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This assignment will present a nursing care study of a patient on a cardiac ward. The patient will be referred to as Ann to maintain confidentiality (NMC, 2008). Ann’s consent was gained prior to starting this care study. The care study will be developed using the Nursing process and the Roper, Logan and Tierney model. These will both be outlined. The assignment will focus on the assessment process and one problem identified during the assessment and the nursing care which followed this.
I was placed on a cardiac ward within the Trust for my phase four placement.
The ward deals with patients who have acute cardiac conditions including myocardial infarction. The ward also accommodates those with chronic cardiac conditions such as congestive cardiac failure, pulmonary oedema and triple vessel disease. Patients awaiting cardiac surgery may have to wait quite a while on the ward. There are both male and female patients on this ward and the ages range from sixteen to very elderly.
A sixty three year old lady named Ann was admitted to the ward on my first week on this placement. She was admitted to the ward via Accident and Emergency.
Ann had taken ill at home previously that day and her husband had called for an ambulance. Ann presented with chest pain radiating down her left arm, shortness of breath, nauseated, fatigue and weakness. Investigations later showed that Ann had experienced an Acute Myocardial Infarction. Acute Myocardial Infarction, also known as heart attack, is characterised by the ischemic death of myocardial tissue (Porth, 2005).
Diagnosis of an Acute Myocardial Infarction is based on the presenting signs and symptoms, Electrocardiogram changes and serum cardiac markers (Porth, 2005).
Whilst Ann is on the ward she will be monitored continuously via Electrocardiogram. I chose Ann for my care because I was on duty when she was admitted to the ward and I assisted with her admission. As this was my first week I knew I would have a six week opportunity to follow Ann’s journey of care. As Ann was very anxious and nervous when she arrived on the ward I spent a lot of time talking to her to make her feel at ease. I built up a good rapport with this patient.
Mehrabian (1981) states that developing a rapport with the patient involves being professionally friendly, showing interest and actively using non verbal and verbal communication skills. I also chose Ann because from doing her assessment I could see she had other underlying problems aside from her cardiac condition. Ann was hypertensive, high cholesterol, type two diabetes and was overweight. After being told Ann was going to be awaiting for inpatient cardiac surgery I agreed along with my mentor that Ann would be a good case for my care study as she is at high risk of developing pressure sores whilst in theatre and recovery.
Taking a patient history is arguably the most important aspect of patient assessment (Crumbie, 2006). Ann is married forty years to her husband Jim who is a bricklayer. Ann recently retired as an office worker. They have two daughters and one son together and three young grandchildren whom she occasionally looks after. Ann smokes 20 cigarettes a day and drinks 2-3 units at the weekends. Ann was diagnosed with diabetes type 2 seven years ago and is medication and diet controlled. Ann also suffers from hypertension and high cholesterol. At five foot four inches and thirteen stone Ann is overweight.
Ann has a history of three Acute Myocardial Infarctions and has had PCI stenting three times. There is a history of myocardial infarctions in her family as her father died at the age of seventy following an acute Myocardial Infarction. This is a brief history of Ann from what I have taken from her assessment; a full assessment can be seen in the appendix. According to Barret D (2009), in order to care for patients individual needs there must be a nursing process by which nurses can deliver patient centred care supported my nursing models or philosophies.
In order to deliver this care, a five stage approach must be taken (Hogston, 1999). These five stages are assessment, diagnosis; care planning, implementation and evaluation, all together equal ADPIE (Kozier B, 2004). The cardiac ward used Roper, Logan and Tierney model to assess the patients being admitted to the ward as a way of comparing how a patient’s life has changed due to illness or admission to the hospital (Roper N, 1980). This model was the first to be developed in the United Kingdom.
Tierney (1998) claims the contribution that the model has made to nursing is that it has encouraged nurses to refocus on health rather than ill health. The model also shows the complexity of nursing. The model covers the patient’s whole lifespan. In the model patients are seen as engaging in twelve basic activities of living (Pearson et al 2005). The twelve activities of living are maintain a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying.
Each activity is seen to have five influencing factors, those being, biological. Psychological, socio-cultural, environmental and politico-economic. A copy of my own assessment of Ann using this model is included in the appendix. Minardi (2007) maintains that assessment is an evolving, incremental gathering and processing of information relevant to the clients situation or needs. Assessment must take place firstly to get a picture of the patient before setting out any goals or care planning.
At this stage I established what Ann could and couldn’t do of the activities of daily living. The twelve activities of daily living provide the framework for assessment. Assessment is a systematic, deliberate and interactive process that underpins every aspect of nursing care (Heaven and Maguire, 1996). The nurse must involve the patient in the process and make the assessment patient centred. Ford and McCormack (2000) state that assessment is best approached through biography because people come with a past, present and a future.
