Collaborative Nursing and Assessment - Case Study Example

Running Header: CARING FOR MRS. P Caring for Mrs. P: Collaborative Nursing and Assessment Your Your of Submission While all patients are deserving of empathy to one degree or another, the case of Mrs. P is particularly ripe for a caring nurse. The interpersonal process will be particularly crucial in her case. For the past nine years, she has been a paraplegic, as a result of a spinal compression. Since then, such struggles as chronic constipation, asthma, and recurring infections have been a part of her daily life. Thankfully, Mrs. P has had a daughter who has been willing to come by twice a day - once to help her from her bed to her chair, and again at night to visit her for a few hours. Up until now, she has had no support from the social service system, as she did not feel it to be necessary. It could easily be difficult to get Mrs. P to accept the assistance of social services. Her history shows a dogged desire to live as independently as possible, despite the fact that her medical conditions have made her life extremely uncomfortable. At her age, she may well feel that she can lead an autonomous existence, and that any worsening of her current symptoms is only a temporary annoyance. Tolerating them for a short time, in her mind, might well be preferable to accepting the intrusion of daily skilled nursing visits, confinement in an assisted living facility, or even more intrusive medical care. In community nursing, there are a number of models that can be used in a situation like this. For a model to work for Mrs. P, it must take into consideration the realization that accepting the intrusions of extended medical care will rob the patient of a great deal of dignity, as far as preserving the idea of autonomy in society. And so any nursing professional will have to be sensitive to Mrs. P's perceived needs, and treat her as a stakeholder in any discussion about her medical care. Also, given the diverse nature of Mrs. P's conditions, this is a case that will require significant interaction among the various care disciplines. Depending on her level of inactivity, a tissue viability nurse could be needed, as could a dietitian. Occupational and physical therapists should also be consulted, to discuss Mrs. P's ongoing needs. Psychiatric referrals could also be needed, if Mrs. P should slip into depression as a result of her worsening physical condition. If members of Mrs. P's care team do not interact thoroughly, it would be easy for one member of her team to make mistakes that would affect the others' ability to find positive solutions for Mrs. P's conditions. Mrs. P's daughter should also be consulted, not only because she has spent such considerable time and energy helping to care for her mother in her degraded physical condition, but because if Mrs. P's daughter is comfortable with the recommendations of the care team, then she will be able to sell her mother on those recommendations, and make the job of Mrs. P's medical team even easier. One model that would be suitable for this case would be the Roper-Logan-Tierney. The Roper-Logan-Tierney model of nursing care has two primary tenets. The first is its basis on the activities of daily living. This model asserts that there are twelve activities that comprise one's daily existence: maintaining a safe environment, communicating, breathing, eating/drinking, eliminating waste, washing/dressing, regulating one's temperature, moving, work/play, expressing sexuality, sleeping, and dying (Roper, Logan, Tierney 1980, p. 24). The second is the idea of a life span continuum, where in one begins at birth in a state of complete dependence, progresses to a state of complete independence, and then regresses to complete dependence at some point before death (Roper, Logan, Tierney 1980, p. 27). After assessment, it became clear that just about the only activity of daily life that Mrs. P's medical condition did not threaten was the last one (dying). While Mrs. P's daughter was doing the best that she could to help her mother, while also keeping a job and pursuing her own life, Mrs. P's medical problems were many - and dangerous. Because of her own immobility, Mrs. P had developed severe pressure ulcers (grade 3) on her buttocks. Specifically, the ulcers appeared on both buttocks and the medial aspect of her right thigh. On the right buttock, the ulcer was grade 3 and 7 cm in length and 5 cm in width. On the left buttock, the ulcer was also grade 3 and 6 cm in length, 5 cm in width. It was impossible to determine the depth of either ulcer, because of the extensive amounts of slough that were present. The wound on the medial aspect of her right thigh was not a pressure ulcer; it turned out that the catheter had been rubbing there, causing the wound. These wounds were documented using charts, mapping, and photographs. As a result of this, Mrs. P was referred to a tissue viability nurse to handle the job of healing her ulcers and regaining tissue stability in the areas that had received such friction and pressure from extended stays in the same position. Using a Waterlow score card (Waterlow), Mrs. P got 2 points for having a BMI over 30, 3 points for having two grade 3 ulcers, 2 for being female, 2 for being 62 years old, 1 point on the malnutrition score, 3 points for urinary and faecal incontinence, 5 points for being chairbound, 2 points for anaemia, and 6 points for paraplegia. This total of 26 points put her well into the very high risk group (20 total points or more), and dictated the way that her wounds would be managed. Initial wound management included the sharp debriding of slough and necrotic tissue by the tissue viability nurse. Hydrogel was applied, to facilitate continued debridement. Intrasite Conformable was the initial dressing, followed by Allevyn Hydrocellular, and then secured with C-View, to help prevent contamination from material from the catheter. Dressing were maintained daily for four months, and then maintained every other day. Full healing was achieved after nine months of this care. Because Mrs. P did not have access to a specialized mattress that would help her alternate the places in which pressure was put on her skin, she was provided with a