Assessment and Care Planning
This essay deals with the holistic assessment of a patient who was admitted onto the medical ward where I undertook my placement. Firstly, the relevant life history of the patient will be briefly explained. Secondly, the Roper, Logan and Tierney model of nursing that was used to assess the care needs of the patient will be discussed, and then the assessment process will be analysed critically. Identified areas of need – breathing and personal cleansing – will be discussed in relation to the care given and with reference to psychological, social, and biological factors as well as patho-physiology. Furthermore, the role of inter-professional skills in relation to care planning and delivery will be analysed, and finally the care given to the patient will be evaluated.
Throughout this assignment, confidentiality will be maintained to a high standard by following the Nursing and Midwifery Council (NMC), Code of Conduct (2008). No information regarding the hospital or ward will be mentioned, in accordance with the Data Protection Act 1998. The pseudonym Kate will be used to maintain the confidentiality of the patient
Kate, a lady aged 84, was admitted to a medical ward through the Accident and Emergency department. She was admitted with asthma and a chest infection. She presented with severe dyspnoea, wheezing, chest tightness and immobility. Kate is a patient known to suffer from chronic chest infections and asthma, with which she was diagnosed when she was young. She takes regular bronchodilators and corticosteroids in the form of inhalers and tablets. Kate lives on her own in a one bedroom flat. She has a daughter who lives one street away and visits her frequently. Her daughter stated that Kate has a very active social life; she enjoys going out for shopping using a shopping trolley.
Elkin, Perry and Potter (2007) outlined nursing process as a systematic way to planning and delivering care to the patient. It involves four stages: assessment, planning, implementation and evaluation. Assessment is the first and most critical step of the nursing process, in which the nurse carries out a holistic assessment by collecting all the data about a patient in order to identify the patients nursing problems (Alfaro-Lefevre 2008). Holland (2008) stated that assessment as an on-going process used to identify needs, preferences and abilities of a patient. Rennie (2009) stated that subjective and objective data, as well as medical and social history are collected during patient’s interview.Among the physical aspects assessed are vital signs and general observations of the patient. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan (Wilkinson 2006). Assessment is of benefit to the patient because it allows his or her medical needs to be known, but it can feel intimidating or embarrassing so the nurse needs to develop a good rapport (NursingLink 2012). Under time pressure this can sometimes be neglected. Are tools usedAre the tools user-friendlyWhat are they forWhy do we have them?
After assessment, care plan is formulated. Barrett, Wilson and Woollands (2012a), defined a care plan as an integrated document that addresses each identified need and risk. Care planning is important because it guides in the on-going provision of nursing care. Good care planning allows healthcare professionals make evidence-based decisions about care based on a comprehensive assessment, and to prove this, if necessary (Barrett, Wilson and Woollands 2012a). Care plans can be problematic when they are not filled in correctly or are completed carelessly. This can jeopardise patient care. Every nurse has a professional responsibility to make sure that care plans are filled in to the best of her ability to help herself and her colleagues to continue the process of giving the best care possible necessary (Barrett, Wilson and Woollands 2012a).
Before assessment takes place, the nurse should explain when and why it will be carried out; allow adequate time; attend to the needs of the patient; consider confidentiality; ensure the environment is conducive; and consider the coping patterns of the patient (Jenkins 2008). The nurse should also introduce herself to help reduce anxiety and gain the patient’s confidence. During assessment, the nurse needs to use both verbal and non-verbal communication. Using non-verbal communication means that she should observe the patient, looking at the colour of the skin, the eyes, and taking note of odour and breathing. An accurate assessment enables nursing staff to prioritise a patient’s needs and to deal with the problem immediately it has been identified (Esmond 2011). Documentation is also very important in this process; all information collected has to be recorded either in the patient’s file or electronically (NMC, 2009b).
