CASE STUDY: CASE STUDY ON Positive Health Care for Individuals 2008 By :: MOTILAL DASS Registered Nurse (India) HNC Health Care (Scotland) -1- CASE STUDY: CASE STUDY Positive Health Care for Individuals Motilal Dass In order to a complete case study for the unit of Positive Health Care for Individuals (DR3R34), I chose a patient who had undergone a colostomy operation. To comply with the Data Protection Act and also to ensure patient’s confidentiality the patient’s name is not disclosed through out the case study, as Nursing and Midwifery Council states that you must treat information about patients and clients as confidential and use it for the purpose for which it was given (NMC-2004). The Data Protection Act (1998) declares that all the records about client which are filled will be seen as data, whether electronic or paper and individuals are given rights which include the right to confidentiality- that the information should not be accessible to unauthorised people. The patient is Mrs. ‘X’ a 78 year’s old lady and she was transferred from Ayr General Hospital to the residential care home. On admission various assessment tools were being used to find out base line physical parameters. The assessment tools were Modified Early Warning Score, Waterlow scale (pressure ulcer risk assessment tool), menu planner and body mass index calculator. Her base line data’s were obtained as temperature 36.9 degree Celsius, pulse rate 76 beats/minutes, respiratory rate 16 beats/minutes, blood pressure 110/70 mm of Hg (mm of Hg means millimetre of mercury), body mass index 16 and it was calculated using the formula: patients weight in kilogram divided by her height in meter squared. General risk assessment was also done by removing unnecessary objects from the patient’s room and only the useful things were kept inside the room. I used the facilities provided by the employer to facilitate the quality patient care. This helped to minimise the risks as Manual Handling Operations Regulations (1992) states that make proper use of equipment provided to minimise the risk of patient injuries. The patient had to undergo a colostomy operation and this was the choice of surgical treatment because of the clinical manifestation of the carcinogenic condition of colon this surgical intervention was performed. Colostomy means a surgical opening into the colon for the purpose of creating the diversion for eliminating the faecal matter. Tortora et al (1996) states that the large colon has three parts called ascending colon, transverse colon and descending colon. As a result of this procedure her dependence continuum got hindered. In this context of case study, while viewing the patient’s disease condition, the treatment regime is appropriately suited. To implement the appropriate care to this patient the Roper Logan Tierney model of care plan is being used. Roper Logan-Tierney Model of care includes twelve activities of daily living. Due to existing treatment regime this patient was not being able to carry out the Activities of Daily Livings by herself. The activities in which she required assistance were identified as eating and drinking, eliminating need, personal cleansing & dressing, maintaining a safe environment, controlling body temperature, mobilising, working and playing and also expressing sexuality. -2- CASE STUDY: To ensure that the patient gets the holistic nursing care, the nursing process was followed. The nursing process is being defined as the systematic planning of care using the steps assessment, diagnosis, planning, implementation and evaluation. Nursing process is the vicious cycle where if the goals and objectives fail to produce satisfactory outcome then the whole process is revised until positive outcome is received by the patient. To this patient the holistic nursing care was implemented. The holistic nursing care means the combination of physical, mental, social and spiritual needs are being met during the care process. The care process was formulated by respecting the patient’s beliefs and finding out her preferences and at the same time depending on the scientific rationale behind each component of the care process. The patient was directly involved in this planning process regardless her existing disease condition. Eventually the involvement of the patient into the planning process made the care much effective. The care plan was done on the basis of Maslow’s Highrerchy of need, here patient’s needs are prioritised accordingly and the three most Activities of Daily Livings have been explained in details: Eating & Drinking: Assessment: In this phase, information collected from the patient and nursing history, thereby the potential and actual problems were identified accordingly. From the existing condition, it was assumed that the dietary pattern of this patient has been altered drastically. The patient was no longer capable of eating solid diet as bulk portion at times she had to procure only semi-liquid and liquid diet. There was loss in body weight and appetite reduced. Her BMI was 16, which suggests she was underweight. Diagnosis: Her nutritional status altered and this was less than normal