Adult Nursing Practice: Care of the Patient with Stroke - Essay Example

? Adult Nursing Practice: Care of the Patient with Stroke Number] Adult Nursing Practice: Care of the Patient with Stroke Introduction Education, especially in the field of nursing, involves both the inculcation of nursing theories, as well as the application of these theories into the clinical practice. The weight of these two components of learning vary depending on the views of the nurse, but some authors claim that the practical application of nursing theories is a more important facet of nursing education. In fact, Kozier, Erb, Berman, Snyder, Lake, and Harvey (2008) mentioned in their book that most theorists tend to side more with the aspect of ‘learning through experience’. Indeed, this preference for experiential learning can be most seen in the student nurses’ practice placement. Also, from the views of the students themselves, Fell and Kuit (2003) revealed that most students prefer learning in the clinical setting rather than in the classroom. Therefore, it is apparent that clinical learning, through practice placements, is a significant aspect of nursing education. However, a main issue with practice placements is the difficulty by which teachers can assess their students’ learning or development. Thus, educators developed ways for assessing student learning in practice placements, by letting the students reflect and assess the care they have observed or implemented. One way of achieving this is through a reflection on a significant episode of care for a patient. In relation, this paper will attempt to do just that, by assisting the student in reflecting on a significant care delivered to a patient whose care this author has been involved with in the recent term. This paper will first present an overview of the case to be studies, and it will then explore the pathophysiology of the disease condition to be discussed. The psychosocial influences of the patient’s illness, as well the reflections on the care given will be discussed. The case to be explored involves the care of Mr. Smith (pseudonym, for purposes of patient confidentiality), a 60 year old male who has been admitted to the institution after experiencing a severe pain in his abdomen. He presented to the Emergency department with complaints of severe pain in the left lower quadrant of his abdomen, which has progressed over the past few days. In addition to the gradual increase of the said pain, the patient verbalized that the pain was constant, even after rest or the intake of analgesic. In addition to the symptom of pain, the patient has also been experiencing diarrhea, which was a concern for him since his regular stool pattern was mostly regular and hard. Based on the patient’s case, certain differential diagnoses were given. The most probable diagnosis given by the doctor was diverticulitis, but other diagnoses were also considered. The care, assessment, diagnosis, and management of the patient will be further discussed in the following portions of the paper. However, among the greatest concerns with the patient is the fact that his family, his status, and his personality made it difficult to care for him. Mr. Smith owned a small enterprise that was, according to the patient, “beginning to rise and compete with the bigger players out there”. As an effect of this, the patient was constantly in front of his laptop or cellular phone, dictating notes to a secretary, or discussing business with another partner. The patient would also often neglect his medications, even his meals (he was given a liquid diet) and when the nurse would go and check on him, he would often lie about drinking his meds. To make matters worse, the client’s family rarely visited him, with his wife dropping by for only a few minutes after she had come from the salon or the gym. In the two days’ confinement of the patient, his son also rarely visited, since the said son was supposedly busy maintaining the family business. The patient’s daughter was still studying in college, but she was the one who skipped her classes, despite her father’s protests, so that she could watch over her father. This data, a little of which was gleaned during thorough assessment and history taking, revealed the possible complications to be faced in the care of the patient. The patient was first assessed in order to determine what care should be given to the patient. The patient was administered with gastrointestinal studies, but a CT scan was used to truly confirm the diagnosis, since it is considered as the diagnostic tool of choice because of its 93% and above sensitivity (Greenberger, Blumberg, & Burakoff, 2009). Afterwards, it was then confirmed that the patient has diverticulitis with a beginning or mild abscess at the distal portion of the diverticula. After the diagnostic test, the patient insisted to be discharged immediately, but was not allowed to leave because of the small abscess seen in his diverticula. Intravenous antibiotics were then initiated, and a bowel rest with reduced physical activity was recommended for the patient. Mr. Smith was forced to stay in the hospital overnight, since he was scheduled for CT guided abscess drainage in the morning. After the said procedure, the patient insisted on going home but he was advised to rest. By the morning of the third day, the patient asked to sign a HAMA (Home Against Medical Advice) and he was then discharged with instructions to continue his medication and come back for a follow-up check-up. Moreover, in reflecting over the said care of the patient, Gibbs Model for Reflection (1988) will be utilized. This model involves a circular method of reflection, wherein the person reflecting not only provides a description of the experience but also some analysis and evaluation of what has transpired during the experience being reflected on (Beckwith & Franklin, 2011). One of the greatest features of the model is that it looks at the experience, and at the same time it provides an avenue by which the practitioner can determine what went wrong, what could have been