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Acute Care: Care Implementation and Evaluation. This assignment will be based around the care that is implemented and evaluated, within a National Health Service (NHS) Foundation Trust (FT). The focus of the assignment will be to discuss two health problems that a selected patient has and has been admitted to the FT with. The selected patient had been admitted into FT with breathing difficulties and also suffering from dehydration. The assignment will focus upon the goals that are set for the patient whilst in FT and the reasons why the goals are set.
The patho-physiology of the two problems will also be discussed and also the care that had been implemented to achieve the goals. Throughout the assignment, the patient will be known as Terry with the permission from the patients parents, according to the Nursing and Midwifery Council (NMC, 2008) confidentiality guidelines. The assignment will also aim to discuss the role of the Health Care Professional (HCP) in planning appropriate care for the patient, in particular, using the assessment technique of goal setting by using Specific, Measurable, Achievable, Realistic and Time Set (S.
M. A. R. T) target planning technique (Roper et al, 1996). The reasons for planning care can involve the HCP assisting in preventing potential health problems, for example, breathing difficulties for the patient becoming worse and to also assist in solving problems where possible. Care planning can also assist in alleviating possible health problems that cannot be solved by HCP’ s and so will need the assistance of Multi Disciplinary Team (MDT) , for example, consultant, physiotherapists to further improve an develop the care plan.
Terry is a 42 year old single man, who lives with his parents, and has suffered from a number of illnesses throughout his life, for example, optical glyoma, Deep Vein Thrombosis (DVT), epilepsy, and also learning difficulties. Terry has difficulty with breathing, and this appears to have been caused by respiratory rhythmicity centre in the medulla and the pons (areas of the brain which can control breathing) and these appeared to not be working in the correct way (MacKenzie, 1996; Waugh et al 2006).
Terry’s reduced neurological status was due to trauma that had been suffered in the motor pathways, and the peripheral nerves, in the brain (Iggulden, 2006). Terry was admitted to the Intensive Care Unit (ICU), within the NHS FT, suffering from numerous problems that were mainly neurological. Terry’s admission to ICU was due to the increased breathing difficulties that he was experiencing. Due to the breathing difficulties, the nursing team, and Terry’s consultant, agreed that it would be best for Terry to have a percutaneous tracheostomy inserted.
Due to Terry suffering from a probable cerebellar lesion, severe learning difficulties and poor communication skills; it did appear that Terry could not understand what the nursing team were informing him of, the medication that he needed and the care that was being delivered (NMC, 2008). Due to the fact that Terry appeared not to be able to understand or communicate with the nursing team, and that his parents and family members were with him, the nursing team, and myself, ensured that the parents, and family members, were informed of what was happening regarding the care that had given to Terry.
The fact that Terry could not understand the instructions given to him, due to learning difficulties, consent to insert a percutaneous tracheostomy had to be given from Terry’s parents, to the Consultant (NMC, 2008). The tracheostomy that had been inserted into Terry helped the nursing team in the ICU and on the ward, to oxygenate Terry to the optimum level of 98%. The tracheostomy, also ensured that Terry was able to maintain a breathing rate of between 35 and 50 breathes per minute (Bailey, 2008).
Although Terry was able to maintain a respiration rate, the normal respiration rate for an adult is normally between 14 and 18 breathes per minute (Bailey, 2008). The nursing care that had been implemented included ensuring that oxygen was flowing through the tracheostomy and this ensured that Terry had enough oxygen in his body for his heart and lungs to function, and that the heart pumped the oxygenated blood around the body (Machin et al 1996; Roper et al, 1996; Bailey et al 2008).
Due to Terry’s respiration centre not working properly, and suffering from breathing problems, this meant that gaseous exchange was impaired, and led to a risk of respiratory acidosis. Gaseous exchange is where the oxygen goes into the alveoli capillaries, and the carbon dioxide is moved out of these capillaries (Bailey, 2008). The respiration centre is made up of a group of nerve cells, which are in the reticular endothelial system of the medulla oblongata.
These cells send impulses to the motor neurones, via the spinal cord, and are then sent to the intercostal muscles (Bailey, 2008). The trauma that Terry had suffered with, was a possible cerebella lesion when he was a child. When Terry was admitted, his oxygen level was 82% (Bailey, 2008). The goal for this problem was to keep Terry’s respiration and oxygenation at a level that was suitable. A suitable level of respiration for an adult is between 14 and 18 breaths per minute, and an oxygen level of around 97 to 98% (Bailey, 2008).
