PATIENTS’ CASE STUDY.
This essay aims to describe a patient’s health condition and needs during their stay at the hospital. Patient chosen has a chronic diarrhoea and abdominal cramping, his assessment will be fully discussed using Roper Logan nursing framework and rationale for choice of patient and framework will be considered.
In addition, an aspect of care in relation to the clients needs will be identified and the strategies used in achieving the goals and aims of care will be analysed and discussed from a biological, psychological and social perspective.
According to (NMC2008) code of professional conduct which stipulated that information about the patient, must be maintained and protected and should only be used only for the purpose it is intended. The patient will be addressed as Mr Abdul Cole in other to maintain confidentiality. Members of the multi-professionals involved in the care of the patient will be discussed as well.
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Mr Cole a 74 years old man lives with his son and daughter in-law in a two bedroom flat. He was admitted in the hospital due to chronic diarrhoea and cramping abdominal pain. After series of test done by the A&E team, he was diagnosed with Clostridium defficile (C. diff.). Mr Cole has history of chest pain and pneumonia.
The rationale for choosing this aspect of care is because I was assigned with a registered nursing to carry out the patient’s admission and all aspect of nursing process. Choosing this patient will also enhance my understanding of care delivery by examining the flexibility and responsiveness of implementing care plan and nursing frame work to changes in patient conditions.
Cunha (1998) defines Clostridium defficile as a slender, Gram-positive anaerobic rod which is spore formation and motile and is capable of surviving in the environment for prolong period. Bacteria of this type may be a normal component of gut flora and flourish when other gut organisms are eradicated by antibiotics (Zadik & Moore 1998). In 1980s it was identified as a major cause of antibiotic associated diarrhoea (AAD) (Duerden et tel. 1994). It is now one of the most commonly detected enteric pathogens and an important cause of nosocomial infection in nursing homes and hospital (Zadik & Moore1998).
C. difficile does not cause any problems in healthy people. However, some antibiotics that are used to treat other health conditions can interfere with the balance of ‘good’ bacteria in the gut. When this happens, C. difficile bacteria can multiply and produce toxins which then cause illness such as diarrhoea and fever. Diarrhoea results when the balance among absorption, secretion and intestinal motility is disrupted (Hogan 1998). It has been defined as an ‘abnormal increase in the quantity, frequency, perianal discomfort and incontinence’ (Basch 1987). In Mr Cole’s case, his diarrhoea was associated with prolonged use of antibiotic to help cure his pneumonia which led to C.diff infection.
In other for healthcare professionals to identify patient’s needs and ways to meet them, assessment has to be carried out on the information obtained by observing the patients general appearance, information from patient and their family, medical and social history, observation and physical examination (Hinchliff, 2003). According to Person et al (2002) nursing process is a dynamic and logical method in which the nurse may sensitively and systematically approach-nursing practice to achieve goals with patient and ensures care is planned and executed appropriately. The nursing process consists of five stages, assessment, diagnosis, planning, implementation and evaluation.
Assessment is importance to determine a client’s care needs and it is the crucial first step. Patient’s pattern and behaviours are compared with their current health status to avoid omitting care needed or may be provided care which are not needed.
Nursing Diagnoses according to (Carpenito 1993), provides the basis for selection of nursing intervention to achieve the outcome fro which the nurse is accountable.
Planning is the stage that helps to decide which problems are priorities, determining the goals for care and selecting interventions to create a plan of care.
Implementing involves giving the care with interventions that are appropriate for the clients. Also includes documentation of care.
Evaluation is the final step which involves deciding whether the intervention has helped the patient or the plans might need changing.
Whilst the nursing process offers a systematic way of looking at care delivery, on its own it is not particularly useful as it does not give any indication as to what to asses. It indicates that care should be planned, implemented and evaluated but again offers little direction as to how to do this. Another way of organising the information needed collected by nurses is using ‘Activity of Daily Living Model’ proposed by Nancy Roper, Winifred Logan and Alison Tierney (1996), this model can be summarised as consisting of four components, which all contributes to individuality in living , namely; the lifespan continuum from conception to death; 12 activities of daily living, five factors that influence each of these activities, that is, physical, psychological sociological, environmental and politico-economic; and a dependence/independence continuum. Although, all the stages of the nursing processes was mentioned and summarised, this essay only focuses on the process of assessment based on activity of daily living by Roper Logan et al (1996).
According to Miller (2000) assessment consists of collecting and receiving in formation about the patient and identifying any problem that may be detected during the process. It also involves systematic way of organising care through skilful interaction with patients, family and friends to asses how their condition has impact on their activity of living (Roper et al 1996). However, the equality of the assessment will depend on the nurses’ ability to put together all the sources at their disposal. According to Roper et al (1960), information gained in the initial assessment form baseline from which further information can be evaluated.
The assessment carried out was base on Roper Logan and Tierney (1996) nursing frame work. The rationale for choosing this framework is that it uses a list of patient’s activity of daily living, maintaining safe environment, breathing, mobilising, eliminating, controlling body temperature, working and playing, sleeping, communicating, eating and drinking, personal cleaning and dressing, expressing sexuality, dying. This highlights basic human needs, impact of ill health on patient’s lifestyle (Andrews 2002). According to Roper et al (2002) the model allows the professionals to concentrates on the physiological functional abilities of the patient to carry out those activities of daily living independently. This essay will focus mainly on activities which are affected by the patient’s condition.
