I have focused on a client whom has mobility impairment due to recurring falls. This patient was referred to the care of the elderly ward where she received intense rehabilitation to help maintain independence. I will explore the issue as a holistic assessment.
For this care study the names of the people and places concerned have been altered in order to protect and maintain confidentially, this is to abide by the Nursing and Midwifery Council Code of Professional Conduct (NMC) 2004. The name of the client for this care study will be called Mrs Eileen Adams. (See appendix).
Mrs Adams was admitted to the care of the elderly ward for rehabilitation purposes.
Rehabilitation is described by Mosby (2006) as the restoration of a patient to normal or near normal function after a disabling disease or injury. Gibbon (1992) expands on this by defining rehabilitation as being concerned with the restoration of an individual’s social, physical and emotional function and their abilities to their prior level. However in Mrs Adams situation this was not a realistic aim. This holistic view of rehabilitation is also in agreement with Walsh (2002) who states that rehabilitation as re-enablement must have a therapeutic value for the person concerned, with the ultimate aim of maximising their social well being. This was evident in Mrs Adams case as by rehabilitating her independence was promoted.
Upon admission to the ward the nursing intervention was to assess her needs and goals. The Roper-Logan-Tierney model of nursing practice was used to assess her needs. A model such as this is practised in a health care setting as living is a process in which we all undertake activities daily and it is necessary that health care professionals can assess and evaluate goals for patients in order to aid in the progression to a healthier life (Holland et al, 2004). Also this model is based on patient centred care which proves more beneficial to the patient as it prevents, alleviates and solves the problems the patient has encountered (Holland et al, 2004). The Roper-Logan-Tierney model consists of twelve activities of living. (See appendix 2). A falls assessment and a moving and handling assessment were also carried out.
Following Mrs Adams needs assessment it was evident that the activities she needed assisting with was personal cleansing, dressing and most importantly mobilising. Her falls assessment and her moving and handling assessment proved that she not capable of maintaining a safe environment as she was at high risk of accidents. Theses assessments are vital to patient centred care the National Service Framework for Older People (NSF) (2001) is a key concept in the care of an older person.
Upon admission Mrs Adams was referred to the physiotherapists. The multidisciplinary team worked closely together in Mrs Adams rehabilitation process. Involving her in her own care and the decision making process, this empowered Mrs Adams which is considered good practice (Thompson, 2004). Empowerment is defined as a process of helping people to assert control over the factors which affect their lives (Gibson, 1991). Also by involving a patient in the decision making process promotes their individuality (NSF 2001). By complying with these needs Alexander et al (2006) cited the work of Evans et al (1995) that a multidisciplinary team brings together separate but interlinked professional skills to improve Mrs Adams chance of attaining her goals. Mrs Adams had a combination of long and short term goals. Her short term goal was to improve her mobility hence promoting her independence this in turn would make personal cleansing and dressing easier. Her long term goal was to go home and regain her independence. Care plans were issued to help the multidisciplinary team; her strengths were focused on rather than her weaknesses (Davis et al (1999). This approach aided Mrs Adams progress as she was very determined to go home. Together Mrs Adams and the team identified her needs, clarified her goals and set targets also taking into account her base line of function; this is considered good practice by Walsh et al (1999)
Activity of living: Mobilising independently
As mentioned previously to aid the development of Mrs Adams mobilising she was referred to the physiotherapist. Also Mrs Adams was very determined and persistent to reach her previous ability to mobilise, her family were also very proactive in her care which Brummel-Smith (2003) states that patients whose families are active members in their rehabilitation are nearly 25% more likely to return home from the acute hospital
Ryan (2004) states that being in control of movement coincides with pride, dignity and self esteem hence mobility problems relate to substantial psychological and emotional effects. This is confirmed again by Ryan (2004) that a minor reduction in mobility can have a negative impact on a person’s outlook and quality of life. Yet Mrs Adams was fully aware that the rehabilitation process was a slow and gradual process.
It was also vital for the team to find a balance between helping Mrs Adams to do a certain task and allowing her to do the activity during her rehabilitation program was sometimes difficult as providing as providing too much assistance caused Mrs Adams to be disempowered along with doing too little may cause Mrs Adams to struggle unnecessarily. Thus it is important to carry out assessments and evaluation continuously.
