The extremely fast paced and time-constrained ward of a modern day hospital is an environment that invites the possibility to overlook some of the important aspects of a patients care (Milliken, 2007). Taking this potential problem in to consideration, it is clear that there is a demand for the individualized and structured approach to the planning and delivery of the patients care.
The demand for this type of approach to care has been long recognised in the nursing profession.
Historically, since it was first mentioned by Ida Jean Orlando in 1958, it has been referred to as a nursing process (Marriner-Tomey and Allgood, 2006). According to Timby "nursing process is an organized sequence of problem-solving steps used to identify and to manage the health problems of clients" (Timby, 2009,). It is necessary to highlight, that as it is stated by Roper, Logan and Tierney (2000), this effective logical method of thinking in practice is not exclusive to the nursing, rather it is has been used in many disciplines and later was adopted by nursing theorists. More importantly, that adaptation was done in order to apply in practice the concepts of existing theoretical nursing models: "abstract frameworks, linking facts and phenomena, that assist nurses to plan nursing care, investigate problems related to clinical practice, and study the outcomes of nursing actions and interventions." (McFerran and Martin, 2008). It would be correct to suggest that the nursing models are the foundation for the continuity of holistic patients care. Therefore, the intention of this case study is to demonstrate a detailed account of an effective single shifts" assessment of a patients" health condition, based on the application of the chosen model of nursing.
In order to contemplate this case study the introduction of the patient is necessary; in this process it is essential to maintain the confidentiality of the patient (NMC, 2008). For this purpose the male patient in question is going to be assigned an alias John. John is a twenty two year old male with a long term, medical history of the polycystic kidney disease. It is the most common inherited disorder of kidneys occurring in one in a thousand newborn, and it is presenting itself in the development of hundreds of thousands of space occupying cavities; that are filled with fluid and called cysts. This pathologic process is underlined by the cell death in the rest of normal kidney tissue that progressively impairs the renal function (McKinley and O"Loughlin, 2006). As a result of polycystic kidney disease John has developed the stage 5 of the chronic renal failure, also known as an end stage renal failure. This stage is characterised by ninety percent loss of kidney function, and is preceding the dialysis therapy or kidney transplant operation (Tortora and Reynolds -Grabowski, 1996). Johns" case is very representative of an end stage renal failure cases. Not only has he had a history of hemodialysis therapy; a type of the therapy that is meant to artificially recreate blood waste separation through the use of kidney machine (Tortora and Reynolds -Grabowski, 1996). But also, in the time frame of this case study, he is on the second day post kidney transplantation operation.
It is important to mention that John has received his kidney from living-related donor, his mother. As well, it needs to be noted, that John is financially dependent on his mother, because of the changes in his lifestyle and inability to perform full time work; resulting from his medical condition. The combination of these biological and psycho-social factors, that will have an effect on his health status, makes John a very interesting patient for this particular case study.
Prior to the patient health status assessment, it is important to establish what model of nursing is going to be used, and explore the models contents and the reasoning for the choice made. The model of choice for this case study was developed by Nancy Roper, Winifred Logan and Alison Tierney, and is known as The Roper-Logan-Tierney Model. The core principles of this model of nursing were initially introduced by the aforementioned authors to United Kingdom nurses in 1980, within the first edition of the publication titled The Element of Nursing (Roper et al, 2000). That publication was followed by three more editions under the same name, over the course of 20 years, and finally the model has taken its currently used form, in the monograph published in 2000 and titled The Roper-Logan-Tierney Model of Nursing Based on Activities of Living (Roper et al, 2000).
In summary, the goal of this model is the conceptualization of nursing through the identification of the core of nursing activities, across any field of nursing practice, and a consequent creation of the framework for the care of the patients in the wide variety of situations (Roper et al, 1996 cited in Holland et al, 2008). To avoid confusion it is important to note, that although this a model of nursing that is based on the model of living, within itself it is also divided into two parts the model of living and the model of nursing. The five concepts, which are identified for the model of living: activities of living, lifespan, dependence and independence continuum, the factors influencing activities of living, and the individuality in living. The only part that is different in the model of nursing is the substitution of the fifth concept the individuality in living for an individualizing nursing. This is rather a similarity than a difference, between the model of living and the model of nursing, and this similarity is indeed intended by the model; in order to encourage the minimal disturbance to the patients" pattern of living (Roper et al, 2000).
An outline of these concepts is useful for the understanding of the model.
The first, of five concepts that should be examined, is the activities of living. As it is explained by Holland, Jenkins, Solomon and Whittam (2008) "living is a complex process which we undertake using a number of activities that ensure our survival" (Holland et al, 2008). This model identifies twelve interconnected activities of living, namely: maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilizing, working and playing, expressing sexuality, sleeping, dying. Most of these activities will be relevant to this case studies assessment and are going to be used and explained in detail at the appropriate time.
