Portfolio of Evidence to Demonstrate Care of a Client from Clinical Placement
The aim of this assignment is to produce a portfolio of evidence based on two nursing needs. A client from practice will be incorporated throughout in order to demonstrate an understanding of the relationship between the problems of the chosen client and the nursing care provided to alleviate them. Firstly, this paper will present the factors leading to my client’s admission to the clinical area in which I was placed. This will be followed by personal history and assessment of the client’s general condition during admission on the ward.
It will be imperative for the purpose of this paper to demonstrate ability in using research based rationale for actions carried out by nursing staff and other members of the multi disciplinary team. Therefore, assessment, clinical decision making and selection of nursing interventions will be discussed by exploring evidence that informs these processes (Newton, 1991). In an attempt to justify why certain needs were selected for discussion, great emphasis will be placed on Roper, Logan and Tierney’s (RLT) (1996) activities of living model. Newton (1991) suggests nursing models represent the reality of nursing in ideal terms.
Literature gives weight to RLT model by explaining it is the most commonly used in general nursing care within British and European practice (Holland et al 2003; Tierney 1998). In conjunction with the identified needs, the physiological and psychological effects in relation to the needs will be explored. In order to maintain confidentiality I have provided my client with a pseudonym (Nursing and Midwifery Council, 2002a). Dave is a 43 year old gentleman who was presented to the Accident and Emergency Department (A&E) via emergency services with a suspected myocardial infarction (MI).
An MI is sudden interruption of the supply of blood to the heart, usually resulting from obstruction of one of the two coronary arteries which originate in the aorta and supply blood to the myocardium which is heart muscle (Boyle and Senior 2002). Dave was conscious and complained of central chest pain, radiating down his arms and into his jaw. On admission it was noted he was short of breath, clammy, nauseous. The pain had begun three hours before when he was at home decorating. He explained the pain was ‘unbearable’ and persisted despite resting.
Acute pain indicates that tissue damage is occurring and is a warning signal to that individual that action is required to stop further damage (Mcleane, 1999). Pain in unrelated areas during an MI is known as referred pain. Alexander et al (2000) explain how this is common as pain from deep somatic tissue can be felt in unrelated but predictable locations. Primarily, to relieve pain diamorphine had been injected intramuscularly by emergency services. Diamorphine is an opioid, a potent analgesic which relieves severe and persistent pain (Oxford Dictionary for Nurses, 1998).
It would provide pain relief within 20 minutes of administration and last for 3-4 hours (Alexander et al). In addition to relieving pain the BNF (2005) describes how opioids confer a state of euphoria; therefore, this would help in relaxing Dave during routine tests. Whilst on A&E, Dave was administered reteplase and aspirin which are thrombolytic ‘clot busting’ drugs. They increase blood flow to the heart muscle to prevent further damage, assist healing and increase chances of avoiding death (NICE, 2005). A 12 lead electrocardiogram (ECG) was performed, recording the rhythm and electrical activity of the heart (BHF, 2004).
Docherty (2003) suggests 12 lead ECG’s are one of the most useful tools used in evaluating a cardiac patient. On the basis of symptoms and review of the ECG a provisional diagnosis was made that he had suffered a myocardial infarction. According to the World Health Organisation criteria used for diagnosing definite MI is sometimes not available within the first 6 hours of symptoms (McKenna and Forfar, 2002). Therefore, a medical decision was made to transfer Dave to an acute cardiology ward where further investigations would take place. In order for a definite diagnosis, cardiac enzymes levels would be determined via a blood test.
Cardiac enzymes are chemical substances contained within muscle cells and are released into circulating blood as a result of myocardial necrosis. The levels peak after 12 hours, therefore a valid result would be obtained after admission to the ward (BHF, 2004; Alexander et al, 2000). In a stable condition and accompanied by his wife Dave was transferred to the ward. On arrival, nursing staff welcomed them as Dave was shown to his prepared bed space. Although anxious, Dave was alert and orientated to the ward and placed under the care of a cardiologist who was due for ward round that afternoon.
The Department of Health (1999) suggests early medical intervention is the key to protecting patients, ensuring that the doctor and patient are aware of the nature and seriousness of the problem and the actions needed to address it. Dave’s wife was equally anxious and appeared very upset. Trained staff provided reassurance, however assessments had to be carried out on Dave who was priority in the initial plan of care. The BHF (2004b) describes that whirlwind activity can be frightening for relatives, but during testing and diagnosis, health professionals must focus their attention on the patient.
The relevant admission documents were collected and the assessment procedure was explained to Dave. It was important to understand that hospitalization is a stressful time (Hinchliff et al, 2003), therefore, this was my first opportunity in attempting to build a therapeutic relationship with my client. Hinchliff et al (2003) suggests Nurses should aim to relax the patient using open friendly communication skills which will provide reassurance and treat Dave as an individual. This approach earns nurses trust, thus enabling the client to provide information for the purpose of assessment (Hinchliff et al, 2003).
