Introduction
A number of patient assessment tools have been developed for the assessment of older people focusing on the patient’s ability to maintain activities of daily living (Ware, 3-11). These instruments, however, lack a systematic assessment of patient preferences as an important part of successfully initiating patients in making necessary changes in health behavior to regain or maintain capabilities in independent functioning. A holistic perspective nursing adopted as its underlying philosophy the need to integrate patients’ values, beliefs, and goals into nursing care but patient problems have usually been identified from the perspective of health care providers and their assumptions about which problems are important, without verifying these assumptions with the recipient of care – the patient (Moore & Kramer, 163-168). Evidence showed that a successful clinical relationship is one where patient and caregiver arrive at a consensus concerning the problem, physiological processes, prognosis and optimal treatment (Felch, 12) and a negotiated approach to decisions about patient care has been encouraged. In this essay, I will try to demonstrate client assessment from a nursing point of view that includes evaluating body functioning according to the Lorensen’s Self-Care Capability Scale (LSCS) that includes eating, drinking, eliminating, sleeping, moving, bathing, and grooming. Following this, I shall develop a nursing care plan in a case study format. Assessment is the first stage in the nursing process, and in order to conduct it rationally, a nurse must competently collect data from many sources, then analyze and synthesize it, before using the obtained data to develop a healthcare plan followed by the final evaluation. Accurate judgments can then be made about the patient’s health status and the nursing intervention required (Lazerowich, 121-126). The selected patient will be discussed using a model/framework for assessment that is used in practice. Three main needs of the patient will be outlined in the post-operative period following surgery.
Chosen Patient
Ms. Anderson, a 75-year-old woman presents at her annual physical examination. Her medical history, physical examination, and test results are as follows. In order to gather data about Ms. Anderson, a data collection tool was used. The tool contained the assessment of bodily functions according to LSCS and addressed the need to maintain those functions (see appendix).
Health History
Health History has been smoking heavily for 25 years. Considers herself ill during the course of the last 15 years, when after retirement Ms. Anderson started working as a janitor, where she experienced unfavorable thermal regimens. During her janitor work often experienced an ailment and took sick leaves from work once or twice each year. She left the job in two years, however continued to experience ailment two times annually. The symptoms usually included a fever of 37.6-38.2o C, coughing with a scanty amount of colorless sputum, accompanied by general weakness and dyspnea at rest. During ten years Ms. Anderson was diagnosed with an acute respiratory viral infection, or acute respiratory disease, and prescribed antibiotics such as erythromycin, which caused the significant improvement. The fever disappeared in 7-8 days. The amount of sputum slightly increased and the coughing faded away. The patient recovered on the 2nd -3rd week. Three years ago she went to a different doctor, who arrived at the diagnosis of chronic bronchitis. Within the last three years, the aggravations became more frequent (3-4 times per year). The latest aggravation happened 3 weeks ago when during another exacerbation of chronic bronchitis the overall well-being started to decline (this followed Ms. Anderson going outside on the 5th day of chronic bronchitis exacerbation): gradual rise of body temperature (38.4o C in 24 hours), slight Algor and hyperhidrosis, increase of the coughing, the onset of dyspnea.
In 24 hours following these symptoms, Ms. Anderson called the ambulance. At the time of admittance to the hospital, her fever was 39.0 o C. From the patient’s words during the last three winters, her smoker’s cough produced sputum on most days. She complains of fatigue, constant coughing, and shortness of breath at rest. She is limited in her activities of daily living but she states that she is not taking part in any sports. The patient appears to have no asthma, allergies, gastrointestinal, or cardiac symptoms. Her family history revealed that her mother died at the age of 70 from stroke and her father died at age 67 from lung cancer. Both were heavy smokers. One sister aged 42 has breathing difficulties and is taking adrenoceptor agonists (salbutamol). Ms. Anderson has undergone an appendectomy 25 years ago. At about the same time she was in the hospital for removing calculus in both kidneys, and an x-ray revealed a cyst in the left kidney. 20 years ago she has undergone nodular hysteromyoma surgery. Around 22 years ago the patient was diagnosed with primary hypertension, as well as ischaemic heart disease: stenocardia. In 1992 Ms. Anderson survived a cerebrovascular accident.
