Assessment and Care Planning: Holistic Assessment

IntroductionThis essay deals with the holistic taskment of a affected role role who was admitted onto the medical ward where I undertook my partment. Firstly, the relevant life autobiography of the diligent leave be briefly excuseed. Secondly, the Roper, Logan and Tierney forge of breast feeding that was apply to assess the c be postulate of the diligent will be discussed, and then the legal opinion process will be analysed critically. Identified areas of need will be discussed in relation to the distribute given and with reference to mental, complaisant, and biological factors as rise up as patho-physiology. Furthermore, the role of inter-professional skills in relation to attending g inhabiting and deli actually will be analysed, and finally the superintend given to the persevering will be evaluated.Throughout this assignment, confidentiality will be keep to a postgraduate standard by following the care for and midwifery Council (NMC) enrol of manage (2008) . No in embodimentation regarding the hospital or ward will be menti wizd, in accordance with the Data Protection Act 1998. The pseudonym Kate will be use to maintain the confidentiality of the forbearing.The PatientKate, a lady sr. 84, was admitted to a medical ward through the Accident and Emergency department. She was admitted with asthma attack attack and a titty infection. She presented with severe dyspnoea, wheezing, chest tightness and immobility. Kate is a long-suffering known to suffer from chronic chest infections and asthma, with which she was diag perfumed when she was young. She takes regular bronchodilators and corticosteroids in the plaster bandage of inhalers and tablets. Kate extends on her own in a one bedroom flat. She has a daughter who lives one street a counsel and visits her frequently. Her daughter stated that Kate has a rattling active social life she enjoys going out for obtain using a shopping trolley. legal opinion of the PatientAssessment The oryIn this ward, the Roper, Logan and Tierney model of nursing, which reflects on the xii activities of living, is used as a base for assessing unhurrieds (Alabaster 2011). These activities are maintaining safe environment, communication, lively, eating and drinking, elimination, individualized cleanse and dressing, dictationling organic structure temperature, mobility, working and playing, sexuality, sleeping, and dying Holland (2008, p.9).Elkin, Perry and Potter (2007) adumb send nursing process as a systematic way to devise and deliver care to the diligent. It involves four stages perspicacity, planning, implementation and evaluation. Assessment is the prototypic and just some critical step of the nursing process, in which the foster carries out a holistic assessment by collecting all the info nigh a long-suffering (Alfaro-Lefevre 2010). The nurse uses physical assessment skills to obtain baseline info to manage endurings problems and to dish up nurses in th e evaluation of care. Data tramp be lay in through observation, physical assessment and by interviewing the tolerant (Rennie 2009). A complete assessment produces both intrinsic and tar carry area findings (Wilkinson 2006). Holland (2008) defines subjective data as information given by the patient. It is obtained from the health history and relates to sensations or symptoms, for simulation pain. Subjective data as well includes biographical data such as the name of the patient, address, following of kin, religion etc. Holland defines objective data as observable data, and relates it to signs of the disease. Objective data is obtained from physical examination, for eccentric of blood pressure or urine.Before assessment takes identify, the nurse should explain when and why it will be carried out allow adequate while attend to the needs of the patient consider confidentiality ensure the environment is contributive and consider the coping patterns of the patient (Jenkins 200 8). The nurse should as well as introduce herself to answer reduce concern and gain the patients confidence. During assessment, the nurse needs to use both verbal and non-verbal communication. Using non-verbal communication means that she should key the patient, looking at the colour of the unclothe, the eyes, and taking none of odour and living. An finished assessment enables nursing staff to prioritise a patients needs and to deal with the problem immediately it has been identified (Gordon 2008). Documentation is also very substantial in this process all information stash away has to be recorded either in the patients commove or electronically (NMC, 2009b).Carrying out the AssessmentKate was allocated a bed within a four-bed female bay. Her daughter was with her at the bedside. Gordon (2008) stated that understanding that any entry to hospital atomic number 50 be frightening for patients and allowing them some time to get used to the environment is classic for nursin g staff. Kates daughter was asked if she could be present while the assessment was carried out, so that she could help with some information, and she agree. Alfaro-Lefevre (2008) recommended that nursing assessments take place in a separate room, which respects confidentiality, and that the patient be free to participate in the assessment. Although there was a room available, Kates daughter said it was fine for the assessment to take place at the bedside because her mother was so restless and just wanted to be next to her. The curtains were pulled around the bed, though William and Wilkins argued that it ensures visual privacy only and not a barrier to sound. NMC (2009a) acknowledges this, along with the need to speak at an steal volume when asking for person-to-person details to maintain confidentiality.The assessment form that was used during Kates assessment address private details and the twelve activities of living. A moving and handling assessment form was also finish beca use of her immobility. First, personal details such as name, age, address, nickname, religion, and housing status were recorded. cultivation was also recorded about any agency regard, along with next of kin and contact details, and details of the general practitioner. Holland (2008) stated that these details should be accurate and legible so that, in grimace of any concerns about the patient, the next of kin can be contacted easily. The name and age are also vital in entrap to correctly identify the patient to avoid mistakes. Knowing what type of a job the patient does