The second concept of this model is the lifespan, an ever-changing continuum of an individual existence every aspect of which is influenced by external and internal factors of various natures (Roper et al, 2000). This concept is based on age and aims to identify an array of factors that may affect an individual depending on where on their lifespan they currently are. Therefore there are five stages of life that had to be introduced by this model: infancy, childhood, adolescence, adulthood, old age.
The third concept, the dependence and independence continuum is directly linked with lifespan and activities of living (Holland et al, 2008), the idea of this concept is that every individual is being dependent at some point and in some form or a way on the environment that they exist in, or on the factors that they are influenced by.
It has been indicated by this model that in the case of the fourth concept the factors influencing the activities of living, there are numerous factors of influence. Consequently, in order to avoid over-complication of the model, only five main groups were generated. These groups are all inextricably linked and are as followed: biological, psychological, sociocultural, environmental, politicoeconomic (Holland et al, 2008).
The final fifth concept, individuality in living is stressing the attention to the difference in the ways that activities of living are carried out by each individual, and how this difference will continue to increase under the influence of all of the internal and external factors. (Roper et al, 2000) Alternatively, nursing model offers the fifth concept, the individualizing nursing care. This concept is ensuring that the care for every patient has to account for the patients" individuality (Holland et al, 2008).
This particular model of nursing was chosen for the case study, not only because it appears to be relatively simple to understand, but also because it is widely accepted and used in the United Kingdom educational facilities; and consequently its popular for practice within the National Health Service and the private sector(Holland et al, 2008).
All of the aforementioned concepts of this model, in conjunction with the nursing process, are the framework for the assessment of nursing care that John needs. Bear in mind that, John has had an initial nursing care assessment, at the time of admission to the hospital, there is objective data from that initial assessment for the baseline of this continuing assessment (Holland et al, 2008). The ultimate aim of this planed care is to over time, empower the John to again become fully independent, and return to his normal pattern of living (Walsh, 2002). But, due to the confinement of this case study, only one day account of the relevant nursing assessment and intervention is going to be given (McCloskey and Bulechek, 2011). Finally, it must be noted that, when assessing Johns" patient needs and problems, priorities need to be given to the more relevant at the time of assessment, concepts of the framework (Holland et al, 2008).
As it has been mentioned earlier, the time frame of this study is the second day post kidney transplantation operation. Therefore John is on the stage of postoperative recovery with a number of risks and complications, such as: bleeding, wound infection, imbalance of electrolytes and transplanted kidney rejection (Danovitch and Geffen, 2005). Consequently, he is on the very restrictive medical protocol of the post operative observations and precautions. As a result of both, the restrictions and the risks present, Johns" overall dependence level is substantially high and many of his activities of living are impaired.
The first and, as identified by Roper et al (2000), the most basic and important activity of living, that is going to be impacted upon in Johns" case, is his ability to maintain a safe environment. When assessing this activity of living, both internal and external environment has to be taken in to consideration (Holland et al, 2008). Essentially, what is meant by the internal environment are the biological and psychological factors that are affecting the John, and by external environment is the interaction with the physical environment itself and the sociocultural factors within it (Holland et al, 2008).
In Johns" case, as of the post kidney transplant operation patient, the internal environment is the one that has to be continuously reassessed and monitored. The first biological factor justifying this prioritization is the John being immunosuppressed by the medication as a part of the perioperative and postoperative protocol; therefore he is at higher risk of acquiring the chest infections and the wound side infections (Danovitch and Geffen, 2005). According to Challinor and Sedgewick (1998), second biological factor that is necessary to consider, is the Johns" fluid status. It is a complex combination of measurements of cardiovascular observations, body weight changes, visible oedema, and biochemical markers of patient blood tests; that reflects his current fluid balance, and is vital for the prevention of circulatory complications (Wu et al, 2004). For John, the inability to maintain the fluid status within the optimal range can result in fluid overload and possible pulmonary oedema (Challinor and Sedgewick, 1998). The third biological factor ascertained by Challinor and Sedgewick (1998), is the respiratory depression that can occur as a result of administration of opiates to John. That opiate administration is used as a pain control and necessary for John as he, as the kidney recipient is susceptible to chronic pain (Nourbala et al, 2007).