dynamic mattress and cushion. Initially, she was nursed on alternate sides of her body, to let the ulcers breathe and begin to heal. As the healing progressed, her care plan began to include structured sessions of time out of bed to promote her psychological and social health. Additionally, Mrs. P was extremely obese (90 kg weight at a height of 5 ft. 4 in.). However, her appetite was poor, and her full blood count Hb was only 7.8g/100mL. She was referred to a dietitian, who recommended supplementing Mrs. P's meals with high protein sip feeds, each containing 30-40g of extra protein. To help eliminate the anaemia, she was given three units of blood by the Acute Care at Home service. Because of the leaks in her catheter that had exacerbated the severity of her ulcers and thigh wound, Mrs. P had her catheter reinserted. Given the highly sensitive nature of the daily activities that are affected by catheterization, including the process of elimination and expressing sexuality, it is highly important for the medical team to act with sensitivity and dignity in this instance (Catheter Care). Eventually, Mrs. P's daughter agreed to the use of a live-in caregiver, because her mother needed care that she could not provide herself, because of her professional and personal commitments. The duties of the live-in caregiver included personal care, assistance with the catheter maintenance, providing meals, and other forms of help. Without swift intervention, this was a medical case that could easily have turned out fatally. Mrs. P had a number of dangerous infections going on at once, and the damage to her skin, in places in close proximity to urine and faecal matter, could have caused her infection to worsen quickly. There are two aspects of this case that are suggestive of the proper use of nursing. First, the swift analysis of her situation identified that most of her activities of daily life were at risk, to such a degree that she was well on her way to that end of the life cycle continuum that would make her almost totally dependent on others for her well being. Second, the vast number of conditions that Mrs. P faced made effective teaming across the lines of medical disciplines crucial. Because both of these aspects happened, and happened swiftly, Mrs. P was able to receive effective treatment and placement with the appropriate level of medical and social services. One aspect of this situation that bears mentioning is the crucial nature of confidentiality. There are a number of ethical considerations that come into play with this topic, particularly given the large number of medical and social professionals who are being utilised in this case. First is the principle of respect for patient autonomy, also known as deontological theory. According to this idea, the patient is assumed to have control over his or her own life, and so should have the right to decide who should have access to his or her own personal medical information. It might occur to some medical professionals to wonder if it is a true breach of confidentiality to relate patient information without making the patient aware, or doing so in such a setting that it would never be possible for the patient to know that his or her information had been shared. This idea of respect implies that, even if there were no way for Mrs. P to know that her tissue vitality nurse had shared her story with another patient, the breach of ethics would still be very real ("Patient Information and Confidentiality 2003"). Another ethical consideration is the idea of the implied promise. Because of the very nature of the relationship between health care professional and the patient, it could be assumed that there is an implied contract between the two, which could be said to include an implied promise that health professionals will keep their patients' medical information confidential. Because it has been legally established in precedent that patients have a reasonable expectation that their doctors, nurses, or other professionals will keep records and information confidential, it is reasonable to expect that, if that information is divulged, the patients would be entitled to feel that a promise had been broken. This is slightly different than the idea of patient autonomy because it relies on the nature of the doctor-patient relationship, rather than on the ability of the patient to conduct his or her medical affairs as an autonomous individual ("Patient Information and Confidentiality" 2003). Another ethical consideration is the idea of virtue ethics. This focuses on the doctor alone, rather than either on the relationship or on the wishes of the patient. This approach asks the virtuous doctor what he or she would do in a given situation. In other words, what would a virtuous doctor consider ethically when deciding whether or not to disclose confidential patient information ("Patient Information and Confidentiality" 2003). Consequentialism is an ethical angle that looks at the outcome of the breach of confidentiality. In other words, a breach of this nature would either be right or wrong, based on an analysis of the consequences of this breach. For example, one example of a consequence could be that a patient whose information is revealed could later become bitter towards doctors in general, and not trust them enough to seek medical attention should later problems arise. However, there may be compelling situations that make this consequence less unpalatable than the result of NOT breaching confidentiality. An example of this could include infectious diseases that could harm third parties, should they not be made aware of the condition of the patient ("Patient Information and Confidentiality" 2003). Works Cited "Catheter Care" (2006). Accessed 31 January 2007 online at http://www.nurseminerva.co.uk/catheter.htm "Patient Information and Confidentiality." (2003) Accessed 31 January 2007 online at http://www.ethox.org.uk/Ethics/econfidential.htm#ethical Roper, N. Logan W. Tierney A. (1980). Elements of nursing. Churchill Livingstone, Edinburgh. Waterlow J (2005). "Waterlow Ulcer Pressure Ulcer Treatment/Prevention Policy." Accessed 31 January 2007 online at http://www.judy-waterlow.co.uk/downloads/Waterlow%20Score%20Card.pdf Read More