Alfaro-Lefevre (1998) suggests comprehensive data is collected in three phases, before you see the person, when you see the person and after you see the person. Initially, some information was transferred from A&E notes, such as personal history (see appendix 1). Dave resides in a house with his wife and two children. He is self employed as a butcher, jointly owning the business with his wife. Dave admits to smoking 20 cigarettes per day and drinking 20 units of alcohol per week.
Research suggests that as a smoker Dave was 33 times more likely to have a heart attack than a non-smoker aged 45 years or under (Cook and Melby, 1999). Castledine (2004) suggests obtaining personal information and a detailed health history is the first stage in determining the health status of a client. Dave had a past medical history of hypertension that remains stable with treatment. His past family history indicated his father suffered hypertension and coronary heart disease consequently he died six months previously.
The British Heart Foundation (2005a) suggests there are many heart conditions influenced by hereditary factors. However the National Service Framework for Coronary Heart Disease explains that genetic inheritance is an important consideration, however lifestyle changes can help to lower the risk (DoH, 2002). Skirton and Patch (2005) suggest nurses should know about genetic science because it is important to understand the prevention and management of some conditions. Therefore, it was important to retrieve this information and provide reassurance to Dave who appeared unsettled by the thought of following in his Fathers footsteps.
At this point Dave was informed that a referral would be made to the cardiac rehabilitation nurse who would collaborate with him to provide advice relating to preventative measures in order to minimise future risks. Dave underwent an initial assessment according to trust protocol. This assessment, based around the Activities of Living, also incorporated screening tools such as nutritional and Moving and handling scoring. Assessment is an important stage, as it guides a plan of care (Healy and Timmins, 2003). Aggleton and Chalmers (2000) suggest nursing assessments should be carried out as soon as possible.
This is supported by the NMC (2002b) who explain that by law initial assessments are to be made within 24 hours of admission. Utilising the Roper, Logan and Tierney AL model will enable the identification of problems and allow the nurse to collaborate with the client in planning care in the form of realistic and achievable goals (Alfaro-Lefevre, 1998). It is ideal as Newton (1991) describes how it views a person as the focus of nursing, by incorporating the idea that nursing is concerned with helping people at all stages of their life span aiming to achieve their optimal level of health.
Furthermore, this is achieved by helping them to solve, alleviate, cope with, or prevent problems relating to activities of living. Aggleton and Chalmers (2000) suggest health is affected by biological and psychosocial factors, however, they argue the RLT model appears physical, but a deeper assessment can indicate social factors. This claim is supported by Griffiths (1998) who agrees it is not the model adjusted, it can only appear this way if it is documented incorrectly by nurses.
It was discovered that when carrying out the AL assessment that some problems were interrelated with several activities of living (see appendix 2). Chest pain was interrelated with mobility, pain and discomfort and anxiety. Pain is difficult to observe and usually needs verbal clues in order for it to be reliable (Alexander et al, 2000). However, using the trusts numeric pain scale as a tool and obtaining a verbal description from Dave the degree of pain he suffered was documented. Pain scales have demonstrated reliability and validity, and are considered sensitive measures in pain intensity (De Walters et al, 2003).
It was clearly identified that chest pain and further potential chest pain was an obvious need and Dave was openly anxious about the severity of the pain he experienced. Anxiety featured in communicating, fears and anxieties and pain, it also became an issue when discussing how Dave’s safe environment would be maintained. Advice was provided which informed he would be commenced on up to five days bed rest as trust policy indicates. This was supported by Dave’s moving and handling profile, which assessed my client’s level of dependence along with his mobility status.
Given that this was day one of the regime for MI patients it is incorporated within the trust protocol that Dave would be nursed in bed, thus making him fully dependant. Thomson (1997) supports this policy by promoting bed rest as it is effective in improving oxygenation, therefore enhancing healing and relieving pain. This became an area of concern for Dave as he was anxious about coping with being confined to his bed/chair for this period, even more so on learning that commode privileges would be required for two of these days.
Senior staff urged that under no circumstances must activity take place. However, The Department of Health highlights patient choice in ‘Building on the Best’ (2003a) therefore, it was important for Dave to understand the consequence of infringing this advice and the possibility of negative consequences on his current condition. Following promotion of this issue and persuasion from his wife Dave fully agreed to co-operate with this decision.
In support of this situation, Martin (2004) suggests choice is only real when the patient understands what they are choosing between. Johnson (2004) suggests service users should receive all information relating to how their care will be given in order to allow them to make an informed decision. This approach helped when prioritising Dave’s care and incorporated a partnership between Dave and myself. This is supported by Johnson (2004, p135) who further states “it is always important to remember who the customer is in this process”.
Discussion will take place in relation to care plans implemented for pain and anxiety. The importance of this selection became apparent on analysing the AL assessment and finding these needs were identified in other categories as well as their own. With reference to pain in cardiac patients, MIMS handbook of pain management (2004, pp64) suggests “relief of pain minimises the stress response and improves prognosis for the patient”. Therefore this distinguishes a link between these problems and provides justification for the selection.