Student Nurse

Maximising Health using the Nursing Process


Mrs. X has been selected to demonstrate how to maximize health. She is a lady who is residing in a nursing home. She is 80 years of age and due to a suspected CVA she is unable to self mobilize and is dependent upon a hoist for transferring. She also has dysphagia and is fed via a Percutaneous Endoscopic Gastronomy (PEG) tube. She is unable to verbally communicate and is doubly incontinent. It is intended to maximize the health of Mrs. X by focusing upon the PEG feed and issues that surround that. Issues include ensuring adequate mouth care, adequate nutritional intake and psychological impact of having a PEG tube inserted. To maximize the health of Mrs. X the nurse must determine what the patients' perspective of health is. This can be done through entering into the nursing process.

The nursing process is a problem-solving framework for planning and delivering nursing care to patients and their families (Atkinson and Murray 1990). It consists of four phases - assessment, planning, implementation and evaluation. This systematic approach to care is cyclical in nature and when used in nursing practice, will result in competent nursing care. The nursing process is beneficial to both the practitioner and the patient. When the nurse becomes skilled in the use of this tool, s/he will gain confidence, job satisfaction, professional growth and opportunities to share knowledge. Benefits to the patients include continuity of care, improved quality of care and autonomy (when involved in the process, Atkinson and Murray 1990). However, due to Mrs X communication difficulties she is unable to participate in the process. To ensure an element of autonomy, Mrs X next of kin is involved in all stages of the process.

Assessment can be defined as 'the first stage of the nursing process, in which data about the patients health status is collected and from which a care plan may be devised' (Oxford Dictionary for Nurses, 1998). However, Ford and McCormack argue that 'assessment is not just the undertaking of a set of technical skills, rather, it requires a certain kind of relationship between those who participate in it and with whom we share the purposes and standards of the practice' (1999). Assessments should not only focus on the needs presented by the patient, but on the strengths and abilities that the patient may bring to bear on resolving those needs (Department of Health 2002a). This approach enables the nurse to use the assessment to plan care that is truly person centred. It was with this theory that Mrs X was assessed. This is best approached through biography because all patients have a past, a present and a future. When undertaking person centred assessment, nurses have a key role in creating a picture of the patient that enables decision making which is representative of the patients life as a whole (Dewing and Pritchard 2000). A biography can be built through discussions with the patient, patients' family and friends. It is important to gain a knowledge and understanding of the patients' perspectives and needs to develop a care plan, as the care plan has to be meaningful to the patient if it is to be successful in maximising health. To make it meaningful, it is important to focus on social, psychological and spiritual needs of the patient, rather than just focusing upon medical needs. Through discussions with Mrs X next of kin, the nurse became aware of things that were important to Mrs X. It became clear that Mrs X enjoyed being in the company of lots of people, she valued listening to classical music, she was interested in art and she didn't like taking medication. Mrs X regularly attended a local Catholic Church up until she was admitted to hospital. Issues surrounding the event of Mrs X death were discussed at the assessment stage. It was important for Mrs X to receive a visit from the parish priest before she passed away, if possible. The only other concerns expressed were that she had classical music playing at her time of death. It was with this knowledge of Mrs X, and her identified needs, that the nurse could begin to draw up a meaningful plan of care.

Planning is the second phase of the nursing process. In this phase, the nurse develops a plan to assist the patient to meet needs identified in the assessment process. This second phase is broken down into three stages, setting priorities, establishing goals and planning nursing interventions (Atkinson and Murray 1990). The nurse and patient/next of kin should mutually categorise identified needs into high, medium or low priority. However, this could lead to conflict as the nurse may have different priorities to the patient. This is where it is paramount to gain an understanding of the patients' perspectives and not exert your own values, as a nurse, upon the patient. It is important to focus on the problems the patient feels are of highest priority unless they interfere with treatment. Excellent communication skills are needed here to educate the patient regarding treatment they need, to enable them to make informed decisions regarding their care. Rowe states that 'it is the nurse's responsibility to communicate effectively with the patient to bring about optimum nursing care' (1999). Mutual priority setting with the patient serves two purposes. Firstly it involves the patients in the planning of their own care. Secondly, it enhances the relationship between nurse and patient. The second stage is establishing goals. A nursing goal can be defined as 'a statement of what the nursing intervention is intended to achieve' (Oxford Dictionary for Nurses 1998). Goals should be simple, measurable, achievable, realistic and time scaled. To meet these goals, the next stage needs to be completed, setting nursing interventions.

