This essay is based on the Case study of a patient named as Mrs Ford. It will be written as a logical account, adopting a problem solving approach to her care. She is elderly and has been admitted onto a medical ward in the hospital, following a stroke. This essay analyses the care that she will receive and focuses on the use of assessment tools in practice. Interventions will be put in place directly relating to the assessment feedback and in line with best practice. Mrs Ford is a 70 year old lady who has been admitted following a stroke. She is accompanied by her husband. Mrs Ford is a fictional name used in this essay due to confidentiality (Nursing and Midwifery Council (NMC), 2010). A holistic approach to nursing care will be implemented and all dimensions of Mrs Ford considered during her admission, including all physiological, sociological and psychological aspects. Holistic nursing is healing the person as a whole, including the body, mind, emotion, spirit and environment, because everything is interconnected (Klebanoff and Hess, 2013).
The problem solving approach applied to her care is the process of clinical reasoning. Clinical reasoning is a complex thought process that analyses specific information and comes up with possible interventions before deciding on the best course of action (Simmons, 2010). Both Mrs Ford and her husband are anxious, and of their 3 children only one lives close by. Prior to admission Mrs Ford was independent and had been living with her husband in their own bungalow in a local village. She is a retired manager and was previously enjoying her retirement. The only medical history she has stated is hypertension occurring over the past 10 years of which she is on anti-hypertensive medication for. Mrs Ford is classed as obese with a BMI of 30 (WHO, 2006) and is currently presenting in hospital with a stroke. She has hypertension and is increasing in age which are the two most important predisposing risk factors for this type of vascular disease (Lindley, 2008, p.20).
Due to the stroke she has a left sided weakness called hemi paresis, which is paralysis of one side of the body (Waugh and Grant, 2014, p.182). On admission to the hospital ward Mrs Ford is handed over to the nurse on duty ensuring that confidentiality in line with the code of conduct is adhered to (Nursing and Midwifery Council, 2008). This is achieved by not conversing about sensitive patient information in a public place where others may hear, but in a designated or quiet area on the ward where the exchange cannot be overheard. The relevant paperwork will also be read through in accordance with Confidentiality and Data Protection (Department of Health, 2003 and The Data Protection Act, 1998). The nurse then gathers data relating to Mrs Ford using a variety of different applicable assessment forms. Assessment is the first step of the five stage nursing process which consists of detailed phases that are used as a framework for nursing care (Nursing Process, 2014).
Roper, Logan and Tierneys (RLT, 1996) Model of Nursing is made up of Activities of Daily Living (ADL), which consists of 12 activities. These are used to guide nurses to which assessment models could be completed for a patient. The RLT model of nursing brings theory and practice together clearly, incorporating the complexity of a person as a whole (Salvage, 2006). This collection and assessment of data can flag up any actual or potential problems. Care plans are then put in place and are re-evaluated as per guidelines. Specific tools used to gather relevant assessment data include the Waterlow, Falls and MUST assessment forms. Even though the use of standard nursing tools is employed, nursing itself must remain holistic and employ person centred care. Person centred nursing is treating each patient as an individual, respecting their personal beliefs and decisions and building a therapeutic relationship based on trust (McCormack and McCance, 2010, p.1).
This enables each patient to receive the best possible individual care and also helps to promote evidence based care rather than ritualistic care. Evidence based care is objective and does not use practices that are based on tradition and/or habit (Jolley, 2010, p.47). The National Institute for Health and Care Excellence (NICE, 2005) encourages Risk Assessment scores (RAS) to be used in conjunction with the nurses clinical judgement not instead of it. Mrs Ford is vulnerable and will need restorative care. A vulnerable adult is defined as someone over the age of 18 who is not able to look after themselves or protect themselves from harm and might need help from care services (Lord Chancellors Department, 1997). Although DOH et al. (2009) state that there are people who want to change the term vulnerable adult to a person at risk.