Kate was allocated a bed within a four-bed female bay. Her daughter was with her at the bedside. Gordon (2008) stated that understanding that any admission to hospital can be frightening for patients and allowing them some time to get used to the environment is important for nursing staff. Both Kate and her daughter were asked if it was okay for her daughter to be around while assessment was carried out, so that she could help with some information, to which both agreed. As Kate was an adult and was judged by the nurses present to understand what she was consenting to, it was acceptable for her to consent to having her daughter present (Ebersole and Hess 1998). Her confidentiality was not compromised because she agreed to the presence of a family member. Alfaro-Lefevre (2008) recommended that nursing assessments take place in a separate room, which respects confidentiality, and that the patient be free to participate in the assessment. Although there was a room available, Kate and her daughter said it was fine for the assessment to take place at the bedside especially that Kate was so restless. The curtains were pulled around the bed, though Sibson (2010) argued that it ensures visual privacy only and not a barrier to sound. NMC (2009a) acknowledges this, along with the need to speak at an appropriate volume when asking for personal details to maintain confidentiality.
In this ward the Roper, Logan and Tierney model of nursing, which is based on the twelve activities of living, is used as a base for assessing patients (Alabaster 2011). This model is extremely prevalent in the United Kingdom and it is used as a checklist on admission in order to get as much background data about the patient Holland (2008, p.9).
The assessment form that was used during Kate’s assessment addressed personal details and the twelve activities of living. Personal details such as name, age, address, nickname, religion, and housing status were recorded. Information was also recorded about any agency involved, along with next of kin and contact details, and details of the general practitioner. Holland (2008) stated that these details should be accurate and legible so that, in case of any concerns about the patient, the next of kin can be contacted easily. The name and age are also vital in order to correctly identify the patient to avoid mistakes. Knowing what type of a job the patient does or the type of the house she lives in helps to indicate how the patient is going to cope after discharge. Holland also insisted that religion should be known in case the patient would like to have some privacy during prayers, and this should be included in the care plan.
The second assessment to be done focused on physical assessment and the activities of living. Barrett, Wilson and Woollands (2009) suggested that when enquiring about the activities of living, two elements should be addressed: usual and current routines. Additionally, identifying a patient’s habits will help in care planning and setting goals. During physical assessment, Kate demonstrated laboured, audible breath sounds and breathlessness. Use of accessory muscles and nose flaring was also noted. She was agitated and anxious. Her vital signs were: pulse 102 beats /min; respirations 26/min; temperature 37.4 degrees Celsius; oxygen saturation 88%; and peak flow 100 litres. Taking and recording observations is very important because it helps to recognise the significance of changes in vital signs. Observations also help to detect any signs of deterioration or progress in the patient’s condition (Field and Smith 2008). Carpenito-Moyet (2006) stated that it is important to take the first observations before any medical intervention, in order to assist in the diagnosis and to help assess the effects of treatment. How did all this affect her ability to provide you with information during the assessment?
Kate’s initial assessment was carried out in a professional way, taking account of the patient’s particular circumstances, anxieties and wishes. After the baseline observations were taken, the twelve activities of living were analysed and Kate’s needs were identified. How gave the information, Kate or the daughterDid this affect the way the questions were askedOr the information receivedCould Kate answer all the questionsDid the daughter know the answer to all the questionsAmong the needs identified, breathing and personal hygiene (cleansing), being priority needs, will be explored.
Breathing will be discussed first being an underlying problem which Kate presented with before moving on to personal cleansing. Wilkinson (2006) states that a nursing diagnosis is an account about the patient’s current health situation. The normal breathing rate in a fit adult is 16-20 respirations/minute, but can go up to 30 due to pain, anxiety, pyrexia, sepsis, sleep and old age (Jenkins 2008). In old people, muscles become less efficient, resulting in increasing efforts to breathe, causing a high respiratory rate (Mallon 2010). On assessment, Kate’s problem was breathing that resulted in insufficient intake of air, due to asthma. She was wheezing, cyanosed, anxious and had shortness of breath.