Physical examination
The general condition of the patient is satisfactory. The consciousness is lucid. The body constitution is normothermic, height – 153 cm, weight – 92 kg, posture is slouchy, limps when walking. The body temperature is 36.8o C. Facial expression is calm. The skin color is pale, without cyanosis. The skin is dry turgor pressure is low. Mucosal membranes are pale. The nails are without any visible deformations. The subcutaneous fat is well developed, mostly on the abdominal, lumbar, and femoral regions. Insignificant pastousness in the lower leg regions. The main groups of lymphatic nodes are not enlarged during palpation. The muscles are of sufficient development, with low tonicity. Bones are without visible alterations. Joints demonstrate alterations in both radiocarpal, and the left popliteal joint, which is tender during palpation. The patient also complains of paroxysmal pain in the spinal cord. The thyroid gland does not palpate. The respiration is thoracic, symmetrical, and shallow, with 20 breaths per minute. The palpation revealed low elasticity of the thoracic cage. Pectoral fremitus is increased insignificantly. The auscultation of the lungs revealed adverse respiratory murmurs – small bubbling rales in the left axillary and scapular regions. Complains of constricting pains behind the sternum after physical exertion. The arterial pulse rate is 80 beats per minute. The abdomen is slightly enlarged due to fat deposits. The edge of the liver is algesic during palpation. The urogenital system and nervous system are without pathology. The vision acuity and locomotor reactions are lowered.
Test Results
The complete blood cell count revealed: Hemoglobin – 118 g/l (low), erythrocytes 4.4, globular value – 0.85 (low), leukocytes – 6.7/L, monocytes – 6%, eosinophiles – 5%, lymphocytes—26%, blood platelets – 180/L, ESR – 5 mm/h. The biochemical blood assay: total protein – 65g/l, alanine aminotransferase – 24 mmol/l, aspartate aminotransferase – 28 mmol/l, glucose – 5.2 mkmol/l. The urine test showed no traces of erythrocytes or urinary cylinders. The urinary level of leukocytes is 452 mln/l. The sputum test results are as follows: color – gray, type – mucosal, consistency – mucilaginous, eptithelium – small amounts, leukocytes – 25-30 within the visual field. The streptococci from the sputum demonstrated resistance to penicillin, ristomycin, chloramphenicol, and tetracycline. The x-ray of the pectoral region revealed emphysema with diffuse pneumosclerosis. The lung pattern is deformed, as there is lesser circuit hypertension. There are infiltrative alterations in the basal layer of the left lung. Both ventricles of the heart are enlarged equally. The sonographic examination revealed enlarged liver and induration of the kidneys with an insignificant amount of concrements (0.3-0.5 cm). The ECG showed the electrical axis of the heart rotated to the left, and slight hypertrophy of the left ventricle. The conductive function is adequate (P-Q=0.14sec., QRS=0.08 sec). PO2 = 50 mmHg.
Functional Assessment
Spirometry is compatible with mild obstruction and no significant reversibility. During physical exercise – explicit dyspnea.
Cognitive and mental health assessment
The patient’s consciousness is clear, she is well oriented in time and space, answers the questions adequately, but with delay, does not appear to be talkative. The papillary reaction to light is normal, although the visual acuity is lowered. The face is symmetrical, and there are no signs of meningeal symptoms.
Socio-environmental assessment
Ms. Anderson is retired and is currently residing with her sister. The living conditions are satisfactory.
Nursing Care Plan
Nursing Care Plan – based on the history of the current disease, namely that the onset occurred against the background of chronic bronchitis aggravation, it is rational to verify the diagnosis of chronic obstructive bronchitis (Royer, 42). The most informative are Ms. Anderson’s complaints which are indicative of this illness. The most significant assessment data are the results of functional external ventilation tests that indicate an obstructive alteration in the current patient. In such a manner, the chronic obstructive bronchitis diagnosis is based mainly on the history and complaints of the patient, as well as functional ventilation tests (Burke & Laramie, 43). The diagnosis of acute sinister bronchopneumonia of medium severity is based mainly on the patient’s complaints which include fever of 39.2 accompanied by chills, coughing, and heaviness in the left side of the chest, just below the scapula, improvement of the condition after antibiotic therapy. The examination findings, such as respiratory small bubbling rales in the left axillary and scapular regions also contribute to the above diagnosis. The laboratory finding that is evident of inflammation ESR below 20 mm/h. The infiltrative alterations of the left lung on the x-ray are also relevant. Summarizing the above data it is certain that Ms. Anderson has bronchopneumonia that has typical characteristics, such as slight symptoms of intoxication and inflammation (Murray, 18). The x-ray of the chest, as well as auscultation, helped determine the affected side. It is clear that the duration of the disease is of medium severity, as the patient is 75 years old, and has chronic disabling diseases in her medical background (arterial hypertension, chronic obstructive bronchitis).