Analysis of Roper et al’s five factors, influencing activities of living include biological, psychological, sociocultural, environmental and politico economic are very important factors when mobilising a patient and will be taken into consideration. However the only factors that apply to Mrs Adams are biological and sociocultural. Biologically mobilisation of Mrs Adams was vital in order to reduce her risk of pressure sores and deep vein thrombosis, (SIGN, 2002). Committee of the Institute of Medicine Division of Health Care Services (1990), also supports that early mobilisation is key in promoting the biological health of the patient and reducing risks of deep vein thrombosis also Mrs Adams body posture affected her mobility as she has a bent spine due to kyphosis. Socioculturally Mrs Adams suffers from a worsening condition of congestive cardiac failure (CCF), PPM, high blood pressure, diverticulitis, angina, arthritis in her left knee which has caused an abnormality, heart failure, shortness of breath whilst eating.
Upon admission Mrs Adams was transferred from bed to chair using the full hoist. However the use of a full hoist in Mrs Adams case was not beneficial as she had the potential to be mobile. Full hoists do not promote the independence of a person and causes muscle wastage (Smith, 2005). Hence it was in Mrs Adams best interest to mobilise without the use of the hoist in addition to this Mrs Adams did not feel comfortable transferring with the aid of a hoist as she stated she found it intimidating. Upon Mrs Adams admission a Waterlow was carried out. Carrying out this procedure is considered good practice as Laverty, Naylor and Soady (2004) states that patients with a risk of acquiring a pressure ulcer should be assessed either on admission to hospital or in the community when they first come into contact with the health care services. However, the National Institute for Clinical Excellence (2001) argue that risk assessment tool’s are to be used as only a guideline to support nurse’s clinical judgement hence not to replace it. However Walsh (2002) deems that the Waterlow tool is only successful if used regularly, upon admission or when a patient condition changes.
Following the physiotherapist assessment it was clear to the multi-disciplinary team that Mrs Adams had the potential without the aid of a full hoist. The physiotherapist worked with Mrs Adams twice daily and each session lasted forty five minutes. Within one week Mrs Adams was mobilising with the aid of a frame. This promoted her self esteem and her social function and through this assisted in her rehabilitation (Alexander, 2006 and Walsh, 2002). This also helped rehabilitate Mrs Adams by promoting her independence in this activity of living which is in accordance with the NMC (2004) as one should involve clients in their own care. Ryan (2004) states that being in control of movement coincides with pride, dignity and self esteem hence mobility problems relate to substantial psychological and emotional effects. Therefore by mobilising Mrs Adams the team promoted her psychological rehabilitation (Alexander, 2006) by reducing the risk of her acquiring a DVT (Committee of the Institute of Medicine Division of Health Care Services 1990).
Throughout the rehabilitation process decision making was a continuous issues surrounding Mrs Adams treatment. Mrs Adams felt that she would be much happier to continue her therapy at home with her family. As a professional involved in her care, I felt that her decision would not benefit her progress as Elton and Valente (2003) cite the work of Anderson et al (2000) who found early discharge did not improve (or worsen) health or quality of life for patients at home. Mayo et al (2000) (as cited by Elton and Valente 2003) agrees with early discharge; provided that the appropriate home based rehabilitation was present. I felt that it would benefit Mrs Adams to finish her rehabilitation in hospital, as Mrs Adams finds it hard to cope with change. Right through Mrs Adams care, a nurse-patient relationship developed between Mrs Adams and I. This had an advantage as Mrs Adams had self belief and confidence in my decision making ability (Williams 2006) and agreed to continue his therapy in hospital despite the concerns of her family while relying on my ability to engaging Mrs Adams to share the power and control of the decision made (Castledine 2005). Also evidence suggests that early rehabilitation in hospital will improve the patient’s outcome (DoH 2001).
Activity of living: Personal cleansing and dressing.
As mentioned in the appendix Mrs Adams was having difficulties coping with her personal cleansing and dressing.
As Mrs Adams was very pro active regarding her care it gave the team a good insight into her daily life this insight was also reinforced by her family’s involvement. It was clear that Mrs Adams was very hygienic and proud of her appearance. Her lack of motivation for her personal hygiene could be due to her increasing lack of mobility or shortness of breath as this would inevitably make it difficult to stand for long periods of time. Roper et al (1996) states that old age is an major factor regarding personal cleansing and dressing as when we get older, even the most menial of tasks can be a struggle and can be emotionally damaging to a persons self esteem when an individuals ability is compromised.
