The traditional way of trying to assess if a particular treatment or the clinical condition of a patient has changed, is by running blood tests, clinical evaluation, and other laboratory tests. While these measures undeniably give us certain levels of information about a patient, they tell us virtually nothing about the disease process from a personal and social context. (Higginson et al 2001). No illness exists in a vacuum.
This essay is a discussion of the concept of individualised care with particular reference to my recent placement on a geriatric ward. I am going to discuss the case of Mrs.J., a 83 yr. old lady.
Mrs J has been on the ward for two weeks. She was originally admitted with a chest infection. She was very ill at the time of admission and it was not easy to get a history from her. We could only establish that she lived on her own and had been found by a neighbour who had called her General Practitioner who had then arranged her admission. Her chest infection was treated and she responded reasonably quickly.
As she became more lucid, it became obvious that Mrs.J. had had a mild stroke leaving her with an expressive dysphasia. It was not possible to ascertain whether these changes had been present for a long time or had just come on, as she had not seen the General Practitioner for nine months prior to this admission.
We also discovered that Mrs.J. had developed a mild form of Type II diabetes mellitus as she was putting out small but constant levels of sugar in her urine and her blood sugar levels were mildly elevated.
In brief, her care plan called for her to mobilise with the physiotherapist, to receive speech therapy for her dysphasia, to see the dietician for advice regarding her dietary control of her Type II diabetes mellitus and to see the social work team for assessment for discharge as it was considered unlikely that she would actually be sufficiently self-caring to be able to discharge to her home.
The nursing profession, almost by definition, is a very personal and interactive profession. (Yura et al 1998)
In order to provide good individualised care there must be a number of interactions in place. The nurse must have a good understanding of the medical elements of the case and also have a good knowledge of the patient both as a person and of all their circumstances. (Meleis 1991) This helps to allow the formulation of good individualised care without making any inappropriate decisions that may be based on an incomplete understanding of the situation.(Holzemer et al. 1994)
The case of Mrs.J. is complicated because of her expressive dysphasia. In a nursing context the “interpersonal processes” that are necessary to establish rapport and empathy were made very much more difficult. (Platt et al 1999). The verbal and motor cues that are a vital part of this essential process were not there by virtue of her cerebro-vascular accident, and it made proper and meaningful conversation very much more difficult. (Carpenito 1997).
It was not helped by the fact that she did not appear to have any close relative that we could use to get information. It was not simply a matter therefore of deciding what was medically the best for her, but in order to try to engage with her on the level of empowerment and education, we had to try very hard to understand her feelings and situation in order to provide individualised care. (Woolhead et al 2004)
If we try to apply the Roper Logan & Tierney model of nursing care (Roper et al 1983) to Mrs.J.’s situation of needing dietary advice for her newly diagnosed Type II diabetes mellitus, the aim would be to try to provide individualised care and to take into account the degree to which the problems of her inability to communicate actually interferes with the other activities of daily living. (Howe et al. 2003). It is in this respect that the concept of individualised care becomes clearly apparent.
For the average patient., it may simply be appropriate to fill out a dietetic referral slip and let the dietetic department do the rest. If we wish to fully implement the concept of individualised care, then we would need to establish that Mrs.J. needed and understood why she needed dietetic advice, that she could adequately understand what was being said, (Kuhse et al. 2001), and also make sure that the dieticians were fully aware of all aspects of the situation when they were able to visit her and give advice. (Newell et al 1992)
This approach allows us to make an assessment of both the positive and negative aspects of the decision. We can also make an assessment of whether Mrs.J. would eventually be in a position to take responsibility for her own diabetic (or dietary) care in the long run. (Marks-Moran et al 1996)
In individualised care, it is important to be as empathetic as possible to the patients needs. One must appreciate the fact that, in this particular case, the imposition of a diet may be seen by the patient as yet another (iatrogenic) restriction imposed upon an already severely restricted lifestyle. Generally speaking, concordance and explanation are better than dogma and enforced compliance (Marinker 1997).
Another important aspect of individualised care, is the process of reflection (Gibbs 1998). It is generally comparatively easy to make clinical decisions, but the key to ensuring that they are actually the correct decisions for that individual patient, is to reflect upon them and consider all of the aspects of that particular patient’s case, which may not have actually been impinging upon the original decision making process. (Taylor 2000).
For example, it is almost certainly the correct decision to invoke the help of the dietician to assist Mrs.J. in managing her Type II diabetes mellitus. It is however, possible that, upon reflection, Mrs.J. might not be able to adequately manage her diet because her motor problems now preclude her from going independently to the shops, and the person who buys her food for her may have absolutely no idea of the basic concepts behind the maintenance of a regular and restricted sugar intake.
Mrs.J. ‘s case fortunately did have a comparatively happy ending. She accepted the dietician’s advice and proved to be remarkably adept at both managing and manipulating her dietary needs.(Carr et al 2001). It became apparent that part of her confusional state and her dysphasia, was actually due to her hyperglycaemia.
As her hyperglycaemia improved and her blood sugar levels returned to more normal levels she rapidly became more communicative. The interpersonal interactions that we referred to earlier, then became both easier and certainly more meaningful. (Stowers et al. 1999).
Mrs.J. improved to the point where she was well enough to allow discharge to warden assisted accommodation. Her warden came onto the ward to learn how to help manage the dietary considerations and was able to speak at length to the dietitian. I would like to think that the warden left the hospital as empowered and educated as Mrs.J. was.
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