My intention within this assignment is to focus upon the assessment of an individual patient which was in my care whilst on my clinical placement. This assignment is built up of two parts; the first part is the assessment process for this patient so that when the patient is in a health care setting their needs and health conditions are all met. There will be a holistic approach in order to make sure that all areas are covered, so that every area of the patient’s health and wellbeing is assessed.
To make sure this is covered correctly I will be using Roper el al (1980) 12 activities of daily living. The framework for this is very straight forward and most nursing hospital assessments are formed around this. This is because it is a good way of measuring a patient’s capability while they are in your care. The second part of the assignment will discuss a nursing intervention which I helped to deliver to meet a goal of care for the patient. It is important to address that for legal and ethical issues these include confidentiality.
As part for the Nursing and Midwifery Council Guidelines (2002) on confidentiality the name of the patient within this assignment will not be named because of this reason for this assignment the patient will be revered to as Mrs A. (www. nmc-uk. org) Before a full nursing assessment can be done using the 12 activities of daily living (1980) a look at Mrs A full past and current medical history. Mrs A is an eighty seven year old retired women, she is 5 foot 4 inches and is a weight of 8 stone on admission this gives her a healthy body mass index of 18.9.
She was admitted to the ward for why she has dizzy spells. She has Bradycardia that turned to sinus node dysfunction and in 1997 she had an artificial pacemaker fitted since there have been no problems, she also has Irritable bowel syndrome(IBS), a weak bladder, xerosis on both legs with an open wound to right leg, Mrs A clinical observation when admitted to the ward were; blood pressure of 149/58 65 beats per minutes respiratory rate 14 temperature of 36. 4 and oxygen saturations 98% this shows her vital signs are in normal range.
All of the information that was needed was collected from the patients Mrs A, who answered the questions that needed answering but the information that was collected from her medical note. All of this information in a elected form was much better that just one set of information in finding out all the information that is needed to makes a full assessment. To start the assessment the first activity of living that maintaining a safe environment this includes everything that is around her that could have an impact on her health.
As she is in hospital which is a working building, the Health and safety act (1974) (www. se. gov. uk) plays a big part in this and if this is followed then there should be no problems. She doesn’t smoke so she does not have that environmental factor in her life. Also to maintain a safe environment psychosocial factors need to be addressed such as different behaviours or inappropriate fears she has none of these. The next part of activity of living is communicating, this is a very important part of a nursing assessment as to find out how a patient is feeling and thinking this can be very difficult if communication can’t happen in a normal process.
She has no sight or hearing problems and is able to communicate verbally easily. The only problem is that she a shy and private person that doesn’t enclose easily while discussing personal matters this should be taken with a respect. The next activity of living is breathing, we know from Mrs A admission her respiration rate is 14 if this was to change at anytime this could indicate any sort of health problems that could affect her such as a chest infection.
Also as part of this as a nurse to provide the right care harmful factors such as pollution, chemicals and any other things that can go in to the air which could affect her breathing should be eliminated. Eating and drinking need to be fully discussed as she have some dietary requirements due to cultural, religious or health reasons. She does not have any of these, but because of her Irritable bowel syndrome she try’s to avoid foods that are spicy, tea, coffee and alcohol as these makes the symptoms worse.
To makes sure this happens is to makes sure when she is ordering her meals she knows what is contained, a jug of water will be given to keep hydrated. Overall it is very important to make sure that she is eating and drinking to make sure her health doesn’t deteriorate. The next stage of the model that follows on from this is eliminating, as she has IBS she needs to be close to a bathroom in case she has the sudden need to open her bowel as this can be very unpredictable. She also has a weak bladder and is sometimes incontinent; at home she wears incontinence pads which she has with her.
As with all areas in this model they are all linked together as mobilising can easily carry on from eliminations, as she must be able to mobilise to the bath room, normally she is mobile with a stick since these dizzy spells causing her to fall she now needs assistants with one person to walk along side her. Also because of the wound on her leg this is causing a bit of pain that is making normal mobility hard. She had the aid of the nurse call bell so that she can get assistants from the nursing staff.
Personal hygiene and dressing is very important as bad hygiene can cause skin infections. When discussing Mrs A normally has a shower every other day, she tries not to use soap with a moisturiser in to help keep the skins natural PH as she has mild xerosis on her legs. At home she normally is independent with all her hygiene needs, but due to the dizzy spells and seizures she needs someone to be with her at all times to make sure that she doesn’t fall, to help with things that she may need to bend down and washing her hair also makes her feel dizzy.
She has expressed that she doesn’t want a male nurse/support worker helping with any of her hygiene in order to keep her dignity and privacy, she also would like to change her clothes every day and to wear clothes in the day and night wear when going to bed. The next part of the model is controlling body temperature, this can be done by checking temperature when vital signs are done also asking how she feels, if she is cold maybe getting her a warm drink or blanket around her to keep her warm.
Also making sure the heating is right or if the window is open, and if she is to warm maybe proving a fan or a cool drink. The body temperature should be monitored to make sure there are no signs of infection. Working and playing is part of the model due to the fact depending on the job that they do can have an impact on their health. Mrs A is a retired who now spends her time going to church, or with friends and family. As she is in the hospital she can still see her family when they come to visit her, she can go to the chapel at anytime if she wishes.
