Assessment_and_Care_Planning_of_the_Adult_in_Hospital

Assessment and Care Planning of the Adult in Hospital Hospitalisation has a big impact on person’s life. When attending with people in hospital health care professionals use care planning to make sure that individual needs are met and that there is on-going personalized plan for the duration of the stay, however long or short it may be. In the course of this essay, I will be following a patient that has been on my clinical placement. I will be discussing the models and the theories that predicate nursing in my clinical area. I will be looking at two needs of my patient and state how we assess these. To abide by the Nursing and Midwifery Council Code of Conduct (NMC, 2008a), I will be changing my patient name to Tony and make sure that confidentiality is kept at all times. The patient I have chosen to study is Tony. He is an eighty five year old gentleman. He was admitted to the care of the Acute Stroke Ward in the local hospital where I had my nursing placement. Tony was admitted in Emergency Department after collapsing at home. On admission, he presented with facial droop, left sided weakness, frontal headache, slurred speech and mild confusion. According to Computed Tomography (CT scan) and other blood examination this patient has been diagnosed of having Ischaemic Stroke. Ischaemic stroke occurs when the arteries in your brain are narrowed or blocked causing severely reduced blood flow (ischemia) due to in-situ thrombus or embolus( Mant and Walker, 2011). Tony has past medical history of heart attack (MI), hypertension and type 1 diabetic mellitus. He lives with wife in a three bedroom bungalow. He is very independent with his activities of daily living. While in the hospital, Tony’s care is being managed by the stroke team which consist of doctors, stroke specialist nurses, ward nurses, physiotherapist, speech and language therapist, occupational therapist and dieticians. To understand the nursing assessment process, the author feels it is important to know what the nursing process is. Nursing process is a systematic sequence of problem solving steps to determine and to manage the health problem of patients (Timby, 2009). White (2009) states that, nursing process lays out a plan of care that guides not only the care provided but also the precise recording of that care. All good nursing care begins with assessment which is the on-going process of collecting data about patient’s responses, health status, strength and concerns ( Walsh and Crumbie, 2007).Saxon and Lillyman (2011) states that, assessment is not a one-off activity by healthcare professionals when patient first admitted in the hospital, but an on-going process that every encounter or visit with the patient will require some assessment in relation to changes in their condition, changes in their personal goals and quality of life requirements. Assessment is the first stage of the nursing process. Nursing process is the continuous collection and analysis of information about a client needs and problem and to develop plans of care in partnership with other healthcare professionals (Rosdahl and Kowalski, 2008). Effective assessment of the patient will promote the safety, continuity and equality of patient care (Dougherty and Lister, 2011a). Individuals go through different types of nursing assessment depending on their needs and priorities of care, the symptoms that have been presented, and the clinical settings (Taylor, C. et al, 2008). Viljoen (2009) states that assessment starts the time initial contact are made with the patient and continues during interview between nurse and patient. This care study used a comprehensive assessment on this particular client. A comprehensive assessment involves collection of subjective data around patient conception of his/her health of all body parts or system, past health history, family history and lifestyles, and also health practices which consist information related to patient overall function as well as objective data gathered during step by step physical examination (Webber and Kelly, 2009). Comprehensive assessment provides baseline patient data including a complete health history and current needs assessment (White, 2005). In every admission in the ward where the author base, there is an assessment booklet called “Adult Admission Assessment Booklet” that has been used to assess patient. This booklet contains ten (10) parts in assessing the different needs of the patient. The first part of this booklet is called special risk which is mandatory to fill in for every patient. The information contained on this page consists of MRSA status, allergies, latex sensitivity, bacterial status and it also includes any special needs and implanted devices. The purpose of gathering data is very essential as this highlight risks which patient could encounter during different procedures carried through by member of staff. And also on the information given, it will keep patient risk of infection and risk of allergic reaction to its minimum. The second part of the booklet is the Patient Summary. On this page, the information includes personal details, next of kin details, consultant name, diagnosis, reason of admission, past medical history and expected date of discharge. This part of the assessment provides personal information of the patient. This gives nurses a quick and precise synopsis of patient present and past medical conditions which is important in care planning. The third part of the booklet is called “Activities of Daily Living (ADL) which is based on Roper-Logan-Tierney model of care. This model is base mostly upon the activities of daily living. The ten activities of daily living were incorporated on this booklet, which are: communication (cognitive impairment, language spoken, hearing), breathing ( if patient is smoker or problem such shortness of breath, congestive obstructive pulmonary disease), pain, personal hygiene ( is patient independent'), nutrition (any special diet, food allergies, nil by mouth), elimination ( does patient use laxatives, catheter), emotional needs, fears and anxiety due to illness, diagnosis or procedures, sleep