This essay focuses on the nursing care received by a patient during practice placement in the community. The rationale for choosing this patient is because the author participated fully in providing care needs for this particular patient. A good nurse and patient relationship was developed which enabled the author to feel confident and at ease whiles providing care. The author learnt and developed new skills, which will be essential for future clinical practice.
There will be a brief account of the patient’s patient profile. Models used to identified the patient’s actual and potential problems will be discussed. The author will then critique the models used identifying the strengths and limitations. (Care Plan in Appendix One) In conclusion the author will reflect on the care given and how it will enable self-improvement in providing quality nursing in the future.
In compliance with the NMC (2002) Code of Professional Conduct for confidentiality, the patient involved in this care study will be referred to as Mr. Ian Clarke to protect his identity. After clearly explaining my intentions, Mr. Clarke gave me his verbal consent to be subject of my care study without obligations.
Mr. Ian Clarke is a 60-year-old English man. A chain smoker who smokes about 15 – 20 cigarettes a day. Mr. Clarke was once married but separated from his wife many years ago. He has 2 children but is not in contact with them. At present Mr. Clarke lives in a single hotel room, provided by social services after spending long periods of time in Prison and later on the streets. He has a lady friend who visits regularly, they have known each other for over 5 years.
Mr. Clarke has a medical history of hypertension, type 2 diabetes mellitus, which was diagnosed 5 years ago and has been administering insulin (Human Mixtard 30/70) twice daily to control his diabetes. His presenting complaint is his leg ulcer, which has developed on both garter areas of his leg. This has been ongoing for the last 2 weeks and he is still undergoing further investigations.
The purpose of the District Nurses daily input is to assist Mr. Clarke to administer his insulin injection, give him his other medications, check his blood glucose levels, monitor his blood pressure, re-fill his dossett box on a weekly basis , order any required prescriptions and book transport for any pending appointments to the hospital, e.g. diabetic clinic. Also dress his leg ulcer, which is done twice a week. Necessary referrals were made to other agencies as required. Awaiting the right diagnosis of Mr. Clarke’s ulcer, the district nurse with the author used their own initiative to dress the ulcers.
Mr. Clarke spends most of his day in his hotel room watching television and smoking. Due to his leg ulcer Mr. Clarke was not been able to go to the nearby park, which he visits with his lady friend to feed the birds.
For this care study a combined model was used. Roper et al (1996) Activities of Living model and Orem (1995) Self-care model were used.
Roper’s (1996) activity of living model was applied to identify Mr. Clarke’s problems as related to his ability to carry out each of the activities of living. The Roper et al model (1996) is based on ideas drawn directly from practice and can be identified as being ‘ for real nurses, nursing real people, Newton (1991).
Orem’s (1995) self care model was combined with Roper’s et al (1996) model, to educate, motivate and empower Mr. Clarke with his well-being. Orem’s (1995) emphasis on client autonomy and motivation is consistent with the aim of helping individuals accept responsibility for themselves.
According to Cavanagh (1991), Orem believes that self-care is the contribution made by adults to their own continued existence and involves the practice of activities to maintain health and well-being. The nurse acts to assist patients and their associates to achieve self-care, taking ability and need into account. Due to word limitation Mr. Clarke’s ability to perform each activity of living has been explained (Appendix Two).
Potter et al (1992) stipulated that, “An assessment is a continous process of collecting data regarding patient’s responses, health status, strengths and concerns”. The data can be used as a baseline, in which further information can be compared, (Hinchcliff et al, 1998).
Before carrying out the assessment the author made Mr. Clarke a hot drink to reduce anxiety and promote comfort, also all distractions were removed by closing the door and turning off the television.
To begin the interview the author firstly introduced herself and acknowledged the presence of the mentor and explained the purpose of the interview. According to Walsh (1996), how a patient is approached is very important. During the interview eye contact was maintained, open and closed questions were asked allowing and encouraging questions from Mr. Clarke. Throughout the interview full terms were used and abbreviations avoided. Privacy was maintained by carrying out the interview in Mr. Clarke’s own hotel room. This maintained Mr. Clarke’s dignity, which helped and encouraged him to express his ideas, fears, feelings and facts that helped identify immediate and long range needs.