A nursing intervention can be described as 'specific activities which the nurse plans and implements in order to help the patient to achieve a goal' (Atkinson and Murray 1990). Specific nursing interventions, as stipulated in the care plan, will ensure continuity of care. There are often various measures the nurse can pick to meet the same goal so it is important to set interventions with the patient. This will ensure autonomy, co-operation and empowerment of the patient. Interventions are a set of instructions for the staff to follow when delivering care to the patient. They must be specific to combat misinterpretation. Nursing interventions can be instructions ordered by a member of the multi-disciplinary health care team e.g. speech therapist, and require implementation from the nurse.

The goals and interventions are as follows. Each goal will precede the interventions. 1) Prevent oral infection/inflammation. Use a glycerine and thymol swab to clean Mrs X mouth every morning and evening. Apply Vaseline to lips every morning and evening to prevent dryness. 2) Prevent infection/inflammation at PEG site. Clean site every morning and evening. Apply a thin layer of conotrane cream to site to prevent friction and redness. Ensure adherence to universal precautions when dealing with the tube to prevent cross infection. 3) Ensure adequate nutritional intake. Set up feed as per regime, allowing nine hours between each feed. Document start time for each feed. Discontinue feed if vomiting and contact nutrition nurse. Monitor weight fortnightly. 4) Ensure adequate hydration. Flush 100mls water through PEG tube prior to starting feeding and when feeding has finished. Document when given and amount given. Document any signs of dehydration. 5) Prevent oesophageal reflux. Mrs X should be sat upright or lying on right side throughout the giving of feed. 6) To develop Mrs X swallowing abilities. Place 5-10 mls of custard/yoghurt on Mrs X lips every lunchtime and allow to taste and swallow, as directed by speech therapist. In relation to goal 2, it is paramount to adhere to infection control policies to minimise the risk of cross infection to the patients. If the PEG site were to become infected, a reddening of the skin would indicate the infection. This is the body's way of maintaining its own safe environment. The reddening is a rush of blood, containing lots of white blood cells, to the site of infection to begin the fight against the infection (Roper et al 1996). There are methods the nurse can take to maintain a safe environment. Regarding Mrs X these methods include ensuring the PEG machine is working properly, using equipment properly and adhering to health and safety guidelines and legislation. Also by taking simple measures such as ensuring all hazards are dealt with, e.g. loose carpeting is secured.

These six goals are relating to biological aspects of having a PEG tube insitu. However, it is important to look at the social and psychological aspects as well as the biological. It has been discovered that Mrs X was quite a social person and enjoyed spending time with other people. As Mrs X no longer eats a meal, she is missing out on the social aspect of spending time with other people eating meals. From a psychological aspect, she no longer has the satisfying feeling of being full or just having something tasty to eat. It is important for the nurse to counteract this and try and make up for this loss in someway. This is done through enabling Mrs X, where possible, to spend time in the company of other people, be it staff, residents, visitors or members of the activity therapy team. Also, it is stressed that goal 6, to develop Mrs X swallowing abilities, must be carried out daily so that Mrs X can still experience the sensation of tasting food.

The planning of care also involves identifying what services are available to the patient. Mrs X resides in a nursing home, this ensures that she has 24 hour access to registered nurses and a team of care staff. This is the first service available to her and members of this team will provide most aspects of her care. However, due to Mrs X PEG tube, she does require specialist services. The National Service Framework (NSF) for older people states that 'people who are thought to have had a stroke should participate in a multidisciplinary programme of secondary prevention and rehabilitation' (DoH 2001). This opens up a lot of services for Mrs X. Rehabilitation services include physiotherapists, occupational therapists, and speech therapists e.t.c. The particular services that were utilised for Mrs X are the community speech therapy team and the dietician. They visit the home at regular intervals to assess Mrs X progress. The staff in the nursing home provides all other aspects of care. Mrs X does access other services including general practitioner, opticians, dentists and chiropodists. Occasionally she will attend music sessions that are supplied by the activity therapy team.