patterns and medications. Lawson and Peate (2009) states that The Roper-Logan-Tierney model assess the individual’s respective independence and probable for independence in activity of living keeping in mind their lifespan, development and the five key factors on a continuum raging from full dependence to complete independence in order to specify what interventions will lead to increase independence in addition to what on-going support is or will be required to compensate for dependency. Comparing Roper-Logan-Tierney to other model such as Orem’s model, the latter gives more emphasis on helping with their daily activities and is very committed to holism while Orem’s theory talks about self-care and how patient try to help themselves (Funnell, Koutoukidis and Lawrence, 2008). The Roper-Logan-Tierney nursing model will use in Tony’s care because it is more holistic approach to nursing. The fourth part of the assessment booklet is patient social history. I ask the patient question about the type of accommodation where patient lives in, if they get any social support and other benefits provided by the community which in turn all information gather will be used in all arrangement before discharge. The fifth part is “The Fast Alcohol Screening Test (FAST) this is where I ask patient about their alcohol drinking habit. If in this test a patient scores 3 points or more it qualifies them as a hazardous drinker. Then they in turn refer to drug and alcohol liaison nurse. The next part will about pressure ulcer risk assessment- “Water Low Score”. There is a scoring system determined by different risk factor including patient age, weight, continence, mobility, medication and neurological deficits. If the score is more than 10, the nurse needs to start an adult pressure area care records. In addition, pressure relieving equipment needs to be prioritized. The seventh element in the booklet is the “Nutrition Screening Tools”. This part identifies adults who are malnourish and people which dietary difficulties. The eight element of the booklet is the “Pain Assessment”. The pain assessment in the booklet is derived on the numerical, verbal and visual score. The next element of the assessment booklet is the “Moving and Handling Patient risk Assessment”. When initiating this assessment the following needs to take into considerations: reduction of mobility due to age, illness and medications. Patient psychological state and level of assistance needed with mobility are assessed by the nurse. The staff nurse must also determine moving and handling task that is applicable to patient needs. A total risk score will determine how safe to move the patient and how many staff require to mobilise the patient. There should be a systematic review of patient mobility if their condition improves and reassessment must be done. The last element of the assessment booklet is the “Patient Risk of Falling”. Nurses must accumulate information about patient fall history, mobility and cognitive impairment in which in turn will give nurses indication how likely the patient will have a fall. The two health needs that the author will be focusing are mobility and nutrition. The author will be discussing the different assessment that’s been used to identify the patient needs. The first issue of this patient is mobility. Holland et al (2008) states that mobility is the movement generated by groups of muscles, enabling people to stand, sit, walk, and run as the same time as groups of smaller muscles generating movements such as those involved in manual dexterity or in facial expressions, hand gesticulations and mannerism. Sirven and Malmut (2008) also states that mobility refers to sequencing, scaling and timing of muscle or contractions and play a role in body positioning along with posture and alignment during standing and sitting. Impaired mobility is a state which an individual has restricted ability for independent physical activities (Halloway, 2004). The deficits and disability resulting from stroke severely impact all aspects of patient life. The patient may suffer from shock, irritability, loss and grieving, a sense of losing their role in the family, social isolation, mood changes, depression and problem with communication (Medifocus, 2011). A stroke which affects the brainstem can cause function disorders involving cranial nerve which can cause altered sense of taste, impairment of hearing or visual, drooping eyelids (ptosis), paralysis of the ocular muscles, attenuation of defence reflexes, for instance gagging, and swallowing reflexes, pupil reflexes in response to light, numbness in the face and weakening of the facial muscle (one side of the mouth droop), difficulty sustaining the balance, it also altered breathing and heart frequency and paralysis of sternocleidomastoid muscle which affects the proper turning of the head and the tongue muscle (Mehrholz, 2012). While Tony is in the ward, he showed left sided weakness, facial droop and swallowing problem. On the initial assessment of the physiotherapist showed that the patient has lost his balance and coordination. Physiotherapist used the Modified Rivermead Mobility Index to show the plan of care for Tony. The Rivermead Mobility Index tells how much help the patient needs and plan of care with regards to their mobility (Pryse-Philips, 2009). Within the mobility index it include the task such as patient turning in bed; from lying to sitting; sitting to standing; standing; transfers; walking indoor; and if they can walk to stairs. Each of this task has a corresponding score key which are: 0- means unable to; 1- means assistance of 2; 2- means assistance of 1; 3- means supervision with verbal instruction; 4- means needs aid or appliance; and 5 is independent. According to the rivermead mobility index, Tony scored 1 for each task besides the stair which he scored 0. He has a total score of 7 which means he needs assistance of 2 staff. The Nursing and Midwifery Council (2008b) states that nurses must support people in caring to enhance and manage their heath. NMC (2008c) also states that nurses must deliver care based on the best available evidence or best practice. I was asked by