Developing how it informed the service delivery of patient

Developing
Proficiency in Professional Nursing Practice

In
the essay there will be a critical examination of the nursing care delivered to
a patient with complex circumstances, during one shift on duty. This includes
justifying and critically evaluating the nursing assessment and care strategies
used for the patient. The assignment will include an analysis of the clinical
course of a specific condition, and the nursing interventions which were
required to meet the holistic needs of the patient. An evaluation of the
clinical decision making used will also be included, and how it informed the service
delivery of patient care. Throughout the essay the patients name has been
changed to Mrs Smith. This is in coherence with NHS England (2016) which states
that all employees having a legal responsibility of maintaining confidentiality
of all patients, therefore protecting their private information and anonymity. The
focus of the assignment is on a patient who came into a hospital setting
following a stroke.

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Patient
Summary

Mrs
Smith was a 42 year old female patient with severe learning disabilities Mencap
(2018) describe a severe learning disability as a disability where individuals
need support with everyday activities. This is due to a reduced intellectual
capability, for instance individuals with a learning disability may find it
difficult completing tasks such as washing and dressing on their own. Mrs Smith
was admitted to hospital following an ischaemic stroke. This type of stroke can
be defined as a narrow or blocked artery in the brain, where the blood supply
becomes severely reduced and therefore depriving brain cells of the oxygen and
nutrients they need (Mayo Clinic 2017). Mrs Smith presented with right sided
weakness, affecting her arm and leg. The individual lived at home with her
elderly mother who was a full time carer for Mrs Smith. The patient needed
daily assistance with her personal needs such as being encouraged to wash and
dress. Since Mrs Smith father passed away, her mother found it more difficult
to manage her daughters care on her own but was reluctant to seek help. The
patient had borderline hypertension, which was diagnosed by her GP a few years
ago. During the appointment her GP advised her on a healthier lifestyle,
however due to her learning disabilities the patient was unable to understand
the information she was given. Mrs Smith preferred the comfort of her own home,
with her mother, and felt anxious about leaving the house and communicating
with other individuals. This meant she did not attend regular GP visits to
review her health issue. The patient also had an increased body max index score
of 30, which meant that the individual was overweight. A body max index score
(BMI) is a method used to determine whether an in individual is at a healthy
weight, overweight, or obese. The BMI score is calculated using an individual’s
height and weight. (BUPA 2018).

Background
Prevalence

Hankey
(2017) defines stroke as a condition which occurs suddenly. He also states that
in an ischemic stroke there is a loss of neurological function in the brain,
lasting longer than twenty-four hours. Hankey describes the most common
symptoms of stroke being sudden weakness in parts of the body, altered speech,
visual loss and double vision. However, Randolph (2016) argues that other
common symptoms of stroke include confusion, dizziness, and poor balance when
walking. Recent statistics from the Stroke Association (2017) describe the
statistics relating to stroke. The association describes how there are more
than 100,000 strokes happening in the UK every year. This means that there is
around one stroke, happening somewhere in the UK, every five minutes. These
statistics show that stroke is one of the main leading deaths in the adult
population within the UK. The cost of stroke costs the NHS around £1.7 billion
each year.

Mrs
Smith had an increased risk of stroke due contributing factors, such as her
high BMI score. Studies have shown there is a link between obesity, and
developing an increased risk of having an ischemic stroke ((Katsiki, Ntaios and
Vemmos, 2011). Statistics from NHS England (2017) states that in 2015, 58% of
women and 68% of men in the UK were classified as being obese. This evidence
shows how obesity is a major problem in the UK, with numbers of obese people
rising each year. Obesity can lead to other health complications such as
diabetes, heart problems, stroke and mental health problems.

Obesity  how does it cause stroke Type of stroke, how
it develops, likelihood of patients with stroke , clinical presentation.

 

 

 

Nursing
Assessment

During
the nursing assessment Mrs Smith observations were regularly checked. The patient’s
observations were recorded using the national early warning system (NEWS). The
national early warning system involves recording a patient’s respiration rate,
oxygen saturations, blood pressure, pulse rate, and temperature (Kolic et al.,
2015). After checking Mrs Smith’s vital signs, it was noted that her blood
pressure (134/96), respirations (20), oxygen saturations (99%), pulse rate (86)
and temperature (36.5) were all in the satisfactory range, in compliance with
Royal Collage of Nursing guidelines (2016). As a nurse a NEWS chart is
frequently used for patients in a hospital setting. The charts consists of a scoring
system which alerts of any deterioration in a patient’s condition. It does this
by identifying a person’s vital signs and recognising when they are in need of
urgent medical assistance. It is certain that the national warning system does
well at monitoring a patient’s state of health, due to be able to escalate
problems early. It was important that Mrs Smith had her NEWS recorded regular
following the ischemic stroke she had. There is evidence which shows that an
individual’s blood pressure changes following a stroke, due to an impairment in
the brain where the autoregulation of blood flow is disrupted. The evidence
shows how blood pressure is higher after having a stroke, and that it decreases
after a couple of days (Wong and Read, 2008).