As stated by the Safeguarding Vulnerable Groups Act (2006), Mrs Ford is a vulnerable adult because she is elderly, needs assistance and has a new disability. She is anxious and knowing that the nurses are treating her individually and with compassion will make her feel safer. Although she is vulnerable and at risk there is nothing to indicate that Mrs Ford does not have capacity. Mental capacity is assumed unless proven otherwise and patients should be able to make their own decision even if it is an unwise one (Mental Capacity Act, 2005). Therefore Mrs Ford can make informed decisions and consent to all aspects of her care. With Mrs Ford’s consent, her family can be involved in her care and they may be able to assist with assessments through their knowledge of the patient. This will help empower both Mrs Ford and her family as they will feel more involved in her care and she will be able to contribute more with their help.
Mrs Ford will be assessed using the Waterlow tool. Pressure ulcer risk assessments are recommended to be carried out on all patients, specifically within 8 hours of being admitted to the ward (EPUAP, 2014, p.14). The Waterlow assessment tool is comprehensive and encompasses some previously unused concepts of risk, but some of the sections are open to interpretation (Papanikolaou et al., 2007). Many people say that the tool has a high sensitivity score but a low specifity score (Balzer et al 2007). Both of the previous statements suggest that some of the questions asked in the Waterlow tool may not be specific enough as nurses have to use their own judgement which can vary, therefore changing the risk score. Waterlow is the most widely used tool out of more than 40 different risk assessment tools (Thompson, 2005). Using the data collected, the Waterlow prevention tool indicates that Mrs Ford is at high risk (Waterlow, 2005c). She is having difficulty changing her position in bed or in the chair and has limited mobility in her left arm.
She has also been incontinent of urine since being on the ward and it is strongly recommended that preventative skin care is carried out, keeping skin clean and dry (National Pressure Ulcer Advisory Panel et al, 2014) . Both of these things are taken into account in the risk assessment score which indicates that preventative measures should be taken to ensure no tissue damage. Mrs Ford should not develop any pressure ulcers whilst in hospital because that would be negligent care. Mrs Ford will be ordered an alternating pressure mattress overlay and a specialist foam cushion as per policy (waterlow,2005c). Preventative nursing interventions will also include turning or moving Mrs Ford frequently at a minimum of 6 hourly, although there is not much evidence to guide us on the most effective frequency of position changes (NICE, 2014).
This will be done using the correct and most up to date manual handling techniques (Manual Handling Operations Regulations (as amended), 1992). The SSKIN bundle is an evidence based tool that is part of the ‘Stop the Pressure’ campaign that helps to prevent the occurrence of pressure damage and focuses on Surface, Skin inspection, Keep moving, Incontinence and Nutrition (NHS Midlands and East, 2012). This suggests that having a nutritionally high diet is very important in the prevention of pressure ulcers, along with having the right mattress and detecting pressure damage early (ibid). Nurses need to consider all dimensions including psychological when carrying out certain assessments for these tools. When checking patient’s skin integrity or when weighing a patient, dignity must be maintained. Dignity should be kept at all times and drawing the curtains around the bed space may protect modesty so Mrs Ford does not feel embarrassed and/or devalued (RCN, 2008, p.5).
Mrs Ford will also be assessed using the inpatient falls assessment tool. The National Institute of Clinical Excellence (2013, p.15) do not agree with falls risk prediction tools but state that all patients over 65 should be regarded as at risk. Taking this into account, because she is over the age of 65 which NICE (2013) states has the highest risk of falling, the nurse will undertake a multifactorial falls assessment. Using the appropriate multidisciplinary assessment for falls is the key to falls prevention and intervention (Kenny et al., 2013) The results from the assessment indicate she is at risk because she is currently having difficulty walking, is on anti-hypertensive drugs and her clinical observations are indicating postural hypotension. Her other observations are all ok and the variation between her lying and standing blood pressure will be recorded on her National Early Warning Score chart (NEWS, 2012).
