Introduction
The nursing profession has been defined as a very personal and interactive profession (Yura and Walsh, 1998) and to deliver and provide good patient care many authors have suggested that individualised care ensures that the patient is viewed as a person and as an individual within a set of certain circumstances (Meleis, 1991).
To ensure patients are viewed as an individual within a set of circumstances (Meleis, 1991) it is useful for nursing practitioners to adopt a holistic approach to care.
Holistic nursing is defined as a process where the patients are not simply treated due to the physical symptoms of a disease or condition, but are considered as a whole and the the totality of the person being treated is explored to include: mental, emotional, spiritual, social, cultural, relational, contextual and environmental aspects (Mueller, 2010).
This assignment will focus on a patient case study and will explore the nursing intervention, assessment and individualised care the patient received.
When presenting a patient case study it is essential to acknowledge the issues surrounding confidentiality.
The Nursing and Midwifery Council state in the code of standards of conduct, performance and ethics for nurses and midwives (NMC, 2008a) that it is essential to ‘make the care of people your first concern, treating them as individuals and respecting their dignity’ and this is an important consideration when writing an essay based on a case study.
To ensure that this assignment complies with the Code of Professional Practice (NMC, 2008a) the author will ensure that client confidentiality will be maintained and respected throughout.
To ensure that client confidentiality is upheld, the client selected for this assignment will only be referred to as Mrs P so that no personal identification or features of their care is highlighted; furthermore to ensure confidentiality is upheld, although this assignment case study has been selected from a client encountered by the author in clinical practice from their training and student development, no identifying hospital details, places of reference, names of service providers or dates of intervention will be supplied.
Mrs P – A Clinical Case Study
Mrs P is a 78 year old lady who currently lives alone in a centrally located council owned property in a town in the West Midlands.
Mrs P was married in the 1950’s and her husband worked in an engineering factory until he had to retire due to ill health and he then unfortunately passed away in the mid 1990’s.
Mrs P has lived alone since this time, moving in 2001 from their family home to a smaller council owned first floor flat.
Mrs P was born in the West Midlands to an Irish father and English mother and she is the only surviving sibling of a family of six. Mrs P has two sons and a daughter, who unfortunately died from breast cancer, aged 56. Mrs P’s two sons who live locally.
Mrs P left school age 14 and went to work as a cleaner in a factory; she left employment to raise her children but prior to this she worked in a munitions factory during the war. Mrs P did not work again once she was married and has had financial support through the governments benefit system and through a small private pension obtained through her husband’s company.
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Mrs P has a relatively unremarkable medical history up until retirement age when she required a hip operation to repair a fracture following a fall. Since this time Mrs P suggests that her health began to ‘struggle’ and she has been diagnosed with hypertension, type 2 Diabetes, in 2006 she had a stroke and more recently has seen her GP at the insistence of one of her sons about her memory, it has been identified by the GP that following her stroke Mrs P has developed a mild cognitive impairment and this is the reason for the problems she is having with her memory.
Mrs P was a heavy smoker up until she had her stroke in 2006, she only consumes alcohol on ‘special occasions’ and describes her diet as generally healthy with a ‘few treats’ now and again.
Where Mrs P lives there is a small community of older people in the same building and the warden arranges activities on a daily basis such as coffee mornings and bingo. Mrs P; although friendly with her neighbours; does not attend these activities as she ‘doesn’t want to socialise particularly’ with them.
Mrs P attends her local Church on a Sunday and describes herself as a ‘Christian’, she relies on her son to take her and another member of the congregation to bring her home, if her Son is away with work she is unable to attend.
Mrs P generally goes out to the local shops on a daily basis to get food and a newspaper; she does not go out currently for any social activity unless she is taken to one of her sons for tea or is taken to church. Within recent weeks Mrs P has not been going out very much as she has ‘not felt up to it’.