A plan for care is formulated to address the actual and potential problems identified in the course of assessment. A care plan is in four stages, which is assessment, nursing aim, nursing action and evaluation.
Following the assessment phase and identification of Mr. Clarke’s problems, it is necessary to move to the planning of care. At this stage the nurse in conjunction with Mr. Clarke set achievable goals and be realistic in terms of the capacity with his own values and priorities.
Through assessment of Mr. Clarke the author identified different aspects of care but only chose two aspects in need of care, which is his leg ulcer and diabetes(Type 2).
One of the primary aims of assessment in a patient with an ulcer is to determine the cause of that ulcer, by referring to his medical history, also to confirm if it is a venous or arterial ulcer. Mr. Clarke had to undergo some investigations such as having a Doppler ultrasound and swabs taken from the wound site. He was referred to the physiotherapist due his restricted mobility.
The mentor and the author assessed Mr. Clarke’s ulcers. The ulcers appeared to be on both garter areas of his legs. They appeared as shallow holes and the skin felt warm but dry and crusty; they had a mottled brown staining with a slight unpleasant smell. The legs were very swollen. Mr. Clarke complained of itchy skin and he also informed he was sensitive to Lanolin. The calf, ankle and wound size, depth and location was measured and recorded on a ‘wound management chart’ used in the practice area, as a baseline also protocol for wound care was followed. He was not experiencing or complaining of pain. Because of the unpleasant smell a swab was taken from each leg to check for infection present as this might hinder healing (Moffatt, 1995).
Mr. Clarke had a Doppler test performed by the author under supervision of the mentor. This test can give precise information as to the venous system, as it is the measurement of ankle; brachial pressure index (ABPI).
It should be noted that Doppler test cannot diagnose the origin cause of ulcer but it does assist in the correct diagnosis and appropriate treatment of ulcers (Cullum, 1994). After the test was performed it was concluded that Mr. Clarke’s had a venous leg ulcer. Venous leg ulcers occur in the Garter area halfway up the calf and down to just below the ankle.
Using the calf muscle pump veins drain blood from the feet and lower leg uphill to the heart and they have one way valves that prevent blood flowing back down hill. If the valves do not work properly and close in the normal way blood will flow back and cause congestion. It was recommended that Mr. Clarke should have compression therapy and grade two bandaging using four-layer bandages, which is moderate compression of the ankle between 18 and 24 mmHg.
The pressure exerted by a bandaging system can be calculated using Laplace’s law. (Moffatt, 1994). The four-layer bandages helps to keep the wound warm and it absorbs all exudates.
Bandaging is the most important component in the treatment of venous ulcers. It controls oedema by compression as it gives more support at the ankle and less at the knee to compensate for the failure of the perforators in the leg.
Aseptic technique was used to prevent cross infection from leg to leg. The ulcers were cleaned to help create the optimum level condition for wound healing by removal of excess debris and exudates. This was done using warm normal saline because it is an isotonic solution and therefore, does not donate fluid or draw solutes from the wound. The bandaging was changed after every four days and measurements and recordings were taken.
Mr. Clarke was referred to the physiotherapist. They visited three times a week and taught Mr. Clarke regular exercises to be done during the day as this helps to stimulate the calf muscle pump which assists with venous return. Since his legs were swollen the provided him with a footstool to alleviate his legs and also use the support of pillows underneath. He was educated not to sit or stand in one position for long periods of time. Due to his itchy skin he was advised not to scratch his legs too hard as this can break or damage the skin and cause infection. Also not to cross his legs. He was advised to maintain good nutritious diet as this has proven to assist with wound healing.
After four weeks of treatment healing was in progress, although ulcer developed by diabetic could take longer to heal due, e.g. circulatory problems. The ulcers were granulating; the size had reduced as compared to the baseline. His legs were improving they were no longer swollen. There were less exudates, no smell and the surrounding skin was soft and it appeared pink in colour. The leg ulcers were re-assessed and the bandages were changed to stage one which has less compression than the stage two bandages. Mr. Clarke was very pleased with the care given and progress.
DIABETES MELLITUS TYPE 1
It is currently thought that a genetic predisposition to the disease, possibly combined with environmental triggers, activates mechanisms, which lead to progressive loss of pancreatic B cell. In insulin-dependent diabetes mellitus, insulin secretion is totally (or almost totally) absent, and as a result lifelong treatment with insulin is required (Fawcett et al, 2000).
