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Care study

Care Study

I recently completed a placement in the community, and decided it appropriate while there to focus my care study assignment on leg ulcers as I witness various chronic wounds being assessed and dressed and wished to acquire more knowledge on the subject. Chambers et al, (1996) suggests that chronic leg ulcers present a large problem to nursing today. My care study will focus on one particular lady who was suffering from a venous leg ulcer. For the purpose of this case study I will call that patient Miss. A, as a nurse has a legal, professional and ethical duty to protect all confidential information concerning patients by recognizing the primacy of the patient and practice in an ethical and legal framework (NMC, 2002). The patient gave informed consent and agreed to be involved with the care study after being given adequate information and given time to decide whether or not to agree to be written about. It was discussed and explained that the care study would involve the condition of the patient, assessments, prioritise the needs which arise and contribute and develop a plan of care. This would be done by assessment, planning, implementing and evaluating which is the constant cycle of the nursing process. (Alexander et al, 2000).

Miss A is an elderly lady who has lived with her sister for many years; she has limited mobility and relies on her sister for most of her care. Miss A is a very private woman and required encouragement from her sister for the nurse to attend to assess her wound which was thought to be a leg ulcer, she also felt generally unwell.cocf cfr secfcfw orcf cfk incf focf cf.

Leg ulcers cost the NHS approximately £400m per year and is estimated that at any one time 100,000 individuals will receive treatment for this condition in the community, which remains to be the most frequent encountered wound that community nurses are called upon to treat (Williams, 1996). A leg ulcer is defined as a loss of skin below the knee on the leg or foot which takes more than six weeks to heal, the occurrence of leg ulcers increases with age and is most common in women (Watson, 2002).

The underlying cause of a venous leg ulcer is poor venous return which can be recognized by oedema, skin pigmentation and are usually flat (Watson, 2003). It is important that this type of ulcer is assessed by the use of a Doppler test (Maylor, 2002). The nurse must check that the patient is complying with recommendations: elevation of the limb to prevent oedema and aid venous return, exercise and compression bandages/stockings. Chair bound patients are encouraged to strengthen the calf muscles by moving the feet up and down, this action also helps to pump the blood up the vein. On no account should the patient stand or dangle the limb for long periods without moving (David, 1986).

The management of leg ulcers is divided into three stages: assessment, treatment and prevention, the most important being assessment, as it is a vital first step in treating all types of leg ulcers as the district nurse is the primary nurse and has sole responsibility for deciding which type of ulcer is present and what dressing to use (Pudner, 1997). Primary nursing care is when the nurse has total responsibility for the planning, delivery and evaluation of care for the duration of the patients care (Pearson, 1988). Visit coursework bf in bf fo bf for bf more writing bf Do bf not bf redistribute

The District Nurses I was working with used a care pathway which had been modified for community use; care pathways are holistic multidisciplinary plans which predict the course of events in the treatment of patient's problems. These events must be specified on a timescale, and all incidents, actions and interventions must be identified (Reinhart 1995). The Roper Logan and Tierney's Activities of living model of nursing was used as a basis for her assessment of the patient. This can be viewed as the first stage of the Nursing Process; assessment, planning, implementing and evaluating. This assessment sheet outlines the client's actual and potential problems with regard to daily activities; the assessment is also about collecting data and communicating with the patient. It is widely used as it is looked upon as a holistic model and suggested that it is not merely a checklist but a guide to enable a nurse to care for a patients needs effectively. (Gilling, 1996) However all information documented is confidential and nurses are accountable for any entries made by them (NMC, 2002) Documentation is often targeted by nurses because of the increasing amount of paperwork involved, which nurses feel is limiting the amount of time a nurse can spend with each patient (Brindle 1998). However nurses must always bear in mind the reasoning for this as litigation with regard to health care is not uncommon (McHale 1998). Any nursing document can become a legal document, if requested by a court of law therefore it is essential that medical staff follow legislation and good record keeping (Young, 1995). The NMC (2002) has a booklet entitled 'Guidelines for records and record keeping,' designed to guide nurses in their documentation. The NMC (2002) also has booklets on professional code of conduct highlighting the importance of responsibility and accountability. This gives nurses guidelines ensuring they understand the implications of their actions and working within their own limitations. Therefore whatever intervention a nurse is using she must be able to justify the rationale for its use, have evidence based knowledge about intervention and be able to react in a professional manner if adverse effects occur.

