Paper on Two Aspects of Care Delivery in Nursing
Paper on Two Aspects of Care Delivery in Nursing
All aspects of care delivery in nursing are underpinned by government frameworks and guidance from accredited bodies such as The National Institute for health and Clinical excellence (NICE) and the Department of Health (DoH). For this assignment, it was necessary to choose a patient I have cared for as part of my placements in my final year, select two aspects of their care needs and analyse the care management through any clinical decisions made and to back up why the care was given a certain way with relevant research in addition support the information found with any legal or ethical issues that may have arisen. In line with the Nursing and Midwifery Council's Code of Conduct, to ensure confidentiality is upheld throughout this assignment, no actual names of the patient, staff or the placement ward's names will be used (NMC 2008).
My patient who will be referred to as Mr X, is a 78 year old gentleman who was transferred to my ward from the medical admissions unit, who informed me that the reason for admission was due to him having suffered a cerebrovascular accident (stroke) at home resulting in a right sided weakness and slurred speech - partial aphasia, in addition they also discovered he had reddened and broken area to his Right heel finally that due to the current condition of the patient, he would be in need of a carewave mattress and possibly gel cushion for his heels.
When Mr X and his wife arrived on the ward, my mentor informed me I would be the named nurse and asked me to admit the patient and complete any care plans and assessment charts I believed would be relevant for him. Through talking to his wife who had accompanied him on admission, I discovered that Mr X was right handed, and so due to his weakness, it would hinder his capabilities to feed himself properly, therefore I decided to complete a nutritional assessment, as recommended by the National Collaborating Centre for Acute Care to document his current status in addition to provide a baseline for evaluating his nutritional needs during his stay in hospital (NCAC 2006).
Furthermore following his stroke, I thought that due to his slurred speech, his swallowing ability may have been affected which in turn may result in a certain level of dysphagia (Child 2001), being aware of my own knowledge limitations I decided to ensure the patient received the best care I would need the help of other members of the Multi Disciplinary team, and so in line with the NICE Quality Standard in regards to stroke, states that within four hours of admission the patient is to have their swallow assessed by a specially trained healthcare professional (NICE 2011), and so because of this, I completed two referrals one to the Speech and Language team in the hospital to come and assess his swallow also they are able to advise on posture also give the patient exercises to strengthen their swallow. Along with this, I also completed a referral to the dietician as his diet and fluids may have to be modified (Dougherty &Lister 2008), such as soft diet and thickened fluids moreover he may need nutritional supplements such as fortisips , etc. Whilst waiting to hear back from the specialists I reproached the possibility of Mr X having to be given assistance with feeding with his wife, explaining that her husband may not like the idea of one of the staff feeding him due to them being unfamiliar to him and asked if she would be able to come in at meal times to assist in turn minimising the impact on Mr X’s self esteem (Green2006). I also explained to his wife we would be able to offer assistance and advice when she needed it, in regard to correct sitting posture to feed a patient.
By early afternoon that day, the Speech and Language Therapist came to the ward to complete an assessment of Mr X. She determined that initially, his swallow was not safe and following their protocol he was to be Nil by mouth and that the Dr’s needed to canulate the patient so he could receive Intra venous fluids to maintain hydration (Harwood 2005). She also advised that when the patient’s swallowing improved, she recommended that he be started on a puree diet with gravy and to initially start on level three thickened fluids to reduce chance of aspiration also due to the thickness, the fluid would have to be given using a spoon (O’Leary 2010).
Furthermore I was advised that the therapist would come and re-assess on a daily basis and that I should inform her of any change in his condition in addition, that once the patient is able to tolerate this and there have been no issues then the level will be reduced slowly or even returned to the next highest if needed. The dietician who was also present added to the advice that when the patient was able to start oral intake, that she would prescribe fortcreme complete to ensure should the patient decline his food at least we would be able to have eat something that is high in energy and calories to ensure his body gets what it needs (Nutricia 2011). All the advice given was in line with the NICE guideline on management of acute stroke and transient ischemic attack (NICE 2008).