As Mrs Adams was more mobile at this stage of her rehabilitation process thus it was decided that a washing and dressing assessment was carried out this was done by the occupational therapists. The occupational therapists and the nursing team worked very closely for Mrs Adams to achieve optimal independence with his activities of living. Mrs Adams walked with the aid of her frame to the toilet then she was left in private to have a strip wash. Mrs Adams was advised to wash the areas of her body she had the ability to reach and to call for assistance for the areas she was unable to wash. Twigg (2000) believes that washing and dressing is a private activity where socially and culturally a person carries out ones own hygiene needs to there own ability and comfort. This considered good nursing practice by Dougherty et al (2004). The Department of Health (2001), states that it is of utmost importance to ensure that patient privacy and dignity in maintained. Research shows that there is evidence to prove that treating people with dignity and providing dignified care can have a positive effect on treatment, social outcomes and health and well-being (Tadd et al (2002). When Mrs Adams called for assistance the only area of which she was unable to reach was her back, assistance was given while assisting Mrs Adams care was taken not to reveal any part of her body that was not necessary to be exposed this was done to maintain privacy, dignity and body temperature. This is considered good nursing practice by Dougherty et al (2004). The Department of Health (2001), states that it is of utmost importance to ensure that patient privacy and dignity in maintained. Research shows that there is evidence to prove that treating people with dignity and providing dignified care can have a positive effect on treatment, social outcomes and health and well-being (Tadd et al, 2002). When the assessment commenced it was clear that the only factor affecting Mrs Adams washing and dressing technique was her decreased mobility, this is evident as when her mobility was restored her independence grew. Hence Mrs Adams felt more confident and thus was enabled to pursue her activities of living prior to her admission to the care of the elderly ward. At this stage Mrs Adams was ready for discharge, her mobility was regained and her cleansing and hygiene needs were restored. With the support of her family the team were confident that Mrs Adams could cope at home.
Mrs Adams time spent in hospital was not a prolonged one. This was due to the fact the team empowered her and encouraged Mrs Adams to make her own choices about the care that she received. This is considered to be good practice as Walsh (2002) believes that good nursing care is the willingness to work with people to help them make informed choices for themselves. This compounded with the fact that she was given the option of verbal consent which is in accordance with the NMC (2004).
Overall Mrs Adams rehabilitation process was a successful one the mulit-disciplinary team worked well together and successfully shared information gained through assessment which leads to a positive outcome for the patient (Nolan et al, 1996). The nursing team played a considerable role within Mrs Adams care in rehabilitating her. This involved maintaing physical well being of Mrs Adams, providing high quality of care such as prior to Mrs Adams mobilization the nursing staff positioned her to help prevent pressure ulcers occurring as immobility can result, there was also consistant bed side care.
In conclusion Mrs Adams time on the ward was a successful one. Assessments were carried out which included the Roper-Logan-Tierney model of nursing of twelve activities of living in which two act ivies were concentrated upon. A holistic good was taken into account when considering five factors, biological, psychological, sociocultural, environmental and politico economic. I have gained good knowledge and realised that patient centred goal planning is the key to effective rehabilitation. By encouraging self autonomy and self efficacy helped to promote the patient to choose the best and possible treatment. I focused on this patient as I felt that this would have been an excellent opportunity to work and learn the essential skills that are required in the process of rehabilitation. It was such an achievement to know that Mrs Adams was able to return home to her family. I have gained may skills such as making nursing judgement of Mrs Adams progress which I was able to report back to the other team members, provided better patient care around her rehabilitation such as promoting independence. I feel that this was successful for both Mrs Adams and I.
Reference list for reflection
Alexander M., Faucett J., Runciman P., 2006 Nursing practice: Hospital and Home: The adult 3rd edition. Churchill Livingstone, London
Brummel-Smith J, 2003 Guide to the handling of people 5th edition HTT manager service limited in sheilfing
Castledine G 2005 Nurses must strengthen the nurse/patient relationship British journal of nursing 14 (1); 55
Committee of the Institute of Medicine Division of Health Care Services 1990 http://www8.nationalacademies.org/cp/default.aspx
Davis S, O’Connor 1999 Rehabilitation nursing foundations for practice. Baillierre Trindal, London
Department of Health., 2001 National service framework for older people. DoH, London
Dougherty L., Lister S., 2004 Manual of clinical nursing procedures 6th edition. Blackwell Science, London.
