Theories and Practice of Adult Nursing

Mrs X is an 84 year old British lady. She has type 2 diabetes, hypotension and she is also MRSA positive. She was admitted to her local hospital where she was diagnosed with acute coronary syndrome and pulmonary oedema, but has now been transferred from her local hospital to this current care setting because of this diagnosis. After admission patient Mrs X had an angiogram, via right femoral approach, which has shown multi vessel disease (LMS, LAD, LCX and RCA). She had a failed angiogram via right radial approach. Mrs X has also had an Intra-aortic balloon pump inserted via right femoral approach. On arrival to the ward significant, vital observations were taken, these were blood pressure, O2 saturation, respiration rate and heart rate, her blood glucose level was also measured as she was diabetic.

An admission ECG test was also done. This patient has been chosen for the case study as a very effective care plan has been written for her needs while she is in hospital, also the care that Mrs X needs and the problems she is facing is very common for other patients on this ward, therefore it will help develop understanding for other patients as well as her and will also help build on further knowledge for the future. A very informative care plan has been developed for Mrs X by looking after from when she was admitted to the ward and seeing and reading about the problems she has. The involvement in her care has also helped nurses build a therapeutic relationship with her.

The nursing model that will be using is the Roper, Logan and Tierney model of nursing. The Roper, Logan, Tierney model (1996) centres on the patient as an individual and his relationship with the five components of the model. The five components are activities of living, lifespan, dependence/independence, factors influencing the activities of living and individuality in living (Holland et al 2008). This model is based on the 12 activities of living and nursing, which are maintaining a safe environment, communication, breathing, eating and drinking, elimination, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying. The activities of living are influenced by biological factors, psychological factors, socio-cultural, environmental and politico-economic factors. The model takes a holistic approach to nursing care and focuses on the patient as a whole and not just their illness.

On admission a patient assessment was carried out on Mrs X she was assessed according to the hospital policy. The framework that was used to carry out this assessment is shown as Appendix 1. This is the nursing assessment framework used at the hospital when each patient is admitted to the ward. When Mrs X was admitted to the ward after having surgery the assessment form was filled out from information retrieved from her case notes and her medical history. She was also personally asked the questions on the form in a planned assessment interview so the assessment could be as accurate as possible; therefore the precise and correct judgement can be made for the care Mrs X needs (Holland et al 2008). The planed assessment interview which took place when Mrs X was admitted to the ward was an opportunity to collect detailed, specific information in order to offer the most effective interventions (Mallet and Dougherty, 2000). This was carried out using a holistic approach and assessing her overall needs, instead of only looking at her medical needs, these include physical, psychological, emotional and social needs. There are many problems to be addressed for X but the three main problems that my care plan will address are:

Maintaining a safe environment

Eating and Drinking

Mobilising

The first problem is maintaining a safe environment. For Mrs X the focus will be on her internal environment rather than external environment. Other problems associated with maintaining a safe environment that need to be assessed are that the patient has a cross infection which is MRSA (Methicillin-resistant Staphylococcus aureus). Mrs X has had an intra-aortic balloon pump inserted and the surgery has caused her stress and anxiety which has led to hypotension. She is also in a lot of pain due to the surgery.

The goals that have been set to do this are to make sure that the hospital environment is safe for Mrs X, to ensure that Mrs X knows how to prevent accidents and stay out of danger, maintain a safe internal environment by making sure that Mrs X is not in any pain and that she is not bleeding, or to know about it if she is. The short term goal to prevent infection from spreading by following the infection control precautions. This will be implemented by keeping the patient in a separate room to the other patients to stop the infection spreading to them. By wearing gloves and an apron when giving care the patient and maintain hand hygiene by washing my hands once I have finished treating the patient. The long term goal that has been set for the problem of infection is to eliminate MRSA infection. The Hospital MRSA policy report (2009) says that MRSA is a bacterium that can reside on the skin and is found in the nose of about one-third of healthy individuals. The long term goal of MRSA will be implemented by following the MRSA protocol, which is to wash the patient with a skin disinfectant called hibiscrub.

Chlorhexidine gluconate is active against a wide range of bacteria, yeasts, some fungi and viruses. It is most active at neutral or alkaline conditions. It binds strongly to skin, mucosa and other tissues and is therefore will disinfect the skin and kill all germs and bacteria. The hibiscrub will cleanse Mrs X’s skin and will help reduce the chances of infection. The goal for the intra-aortic balloon pump (IABP) is to maintain a safe environment for the balloon pump, to maintain patient safety, to prevent deterioration of Mrs X as she is dependent on the intra-aortic balloon pump, to detect signs of risk of infection, to detect signs of bleeding and treat immediately, to reduce her anxiety and to monitor blood pressure to a safe range. This will be implemented by making sure the patient is lying flat and that she doesn’t move her leg that the balloon pump has been entered through and that she uses her other leg instead for movement and to re-adjust herself and to only tilt the bed to a certain level when she is eating. It will also be implemented by checking her observations regularly and by informing the nurse in charge and doctor when blood pressure is escalating and by doing daily ECG tests. To detect risk of infection hourly temperature and observations will be done for the IABP site, the colour, warmth and sensation will be checked.

The insertion site will also be checked for oozing and haematoma. As Mrs X is very anxious to reduce her anxiety the procedure was explained to her and her family by the doctor and she was kept informed of any changes to her treatment. The goal that has been set for pain is to ensure that Mrs X’s pain levels are to a minimal extent as possible. This was implemented by asking Mrs X often about how much pain she was in and by asking her to score the pain on a scale of 0-10 each time. She was also asked if she would like pain killers each drug round and was given analgesic medications such as paracetamol and codeine to ease the pain. Mrs X was also given morphine as she was in chronic severe pain.