Wilkinson (2006) explained that a goal statement is a quantifiable and noticeable criterion that can be used for evaluation. The goal statement in this case would be for Kate to maintain normal breathing, which is normally 12 – 18 breaths per minute in adults (Mallon 2010), and to increase air intake. The prescription of care for Kate depended on the assessment, which was achieved by monitoring her breathing rate, rhythm, pattern, and saturation levels. These were documented hourly for early identification of any deterioration of condition; it also encouraged early identification of interventions. Readings were compared with initial readings to determine changes and to report any concerns. The other part of the plan was to give psychological care to Kate by involving her in her care and informing her about the progress, in order to reduce anxiety. Barrett, Wilson and Woollands (2012a) stated that it is very important to give psychological care to patients who are dyspnoeic because they panic and become anxious.
Checking and recording of breathing rate and pattern is very important because it is the only good way to assess whether this patient is improving or deteriorating, and it can be a very helpful method for nurses to evaluate the care of the patient (Jamieson 2007). Mallon (2010) stated that, if the breathing rate is more than 20, it indicates that the body is trying to increase its intake of oxygen to meet unusual demands. This can happen even after doing exercise, not only in people with respiratory problems (Blows 2001). Griffin and Potter (2006) stated that, respirations are normally quiet, and therefore if they are audible it indicates respiratory disease, wheezing sound indicates bronchiole constriction. Kate’s breathing was audible and the rate was also above normal and that is why breathing was prioritised as the first need
Oxygen saturation level was also monitored with the use of a pulse oximeter. The normal saturation level is 95-99% (British National Formulary ((BNF)) 2011a). Nevertheless the doctor said that 90-95% was fine for Kate, considering her condition and her age. Kate was started on two litres of oxygen using nasal catheter and she maintained her oxygen saturation between 90 and 94%. With nasal catheter, Kate was able to communicate with the nurses and her daughter what about comfort?. The peak expiratory flow was monitored and recorded to identify the obstructive pattern of breathing that takes place in asthma (Hilton, 2005). This is another method that is used to assess the effectiveness of the medication (inhalers) the asthmatic patient is taking, and this test should be carried out 20 minutes after medication has been absorbed. It is the Trust’s policy to do hourly observations on patients who have had one, two or three abnormal readings, until readings return to normal. Kate was observed for any blueness in the lips and oral mucosa as this could be a sign of cyanosis. All the prescribed nebulisers, inhalers, bronchodilators, corticosteroids, antibiotics and oxygen therapy were administered according to the doctor’s instructions. Bronchodilators are given to dilate the bronchioles constricted due to asthma, and corticosteroids reduce inflammation in the airway (BNF 2011b). Kate was also started on antibiotics to combat the infection because, on auscultation, the doctor found that the chest was not clear.
Kate was being reassured during care, her daughter was encouraged to be visiting her mum regularly because she used to be settled whenever the daughter was around. The call bell was always in reach for to call when in need.
Kate was nursed in an upright position using pillows and a profiling bed in order to increase chest capacity and facilitate easy respiratory function by use of gravity (Brooker and Nicol, 2011). In this position, Kate was comfortable and calm while other vital signs were being checked. Pulse rate and temperature were also being checked and recorded because if raised, they indicate infection in the blood.
Considering Kate’s age and her breathing problem, she needed multi- professional teamwork. NMC (2008) encouraged teamwork to maintain good quality care. Kate was referred to the respiratory nurse who is specialised in helping patients with breathing problems. Specialist nurses have expert knowledge of a particular area of nursing, and as well as offering direct care, like ‘normal’ nurses, they educate patients in the management of their condition and can provide a consistent point of contact for sufferers of particular illnesses, which can help with psychological well-being (Royal College of Nursing 2010). Kate was on oxygen since admission; therefore she was taught about importance of healthy breathing and taught her about breathing exercises to help her wean from oxygen.
Due to breathlessness and loss of mobility it was difficulty for Kate to maintain her personal hygiene. Hygiene is the practice of cleanliness that is needed to maintain health, for example bathing, mouth washing and hair washing. The skin is the first line of defence, so it is vital to maintain personal cleansing to protect the inner organs against injuries and infection (Hemming 2010). Field and Smith (2008) stated that personal cleansing also stimulates the body, produces a sense of well-being, and enables nurses to assess the patient holistically. Personal hygiene is particularly important for the elderly because their skin becomes fragile and more prone to breaking down (Holloway and Jones 2005). This is due to slower epidermal cell renewal and a reduction in collagen (Hess 1998). Therefore this need was very important for Kate; she needed to maintain her hygiene as she used to, before she was ill.