requirement of her body’s need. Planning: Periodic record of her body weight. Encouraging the patient to take feeds regularly. Vitamin supplementary could be given as per the advice of the dietician. Consult a dietician or a doctor. Motivate to consume food. Implementation: There were adequate resources available to carry out the plans which were mentioned. It was not possible by me alone to deliver all the care which was planned, so I needed help from other carers and nurse to make the plan effective and this helped me in reaching the positive outcome at the end. During my placement each week I checked the weight of this patient and maintained an accurate record of this. This was very much helpful to me to compare the progress of the patient. During my placement, most of the time I carried out the nursing actions and implemented them according. Whenever I felt I needed to consult the staff nurse I did it so. At time to time I motivated patient to consume food. -3- CASE STUDY: Evaluation: Evaluation is an ongoing process and it helps to deduce conclusion pertaining to the care implemented to the patient. K.Holland et al (2004) states that when evaluating the care plan, you will need to establish if the goals have been completely met partially met or not met at all. I evaluated the care plan and found that it was effective and patient gained weight in last two months. Eliminating Need, personal Cleansing and Dressing: Assessment: This patient had to undergo a colostomy operation due to the carcinogenic condition of the descending portion of colon. She could not defecate normally and as a result of this she has got a diversion of eliminating faecal matter through the colostomy opening. She also needs assistance in cleaning and emptying this bag and more appropriately maintaining her hygiene. Diagnosis: Abnormal elimination pattern and maintenance of hygiene noted. Particular concentration was given on hand hygiene as the Postnote (2005) states that probably the single most effective way of combating health care associated infections is to improve hygiene in healthcare settings, in particular hand hygiene. Planning: Prevention of infection, hand washing, regular changing and emptying of the colostomy bag, bathing the patient, dressing her up with the clean dress, and regular changing of sanitary pad, preventing the risks of infection and care of the stoma. Implementation: The colostomy bag was emptied regularly. The bag was changed in every two subsequent days. Patient was given bed bath and tub bath as well. Patient’s privacy and dignity was always maintained by keeping the door shut and not exposing the private areas without patient’s awareness and the patient was treated as an individual as Nursing and Midwifery Council (2004) states that respect the patient or client as an individual. The site of the stoma was cleaned with antiseptic solution. Whenever the bag was changed it was discarded in a plastic bag and send for incinerating it. The sanitary pad was also changed whenever found them wet and they were discarded in bins and disposed. Appropriate hand washing technique was followed before and after giving care to this patient. Evaluation: All the cares which were planned were implemented. There was little redness and rash observed around the site of the stoma but this was notified to the nurse in charge. The redness indicated there was initial sign of infection as its one of the component of inflammation. As result of the planning step was revised and care implemented accordingly and later on there was not sign of infection noted. -4- CASE STUDY: Maintaining a Safe Environment Assessments of patient’s ability to maintain own safe environment was done on the basis of clinical observations and previous medical history. This patient was vulnerable to falls as she could not support herself while she tried to walk or sit on a chair. She always required assistance in almost every area of daily living activities. Diagnosis: The medical history reveals that there were high risks for falls and injuries. As without assistance she could hardly walk or sit or even move from one side to the other. There was also high chance of getting weakness and fragile due to confinement and prolong bed rest and these were identified as potential factors which aggravated the physical condition of this patient. Psychologically this patient was agitated and depressed as her body image was altered from normal. As a result she had low self-esteem. She was concerned about her family members and friends so she kept on asking their well being from time to time. She was interested to go to pubs and clubs to meet her friends, share her views and feelings but she could not do this due to the existing condition, as a result of this her social life is not well balanced. This patient was experiencing the restricted life style so she always looked gloomy but I kept her assuring. Planning: At the planning stage I made sure to use the hoist and adequate assistance from other carers or nursing staffs, use of bed rails, wheel chair was provided to take patient whenever required, use of strap was ensured and patient was never left alone