done, and what else could be done in the future. Gibbs’ model of reflection involves six major steps: Description, Feelings, Evaluation, Analysis, Conclusion, and Action Plan (Burnett, 2009). Placed in a form of a cycle, these six major steps of the reflective model proceed from one step to the other, beginning with a description of the event or experience. In the description of the said event or experience, the individual must describe the event in the most matter-of-fact way possible, without the initial analyses and interpretations (Jasper, 2003). After the said description, the practitioner will then explore the feelings and emotions that came to him/her during the experience. Upon exploring these feeling, the model recommends the evaluation of the event, wherein the positive and negative things will be investigated. In here, the person will list down the good aspects of the experience, as well as the bad. Afterwards, the nurse can then move on to the next step which involves “Analysis”. Under this step, the nurse practitioner tries to make sense of the situation by drawing out the deepest meaning of the experience, as well as of the feelings that came to him/her during the event or situation (Bulman & Schutz, 2004). Once the practitioner has looked into the meanings of the experience and feelings, she/he can then proceed to the conclusion step. Under this, the practitioner tries to determine and enumerate what else could have been done by all the parties concerned in the situation. Finally, after this conclusion, the reflective nurse would then attempt to create an Action Plan, wherein the nurse would answer the question, “if the same situation arises again, what would the nurse do differently?,” and explore how changes can be applied into practice (Johns, 2004). These steps will then be used in the reflection with the care of Mr. Smith. Pathophysiology of Disease Condition Before the care of Mr. Smith can be explored further, the nurse must first understand the mechanism by which the disease process affects the patient. Therefore, this section of the paper will explore the pathophysiology of diverticulitis. In the discussion of diverticulitis, it must be noted that its symptoms almost always mimic those of other diseases. For example, another alternative diagnosis of diverticulitis is cancer, or a neoplasm in the intestines, specifically the large intestines, especially since the symptoms given by the patient are actually more related to those of a perforated cancer of the colon (Welling, 2006). In relation, some other related or differential diagnoses for the patient include ischemic colitis, helminthoma, Crohn’s disease, ulcerative colitis, and a lot others (Sheiman, et al., 2008). Still, diverticulitis, in its most basic sense, involves the inflammation of the diverticulum (single) or diverticula (multiple). The diverticula are protrusions, or out-pouchings in the wall of the large intestines or colon. More specifically, they can be considered as herniations or protrusions in the surfaces of the walls of the large intestines that project out into the softer layers of the intestinal covers, as well as into the smooth muscles of the abdomen. The diverticula most commonly form along the openings created by the vasa recta, vessels supplying and accepting nutrients (Nguyen, 2009). Normally, the formation of a diverticula can be uncomplicated, often not presenting any symptoms, which is the case with diverticulosis. However, when the diverticula become inflamed, or they can become inflamed, as in the case of diverticulitis, symptoms begin to appear, such as those presented by Mr. Smith. When the said inflammation becomes severe, two scenarios can occur: the inflamed diverticula can foster infection leading to sepsis (Masoomi, Buchberg, Magno, Mills, & Stamos, 2011), or it can perforate leading to further damages within the abdominal cavity. In case of a perforation, the patient can undergo hemorrhage and peritonitis, which would warrant and immediate and acute intervention (Lewis, et al., 2011). The diverticula or herniations are created because of the weakening of the abdominal and intestinal muscles. Different factors can cause the said weakening, and one of these most common risk factors for diverticulitis include the person’s low fiber component in his/her nutrition (Aydin & Remzi, 2010). With the decreased consumption of fiber, the patient decreases the bulk of his/her stool, which is also viewed as a significant cause of diverticulitis. With the decreased bulk in the stool, the intestines hardly exert adequate effort during peristalsis, and the intestinal muscles are then not properly “exercised” (White & Duncan, 2002). Some other factors cause the weakening of the intestinal and abdominal muscles, such as smoking (tobacco use), NSAIDs, corticosteroid use, and a lot others that cause and excessive increase in the pressure within the colon (Ignatavicius & Workman, 2006).Some other races, such as Hispanic and Asian races were also seen to be more predisposed to diverticulitis (Zaidi & Daly, 2006). In the case of the patient, his diverticulitis began as a nonradiating abdominal pain, which became severe as the days passed. This can be explained by the fact that the diverticula, originally beginning as diverticulosis began to inflame and infect, causing the pain. The fact that the pain is located at the left lower quadrant can be explained by the anatomy of the intestines, wherein majority of the colon is located at the lower portion of the abdominal cavity. In addition, pain in the left lower quadrant can also be explained by the structure of intestines, as well as the finding that majority of recorded and studied diverticula that develop form in the last portions of the colon (sigmoid and later parts of descending colon), the bulk of which is at the left side of the body (Zaidi & Daly, 2006). The observed change in the frequency and consistency of the patient’s stool, can also be explained by the fact that because of the diverticula, normal bowel flow is obstructed leading to abnormal bowel movements (Sheiman, et