Patient Assessment and Care Plan Essay

Patient Assessment and Care Plan essay

The following assignment will be discussed using the model of nursing called Roper Logan and Tierney (RLT). This assignment aims to produce an assessment that is patient centred and holistic and to provide a detailed care plan that is based on the selected patient and relates to an 'actual problem' they are experiencing. The RLT model will used to assess, implement, plan, and evaluate the nursing care of the selected patient in relation to the 12 Activities of Living (ALs) (Holland 2008). The factors that influence the Activities of Living are: psychological, biological, environmental, politico economic and sociocultural. The mentioned factors aim to be included in the assessment of the selected patient (Holland 2008).

In order to begin this assignment permission was asked from the patient that was admitted to the hospital setting. In terms of the best interest of the patient, their confidentiality had to be protected. Therefore, on asking for the patients' consent to base this assignment on themselves they were also reassured that their confidentiality will be protected. This will be carried by using pseudonym of Mr Brown as per the data protection act (1998) and nursing and midwifery council (NMC) (2008).

Mr Brown is a 73 year old gentleman that was admitted to a medical ward in a hospital within his local area after being rushed to Accident and Emergency (A&E). Mr Brown's breathing has troubled him for many years, but symptoms had worsened while at his home with his wife. Mr Brown was experiencing wheezing, breathlessness and constant coughing leading to sputum forming, to which according to Barnett (2009) are the primary stages of developing Chronic Obstructive Pulmonary Disease (COPD). Mr Brown's wife noticed that he was not coping and called for an ambulance. During his stay at the A&E department Mr Brown was diagnosed with COPD, and from this Mr Brown's patient journey had started.

Chronic Obstructive Pulmonary Disease (COPD) is complications related to the respiratory tract, patients that have COPD will have issues with air flow and lung function. Over time, inflammation on the smaller airways can occur and it can also then progress to the larger airways to which the bronchial tubes become scarred which results in obstructs the respiratory flow of the patient with the COPD. Discussing COPD from a medical aspect, the primary symptoms that occur are coughing, and episodes of wheezing. Shortness of breath is experienced by patients that are over 40 years old and as the disease progresses some patients results in not being able to walk or carry out personal care, due to the breathlessness developing into something more problematic (Madden, 1999).

In relation to Mr Brown as he arrived on to the medical ward later that day and was attached to an oxygen mask. The nursing rationale behind prescribing oxygen to Mr Brown is simply to keep his saturation at a safe level, as low levels of oxygen in the blood will lead to Mr Brown experiencing hypoxemia which Edwards (2005) stated it to be life threatening for COPD patients. On arrival, Mr Brown was experiencing dyspnoea; a medical term given to patients experiencing shortness of breath and due to this, communicating became difficult for Mr Brown.

Mr Brown was a smoker for 45 years and has been free of smoke for 4 years now, Tutt and Jennings (1999) state smoking as being one of the main causes of COPD occurring in adults. It is said that patients bring problems like COPD on themselves and it can resolved only by the patient. It important to understand that patients that have a smoking history do not rule out the possibility of having asthma and not all patients with COPD has a history of smoking (Booker 2003). As this is Mr Brown's first time experiencing an exacerbation of COPD, his current forced expiratory volume in a second (FEVI %) at the moment is 65% which verifies that Mr Brown is at stage II COPD which is known to be the moderate stage of COPD (Scullion 2004). Currently, Mr Brown is on short- acting bronchodilator as he requires it.

On admission, Mr Brown was introduced to the nursing staff, shown where the toilet/shower room is and explained the buzzer system should he need to call a member of staff. According to Holland (2008), the safety of the patient in a hospital environment one of many important factors to maintain, and to help put this into practice a baseline of Mr Brown observations would take place on the day of admission. Observations would include blood pressure, temperature, respiratory rate, oxygen saturation, heart rate/pulse and weight/height. Benison (2007) states that obtaining a baseline of observations from the patient on admission is vital, this is because it would be beneficial for nursing staff to clearly see improvement of their patients and make them aware of any deterioration of the patients health status (Benison, 2007). Using the Scottish Early Warning Signs (SEWS) chart, Mr Brown's primary observations were taken and recorded on to the SEWS chart. Mr Brown's blood pressure measured at 142/84, temperature was recorded as 36.2oC, respiratory rate (RR) was sitting at 32 a minute, heart rate/pulse was 96 beats per minute and lastly oxygen saturations was sitting at 85%. Height and weight was taken and documented, Mr Brown's height was 5ft 7inches and his current weight was 69kilograms. It is vital to have the patients' weight and height documented on admission so the nursing staff can keep an eye on the patients' nutrition and able to maintain the appropriate weight throughout their stay in hospital, the height is needed to work out the patients' Body Mass Index (BMI). This will determine the patients' weight status, if they are underweight, healthy, overweight or obese. Mr Brown's BMI sits at 23, which determines that his weight status is healthy.

As all the needed information is documented, Mr Brown was started on a Malnutrition Universal Screening Tool (MUST) (See Appendix One). This tool is vital for all patients that have a long stay in a hospital environment so that the patients BMI and weight loss can be monitored and prevent them from at risk of malnutrition (Merriman, 2008). Currently, Mr Brown's BMI is healthy and unplanned weight loss has not occurred thus Mr Brown's MUST score is 0 at present. Although, according to Francis (2006) due to the medications that COPD patients are commenced on unplanned weight loss can occur. Therefore, Mr Brown has been documented for nursing staff to carry out daily weights so that unplanned weight loss can be prevented.

A few days after Mr Brown's admission to the ward, it was brought to the nursing staff's attention that two problems were occurring in Mr Brown. These