Introduction
Different governmental policies endorse nurses to use each and every reachable chance to encourage the health and wellbeing of patients (Department of Health 2010). Nurses enjoy a unique and distinct connection with patients, which promotes trust that patients can have in nurses. Therefore, it is the essential duty of nurses that they should use their powers and trust to inspire behavioural change in the patients who have poor health due to their unhealthy behaviour about themselves. The most important way for this purpose is to empower the patients by involving them in their care plan. The involvement in any kind of decision making activities and plans will bring positive change in the behavioural response of the patient in health related matters. Moreover, effective problem solving decision and strategies making skill derived from a strong basis of information are behaviours expected from nurses that require to be grown during their professional education. The goal of this assignment is to offer needs or problems orientated approach to care using a nursing process (Taylor 2000).
In this case study, a problem solving approach is used for assessing, analyzing, planning, implanting and evaluating the patient’s problem. The problem of a patient is recognised following a thorough assessment, and then plans are made for her care and implemented and evaluated for the achieved outcomes from the intervention given.
Case Study
Mrs Thomas was a 70 year old widowed female living alone in a bungalow which was controlled by the warden. She had 3 children who are all married; however one of them lived in close proximity and also visited often. She was admitted to the Medical Assessment Unit following a fall in her home and was managed using a problem solving approach.
Problem Solving Approach
Fraser (2003) defines a clinical problem-solving approach as a process in which a practitioner extracts pertinent and particular information obtained from patients to assist differentiate between working diagnoses, makes suitable working diagnoses, searches for discriminating and related physical signs to help verify or disprove working diagnoses, properly infers and applies information taken from all sources regarding a patient, puts into practice the knowledge of basic, clinical and behavioural sciences to the detection, treatment and solution of problems of patients and distinguishes limits of competency and responds properly. This approach is utilised below for Mrs. Thomson.
Assessment
Once Mrs Thomas was comfortable, the nursing assessment was begun. An assessment is basically the compilation of information from a person, to establish their requirements and develop an obvious potential of their situation. This process depends on thorough and complete assessments to be a success. An important nursing skill is monitoring a patient, via all five senses, from hearing to enhance information, to feeling them via a touch, assessing their body temperature and their skin condition (Brooker and Waugh 2007). Holland et al (2004) is also of the opinion that an assessment recognises the main concern amongst the problems. This necessary information can be gathered in a number of distinct ways, from watching a patient, examining, and communicating with them. Gathering of information can also be made via a relative mean if, for instance, the patient who is the primary source is comatose or unconscious. Information can be obtained from the patient, the friends or family of patients and even from the health records or evidence (Peate 2010).
Further, in order to carry out a full assessment different assessment tools were used based on Mrs Thomas clinical presentation. Her assessment was carried out by her bedside and in order to respect her privacy the curtains were drawn out. The assessment needs to be carried out appropriately and correctly. Barrett et al (2009) states that nurses who perform incomplete and disordered assessments, may not be successful in finding a major problem, or seeing an underlying issue. Assessment is the keystone on which a patients care is designed, applied and assessed (Roper, Logan, Tierney 2008)). Sutcliffe (1990) also stated that incomplete or poor assessment consequently causes poor care planning and execution of the care plan. Therefore, in order to carry out a precise assessment full concentration was made following all the standards.
Physical examinations revealed the presence of bruising to the left side of her face, and her upper and lower body. She also complained of a general, non-specific soreness of the whole body and headache. There was a problem of urinary incontinence, and her urine also smelled offensive. However, there was no other significant past medical and surgical history.
A number of risk assessment tools were used when assessing Mrs Thomas. These were the waterlow score, malnutrition universal screening tool (MUST), activities of Living and falls risk assessment score. The waterlow score helps to find out whether there is a possibility of developing a pressure ulcer in a patient or not (Waterlow, 2005).The MUST tool is a screening tool for nutritional assessment that identifies under nutrition and over nutrition (obesity) in a patient (BAPEN, 2008). Activities of living model is basically a tool comprising twelve activities that are intended to maintain a normal living, and include communication, eating and drinking, breathing, keeping a safe environment, personal cleansing, excretion, body temperature control, dressing, playing, working, mobilising, sleeping, expressing sexuality, and eventually dying. All of these activities are vital. However, these are affected by the illness. The fall assessment tool is to evaluate if a patient is at danger of a fall, taking into consideration their history as well as their present condition (Hendrich 2013).