The patho-physiology of breathing difficulties includes a lack of oxygen to the tissues of the body, including the brain, and even death (MacKenzie, 1996; Waugh et al 2006). Due to Terry haiving an oxygen saturation level of 82%, we set the goal that we would aim for and set this goal with his parents. The goal that the nurses had set with Terry’s parents, due to the fact that Terry had learning difficulties and could not set the goal with the nurses. The goal was set as the nurses aimed to have his oxygen saturation level between 95% and 98% within two hours.
The goal had to fit in with the Specific, Measurable, Achievable, Realistic and Time Set (S. M. A. R. T) target planning technique (Roper et al, 1996; Faulkner, 2000). Terry’s sitting and lying position had to be carefully planned around him, this ensured that we as a nursing team where able to ensure that his lungs would expand to their optimum and to maintain a satisfactory oxygen saturation levels within his body (Roper et al 1996; Machin et al 1996; Hackman, 2008). The normal oxygen saturation level is between 95% and 98% (Woodrow, 1999).
The fact that Terry had an oxygen saturation level of just 82%, the Consultant had to prescribe oxygen for Terry. The oxygen that had been prescribed for Terry, had been increased from 24% to 40% (NMC, 2002). The consultant advised us to ensure that the oxygen was to be humidified. Due to Terry having the tracheostomy, we were able to deliver the oxygen with the use of a tracheostomy mask and what is called a T-piece circuit (Machin et al 1996; Dolan, 2008; Soady, 2008).
The consultant also advised the nursing team to ensure that neurological observation’s were undertaken, especially the oxygen saturation levels, every 15 minutes until Terry’s oxygen saturation levels had risen to 96% (Machin et al 1996; Dolan, 2008; Soady, 2008) The neurological observations with regards to the goal, meant that the nurses were able to deliver oxygen, which would enable the oxygen saturation level to be maintained (Machin et al 1996; Dolan, 2008; Soady, 2008).
Once the nursing team had ensured that the oxygen had been delivered to Terry at 40% and was humidified, they then ensured that 15 minute observations were maintained. The Consultant had to ensure that the 40% oxygen that he had verbally prescribed, was documented and written clearly in Terry’s medical notes and on his prescription sheet (NMC, 2002; NMC, 2004). The fact that Terry had been prescribed the higher rate of oxygen, this needed to be clearly documented within Terry’s nursing notes (NMC, 2004).
The documentation was needed, so that the other nurses were aware of the change. Although the observations had been maintained every 15 minutes, with regards to Terry’s oxygen saturation levels, this ensured that the nursing team maintained Terry’s neurological observation’s (Machin et al 1996; Dolan, 2008; Soady, 2008). The goal that had been set by the nursing team and Terry’s parent’s, for his oxygenation levels did fit into the Specific, Measurable, Achievable, Realistic and Time Set (S. M. A.
R. T) target planning technique. The goal was specific, measurable and realistic for Terry and the nursing team caring for him, as well as being achievable in the time frame that had been set by Terry’s Consultant (Faulkner, 2000). Due to the fact that the nursing team had achieved this goal for Terry, proved that the nursing care and interventions made by the nursing team, were effective. The nursing care and interventions were effective enough, for this goal to have been met (Roper et al 1996).
The goal that had been set for Terry with regards to his oxygen saturation level, had to be documented. The goal had to be documented within the nursing notes, which the nursing team had to document clearly. The nursing team were able to hand over the information about Terry, to the nursing staff that would have been caring for him on the next shift. (NMC, 2004) The second of Terry’s problem’s is that he was at risk of dehydration, this was due to the fact that Terry could not swallow as he had a reduced neurological status.
The fact that Terry could not swallow was due to the motor area of cerebral cortex of his brain, did not work in the way that it should (Waugh et al 2006). The motor area of the cerebral cortex of Terry’s brain, was damaged due to the increase in epileptic seizures. Dehydration can cause the cells to deplete, due to not having enough fluids for them to replenish. The cells replenish in the sense that the fluids help the cells to regenerate, regulate the body temperature, to dilute the waste products within the body, and to maintain the level of fluids within the tissue fluid and blood (Waugh et al 2006).
The patho-physiology of dehydration includes thirst, the mouth being dry, the tongue would look leathery, and fluid from within the tissues and skin would be withdrawn (Roper et al 1996; Brown, 1997; Day, 1997). Due to Terry not being able to drink fluids, he was not able to regulate his own body temperature, nor was his body able to dilute the poisonous substances in his body (Waugh et al 2006). Due to fluid being withdrawn from the body, this would mean that the body would not be able to maintain its own volume in blood (Roper et al 1996).
