In this assignment I will present a patient I have cared for during one shift on my placement ward. Using the Holland et al (2008) Roper Logan Tierney model of care which focuses on the activities of daily living a description of care received by the patient will be outlined. Any reference made to the patient is under pseudonym and referred to as Mrs Oni to protect the patient confidentiality according NMC Code of conduct (2008). To comply with guidelines set out by Department of Health (2009) full verbal consent was first obtained from the patient before any information was used in this assignment.
My placement was in abdominal and orthopaedics surgical ward were patients were routinely admitted from accident and emergency and prepared for surgery and admitted after surgery. I have chosen a 33 year old female patient admitted to accident and emergency department and then to the ward with acute lower abdominal pain and later had non elective surgery for appendicitis.
It was my duty under the supervision of my mentor, during this shift to monitor and maintain internal and safe environment, communicate and encourage patient to mobilise and wound management. The assessment tools utilised to create a care plan according to priority are those implemented and used by the trust. All activities discussed will be reflected upon as part of personal and professional development.
Mrs Oni is a married mother with two children under the age of ten. She is a health support worker and is employed full time. Mrs Oni complained that the pain started at the umbilicus region and then later the pain intensified at her right lower abdominal quadrant. When she was admitted upon examination by the general surgical team it was reported that her abdomen was tender and gardening. Other symptoms presented included constipation, nausea, fever and loss of appetite which all common to the condition.
Patient had past medical history of being treated for urinary tract infection to rule out this as a possible reoccurring cause a urine analysis was performed and sent to microbiology testing and further analysis. Bloods were also taken to check for raised neutrophil (white blood cell) count. No previous history of abdominal pain, aggravating factors, patient felt relief when lying down with knees pulled up, presented no urinary symptoms, no alcohol consumption, and patient is not on any medication. On observing Mrs Oni she appeared anxious and was tired due to pain.
When the patient was assessed using interview skills and attempting to form a therapeutic relationship with the patient it was revealed that Mrs Oni wanted to maintain a traditional African diet rich in fibre with lots fruit and vegetables, but found it hard to find time to prepare the meals and replaced it with unhealthy snacks while at work and didn’t eat at regular meal times. She also revealed that she did not get much exercise and weight gained plummeted after her second child.
Oxford dictionary for nurses state that the appendix is ‘the short thin blind ended tube, 7 â€“ 10 long and is attached to the end of the caecum’. The caecum is the first part of the large intestine according to Clancy & McVicar (2002) appendicitis occurs when this tube becomes filled with faecal matter and or with other debris. It can also occur if the caecum is obstructed resulting in damage and blockage to the appendix. In both cases inflammation occurs which can cause rupture of the appendix and appendectomy surgery is required to stop other bowel and abdominal inflammatory conditions developing.
I have chosen this patient because NHS Choices (2012) states that appendicitis is considered to be a common condition and that around 7% of UK population will develop the condition at some stage in the lives. It also states a lack of fibre in in diet can be a cause for the condition. I have also formed a good therapeutic relation with the patient.
USING ROPER LOGAN TIERNEY MODEL
Cronin & Rawlings-Anderson (2004) cited Walker & Avant (1995) who described practice theories as goal oriented actions.
Llewellyn & Hayes (2008) describes the model as an aid in assisting and measuring the patient’s ability to achieve independence at each stage of care. All 12 activities include, maintaining a safe environment, communication, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying. All activities according to Holland et al (2008) are used as a framework for the assessment, planning, implementing and evaluating process in the provision of care.
Maintaining a safe environment is one example of how the activities can relate to patient care. Diamond (2011) uses the care setting as an example how a person human rights can become easily compromised. The Human Rights Act (1998) article 3 states that ‘No one shall be subjected to torture or to inhuman or degrading treatment or punishment.’
This clearly illustrates that the environment in which a patient is care for should be maintained to ensure patient physical, mental and psychological wellbeing while also reducing the risk of infections. The Roper et al model of care is therefore a useful tool for ensuring that all patient needs are considered. Holland et al, (2008) also includes care for the internal environment that which is on a cellular level. This aspect forms a very important part of the recovery process for the case study patient Mrs Oni.
ACTIVITIES OF DAILY LIVING FRAMEWORK OF CARE
Chinn & Kramer (2008) argues that a nurse’s action can help to improve patient experience by using their awareness and theoretical knowledge in situations, thus dislodging patient fears about situations that are new to them.
The handover received for Mrs Oni described the patient sleep patterns throughout the night, stated the analgesics; paracetamol and tramadol prescribed for pain, discussed patient mobility, discussed patient intervention that was the physiotherapy sessions which were required for chest exercises, wound care discussed where surgical clips removed from the wound sloughing observed and surgical team notified as a result antibiotics now prescribed eight hourly and stated wound dressing needed to be changed and catheter to be removed.
Although the assessment of the patient was received from a secondary source in handover the patient care still needs to be assessed in order to establish care priority for the patient. Holland et al, (2008) assessment is therefore the first stage in the process where the nurse uses communication skills to gather to begin planning care for the patient.
