Nursing Case Study

The aim of this study is to provide a detailed account of the nursing care for a patient who is experiencing a breakdown in health. One aspect of their care will be discussed in relation to the nursing process. The model used to provide an individualised programme of care will be discussed and critically analysed.

Jack, the patient presented through Accident and Emergency to Ward D3, an acute medical ward specialising in respiratory medicine. He was admitted due to an exacerbation of dyspnoea, which was more significant over the last twenty-four hours. The writer met Jack on admission to the ward.

Jack a 58 years old engineer, is divorced with one daughter. Jack is a smoker for the past thirty years; he smokes twenty cigarettes a day. He has a family history of lung cancer, his father died two years ago from lung cancer. Jack has a four-year history of dyspnoea. He has also experienced a persistent cough, productive of a small amount of yellow stained sputum. The cause of these symptoms had not been determined, as Jack has not visited his general practitioner in fifteen years. In the twenty-four hours prior to his admission, Jack noticed a considerable increase in his symptoms, he was now dyspnoeic at rest and could not mobilise as it caused him considerable respiratory distress. Jack called his daughter who in turn accompanied him to hospital.

The model used to plan Jack’s care was the ‘Activities of Living Model’ developed by Nancy Roper, Winifred Logan and Alison Tierney (1980). It is the model used on the ward as it facilitates individualised and holistic nursing care. In conjunction with the nursing process it is possible for nursing interventions to be planned, implemented and evaluated following the initial assessment with the patient to identify actual and potential problems for each of the activities of living. The initial assessment provides a baseline for future assessments, as assessment is an ongoing activity, beginning on admission and continuing until discharge. From the initial assessment breathing was identified as a problem for the patient. Other problems were identified however; due to the confinements of this assignment breathing will be the only problem discussed.

Breathing is perhaps the only activity of living that most individuals perform independently throughout their entire lifespan (Roper et al., 1980). We inhale to obtain oxygen and exhale to expel carbon dioxide. Gaseous exchange occurs within the alveoli of the lungs, the respiratory organs. The mechanism of breathing is an involuntary action controlled by the autonomic nervous system. Oxygen is essential to maintain life, as it is required on a cellular level for aerobic respiration from which energy is obtained. In order to plan the care Jack is to receive, a comprehensive assessment of his breathing needs to be obtained. The nursing process is an organised, systematic method of delivering care that enables individualised care to actual problems or to prevent problems (Alfaro 2001). The patient is individually assessed from which an individualised care plan is formulated and implemented.

The purpose of the assessment was explained to Jack. Firstly, subjective data was obtained from Jack. His usual breathing habits were established to be that he normally suffered from dyspnoea. Dyspnoea is not measured objectively; it is the individual’s subjective perception of abnormal or uncomfortable breathing (Hodge and Morgan 1998). The factors affecting breathing were the presence of a productive cough and Jack’s history of smoking. Jack acknowledged that the dyspnoea has affected his living arrangements at home. He was not able to manage to get up the stairs; consequently he had been sleeping downstairs on a sofa bed for three months. It had also affected his personal hygiene as he also found this difficult since the bathroom was upstairs. Objective data was then collected by the nurse, which included Jack’s vital signs. It was apparent at the time of assessment that Jack was experiencing difficulty with his breathing. The rate, depth and pattern of Jack’s respirations were recorded for a full minute to provide an accurate recording (Mooney 2003).

The oxygen saturation was recorded to be 84% on air using a pulse oximeter. The nursing goals planned for Jack were: that his breathing would be within his normal limits, for his oxygen saturations to be maintained over 90% and for his cough to be less problematic. To assist in achieving these goals Jack would be fully involved with the planning of his care. The nursing and medical staff would perform lung function tests to determine the cause of his symptoms. It was ensured that prior to any medical test detailed explanations would be given to Jack. Hayward (1975) suggests that information given to and understood by the patient can aid to reduce anxiety. He was commenced on prescribed humidified oxygen therapy at 24% when required to alleviate attacks of acute dyspnoea.

A referral was made to the physiotherapist for chest physiotherapy, which would facilitate the clearing the lungs of accumulated mucus. As Jack was experiencing difficulties maintain his hygiene, it was planned to assist Jack in achieving his personal hygiene needs. He was provided with the facilities daily for personal cleansing at his bedside. To ensure Jack’s privacy and dignity the curtains were closed whilst he washed. Jack was advised on how to use the nurse call system to request help if required. It was ensured that his personal items and the nurse call were assessable. Clean pyjamas were provided.

The care given was initially evaluated daily until Jack’s symptoms improved. This is to ensure that the appropriate care is given and to plan for any further problems that may occur.

The cause of Jack’s symptoms was determined to be that he was suffering from moderate chronic obstructive pulmonary disease (COPD). Jacks observations were recorded every four hours including oxygen saturations and respiration rate to determine whether Jack’s normal breathing pattern had been achieved. Initially this was not being achieved therefore the planning stage of the nursing process was revisited. It was planned that Jack would be nursed in an upright position supported by pillows to assist optimum breathing. This position ensures the best possible chest expansion unhampered by the pressure of the abdominal organs under the diaphragm (Comroe 1965). Due to his recent diagnosis, Jack was prescribed two bronchodilating inhalers Combivent (short acting) and Serevent (long acting). They work by expanding the airways to prevent and relieve symptoms of COPD.