Miss As initial assessment showed that she required support for her medical condition (leg ulcer), emotional support and encouragement of independence. It was also established at this point that Miss A had some years ago been admitted to hospital after suffering from a Myocardial Infarction, and continued to suffer from angina. Although this was not a priority at this point as her angina was stable I felt it appropriate to gain knowledge on this subject.

More than 1.4 million people suffer from angina and 300,000 have heart attacks each year, which makes Coronary heart disease (CHD) one of the biggest killers in England (DoH 2000). For this reason The National Service Framework for Coronary Heart Disease (DoH 2000) introduced 12 standards to ensure that patients would receive equal access to services and equal standards of care, regardless of postcode. Also when providing care for patients it is important to work in accordance with the Public Health Strategy. The Department of Health (1999) document, Saving lives: our healthier nation is a government action plan to tackle poor health and inequalities in health. One of the targets in this plan is to reduce the death rate for coronary heart disease in people under the age of seventy five by two fifths by the year 2010. An effective cardiac rehabilitation programme can reduce mortality rates by lessening the risk of problems reoccurring and can significantly improve patients' quality of life (Jones & West, 1995).

Myocardial Infarctions occur when one of the coronary arteries which supply the heart muscle is blocked by a clot. As a result, part of the heart muscle is starved of blood and oxygen which causes it to become damaged. Myocardial refers to the heart muscle and infarction to the blockage, The narrowing of the coronary vessels is often a gradual process which could have been going on for years and is often linked with 'risk factors' such as smoking, high blood pressure, high blood cholesterol, physical inactivity and being overweight.
Research has also shown that people who have a family history of coronary heart disease (CHD) are at a greater risk of developing CHD. (BHF, 2002).

Miss A did indicate that she had never exercised much throughout her life, and leading a busy life she was not always able to stick to a healthy diet. Early health promotion and education is essential to change people's lifestyle in order to reduce the risk of coronary heart disease (Naidoo & Wills, 2000). However Miss A still did not participate in any exercise and ate an unhealthy diet.

On examining Miss As wound it presented generalized oedema, exuding and was shallow with diffuse edges. It was recommended for Miss A to lie down on her bed for one hour and the nurse and myself would come back to carry out a Doppler test. A Doppler ultrasound assessment is usually performed after the initial assessment, when it is thought that the ulcer is venous but confirmation is needed that the arterial circulation to the leg is not impaired. Maylor (2002). Other baseline observations and blood tests were also carried out by myself, these observations are essential as they might indicate the presence of infection, deterioration in a patient's condition and many other disorders. For this reason it is essential that they are measured accurately so that when detected nursing intervention can occur. Watson (1998). After taking the required measurement the results need to be interpreted, taking into account what the patients normal measurements usually are. A patient's body core temperature is maintained close to 37 C although 36.4° and 37.2° C are within normal limits. Watson (1998) In a healthy person, blood pressure increases from 120/75 at age 30, to about 140/90 at age 40 and over. Blood monitoring was also carried out as to eliminate diabetes. All information was recorded accurately in Miss As care pathway. cal1966, please do not redistribute this coursework. We work very hard to create this website, and we trust our visitors to respect it for the good of other students. Please, do not circulate this coursework elsewhere on the internet. Anybody found doing so will be permanently banned.

Miss As temperature was normal at 36.8° and her blood pressure slightly high at 160/110 which I pointed out to my mentor; however Miss A was extremely anxious which can contribute to an increased reading. Her BM was also within normal range. These findings were explained to Miss A and we left in order for her to lie on the bed.

