A justification for a systematic assessment that considers the role of the nurse and others to meet a patient’s holistic needs.
A good nursing assessment provides the building blocks to form individualised patient care. To formulate a systematic assessment, models and frameworks are used together, such as the Model of Nursing (MoN) (Roper et al, 2008) and the Nursing Process (NP) (Melin-Johansson et al, 2017). The application of the NP framework helps to identify what holistic information needs to be gathered to form an effective plan of care following a five-stage framework; assessment, diagnosis, planning, implementation and evaluation (Kadioglu et al, 2017). The assessment stage of the NP provides a systematic structure to collecting, analysing and sorting information to inform a nursing care plan which identifies interventions to improve health (Kadioglu et al, 2017). The MoN helps to implement the assessment stage of the NP and gives a structure to obtaining information on the patient’s activities of daily living (ADL); mobility, sleeping, eating and excretion (Petiprin, 2016). Alongside, clinical assessment tools are used to gather specific, subjective and objective data to create a person-centred approach to care, for example Waterlow pressure area risk assessment tool (Waterlow, 2005). Assessment tools also highlight what specialist clinicians are needed to provide a multidisciplinary approach, such as tissue viability nurses can help advise on the prevention and treatment of pressure sores (Trueland, 2015).
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The role of the nurse is to take a pragmatic approach when applying the NP (Melin-Johansson et al, 2017) and the MoN (Roper et al, 2008) to make their assessment relevant to the patient and clinical area of practice. This assignment aims to look at the nurse’s role in the importance of systematic assessment, with the engagement of multidisciplinary working and the use of frameworks and models as supporting evidence to inform care. Furthermore, it will look at how assessment tools aid to inform holistic care planning and these tools will be applied to a nursing scenario to demonstrate their application.
Leonie is a 58 year old female of African-Caribbean descent. She has been admitted to the pre-admission surgical clinical prior to planned surgery for her cardiac disease. Her coronary artery bypass graft surgery is planned for two days’ time. You are the nurse completing her pre-admission documentation and assessment.
Leonie’s past medical history includes angina, chronic obstructive pulmonary disease and bipolar disorder (manic-depressive illness). She takes a range of medications for her conditions.
Leonie lives at home with her husband, Brian, in a terraced house. She has three children: one child lives at home and two children live several hundred miles away. Brian is present at the time of your assessment.
Planned Assessment Approach
The MoN (Roper et al, 2008) is based around maximising the independence of patients, through implementing interventions, to perform ADL (Petiprin, 2016). For the successful application of the model, the nurse will identify how the illness has impacted upon the patient’s normal classification of independence on a holistic scale. The key role of the nurse is to apply the model to synthesise a realistically achievable care plan, with the aim of returning the patient back to their normal state of health, by implementing holistic interventions (Holland et al, 2008).The model also recognises the importance of Maslow’s Hierarchy of needsand sets guidelines for interventions to help the nurse facilitate the patient reaching self-actualisation through not only physical recovery but with the importance of intellectual, emotional, socioeconomic stability (Best et al, 2008).
Unfortunately, the MoN (Roper et al, 2008) has become a standardised approach and has often been referred to as a check list which limits person centred care planning (Nursing Times, 2012). It is also has limited successful application, as it is not always viable to complete an assessment on all aspects of ADL due to time constraints, patient compliance, lack of trust and therapeutic relationship (Chellel, 2001). Although as the NP (Melin-Johansson et al, 2017) advances, therapeutic relationships develop, and more aspects of the model can be fulfilled. Realistically this makes the MoN an ongoing assessment process which may not always be completed during the initial assessment, so needs to be re-evaluated throughout care planning (Barrett et al, 2009).
The NP (Melin-Johansson et al, 2017) framework helps to systematically organise and plan care interventions using clinical judgment and critical thinking to evaluate patient’s holistic needs. With the combined application of the MoN (Roper et al, 2008), it identifies complex care needs and highlights the importance of specialist multidisciplinary engagement. It also provides the opportunity to create a trusting therapeutic relationship with the patient as it is heavily reliant upon their input to assess effectively (Toney-Butler and Unison-Pace, 2018).