The diagnosis of respiratory distress is arrived upon based on the patient’s complaints – dyspnea when going up the stairs, or walking for 200 meters, as well as on the external ventilation tests. Based on the above findings Ms. Anderson can be diagnosed with Chronic Obstructive Pulmonary Disease (COPD). When prescribing treatment it is important to note that the patient besides bronchopneumonia and chronic obstructive bronchitis is suffering from arterial hypertension and exertional angina (Shaw, Peterson & Mark, 141-148). It is essential that Ms. Anderson receives her treatment for bronchopneumonia as soon as possible, as in this case, it will be effective. This patient must be hospitalized, as she is over 65 years old, has severe accompanying conditions, and can not be provided with adequate care at home. From a nursing point of view, it is necessary for the patient to follow a strict bed regimen (Ebersole & Hess, 75). This means that her eating, drinking, and elimination needs must be rationally satisfied. The nurses must also take care of the patient’s hygiene. This includes frequent bathing and grooming. The bed regimen may be not as strict, once the signs of intoxication and fever go down. The patient’s general satisfactory condition means and that she moves actively means that there is no need for decubitus ulcer prevention. The treatment that she receives must include primarily penicillin-type antibiotics, for example, intramuscular injections of ampicillin twice a day (Ruben & Stout, 164). It is rational to prescribe combined antibiotic therapy, as there is accompanying pathology and immune deficiency. This additional treatment should include aminoglycosides, such as gentamicin that is injected intramuscularly twice a day.
The duration of the therapy shall depend on signs of improvement, a decrease in the body temperature, and level of intoxication. It is necessary to continue this treatment for five days after the condition improves. Expectorant drugs such as bromhexine are also required to drain the bronchial tree, especially the segmental bronchus in the affected locus. Immune modulators are needed to correct the immune status (Freeman, 64-94). In order to do this, the patient shall be administered ascorbic acid, thiamine, and tocopherol in form of intramuscular injections. A nursing care plan may also include physiotherapy that can be used to rehabilitate Ms. Anderson’s condition after the acute period has passed (Kemp, Brummel-Smith & Plowman, 9). The most effective physiotherapy would be bronchial spasmolytic inhalations. These can include such medications as beta-2 adrenal agonists. There is also a possibility of conducting exercise therapy that will increase tolerance to physical stress. Various coronarodilators can be used to prevent complications of ischemic heart disease and stenocardia. The expectancy of absolute recovery outcome for a patient that had acute bronchopneumonia and chronic obstructive bronchitis is negative (Hart, Laden, Schenker & Garshick, 1013). This is due to the lengthy progressive duration of chronic bronchitis, old age, and accompanying pathology of the heart. The most effective healthcare strategy, in this case, is decreasing the development of major chronic disorders.
Educational Nursing Care Plan
Nursing Diagnosis
The patient/client has a problem/potential problem in his/her need for adequate breathing because she is not able to perform the physical exercise without showing signs of explicit dyspnea.
Expected Outcome
The best possible situation that this particular patient/client can achieve in three days is that she will be able to walk without experiencing severe shortness of breath.
Evaluative Criteria
I will know if the expected outcome is achieved if I can observe Mrs. Anderson walking for 200 meters without experiencing dyspnea.
Planned Interventions
The most appropriate way for the patient/client to achieve their Expected Outcome is for the patient/client and me to ensure that Mrs. Anderson has adequate oxygen supply to her lungs.
Rationales
The reasons I have chosen these particular interventions are because a higher supply of oxygen will cause better oxygenation of hemoglobin in her blood and shall prevent hypoxemia and improve the quality of life, by enabling the patient to perform activities of everyday living. This rationale will also prevent the possible complications of COPD, such as cor pulmonale or pulmonary hypertension. In order to provide better oxygenation of hemoglobin, long-term oxygen therapy (LTOT) must be used as the most effective rationale. There are many forms of administering LTOT, however, in this case, a reservoir, nasal cannula should be used. It will collect the expired gasses and enable the patient to rebreathing the air from the oxygen delivery system during the next breath. The nasal cannula is equipped with a sensor of oxygen pressure in the nose and shall deliver oxygen only during inhalation.
Evaluation
Using the evaluative criteria, what I now observe is an increase in exercise tolerance and improvement of mental functioning, as the patient is able to walk a distance of 200 meters without feeling dyspnea, and also appears to be in a more lively mood and more talkative.
This corresponds with what I anticipated therefore I will advise the patient to continue using LTOT in home conditions after being signed out from the hospital.
Conclusion
In assessing Ms. Anderson, I found that the models discussed above were practical to gain insight into the care and treatment needed. I established that in order to properly provide an effective nursing plan, it is necessary to focus on the patient’s needs, her interpretation or understanding, as well as require or might want to do and can do in order for her to improve her own health.