unattended, care of pressure areas. Implementation: I have provided care to maintain her life and to prevent deterioration by focusing on the physical status of this patient. Each time I attended this patient I made sure to keep the side rails well fixed and head was supported by extra pillows and even special care was provided to bony prominence areas to avoid pressure sores. I always summoned help from other carers and nursing staffs when I needed to turn the position of this patient. Evaluation: This was effective care which was rendered to this patent and patient’s out come was satisfactory. There was no evidence of developing pressure sores or history of falls noted during the period I took care to this patient. The patient was given all the choices about receiving the care. Prior to implement any care a formal consent was taken from the patient, as NMC (2004) states that you must seek consent before giving any care to the patient or client. I maintained patient’s dignity by being polite to her during the conversation; I used the term ‘madam’ to make her feel happy. Due to colostomy bag attachment, at times there was foul smell in her room but I ignored this, adjusted with the existing environment and provided care. -5- CASE STUDY: Her socio-economic history revealed that she was from middle class family but I did not go for class stratification while providing care to this patient I adhered to antidiscriminatory practice, where richness or poverty have insignificant role to play. Once I took this patient for bath, suddenly I was told by one of the carer that the patient needs to have her hair wash done; this was not mentioned in the care plan. I got interrupted and went to the staff nurse to get it clarified. I was told by the staff nurse that hair wash is not mentioned in care plan on Thursday; but it was mentioned to be done on each Sunday. I met the carer who told me but she apologized for coordinating inappropriate information. This was the most conflict situation that I faced during implementing care to this patient but I reacted positively. To establish and maintain a positive health environment for the this patient each team members worked in well coordinated manner with other team members and everyone of us portrayed professional skills by the standard of care the patient was given. I was also integral part of this team. The way I have delegated care to this patient, sought and got support from the members of the care team was beneficial to me. I have developed a professional understanding during this case study which I had to do. I have shown effective co-ordinating skill along with other team members. Everyone in this team played a vital role and I could relate this role theory to the Belbin’s Team Roles Theory. Dr. Meredith Belbin (1994) stated that team workers make helpful interventions to avert potential friction and enable difficult characters within the team to use their skills to positive ends; they tend to keep team spirit up and allow other members to contribute effectively. There was a good reciprocity and mutual understanding among the team members. To ensure the optimum quality of patient care I worked in collaboration with the team members. Through out this case study I kept patient as a central point of receiving care. All the care given to this patient was recorded properly and got them countersigned by the nurse on duty. At each stage of intervention, I respected patients autonomy as NMC (2004) states that you must respect patients’ and clients’ autonomy – their right to decide whether or not to undergo any health care intervention-even where refusal may result in harm or death to themselves. I demonstrated effective communication skills while I interacted with this patient. I preferred to use the non-verbal method of communication and I mostly used actions to convey messages to this patient as Kenworthy et al (2002) states that actions speak louder than words. The patient could easily understand me and co-operated well. In conclusion, an effective patient care strategy was demonstrated by me while the care was being given to this patient. -6- CASE STUDY: References: Belbin’s Team Role Theory [online] 1994, London; available on: www.srds.co.uk and accessed on April 23rd 2008. Holland K, Jenkins J, Solomon (2004): Applying the Roper Logan Tierney Model in Practice, 2 ed. Edinburgh: Churchill Livingstone. p. 195 Kenworthy N, Snowley G, Gilling C (2002): Common Foundation Studies in Nursing 3rd ed.Edinburugh: Churchill Livingstone. p. 258 NMC code of professional conduct: standards for conduct, performance and ethics (Nursing & Midwifery Council) London, p.3, 5 Occupational Therapy Training [online] 2007, London; available on: www.otdirect.co.uk and accessed on April 25th 2008. Tortora GJ, Grabowski SR (1996): Principles of Anatomy and Physiology 1st ed. Biological Sciences Text Books, Inc. and Sandra Reynolds Grabowski. p.793 The Postnote (2005) Infection control in health care setting, London. [Online]: available www.parliament.uk [accessed on April 27th 2008] Author: Motilal Dass Registered Nurse (India) HNC Health Care (Scotland) E-mail:
[email protected] -7-