Dimensions of Care
The elderly population in the UK is growing significantly in number and recent figures produced by the Office for National Statistics (2010a) suggests that over the last 25 years the percentage of the population aged 65 and over increased from 15 per cent in 1984 to 16 per cent in 2009, an increase of 1.7 million people. On a local level where Mrs P lives this national trend is also reflected with evidence of a growing population of individuals over the age of 65 (Office for National Statistics, 2010b).
The incidence of strokes in the elderly is significant and research highlights that each year around 110,000 individuals in England and Wales have a stroke and a further 30,000 people go on to have further strokes (Department of Health, 2001). Stroke is the single most significant cause of severe disability and the third most common cause of death in the UK (Wolfe et al, 1996).
Memory problems are a common cognitive complaint following stroke (das Nair and Lincoln, 2008) and it is not uncommon for individuals who have developed problems with their memory to go on and develop more serious problems such as dementia (Maud, 2006).
The visit to Mrs P at home by health professionals was to obtain a blood sample and to check her blood pressure. Mrs P had rang the surgery earlier in the week and asked for a home visit from the GP, although no acute medical problem had been identified, the GP felt it was appropriate to follow his assessment up with some routine tests.
Mrs P was warm and welcoming and it was explained to her that the author was a student, she was agreeable to being part of the learning experience and gave her agreement that she would be willing to talk about herself and her health issues. As previously identified confidentiality plays a significant part in the relationship between patient and practitioner and to clarify a duty of confidence arises when one person discloses information to another in circumstances where it is reasonable to expect that the information will be held in confidence (NMC, 2008b). It was explained to Mrs P what the information would be gathered for (for nursing records and for this assignment) and she gave her verbal consent that she agreed to this, once she had been informed about confidentiality aspects.
The visit to Mrs P was to conduct two clinical procedures; taking blood and taking her blood pressure; and it was observed that the qualified nursing practitioner asked Mrs P prior to conducting each procedure if she agreed to have them done. On both occasions Mrs P gave her agreement.
This process is known as obtaining consent and it is important part of nursing practice to ensure that as a practitioner consent is obtained from the patient before any procedure or care is carried out and that respect must be paid to individuals who decline care or treatment. The NMC (2008a) Code of Professional Practice clearly sets out guidance in relation to obtaining consent and to fail to do so could be viewed as a breach of conduct.
One of the Issues identified in the code of conduct highlights issues about consent and individuals who lack capacity.
The Mental Capacity Act (2005) is designed to protect people who can’t make decisions for themselves or lack the mental capacity to do so. This could be due to a mental health condition, a severe learning difficulty, a brain injury, a stroke or unconsciousness due to an anaesthetic or sudden accident (NHS Choices, 2010). The purpose of the act is to ensure individuals are able to make as many choices for themselves as they can and as a measure of protection for individuals who may not be able to make decisions for themselves due to the reasons listed above.
Mrs P had experienced a stroke and had been diagnosed with a mental health condition (cognitive impairment), factors which could contribute to an individual not being able to make decisions for themselves because they lack capacity.
The qualified practitioner explained to the author following the visit that when Mrs P had seen her GP for her memory problems, he had conducted a mental capacity assessment to see if she was still able to make decisions for herself regarding her care.
A capacity assessment clearly states that the ‘assumption of capacity’ is the overriding principle of capacity assessment (Church and Watts, 2007). The act clearly sets out that a person is deemed to have capacity unless it is proved that they have an impairment or disturbance of mental functioning (such as an intellectual disability, dementia or other cognitive impairment, acquired brain injury or mental illness) and this impairment is sufficient to affect their capacity to make a particular decision (NHS Choices, 2010).
Mrs P’s GP had identified in the records that although Mrs P had experienced a stroke and had developed cognitive problems following this, she still had the mental capacity to make decisions for herself regarding her care and treatment.