However when returning at the lady's home Miss A had not complied with the nurses wishes and had declined to lie on her bed for the Doppler test to be carried out.Although she had complied with all the information required for her initial assessment, she had suggested to her sister that she did not need any help from nurses and would feel better tomorrow. This I felt was an ethical dilemma as it was important for the test to take place for treatment to commence, however a nurse must respect a patients choice of treatment or refusal of it. Therefore the relationship between beneficence and respect for autonomy often conflict when caring for patients. However literature suggests that there are many reasons why patients do not comply with treatments, unfortunately these patients are often viewed as bad patients and gain the reputation as being awkward. Although Lambert (1992) suggests that it is more likely that the patient had misunderstood the information, forgotten about it or received inappropriate advice. Parry (1970) identified certain factors that could affect a person's ability to understand the information; these can sometimes include such things as poor attention due to being anxious, language barriers or confusion due to pain. Therefore it is vital for the patient that the nurse uses effective communication skills (Wilson, 1998). For this reason it is felt that a nurse should follow best practices in their working day. It is essential that the nurse listens carefully, does not talk down to a patient and always respect the patient's wishes by keeping the patient fully informed and include them in all decision making (Wilson, 1998) Visit coursework gd in gd fo gd for gd more dissertation gd Do gd not gd redistribute

It was felt by the nurse and myself that maybe the importance of the test has not been explained appropriately to Miss A, and that Miss A had been told to lie on her bed and not asked to. My mentor apologized to Miss A and her sister suggesting that she herself was at fault and stated this communication problem would not happen again. Communication comes in many forms, not just spoken, therefore it is essential that a nurse understands communication concepts and delivers and receives the correct message to patients and other healthcare professionals. The nurse and patients relationship should always involve equality, for the nurse and patient to gain a rapport and trust, the nurse must understand the behavior of the patient and act upon this. Example. Some patients may feel uncomfortable if a nurse is standing too close to them, whereas other patients may feel more secure the closer the nurse, this is proximity behavior. A Language barrier may prove to be a problem; this may be because of a strong accent, which could be difficult to understand, age, culture and gender may also come within this category. Facial expressions, heads shaking, nodding and hand gestures may be used to get the message understood (French, 1994).

For this reason a nurse must be able to use effective verbal and non verbal communication skills, there are many different ways of expressing ourselves, Argyle (1972) suggested there were nine nonverbal behaviors that we use to communicate, some of these include such things as gestures, appearance, proximity and facial expressions. Miss A had felt some what confused as to what a Doppler test was and thought it may have been a painful procedure which was the reason for non compliance.cobd bdr sebdbdw orbd bdk inbd fobd bd.

Miss A felt much happier after this discussion and happy for the nurse to continue with her treatment. It is also important for a nurse work within an empathetic attitude and develops a therapeutic relationship with her patient to ensure the patient feels at ease with the nurse as trust is an important aspect of care.

During the implementation of a wound dressing, it is essential for a nurse to bear in mind the recommended ideal environment for healing to take place. The literature that I referred to about this ideal environment all list similar properties: The notion of a 'moist' healing environment is a fairly new concept, and is often not readily accepted by some health professionals. However, all of the literature that I consulted mentioned a moist environment as extremely conducive to healing. (Miller, 1996) states that George Winter introduced the notion of moist healing, after performing trials on pigs: Superficial wounds dressed with polythene healed twice as quickly as those exposed to air only. Miller goes on to mention that clinicians were critical of moist healing, stating that it led to a greater risk of acquiring infection. However, Hutchinson and Lawrence (1991) discredited this argument.

The size of the wound was monitored on each dressing change, in order to record the progress or deterioration of it, especially as there were other health care professionals tending to the wound on different occasions; this ensures continuity of care. Miss As care plan was also always kept up to date for this reason; including any change with her sister as carer's needs must also be considered and documented in accordance with the Trusts strategy for carers. (Strategy for Carers, 1999).

