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Device a plan of care for one

Device a plan of care for one, client/patient you have nursed in your homebase placement.

Identify a patient you have nursed in your home base and briefly provide background information.

Mrs Brownie is a 79-year-old lady, who came into my home base placement because she had a urinary tract infection (UTI) and diarrhoea. Mrs brownie is all care, which means she needs full assistance with hygiene needs, which requires two nurses to assist her. Occasionally she has respiratory problems, but she manages to breathe without oxygen therapy. Mrs Brownie wears glasses and is also registered blind. She also has eating problems, because of difficulty with swallowing, therefore is fed, through a peg tube. She has a urinary catheter due to being highly immobile.

Mrs Brownie has difficulty with her sleep pattern at night. She has a history of Multiple Sclerosis (MS), Miticillin resistant Staphylococcus Areus (MRSA) 4 years ago and UTI, which is recurrent. She is allergic to Trimethroprim tablets. Mrs Brownie doesn’t smoke but drinks wine occasionally. Mrs Brownie aimed to be discharged from the hospital but her husband has refused to have her back, unless a tract hoist is provided at home. Mrs Brownie’s husband is worried about her lack of mobility. He claimed he couldn’t manage to care for Mrs Brownie if a tract hoist was not provided. In the meantime the staff nurse in my ward organised for approval from the council to provide one.

Briefly discuss the contribution of nursing care plans to the practice nursing.

A Nursing Care Plan is a document that is needed to be able to identify a patient’s problems. It is a document for assessment on a regular basis in which to measure a patient’s progress. A nursing care plan also is a source of information where appropriate nursing care will be acknowledged. For example, with wound assessments care plan, nurses can set targets to deliver a better wound care assessment to the patient by implementing these. According to Basford and Slevin (2003) an effective use of nursing care plans will deliver greater competence to the nurses. This is equally true, as nurses follow the care plan to deliver proper care. A nursing care plan also identifies the patient’s needs, such as special requirements and checking a patient’s possible deterioration. It can formulates goals and nursing interventions, for example, to deliver appropriate care nurses have to set realistic goals and interventions for the patients care needs. This may be focused on delivery of nursing care, such as physiological or behavioural imbalances in a deficit of self- care (Aggleton and Chalmers 2000).

Furthermore, using a nursing care plan is a good way to communicate. Communication is a massive part of nursing care asset’s where the nurse-patient relationship evolves. Nurses should also have a good listening skills to allow a patient’s respect to develop (Peplau 1991). In addition, a nursing care plan is a legal document for litigation. It is evidence to the nurses for future reference, such as evidence in court.

Nevertheless, depending on the model being used, different types of intervention will be appropriate in order to achieve the goals set in the care plan (Aggleton and Chalmers 2000).

To be able to set a plan for care, a model should be applied. There are many models in nursing frameworks where the process of nursing can be used to provide an opportunity for the nurses to apply her intellectual and creative skills in active seeking information about the patient (Peplau 1991).

List two problems that the client/patient considers priorities and state these in patient centred terminology.

1.      Mrs Brownie has difficulty with swallowing.

2.      Mrs Brownie has not opened her bowels for a week.

List the goal statements for the two priority problems identified. The goals should be measurable, realistic and achievable and stated as short, intermediate and long term.

"Has difficulty with swallowing"

Short term goal

Mrs Brownie will demonstrate swallowing a few sips of thickened fluids or two to three spoons of yogurt under the supervision of qualified staff five times a day within two days.

Intermediate goal

Mrs Brownie will demonstrate improvement in swallowing with a few spoonfuls of soft diet and normal fluids with the help from Speech and Language Therapy (SALT) within two weeks.

Long term goal

Mrs Brownie will demonstrate feeding herself with normal diet and normal fluids within one month.

"Has not opened her bowels for a week"

Short term goal

Mrs Brownie will demonstrate that she can drink plenty of fluids and takes more fibre diet with the help of nutritional team within two days.

Intermediate goal

Mrs Brownie will demonstrate she is free from pain of constipation with the help of Lactulose and continued fluids intake within three to four days.

Long term goal

Mrs Brownie will demonstrate full recovery from constipation with continuing fluid intake without the help of nutritional team within a week.

Discuss the nursing interventions for one of the two problems identified. This section should be detailed demonstrating the action the nurse will take the rationale for the action and be supported by relevant referenced material.