Now that the care is planned we enter into the third stage of the nursing process, implementation. To implement a care plan the nurse should document the care plan so that it is a written piece of work available for members of the team to read. The primary component of this stage is the actual delivery of care to the patient. However, there are factors that may influence the delivery of care. In the case of Mrs X this might be that there isn't enough staff with the ability to operate the PEG feeding system. Also, with Mrs X residing in a nursing home they may not be able to get the specialist staff in, including speech therapists and dieticians. Legal and ethical issues may affect the delivery of care. Patients need to give consent for any treatment they are to receive. This has implications if the patient does not give consent, then the PEG tube cannot be inserted and that care cannot be delivered. The Nursing and Midwifery Council (NMC) state in section 3 of the code of conduct 'you must obtain consent before you give any treatment or care' (2002). Without consent then the patients' rights are being violated regardless of whether the treatment is urgent. However, the issue of consent isn't just as simple as obtaining 'the green light' to give treatment. Seeking consent gives the patient autonomy of care. Autonomy can be defined as 'the capacity to think, decide and act on the basis of such thought and decision freely and independently, without hindrance' (Gillon 1985). The patient needs to be informed about the treatment so that they can give consent that leads truly to autonomy. This principle raise two questions, what is sufficient information and how can this concept be applied to a patient who has limited autonomy. The Department of Health state that sufficient information is 'as much information as they reasonably need to make their decision, and in a form they understand' (2001). This offers guidelines but still leaves the concept of informed consent a very subjective concept. Gillons definition of autonomy suggests that a person is autonomous if they have the ability to think and decide freely and independently. When patients have limited autonomy the issue of informed consent depends upon their competence. Welie and Welie define competence as 'being fit for the purpose' (2001). Therefore, when patients are competent to give consent they have the skills necessary to make an autonomous decision about their health. Welie and Welie suggest that one of the skills necessary is ' for the patient to communicate and account for the decision' (2001). If the patient lacks this skill they are considered incompetent to give informed consent. According to section 3.6 of the NMC's code of conduct, if a patient is considered incompetent to give consent then the patients known wishes should be taken into consideration and criteria for treatment must be that it is in their best interests (2002). Due to Mrs X communication difficulties she was deemed incompetent to give informed consent. The PEG tube was inserted following criteria as stipulated in the code of conduct. Other factors that may influence delivery of care include government and local trust initiatives. Government initiatives include the NSF for older people. This was set up in 2001 by the DoH and it sets national standards for the care of all older people. Its main guiding principles are that all care should be client centred, care should be non-discriminatory, practice should be evidence based and it strongly promotes multi-professional collaboration to enhance the care of the patient (2001). This initiative was set up to improve the care of older people. Local trust initiatives include Principles of Care. This intends to standardise care given to all patients being cared for in a hospital or nursing home. This gives guidance on how certain procedures should be carried out and also ensures that each ward/home uses the same assessment tools. This is intended to improve patient care by setting standards across the trust and ensuring that the care that is implemented is of a high standard.

Now that the care plan has been implemented, the final stage of the nursing process is entered, evaluation. Evaluation has similar characteristics to assessment. It is an ongoing and continuous process and also occurs at timed points in a formal setting. The initial stage of evaluation is to decide whether the patient has met the goals established during the planning stage. The goal is evaluated at the stipulated time and is done by gathering information about the patient regarding this goal. Information can be sought from the patient, the patients' family/friends, the health care team and the patients' notes. If the goal has been met then it can be removed from the care plan. If the goal has not been met, the nurse has to establish a reason. This is the secondary stage of evaluation. At this point the nurse will look closely at the goal. Maybe the goal isn't realistic or measurable. If this is apparent, then new appropriate goals will have to be set. The nursing interventions might not be successful in meeting the goal, if so, new interventions should be set. The patient might not be co-operating with the care plan, therefore not meeting the goals. This situation demands the division of new goals and interventions. The setting of new goals and interventions leads the nurse back to the beginning of the nursing process, and the whole cycle starts again.

It is at this evaluative stage that the nurse can look at the effectiveness of the care plan. The goals mentioned in this essay were evaluated four weeks after they were initially established. All of the goals were found to be successful in maximising the health of Mrs X and none of the goals were changed or removed. Throughout the four weeks Mrs X has maintained adequate levels of nutrition and hydration, showing no signs of malnutrition or dehydration. Also, her mouth has remained in good health, sustaining no problems. Through discussions with Mrs X next of kin and the multi-disciplinary team, it was agreed that the care plan was successful and should remain unchanged.

In conclusion, this systematic approach to care has proved to be beneficial to the patient. The care delivered to Mrs X has achieved its aim as it has maximised her health.


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