The patho-physiology of not having enough fluids also includes the kidneys would excrete less than they normally would; a person would be lethargic; the skin would lose its elasticity and would appear to be more wrinkled (Roper et al 1996; Brown, 1997; Day, 1997). If Terry had been suffering from dehydration, his would have looked sunken and his urine output would be reduced as well as being more concentrated. If Terry had been suffering from a severe case of dehydration, his blood volume would be reduced.
If the blood volume was to cause a circulation deficiency, this would cause his kidneys to fail to excrete the waste products that they normally excrete (Roper et al 1996; Brown, 1997; Day, 1997). Due to Terry not drinking the recommended two litres of fluids per day, we had to set a goal. The goal that had to be set, had to be set with Terry’s parents (Roper et al 1996). The goal for the second problem, was to prevent dehydration during Terry’s stay in hospital, through ensuring that Intravenous Saline was delivered through venous access (Dougherty et al 2008).
The Intravenous Saline had to be delivered through venous access, due to the fact that this was the most effective way in which to infuse fluids. The fluids had to be infused over a period of 24 hours, due to the volume of the fluids. The Consultant prescribed two litres of Intravenous Saline, and the nursing team ensured that it was delivered (NMC, 2002; NMC, 2004; Dougherty et al 2008). Due to the fact that the fluids needed to be infused, the nursing team ensured that the fluids were delivered through the venous access, by using an infusion pump.
The pump that was used by the nursing team, was the volumetric pump. The volumetric pumps allow health care professionals to administer large amounts of infusions, and this is why were used this type of pump to deliver the fluids that Terry needed over a 24 hour period (Sarpal, 2008). Due to the fact that the nursing team were delivering Intravenous Saline to Terry, it was important that this was documented by the nursing team within his nursing notes. The fact that this was documented in Terry’s notes, ensured that the information was handed over to the nursing team on the next shift (NMC, 2004). It was important hat a fluid balance chart was also documented, as this would help the nursing team to ensure that the amount of input from fluids, was similar to Terry’s urine output. The fact that the nursing team were able to monitor Terry’s fluid input and output, ensured that his body was not retaining any of those fluids within a 24 hour period (Hunt et al 2008). The goal for dehydration by providing two litres of Intravenous Saline over a 24 hour period, did fit into the Specific, Measurable, Achievable, Realistic and Time Set (S. M. A. R. T) target planning technique. This was due to the fact that the goal was specific, measurable and time set.
The goal was achievable and realistic, but only while Terry’s venous access was as good as it was. When Terry’s venous access for the Intravenous Saline to be delivered was poor, this meant that the nursing team had to find another route to deliver these fluids. The nursing team had to re-set the goal for delivering the Intravenous Saline. (Faulkner, 2000) Due to the fact that the nursing team could not deliver the Intravenous Saline through the venous route, had to be documented. The nursing team had to document the fact that Terry had poor venous access, and that they had asked his Consultant to review Terry (NMC, 2004).
When Terry’s Consultant had been to review him, the Consultant advised the nursing team to deliver the Saline through Terry’s PEG tube. Terry’s Consultant had to document the fact, that he had advised the nursing team to deliver the Saline through Terry’s PEG tube. The Consultant also had to document that his advice was due to Terry’s poor venous access in Terry’s medical notes, and he had to document this on the prescription chart (NMC, 2004). Due to Terry having a Percutaneous Endoscopic Gastrostomy (PEG), the nursing team and Terry’s parents re-set the goal to deliver the fluids that Terry needed (Faulkner, 2000).
The new goal that had been set, was to deliver one litre of Intravenous Saline through Terry’s PEG tube. The litre of Saline was delivered to Terry through his PEG tube, over an 8 hour period rather than a 24 hour period. Even though the nursing team had to deliver the fluids through the PEG tube, they had to ensure that the goal did fit into the Specific, Measurable, Achievable, Realistic and Time Set (S. M. A. R. T. ) target planning technique. This goal was specific, measurable, achievable, realistic and time set for Terry and the nursing team (Faulkner, 2000).
Before the nursing team could deliver the Saline through Terry’s Percutaneous Endoscopic Gastrostomy, the Saline had to be prescribed by his Consultant. The Consultant had to document the Saline on Terry’s prescription chart, and also had to document the route that the nursing team were to deliver the Saline (NMC, 2004). The Saline that had been prescribed by Terry’s Consultant, also had to document in Terry’s medical notes, that he had prescribed this and also document the route that he had advised to the nursing team (NMC, 2002; NMC, 2004).