Nursing actions for Mrs Brownie is to focus on preserving comfort, dignity and privacy and preventing further damage. It is hardly surprising that most people suffer acute embarrassment, when they require assistance to go to the toilet (Basford and Slevin 2003). Mrs Brownie was prescribed Lactulose 10 ml BD (twice daily) as a stool softener. Nurses should introduce 2-3 litres of fluids a day, to Mrs Brownie to prevent her from further constipation and dehydration. According to Basford and Slevin (2003) sufficient fluid intake, such as water and other beverages will prevent constipation.

In addition nurses should also introduce more fibre into her diet as a diet with low fibre can lead to constipation. Fibre should be sought from a variety of sources and intake should be spread throughout the day, not just taken at breakfast (Chiarelli and Markswell, 1992). It is therefore important that patients are aware of the foods that contain fibre and how to include these in their daily diet.

Mrs Brownie should also increase her physical exercise as this will help to increase peristalsis, such as help from physiotherapy as she can only do minimal movement due to her MS (Christer Ruth, 2003). Although Mrs Brownie needs full assistance, she should not do anything too vigorous. Also some simple adjustments such as changing position in bed and moving into the chair should be encouraged. Mrs Brownie needs to be referred to a dietician to educate and encourage her to take a proper diet to prevent further problems.

Nurses should also maintain good communication skills with Mrs Brownie to ensure that any worries will be discussed. According to RLT (Roper-Logan-Tierney) model, communication is an essential part of social interaction (Roper et al, 1991). Although, interaction is a huge part in nurse-patient relationship, nurses should also have good listening skills. Peplau (1991), state that listening to the patient allows respect to develop. It demonstrate the interest for the nurse in what the patient is saying, and it provides essential information for the nurse’s understanding of what the patient is experiencing (Peplau, 1991). For example, Mrs Brownie has worries of constipation, which is difficult for her to express. Nurses should make time to listen to her and establish worries by giving comfort, dignity and privacy as mentioned above to insure that she will be at ease.

Nevertheless, nurses are in an ideal position to provide preventative care and health promotion/ education in conjunction with the multidisciplinary team (Christer Ruth, 2003). Educating people/patients involves more than simply giving information; it empowers patients to cope with their own needs. Teaching Mrs Brownie to take a proper diet and drink more fluids will prevent further problems. The NHS (DoH 2000) reinforced the importance of getting the basics right. From this, the essence of care (DoH 2001) documents, involved, which aims to improve the quality of patients’ care by introducing benchmarks in certain key areas, one of which is continence management, including bowel care.

Write a summary (Summative evaluation) statement that reflects the patient care as a last entry in the patients’ notes.

Mrs Brownie is really pleased to know that she is going home soon. Her family is aware of her discharge. She is cheerful and thanking the entire staff for all the care they’ve given. Mrs Brownie has recovered from constipation and swallowing problems. She has achieved short term and intermediate goals, whilst still continuing to work on the long-term goal after her discharge.

Mrs Brownie went home at 2:30 pm today 10th April 2004. All the family members were present. All the paperwork for her discharge and referral were ready, (To Take out (TTO’s), Social Workers and community nurse). A nurse accompanied her to the ambulance transport. Her husband was present and guided her inside the ambulance. A nurse explained to her about taking the medication properly, and to avoid mixing them. She would be seen as an outpatient in three weeks time, and transport was arranged for this.

As she was still not fully independent in mobilising, and had not returned to full independence for eating and drinking, eliminating, personal hygiene needs, therefore a community nurse was arranged to visit her everyday until she’s capable of doing these activities of living. The Roper- Logan- Tierney’s (RLT) model of care worked well for her in achieving the realistic and measurable goals for her problems.

References

Aggleton, P. Chalmers, H. (2000). Nursing Models and Nursing Practice. 2nd Edition, Houndmills, Basingtoke, Palgrave.

Basford, L. Slevin, O. (2003). Theory and Practice of Nursing. An integrated approach to caring practice. 2nd Edition, London, Nelson thornes.

Chiarelli, P. Markswell, S. (1992). Let’s get things moving-Overcoming Constipation. NSW, Australia, Gore and Osment Publications.

Christer, Ruth. (2003, June 24) Constipation: Causes and Cures. [Online] Available:

http://www.nursingtimes.net/nav?page=nt.editorial.primarycare&gridPage=9 [Accessed 13/09.2004, 22:30pm].

DoH (2000). The NHS Plan. London, the Stationary Office.

DoH (2001). Essence of Care. Patient-Focused Benchmarking for Health Practitioners. London, The Stationary Office.

Peplau, H. E. (1991). Model in Action. London, Howard Simpson.

Roper, N., Logan, W., and Tierney, A. (1991). Model in Action. Houndmills, Basingtoke, Macmillan Press Ltd.



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