Mrs Thomas was assessed using MUST initially and she was found under weight with BMI 18. She was then assessed using waterlow score because she is at high risk of developing pressure ulcers. Mrs Thomas was assessed and given a point value through these regions such as type of skin, visual risk areas, build or weight for height, mobility, malnutrition screening tool and continence. The score came out to be greater than 10, showing a greater risk of developing an ulcer.
On further assessment, she was found to be suffering from cognitive impairment and was also disorientated to time and place. 12 activities of living were assessed as proposed by Roper et al (2008). She was found to be socially active and independent with a good circle of and contact with friends. She also used to attend local events and did her shopping weekly with her daughter.
Objective and subjective data both were collected during the assessment from Mrs. Thomson. The objective data collected such as blood pressure and temperature were recorded and were found in satisfactory limits. In order to take a subjective data Mrs Thomas was taken in complete confidence that her all details would be kept confidential so she could share anything she wanted to. She was explained that a complete detail will help us in recognising her problem and therefore treating it onward. She told that she used to be a happy person but now she felt her loneliness and remained sad. Therefore, she didn’t feel like eating or doing anything. Her problem was then analysed to reach some particular nursing diagnosis.
Analysing
Based on her complaints, assessment and physical examination, a nursing diagnosis was made. The nursing diagnosis considers the medical diagnosis in addition to the holistic requirements of the patient taking into consideration their spiritual and biopsychosocial necessities and the consequence these may exert on the patient and how they cope with their disease (Hinchliff et al 2008). This also facilitates the nurse to interpret the information achieved during the assessment and recognise the nursing problems (Lunney et al 1997).
Nursing diagnosis is an important action in the nursing process; it counts on a precise and complete nursing assessment and makes the foundation of nursing care-planning (Minton, & Creason 1991). It is the end result of nursing assessment, a lucid declaration of the patient’s problems as determined from the process of assessment (Roper et al., 2008). In this case, four potential diagnoses were made i.e. Depression, Urinary tract infection, A potential risk of development of pressure sore and Malnutrition.
A diagnosis of depression was based on her feelings of loneliness, for which she left eating, enjoying and taking part. Since she left eating, she became underweight, and therefore malnutrition was also diagnosed. She was suspected of suffering from urinary tract infection and this might have lead to delirium. Pressure sore was already evident on her sacrum and it might be lying on a floor after a fall for a long period of time.
Planning
The next step was the planning. The planning step of the process is where attainable objective needs are made via discussion with the patient and or his care givers (Benner, Tanner and Chesla 1992). This step is therefore over lapping and interdependent and the success of this step relies on the comprehensiveness and quality of the assessment. The nursing planning is actually where all the information obtained in the assessment part is utilised to plan the patient care. The plan of care is to resolve the genuine problems of the patient (Lunney et al 1997). It also aims to facilitate the patient tackle their disease in an optimistic approach and to make them as restful and free of pain as possible.
Thus, in order to ensure good planning all the information gathered from Mrs Thomas in the assessing step was utilised here. The planning was done by taking into an account not only the medical diagnosis but also the holistic requirements of the Mrs. Thomson in view of their spiritual and biopsychosocial needs or wants (Hinchliff et al 2008). Holistic approach was focussed in order to ensure psychological, physical, spiritual and social aspects of the Mrs Thomas (Meurier, 2005).
Setting plan or goal is important for the wellbeing of the patient. It plays a role as a spur for the patient and persuades them to work towards this (Kemp and Richardson, 1994). The more the information collected in the assessment, the simpler is to make the plan of care. The chief aim of a nursing plan is to offer the information on which individualized, systematic care can be based. Nevertheless a comprehensive individualized care plan for a particular patient needs to be capable to perceive exactly what is mandatory for the patient, the NMC (2008) stats that nursing interventions should be specific for the particular patient, anchored in best evidence, quantifiable and attainable.