When the nursing staff had commenced the delivery of the Saline through the Percutaneous Endoscopic Gastrostomy (PEG) tube, they themselves had to document this. The nursing team had to document the Saline running through the PEG tube, to enable the nursing notes for Terry to be up-to-date. The nursing team to document the amount of Saline that was to run through Terry’s PEG tube, and what time the Saline infusion began. The nursing team also had to document how much of the Saline was to be infused in any one hour, when the Saline was due to finish, as well as document the lot number and expiry date that were on the bag of Saline. NMC, 2002; NMC, 2004) The documentation of the infusion of the Saline running through Terry’s Percutaneous Endoscopic Gastrostomy (PEG) tube, ensured that the nursing team could hand over the information to the nursing team that were due to care for Terry on the next shift (NMC, 2004). The goal that had been re-set by the nursing team, and Terry’s parents, fitted in with the Specific, Measurable, Achievable, Realistic and Time Set (S. M. A. R. T. ) target planning technique (Faulkner, 2000).
The fact that the goal had to be re-set, ensured that the nursing team had been able to deliver the Saline through the Percutaneous Endoscopic Grastrostomy (PEG) tube. The goal to deliver the Saline through the PEG tube, had been specific, measurable, realistic and time set for Terry and the nursing team. This goal had been achieved, due to the fact that the care that the nursing team had been able to deliver the Saline in the time that they had set with Terry’s parents (Faulkner, 2000).
Due to the goal being achieved in the time frame that had been set by the nursing team, and Terry’s parents, meant that the nursing team had been able to deliver the care that had been needed to achieve this goal (Faulkner, 2000). I am now at the point in this assignment when I can reflect. For my reflection, I will be using the Gibb’s Reflective Cycle to reflect upon this assignment, which is documented within his book that was published in 1988 and entitled Learning by Doing: A Guide To Teaching and Learning Methods (Gibb’s, 1998). Due to the fact that Terry ad a number of health problems, I had a hard task of choosing which two that I would use. I did have to think long and hard about which two health problems that I would use, but I was given permission from his parents to enable me to write this assignment (NMC, 2008). The two health problems that I had chosen, were breathing difficulties and dehydration. Due to the breathing difficulties that Terry suffered with, meant that his oxygen saturation levels were low. Due to Terry’s breathing difficulties, this is why the nursing team, and his Consultant, had to gain consent from Terry’s parents, to insert a percutaneous tracheostomy.
The fact that the tracheostomy was inserted soon after Terry’s admission, enabled the nursing staff within the ITU and the ward of the NHS FT, to ensure that Terry’s oxygen saturation levels were maintained. Therefore, this is the reason why a goal was set. Due to a goal being set for Terry’s oxygen saturation levels to be maintained, provides evidence to show that the nursing interventions were effective. The effectiveness of these nursing interventions, proves that goals that are set for an individual patient can also be met.
The second goal that had been set for Terry by the nursing team, and his parents, had fitted in with the Specific, Measurable, Achievable, Realistic and Time Set (S. M. A. R. T. ) target planning technique. Due to the fact that this goal was only partially met, did not necessarily mean that the care that had been delivered to Terry, had been ineffective. The care that had been delivered to Terry had been effective, but the goal could no longer be achieved through the venous route, due to the fact that Terry’s venous access was poor. Due to Terry’s poor venous access, this is why the nursing team had to re-set the goal with his parents.
The goal that had to be re-set, fitted in with the Specific, Measurable, Achievable, Realistic and Time Set (S. M. A. R. T. ) target planning technique. The goal had been re-set, and had also been achieved in the time frame that had been set with Terry’s parents. The goal that had been re-set, had been achieved in the time frame that had been set. The goal had been achieved due to the fact that, the nursing team were able to deliver the Intravenous Saline through the Percutaneous Endoscopic Gastrostomy (PEG) that Terry had in place.
The fact that the nursing team could not achieve this goal when it had first been set, was not an issue that could have been anticipated. Even though nursing teams can not anticipate why the goals are not met, they can re-set the goal and in time, meet the new goal. Therefore, the nursing care and interventions that are delivered, do make nursing care effective. Documentation of all care from the nursing team was important, due to the fact that the nursing team on one shift, were able to inform the nursing team of the next shift.
Documentation also ensures that if the nursing team were unsure of any test results, that they were able to look over the nursing notes to ensure they knew where we were up to with the patient. The Consultants documentation in the patients medical notes, ensured that other doctors or Consultants were also aware of the patients condition and any tests that may have been ordered. Bibliography. Bailey, M. , Crossen, S. , Holland, J. , & Hollis, V. (2008) Observation’s in Dougherty, L & Lister, S. (eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 7th ed. Chapter 25, Pages 496-544.
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