Sleep is a very big thing when staying in hospital as it can help aid healing and recovery from illnesses. This should be discussed to find out her norm, she said that she has no problems with sleeping and normally sleeps for 6 hours a night as she is a light sleeper Expressing sexuality can sometimes be embarrassing for some patients and staff to talk about but it is important to discuss as this could have an impact on their medical condition.
Mrs A has been married for 65 and still lives with her husband, they are still sexually active but since the dizzy spells this has stopped but she said she is ok with that as she wants to get better first. While Mrs A is in hospital she wants to express her femininity by wearing makeup and perfumes, it was explained that it wise that it is fine as long as the perfume is not offending any other patients and that some medical tests she may need to take her makeup off, she is fine with that.
Death may be a very difficult thing to talk about but it may be appropriate to talk about it in order to find out views and feelings that the patient may have. She is not ready to die, but if it did she has a will so that her family know her wishes. She believes in the Church of England and that she will go to heaven when she dyes and is very comfortable to talk about it. As part of her care it is very unlikely that she should die while she is in the hospital for her condition, but it has been expressed to her that some tests do carry risks and these will be discussed with her if these tests need to be carried out.
By following the 12 actives of living (Roper et al 1980), I believe that all areas are covered within my assessment. When doing any assessment communication needs to be considered as the way in which we communicate can have an impact on the information that is collected for the assessment as a good relationship needs to be established between nurse and patient (Ashworth 1980). To make sure this happens non-verbal and verbal communication should be taken in to consideration.
When assessing Mrs A my own non-verbal communication was open and relaxed throughout the assessment, this made she sit in the same sort of manner so that we could both have good eye contact and it made answering the questions very easy for Mrs A as she could tell that I was engaged and listing. The assessment was done in a separate room so that there were no distractions and Mrs A didn’t feel embarrassed about talking openly. This was done to make sure that her privacy and dignity was kept, otherwise this could have been a barrier to communication if the assessment questions were asked in a bay of patients.
Overall me and Mrs A both had good communication skills so conversations was made easy. From all the information in the assessment one problem has been chosen as the goal of care for Mrs A this is been the open wound on her leg. The reason for this because it is affecting her mobility and it is very important to try and make sure this doesn’t decrease or that the wound doesn’t get infected due to the environment that she is in.
If the wound does affect her mobility one of her 12 actives of living (Roper 1980) will soon start to affect other things such as breathing as there is a higher risk to get a chest infection, also elimination can change as more likely to suffer from constipation if having a loss mobility and pressure sores. Before any sort of nursing care is implicated it is very important to make sure that a full nursing process is followed (www. nursingavenue. com). This has five stages that help problem solve, the first part is to assess the patient and gather information.
Some of this has already done when following the 12 activities of living (Roper 1980). The next stage is to identify the problem, this being that there is an open wound on Mrs A’s lower right leg, from looking at it there are signs that this could be a Venous leg ulcer as there is a slight bit of welling on the leg, it has brown staining from the ankle to the knee. To ensure the right diagnosis before treatment medical staff will have to review and she will be sent to a radiographer for a Dopper Ultrasonography which assesses the supply of blood in the legs, this will help make sure Mrs A gets the correct treatment.
These results do show that there are problems with the circulation system in her leg indicating that it is a venous leg ulcer. Also a part of this we need to find if she has any complaints about her leg, she says that there is some itchiness but she is not sure if this is due to the xerosis. The main complaint is that she does have some pain, in order to measure this a visual aid is used supplied by Activea Heathcare Ltd. who are a wound care supplier (shown in Appendix 1), this has been adapted from Mcaffrey et al (1989) measurement scale.
Using this Mrs A was able to easily describe her pain using words saying that it is annoying, just to make sure that it was right using the face pain score on the other side by Wong et al, all though it was made for paediatric nursing it is still relevant as some people find it much easy to relate to faecal expressions. From this assessment the pain score was five, this is now a medical thing as they will need to prescribe some analgesics in order for nursing staff to help with the pain.
The next stage of the nursing process is a plan of care; these must have goals in to meet. These goals must be SMART goals, this means that they should be specific, measureable, attainable, realistic and timely (www. scribd. com). For Mrs A the nursing intervention specific goal is to make this open ulcer on her leg to heal. This will be measurable as it is a visible thing to monitor, but to make sure that it is healing measurements of the ulcer will be taken. Also we can measure this from the pain that it is cursing as hopefully as the ulcer heals the pain goes down.
This can be monitored using the pain measurement scale (McCaffery 1989). This then must be an attainable goal, as the ulcer is small with the correct implementation it should work, but if the ulcer gets infected or Mrs. A picks at the ulcer or scratches it too often this could stop the healing process. This goal is realistic as many leg venous ulcers renew back to normal healthy skin if they are treated correctly. The time goal for this is nine days but the dressing must be changed every three days.