The assessment of first factor is performed via the four hourly observations of such vital signs as blood pressure, pulse, temperature, bloods oxygen saturation level and respiration count (Danovitch and Geffen, 2005). The most recent record of observations of Johns" vital signs is as follows: blood pressure of one hundred thirty over eighty millimetres of mercury, pulse of eighty five beats per minute, temperature of thirty seven degrees centigrade, oxygen saturation level of ninety eight percent and the respiration count of fifteen breaths per minute. Furthermore, Johns" observations, throughout the shift, have been stable with only minor fluctuations, indicating no signs of possible chest infection, and were within normal range. Nicol, Bavin, Cronin and Rawlings-Anderson (2008) define the normal range, for the systolic blood pressure reading, between one hundred forty to ninety; and for diastolic between ninety to sixty millimetres of mercury. The normal pulse range is between sixty to eighty beats per minute, temperature is between thirty six to thirty seven point two degrees centigrade, oxygen saturation level in blood above ninety five percent and the respiration of twelve to twenty breaths per minute (Nicol et al, 2008).
Although the Johns" wound side assessment for the signs of infection shows no bleeding, swelling, redness or heat, but it does show an insignificant amount of straw like fluid leakage (Nicol et al, 2008). The dressing has been changed, observation recorded, fluid sample has been collected and referred to the medical team; for the investigation of the possibility of urine leakage (Danovitch and Geffen, 2005). Therefore at the present time Johns" investigation does not indicate the wound infection development, but it will have to be continuously reassessed. It is relevant to mention, that John has the Redon vacuum wound drainage in situ, on the lateral side of the right iliac fossa. This drainage has been inserted perioperatively for the purpose of evacuation of any minor surgical bleeding, around the wound side, and for the prevention of perinephric hematoma development (Danovitch and Geffen, 2005). Therefore, as a part of Johns wound examination, the volume of the content of this drainage has been continuously reassessed and recorded, after increasing by ten millilitres over the course of this shift, it is now at the acceptable twenty two millilitre mark (Kiberd et al, 1999).
Before the second factor is assessed it is important to specify that for the first few days including this shift, because of the absence of the bowel sounds, John has no oral intake (Danovitch and Geffen, 2005). Consequently the fluid replacement therapy is commenced intraoperativly and carried on through the first few days, in order to enable an immediate postoperative urine output; and encourage the kidney function to reach the normal level as soon as possible (Danovitch and Geffen, 2005). Also, to allow this continuous and measurable urine output and as a part of fluid replacement therapy protocol, John has the Foley urinary catheter in situ draining in to the bedside urometer (Danovitch and Geffen, 2005).
Considering all of this, Johns fluid status assessment is performed through the combination of the use of as vital sign observations with the visual observation for the signs of oedema, also the comparison of the beginning of this shift weight measurement with the next prior weight measurement is performed; and this assessment process as a whole is supported by continuing hourly measurement of fluid intake and output and fluid replacement therapy (Danovitch and Geffen, 2005; Wu et al, 2004).
In case of John, his weight for this shift is seventy five kilograms; the difference, with a last recorded weight of seventy three and a half kilograms, is one and a half kilogram. His most recent urine output is ninety millilitres of urine over an hour; and throughout this shift it never dropped below required fifty millilitres or surpassed maximum allowed two hundred millilitres (Danovitch and Geffen, 2005). Based on conjunction of this measurement with aforementioned vital sign observations, John is not showing symptoms of chronic fluid overload, such as shortness of breath, generalized and feet oedema; or as a contrary the symptoms of volume depletion, such as hypotension, tachycardia, decreased urine output (Challinor and Sedgewick, 1998; Wu et al, 2004).
The assessment of the third biological factor is also based on the data gained from observations of Johns respiration rate and oxygen saturation level (Challinor and Sedgewick, 1998). As aforementioned, both observations, in Johns" case are normal and in combination with his low, recorded demand for the opiate administration, it is indicative of a low risk of respiratory depression (Challinor and Sedgewick, 1998).
On the other aspect of Johns ability to maintain a safe environment, which needs to be mentioned are the psychological factors affecting his recovery. To correlate that to Johns" case, it has to be recalled that he is the recipient of the kidney donated by his mother, who is also at present time his carer. For the young male like John this level of dependence could be a significant stress factor and the need to be independent is quite high on his hierarchy of needs (Maslow, 1970).
The goal of this part of assessment is to recognise this need and to provide the care that is needed in order for John to reach self actualisation (Roper et al, 2000). It is achieved through the recognition of this potential need at the initial Johns assessment upon admission; and then, through the continuous encouragement of John in mobility and independence in meeting other activities of living, not impacted by this operation (Roper et al, 2000; Holland et al, 2008). In this regard, John has set out of his bed at the beginning of the shift and had a bed side wash with the minimal assistance.
During the account of this case study no other activity of living is impacted upon, to the extent of it needing the nursing assessment and intervention.
In conclusion, it seems valid to state that, although there is a continuing debate about application of this model of nursing in practice; as a framework in conjunction with nursing process, it clearly allows the achievement of an effective assessment, of patient"s current health condition (Roper et al, 2000; Walsh, 2002).
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