Mr Cole was admitted in to one of the side rooms on the ward as he requires barrier nursing due to his toxic producing C.diff. Diarrhoea and enteric isolation notice was placed on the door of the isolated room. Segregation from other patient must continue until stool cultures are clear of infectious organisms. The policy of my place of practice is to treat infectious conditions seriously and adopt universal precaution such as wearing gloves, apron and gowns, disposing of all excreta immediately to reduce the risk of spreading the infection to others.
I was accompanied to the patient’s side room by a registered nurse to begin the patient’s assessment. The doors were shut and curtains drawn to maintain patient’s privacy and dignity. Mr Cole’s information was collected from various sources such as her medical notes and families.
Maintaining a safe environment
It is very important that patient is safe in a particular environment especially when not supervised. This includes orientation, alertness and mental being. Mr Cole was very conscious at alert on arrival and during the assessment; he had no hearing or sight difficulties, no physical or learning disabilities. However patient was very restless and uncomfortable due to his abdominal cramp.
Ability to communicate effectively contributes to successful assessment, as it builds a relationship with the patient. According to Brooker (2003) communication is an important aspect of nursing intervention for any individual patient. In all form of care situation, the basic of the care is centred around the ability of the carers to form a relationship is deemed to therapeutic in that it based on mutual respect, trust and friendliness, which start from admission onwards (Roper et al 1990).
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Communication involves both verbal and non-verbal messages that convey feelings and information. The purpose of successful communication is to ensure appropriate social contact and professional interaction to meet the needs of patients and their families (Macleod Clark et al 1991). The provision of clear information and explanation on admission to hospital and prior to medical procedures may result in decreased anxiety, decreased pain levels, a reduced number of complications and side-effects of treatment, improved compliance, an enhanced coping ability and an increase speed of convalescence (Wilson-Barnett 1982).
Patient was able to speak clearly he can hear and see but has difficulties communicating with us due to language barrier. Mr Cole understands very little English and was unable to give major information to nursing staff during the assessment. Consent was obtained from Mr Cole for his family to translate and express his needs. It is suggested that effective communication makes a positive contribution to an individual’s recovery by acting as a buffer against fear and confusion (Nichols 1993). Other different way of communicating with patient includes body and sign language.
The process of breathing is a fundamental aspect of life it is inevitable and could lead to a fatal consequence when the process is interfered. Breathing helps the balance between carbon dioxide (C02) and oxygen (02) in the blood. 02 is required by the body to release energy at cell level so that the individual can participate in activities. The waste product produced through the use of 02 is C02. During the assessment, we detected that Mr Cole recently had major episodes of pneumonia and chest pain, which might still have some impact on his breathing and health. Respiration supplies the body with oxygen and removes carbon dioxide through diffusion between alveolar of lungs and blood in the capillary (Marieb, 1998), changes could lead to tachypnoea or bradyproea, Mr Cole’s respiration rate was observed and recorded at 16 breaths per minute, oxygen saturation was 98% at that moment, he could breathe clearly without struggle and no whizzing noise was heard during the assessment. Ability to undertake a swift assessment of the client’s ability to breathe and instigate removal of an obstructive and/or rescue breathing if needed is crucial. Factors which may affect breathing includes: psychological; stress, anxiety or depressions. Sociocultural; smoking, level of family support. Environmental; pollution or work related factor. Politico-economic; poor diet and or limited finances. Past history; past illness.
Eating and drinking
According to Catherine Caskett, good nutritional status is essential to an individual’s health and well-being. Poor nutritional status as been associated with delayed recovery and an increase in mortality, which also increase the cost of health care.
As the assessment continues, Mr Cole’s family was encouraged to discuss the patient’s diet history, medical history, social setting and his usual weight. Information given shows that Mr Cole has lost weight during the past 2weeks and due to his current condition he is prone to loosing more weight if a goal is not set to minimise his diarrhoea. Taylor (1997) state that diarrhoea can have profound physiological and psychosocial consequences on a patient. Severe or extended episode of diarrhoea may result in dehydration, electrolyte imbalance and malnutrition. Food aversions may develop or patient may stop eating altogether as they anticipate subsequent diarrhoea following in take. Consequently, this leads to weight lose and malnutrition. Mr Cole refused to eat and drink since the time of his admission. His weight and height was measured to calculate his body mass index (BMI) to monitor his weigh pattern whether gain or lose. According to bacon (1996) it was stated that body mass index is on of the most commonly used indices for assessing the weight status of adult patient. Mr Cole’s BMI measurement was 18 which prove that he was malnourished and underweight. Garbett(1999) argued that in nursing , it is important to understand anatomy and physiology of the body in order to detect any abnormalities, and make necessary intervention. Roper et al, (2000) stated that in the model of nursing, the state of individual in anatomical and physiological terms is planning and implementing relevant nursing intervention and evaluate the effects to help Mr Cole maintain sufficient food and water intake, he was prescribed IV fluids 200ml hourly and offered him frusibin energy drink. Mr Cole’s family were also encouraged to bring patient’s preferred drink and food which in turn might appeal him and help restore his appetite. Mr Cole was offered halal meal which is similar to that he has at home, reflecting religion and ethnic background. Small amount of food were presented because larger amounts may cause him to experience chest pain due to abdominal distension. (Redfern and Ross, 2001). A member of multi disciplinary team such as dietician was informed of his nutritional status.