One of the recognised limitations of the NP (Melin-Johansson et al, 2017) is around a lack of knowledge and understanding that nurses may have in implementing it (Dougherty, 2015). This can be resolved through effective identification during ward auditing, which can identify patterns of incomplete and inconsistent holistic care planning and if nurses are working in line with care standards (Brady, 2004). The aim according to the National Clinical Auditing and Patient Outcomes Programme is to identify areas of concern and address these through clinical education and training (NHS, 2016).
The combined approaches of the NP (Melin-Johansson et al, 2017) and MoN (Roper et al, 2008) are most suitable and effective in informing and synthesising the assessment of Leonie from admission to discharge and inform the plan of care through the application of assessment tools.
At the start of an assessment the nurse’s role is to create a therapeutic environment whilst maintaining patient confidentiality (Mazqai, 2015). The nurse must maintain a non-judgemental approach in line with the NMC code of conduct ‘practise in a holistic, non-judgmental, caring and sensitive manner that avoids assumptions and recognises and respects individual choice’ (The Nursing & Midwifery Council, 2018 p.6). As a result, the nurse may offer Leonie the choice of a side room to talk through the assessment, to reduce any anxiety and offer any adaptation to help her during her stay to manage her bi-polar disorder.
During the initial stage of patient assessment, positive patient identification (PPI) is fundamental in line with NICE guidelines, for patient safety (National Institute for Clinical Guidelines, 2012). The nurse should ask the patient their full name and date of birth before issuing a wrist band. This ensures the nurse is discussing the right information with the right patient and adhering to data protection and confidentiality legislation (Jones, 2013). A patient safety alert audit indicated that initially PPI can help to reduce medication dispensing errors to provide effective patient care (NHS England, 2014).
During the next stage of the assessment, the nurse will take an initial set of physical observations and a blood test. Research demonstrates that full physical assessment on admission can alert the nurse to any potential infection markers or illness that could prevent surgery taking place and reduce risks of complications (Semrád, 2014). It also gives the nurse a baseline set of observations where a comparison can be made postoperatively to identify the normal range, working in line with The National Early Warning Score (NEWS) (Bowen et al, 2018). When doing these observations, the nurse will be recording heart rate, blood pressure, temperature, respiration rate and oxygen saturations. This tool is used to detect deterioration in patients to improve early intervention. The nurse would use this assessment tool and clinical judgement to monitor changes to the baseline measurements (Karen, 2012).
When using NEWS, the nurse needs to consider past medical history, and in this case, Leonie has chronic obstructive pulmonary disease and bipolar requiring a range of medication which can alter observations and score highly. This illustrates a disadvantage to the NEWS tool as it does not take into account the individual’s normal ranges (Karen, 2012). However, NEWS is the most widely used tool and shown as effective in identifying deterioration and care needs for intervention
The nurse will use the Body Mass Indicator (BMI) tool, to measure Leonie’s weight and height to see which parameter she falls into; underweight, healthy weight, overweight or obese (Smith, 2012). The nurse will work collaboratively with the anaesthetist by sharing information gathered about BMI to accurately calculate procedural medication. This tool is easy to apply and gathers the required information quickly (Ferrera, 2006). However, it does not take into account muscle mass and, therefore, in circumstance where a patient is athletically built with large muscle mass, may suggest an inaccurate result (Al-Gindan et al, 2016). This is where the nurse needs to apply clinical judgement and record in the nursing notes.
On admission the nurse will assess Leonie’s skin using the Waterlow pressure area risk assessment tool (Waterlow, 2005). It identifies potential risk of pressure sore development by looking at contributing factors like; BMI, gender, skin type, continence, mobility, medication, major surgery and the combined use of the Malnutrition Universal Screening Tool (MUST) (Borgmeijer-Hoelen, 2011). The MUST monitors unplanned weight loss and produces a score indicating low, medium or high risk of malnutrition. This combined use of these tools during admission implement the appropriate actions such as dietician referral, goal management and weekly review which can reduce the occurrence or deterioration of pressure sores (Borgmeijer-Hoelen, 2011). These tools are implemented together as malnutrition can affect skin deterioration, increasing the likelihood of pressure sore development. The combination of anaesthetic and low mood can suppress Leonie’s appetite, so it is crucial her weight is monitored to inform nutrition, aiding in healing and recovery (Macintosh and Moore, 2011). The information gathered as part of these assessments will be applied to an individual care plan as appropriate, for example a pressure sore prevention care plan if the patient is deemed at risk.