Gibbon B., 1992 The patient in need of rehabilitation In: Alexender M,. Faucett J., Runciman P., (eds) Nursing practice: Hospital and Home: the adult 3rd edition. Churchill Livingstone, London pg 1117
Gibson., 1991 A concept Analysis of Empowerment. Journal of Advanced Nursing. 16:354-61
Holland K, Jenkins J, T Soloman, Whittau J 2004 The Nursing model in practice, 4th edition. Churchill Livingstone, London
Mosby 2006 Mosby’s dictionary of medicine, nursing and health professions 6th edition. Mosby Elsevier, Missouri.
National Institute for Clinical Excellence (NICE) 2001 Inherited clinical guidance: pressure ulcer risk assessment and prevention. NICE, London
Nursing and Midwifery Council 2004 The NMC code of professional conduct: standards for conduct, performance and ethics NMC London.
Tadd W., Bayer A., 2002 Dignity in health care: reality or rhetoric, reviews in clinical gerontology. 12 (4) 1-4
Thompson N. 2006 Anti-discriminatory practice 4th edition. Palgrave Macmillan, Basingstoke.
Walsh M., 2003 Watson’s clinical nursing and related sciences 6th edition. Bailliere Tindall, London
Walsh K, Roberts J, Bennett G, 1999 Health carre for elderly; mobility in lod age [online] British Nursing Index 16 (2): 69-74. Avaible from www.bri.com [27.01.2007]
Willams J 2005 Advances in prevention and treatment of stroke and TIA Nursing Times 101 (14) 30-32.
Roper N, Logan W, Tierney A, The elements of nursing: A model for nursing based on a model of living. 4th edition Churchill Livingstone London.
Ryan J, Berry J, Lang AF, Kneafsey R, 2002 The role of nurses in the multi professional rehabilitation general advice or nurses. 37 (1):70-78
Triggs G, 2005, Fundamentals of nursing essence of care, Oxtoby, London
Mrs Eileen Adams is 93 year old lady. She lives alone in a semi detached bungalow. Her main carers are her son and his wife, whom live in a caravan in the garden and are very supportive. She also has two daughters, one visit’s on Thursdays and the other on Tuesdays. Two weeks prior to Mrs Adams admission she was able to carry out all of her activities s of daily living independently. At home Mrs Adams mobilises with a frame, she has a commode by her bed and uses a raiser/recliner chair. Mrs Adams also has a stair lift in situ. She has a wheelchair for when she goes outside. Her family maintains that she needs a lot of help with cooking and cleaning and believe that her ability to cope with her own personal hygiene has declined. However Mrs Adams suffered a fall in her home. Upon admission to the ward she was for all care and was transferred from bed to chair with the aid of a full hoist. Mrs Adams suffers from a worsening condition of congestive cardiac failure (CCF), PPM, high blood pressure, diverticulitis, angina, arthritis in her left knee which has caused an abnormality, heart failure, shortness of breath whilst eating and she also has a kyphotictt back of which causes her lean forward in a bent position of her spine this has resulted in an altered sense of gravity. Mrs Adams has no past history of smoking and no known drug allergies. While in hospital the medication she received was, Perindoril 2mg (po) this drug is used for heart failure and hypertension (BNF 2002), Lansoprazole 15 mg (po) this drug inhibits gastric acid by blocking the hydrogen-potassium adenosine triphosphatase enzyme system of the gastric parietal cell (BNF 2002), Asprin 75 mg (po) this is used for mild to moderate pain or the prevention of an MI (BNF), Clexane 20 mg subcationuasaly this injection is important for anticoagulation (BNF2002). Her family are concerned that when their mother is discharged from hospital that she will not cope and they believe that she should receive 24 hour care.
Throughout this care study, I have gained my patients consent before any treatment of care commenced, I will remain confidential at all times regarding the patients name (0f which has been altered) and condition. Cooperate as a team member by exchanging information to other professionals when necessary and maintaining my professional knowledge and compliance at all time (Code of Professional Conduct NMC 2004)
British Medical Association 2005, British National Formulary London, BMJ Publishing Group pp.
Nursing and Midwifery Council 2004 The NMC code of professional conduct: standards for conduct, performance and ethics NMC London.