The qualified practitioner indicated that although this assessment had been made by the GP and we were aware she had been assessed to have capacity to make a decision for herself about having bloods taken and having her blood pressure checked, it was important to remember that if Mrs P was to be visited and her presentation had altered, for example, if she was more forgetful or confused, then it would be necessary for her capacity to be assessed again before seeking her consent to have procedures and care delivered.
Prior to the blood test and blood pressure being taken, Mrs P was asked if her sink could be used so that hand washing could take place.
Hand washing is encouraged by the local Healthcare Trust and nationally by the NHS; it is viewed as everybody’s responsibility to be aware of infection control issues. There is a specific local policy to be adhered to and this is not just for hospital based staff it is for community staff to adhere to as well.
Hand washing is the single most effective measure in the prevention of spread of infection and there are five main points in the delivery of patient care when hand washing should be demonstrated; these are; before touching a patient, before a clean/aseptic procedure, after body fluid exposure, after patient contact and after touching patient surroundings (Health Protection Agency, 2009).
Hand hygiene is also considered as one of the most important measures to reduce the transmission of infection (Pittet et al, 2000) and studies have repeatedly documented the importance of hand washing even though as a simple procedure it is not sufficiently recognised by healthcare workers (Pittet et al, 2000).
The local trust policy clearly states that hand washing is mandatory prior to conducting any clinical procedure therefore this task was completed prior to the bloods being taken to ensure the risk of infection was reduced. Once the bloods and blood pressure had been taken, alcohol hand gel was applied to the practitioner’s hands as an additional infection control measure.
Alcohol hand rubs are recommended at a local and national policy level as it is an effective and quicker to use approach to hand hygiene, it is much better tolerated by the hands and it is convenient as it is carried around on the person (National Patient Safety Agency, 2008).
The hand washing was conducted in Mrs P’s kitchen and it was noted by the qualified practitioner that there was out of date food on the side and that her dosette box which held her medication was indicating that she had not taken her medication on at least five separate occasions over the course of the last week.
Whilst the qualified practitioner was taking the bloods, Mrs P was asked about how she gets her shopping and what she cooks for herself on a daily basis. Mrs P suggested that she goes to the shops daily and cooks for herself, however with her not feeling physically well over the last week she had not been able to go out and get shopping. The qualified practitioner asked Mrs P if her son would be able to get her some shopping and if she would give her consent to the practitioner giving him a ring to ask him to pick up some essential items for her. Mrs P agreed.
The qualified practitioner also asked Mrs P about her medication in the dosette box and was informed that sometimes she ‘forgot to take it’ and if her son rang he would remind her, but if he was away with work (like he had been that week) she had to remember herself.
Mrs P was asked if she would be willing to consider a referral to social services for an assessment to see if there could be any extra help provided to her at the current time when she was not feeling physically well enough to go shopping and that they may also be able to provide support with preparing meals and prompting medication.
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Mrs P stated clearly that she did not need any help and felt that she could manage independently without any support, she disclosed that her sons had ‘been on at her’ recently to accept social services care, however she felt she didn’t need it as she could manage. Mrs P also stated that she didn’t want social workers ‘interfering and being nosy’ and that she ‘didn’t trust them as they would probably want to put her in a home’.
Mrs P gave a very clear opinion on why she did not want to agree to a social care assessment and although the evidence in the home environment (rotten food, no evidence of meal preparation, poor medication compliance) would suggest she did need some social care support, Mrs P was firm in her decision not to agree to an assessment.
Under the Mental Capacity Act (2005) there is clear reference to the decision making process of individuals and how they are able to make ‘unwise decisions’. In this instance Mrs P would appear to be making an unwise decision not to accept help, however she has been assessed to have the capacity to make this choice based on her own informed belief and value system.
The qualified practitioner did not pursue this further with Mrs P but in a telephone conversation with Mrs P’s eldest son later that afternoon she did ask him about social services involvement and was informed that Mrs P has had a lifelong distrust of social services who she felt were ‘busy bodies’ and they had tried on numerous occasions to get her to agree to having some help at home but she had refused. Mrs P’s son indicated that they did not know why she was so against social services but they felt it might be down to something that happened when their father was unwell and was seen by a social worker in hospital who Mrs P had told them had wanted to place him in a care home rather than let him go home, which had upset her greatly at the time.
