Adam Nursing care study

INTRODUCTION
This is a nursing care study of people with physical illness. For the purpose of this study a single patient’s care was focused on. The patients name is Adam and he is a middle aged man who is separated from his wife and lives with his mother. Adam is an alcoholic who was referred to hospital against his wishes, by his G.P. He presented with heel ulcers secondary to vasculitis, a groin skin infection and cellulitis secondary to poor hygiene. This study looks at how Adam felt about being in hospital and what he hoped to gain from his treatment. The role of the multi-disciplinary team in treating Adam. The areas seen as problematic for Adam and the plans made to overcome these problems. Also described is my relationship with Adam and the role I played in his care. In conclusion the different needs of patients in general hospital and mental health care settings is looked at.

HOW ADAM CAME TO BE IN HOSPITAL

Adam came to be in hospital as a result of his G.P. referring him to accident and emergency. His mother whom he lives with had summoned the G.P. to the house as she was worried about his general state of health and in particular about open wounds on his heels that had begun to smell. His condition was deteriorating rapidly but he did not want the doctor called and this led to a significant delay in his receiving treatment.

Adam has a history of alcohol abuse (C2H50H) and in the weeks prior to his presentation at A&E. he had taken to sitting and sleeping in a chair in front of the television and consuming alcohol. According to his mother he was urinating and vomiting on himself but refused to look after his personal hygiene needs. He was also refusing to take his Librium which was prescribed to him by his doctor. Adam’s G.P. called an ambulance and he was brought to A&E on a stretcher. His presenting features were G.P. referral due to bilateral breakdown both heels, oedematous and exudates, pain and rash in groin area. Adam had a history (HX) of asthma, peptic ulcer disease (PUD), Appendectomy, alcohol liver disease, obstructive jaundice and cellulitis. Cellulitis-: (inflammation of the cellular or corrective tissue of the body.) PUD-: Peptic ulcers consist of areas of erosion of a mucosal surface bathed with acid gastric juice. They are located typically in the stomach and a major causative is excess alcohol.

His confirmed diagnoses was (1) Bilateral heel ulcers (pressure sores) secondary to vasculitis. (2)Groin skin infection and cellulites due to poor hygiene. He was noted as an infection control risk due to open wounds and poor hygiene. Also noted as a problem for alcoholism and alcohol neuropathy. His right heel wound was open and clean but his left heel wound was necrotic. It is worth noting at this stage that apart from his alcohol problem there is no mention of his diagnosis of psychiatric problems or referral for psychiatric assessment.

HOW ADAM FELT ABOUT BEING IN HOSPITAL AND WHAT HE HOPED TO GAIN FROM HIS TREATMENT

Adam was very unhappy about being in hospital although this was tempered with great praise for doctors and nurses and the general care he was receiving. He was a very compliant and pleasant patient but seemed to be totally unconcerned about his physical condition or his personal hygiene.

Adam at first was completely immobile and as part of his treatment regime was a daily shower, it offered a good opportunity to communicate with him. However when his physical needs were dealt with Adam spent most of the day in a chair beside his bed with his legs raised. His main complaints were that he was very bored and that the hospital did not serve alcohol. He had a good rapport with both staff and other patients and would often ask if somebody was going to the shop as he did not seem to get any visitors. He disclosed that he had been married for ten years but had been separated for two years and that he was a professional painter by trade but had been unemployed for four years due to his health. When asked if he attributed his bad health to his abuse of alcohol he replied “yes” but he had no intention of stopping. When asked what he hoped to gain from his treatment programme his only reply was that he could once again be mobile so he could go home and “have a few drinks”.

THE ROLE OF THE MULTIDISCIPLINARY TEAM IN TREATING ADAM

There were many different disciplines needed to give Adam the best possible treatment. Although his primary problem was a surgical matter i.e. open wounds to his heels, there were many other conditions requiring attention. Together these disciplines are known as a multidisciplinary team. The following are some of the roles of this multidisciplinary team. The surgical team-: consisting of a surgical consultant, registrars, interns and student doctors. As stated they treat the surgical needs of the patient e.g. open wounds.