A
Glasgow Coma Score (GCS) was also regularly completed for Mrs Smith following
her stroke. The GCS is a type of assessment used on patients to access their
levels on consciousness (Reith et al., 2015). It involves assessing how orientated
a patient is and how well they are able to follow simple commands. The Glasgow
coma scale also included checking Mrs Smith’s eyes to make sure each pupil was
reacting to light and equal in size. As a nurse checking Mrs Smith’s GCS score
after her stroke was important to access the amount of neurological damage in her
brain. It was also used to identify factors which could potentially predict early
onset of further strokes. However Miah et al (2009) argues that although the
GCS is a good tool to use, it should not be used solely and that other
assessment tools should be used alongside it to identify a stroke. When
assessing Mrs Smith it was identified that she was scoring a GCS of fourteen
out of fifteen, due to appearing slightly confused. Although another key thing
to remember, when reflecting on evidence taken from NICE guidelines (2014), is
that patients with neurological disorders scoring a lower GCS should be taken
into consideration. For instance due to Mrs Smith’s learning disabilities,
slight confusion was normal for her when interacting with other people. The
patient sometimes required information to be repeated a couple of times before
retaining and understanding what has been said.

As
a nurse it was important to check Mrs Smith pain score to ensure that patient
remained comfortable. Grayson (2016) explains how pain is a very uncomfortable
experience for a person to have, however it can be used to determine if
something is wrong in the body. He also states that if an individual is
experiencing a lot of pain it can cause a negative impact on their quality of
life. In agreement with this statement, as a nurse it is important to maintain
good control over a patient’s pain. Paul Ingraham (2018) describes how the
feeling of pain comes from receptors in the brain. When these receptors are
triggered, a chemical is released moving itself from the spinal cord to the
brain. In a person’s brain, the cerebral cortex will receive and process the
message of pain. Due to Mrs Smith’s learning difficulties she found it
difficult to understand and rate her pain using the 1 to 10 scale. To overcome
this issue pictures of different face presenting various emotions were shown to
the patient, in order to help her present any pain she had. The pain scale used
was developed by the Wong Baker Foundation (2009). It was developed to increase
the effectiveness when being able to rate pain, and therefore improve how well
it is managed and cared for. Mrs Smith found the tool easy to use and was able
to identify how she was feeling straight away. The patient pointed to a face
which suggested she was uncomfortable and experiencing some pain. The situation
was handed over to a doctor, who prescribed 1g of IV paracetamol.

When
giving medication to a patient, nurses must always comply with relevant policies
and procedures. There are many checks to follow before giving out medication,
this is to ensure the safety of all patients. Before preparing medicine, it is
important to check factors such as the side effects, indications and cautions.
The British National Formulary (BNF 2018) sets out guidelines and standards
which must be followed. The BNF includes guidance on how to manage medication,
information about their uses and correct doses, as well as how they should be
administered. As part of nursing interventions it was important to check that
Mrs Smith’s dose of paracetamol was prescribed correctly. This was done by using
the BNF to confirm that intravenous paracetamol, for a patient of 50kg and
above, should not exceed 1g every 4-6 hours. It was also checked that the dose
must be given to the patient over 15 minutes. Bateman and Vale (2016)

 

(Bateman
and Vale, 2016)

Paracetamol poisoning is common. If untreated, liver and/or renal
failure can develop. The administration of acetylcysteine within 8–10 hours of
overdose will minimize or prevent hepatic damage and ensure survival
irrespective of the magnitude of the ingestion. Important prognostic factors
are the international normalized ratio, pH and plasma creatinine concentration.

 

 

 

 

 

Swallow
test

Following
a stroke it is important for all patients to be sip tested, to ensure they can
swallow safety. This had to be done before Mrs Smith was allowed to consume any
food or fluids.

 

Hospital
Passport

On
admission a hospital passport was completed for Mrs Smith. The information
provided was gained from talking to Mrs Smith’s mother. The passport include
the patients like and dislikes, food they enjoy and other factors about her
life.

 

 

Skin
assessment

Regular
skin checks were important for Mrs Smith. Due to her stroke the patient found
it difficult to re-position herself in bed, as a result of her right sided
weakness. Mrs Smith was at a high risk of developing a pressure ulcer. A
pressure ulcer is defined as injury to an individual’s skin or tissue, normally
over a bony area of the body. When a lot of pressure is applied to the skin it
can cause open area to form, and therefore increasing the patient’s risk of
infection (Hunter and Edwards 2017).

Ted
Stockings

After
a stroke, patient can be at high risk of developing a blood clot due to staying
in bed for a long period of time.

Fluid
food chart

It
was important for Mrs Smith to have the amount of fluid and food she was
consuming monitored.

Must

 

 

Cathether
Care

The
patient required a catheter after she had gone into urine retention.

 

Referals

 

 

 

 

 

 

Evidence

 

 

 

 

Care

In
summarisation there were many important key interventions in the planning and
delivery of Mrs Smith’s care. One of the main interventions was recognising Mrs
Smith’s learning disability and reflecting how her care was delivered around
this.

 

 

 

Conclusion

In
conclusion, Mrs Smith’s holistic needs were met through nursing interventions