The son also had informed the qualified practitioner he would arrange for some shopping to be delivered and for any out of date food to be thrown away.
With the clinical procedures completed, Mrs P was thanked for her hospitality and for her agreement in participating in the clinical procedures and in the collection of information for this assignment. Again issues regarding confidentiality were repeated to Mrs P and she again stated that she understood and gave her permission for the information to be used as a learning process.
Although Mrs P refused to have an assessment from a social worker with a view to receiving home care support, there would potentially be other avenues of support available which may be beneficial to improving Mrs P’s quality of life and health status.
In relation to the issue regarding compliance with medication it may be possible to suggest to a family member that they ring Mrs P to prompt her to take her medication or to explore resources such as medication alarms that go off to remind people to take their medication which can be bought from high street pharmacists or from specialist websites for people with memory problems or dementia.
By not taking her medication Mrs P places herself at risk of further health complications, particularly as one of her medications is for reducing high blood pressure (hypertension) and this is important in reducing the incidence of further strokes (Department of Health, 2001).
Mrs P is reliant on her son to take her to church and this is a way of her meeting not only her spiritual needs but her social needs as after the service she will gather with other elderly attendees for a cup of tea in the church hall before being brought home. If her son is not able to bring her she does not attend. One way of addressing this would be to look into if there are any voluntary drivers as part of the church community or if there is a council run scheme such as a ‘ring and ride’ bus that could take Mrs P to church on the days her son is away working.
It is important for Mrs P to maintain her social contact as social isolation in the elderly is one of the main contributing factors to the development of other health problems such as depression (Department of Health, 2010; Smith, 2010).
Whilst Mrs P is feeling physically unwell and not able to walk to the shops everyday it may be valuable to get shopping and food delivered. Voluntary agencies such as Age UK (formerly Help the Aged and Age Concern who have combined to form Age UK) may be able to offer support such as a shopping service or to assist Mrs P with ordering ready meals from either a large supermarket chain who deliver or from a company specifically set up to provide and deliver dinners for the elderly.
Age UK may also be able to provide Mrs P with a well check to ensure that all her needs are being met, for example they would be able to review her benefits to ensure she is getting all that she is entitled to; they may also be able to provide befrienders who may be able to reduce the risk of Mrs P remaining socially isolated by visiting regularly particularly when her son is away working.
Conclusion
Mrs P came to the attention of the nursing service following a referral from her GP for a blood test and for monitoring of her blood pressure. These clinical tasks were completed, however this assignment has identified that there are many issues that can present when nursing staff are visiting and assessing a patient, particularly when they are in their own home and particularly when providing a holistic nursing approach to individualised care.
Throughout the assessment and involvement with Mrs P it was observed that the qualified practitioner not only completed the tasks required for a physical health screen, she also assessed other elements of Mrs P’s health and well being including her social, nutritional, mental, spiritual and emotional well being.
This approach encapsulated the principle of holistic nursing where the patient has been seen and assessed as a whole rather than just being viewed as someone that required bloods and blood pressure to be taken.
Viewing Mrs P holistically enabled the qualified practitioner to see that there is a complex and interwoven set of needs and issues that require addressing for Mrs P to maximise her health and the response to meeting these needs was individualised and tailored specifically for Mrs P.
The concept of an holistic approach to nursing care which is individualised and of significant quality is strongly advised and advocated in the nursing literature, it is a process which ensures needs are met through comprehensive assessment and ultimately benefits the patient and supports the process of health improvement and need lead care.
Holistic nursing moves away from prescriptive nursing and the medical model of care and moves more into a needs lead approach rather that an illness lead approach, which ultimately benefits the patient and has the potential to have the most rewarding and positive impact on their life and health.
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