On evaluation Mrs X was seen to be improving her activity of living ‘maintaining a safe environment’ everyday as she was regularly cleaned and disinfected for her MRSA infection. Her balloon pump was checked daily to reduce infection on her IABP site. Mrs X’s level of anxiety was gradually reducing, with the help of the doctors and nurses, as everything she needed to know was clearly discussed with her and family.

The second problem is eating and drinking. Roper et al (2000) states that eating and drinking is essential to human existence because it provides the energy source that the body needs to maintain cells and grow new cells. Eating and drinking are essential to maintain the body’s homeostasis, and we need to eat the right food and drink the right fluids that ensure the right balance (Holland et al 2008). The goals that have been set for this problem are to make sure Mrs X is eating a sufficient amount of food each meal time and to encourage her to eat. To make sure her blood sugars are kept to the required amount. Mrs X also had renal dysfunction so we need to ensure that she is drinking plenty of water and fluids to keep her body hydrated so that she can pass urine. Mrs X also has type 2 diabetes the goal for this is to keep her blood glucose levels within a normal range. Mrs X’s blood glucose level monitoring will be implemented by regular blood sugar tests before and after each meal.

NHS (2010) states that a normal blood glucose level is 4.0-6.0 mmol/l before meals and less than 10.0 mmol/l two hours after meals although this can vary from person to person. Keeping a check of the amount of food and liquids Mrs X is consuming will be implemented by keeping daily records of all intakes of food and drink on a food chart and fluid balance chart. As Mrs X was fed by the nurse or health care assistant (HCA) each meal time the goals were also implemented by the nurse or HCA encouraging Mrs X to eat and drink. Additionally, Mrs X was also referred to a speech and language therapist as her poor diet was associated with her having swallowing difficulties. After being seen by the therapist Mrs X was advised to go on a puree diet. This ensured that Mrs X would be able to swallow her food.

On evaluation, although Mrs X’s eating and drinking needs were being met, she still had an extremely poor appetite and her food chart showed that she was consuming a very small amount of food. She was also exceedingly dehydrated as she was having no oral intake, due to this she was unable to urinate which resulted in her renal function deteriorating even further.

The third patient problem is Mobility. Movement is essential for many other activities of living; not being able to move can have a major impact on individual lifestyle and social activities (Holland 2008). Richard and Edward (2003) state that mobilisation is making the body capable of movement. As Mrs X had surgery before she came up to the ward, she was unable to mobilise as she had to lay flat due to the intra-aortic balloon pump insertion, due to this she was bed bound. Nicol et al (2004) stated that, immobility can result in problems such as, deep vein thrombosis, pressure ulcers, stiff joints, chest infections, pulmonary embolism, constipation and muscle atrophy. Therefore it was important that relevant action was taken in order to prevent this.

Most immobile patients on the ward who are bed bound usually get put on turn in charts, which are filled out to show the different positions the patient has been turned into to reduce the risk of pressure ulcers. However, as Mrs X has had an inter-aortic balloon pump inserted she cannot be put on a turning chart because moving her could cause the catheter to move out of place or kink and this could result in the pump not working properly or cause damage to the vessel the IABP had been inserted through (hhttp://www.arrowintl.com/documents/pdf/education/iab-bk1200.pdf, 2000). Therefore the goal is not to enable her to mobilise, as she cannot physically do so, instead it is to reduce problems that could occur due to not mobilising. The goal is to assess the patient for problems caused by
reduced mobility, e.g. pressure sores/ulcers and deep vein thrombosis and to prevent these problems from occurring.

The risk assessment showed that Mrs X was at high risk of developing pressure ulcers as her score was 19. Waterlow 2007 states that a patient with a score of 10 or above has a high risk of developing pressure ulcers. Therefore, Mrs X was ordered a pressure relieving mattress in order to prevent this and was immediately put on a care plan so she could be assessed daily. Mrs X is also bedbound so she is at risk of developing Venous Thromboembolism (VTE) which is also known as deep vein thrombosis (DVT) and pulmonary embolism. Sanofi Aventis (2010) states that DVT is when a blood clot forms in a vein deep within the leg, this can be caused by narrow, blocked or damaged blood vessels as a result of poor blood circulation and inactivity. To prevent DVT Mrs X was seen by the doctor and was prescribed heparin injections. Heparin is an anticoagulant drug which is used for thinning the blood (BNF 2011). She was also prescribed Thrombo Embolic Deterrent (TED) stockings. The TED stockings are worn to increase the venous tone and reduce venous stasis (Byrne 2001). Mrs X was informed about the interventions being carried out and the nurse also discussed them with her and asked for her consent before she gave her the heparin injections and before the Thrombo Embolic Deterrent were applied (NMC 2008).

In conclusion this essay has touched on care planning and effectively implementing patient problems by setting reachable goals for each problem. The Roper, Logan and Tierney Model (1996) gave a systematic direction to nursing care and is a nursing model which is widely used by hospitals across the UK, in both medical and surgical wards. The assessment was used throughout the patients care and was also used to show how the patient’s life has changed since admission into the care setting. The goals of the care plan and the interventions were agreed on by both the nurse and the patient and the evaluation showed whether the goal had been achieved. Overall, the model was very effective as it helped improve the care of Mrs X and furthermore developed her activities of daily living.