Certain interventions will be put in place including ensuring that Mrs Ford is wearing well fitting, non-slip slippers and that there is no clutter around her bed space for her to trip over. She also must have her call bell easily to hand and a pressure sensitive alarm could be considered if needed. The physiotherapists will help her with exercises to maintain muscle strength and adapt and/or realise her new limitations, and staff will assist her when mobilising in general. Drinking lots of fluid will also help keep her blood pressure up so she does not feel faint. Mrs Ford will be assessed using the Malnutrition Universal Screening Tool (MUST) because all patients who come into hospital are screened to identify adults at risk of malnutrition or who are obese (BAPEN, 2011). Stratton et al. (2006) state that the MUST tool is easy for people to use.
The MUST tool can also be used to measure the height and weight of patients that were unobtainable but can now be measured using alternative measurements such as using the ulna length to calculate height (Todorovic, 2003). Collective subjective criteria such as loose fitting clothing or dysphagia is also used to estimate nutrition risk with patients who may not be able to give a history (ibid). Using the MUST screening tool indicates that Mrs Ford is at a high risk of malnutrition because she is acutely unwell and may not have a good nutritional in take for 5 days. Difficulty in swallowing called dysphagia can cause implications such as an inadequate food intake leading to malnutrition (Gariballa, 2000). She will be referred to the Speech and Language Therapist who will assess her swallow reflex to ensure she is safe to eat. SALT may recommend a soft or puree diet for her.
Mrs Ford is managing to drink ok but if no intervention is made with her eating her nutrition may suffer. EPUAP (2014, p.53) state that bariatric patients should be seen by a dietician as they may be malnourished despite being obese. The dietician may prescribe some supplements if needed. Supplemental high energy density drinks such as Fortisip Compact by Nutricia could be beneficial as they increase calorie intake and ultimately weight (Hubbard, et al. 2009). Mrs Ford may also need help with eating as she has weakness in one arm. A food chart would be commenced for 3 days to ensure adequate dietary intake and then she would be reassessed after the 3 days, or before if necessary. Tuckman’s team development model identifies that teams need to work through processes effectively together, taking into account others feelings in order to achieve the objectives (Tuckman, 1965).
This includes multi disciplinary teams working together and also the patient and nurse team working together. Due to the stroke Mrs Ford has slurred speech which is making communication difficult for her. Nurses have to work together as a team with other health care professionals in a multi disciplinary setting so referring Mrs Ford to a speech and language therapist may help her with her difficulty in communicating. Mrs Ford will be monitored whilst in hospital and asked if she has any pain, in line with best practice. Nelson’s (2014) study characterizes the best practice concept as being a recommendation that is based on a quality-focused outcome promoting effectiveness. As Mrs Ford is having difficulty with her speech she may wish to convey her level of pain using pictorial or numerical aids. She could be asked to scale her pain from one to ten so that the nurse can effectively understand the level of pain she is in, so the doctor can prescribe the correct pain medication if any is needed.
Assessment tools used in practice are an effective way of ensuring a universal baseline for good care as long as they are used in partnership with patient centred care. The tools used for Mrs Ford have enabled the identification of a falls risk, a pressure ulcer risk and a nutritional risk. This has enabled the following interventions to be put in place. Staff will assist Mrs Ford when mobilising and the physiotherapists will also work closely with her. She will be assisted to change position frequently and will be supplied with a specialised mattress and cushion to relieve pressure. Mrs Ford will wear non-slip slippers that fit well, will have her call bell within reach and will have no clutter around her bed. She will be encouraged to drink plenty of fluids and may be assisted with her diet. The interventions have worked well and have protected the patient from harm. She has been referred to the physiotherapist, the dietician and the speech and language therapist within the hospital as it is a multidisciplinary setting. This has helped to ensure that no harm has come to the patient whilst in hospital and her admission will not be prolonged.
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