the nurse to monitor Tony’s neurological observation every two hours, it relates to the evaluation of the integrity of individual’s nervous system. Neurological functions assess by observing five critical areas; these are level of consciousness, pupillary activity, motor function, sensory function and vital signs (Dougherty and Lister, 2011b). I was also asked by the registered nurse to put this patient on turn chart. It is essential to turn Tony at least every two hours because patient may not feel increases in pressure or have the ability to adjust their position while in bed. The loss of motor control can contribute to abnormal posturing (Porth, 2010). Repositioning also help prevent pressure sore (Romanelli, Clark and Cherry, 2006). The nurse also placed this patient on air mattress to reduce the risk of pressure ulcer and promote comfort. The staff nurse also encourage patient to perform active and passive range of motion exercises in all extremities several times a day, this exercises preserve muscle strength and prevents contractures mostly in spastic extremities (Kozier et al, 2008). Before we do any nursing interventions we always asked patient consent. Nurses and myself assisted Tony’s in performing movements and task, beginning with the tasks that require a small range of movements and encourage control such as sitting upright and maintaining balance. After the patient stayed in ward for a week, Tony’s condition improved vastly. I was asked to refer this patient to physiotherapist for re-assessment. The second need that I will be discussing is Tony’s nutrition. Nutrition is important part of human existence. Ingested food is essential as an energy sources or fuel from which cells can produce adenosine triphosphate (ATP) to consummate particular energy dependent activities such as transport, contraction, synthesis and secretion (Sherwood, 2011). In assessing nutritional status of the patient who is admitted to hospital must be systematic. Nurses are requires to use valid tool in assessing patient nutritional needs. On admission nurses must gather basic information about the patient that includes patient weight and height, ability to eat, dietary requirements and food allergies, religion and cultural needs. The Nutritional Screening Tool that has been used on Tony assessment is based on Body Mass Index (BMI) weight loss and illness score. The first step is to obtain the current weight and height of Tony to establish his Body Mass Index (BMI) and identify whether he had weight loss in the last 3 months. The next steps are to know patient appetite, his ability to eat and also information on stress factor that might affect his nutrition. There are relevant score from each section, for example with regards to his ability to eat, the relevant score means; 0 point for independently feeding self, no diarrhoea and well hydrated; 1 point for problem with handling food, frequent regurgitation or mild diarrhoea; 2 point for difficulty swallowing, requiring modified consistency, problem with dentures; 6 points for unable to take food orally, unable to swallow (dysphagia), and with each relevant score the nurse can categorise the patient whether they are high, medium and low risk of choking. Tony scored 6 points on the assessment which is high risk and an appropriate care plan is set to meet his nutritional needs. In accordance to his plan of care, he was referred to speech and language therapist and dietician via hospital system. The nurse also carried out simple bedsides swallow test using a recognised assessment tool to identify Tony’s swallowing problems as advised by Intercollegiate Stroke Working Party (2008). Patient swallowing needs to be assess by speech and language therapist within 48 hours, if patient still unable to swallow after that allocated time, clinician will start patient on nasogastric feed. The dietician will complete the caloric and protein needs of the patient according on his/her medical condition (Morris, 2011). Nasogastric tube feeding is used to supplement feeding of individuals of all ages who have swallowing or feeding problem (Gates and Barr, 2009). It provides the means by which a naturally adequate diet can be provided directly into stomach by passing the oral route (Best, 2011). Patient nutritional status needs to be continuously monitored and reviewed. The assessment must be done and recorded weekly on the nutritional screening tool (Royal College of Physician, 2002). There are a numerous nutritional tools that have been used in the past, however some of them have been questioned due to their reliability and validity. There are limitations to previous tools which were not cost effective, time consuming and complicated that change has to be made and retest for sensitivity, make them simple and easy to use (Jones, 2005). The last part of this essay is to reflect on my inter-professional skills which relate to the care planning and delivery process. Reflection is the process of internally analysing and exploring an issue generated by an experience which creates and clarifies meaning in terms of self and which results in a changed conceptual perspective (Hart, S., 2010). As a process, reflection is initiated in order to gain understanding, insight and new knowledge about practice (Mckenna, 1997). Working at Acute Stroke Unit with experience mentor and nurses, I was able to assimilate the importance of using appropriate nursing assessment and care planning in patient with stroke. I was able to accompanied patient from admission process to his assessment and care planning, and was able to identify care needs of this patient. From the whole assessment process, I gained better understanding and became familiar in using the different tools that has been use in the hospital in particular the ones that was in Tony’s assessment. My knowledge about the nursing process that takes place has increase, taking into account that assessment process is individualize in each person. The author displayed that nursing assessment is an important part of nursing role, it is a holistic, based on available knowledge and nursing skills. 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