In this essay, I am going to discuss the care given to
an acutely unwell patient, applying a nursing model to assess the patient’s condition
and meet their needs. The model that I have chosen is the Roper-Logan-Tierney
model for nursing. I will discuss the assessment of the patient’s condition and
relate this to the appropriate pathophysiology. I will also be exploring the
possible implications for my future nursing career. Lastly, I have changed the
name of this patient to comply with the Nursing and Midwifery Council (NMC
2015) by maintaining the confidentiality of the patient.
Alex is a 14-year-old male who has come into the ward
from Accident and Emergency (A&E) presenting with a left transverse fractured
tibia, the injury was sustained from playing football (X-Ray had confirmed the
facture). Alex has had plaster of Paris cast applied during A&E to make
sure there was no further damage was done. He has gone into theatre to have
rods placed into the tibia and another plaster of Paris cast will be applied.
Alex was admitted onto the paediatric ward for post-operative observation.
I first met Alex in the recovery room. On return to the
ward, Alex was awake but had a reduced level of consciousness due to the
effects of anaesthetics, he was also on 2L of oxygen with nasal prong to help
with breathing. As he was saturating 100% on air, he had been taken off oxygen.
Alex was on patient controlled analgesia (PCA) morphine via intravenous (IV)
during the surgery. Anti-emetic drugs was prescribed to the patient during the
surgery to treat post-operative nausea and vomiting.
Alex was on IV fluids pre-operative to maintain fluid as
he was nil by mouth (NBM). Alex post-operative observations were; temperature:
39.0 C pulse: 110 /minute, respirations: 24/minute, systolic blood pressure
(BP): 100mmHg and SpO2: 100% self-ventilating on air, capillary refill time was
<2 seconds. Alex had normal recordings for his blood pressure, SpO2 and his capillary refill time but he is currently pyrexial, tachycardic, tachypneic. According to Glasper et al (2015) the normal observation range for > 12 years is;
temperature: 36.5ºC – 37.2ºC, pulse: 60-100/
minute, respiration: 15-20/minute, systolic blood pressure (BP): 100-120mmHg, the
normal SpO2 is >95.
Neurovascular observations were done on Alex; pallor –
pink, paresthesia – present, paralysis – good, pain – 7/10 (10 being most painful)
analgesia given to reduce the pain, pulse – strong, polar – warm, perfusion – <3 seconds. According to Hogston (2011), to ensure patients are assessed and have suitable intervention in their care, nurses should be using frameworks to give holistic care. The Roper-Logan-Tierney Model for Nursing is a theory of nursing care based on activities of daily living. There are twelve activities of living but the four I will be talking about is; breathing, controlling temperature and eating and drinking and elimination. The NMC states that nurses should use person centered care for patients, this is further supported by Brooker (2013) who says that it is important for nurses to care for patients as individual by thinking of their physical, emotional, psychological, social, cultural and spiritual needs to provide holistic care. The model is used as an assessment to plan patient care. The theory aims to explain what living means. The theory is categorised into activities of living through assessment which then brings in intervention that supports independence for patients in situations that may be difficult for them. Using the 12 activities of living as an assessment and putting interventions in place is all to encourage independence for patients. Kyle (2008) states that paediatric patients also need independence as well adult patients, so they can have their own privacy and be proud of their achievements as they are maturing. Independence is much needed especially for adolescents as they are growing and are trying to be their own person. Furthermore, giving independence helps build rapport as patient builds trust and are more likely to participate in care. Nurses use the model to assess patient's independence in the activities of daily living. The patients' independence is looked at on a spectrum from total dependence to total independence. This helps nurses to determine what intervention will help to increased independence as well as getting support from family and hospital. Roper (2003) indicated that the theory should be used as a cognitive approach to the assessment and care of the patient but not as a checklist. The patient should be assessed on admission, their independence should be reviewed throughout the care plan. By reviewing the patients care plan on their independence level you can also see if the patients are improving or not, changes can be made based by the review. This is further supported by Barret et al (2014), who emphasises on the importance of care plan and individualising each plan to meet the needs of each patient for effective care. Roper, Logan and Tierney model of nursing has been criticised for generalising patients (Snowden et al 2014). However, Hogston (2011) states that to accurately assess patients and implement appropriate interventions in their care, nurses are encouraged to use frameworks to aid them, therefore indicaticating