Mr Clarke’s blood sugar levels were higher than normal on assessment. He takes insulin before breakfast and bedtime. Mr. Clarke has got history of hypertension and on assessment his blood pressure was 188/92 and this was very high.
The aim was to maintain as close to normal blood glucose levels of between 4 to 10mmol/ as possible while allowing the patient to maintain a normal lifestyle. Promote nutritional status by planned diabetic diet considering patient’s preference and cultural differences. Foster independence in self-care management in carrying out injections and choosing meals. To educate Mr. Clarke on the signs and symptoms of hypo/hyperglycaemia.
Mr. Clarke’s blood sugar levels were monitor twice daily. At breakfast by the author under the supervision of the district nurse and at bedtime by the twilight district nurse. These readings could be then used as a baseline. Human Mixtard 30mg was administered, as per prescription from the doctor.
Used syringe needles were disposed safely in the sharps bin provided. The purpose of administering insulin is to replace the deficiency, its action is to enable the body to metabolise food, absorb glucose into the cell, and thus to lower the blood glucose level. The sight for injection was chosen carefully and a rotation regimen was developed, where the abdomen was used in the morning and the thigh was used in the evening. The district nurse also checked the injection sights for signs of lipohyperthropy.
Due to Mr. Clarke’s hypertension his blood pressure was taken regularly. Remipril, an anti-hypertensive drug as prescribed was administered to bring it down. Mr. Clarke was referred to the diabetic clinic to have his eyes tested as an effect of diabetes cause poor eyesight. Mr. Clarke was also referred to the chiropody for foot care, as disorders of the foot in diabetes can occur as a result of neuropathic and vascular changes.
At the diabetic clinic Mr. Clarke was given information about his diet in relation to his diabetes. He was advised to eat regular meals, which include some starchy foods and high fibre foods, and if he was thirsty to drink low-calorie, sugar free squashes, water and tea without sugar (BDA, 1995). Mr. Clarke was also educated about the signs of hypo/hyperglycaemia and he did understand them very well.
The blood sugar levels were stable and remained within the normal range. Mr. Clarke reported no signs of hypo/hyperglycaemia. There were no signs of bruises or bulge at the injection sights. Mr. Clarke was encouraged to keep to appropriate food due to his diabetes. His blood pressure was monitored and also remained stable.
REFLECTION ON EVALUATION OF CARE
Overall Mr From the author’s point of view the use of Roper’s et al (1996) model provided an opportunity to collect a very realistic account of Mr. Clarke’s life style if living and needs. The Roper et al (1996) model of living was appropriate in the deliverance of Mr. Clarke’s care. When assessing Mr. Clarke the model was easy to apply but it did not have a clear cut area were to put the two problems that were identified for Mr. Clarke although on the clinical area they used their own framework and protocol of wound assessment and management.
The other model used to combine with Roper’s model in this study was Orem (1995) self care model. This model was helpful and easy to use because it mainly talks about educating the patient and making them understand and manage their ill health. This model is also best for community-based patients like Mr. Clarke.
Overall Mr. Clarke responded well to nursing interventions, which proved goals set by the author and her mentor, also other team members were achieved. Mr. Clarke was allocated a nurse who was overall responsible for the care. Individualised patient care involves a therapeutic relationship; it increases quality of care, gives greater job and patient satisfaction (Atkin et al, 1999).
Although all the care givers in Mr. Clarke’s study were successful in implementing the care, the author noticed that the documentation was poor at times, it was not clearly written the actually care that was given in order for the next person to carry on. For example, if a dressing was done it did not include in the notes whether there has been any change in size, depth and appears or if the dressing has been altered. By carrying out the assessment Mr. Clarke mentioned that he was sensitive to lanolin but this was not mentioned anywhere in his notes.
Personally, my involvement in providing evidence based care for Mr. Clarke encouraged me to think laterally when planning and implementing care, as many factors were at play and inter-linked. In addition, it has highlighted the importance of psychosocial assessment in determining possible influence on physical health and most of all developing a therapeutic, trusting relationship if subsequent interventions are to be effective.
Courtney from Study Moose
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