This process is essential to life. Ability to maintain a balance between what amount to retain and excrete is important to patient’s well-being and preserve life. This can be a very sensitive topic to discuss with patients as many patient s despair at the thought of being unable to manage their own toilet requirements. Many of nursing interventions required are of a very intimate nature, and gaining the patient’s trust and consent along with their permission is very crucial.
Mr Cole came in with frequent bowel movement which occur around 4 times every hour, he also experience abdominal cramp each time. During assessment, patient was very distress due to his condition because he has to cope with increased frequency of bowel movement, abdominal pains, proctitis and anal or perianal skin breakdown. Mr Cole was incontinence and was provided with commode for his private use to preserve his privacy and dignity during his episodes of diarrhoea. Mr Cole never had diarrhoea before and this episode of diarrhoea started after prolonged use of antibiotics prescribed for his pneumonia. After the assessment, a stool and fluid chart was implemented immediately; this includes noting the consistency and colour of stool, presence of blood, smell and type. To complete a fluid chart, patient’s input and output need to be monitored, recorded and documented on a fluid chart. Chart to be updated after every bowel motion type to be recorded using Bristol Stool Scales. According to (Wei et al 1997), initial treatment involves discontinuing antibiotics and providing supportive care. Mr Cole was prescribed vancomycin 500mg every six hours and paracetamol 500mg every 6 to 8 hours to control his pain and diarrhoea. A sample from the faeces was sent to lab for further investigation.
Personal cleansing and dressing
This activity involve far more than the physical act of cleansing the skin to reduce the potential of infection and injury. Personal cleansing and dressing is also important in promoting the psychological, social, cultural and overall well-being of the patient. Assessing the patient is important so as to offer them adequate level of assistance and to provide client with necessary information to help them maintain their personal hygiene needs.
Mr Cole is independent with his personal care and requires no help to maintain good personal hygiene. However he needs prompting according to his son, patient can sometimes neglect himself.
Information shows that patient lived with his son and daughter in-law, however he will soon be moving on to live in a shelter home. His moving had a great psychological and emotional strain on both his family and himself, especially considering the new environment he was going to live in. they were worry about how he was going to cope. Newton argues that anxiety mainly become a coping strategy like Mr. Cole felt his ill health inhibited him form staying with his family hence the high level of anxiety. Alexander et al (2002) believe that a patient’s anxiety may contribute to their symptoms getting worse than they actually are. From the outcome of assessment, I have learnt that psychological support is vital in anxious patients.
Following the assessment, the nurses and other members of multi-disciplinary team liaised effectively to provide the care by responding to query raised by the nursing team e.g. psychologist for him and his family to address their anxiety and emotional worries.
According to Hudak et al (2000) social cultural needs may refers to needs relating to the enlightenment of the mind or manners especially through intellectual activities , customs, culture and kinship system, lifestyle and habits and mutual relations of people around us and environment we are brought up in. As a function that is vital to sustain life, diarrhoea can cause anxiety, fatigue, sleep disturbances, feeling of isolation and depression (Roberts 1993: Hogan 1998). The impact on the ability to engage in necessary activities of living might result in dependence on others, loss of social and family roles and reduced quality of life (Margereson, 2001).
Mr Cole belongs to Sikh religion therefore he is encourage and supported by family to socialise by visiting the temple regularly (twice a week) and celebrates other special occasions such as Diwali and birthdays. Family support is very important as it decreases the individual’s stress (rock 1984 cited by Margereson). Failure to provide appropriate support may contribute to further psychological stress (Margereson, 2001).
In conclusion, the frame work used helped to determine the patients ability in relation to activities of daily leaving. It has aid delivery of holistic care as each factor of each activity as been assessed and his level of independence or dependence determined to provide adequate level of care and nursing intervention. by using this simple framework, Roper, Logan and Tierney’s help to direct our thinking in a more logical, sequential way and if every aspect of each activity is covered when patients are assessed a clear picture of their individual needs should emerge without the omission of any important point. However, the model has been criticised not to meet the needs of patient with learning disability or mental health problems. It also has a danger of ‘reductionist’ approach in which patient are made to fit into the boxes rather than allowing flexibility.
Nursing intervention is very important to help patient regain their normal self. One of these interventions includes pharmalogical approach and just simply providing a comfortable environment which enable client maintain his sexuality and dignity. For every nursing practice, there must be a rationale for decision on evidence based research other than experience as this defend care giving and safe guide the patients.
An effective care requires not only a full understanding of patients’ particular illness, but also a grounding in social and physical science so that experience of each individual and family can be interpreted accurately.
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