Nursing_Assessment_Assignment

NURSING ASSESSMENT ASSIGNMENT PART 1 This assignment will focus on a case study of a patient who was a 64 year old lady who lives in her own apartment in a warden-controlled facility. Although she had quite a few healthcare issues, the major diagnosis she had been given by her consultants was that Ann (not her real name) suffered from chronic obstructive pulmonary disease (COPD) and as a result of this she has had re-occurring chest infections. Another major health issue recently was that she had lost a significant amount of weight and was also finding it sometimes difficult to walk about unaided and had had a couple of falls at home in the last three months. The reason why I have chosen Ann as my case study is because it appeared to me her health issues were varied and quite interesting to study. Whilst I was at my primary care placement (working with Active Case Managers in the community) I had the opportunity to undertake an initial assessment on her health. I anticipated that visiting Ann at her home would be an on-going process and would offer me a great opportunity to follow Ann’s health issues throughout the duration of my primary care placement. This assignment will discuss the popular theory created by Roper, Logan and Tierney (1985) that concentrates on the activities of daily living (ADLs). I chose this theory because the assessment forms used by this particular Primary Care Trust used this model to guide the initial assessment of a new patient. The second half of this assignment will focus in more detail on the nutrition needs that Ann requires. I have chosen the Malnutrition Universal Screening Tool (MUST) (Malnutrition Advisory Group, 2005) to discuss any further medical interventions Ann may require. Nurses have acknowledged that patient assessment is the cornerstone of nursing care. However, they are perhaps less comfortable with the idea of formally taking a patient history in order to complete a patient assessment (Lloyd & Craig, 2007, McKenna et al., 2010). Nurses are increasingly being asked to undertake patient assessments as their roles and responsibilities expand. Indeed, this appears to be particularly the case for nurses working in advanced practice roles in a medical setting. A person-centred approach to assessment and care, which has become dominant in recent healthcare strategies (Department of Health (DH) 2001, DH 2009; Scottish Government Health Department, 2010), advocates that nurses who become acquainted with their patients better understand their problems and needs. This approach demands that nurses develop their history taking skills to acknowledge medical, psychological and social and domains. According to Walsh (1998) an assessment taken from a model has the strength of being comprehensive because the author will have most probably thought a great deal about the assessment and tried to ensure that the nurse has the logical and consistent framework of knowledge necessary to plan care consistent with the model. According to Dougherty & Lister (2008) medical assessment is a systematic, deliberate and interactive process that underpins every aspect of nursing care (Heaven & Maguire, 1996). It is the process by which the health care professional and patient can both identify needs and concerns and is seen as the cornerstone of individualised care. Newton (1991) suggests that the term ‘assessing’ is used in the Roper-Logan-Tierney model to describe the first stage of the nursing process, emphasising that this is an active process, and not a once-only event. It consists of collecting and reviewing information about the patient and identifying any problems, actual or potential, which are amenable to nursing intervention. Assessment therefore forms an important part of patient care and should be viewed as a continuous process (Cancer Action Team, 2007). Indeed, careful, individualised clinical assessment of health is necessary in order to provide the best available planned medical care. Clinical assessment is undertaken in a variety of ways depending on the specific health needs of the patient, their stage on the illness trajectory, and their social and institutional context (Bennett & Closs, 2008). Assessment of older people requires a varied collection of information about the biological, physical, social and psychological aspects of the older person. The assessment should enquire about physiological functioning, growth and development, familial relationships, social issues and religious and occupational endeavours (Department of Health, 2002). It is important that the health assessment includes a thorough examination of the patient’s ‘activities of daily living’. The key throughout an assessment is therefore the individual’s biography and personal circumstances. Newton (1991) suggests that descriptions of the Roper, Logan and Tierney model (1985) have been varied over the years. The model has been described as a system model (Aggleton & Chalmers, 1987), as a model that incorporates multiple theories (Thibodeau, 1983) and as an ‘activities of living’ model based on human needs (McFarlane, 1980). Farmer (1986) has described it