The goal for meeting this need was to maintain personal hygiene and comfort. The care plan prescribed involved first gaining consent from Kate, explaining what was going to be done. Hemming (2010) recommended that identifying the patient’s usual habit is very important because each individual has different ideas about hygiene due to age, culture or religion. Identifying usual habits helps individuals to maintain their social life if things are done according to their wishes. Though Hemming said all human beings need personal hygiene, Holland (2008) argued that it is important to ask patients how they feel about being cleaned, especially genital area. Kate indicated that she didn’t mind being assisted with washing and dressing. She preferred washing daily, shower and a hair wash once a week, and a mouth wash every morning and before going to bed.
Kate was assisted with personal care after having her medication, especially the nebuliser. Individuals with asthma experience shortness of breath whenever they are physically active (Ritz, Rosenfield and Steptoe 2010). After having medication Kate was able to participate during personal hygiene. According to NMC guidelines on confidentiality (2009a), privacy and dignity should be maintained when giving care to patients. Therefore, whenever Kate was being assisted with personal care, it was ensured that the screens were closed and she was properly covered. Field and Smith (2008) suggested that assisting a patient with personal hygiene is the time that nurses can assess the patient holistically. Since Kate was immobile, it was very important to check her pressure areas for any redness. She was also checked for any pallor, jaundice, cyanosis or dry skin that needed attention. The care was always carried out according to her wishes.
Kate responded well to the medication she was prescribed; normal breathing was maintained, her respirations became normal, ranging from 18 to 20 respirations per minute, and her oxygen saturation ranged from 95% to 99%. Kate was able to wash and dress herself with minimal assistance. She was discharged on a continuous care package comprising care three times a day, although discharge was delayed by one week so that the care package could be ready.
The model of the twelve activities of living was followed successfully on the whole. The nurse collected subjective and objective data, allowing a nursing diagnosis to be formulated, goals to be identified and a care plan to be constructed and implemented. Privacy is very important in carrying out assessments, and this was not achieved fully in Kate’s assessment. However, this lower level of privacy has to be balanced against causing anxiety to the patient. Kate’s daughter thought that the bedside assessment would be more comfortable for her mother, and therefore cause least anxiety. This was very important because of the effects of potential panic on breathing; therefore, this was the correct balance to strike.
A multi-disciplinary team was involved in meeting Kate’s care goals. This is a good example of the use of inter-professional skills, as a number of different departments were involved in creating and implementing the care plan. However, the system was not as efficient as it should have been: Kate spent unnecessary time in hospital after recovery because the care plan was not yet in place.
Assessment can also take a long time, especially with the elderly who are usually slow to respond. Therefore, more time is needed to be sure that the necessary progress has been achieved before taking further steps. However, poor staffing also affects performance in this area, an observation supported by the Royal College of Nursing (2012).
In conclusion, the assessment of this patient was completed successfully, and the deviation from best practice recommendations (the lower level of privacy) was justified by the clinical circumstances. Progress from assessment to care goals was good, and at this point an inter-disciplinary team was used successfully. However, the one flaw in this process was delays, caused partly by the difficulties of working across different departments, and partly, it seems, by staff shortages.
Ebersole, P and Hess, P. (1998). Toward Healthy Aging: Human Needs and Nursing Response.: St. Louis, MO: Mosby. Chapter 14.
Hess, P. (1998). Toward Healthy Aging: Human Needs and Nursing Response. St Louis, MO: Mosby. Chapter 4.
Nursing Link (2012) Physical Assessment: Chapter 1 History and Physical Examination. Available at http://nursinglink.monster.com/training/articles/298-physical-assessment—chapter-1-history-and-physical-examination
Royal College of Nursing (2010) Specialist Nurses: Changing Lives, Saving Money. London: RCN. Available at http://www.rcn.org.uk/__data/assets/pdf_file/0008/302489/003581.pdf