The medical team-: consisting of a medical consultant, registrars, interns and student doctors. They treat the medical needs of the patient e.g. rash, infections and a later diagnosed jaundice. The nursing team-: consisting of Clinical Nurse Manager, primary nurse, staff nurses and student nurses. The nurses take a holistic approach to caring for a patient and his family. They carry out the administering of medications, wound dressings, removal of sutures and certain other medical procedures that maybe prescribed by the consultant. Nurses also make their own care plans by assessing, planning, implementing and evaluating care. They use the Roper, Logan & Tierney (1976) activities of daily living (ADL’s) nursing model. This model as the name suggests covers the activities associated with everyday living and are listed under 12 headings.  In Adams case he relied heavily upon nurses to perform the ADL’s. As nurses usually work closest with patients and their families they are often central to the multidisciplinary team and have great influence over the type of care given. Nurses also do most of the discharge planning and further referrals to social workers, public health nurses etc. Physiotherapists-: They build up the muscle tissue so a patient regains mobility. They also assess the need for any mechanical assistance e.g. walking frames, walking sticks that may be required for mobility. Dieticians-: Assess and recommend the dietary needs of the patient. Social workers-: Assist with social and financial needs of the patient and their families. They also arrange such services as home help and meals on wheels.

They also advise of entitlements such as social welfare. Public Health Nurse-: They carry out follow up visits when a patient has been discharged. They deliver treatments in the home and take account of the living conditions. Care Staff-: They assist nurses in carrying out ADL’s and can monitor patients for dietary intake and hygiene. They also assist with and encourage mobilization. Catering Staff-: Provide meals and drinks and fulfil and special diet requirements. Cleaning Staff-: Keep wards, showers and toilets clean and safe. They undertake special cleaning requirements where there is a risk of infection.

Although on this ward there was no official multidisciplinary team meetings the different disciplines were in close contact throughout the day. They all shared a common goal of providing the best possible service for the patient.

AREAS INDENTIFIED AS PROBLEMATIC FOR ADAM AND NURSING PLANS MADE TO OVERCOME HIS DIFFICULTIES There were many areas identified as problematic for Adam upon admission. These were alcohol dependency, alcohol neuropathy, infection control risk, he could not perform many of the activities of daily living and on the Medley Score Pressure sore prevention risk assessment he scored 16 which put him in the medium risk category for pressure sores.

HOW NURSING PLAN WAS IMPLEMENTED AND HOW EFFECTIVE/HELPFUL THE PLAN WAS

Each day a nurse would be assigned usually to 6 patients. At the hand-over all nurses were brought up to date on the progress and requirements of each patient. The nursing progress notes would be read out and this detailed any difficulties and interventions used by the previous shift. A printed hand-out was supplied to each nurse listing details of patients name, age, doctor, diagnosis, medical history, mobility, dressings, diet and remarks. A progress report was filled out on each patient and this was kept at the nursing station. Each nurse would familiarise themselves with the details of their 6 patients and would know exactly what was to be implemented and when. Adam’s plan was very effective as there were vast improvements to all areas in need of attention. His physical condition improved immensely and at the time of writing he is due for discharge.

MY RELATIONSHIP WITH ADAM AND THE PART I PLAYED IN HIS CARE

It is fair to say that Adam had good relationships with all the staff and other patients. He has a good sense of humour and puts complete trust in the capabilities of the nurses who provided his care. When I first met him I introduced myself as a student nurse and informed him that I would be working in this area for the day and that if he required anything he should let me know. I noticed that for a long time after this he was closely observing me as we went about the general ward duties. When the time came for his daily shower I asked if he had any objections to me assisting the staff nurse and his reply was “no, you seem to know what you’re doing”. This remark put me at ease and I felt confident when dealing with Adam. Over the following days I had many conversations with Adam, some to do with his condition and others about general topics. I also assisted in his care and I felt that he liked and trusted me. He showed a good interest in what I was studying and I took this opportunity to explain what I knew about pressure sores and personal hygiene in terms that he understood. I must emphasize that this was done in a natural and informative way and I explained that he was helping me with my studies.