or the type of the house she lives in helps to indicate how the patient is going to consider afterwards discharge. Holland also insisted that religion should be known in case the patient would like to have some privacy during prayers, and this should be include in the care plan.The second assessment to be done center on physical assessment and the activities of living. Barrett, Wilson and Woollands (2009) sugge sted that when enquiring about the activities of living, two elements should be addressed usual and current routines. Additionally, identifying a patients habits will help in care planning and setting goals. During physical assessment, when objective data was collected, Kate demonstrated laboured and audible breath sounds (wheezing) and breathlessness. Use of accessory muscles and nose flaring was also noted. She was agitated and anxious. Her vital signs were blood pressure one hundred ten/70 thump 102 beats /min respirations 26/min temperature 37.4 degrees Celsius type O saturation 88% peak flow 100 litres weight 60kg and body mass index 21. Taking and recording observations is very important and is the initial procedure that student nurses learn to do. These observations are made in order to detect any signs of deterioration or progress in the patients condition (Field and Smith 2008). Carpenito-Moyet (2006) stated that it is important to take the first observations ahead any medical intervention, in order to assist in the diagnosis and to help assess the effects of treatment.Kates initial assessment was carried out in a professional way, taking account of the patients particular circumstances, anxieties and wishes. afterward the baseline observations were taken, the twelve activities of living were analysed and Kates needs were identified. Among the needs identified, existent and personal hygiene (cleansing) will be explored.Identified Care NeedsBreathingWilkinson (2006) states that a nursing diagnosis is an account about the patients current health situation. The modal(prenominal) vivacious rate in a fit adult is 16-20 respirations/minute, but can go up to 30 due to pain, anxiety, pyrexia, sepsis, sleep and overage age (Jenkins 2008). In old plurality, muscles become less efficient, resulting in increasing efforts to breathe, causing a high respiratory rate. On assessment, Kates problem was breathing that resulted in depleted intake of air, due to asthma. She was wheezing, cyanosed, anxious and had shortness of breath.Wilkinson (2006) explained that a goal direction is a quantifiable and noticeable criterion that can be used for evaluation. The goal statement in this case would be for Kate to maintain normal breathing and to increase air intake. The prescription of care for Kate depended on the assessment, which was achieved by monitoring her breathing rate, rhythm, pattern, and saturation levels. These were documented hourly, comparing the readings with initial readings to regard changes and to report any concerns. The other part of the plan was to give psychological care to Kate by involving her in her care and informing her about the progress, in order to reduce anxiety. Barrett, Wilson and Woollands (2012) stated that it is very important to give psychological care to patients who are dyspnoeic because they panic and become anxious.Checking and recording of breathing rate and pattern is very important because it is t he only earnest way to assess whether this patient is improving or deteriorating, and it can be a very helpful method for nurses to evaluate whether or not the patient is responding to treatment (Jamieson 2007). Mallon (2010) stated that, if the breathing rate is more than 20, it indicates the need for type O. Blows (2001), however, argued that this can happen even after doing exercise, not only in slew with respiratory problems. Griffin and Potter (2006) stated that, respirations are normally quiet, and consequently if they are audible it indicates respiratory disease. Nurses needs to be aware of these sounds and what they mean, for example a wheezing sound indicates bronchiole constriction. Kates breathing was audible and the rate was also above normal and that is why breathing was prioritised as the first need.Oxygen saturation level was also monitored with the use of a pulse oximeter. The normal saturation level is 95-99% (British National formulary ((BNF)) 2011a). Neverthel ess the doctor up said that 90-95% was fine for Kate, considering her condition and her age. Kate was started on two litres of oxygen and she maintained her oxygen saturation between 90 and 94%. The peak expiratory flow was monitored and recorded to identify the obstructive pattern of breathing that takes place in asthma (Hilton, 2005). This is another method that is used to assess the long suit of the medicine (inhalers) the asthmatic patient is taking, and this test should be carried out 20 minutes after medication is administered. It is the Trusts policy to do hourly observations on patients who have had one, two or three aberrant readings, until readings return to normal. Kate was observed for any blueness in the lips and tongue and for vocal mucosa as this could be a sign of cyanosis. All the dictate nebulisers, inhalers, bronchodilators, corticosteroids, antibiotics and oxygen therapy were administered tally to the doctors instructions. Bronchodilators are given to rar ify the bronchioles constricted due to asthma, and corticosteroids reduce inflammation in the airway (BNF 2011b). Kate was also started on antibiotics to combat the infection because, on auscultation, the doctor found that the chest was not clear.Kate was nursed in an upright position using pillows and a profiling bed in order to increase chest efficacy and facilitate easy respiratory function by use of sobriety (Brooker and Nicol, 2011). In this position, Kate was soft and calm while other vital signs were macrocosm check out. Pulse rate and blood pressure were also being checked and recorded because raised pulse can indicate an infection in the blood.CleansingDue to breathlessness and loss of mobility it was difficulty for Kate to maintain her personal hygiene. Hygiene is the exercising of cleanliness that is needed to maintain health, for example bathing, mouth washout and hair washing. The skin is the first line of defence, so it is vital to maintain personal cleansing to protect the inner organs against injuries and infection (Hemming 2010). Field and Smith (2008) stated that personal cleansing also stimulates the body, produces