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Following surgery, full recovery can be a 12 weeks process (NHS, 2018). Discharge planning starts at the time of the admission to effectively coordinate care, reduce readmission, reduce bed blocking and effectively manage discharge to support holistic care needs (Williams, 2018). This often means a multidisciplinary approach to discharge is appropriate with the care of specialists to meet holistic care needs. Referrals to different departments and services are made in a range of ways; referral forms, telephone, email, face to face contact or a letter (Durocher, 2017).
The nurse will make a referral to Leonie’s practice nurse to change the sterile dressing to her chest and fempop site. The practice nurse will advise on what steps to take to keep the wound dry, clean and prevent infection and offer reassurance regarding normal side effects (Blazeby et al, 2016). The importance of the content in this referral is key to seamless care from secondary to primary healthcare. The referral must include; the outcome of the operation, what was done, what dressings and sutures were used, what the plan of care is moving forward and a point of contact for the practice nurse if they were to have any concerns or report any anomalies. Often referrals are made with limited available information, which can be a barrier to care (Bodenheimer, 2008).
Coronary artery bypass graft surgery can be a traumatic experience and can have long term holistic implications. Recovery can restrict Leonie’s physical and social activities, which may exacerbate her mental health condition (Barth, 2017). As a result, prior to discharge the nurse will make a referral to the Community Mental Health Liaison Team for multidisciplinary engagement. This gives Leonie a point of contact to discuss her feelings and they can monitor symptom exacerbation. Observed in practice on a community mental health placement, it can be difficult to manage referrals across sectors as mental health resources are stretched to capacity and often case workers’ caseloads are too high to effectively see every patient. This may result in a delay and insufficient care provided upon discharge from surgical intervention (Cohen, 2017).
The nurse will refer Leonie to a cardiac rehabilitation programme who aim to aid recovery and help patients to resume as fuller life as possible. The programme is led by nurses, physiotherapists, occupational therapists and dieticians and aims to provide safe individually tailored aerobic exercise, relaxation techniques, information on healthy eating and stress management (British Heart Foundation, 2018).The vast range of clinicians can help with different aspects of the recovery by providing information on life style, support available, their condition, positive reinforcement, recovery and how to prevent further problems (Dalal, 2015). Physio and occupational therapists can help to implement interventions in circumstances of loss of sensation or mobility caused by the operation and intervene in the short term with home adaptations to aid mobility. The programme provides a safe environment for Leonie to engage with others, build positive relationships and stop her feeling isolated, as she can share her emotions and experience with people in the same situation. The programme records weekly observations to monitor recovery and detect any problems. This programme reduces the amount of individual services the nurse needs to refer to, as the tailored service provides multidisciplinary working to provide holistic care for cardiology patients. Research has shown that the implementation of this is beneficial in aiding recovery and has long term benefits to reducing cardiac problems (Kachur, Lavie and Milani, 2018).
In summary, the combination of the NP (Melin-Johansson et al, 2017), MoN (Roper et al, 2008) alongside assessment tools and nursing skills are fundamental key aspects to a successful holistic care plan. This combination ensures a full assessment of a patient’s holistic care needs and indicates appropriate multidisciplinary interventions. By following the systematic stages of the NP to organise and plan care interventions it ensures that all aspects of MoN ADL are evaluated and met. The nurse has a key role in gathering information from the assessments which is then shared with the multidisciplinary team. The nurse needs to be skilled in communication to extract subjective data to inform the care plan, with the aim of helping the patient to meet their maximum independance level with aids and assistance where necessary.
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