This is a short term goal as this can be achieved as she is in hospital. A long term goal for Mrs A is to keep up good maintenance of her skin on her legs by making sure that her xerosis doesn’t get severe as when the skin becomes cracked then she is likely to get another ulcer. This is ongoing as her xerosis is unlikely to go away. Mrs A will be able to attain these following through different guidelines, these being that she tries to avoid having a bath longer than fifteen minutes and showered instead.
Not to use hot water, and when drying not to rub hard on the skin and to pat dry, using Ph balance soap that she already does and moisturize straight after the shower, also if she keeps hydrated this will help the skin. This is a realistic goal for Mrs A as she already has a good hygiene routine and it will not be hard for her to change bits of it. To makes sure that she doesn’t forget she has been given a leaflet and family members have been told. We will know if this works if she doesn’t need to seek medical help for leg ulcers again.
These two different goals identify actual and potential problems that are related to the leg ulcers (Hamilton et al 2007). The plan of care of what is going to happen to help treat this leg ulcer needs to be evidence based so that we know that there is a reason for what is going to be done. The first thing that is going to happen is to make sure that the right dressing is chosen, to makes sure this is done correctly the NICE guidelines must be followed this means that there is necrotic tissue, does it have the ability to heal as if not this will change what dressing is used.
The I is for an infection swab to be taken first to make sure that there is no infection, from looking at this there are no visual signs such as heat or redness, as not all dressings can be used for infected wounds. C stands for characteristics as location of the ulcer needs to be considered as this may change what dressing is used and how many times it needs to be changed. The E stands for exudate meaning the colour and size can determine if it has been treated before or not or even if it indication any other problems like bad nutrition or venous insufficiency (Baranoski 2008).
Following the NICE guideline and consulting with a tissue viability nurse the conclusion was to use a dressing called Atratuman for Mrs A’s ulcer as the ulcer is a bit dry but open to this is a Hydrofiber dressing as it is covered in an oil based product to help keep the moisture in. A study by Paul Hartmann from the Department of dermatology at the university of cologne showed that ‘Atrauman is an effective wound dressing for the management of infected or prone infected wounds this includes ulcers’ (http://ewma. org/fileadmin).
The reason for this is because it has silver in it which can help keep out infection for up to seven days. It can also be used for stage one pressure sores, ulcers to third degree burns. From using Panye martins classification of skin tears we can identified that Mrs A’s ulcer is a category 1. ( Baranoski 2008) The Atratuman dressing is water based so it should stay dry better than other dressings, when the dressing is changed due to the surface structure new epithelium will not be damaged. It is also easy to apply to an ulcer on the front of the lower leg.
This must then be covered with gauze dressing to help keep the Atratuman in place, and dry if it does get wet. As it is a venous leg ulcer the next thing to help with healing is not to tape the Gauze to the leg but to rap the leg up in a compression bandage to hold the dressing to the leg and help the flow of blood, also Mrs A should try and keep the leg levitated to help. (Benbow 2005) The bandaging that will be used is Soft Ban first as it is confusable for the patient as it moves to the contours of the patients body, also if it needs to be taken off quickly it is easy tear.
The next bandage is to use K-lite this is what helps compress the leg. As it is to apply and it is light weight commutable for the patient and also help apply a light compression to the leg. ( http://www. spservices. co. uk) It is very important that the dressing is comfortable as it is going to stay on for at least seven days as long as the dressing stays intact. Now that the planning is done the next part of the nursing process is to carry out the plan, when dressing an open leg ulcer aseptic technique should be use so that inflection is kept to a limit.
This is done with good hand washing and using serialised equipment, first wash the nursing table that is going to be used thoroughly then get all equipment and take it to where the nursing invention is going to take place. Make sure Mrs A leg is washed and dry, then wash hands and put sterilised gloves on correctly, then set up the table, cut the Atratuman and gauze to correct size then making sure you have a clean hand and clean the ulcer with saline fluid and a cotton gauze.
Then get the atrauman to the ulcer, try to peel the protective film away without touching the atrauman to keep it aseptic. Then place the gauze on top and get the soft ban and starting at the toe wrapped the bandage round the leg going up the leg, to make sure that it was not to lose or tight when wrapping the leg when gone under the leg give it a little tug and put my finger on top of the leg and wrap over it and take it out so that it was not too tight. Then the K-lite is applied the same way and making sure to just go from toe to knee and using some tape at the top to secure it.
Then make sure that it is ok for Mrs A then all equipment is cleaned up correctly and hands are washed. After the nursing intervention process has taken place this process needs to be evaluated in seven days when the leg may need to be redresses. After seven days the dressing was taken off and the leg ulcer had got so that this process had worked for Mrs A. When I personally evaluate the nursing possess that took place for my first placement I was glad I got this opportunity to carry out an aseptic wound dressing all by myself with the guidance of senior staff.
I do believe that I need more practice at both my aseptic technique and with my compress dressing even thought it did stay on for 7 days without falling off as I am worried that that might just be beginners luck and with more practise I will feel a lot more confidence. Even though this nursing process did sort out Mrs A’s Leg ulcers I would need to make sure that I have got enough evidence on how to dress leg ulcers. Overall I am very proud of what I have achieved and that in the end my patient was very happy and the problem was solved.