Care Of A Cva Patient example essay topic

Introduction Jean was admitted to us following a stroke. The nursing care required during the acute phase of her illness was complex. I found looking after Jean very rewarding. Her care on the ward was based on the Roper Logan and Tierney Activities of Daily Living Model and I felt that it would be beneficial to reassess her care using a different Model such as Orem's Self-Care Deficit theory which is frequently used in dedicated stroke units (O'Connor, 1996). Throughout this essay a pseudonym will be used to protect the identity of the patient. This is in keeping with the Nursing and Midwifery Councils code of conduct on confidentiality as stipulated in clause 5.1 of the code of professional conduct (NMC, 2002).

In this essay I will introduce my patient and discuss her background and reason for admission. A brief overview of the model will be given. I will complete a full and accurate assessment using Orem's model and one of the problems identified will used as a focus of the care plan. A description of the process will then follow with interventions and rationales for the expected outcome. I will conclude with a reflection on this process and the patient.

The Patient Jean is an 89 year old housewife. She is married and has one grown up son. She lives with her husband, who himself is in good health, in a single storey bungalow. Jean is a non-smoker and very rarely drinks alcohol.

Jean is registered blind and also suffers from blepharitis and low-tension glaucoma for which she has been prescribed Timolol 0.25% eye drops. Jean suffers from unstable angina. From her notes it can also be seen that she had an myocardial infarction in 1985 and had another incident in late 2002 with raised Troponin-T levels of 0.25. Under current guidelines a Tn-T 0.2 ng / ml indicates MI (Fagan, 2002).

There is no family history of heart disease and no documentation which would relate to other risk factors. Jean and her husband are quite independent and manage to do all their own housework and shopping. Their eldest son visits regularly and does odd jobs around the home. Jean was found on the kitchen floor by her husband who then called the ambulance which took her to casualty. It was initially assumed that she had fainted and struck her head when she fell.

She had been loading the washing machine at the time. However CT brain-scanning investigations indicated that Jean had suffered from a massive stroke with left hemiparesis. Jean was admitted from casualty to a female general medical ward. Nursing models Models of nursing provide bases for the development of nursing theories and knowledge (ref). According to Angleton & Chalmers (2000); "Without knowledge about the nature of people and their health related needs, nurses would be unable to go about their work in anything but a haphazard way. Nurses working together should ideally practise with shared understandings about people (that is, with the same model of nursing) to ensure continuity of appropriate nursing care" Other advantages of using a model of nursing are: o Acts as a major guide in decision and policy making o Enables a criteria for choosing new team members. o Other health care professionals of the multidisciplinary team can understand the logic of the nursing care.

(Pearson et al 2000) I will be using Orem's self-care deficit theory (SCDT) to guide care planning. The SCDT consists of three related sub theories of self-care, self-care deficit and nursing systems. The self-care theory proposes that self-care is a learned behaviour that individuals perform on their own behalf to maintain life, health and well being (Orem 1991). There are three essential areas of self care: Universal requisites. These are common to all people. There are eight universal requisites which form a basis for the assessment of the patient.

Developmental requisites are associated with conditions that promote developmental processes throughout the lifespan. Health deviation requisites are concerned with defects and deviation from the normal structure and integrity of human life. (Marriner-To mey & Alli good, 1998) The self-care deficit is concerned with the inability to fulfil self-care requisites. If the self-care ability isn't adequate to meet self-care demand then a deficit occurs (Hodge 2003). When this occurs, nursing interventions are usually necessary.

Nursing system theory proposes that nurses plan and provide nursing care that relates to the patients self-care abilities and meets therapeutic self-care requirements. There are three types of nursing system: A nurse provides all universal and health care functions in a wholly compensatory system. In the partly compensatory system a patient is able to assist and perform some self-care needs. The supportive-educative system is designed for persons to learn to perform self care measures and need assistance to do so (Koz ier et al 1998). Nursing Assessment Assessment is the first phase of the nursing process and is about the systematic gathering of relevant and important patient data (Wilkinson 2001). The aim of this assessment is to establish Jean's self-care needs and to identify self care deficits.