On assessing Mrs Oni it was found that she was still feeling tired after getting a full nights rest. While listening to the patient it was observed that her speech was quiet and chest movements were irregular. The pulse oximetry machine was used to further assess the levels of oxygen in the patient. Correctly using the equipment making sure the patient was not wearing nail polish which can alter readings.
The diagnosis with the reading confirmed that Mrs Oni was lacking oxygen. The normal range for the baseline measurements are charted out using the Glasgow Coma Scale used by the trust. It indicated that reading above 94% is considered within the normal range, Mrs Oni reading were 93%. It was decided that oxygen therapy was needed.
A second intervention after the oxygen therapy was reassessed and had improved the patient breathing was made to prevent secondary infections the physiotherapists work with Mrs Oni, to teach her deep breathing exercises to avoid developing chest infections. The use of communication in assisting Mrs Oni by first providing a vomitus bowl and tissues as needed with the nurse explaining to patient why it was important to expectorate any excess sputum while giving the nurse the opportunity to inspect colour of sputum for signs of infection, according to Basford & Slevin (2001) this reduces the chances of developing other complications.
Mobility according to Perry & Potter (2004) is affected by events and nursing intervention can improve body function and ability to recovery. NICE clinical guidelines (2010) to encourage hydration and mobility to reduce risk of venous thromboembolism (VTE). This condition according to Clancy & McVicar (2002) is where clotting occurs in the veins and affects patients who have had abdominal surgery and experienced child birth.
The surgical team did prescribe some prophylaxis treatment anti-embolism stockings which are referred to as TED stockings. However, the patient refused to wear them and has a right to do so according NHS Choices (2011) under the Mental Health Capacity Act 2005 which advises that a person has the right to voluntarily refuse treatment.
On assessing the patient no real barriers to mobility was observed and with improvements on the patient breathing and fatigue levels, knowledge of psychological issues was required to further diagnose the patient.
Using communication skills to form a therapeutic relationship as an intervention, Mrs Oni revealed that she was very worried about her children, she became tearful but discussing her children helped to remind her that she need to recover quickly to get back to her family and home. She was able to later agree to wear the anti-embolism stocking and began to attempt to mobilise without assistance. Another nursing intervention used to aid Mrs Oni in mobilising was to administer prescribed analgesics for pain management thus reducing the effects of the surgical wounds present.
Personal Cleansing and dressing
Mrs Oni had a wound had become infected and needed to take meropenem by intravenous infusion which according to BNF (2012) an penicillin antibiotic prescribed for intra-abdominal infections, skin and soft-tissue infections. Mrs Oni stated she was not allergic to penicillin upon admission but the side effects from the drug were likely to be nausea, vomiting, diarrhoea, abdominal pain and headaches. According to BNF (2012) patients most at risk of developing anaphylactic reactions are asthma, eczema and hay fever sufferers.
On inspection of the wound while changing the dressing it appear to be less exudate. On previous dressing change I was reported that there was some sloughing which is according to Perry & Potter (2004) pg. 1278 are tissue cells that have died and have been removed from the body. Cleaning of the wound using the aseptic technique and new dressing were applied. Mrs Oni was then assisted with her personal hygiene needs and expressed that she was feeling much better. These actions taken will help to improve body image and reduce risk of prolonging the infection.
Although not mentioned in the handover it is still an effect experience after surgery. The tool used to measure pain is done using a numerical rating system with a scale rating pain from 0 to 10. Zero being there is no pain and ten being the highest value Indicating intervention needed. Perry & Potter (2004) p.1274 definition of pain, ‘subjective, unpleasant sensation caused by noxious stimulation of sensory nerve endings.’ This notion that pain is subjective is very true as each individual experiences pain in a different way according to Ewards R. article in Benzon et al (2005) pain can also be measured through observing behaviour. Mrs Oni did report pain and the prescribed analgesics were given as prescribed. Upon evaluation it was verbalised by Mrs Oni that she was in less pain four hours an hour later after administration.
The important aspect of the reflective process is to develop critical thinking skills which according to Jasper (2006) helps to develop the ability give clear rationales when making decisions. Reflecting using Gibbs et al (1988) cited by Bulman & Schutz (2008) cycle where a series of reflective questions to be thoughtfully answered in retrospect which begins with the experience, a description of feelings, taking in account the positives and negatives, looking at the situation from different angels, what else I could have added to improve the outcome and finally the actions taken. Using the experience of caring for someone post-operative using the Roper et al, framework of care was a good teaching guide and created self-awareness of the process while helping to give a structured framework to gather knowledge in a way that was useful. I felt more comfortable and confident in discussing issues with my mentor on issues of care. The environment was very challenging but the framework help me to focus and achieve my objectives.
Evaluation of care using Llewellyn & Hayes (2008) uses Huycke and All’s (2000) framework that encompasses all involved in the provision and receipt of care. The ward provides a comment card for patients, this way the immediate providers of care the staff receive instant and genuine feedback. This shows the patient experience is valued.