as having a functional approach. Pearson (1983) describes it as a systems/development-based model incorporating certain concepts of Dorothy Orem’s model and the conceptual framework of Henderson’s model (Henderson, 1969). It seems fair to suggest that the Roper, Logan and Tierney model has had criticism over time. Indeed, the model has been criticized for the use of the activities of living as a simple checklist (Reed & Robbins 1991), the emphasis on solely the physical aspects of patient care (Minshull et al 1986, Walsh 1989), and the simplicity of the model (Walsh 1991). Bellman (1996) suggests that the first two problems indicate an inappropriate introduction and implementation of the model in practice. I shall now examine Ann’s nursing history based on the assessment that was completed when I first came into contact with her. Emphasis will be placed on the main medical issues for Ann, namely; breathing, diet and mobility. There will also be a discussion of any initial nursing care that Ann had received prior to me doing this particular assessment. Ann’s greatest health issue at the time of the assessment would have to be the COPD which when I carried out the assessment, had just recently been diagnosed by her consultant at the out-patient’s chest clinic she attended at her local hospital. However, she had been required to carry oxygen cylinders around with her and was using a nose cannula in the event that her breathing appeared to deteriorate throughout the day. She also was prone to developing chest infections on quite a regular basis and being prescribed antibiotics and steroids as a result of this. As mentioned in the introduction, Ann had lost a significant amount of weight recently and also there had been a significant decrease in food and fluid intake. I discussed Ann’s situation with my mentor and it was decided that a nutritional evaluation should be undertaken to determine if she was indeed suffering from malnutrition. After I had examined her medical notes it did appear that she had lost a significant amount of weight, put the weight back on and then lost it again in the past. The staff in the care facility discussed this with me and they stated that when Ann had a chest infection she was always ‘off her food’. The issue of Ann’s mobility appeared to be a concern also as the assessment I completed determined that Ann was a fall and moving and handling risk. I discovered from Ann’s son (who was her carer before she began living at the care facility) that she had a previous history of falls and now used a walking frame all the time. She appears not to be independent however, even with the walking frame and requires assistance to move around and stand from a seated position. There also appeared to be concerns for Jim when he used the toilet as he was having problems with diarrhoea one minute and constipation the next. I did not discuss it at the time, but I was thinking that perhaps he would benefit from a colonoscopy to determine if he was suffering from a health issue concerning his bowels. Perhaps in future cases like Jim’s I could talk a bit more about my concerns to other medical staff and see if they agree with me or not. A list of other health issues can be found in the list of nursing diagnoses: * Communication impaired/decreased * Confusion – at times * Coping * Diarrhoea – at times * Fluid volume deficient * Falls, risk of * Memory * Mobility – walks with aid * Nutrition, imbalanced * Pain, varying amount * Pressure ulcers, varying grades * Problems with decision making * Self-care Deficit: Dressing/Grooming * Self-care Deficit: Toileting * Skin integrity slightly impaired According to the Royal College of Nursing (2006) systematic and sensitive assessment has been a key requirement of government policy in primary health and community care. A multi-agency and multidisciplinary partnership enhances patient care, prevents the waste of valuable resources, and could have a positive impact on the whole of the health and social care system for older people. In general, outcome measurement has focused on a health gain or health maintenance score, or an overall wellbeing result (French, 1997). However, because quality of life is difficult to define and even more difficult to measure - particularly with physically and mentally vulnerable people - outcomes from nursing in continuing care are not easily articulated (Royal College of Nursing, 2004). As a result of Jim’s assessment being taken it was determined that other members of the multi-disciplinary team should be contacted. Therefore, the incontinence nurse was contacted as it was felt that this issue needed investigation immediately. There was a referral to a pain management nurse, as this particular nurse worked in the same office as the district nurses that I was shadowing. It was felt necessary to contact a dietician to get the ball rolling with regards to talking to Jim and Jim’s carers about using supplement drinks on top of the diet he already was being given in the care home. Although Jim had pressure ulcers, it was felt that these could be treated by the district nurses themselves and if necessary a tissue viability