al., 2008). Rectal bleeding also manifests itself in diverticulitis, especially in the case of a perforated or infected diverticulum. Nausea, vomiting, and fever may also present itself with diverticulitis, and the pain experienced by the patient often begins one to three hours post meal, and is relieved by antacids or foods (Black & Hawks, 2009). Gibbs’ Model Step 1: Description In addition to the physical problems of the patient, one other of the greatest concerns that the nurse should address are the psychosocial issues faced by the patient. One most apparent issue observed was the conflict brought about by the disease condition with the patient’s work, or sense of productivity. Indeed, this was most apparent in the patient’s continuous attempts to converse with his subordinates, as well as his repeated requests to be discharged, since he claimed that his pain has been well-managed. From this, it can be seen that the patient’s self-concept or self esteem may have also been affected or threatened, as reflected by his claims that “he feels so useless just sitting” in a hospital bed. Indeed, for individuals with fast-paced lifestyles, being confined into hospital beds may cause them to feel useless and unproductive, which is one of the aspects of care the nurse should look into. In addition, another significant psychosocial issue faced by the patient in relation to his physical problem is his lack of adequate social support. Although the daughter came to watch over Mr. Smith on his second day of confinement, the patient was usually alone during the first day, only actually accompanied by a subordinate or secretary who supervised his bills and other needs. Such a support is hardly adequate, especially in the case of the patient wherein the severe pain he was experiencing would hardly make him a suitable decision-maker for his care. In fact, a person’s decision-making faculties are impaired especially in cases where the pain is so severe. Gibbs’ Model Step 2: Feelings During the Experience When Mr. Smith was first brought into the institution, he was writhing in pain, and he was hardly able to comprehend anything that we asked him. His secretary answered his questions for him, who hardly knew any significant personal details pertaining to the patient’s current condition. When Mr. Smith’s pain has been controlled, it was only then that a more thorough interview was conducted. During the interview, I was shocked by the manner Mr. Smith answered, which was almost dictator. Even then, I realized that the patient was attempting to assert his authority by being bossy and demanding in his care (Schultz & Videbeck, 2009). . In fact, LeMone, Burke, and Bauldoff (2011) supported this idea, wherein the said authors stated that for people used to “living fast”, despair can be brought upon by confinement on a hospital bed. In these times, I realized that the patient’s major source of self-worth was his work and his position, as well as his decision-making (Kattan & Cowen, 2009). This was not necessarily a bad thing, but I began to despair that the care for the patient would become complicated by his character, which was domineering and closed to suggestions. Indeed, I was proven correct when Mr. Smith questioned his doctor during the first day of admission, actually threatening to sue the hospital if he was not allowed to leave the hospital. However, when the pain became severe again, the patient was forced to stay and finally agreed with the drainage procedure. Upon realizing that Mr. Smith’s main source of his identity is his work, I then began to wonder about his family. Where were they, and what could have happened that they were not able to meet his need for attention and love, that he had to become so forceful, just to feel worthy or powerful. This was made clear when Mr. Smith’s wife “visited” for a few minutes to tell him of her wonderful day at the spa, and that their son cannot visit to the hospital. The couple did not even show any sign of affection, much less hug each other. Although I felt a little bit of pity for the patient at this point, I was relieved when the daughter finally came to watch over her father. When I observed Mr. Smith’s behavior, which became more complacent during the stay of his daughter, I realized that Mr. Smith needed care not only in the physical aspect of his self, but also in the emotional. However, this was a feature forgotten by the health team. I believe that if only Mr. Smith was made to withdraw from his stressful work and interact more with his family and friends, better care would have been provided, and the patient would have adhered more to his treatment regimen. Gibbs’ Model Step 3: Evaluation In looking at the care given to the patient, I believe that the healthcare team based their interventions primarily on Maslow’s Hierarchy of Needs (O'Connor & Yballe, 2007). This framework focuses on the different needs of the person that should be addressed towards self-actualization. At the bottom of the hierarchy are the biological or physiological needs, such as food, oxygen, water, and others. Physiological needs also include pain. According to Maslow, before a higher-level need can be addressed, health care practitioners must first tackle the needs located at the lower levels, especially biological needs (Zalenski & Raspa, 2006). Thus, before the nurse can address the patient’s need for love and belonging, she must first solve the problems in the person’s physical domain. Maslow’s theory in itself is actually a good framework in determining the care of the patient. However, the problem with the case of Mr. Smith was that care was only focused on the physical aspect, and when the patient deprived the hospital to carry out the care addressing the higher level of needs, it was already too late to help the patient. Therefore, a better framework could have been used in the care of the patient. It is not just enough to give what the client needs in the physical realm, but also in the other portions of health. Gibbs’ Model Step 4: Analysis In attempting to draw out the deeper meaning