that the model is still in use. Furthermore, this is supported by Mooney (2006), they found that the nursing model was individualised to patients and it meant that excellent quality of care could be given, the nursing model is still used in practice. However, Clarridge et al (2004) argued that the nursing model has become more of a checklist than as an assessment to plan patient care. Thus, could indicate that the model is outdated as its not used in practice for the reason it was created for. When looking after Alex when he was acutely unwell, the activity of daily living priority was; breathing, controlling temperature and lastly eating and drinking and elimination. According to Tondo et al (2017), bedside safety is done to ensure all equipment is working and in place for the patient. Before Alex was admitted to the ward, I had done the bedside safety checks in the bed he was going in. As Alex had surgery he was given anaesthetics and because of this drug, he has had reduced level of consciousness. Davies et al (2006) found that high level of anaesthesia causes drowsiness. Within the first two hours after surgery, Alex had a respiration of 20-24, according to Coyne et al (2010) this is not normal for his age range as his respiration should be between 15-20 breaths per minute. Since Alex had an increased respiratory rate of 24 per minute, this could be due to several factors. As a post-operative patient, Woerlee (1988) proposes that the respiration rate can increase due to pain, hypocarbia, fever and hypoxemia. General anaesthesia depress the hypoxic and hypercapnic respiratory drive. This limits pulmonary ventilation, exacerbation results in postoperative hypoxemia and it becomes susceptible to the development of atelectasis. This happens when respiratory movements are restricted by pain. As this was within the two-hour after surgery, it is vital to monitor the oxygen saturation levels because this is the timeframe when patient is most likely to decrease, McConachie (2009) who also states that observation during this timeframe is key as it detects early deterioration in patient and can be prevented with right care. As Alex had 100% oxygen saturation self-ventilating in room air he didn't require any oxygen to aid him with breathing but his Spo2 was monitored regularly, if there had been a dip then I would have informed my mentor immediately. Breathing was a priority for Alex because of the anesthetic drug effect, it is the most important factor to monitor breathing and if any issues arise then to be able to provide care. I left the oxygen saturation probe on Alex to monitor his Spo2, however, according to Iranmanesh (2011) to prevent pressure ulcers you should change the site of the probe every 4 hours which is exactly what I did. I made sure to check his blood pressure on his other arm when doing observation so that the result of oxygen saturation is correct. The blood pressure cuff tightens the arm and reduces the blood flow, thus would give wrong reading on oxygen level. Alex was pyrexical and spiked a temperature of 39.0C post operatively. He was visibly sweating and feeling uncomfortable due to the pain of the wound site. Even though Reich (2012) states that it is common for fevers to occur in patients who have had surgery and is one of the effects of general anaesthetic drug given. However, from having a fever it could result in sepsis, this is further supported by Cameron (2012) who says that most patients fever is controlled by analgesia and regular monitoring of the temperature should be done to keep an eye on whether temperature drops to normal range. If this is not controlled early on then the fever could result in sepsis, this is when the body is responding to an infection (Stannard 2011). Furthermore, it is important to bring down the temperature to normal ranges to prevent the risk of sepsis, this is therefore a priority in providing care for Alex. Under supervision of a registered nurse, I used the 8 rights of nursing to prepare and calculate paracetamol for the fever and administer the medication. The paracetamol helped to bring down the temperature to 37.4C (Paulman 2007), this is good because as well as reducing the core body temperature to normal parameters, it is also helping with the pain of the surgical wound site. Prior to going theatre, Alex was placed on intravenous (IV) fluids to maintain hydration as he was kept nil by mouth, before surgical review by orthopedic surgeons. It is important for patients awaiting surgical review to be kept nil by mouth. Pudner (2010) states that patients need to be kept nil by mouth from food for at least 6 hours and clear liquid for at least 2 hours, so that under general anaesthesia there is a prevention of pulmonary aspiration of the stomach content, this is so you don't vomit during surgery, this could be fatal. As a way of maintaining hydration, pre-operatively IV fluid is given through a cannula that should be flushed to see if it's working. Furthermore, Josephson (2004) indicates the importance to check the site of the cannula to ensure it is free from phlebitis. According to Bland (2009) one of the main reason for fluid and electrolyte imbalance is due to being nil by mouth pre-operatively. Post-surgery it is important to ensure the patient