Another part of the assessment paperwork to be completed was a detailed skin assessment which as part of the recommendations by NICE must be done within six hours of admission to document any risk of shearing, continence issues, and factors that may impinge on the healing time of any wounds (NICE 2005). Also there is a need to document any reddened areas and or ulcers already present, with dimensions where possible also if there is evidence of suspected infection and wound care products in situ on the trust’s acute and chronic wound assessment and evaluation form, this initial assessment can then be used as another baseline for measuring the progress or deterioration of the wound.
On Closer inspection of the “reddened and broken area” to his heel, and comparing it to the European Pressure Ulcer Advisory Panel’s grading chart (EPUAP 1998) which was adopted by NICE and is another part of their Pressure Ulcer prevention and treatment guideline (NICE 2005) which is part of the trust’s Tissue Viability Team wound assessment pack, and following a second opinion from my mentor, it was concluded that it was in-fact a grade two pressure ulcer. Following this discovery and the fact that the ward’s tissue viability link nurse was not on duty, it was decided that the best course of action would be phone and seek advice from the tissue viability team.
The advice given was to ensure the wound was cleaned thoroughly and a Tegagerm foam heel dressing applied and changed every other day unless strike through was to the extent it needed to be done daily and to order an air matress and stress the urgency. Furthermore ensure it is documented fully and clearly in both nursing notes and skin charts, which coincides with the Nursing and Midwifery Council’s advice on documentation (NMC 2007). They also made it clear to inform both the patient and his wife, that the healing process would not be a fast as normal also there is the chance that the wound could possibly deteriorate due to his current medical state and the fact he is unable to maintain a sufficient level of nutrition (Vuolo 2009).
Along with policies there are quality standard frameworks in place to ensure high levels of care are constantly maintained in the form of benchmarking. Part of the Benchmark for best practice in the prevention of pressure ulcers, it is recommended that the need for repositioning the patient is assessed and documented correctly and constantly updated and monitored (DoH 2010). At ward level this was done by completing a turn chart which can also be used for patients on special pressure relieving mattresses which ensures the patient’s position is changed from right side to left side to back, sitting up and lying down, and my mentor informed me this had to be completed a minimum of every two hours unless otherwise indicated.
Along with completing all the relevant documentation, there are certain ethical issues attached to the way care was delivered, i was aware of the importance of tailoring the care to the individual also known as patient centred care, and allows the patient to have a better grasp of what is being done and allows the patient to make decisions regarding their care (Institute of Medicine 2001). Due to the speech difficulties Mr X was suffering from i decided to involve his wife in care decisions but only discussed his care in front of her husband to ensure he did not feel left out.
From previous experience during the course i had learnt to explain to the patient in my care the reason for using dressings and the type of dressing being used. So when it came to do Mr X’s heel ulcer i explained both verbally and showing that the dressing would be more comfortable for him due to the foam cushion part of the dressing.
Furthermore, i took into account the fact that Mr X’s speech was affected by the stroke and knowing that effective communication is a key skill for all nurses,(Field 2008) whenever i was delivering care i ensured i spoke clearly and that my body language was always positive. Showing empathy and did not appear rushed or annoyed when it took him a long time to say something and tried to help him communicate with other members of the team and catering staff and ensured I respected him, upheld his rights as a human being and was not at the receiving end of discrimination (Lishman 2001).
Moreover, I ensured his dignity was maintained at all times and made sure I treated him holistically ensuring I took into account not only his medical needs but also his psychological, religious and physical needs. All of this is supported by the National Service Framework for older people issued by the Department of Health (Doh 2007).
Before doing this assignment, i was roughly aware how much the role of a nurse is underpinned by policy and guidelines, however, through further reading and researching for this assignment it would have to be said that my knowledge on the rationale of why care is delivered a certain way has definitely improved and am now more aware of the implications of our actions have on our patients, and ensure the patients in my care receive the best treatment in line with current guidelines in the future as a staff nurse. Also following this particular admission, I am now more aware of where to go to seek help and advice from other members of the multi disciplinary team. Moreover, it is clearly important to keep up to date with current government polices and they are constantly being updated.
Finally, although this assignment focused on only two aspects of care it is important to remember that all aspects are just as important as is ensuring the patient where possible is involved in all aspects of their care.