of the experience, I realized that man is really a social being: his existence is affected, and sometimes dictated, by his interactions with others. This was apparent in the case of Mr. Smith, whose need for love was only fulfilled by his work environment, and which was also negatively converted into negativity towards other people. If Mr. Smith’s emotional needs had only been properly addressed, he may not have been too attached to his work, and he may have also been able to form more meaningful relationships with his health care providers. Indeed, more than physical needs, man needs to be affirmed by the relationships that he forms with other human beings. Thus, the nurse needs to recognize that as a practitioner of a humanistic profession, she serves as a form of surrogate family. However, the nurse also needs to remember that in the process of being a surrogate, she must maintain her professional integrity and conduct herself according to the Code of Conduct set by the Nursing and Midwifery Council (NMC, 2008). In fact, it can be seen that the patient’s lack of support was hardly able to help his need to be more productive, which may have then led to his desire to go back to work immediately. Also, the patient’s decision to go out of the hospital (HAMA) mirror his desire to go back to an environment that gives him his source of self-worth (Elder, Evans, & Nizette, 2009), which is his work. Finally, one other psychosocial concern to be considered by the nurses is the fact that with his HAMA, the patient only went back to the environment that caused his diverticulitis in the first place, which can further aggravate the patient’s disease condition. Thus, it is in here that evaluation plays a significant role in the delivery of care, since while the nurse is addressing the patient’s pain, the nurse could already be dealing with the patient’s need for attention and companionship. This need would have been dictated by the nurse’s effective evaluation or assessment of the needs of the patient, as well as on the provisions of other more holistic models. Indeed, these models include that of Parse’s Human Becoming Theory, Roger’s Science of Unitary Human Being, and a lot others (Dossey & Keegan, 2009). The common denominator among all these theories is the fact that they emphasize that needs should be addressed at a holistic level (Pusari, 1998). In all, there were a lot of problems observed in the care of the patient. First, no thorough and in-depth assessment was conducted, since the patient prevented it, and the assessing official himself was not assertive. If proper assessment have been conducted, it would have been determined that holistic care should also focus on the patient’s needs for belonging and affection (Lewis et al., 2011). If effective assessment has been conducted, the emotional (and maybe even spiritual) needs of the patient would have been tackled properly, and the health care team could have reacted more properly. Indeed, through assessment, the nurse would have been able to determine that the patient’s negative attitude may actually have been propelled by the threats in his self-esteem, and the nurse could have interacted with the patient in a manner that affirmed the patient’s self-esteem. Gibbs’ Model Step 5: Conclusion As mentioned earlier, there were other major problems seen in the care of the patient, including the fact that the healthcare provider, the nurse specifically, should have been more assertive (Clark, 2003). If the healthcare provider had been more assertive in the assessment process, the patient would have realized that antagonizing his healthcare team would not be beneficial for the nurse-patient relationship. More importantly, if the nurse had been more assertive, she/he could have risen to the challenge and made the patient aware that he is in a secure and accepting environment, and he does not need to become authoritarian just so that he could feel in control of the situation. Finally, another flaw in the whole experience was the fact that the nurse was not more assertive in communicating with the other members of the healthcare team. Indeed, I was part6ially aware of the patient’s need for acceptance, but I was not assertive enough to communicate my ideas with the physician. This is an important mistake on my part, since the Nursing and Midwifery Council (2008) mentioned that nurses must be assertive, while at the same time respectful, when it comes to the care of the patient. Gibbs’ Model Step 6: Action Plan Given these observed problems, I realized that should they arise again, I would now react differently. First of all, the next time I meet an antagonizing patient who blocks my attempts towards the establishment of rapport, the primary value I must employ is patience. I will remember that behind every action is an underlying reason or motivation. With this, proper assessment would also become one of my primary tools. By proper assessment, I refer not only to the evaluation of the patient’s physical symptoms and history, but also of the patient’s needs in the psycho-emotional and spiritual level. Nonverbal cues would most especially help the nurse in this aspect of assessing emotional needs. Moreover, assertiveness is something that could also be exercised should the same situation arise again. I can be more assertive in explaining to the patient why certain procedures are needed, and why certain medications should be given. Finally, I will be more assertive in giving my observations and ideas to other members of the healthcare team, especially if it is vital to the health of the patient. References Aydin, H. N., & Remzi, F. (2010, August 1). Colonic Diverticular Disease. Retrieved May 30, 2011, from Cleveland Clinic: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/colonic-diverticular-disease/ Beckwith, S., & Franklin, P. (2011). Reflective practice. In Oxford Handbook of Prescribing for Nurses and Allied Health Professionals. (pp. 110-124). Oxford: Oxford University Press. Black, J. M., & Hawks, J. H. (2009). 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