However the relationship with Miss A and her sister was often strained, it was felt that Miss A resented her sister going out and leaving her on her own, it was also felt that her sister was at breaking point as Miss A had recently fallen and was more demanding than usual. It was suggested that a specialist service would be beneficial for a short period of time, Miss A and her sister agreed and a referral was made to Responsive Integrated Assessment and Care Team (RIACT). This is a specialist service that provides immediate care to families in the community which are in crisis for one week; they also prevent admission to hospital for older people who are medically stable to be maintained at home (RIACT Newsletter, 2003). Therefore it is important that all healthcare professionals understand the network of services available within the community setting which can be accessed by the district nurse and the patients. The nursing staff suggested that services such as NHS Direct have helped to reduce calls to the district nurse for advice, therefore leaving more time to spend with patients. Community care uses a framework for the provision of all health and social care services, there aim is to meet the needs and deliver the services required. Community health professionals are at the for front of new initiatives dealing with many people in diverse setting and community services can also provide a lifeline for isolated people suffering with a chronic disorder Audit Commission (1996).

While Miss A was receiving this care her medication was also assessed by her GP and was given extra medication for other medical problems which she was having. This medication increased her feeling of wellbeing and therefore she was more confident about the future. All information between the GP, react service and nurses were documented and discussed accordingly.

It was discussed with Miss As sister that Miss A was not just being awkward and that patients often suffer from anxiety when a wound is difficult to heal or they are in pain. Sleep patterns are often disturbed and pain is often perceived to be far greater at night, a disturbance of body image may also cause distress and may leave a patients feeling dirty or smelly (Lacey & Birchnell, 1986).

It was also recognized at Miss As initial assessment that she would need to be encouraged to carry out more tasks for herself by promoting her independence, this can be achieved by setting small goals ,the goals must be realistic and be within the patients own values and beliefs. The goals are implemented by the form of a care plan and nursing intervention used, the care plans are important for the documentation of the patient's health care needs, to determine patient's problems, priorities and goals. The progress towards the patient achieving these goals are constantly evaluated, revising care plans and reflecting on the patients behavior and change in condition (Potter & Perry, 1995).

On completing my placement Miss As leg ulcer was well maintained but not entirely healed, her independence had grown and she was going shopping once a week with her sister on the community bus which was accessed by the nurse, this service is provided free by the one stop shop, it provides free advice and information in many topics and is an organization concerned with the well being of the community.

In conclusion, there are many different aspects included in the assessment of a patient with a leg ulcer, all of which are vital in order to plan a sufficient recovery. The nurse must not assume that all patients with, e.g. A venous leg ulcer, can receive the same treatment, as, general health, lifestyle, social circumstance and psychological health can make a difference to the prognosis. In this way, the patient will be receiving holistic, individualised care. The nurse must also realise that she is not alone in the care of an individual, and that it is conducive to gain help and advice from relatives and other professionals in the multi-disciplinary team. Relatives and friends can offer a great deal of psychological support to the person. Some of the other professionals that the nurse may wish to contact are the vascular surgeon for severe vascular ulcers, the physiotherapist for advice on mobility, the dietician to assess nutritional deficit, the diabetic link nurse, as well as their other nursing colleagues. Once the patient and their wound have been assessed, obviously a choice of dressing will have to be made. If the wound has been accurately assessed, then the nurse can refer to research/literature which is available in the community; the BNF (British National Formulary), posters, information packs, policies, and books. If the nurse is still unsure about a dressing choice she could contact her local tissue viability link nurse for advice. Then, the dressing choice must be documented in the care-plan to allow for continuity of care. Also by improving the way healthcare professionals communicate with patients the problems of compliance and cooperation with leg ulcer treatment can be addressed. Patients are becoming increasingly knowledgeable about their condition and will challenge healthcare professionals on their knowledge and skills. It is no longer acceptable to present the patient with a leaflet and expect
compliance (Clements, 1998). There are also many legal and ethical implications concerning a nurse, as nurses today have increasing responsibilities, having to make important decisions in many situations. For this reason it is paramount for them to follow a framework of law and ethics. Legal and ethical judgments must be guided by legislation, professional code of conduct and their own moral and ethical beliefs, working within their own limitations. With any treatment informed consent is vital, this arises from the ethical principle of respect for autonomy, all patients have the right to be given adequate and accurate information regarding there treatment and should make there decision based on their own circumstances, values and beliefs with the support from the nurse. The nurse must highlight the benefits, possible harms and what the treatment will involve. It must also be recognised that consent is an ongoing process as care will change as the patient improves therefore continued discussions must take place (Norton, 1995). Medical staff also has a legal obligation to keep all information confidential, this means that a nurse cannot pass on any information to a third party without consent (Hendrick, 2000).