a sense of well-being, and enables nurses to assess the patient holistically. Personal hygiene is particularly important for the ripened because their skin becomes lean and more prone to breaking down (Holloway and Jones 2005). Therefore this need was very important for Kate she needed to maintain her hygiene as she used to, before she was ill.The goal for meeting this need was to maintain personal hygiene and comfort. The care plan prescribed involved first gaining consent from Kate, explaining what was going to be done. Hemming (2010) recommended that identifying the patients usual habit is very important because to each one individual has different ideas about hygiene due to age, culture or religion. Identifying usual habits helps individuals to maintain their social life if things are done gibe to their wishes. Tho ugh Hemming said all human beings need personal hygiene, Holland (2008) argued that it is important to ask patients how they feel about being cleaned, especially in secret areas. Kate indicated that she didnt mind being assist with washing and dressing. She preferred washing daily, shower and a hair wash once a week, and a mouth wash every morning and before going to bed.Kate was assisted with personal care 5-10 minutes after having her medication, especially the nebuliser. Individuals with asthma learn shortness of breath whenever they are physically active (Ritz, Rosenfield and Steptoe 2010). After having medication Kate was able to participate during personal hygiene. According to NMC guidelines on confidentiality (2009a), privacy and self-regard should be maintained when giving care to patients. Therefore, whenever Kate was being assisted with personal care, it was ensured that the screens were closed and she was properly covered. Field and Smith (2008) suggested that assisti ng a patient with personal hygiene is the time that nurses can assess the patient holistically. Since Kate was immobile, it was very important to check her pressure areas for any redness. She was also checked for any pallor, jaundice, cyanosis or dry skin that needed attention. The care was always carried out according to her wishes.The Role of Inter-Professional SkillsConsidering Kates age and condition, she needed multi-professional squadwork. NMC (2008) encourages teamwork to maintain good eccentric care. Kate was referred to the respiratory nurse who is specialised in helping people with breathing problems. Since Kate was on oxygen since admission, the respiratory nurse taught her the importance of healthy breathing and taught her some breathing exercises to help wean her from oxygen. Kate was also referred to the physiotherapist who did breathing exercises with her. Kate was not able to walk without aid so she was also referred to the occupational therapy department to assess how she was going to manage at sign, or if she infallible aids to help her manage the activities of living. Upon meeting together, all the multi-disciplinary team agreed that Kate needed a care package, as she could no longer live without care. She was referred to social services so that they could assess this aspect of Kates future.After one week Kate was medically fit but could not go home because she was waiting for the care package to be ready. Her nurse dual-lane information with the multi-disciplinary team in order to establish continuity of care for Kate. The team prepared for her discharge the occupational therapy staff went to visit her home to check if there was enough space for her walking frame social services arranged for a care package and her nurses referred her to the district nurse to help her with her medication and make sure it did not run out.OutcomeKate responded well to the medication she was prescribed normal breathing was maintained, her respirations beca me normal, ranging from 18 to 20 respirations per minute, and her oxygen saturation ranged from 95% to 99%. Kate was able to wash and dress herself with nominal assistance. She was discharged on a continuous care package comprising care three times a day, and the district nurse helped her with the medication to control her asthma.EvaluationThe model of the twelve activities of living was followed successfully on the whole. The nurse collected subjective and objective data, allowing a nursing diagnosis to be formulated, goals to be identified and a care plan to be constructed and implemented. Privacy is very important in carrying out assessments, and this was not achieved fully in Kates assessment. However, this lower level of privacy has to be balanced against causing anxiety to the patient. Kates daughter thought that the bedside assessment would be more comfortable for her mother, and therefore cause least anxiety. This was very important because of the effects of effectiveness panic on breathing therefore, this was the correct balance to strike.A multi-disciplinary team was involved in meeting Kates care goals. This is a good example of the use of inter-professional skills, as a number of different departments were involved in creating and implementing the care plan. However, the system was not as efficient as it should have been Kate spent unnecessary time in hospital after recovery because the care plan was not yet in place.Assessment can also take a long time, especially with the elderly who are usually slow to respond. Therefore, more time is needed to be sure that the necessary progress has been achieved before taking further steps. However, myopic staffing also affects performance in this area, an observation supported by the gallant College of care for (2012).In conclusion, the assessment of this patient was completed successfully, and the deviation from beat practice recommendations (the lower level of privacy) was justified by the clinical ci rcumstances. draw close from assessment to care goals was good, and at this point an inter-disciplinary team was used successfully. However, the one flaw in this process was delays, caused partly by the difficulties of working crosswise different departments, and partly, it seems, by staff shortages.Reference ListAlabaster, C.S (2011) Care and renewal of people with long term conditions in Brooker, C. and Nicol, M. (eds) (2011) Alexanders nurse Practice (4th ed). capital of the United Kingdom Churchill Livingstone.. Chapter 32AlfaroLeFevre, R. (2008) minute thinking and clinical perceptiveness A practical approach to outcome-focused thinking (3rd ed.). 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