The nursing assessment should have physical, psychosocial, emotional, spiritual, social and cultural dimension, a holistic approach. To be effective the process must be structured and clearly documented. Ann was assessed using the Braden scale (Appendix ) and her score was 18. This showed Ann was at risk of developing pressure sores. A pressure sore results when healthy tissues become devitalized so causing localized tissue death (Bale, 1997). The skin has been broken down when direct, unrelieved pressure occurs over bony areas. According to Waterlow (1988) most pressure sores are preventable.
The Braden identifies patients at risk of pressure sores and the severity of risk, therefore lower score means higher risk. Ann was given her date for surgery which was whilst I was in my final week of this placement. I done the pre operative checklist (see appendix) on the ward and followed Ann to theatre with the staff nurse for the patient handover and also to see how my goal would be maintained in the theatre setting. Patient problems relating to the activities of daily living are identified during assessment and transferred to the plan of care (Pearson, 2003).
Problem identified Following Ann’s assessment (appendix) there were a number of problems identified, for the purpose of this assignment I will focus on one problem, set goals and discuss the nursing intervention I feel is most appropriate to the problem. Ann’s problem has been identified as at high risk of developing a pressure sore during surgery. Goals set Ann’s goals of care will be based on the SMART criteria; subjective, measurable, achievable, realistic and have an appropriate timeframe.
Short term Ensure Ann’s skin is clean and intact before commencement of the operation Medium term Ensure Ann is protected during surgery from developing pressure sores Long term Continue to protect Ann’s skin post-surgery in the recovery ward Discussion of nursing interventions In the theatre Ann self transferred to the operating table with minimal assistance, the anaesthetic nurse done a pre operative check to ensure Ann’s skin was intact on all areas prone to developing pressure sores.
Scott (1999) states that metabolic and circulatory changes resulting from anaesthesia can assist to the development of pressure sores, therefore it is vital skin is checked prior to any interventions. Anaesthesia can lead to periods of low blood pressure (Bliss and Simini 1999) which may affect the pressure areas of the skin because of reduced blood flow and reduced tissue oxygenation. The operating table is hard and solid but is essential for the surgeon to complete the operation without the patient moving.
A pressure relieving overlay mattress is laid on top of the operating table and is made of gel, this aids in reducing the risk of pressure sore development whilst keeping a hard, solid surface for the surgeon to work upon. (Armstrong and Bortz 2001). NICE (2003) guidance is that patients should be placed on ‘either a high-specification foam theatre mattress or other pressure-redistributing surface as a minimum provision’. As Ann had a cannula inserted in her left wrist an arm board was in situ so that Ann’s arm was not in danger of hanging off the table or getting pulled or caught.
These were covered with gel pads to act as a pressure relieving device to prevent pressure sores on the elbows Anaesthetics cause the patient to lose muscle tone and it is important to take care. when positioning the arm board as irreparable damage to brachial plexus could result (McEwan 1996). It was important Ann kept norothermia during surgery as intra-operative hypothermia reduces the blood flow to the skin which can result in hypoxia, reduced skin oxygen tension (Kurz et al 1996) and therefore tissue damage (Scott et al 2001). This was ensured by the use of air pressured heating blankets.
Once Ann’s surgery was finished and the Anaesthetist and surgeon were happy for her to be transferred to the hospital bed and sent to Cardiac Intensive Care Unit for recovery a sliding sheet was used to transfer Ann. (NMC 2008) states it is paramount that nurses know how to use this equipment appropriately. A sliding sheet slides the patient safely and without harm to the nurses or the patient and reduces risk of causing friction burns to the patient’s skin. A further post operative skin check took place before Ann left the theatre.
This was to ensure the skin was still intact and that there were no red areas. Ann’s skin pressure areas had no visible areas. If Ann had developed any pressure sores she would be at a high chance of developing anxiety caused by the pain of the pressure sore and her discharge from hospital may be delayed and she may also require community care after for wound dressings. This would be very inconvenient to Ann who does not drive and would have no transport to the local health centre. She would have to pay for public transport.
Also if Ann had developed pressure sores she would be less trusting of the NHS and would have little faith to return to the hospital again of fear that she may develop another pressure sore. Now that the care has been implemented the next process is evaluation. This should be an ongoing process in patient care. It’s at this evaluative stage that the nurse can look at the effectiveness of the care plan. According to Hogston (1999) the two purposes of evaluation are to see if the initial assessment was correct and if the goal was realistic and achieved.
I went to see Ann on my final day of placement on the post operative ward; Ann had not developed any pressure sores whilst recovering. From looking through her charts I could see this was correct and documented. Therefore I feel my goal for Ann conformed to the SMART criteria and was successful in the best interests for the patient’s health. In conclusion this care study has enabled me to gain a better understanding of the nursing process and the need for a model such as the activities of daily living. The nursing interventions set out for Ann enabled her to stay free from pressure sores whilst in theatre and post theatre.
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