This consequently led to further planning to Jack’s care. The plan was for Jack to demonstrate effective inhaler technique. To achieve this goal firstly, Jack would have to be informed of the reasons why the medication was prescribed. Secondly, he would have to be taught the appropriate technique. A registered nurse did this and Jack was observed when he was using his inhalers until his technique was satisfactory. Jack’s medication regime was explained to him. Poor understanding does not only interfere with the patients cooperation in his treatment, it can also lead to emotional problems that may hinder his return to health (Dodge 1994).

An arterial blood gas (ABG) sample was collected from Jack to evaluate and monitor his COPD. It determines the effectiveness of oxygen therapy to ensure that the patient is not retaining carbon dioxide. The results of the ABG did not require further planning to Jack’s care. The Activities of Living model used to plan the patients care will now be described and critically analysed.

Nancy Roper developed a conceptual model for nursing in 1976 from a study into the clinical experiences of student nurses. She based her model on a ‘model for living’ since nursing is a requirement at only certain times in an individuals life. The model was derived from Maslow’s Hierarchy of Needs (1954) and the work of nursing theorist Virginia Henderson (1996). Henderson identified fourteen ‘activities of daily living’. Roper in turn identified an original sixteen. Roper, Logan and Tierney subsequently elaborated upon the model in 1980. Roper et al developed Henderson’s concept into a model that focuses on twelve activities of living that are fundamental to an individual’s existence irrespective of age.

The model is made up of five concepts which are: activities of living (AL’s), Lifespan, Dependence / independence continuum, factors influencing AL’s and individuality in living (Appendix 1).Within the model four assumptions are expressed. Firstly, an individual is perceived to engage in living from conception to death i.e. the lifespan. During the lifespan an individual fulfils AL’s that are essential to maintain life as well as those that improve the quality of life. Secondly, during the lifespan, an individual progresses along a dependent / independent continuum. Thirdly, internal and external factors influence the dependence / independence of an individuals ability to perform AL’s. Finally, the ability to perform AL’s influence nursing interventions, they form the basis of the care given.

Within nursing there are four basic concepts identified. These influence the development of nursing theory and its application to practice. They are: the individual, health, nursing and the environment collectively referred to as the four metaparadigms of nursing (Northern Arizona University 1998). Within the model individuality of a person is demonstrated in the manner to which they perform the AL’s. The model is centred on health, ensuring that nursing is more than a list of signs, symptoms and treatment of disease. Roper el al considers a model to concentrate on disease in inappropriate for nursing. External and internal factors influencing the performance of the AL’s are recognised. The environment is defined only in the context of its effect on the individual and the effect it would have on the performance of the AL’s (Newton 1991). In developing the model, Roper et al state they were anxious to that the model would be free from jargon in the terms that it used. This was achieved in that the model is articulated in a language familiar to nurses. The model is concise and easy to recall (Roper et al. 1986)

Nursing is well defined. Nursing is only required when an individual is unable to fulfil an activity independently. The role of the nurse is to facilitate independence in relation to the AL’s. However, no method is provided to measure the level of dependence is indicated within the model to assist the planning and evaluation of care. Roper et al suggest that nursing intervention should focus on the patient’s normal routines. Aggleton and chambers (2000) suggest that in the implementing stages should endeavour to minimise the dependence of a patient to seek responsibility for self-care.

The assessment of the AL’s, obtains a wide knowledge of the patient is this encourages a holistic approach to patient care. Roper et al believe that the model focuses on not only what the patient is unable to do but that it also emphasises what the patient can do. However, Aggleton and Chalmers (2000) state, that attention is focused on an individual in terms of the activities they perform giving credence to theory that social and cultural determinants contained in the model centre attention on negative not positive attributes. Rouke (1990) agrees with this opinion saying that the model falls into a trap of reductionism, leading to a dehumanising process. The whole person is separated into twelve fragments, each of which is viewed from a negative point of failure to achieve.

The absence of psychological or social dimension to the model has been criticised (Rouke 1990). Emotions and fears, anxiety and stress attitudes and beliefs are not covered. Roper et al argue that the model does not need to exhaust every aspect of a subject. They assert that sociocultural, psychological and environmental have been considered. Pain is not listed as one of the AL’s. The consideration to pain is limited to dysfunctions which may precipitate pain under the heading each of the AL’s. It demands a questioning approach as to signs and symptoms affect each individual AL’s.

The model is patient centred, it advocates partnership between the nurse and the patient with regards to planning care.

In conclusion, the care of the patient has been discussed in relation to the nursing process. The stages of the nursing process are closely related and it is of paramount importance that a comprehensive assessment of the patient is obtained. The purpose of a model is to provide comprehensive and congruent assessment of the health care needs of the patient by which to base nursing care. Nursing staff can collaborate following the same agreed outcomes and philosophy to provide consistency with relation to care. The Roper, Logan and Tierney model was designed to be used as framework for the nursing process (Roper et al 2000). The activities of living component is supportive and logical for nurses to apply to the stages of the nursing process that encourages consideration of the patient in a holistic approach.