The aim of this nursing care study is to demonstrate that, as a student nurse, the writer is capable of developing and delivering the skills needed for assessing and addressing each individual patient’s care needs. Included in these set of skills, is the ability to develop critical thinking, decisive decision making and the ability to reflect on events so as to become a better health care provider. The patient in which the writer will discuss was based upon an eighty three year old man, pseudonym Mr. Scott who was admitted into accident and emergency via a referral from his general practitioner presenting with exacerbation chronic obstructive pulmonary disease (COPD) with a history of congestive cardiac failure (CCF). On admission to accident and emergency Mr. Scotts’ team took arterial blood gases, ordered a pulmonary function tests and a chest X-ray.
Prior to the exacerbation of Mr. Scotts’ condition he regularly attended a cardiac clinic due to being a long term sufferer of congestive cardiac failure and also attended pulmonary function clinic for tests (pulmonary function tests). Through these clinics Mr. Scott was educated on his medications and current condition. On admission of Mr. Scott, the writer decided to use the frameworks Roper Logan and Tierney (2000); Orem’s Self Care Framework (1995) and Gibbs (1988); which incorporates each tool of assessment known as, plan, implementation, evaluation, educate and reflection. Using the above frameworks, an improvement of Mr. Scotts’ current exacerbation of chronic obstructive pulmonary disease (COPD) was seen to have been resolved and a new evaluation of Mr. Scotts’ care was developed.
The chosen tool of reflection used is known as the Gibbs cycle of reflection. The writer applied this tool in order to evaluate the patient care. The rationale behind this was to attempt to fully understand reflection so as to apply this to everyday practice, thus improving as a student nurse. The Gibbs cycle involves a description of the incident, feelings and thoughts experienced plus the evaluation and analysis of the incident, conclusions and action plan (Gibbs, 1988). According to Barnett (2005) using a tool of reflection, to give an account of experiences in the clinical setting can aid the nurse to analyse and explore their feelings regarding patient care.
Eighty three year old Mr. Scott was admitted to accident and emergency with a referral from his general practitioner, presenting with a recurrent upper respiratory tract infection and a history of exacerbation of chronic obstructive pulmonary disease (COPD) and congestive cardiac disease. Due to his history of chronic obstructive pulmonary disease (COPD), Mr. Scott was sent for a chest x ray to assess the deterioration of his lungs due to his condition. (Alexander et al. 2009) Post admission into accident and emergency, Mr. Scott was sent to St. Pat, Thomas, Johns’ ward where the writer was working at the time as a student nurse.
The writer found, when assessing Mr. Scott, that he lived alone, locally, was a widower of ten years and had two daughters who also lived near by. Although Mr. Scott had many concerns, he also had a good social network such as the support of family and a home help package of six hours a week, which included meals on wheels. The local public health nurse also called to see Mr Scott on a social capacity. Presently the main health concerns which faced both Mr. Scott and his family were; the deterioration of his dyspnoea, related to his chronic obstructive pulmonary disease; pressure ulcers, due to developing pressure ulcers while in hospital in previous years and anxiety from both Mr. Scott and his family due to the unknown. Reassurance was given and they were explained what care he was to receive.
Issue # 1 Breathing.
The key feature of chronic obstructive pulmonary disease (Barnett, 2009) is that of experiencing breathlessness. Being breathless for most patients can be both a stressful and frightening experience, which can raise anxiety levels. In past studies, men predominantly more than women were found to be affected by chronic obstructive pulmonary disease (COPD); but in a recent study carried out by Meilan et al. (2007); research has found that cases of chronic obstructive pulmonary disease (COPD) are increasing in women world wide. The care Mr. Scott received was split in two, short term and long term care; both of which were constantly re-evaluated to maximise efficiency and quality of care.
As part of the short term care plan the writer ensured that the bedside was set up with suctioning equipment help prepared for potential complications. To avoid complications, for example tachypnoea (rapid breathing) which is found to be an early indication of respiratory distress (Jevon and Evens 2001); the golden rule of thumb, depth and rate of breathing was monitored and recorded accurately (Jevon, 2010). Further reducing the risk of complications occurring, Mr. Scott was encouraged to sit up in a semi fowler position while enduring deep breathing exercises enabling him to breathe with greater ease and comfort. The rationale behind this was supported by a study carried out by Duggan et al. (2005).
The long term goal was to ensure that an oxygen saturation level between 88%-94% is maintained (Alexander et al 2009). To monitor oxygen saturations levels, a pulse oximeter was place on Mr. Scott’s finger. The rationale for this is to detect oxygen absorption of haemoglobin (Plaice &Graham, 2000). A study carried out by Groeben (2003) shows that administering high concentrations of oxygen to patients with chronic obstructive pulmonary disease (COPD) will reduce the respiratory drive, resulting in respiratory depression. This finding gives rationale to why a low flow of oxygen therapy is given to patients with chronic obstructive pulmonary disease (COPD). Humidification was added to Mr. Scotts’ oxygen therapy to warm and moisten the gas (Jevon and Ewens 2001) promoting secretions while enhancing patient comfort (Woodrow 2005).The rationale for this is that oxygen is known to dehydrate exposed membranes in the upper respiratory tract.
Issue #2 Pressure ulcers.