sips little water, Alex was only allowed small sips of water and once he could tolerate this, then he was allowed a little more. After a while you can start taking food if there is no vomiting. Alex's' urine output was measured and checked with the normal urine output range for a 14-year-old which is 1 ml/kg/hour (Ricci 2008), it was found that he had little urine output. Gallagher (1995) indicates that little urine output is due to hypovolemia, this is usually an early sign of patient deterioration. However, there could be other reasons for little urine output, it could be because of anaesthetic or due to morphine given during surgery. I was monitoring Alex's fluid input and urine output on a fluid balance chart. I was doing this to see if he is taking enough fluids to maintain hydration as prior to this he was fasting and only on IV fluids, and for him to be passing urine as normal, (Mulroney 1992) even though he had not urinated as much as he should have, if he continues to drink fluids he will be able to soon. I was also checking to see if Alex was having any post-operative vomiting or bleeding on the surgical site. As he didn't have any in the two-hour post-surgery, there was no need to contact the surgeons. For patients to be discharged they need to pass urinate and can tolerate food and drink. As Alex is currently stable, his temperature has gone down, he will have his observation done every two hours and if he is still doing well then, the doctors/ surgeons can review him.Alex had a transverse fracture to his left tibia, which required surgery to have rods placed. As with all surgeries patients must go through preoperative checklist with nurse and surgeon and have a general anaesthesia clearing. To stabilise and prevent any further damage to the fracture, Alex had plaster of Paris cast applied (Al-Hadithy and Panagiotidou, 2012). General anaesthetic is a drug that is used to put you asleep during surgery (Nimmo 1994). The anaesthesitic surgeon looks after the patient the entire surgical procedure and monitors patients breathing and oxygen levels. Raitt (2013) states that the anaesthesia has sections; unconsciousness, analgesia and muscle relaxant. General anaesthetic (GA) is usually administered via IV or inhaled. It works by preventing nerve receptors reaching the brain to keep you asleep. There are several effects of having GA as this could lead to cardiovascular depression and hypothermia. Furthermore, patient controlled drugs such as morphine is administered during surgery to help with pain post-surgery, this also has many side effects such as vomiting, headache and decreased urination. From undertaking this care study of an acutely unwell patient as a student nurse, I have gained imperative knowledge, understanding and skills in caring for fractured orthopedic patient. I now know the hospital policy for admission and management of the condition. As a student nurse, it is vital that I understand the human anatomy and physiology be able to apply it in clinical practice. Furthermore, I have developed my knowledge in the pathophysiology of the fracture and I have improved my skills in doing neurovascular observation. In addition to this, I have learnt to document neurovascular observations confidently as well as understanding the importance of information needed for effective care and care plans. Effective time keeping is another skill I will be taking on and implementing in my future practice. As nurses, you are expected to deliver short term and long-term care effectively, to do this, time management is key. As a result, planning your shift out and looking through the notes/ documentation will help in giving effective care as you will be up to date with the care of the child. Time keeping results in good holistic care being given which is one of the main tasks of a nurse. Additionally, the importance of the multi-disciplinary team I will remember in my future practice. As health care professionals work together such as the doctors, physios and dieticians alongside nurses, the best care can be delivered to any patient. Likewise, it is important to include the family, especially the main care giver because they know their child better than anyone else and know what's the best option would be. In addition to this, if parents/ carers are involved in care at hospital then they will find it much easier to transition the same care but at home in their comfort. Furthermore, effective communication with multi-disciplinary team and parents are vital so information passed on is accurate, it makes the patients and their family/carers feel valued, at ease and in control of the care as well. In conclusion, I have become confident in my clinical skills after observing, taking part in practice, working with patients and families/ carers alongside with multi-disciplinary team. Using a nursing model to provide care for patients it allows care plan to be made successfully keeping in mind the patients preferences and independence. Furthermore, using models effectively helps to identify risks early on, preventing them or if patient deteriorating it allows the best care to be provided till the end. The skills that I have observed and the knowledge that I have gained, I will be implementing in practice for holistic care.