UNIVERSAL SELF-CARE REQUISITES: The maintenance of a sufficient intake of air - Jean is able to breathe easily. There is no sign of a respiratory tract infection which may potential problem due to her being immobile. Her respiratory rate on assessment was 14 and oxygen saturation was 98%. The maintenance of a sufficient intake of water - There is a risk Jean may become dehydrated as she is suffering from dysphagia. Therefore taking fluids may be dangerous in that she may aspirate any fluids. It is advisable not to give her any oral fluids until a full swallowing assessment has taken place.

The maintenance of a sufficient intake of food - Jean dysphagia is a concern here. Jean needs a balanced diet to facilitate getting better. However, as with fluids, a swallowing assessment is required. Jeans BMI is 22.3 (height 160 cm; weight 57 kg) which is in the normal range for her height. Weekly weights will show any weight changes in relation to her lower intake. The provision of care associated with elimination processes and excrement's - Jean is currently incontinent of both urine and faeces.

This was not a problem before the stroke. There is an increased risk of pressure sores to buttocks and sacral areas because of the incontinence. Frequent checking is required to assess whether she has been incontinent. The maintenance of a balance between activity and rest - Jean spends most of her time asleep and is very immobile. She occasionally indicates through facial expressions that she is uncomfortable. There is a risk of pressure sores due to her immobility.

Jean is currently on a special mattress, is moved into a reclining chair for a few hours each day and is turned regularly when in bed. A physiotherapist assessment is required. The maintenance of a balance between solitude and social integration - Jean is having problems with her speech due to her left-sided hemiparesis which involves the speech centres of the brain. It is difficult to ascertain whether Jean can understand what is being said to her. However she occasionally responds with a facial expression or moan.

Her husband and son visit regularly. Jeans blindness may also increase her feelings of isolation. The prevention of hazards to life, human functioning and human well-being - Jean's baseline recording are as follows; temperature 36.8 oC, pulse 72 and blood pressure 186/82. Jean's hypertension is a known problem and will be monitored closely.

When sitting on her chair, Jean has a tendency to slip down and this should be observed to ensure she does not slip off the chair. There is a manual handling risk to nursing staff and Jean requires the assistance of two and a hoist to move her. Promotion of Normalcy in function and development - Jean has reduced communication and no mobility. Her poor eyesight will limit her perception of her surroundings. DEVELOPMENTAL SELF CARE REQUISITES Jeans stroke has meant that she has undergone changes in the natural processes of development. She is less able socialise due to her eyesight and it is fair to assume that Jean's stroke will have a major effect on her development.

It is difficult to ascertain what her reaction to this will be. HEALTH DEVIATION SELF-CARE REQUISITES It is hard to determine Jean's understanding of her current illness and its outcomes due to her aphasia. However, requisites that need consideration in due course are ensuring she takes and understands any new drugs prescribed to her. Jean will also require rehabilitation in areas such as speech, mobility and nutrition. THERAPEUTIC SELF-CARE DEMAND Self care agency - Jean currently has no self-care abilities and needs assistance with all aspects of her care. With rehabilitation, time and the correct therapeutic interventions that Jean will have an increased range of self-care abilities.

Self-care limitations - Jean has limitations in all areas of the universal self-care requisites and health deviation self-care requisites. Her inability to mobilise, neurological problems and eye sight present a severe problem in carrying out her self care. Planning Care The nursing care plan can be defined as a 'written care program designed for a particular patient' (National Library of Medicine 1997 in Maloney & Maggs 1998). Care plans facilitate communication between care givers and direct care and its documentation. The actual process of planning care includes setting priorities, establishing goals, determining interventions and recording the plan of care. The result of the assessment phase is a series of problem statements.

In this case the problem I have chosen is that Jean has impaired verbal and non-verbal communication as a result of her stroke. Once the nurse has a set of problem statements then priorities for care can be set. There are numerous methods at deciding on what is more important but one of the most common is Ma slows Hierarchy of Needs (see fig 1) (Heath, 2000). The next stage of planning is the goal setting phase. Goals are a statement of what the nurse expects the client to achieve and it is sometimes referred to as an objective (Hogston & Simpson 1999). Goals are client centred and should be realistic.

For Jeans problem with communication I have identified a goal - to establish suitable ways of communicating her needs and feelings; to educate others about her problem and to encourage them to communicate with her as a result of this understanding. The patient should be actively involved in the setting of these goals. However for the patient to be able to participate they should be alert and be able to participate in problem solving and decision making. At the moment Jean is unable to carry out both these things. It is essential, that when developing a care-plan that the family is involved. The family can help the patient to achieve their goals and can be a valuable source of information which may aid the nurse in planning care relevant to the patient's likes and dislikes.

