had due to his Diabetes Mellitus condition have been addressed through relevant literature as well as decision making theories. Moreover, the Corbett model of narrative development has also been discussed to find its significance with regard to the decision making theory discussed. Lastly, the matter of confidentiality has also been addressed through the NMC’s Code of Conduct (2008). Nursing assessment and care plan In the month of September 2011, Mr. Tan a 55 year old Chinese man was admitted to a residential home for his fifth time leg amputation. The residential home catered for personalized home care to Mr. Tan. As such, the amputation was as a result of a Diabetes Mellitus condition that he had acquired some time back. Before he was initially admitted at the residential home, some information related to his work and family was needed from him. Hence, it was recorded that he had previously retired from work and he lived with his wife only since his children were all grown up and they had moved out of their home. As such, when he was admitted, he was re-assessed holistically since his condition had deteriorated with the intention of determining his optimal nursing care plan and also the updated and/ or relevant plan of care to suit his needs. Mr. Tan had to undergo holistic nursing so as to not only assist him in his amputation process but also to assist in his general health condition. The RL and T model (Roper et al., 1996) was selected since it specifies the daily activities also known as ADLs or ALs that are to be focussed on while engaging in holistic nursing. Examples of ADLs include: communication; breathing; washing and dressing; sleeping; eating and drinking; maintaining a safe environment; elimination and mobilization (Cardinal Stritch University, 2014; 2013; Roper et al., 1996). As such, the model provides the assessment plan for Mr. Tan since during his pre admission information collection, it was noted that he received dependent care from his wife in activities such as mobility, toileting and dressing. The importance of assessing the patient’s daily activities is that there are noted improvements in their general health (patient outcomes) due to the holistic nursing care that they receive from the nurse at the residential home and afterwards when they are not under the nurse’s care (Kara, 2007; Demir and Erdil, 2013). Moreover, the importance of critically assessing the patient involves the use of the daily activities as well as the five (5) factors – biological, psychological, socio-cultural, environmental and politico-economic (Roper et al., 1996). The nursing care needs of the patient with regard to the Roper, Logan and Tierney’s assessment model include: mobility, toileting and dressing. As such, the nursing care plan with regard to the needs is as follows: Table 1: Nursing care plan Patients Name: Mr. Tan Hospital Number: 123456 Date: 1/3/2014 Identified Patient Problems Goals Interventions Evaluation Date Immobility Toileting needs Self dressing needs Modify current mobility options so as to improve the mobility index of the patient. The goal in this instance was to modify the toileting needs that he was currently depending on. It was noted that if Mr. Tan’s mobility options were changed and further improved. Then without doubt, his toileting needs would also be improved. Hence the goal was to improve his current mobility needs so as to achieve optimal dependent care with regard to his toileting needs. The goal in this instance is to assist the patient to improve on their toileting needs. It was noted that the patient had a lot of dependent care while he was at home. Hence, he did not perform any self care needs for himself. As such, the goal would be to assist the patient to have better mobility options so that he can be in a position to offer self care with regard to his toileting needs. The intervention that was used was to encourage the patient to be more patient with their condition. In addition, the patient was adequately advised as well as provided for disease information since being informed about a condition that one has is much better than not being informed. The intention of this was to assist the patient to be more aware about the mobility challenges that they are prone to undergo while having their condition. Thirdly, the patient was encouraged to undertake in mobility activities such as walking so as to gain body strength and moderate his pain score. Lastly, he was encouraged to take pain killers and/or relievers for his body pains. Evaluation: The patient engaged in some physical activity sessions such as sitting down and standing up. He also was encouraged to walk for some short distances in the residential home. It was noted that his mobility had slightly improved since he was not complaining of too much pain as compared to the time when he was first accessed. During his re-assessment, his pain score had decreased from 4 to 3. This meant that he had mild pain and it was not constantly affecting his body and/or causing his bodily pain. This was attributed to the fact that he was taking pain relievers as disbursed by the nurse. Moreover, when his knowledge about his condition (diabetes mellitus) was reassessed, it was noted that he knew more about his condition and the mobility challenges that he was prone to undergo now and in future. In addition, he knew the number of ways that he could use to counter pain whenever he could endure it. Finally, the patient agreed to work more on his mobility challenges as well as other ADLs while at home. The intervention in this case was to encourage the patient to undertake more and/ or frequent mobility sessions. These included standing up, sitting down, moving around and trying to walk without dependent care. In turn, these actions would help the patient have better mobility skills which would also be reflected in his toileting needs. Evaluation: The patient engaged in a number of mobility sessions while at the residential home. When he was re-assessed after a period of one month, it was found out that his mobility needs had improved for the better. For example, he could be in a very comfortable position to sit down and stand up as well as walk without assistance from his wife. Moreover was the fact that his mobility advancements had a positive impact on his toileting needs. The intervention in this instance was to encourage the patient to undertake seriously on his mobility sessions. The improvement of mobility sessions would also cause a positive improvement on the patient’s other activity plans such as dressing needs. Evaluation: The patient successfully engaged in some dressing activities without dependent care from the wife. Moreover, the patient also promised to undertake his mobility sessions seriously as well as incorporate other body physical activity sessions so as to enable him to be swift with toileting as well as dressing needs. 