In order to plan a care, there are a lot of diverse principles for setting goals. One of these is patient centred, observable, directive, and quantifiable, recordable, comprehensible and lucid, convincing and time related principle (Roper et al 2008). When planning a care a much emphasis needs to be rooted in the independence or dependence continuum established in the assessment stage. The care should be such that it encourages the patient to revert to as practically possible to his/her healthy life.
The basic goal was to first correct the present condition of the Mrs. Thomson. Afterward, the plan was made to correct the real cause behind her present situation and complains. The third aim was to keep her engage in meaningful activities. I believe this is one of the essential elements of care. Life activities facilitate patients keep up their functional abilities and can even augment quality of life (Lyketsos et al 2000). The last goal was to help her come out of her depressive thoughts. The plan was to make her feel good in each and every circumstance, either good or bad, in order to live a life happily and free of health related and other problems. Since according to Roper et al (2008) planning should be done considering the resources available to put into practice the care, everything was planned accordingly for Mrs. Thomson. Next important step was the implementation of care plan.
Implementation
This is an important component of the problem solving approach and where all the set goals in the planning step are put into practice and the aims can begin to be attained through medical and nursing interventions (Van Achterberg, Schoonhoven and Grol 2008). The process of implementation is basically the real giving of nursing care. The process of implementation was carried out for Mrs. Thomson not only by nursing staff but also involving the multidisciplinary team including nutritionist, doctor, psychologist and physiotherapists.
In order to manage certain problems certain coping strategies were developed comprising both adaptive and maladaptive strategies. Mrs. Thomson was encouraged for adaptive coping strategies such as emotional regulation, problem solving approach, positive thinking, acceptance, and cognitive reformation and at the same time Mrs. Thomson was discouraged from maladaptive strategies such as feeling bad, negative, depressed, etc.
But before starting the treatment, an informed consent was taken as it is essential since patients are have full right and they should be managed with respect and dignity considering their values, culture, and beliefs (Paterick et al 2008). Therefore, all the implementation of treatment was given after taking an informed consent. After the treatment, a patient felt quite well. She was given a discharge and asked for the follow-up visits. Following implementation, evaluation was carried out.
Evaluation
The process of evaluation is basically in reality the closing stages of the nursing process (Willms and Sirotnik 1994). Evaluation is where the patient has received the care and now the care given is assessed whether it has worked or not (Vaismoradi, and Parsa-Yekta 2010). It is an ongoing and a constant process and also takes place in a formal background at timed points.
Evaluation can be divided into two different components, the formative evaluation and summative evaluation (Graff, Russell, and Stegbauer 2007). Therefore both the evaluations were carried out on Mrs. Thomson. In formative evaluation information about the independence or dependence continuum of Mrs. Thomson was taken and evaluated. This information was obtained from her as well as from her psychologists and nutritionist. It also involved discussing and noting the issues of Mrs. Thomson either getting improved or worse and finding out if she had moved away or towards from the planned goals. In summative evaluation her holistic opinion was considered i.e. how she felt regarding the treatment; whether he felt that the goals were attainable (Stetler 2006).
Following evaluation of Mrs. Thomson, she was found going well with the treatment. She had adopted many new activities to avoid loneliness. She also showed good compliance with the drugs.
Conclusion
In this paper, the nursing process was carried out on Mrs. Thomson to identify, treat and prevent her potential health problems. The assessment and individualised care planning determined the Mrs. Thomson particular requirements or needs as regards to her health. A holistic approach was the used for her overall wellbeing. Care needs were started out in a manner that both the nurse and the Mrs. Thomson knew precisely what was occurring together with her psychologist, doctor and nutritionists. Eventually, Mrs. Thomson showed an earlier recovery and returned back to her normal and healthy life, -- demonstrating that involving the patients in their care facilitate them to experience they are part of their care team and are more likely to help themselves with their care.
Thus, in problem solving approach in order to make the nursing process effective re-evaluating goals as well as interventions require being ongoing and continuous. This paper has demonstrated that when problem solving approach is used, it offers a first-class basis to providing nursing care.
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