I realised that behind the sense of humour Adam is a lonely man who does not see much of a future for himself. I also realised that although the physical care which Adam was receiving was of the highest quality his psychological needs were not being considered. This I again stress is not a criticism of his care but perhaps in the very busy and very task orientated environment of a general surgical ward there is not the required time to really get to know the person. The benefits of getting to know Adam are that he allowed me to trim his beard and hair which were very overgrown and he now asks for his daily shower. With the help of the physiotherapists and a walking frame he takes a daily walk around the ward and he feels that his mobility is improving. As a consequence of this he has had his Foley Catheter removed and he is delighted about that. This progress was to be expected of Adam but maybe the relationship we formed enabled the process to progress a little faster. In addition I assisted with the daily dressing of his wounds, the process of building up his body i.e. encouraging food and water and assisting in dispensing his medications. In particular I would give him his clexane injections. This is an anti-coagulant and is given sub-cutaneously normally in the stomach area.

CONCLUSION

There are many similarities and some important differences in the needs of patients in a general hospital setting and those in a mental health care setting. The underlying needs of patients in any setting are that they receive the best possible care and attention in a dignified and professional way with a goal of returning to full health or to a level of functioning which is the best their capabilities will allow.

Patients in general hospital are there due to some physical condition. These conditions can be surgical or medical and the symptoms are usually visible e.g. broken bones, open wounds, heart conditions, respiratory problems or cancers. The patient needs a diagnosis, a treatment regime, a prognosis and a time frame for discharge. During their treatment the patients needs can differ. The needs are medication for pain relief or injections, high or low temperatures or blood pressure. They may also need help with their activities of daily living due to immobility or weakness but this is usually on a temporary basis as their condition is generally improving. The patient understands the need for being in hospital and usually co-operates with the treatment programme. There are exceptions to this as patients become anxious or depressed from being in hospital but in my own experience the focus still remains on the physical condition and needs associated with this. In a mental health care setting the needs of the patient may not be so obvious. In some cases the patient may not want to be there or they may feel that they are not ill at all. Their condition may not be understood and therefore there is no prognosis or time frame for discharge. Often they have been very damaged a long time before they present for treatment. Unlike physical illness which is socially acceptable the mental health patient may have been shunned by society.

Their needs are for acceptance; understanding, caring and a genuine interest on behalf of the nurse for the person themselves. They especially need to be able to trust the nurse so as to hand over the reins of their lives when things are particularly difficult for them. To this end they need to form a very special relationship based on mutual understanding, trust and respect. The patient also has need of medication and assistance with activities of daily living but as their stay usually is a long one they need as much as is possible to feel safe and at home in their surrounds. The mental health patient may also have no home, no friends or family who are interested in them, no job and no social skills. Their needs may be for someone to show them a reason to go on living, to make them feel valued and to offer a place of sanctuary. On my own placement I calculated that at any given time at least 40% of the patients needed psychiatric care but only on two occasions were patients transferred to mental health settings. As these general settings are very task orientated, fast passed condition focused places, the idea of holistic care can not be a reality at this time.

REFERENCES
Barker, P. (ed) (2003). Psychiatric and Mental Health Nursing: The Craft of Caring. Arnold: London. Bloom, A. (1978). Medicine for Nurses. (12th ed.) Churchill Livingstone: Edinburgh. Fish, E.J. (1974) Surgical Nursing. (9th ed) Boilliere Tindalc: London Roper, N. Logan, W.W. Tierney A.J. (1996). The Elements of Nursing: A model for nursing based on a model of living. (4th ed) Churchill Livingstone: Edinburgh