1/2/2014 2/3/2014 8/2/2014 9/3/2014 16/2/2014 17/3/2014 Nurse’s Name: Input Name Here Signature: Input signature here Date: Insert date A discussion of these decisions in relation to theory There are a number of problems and/ or challenges which were realized in the beginning of the patient’s assessment. These included the fact that the patient had several challenges since his condition (diabetes mellitus) had deteriorated over a period of time. These challenges were related to: immobility that was caused by pain - as such the patient found it difficult to get up from the chair, sit down and engage in other ADLs. This could have been attributed by the fact that he feared falling down (psychological influence); dependent toileting as well as dressing needs – that were caused by bilateral hip pain that he had developed as a result of arthritis (biological influence). As such, the only way that the patient sought fit to manage his pain was inactivity. In a bid to evidence this ideology, a pain assessment tool was used to establish and adequately determine the level of pain that the patient was experiencing. The pain assessment tool provided the benefit of measuring the patient’s pain and also providing an effective pain plan. In addition to that, it also helped to report on aspects that were related to emotional, sensory, psychological and cultural needs (Cox and Karapas, 2010). As such, a comprehensive pain assessment procedure encompasses variables such as: pain location, timing of the pain, duration of the pain, pain relief procedures, pain intensity and the quality of the pain being encountered by the patient (Cox and Karapas, 2010; Pasero and McCaffery, 2011). Before the pain assessment was undertaken, the score revealed that his pain score was quite high. As such, the report analysis and evaluation results were used to decide on the care plan (as described above in Table 1) that was to be optimally implemented for the specific patient. It is important to note that the decision was made with regard to nursing decision making steps which include: the establishment of the needs of the patient; the establishment of the criteria to be used; consideration of the alternatives; identification of the best alternative for the patient; formulation of a strategic plan; analysis of the achievements based on the plan (Lombardi et al., 2007). Moreover to the issue of pain for the patient, it was also noticed that he had body pains whenever he was walking with or without assistance. As such, the patient was offered pain relievers as an additional form of medication just to relieve his pain for a short while and to encourage activity. Based on the decision making theory and steps (Banning, 2008; Baron, 2005; Lombardi et al., 2007), retrieving personal information from the patient as well as undertaking pre assessment as well as post assessment aided in determining the need for the pain relievers as part of his medication. The effects of this decision by the nurse were also evaluated and it was established that the pain reliever medications were effective since after the re assessment was undertaken after a period of one month, the patient’s pain score had decreased significantly. As such, the decision making theory and steps (Banning, 2008; Baron, 2005; Lombardi et al., 2007) indicate that nurses usually use their communication narratives in a bid to communicate effectively and efficiently to the patient so as to determine the correct decision steps that are to be used for successful outcomes. Apparently, during the pre assessment procedure, the patient had informed the nurse about his pain and what had triggered his inactivity and challenges in other needs such as toileting and dressing. After the reassessment was undertaken after a month, the patient updated the nurse that the pain relievers were of great help to him and he could undertake mobility, dressing and toileting needs with little or no dependent care. It should be noted that during the process of assessment and care planning, a number of decisions had to be made with regard to the patient. These include: the best mobility alterations that had to be implemented to improve his mobility index; the pain relievers that had to be taken by the patient and which were safe with a diabetic patient; the impact of the alterations; how best to encourage the patient and inform him more about his condition and lastly, how to motivate the patient in living with his condition as to offer self care. As such, the decisions which became the most important milestones for the patient outcomes included: mobility alterations and how to regulate pain. This is due to the reason that if mobility was to be improved, this would have an impact on the dressing as well as toileting needs of the patient. In addition to that, if the pain was eliminated and/ or confined, this would enable the patient to become active and engage in activities that boosted his mobility hence his other ADLs. This decision was based on the fact that the patient was in need a number of ADLs in his health outcomes. Hence, the RL and T model (Roper et al., 1996) was selected as it provides a list of activities that have to be achieved by the patient so as to ensure holistic nursing – hence, this decision was peer-aided based on (Roper et al., 1996). In addition to that, cognitive continuum was also implemented with regard to the judgment that the nurse had to make by offering pain relievers to the patient in a bid to ease his pain. The cognitive continuum theory (CCT) is another theory that is used by a number of nursing professionals in a bid to offer intuition based decisions. The positive impacts of this theory have been adequately revealed to aid in making better decisions through understanding the decision making process that a nurse implements while in practice (Cader et al., 2005; Dunwoody et al., 2000; Offredy et al., 2008). Finally, it can be concluded that the CCT model was dependent on Pie Corbett theory of narrative development (Salvatore et al., 2004). This is due to the reason that all the decisions that the nurse made were an involving process of communication and interaction with the patient. Moreover, the patient was open not because he had to but probably due to the reason that the nurse narrated to him a story of another patient who had the same condition as his. As such, the patient felt the need to share with the nurse the pain problem that he had. As such, this model proved to be essential in this scenario by helping the nurse understand the patient and provide a solution to his hidden problem. Conclusion Holistic nursing focuses on healing a patient with regard to aspects such as: the spirit, mind, body, emotions, relationships and the environment (Nursing Theory, 2013). The RL and T model (Roper et al., 1996) was used to determine the daily activity needs that the patient was in need of. As such, the patient was noted to have needs such as: mobility, dressing and toileting which were all correlated to each other. That is, if mobility was an issue to the patient, so was dressing and toileting. Pre assessment was conducted since the health outcomes of the patient were not good and through the use of the decision making theory and steps (Banning, 2008; Baron, 2005; Lombardi et al., 2007) some guidelines were set up by the nurse to the patient. Post assessment was conducted after a month on the guidelines and it was reported that the decisions made by the nurse were effective as the patient attested to that. With regard to pain, the patient also mentioned that since the pain killers were given to him, his pain was slowly decreasing and this enabled him to engage in self care. Based on that assessment, it can be concluded that the tools and techniques employed by the nurse were sufficient. Moreover, the nurse followed the theories and guidelines so as to improve the patient’s outcomes. Bibliography Banning, M. (2008). A review of clinical decision making: models and current research. 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Psychology and Psychotherapy: Theory, Research and Practice. 77(2), pp. 231-254. Read More