nurse would be contacted if the ulcers were to deteriorate further. The assessment that I completed appeared to go reasonably well. There was only a short time in which to complete the assessment as the district nurses had a lot of visits on the day I did the assessment. I would have liked to spend more time with Jim ton discuss his care. I also felt that some of Jim’s characteristics did not always fit neatly into the boxes of the Roper, Logan and Tierney assessment tool. This is echoed by Walsh (1998) who states that the nurse must be free to explore detailed areas with patients that do not have headings on the assessment plan. It may well be that patients want to talk about things that do not neatly dovetail with the headings devised by the author of the model. The model does not seem to take into account any spiritual or sexual matters and does not bring the issue of the patient possibly dying into the assessment. I take the stance that one must not automatically assume that a patient doesn’t want to talk about dying or sexual matters with a nurse. They may feel that the nurse is easier to talk to than perhaps, the patient’s family or a doctor and because of how the assessment form is constructed, that opportunity may be lost for the patient (Clark, 1992). PART TWO The second part of the assignment focuses on the nutritional assessment that was undertaken by me. This was done by using the Malnutrition Universal Screening Tool (MUST). According to the Malnutrition Advisory Group (2005) it is estimated that, at any one time, at least two million adults in the UK are affected by malnutrition. The more vulnerable at risk groups include those with chronic diseases, the elderly, those recently discharged from hospital, and those who are poor or socially isolated. Malnutrition in the older person is a frequent and serious problem (Chen et al, 2001) and often goes unnoticed, mistaken for signs of ageing symptoms of underlying disease (McLaren et al, 1997). Untreated it will lead to increased mortality, morbidity and influence overall well being. I think that it is important to understand a little about an older person and their nutritional input and to ask oneself so questions when carrying out an assessment using the MUST tool to determine nutrition. For example, the older person is likely to have lower activity levels and lead a more sedentary lifestyle than younger people. They are also likely to be receiving medication that may cause side effects (e.g. nausea, constipation and altered appetite) (Holland, et al., 2003). Another possible issue could be a decrease in the ability to handle food and cutlery perhaps due to arthritic hands or mental capacity, difficulty with shopping and cooking, declining oral health and ill-fitting dentures, as well as loss of senses such as taste and smell, can contribute to malnutrition in the older person. In addition, I think that it is important to have in the back of one’s mind that assessment of individual eating and drinking needs will obviously depend very much on the patient’s health problem(s) or medical diagnosis(es). Past history of their patterns of eating and drinking are an essential part of the nursing assessment. As the MUST questionnaire used in the assessment was split into five different stages I thought that using the MUST document was relatively easy and was set out in an algorithm that could be followed with relative ease by any nurse or health care professional who used it. However, as mentioned previously the assessment that I carried out was fairly rushed and I would have liked to have spent time talking with Jim about his concerns and also perhaps have a conversation with his carers or his son who, I am sure could have enlightened me about Jim’s health issues better than if I were to just fill in a form about the patient myself. I also thought that the MUST tool did not offer much scope into the depths of understanding the medical issues that were brought forward during the interview. The MUST algorithm was handy to use, but I felt at the time of the assessment that it did not offer a thorough picture of the patient’s health issues. This may work well in the community as the assessments there I found were done very quickly, but the MUST tool may fall short in providing a full picture as to the patient’s needs and does not take into account previous history of malnutrition. REFERENCES Aggleton, P. & Chalmers, H. (1987) Models of nursing, nursing practice and nurse education. Journal of Advanced Nursing, 12. Cited in: Newton, C. (1991) The Roper-Logan-Tierney Model in Action. London: Macmillan Press Ltd. Batechup, L & Evans, A. (1991) A new strategy, Nursing Times, 88(47) 40-41. Cited in: Harris, R., Wilson-Barnett, J., Griffiths, P. & Evans, A. (1998) Patient assessment: : Validation of a nursing instrument. International Journal of Nursing Studies, 24, 303-313. Bellman, L. (1996) Changing nursing practice through reflection on the Roper, Logan and Tiemey model: The enhancement approach to action research, Journal of Advanced Nursing, 24,129-138. Bennett MI, Closs SJ, Chatwin J. Cancer pain management at home (I): do older patients experience less effective management than younger patients' Supportive Care in Cancer 2009a;17(7):787-792. Cancer Action Team (2007) Long term cancer care. London: Blackwell. Cited in: Dougherty, L. & Lister, S. (2008) (Eds.) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell. Chen, C.G., Schilling, L.S., & Lyder, C.H. (2001) A concept analysis of malnutrition in the elderly. Journal of Advanced Nursing, 36, (1), 131-142. Cited in: Holland, K., Jenkins, J., Solomon, J. & Whittam, S. (Eds.) (2003) Applying the Roper-Logan-Tierney Model of Practice. London: Churchill Livingstone. Department of Health, Social Sciences and Public Safety (2002) Investing for Health,Northern Ireland: DSSPSNI. Cited in: Royal College of Nursing (2006) Nursing Assessment and Older People: A Royal College of Nursing Toolkit. London. Dougherty, L. & Lister, S. (2008) (Eds.) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell. Farmer, E. (1986) Exploring the Issues. London: Kershaw and Salvage. Cited in: Newton, C. (1991) The Roper-Logan-Tierney Model in Action. London: Macmillan Press Ltd. French B (1997) British studies which measure patient outcome 1990-1994, Journal of Advanced Nursing, 26 (2), pp.320-328. Cited in: Royal College of Nursing (2006) Nursing Assessment and Older People: A Royal College of Nursing Toolkit. London. Heaven, P & Maguire, S. (1996) Protocols for practice, applying research at the bedside. Critical Care Nurse, 22, 69-75. Cited in: Dougherty, L. & Lister, S. (2008) (Eds.) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell. Henderson, V. (1969) Basic Principles of Nursing Care. New York: Macmillan. Cited in: Newton, C. (1991) The Roper-Logan-Tierney Model in Action. London: Macmillan Press Ltd. Holland, K., Jenkins, J., Solomon, J. & Whittam, S. (Eds.) (2003) Applying the Roper-Logan-Tierney Model of Practice. London: Churchill Livingstone. Malnutrition Advisory Group (2005) MUST Scores. Bapen. McFarlane, J. (1980) Essays on Nursing. (Project papers based on working papers of the Royal Commission of NHS, No. RC2) London: Kings Fund Centre. Cited in: Newton, C. (1991) The Roper-Logan-Tierney Model in Action. London: Macmillan Press Ltd. McLaren, S., Holmes, S., Green, S. Bond, S. (1997) An overview of nutritional issues relating to the care of older people. In: Bond, S. (ed) Eating matters. A resource for improving dietary care in hospitals. Pp. 15-21. Centre for Health Services Research, Newcastle: University of Newcastle. Cited in: Holland, K., Jenkins, J., Solomon, J. & Whittam, S. (Eds.) (2003) Applying the Roper-Logan-Tierney Model of Practice. London: Churchill Livingstone. Minshull J , Ross K & Turner J (1986) The human needs model of nursing Journal of Advanced Nursing 11, 643—649. Cited in: Bellman, L. (1996) Changing nursing practice through reflection on the Roper, Logan and Tiemey model: The enhancement approach to action research, Journal of Advanced Nursing, 24,129-138. Newton, C. (1999) The Roper-Logan-Tierney Model in Action. London: Macmillan Press Ltd. Pearson, A. (1983) The Clinical Nursing Unit. London: Heinemann Medical Books. Cited in: Newton, C. (1991) The Roper-Logan-Tierney Model in Action. London: Macmillan Press Ltd. Reed J & Robbins I (1991) Models of nursing their relevance to the care of elderly people Journal of Advanced Nursing 16, 1350-1357. Cited in: Bellman, L. (1996) Changing nursing practice through reflection on the Roper, Logan and Tiemey model: The enhancement approach to action research, Journal of Advanced Nursing, 24,129-138. Roper, N., Logan, W. & Tierney, J. (1985) The Roper, Logan & Tierney Model of Nursing Based on Activities of Living. London: Churchill Livingstone. Royal College of Nursing (2004) Caring in partnership: Older people and nursing staff working towards the future. London: RCN. Publication code 002 294. Cited in: Royal College of Nursing (2006) Nursing Assessment and Older People: A Royal College of Nursing Toolkit. London. Royal College of Nursing (2006) Nursing Assessment and Older People: A Royal College of Nursing Toolkit. London. Thibodeau, J.A. (1983) Nursing Models: Analysis and Evaluation. Monterey, CA: Wadsworth. Cited in: Newton, C. (1991) The Roper-Logan-Tierney Model in Action. London: Macmillan Press Ltd. Walsh, M. (1998) Models in Clinical Nursing: The Way Forward. London: Bailliere Tindall. Cited in: Roper, N., Logan, W. & Tierney, J. (2000) The Roper, Logan & Tierney Model of Nursing Based on Activities of Living. London: Churchill Livingstone. Walsh M (1989) Model example Nursing Standard 3, 23-25 Cited in: Bellman, L. (1996) Changing nursing practice through reflection on the Roper, Logan and Tiemey model: The enhancement approach to action research, Journal of Advanced Nursing, 24,129-138. Walsh M (1991) Models m Clinical Nursing The Way Forward BaiUiere-Tindall, London. Cited in: Bellman, L. (1996) Changing nursing practice through reflection on the Roper, Logan and Tiemey model: The enhancement approach to action research, Journal of Advanced Nursing, 24,129-138. Walsh, M. (1998) Models and Critical Pathways in Clinical Nursing: Conceptual Frameworks for Care Planning. London: Balliere Tindall.