References

Alexander, M. Fawcett, J. Runciman, P (2000) NursingPracticeHospital& Home. The Adult. 2nd edition. London, Harcourt Publishers Ltd.

Argyle, M. (1972) The Psychology of interpersonal behavior, Harmondsworth, Penguin books.

Audit Commision (1996) Making a reality of community care. London. HMSO.

Bello, YM. Phillips, TJ. (2000) Chronic leg ulcers: types and treatment. Hospital Practice. Vol. 35 (2): 1017.

Brindle D (1998) Nurses' paperwork cuts time for patient care. The Guardian.

August 5

Bridge, W. & Macleod Clark, J. (1981) Communication in nursing care. London: HM & M publishers Ltd.

British Medical association & the Royal Pharmaceutical Society of Great Britain, (1998 - March), BNF (British National Formulary). London, British Medical Association.

Chambers, E. et al. (1996), Leg ulcer management - a nurse's companion. Basingstoke, Perstorp Pharma Ltd.

David, J. (1986), Wound Management. London, Martin Dunitz Ltd.

French, P. (1994) Social skills for nursing, 2nd Edition .London: Chapman.

Gilling, C. Kenworthy, N. Snowley, G. (1996) Common Foundation Studies in Nursing. 2nd edition. London. Churchhill Livingstone.

Hendrick, J. (2000) Law and Ethics in nursing and Healthcare. Cheltanham, Stanley Thornes Ltd.

.Lacey, J. Birchnell, S. (1986). Body image and its disturbance. Journal of Psychosomatic Research. Vol.30 (6) pp623-631.

Maylor, M. (2002) Teaching bandaging and Doppler usage for venous ulcer treatment. British Journal of nursing. Vol.11 (20) pp20-27.

McHale, J. Tingle, J. (1998) Law and Nursing, Oxford, Butterworth-Heinemann.

Miller, M. & Dyson, M. (1996), Principles of Wound Care - A Professional Nurse Publication. London, Macmillan Magazines Ltd.

Norton, L. (1995) Complimentary therapies in practice. Journal of Clinical Nursing. Vol.4 (6) pp343-348.

Nursing & midwifery Council (2002) Codes of Professional Conduct

http:// www.nmc-uk.org online July (2003).

Parry, J. (1970) The Psychology of Human Communication. London. University of London Press.

Pudner, R. (1997) Which dressing? Part two. Practice Nursing. Vol. 8 (17) p23-28.

Reinhart S (1995) Uncomplicated acute myocardial infarction: a critical path. Cardiovascular Nursing. 31, 1, 1-7.

Strategy for Carers, (1999) North DurhamHealth Care Trust.

Watson, R. (1998) Controlling body temperature in adults. Nursing Standard. Vol12, (20) pp 49-55.

Watson, S. (2002) The pathophysiology of different types of leg ulcers. British Journal of Community Nursing. Vol.6 (3) pp118-124.

Williams, C. (1996) Treatment of venous leg ulcers. Practice Nursing. Vol.10 (7) p35-39.

Wilson, J. (1998) Practice risk management - Effective communication, British Journal of Nursing. Vol.7. (15) p 918 - 919.

Young, A.P. (1995) Record Keeping British Journal of Nursing, Vol. 4 (3) p179.



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