According to Lawrence et al (2010), every individual’s skin changes with time, this is a normal process of ageing. With this change comes a decrease in its elasticity and turgor, therefore with age one has to ensure that vital care of skin is given in an attempt to avoid skin breakdown. Due to Mr. Scott being an elderly man of eighty three, the writer was concerned about skin integrity. A tool known as the water low score was used in order to assess the likelihood of Mr. Scott developing any pressure ulcers during his stay in the hospital (Whiteing 2009). As Mr. Scott had developed pressure ulcers in a past experience, he would have an increased chance of a re-occurrence. In an attempt to prevent this situation the writer requested that Mr.Scott be nursed on an air mattress. (Stafford and Brower 2009). Issue #3 safety and delerium
Anxiety is an emotional state influenced by past experience, which exists at a given point in time with a level of intensity related to an upcoming perceived threat (Passer and Smith 2007) The provision of information is extremely important to the patient as studies from, Biswajit et al. (2009) has shown that an informed patient with a good understanding of their condition reduces anxiety. Harvey (2002), recommend shared control in patient-practitioner interactions in that patients effectively participate in controlling important events. After liaising with Mr Scott’s’ medical team regarding his anxiety, a low dose of Alprazolam brand name Xanax 5mg, was charted and given in an attempt to relieve his anxiety. Alprazolam reduces anxiety within patients (De Witte, et al 2002).
Medical care administered
On admission to the ward Mr. Scotts’ medical team ordered pulmonary function tests. These tests determine what type and extent of restriction the patient is experiencing (Alexander et al 2009); furthermore indicating any increase/decrease in their condition (Daly 2009). Arterial blood gasses were checked in order to determine the amount of O2 to be administered reducing the risk of hypoxia. The rationale for taking arterial blood gases was to determine the bloods Ph and the O2 levels circulating within the blood. (Alexander et al 2009). A sputum sample was also attained from Mr Scott and sent to the lab for culture and sensitivity testing to trace which bacteria is present in the sputum so as to treat the infection (Gray et al 2008). Through reflection the writer recalled that oedema may be present in the lower extremities secondary to Mr. Scotts history of congestive cardiac failure and chronic obstructive pulmonary disease (COPD) and recorded the findings.
The rationale for this was that, Mr. Scott suffered with congestive cardiac failure which increased the risk of developing oedema while in juxtaposition, putting increased pressure on functioning internal organs (Morley et al. 2009). During the writers assessment of Mr. Scott it appeared that he was suffering from a sudden onset of dyspnoea, (laboured breathing). Using critical thinking, the writer administered oxygen therapy at maximum of twenty four percent and immediately informed Mr. Scotts’ team on his condition. The rationale behind administering low dose O2 is due to the fact that the hypoxic drive can be decreased by administering a large dose of O2 leading to respiratory failure and the worsening condition of the patient, (Simmons et al. 2004). Using the Gibbs reflection cycle, the writer believes students should be under constant supervision in order to attain the knowledge of administering O2 to patients diagnosed with chronic obstructive pulmonary disease.
The medical team looking after Mr. Scott prescribed an antibiotic called Tazocin (4.5grams three times a day) to be given intravenously. The rationale for administering this antibiotic was to attempt to fight any infection that the patient may have developed. Also prescribed for Mr. Scott was a steroid and bronchodilator. The rationale for charting a steroid and bronchodilator was that, they are found to decrease inflammation in the air way and also to open up the airway (Greenstein et al 2009). Due to Mr. Scotts’ condition he was a long term user of oral Corticosteroids. Studies (Walters et al. 2008) have shown that, corticosteroids reduce the need for additional medical therapy while, also shorting hospital stay.
On previous reflection (Gibbs 1988) as a student nurse, the writers’ knowledge developed due to reflection from previous patient care. The writer knew that due to Mr. Scott being on steroids, his blood sugar levels needed to be checked once a day as to ensure it stayed within the normal range. The rationale behind monitoring Mr. Scott’s’ blood sugar once a day was due to the side effects that are directly related to the administration of corticosteroids. Such side effects are as mouth ulcers, weight gain and increased skin thinning (mayoclinic.com). The writer encouraged Mr. Scott to rinse his mouth out with water post administration of oral steroids to reduce the development of oral ulcers or a candida infection of the mouth, (Greenstein et al 2009).
The Roper, Logan, Tierney (RLT) 2000 nursing framework aided the writer in focusing upon the care study. This model encompasses key factors such as social status, environmental factors as well as the physical/ psychological factors which influence people in their daily lives (Roper et al 1991; 2003, Newton 1991). This model is designed to be adaptable to any patient and not for the patient to adapt towards the model of nursing; therefore it allows the nurse to care for each patient on an individual level (Roper et al 2000).
Nursing can therefore be defined through this model in terms of helping people to prevent, alleviate, solve or cope with problems (actual or potential) when relating to the activities of daily living, (Roper et al. 1990).
Although the Roper Logan and Tierney’s’ model of nursing covers a holistic view, a model known as the Orem’s Self Care Framework according to Fawcett (1995) concentrates on the individuals’ self maintenance and regulation through a type of action known as self-care. This model could be seen as beneficial to Mr.Scott as a patient whom has been diagnosed with chronic obstructive pulmonary disease as a main part in maintaining good health is a good understanding/ communication, knowledge and education of how to care for ones’ self (Eva et al. 2009).
The aim of this piece of work was to assemble while using tools of assessment an individual care plan. This was to be drawn up together with the patient and the writer so the system of care would be of an individual status. The writer also aimed to demonstrate that with critical thinking and decisive decision making the patient involved received intervention when needed.
As the writer worked on the ward mentioned a strong therapeutic relationship had been built between patient and student nurse, this allowed the patient to feel at ease when asking questions regarding his condition enabling the writer to educate the patient at a higher understanding. Upon Mr. Scott’s discharge he expressed a better understanding of his knowledge about his condition, he also felt that if or when he experienced another exacerbation he would not feel as anxious and be better able to cope with it. Hearing this as a student nurse the writer felt that it had enhanced professional development for further nursing practice.
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