Jean's family were consulted during the assessment phase when information was needed on her background. Also during the planning of care her family were informed and their views and feelings taken into consideration. Nursing interventions or actions are decided upon after the goal setting phase and are put into effect in order to solve the problem and reach the goal (Hogston & Simpson 1999). The selection of interventions is based mainly on evidence based practice. "Evidence based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients". (Sackett et al., BMJ, 1996,312, pp. 72-3 When caring for Jean, at the moment the nurse provides care in a wholly compensatory system.

Here follows the interventions and their rationales: Refer Jean to the speech and language therapist (SALT). The involvement of speech therapists is advocated at an early stage for stroke patients (Wade et al 1995, Mclaren 1997). SALT will assess the problem and find the easiest way for Jean to communicate. SALT can also be of support to relatives of aphasic patients in providing information on the condition (Horton, 2001). When communicating with Jean, reduce distractions in the environment. The nature of the physical environment is very important when considering communication (Kagan & Evans, 1998).

The effectiveness of communication is impacted upon by noise such as television, radios and other conversations (Taylor & Campbell, 1999). Keeping distractions to a minimum will also help to keep Jean focused and enhance the nurse's ability to communicate. Treat Jean as an adult. Do not raise your voice as it will not improve the health of the patient. It will tend to make them frustrated and angry (Sundin & Jansson, 2003). This will in turn lower their self esteem and it is an important therapeutic intervention of the nurse to enhance the patients self esteem (Sun deen et al 1998).

If self esteem needs are not met then the patient may feel helpless and inferior (Maslow, 1970; Heath, 2000). Communicate with Jean frequently using a suitable communication strategy: e.g. a) Eye level; b) Speak slowly and clearly; c) Keep dialogue clear and simple; d) Incorporate non-verbal techniques such as touch. Although Jean has poor eyesight she is not completely blind and will be able to distinguish shape and possibly proximity. Positioning of the nurse when speaking to help create a relaxed environment is very important and there is much literature on the subject (see Faulkner, 1998; Kagan & Evans, 1998; Horton, 2001). In Sundin & Jansson's (2003) study of aphasic patients, touch was considered to be a good communication channel between the nurse and patient. Griffith et al (2003) also found that touch is extremely important and that the development of better non verbal skills was associated with greater patient satisfaction.

Touch is an important consideration with Jean due to her poor eyesight and may also help reduce feelings of isolation. Encourage Jean to communicate It is important to reinforce any of Jeans attempts to communicate. If not reinforced the patient may have feelings of overwhelming anxiety when reflecting on their experiences of attempting to communicate when they were in hospital (Robillard, 1994). Hemsley et al (2001) reported that it was useful for nurses to look at and to attend to the patient during attempts at communication in order to capitalise on the patients non-verbal cues such as facial expression, eye-gaze and body language. Inform family of Jeans aphasia and how this affects her ability to communicate with them. As Jeans condition is serious and the possibility of a full recovery is low it is important that her family fully understand her illness.

It is important for nurses to accept and carry out the role of educator (Heath, 2000). It is important for the family to have as much information as possible to adjust to and accept the changes that may occur in the long term. Encourage Jeans family to communicate with her. Patient's with communication problems feel that their family gave practical help in overcoming their difficulties (Emerson & Enderby, 2000).

Family tend to accept the patient for who they are, help them with speech and making suggestions that make communication easier. The presence of family may also help to fulfil love and belonging needs as people need to feel they are loved and wanted by their family (Heath, 2000). Reflection and Conclusion I found the process of reassessing and applying another model of nursing from the one originally used very interesting and a good educational experience. Assessing jean using Orem's model helped me look beyond the usual assessment procedure used on wards today which by no means goes into such detail, most probably due to time constraints. I gained a more in-depth view of Jean, her problems, her family and was able to appreciate and nurture her self-care abilities, however few there were at the time I care for her. I found that by reading about communication strategies and the problems faced by aphasic patients as well as revising old material I was able to communicate much more effectively and develop an empathic understanding of her condition that I never had before.

This essay has helped me critically review the care planning process that I have already met in practice a.