References
Burke, M. M., & Laramie, J. A. (2000). Primary Care of the Older Adult: A Multidisciplinary Approach. St. Louis, MO: Mosby (p. 43).
Ebersole, P., & Hess, P. (1998). Toward Healthy Aging: Human Needs and Nursing Response. St. Louis, MO: Mosby (p. 75).
Felch, W. C. (1996). The Secret(s) of Good Patient Care: Thoughts on Medicine in the 21st Century. Westport, CT: Praeger Publishers (p. 12).
Freeman, L. W. (2001). 3 Psychoneuroimmunology and Conditioning of Immune Function. In Mosby’s Complementary Alternative Medicine: A Research-Based Approach (pp. 66-94). St. Louis, MO: Mosby.
Hart, J. E., Laden, F., Schenker, M. B., & Garshick, E. (2006). Chronic Obstructive Pulmonary Disease Mortality in Diesel-Exposed Railroad Workers. Environmental Health Perspectives, 114(7), 1013+.
Kemp, B., Brummel-Smith, K., & Plowman, V. J. (1989). Geriatric Rehab Program Focuses on Research, Training and Service. The Journal of Rehabilitation, 55(4), 9+.
Lazerowich, V. (1995). Development of a Patient Classification System For a Home-Based Hospice Program. Journal of Community Health Nursing, 12(2), 121-126.
Moore S.M. & Kramer F.M. (1996) A comparison of women’s and men’s preferences for cardiac rehabilitation program features. Journal of Cardio-pulmonary Rehabilitation 16, 163–168.
(1992). Measuring Functioning and Well-Being: The Medical Outcomes Study Approach (A. L. Stewart & J. E. Ware, Ed.). Durham, NC: Duke University Press (p. 41).
Murray, J. F. (2000). Intensive Care: A Doctor’s Journal. Berkeley, CA: University of California Press (p. 18).
Orem D.E. (1995) Nursing: Concepts of practice. Mosby, St Louis. Palmer R.M., Landefeld C.S., Kresevic D. & Kowal J. (1994) A Medical Unit for the acute care of older people. Journal of the American Geriatrics Society 42, 545–552.
Royer, A. (1998). Life with Chronic Illness: Social and Psychological Dimensions. Westport, CT: Praeger Publishers (p. 42).
Ruben, D. H. & Stout, C. E. (Eds.). (1993). Transitions: Handbook of Managed Care for Inpatient to Outpatient Treatment. Westport, CT: Praeger Publishers (p. 164).
Shaw, L. J., Peterson, E. D., & Mark, D. B. (2002). Chapter 7 Clinical Recognition: Risk Assessment Screening. In Heart Disease in Women (pp. 141-148). New York: Churchill Livingstone.
Ware, J. E. (1992). 1. Measures for A New Era of Health Assessment. In Measuring Functioning and Well-Being: The Medical Outcomes Study Approach, Stewart, A. L. & Ware, J. E. (Eds.) (pp. 3-11). Durham, NC: Duke University Press.
Ziguras, C. (2003). Self-Care: Embodiment, Personal Autonomy, and the Shaping of Health Consciousness. New York: Routledge (p. 41).
Appendix
The Model
LSCS (Lorensen’s Self-Care Capability Scale) was chosen in order to systematically incorporate patients’ preferences in the assessment of older people comprising aspects not found in other instruments. Assessment tools for this patient population include assessing body functioning, such as eating, drinking, eliminating, sleeping, moving, bathing, grooming, Orem’s self-care model as a conceptual framework which is widely known and accepted by nurses.
The model defines three categories of self-care requisites necessary for performing self-care in maintaining life, health and well-being (Orem, 1995) that address the need to maintain bodily functions, such as the need for air, water, food, elimination, rest, solitude, social interaction and prevention of hazards, developmental and health deviation self-care requisites, developmental and cognitive capabilities. These are a prerequisite
to learning new self-care strategies, skills or behaviours (Ziguras, 41) such as the ability to seek appropriate medical assistance, carrying out medically prescribed measures effectively, or altering one’s life-style to promote personal development while living with the effect of pathology and medical measures (Orem, 545-552).
The Royal College of Physicians and the British Geriatrics Society highlighted the need for functional assessment of elderly people as part of routine clinical practice. It recommends the regular use of standardized assessment scales in activities of daily living, communication, cognitive function and memory, depression and quality of life. Regular se of these measures may be useful in planning, clinical care, provision of support services, screening, outcome assessment, clinical audit and casemix.