In this essay, I am going to discuss the care given toan acutely unwell patient, applying a nursing model to assess the patient’s conditionand meet their needs. The model that I have chosen is the Roper-Logan-Tierneymodel for nursing. I will discuss the assessment of the patient’s condition andrelate this to the appropriate pathophysiology. I will also be exploring thepossible implications for my future nursing career. Lastly, I have changed thename of this patient to comply with the Nursing and Midwifery Council (NMC2015) by maintaining the confidentiality of the patient.
Alex is a 14-year-old male who has come into the wardfrom Accident and Emergency (A&E) presenting with a left transverse fracturedtibia, the injury was sustained from playing football (X-Ray had confirmed thefacture). Alex has had plaster of Paris cast applied during A&E to makesure there was no further damage was done. He has gone into theatre to haverods 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 theward, Alex was awake but had a reduced level of consciousness due to theeffects of anaesthetics, he was also on 2L of oxygen with nasal prong to helpwith 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 thesurgery to treat post-operative nausea and vomiting.Alex was on IV fluids pre-operative to maintain fluid ashe 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 hiscapillary refill time but he is currently pyrexial, tachycardic, tachypneic. Accordingto 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, thenormal 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 areassessed and have suitable intervention in their care, nurses should be usingframeworks to give holistic care.
TheRoper-Logan-Tierney Model for Nursing is a theory of nursing care based onactivities of daily living. There are twelve activities of living but the fourI will be talking about is; breathing, controlling temperature and eating anddrinking and elimination. The NMC states that nurses should use person centeredcare for patients, this is further supported by Brooker (2013) who says that itis important for nurses to care for patients as individual by thinking of theirphysical, emotional, psychological, social, cultural and spiritual needs toprovide holistic care.
The model is used as an assessment to plan patientcare. The theory aims to explain what living means. The theory is categorisedinto activities of living through assessment which then brings in interventionthat supports independence for patients in situations that may be difficult forthem.
Using the 12 activities of living as an assessment and puttinginterventions in place is all to encourage independence for patients. Kyle(2008) states that paediatric patients also need independence as well adultpatients, so they can have their own privacy and be proud of their achievementsas they are maturing. Independence is much needed especially for adolescents asthey are growing and are trying to be their own person. Furthermore, givingindependence helps build rapport as patient builds trust and are more likely toparticipate in care. Nurses use the model to assess patient’sindependence in the activities of daily living. The patients’ independence islooked at on a spectrum from total dependence to total independence. This helpsnurses to determine what intervention will help to increased independence aswell as getting support from family and hospital. Roper (2003) indicated thatthe theory should be used as a cognitive approach to the assessment and care ofthe patient but not as a checklist.
The patient should be assessed onadmission, their independence should be reviewed throughout the care plan. Byreviewing the patients care plan on their independence level you can also seeif 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 importanceof care plan and individualising each plan to meet the needs of each patientfor effective care.
Roper, Logan and Tierney model of nursing has beencriticised for generalising patients (Snowden et al 2014). However, Hogston(2011) states that to accurately assess patients and implement appropriateinterventions in their care, nurses are encouraged to use frameworks to aidthem, therefore indicaticating that the model is still in use. Furthermore,this is supported by Mooney (2006), they found that the nursing model wasindividualised to patients and it meant that excellent quality of care could begiven, 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 assessmentto plan patient care. Thus, could indicate that the model is outdated as itsnot used in practice for the reason it was created for.
When looking after Alexwhen he was acutely unwell, the activity of daily living priority was;breathing, controlling temperature and lastly eating and drinking andelimination. According to Tondo et al (2017), bedside safety isdone to ensure all equipment is working and in place for the patient. BeforeAlex was admitted to the ward, I had done the bedside safety checks in the bedhe was going in. As Alex had surgery he was given anaesthetics and because ofthis drug, he has had reduced level of consciousness. Davies et al (2006) foundthat high level of anaesthesia causes drowsiness. Within the first two hoursafter 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 15-20breaths per minute. Since Alex had an increased respiratory rate of 24 perminute, 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 andhypercapnic respiratory drive. This limits pulmonary ventilation, exacerbation resultsin postoperative hypoxemia and it becomes susceptible to the development ofatelectasis. This happens when respiratory movements are restricted by pain. As this was within the two-hour after surgery, it isvital to monitor the oxygen saturation levels because this is the timeframewhen patient is most likely to decrease, McConachie (2009) who also states thatobservation during this timeframe is key as it detects early deterioration inpatient and can be prevented with right care. As Alex had 100% oxygensaturation self-ventilating in room air he didn’t require any oxygen to aid himwith breathing but his Spo2 was monitored regularly, if there had been a dipthen I would have informed my mentor immediately. Breathing was a priority forAlex because of the anesthetic drug effect, it is the most important factor tomonitor breathing and if any issues arise then to be able to provide care. Ileft the oxygen saturation probe on Alex to monitor his Spo2, however,according to Iranmanesh (2011) to prevent pressure ulcers you should change thesite of the probe every 4 hours which is exactly what I did.
I made sure tocheck his blood pressure on his other arm when doing observation so that theresult of oxygen saturation is correct. The blood pressure cuff tightens thearm and reduces the blood flow, thus would give wrong reading on oxygen level. Alex was pyrexical and spiked a temperature of 39.0Cpost operatively. He was visibly sweating and feeling uncomfortable due to thepain of the wound site. Even though Reich (2012) states that it is common forfevers to occur in patients who have had surgery and is one of the effects ofgeneral anaesthetic drug given. However, from having a fever it could result insepsis, this is further supported by Cameron (2012) who says that most patientsfever is controlled by analgesia and regular monitoring of the temperatureshould be done to keep an eye on whether temperature drops to normal range. Ifthis is not controlled early on then the fever could result in sepsis, this iswhen the body is responding to an infection (Stannard 2011).
Furthermore, it isimportant to bring down the temperature to normal ranges to prevent the risk ofsepsis, this is therefore a priority in providing care for Alex. Undersupervision of a registered nurse, I used the 8 rights of nursing to prepareand calculate paracetamol for the fever and administer the medication. Theparacetamol helped to bring down the temperature to 37.4C (Paulman 2007), thisis good because as well as reducing the core body temperature to normalparameters, it is also helping with the pain of the surgical wound site. Prior to going theatre, Alex was placed onintravenous (IV) fluids to maintain hydration as he was kept nil by mouth,before surgical review by orthopedic surgeons. It is important for patientsawaiting surgical review to be kept nil by mouth. Pudner (2010) states thatpatients need to be kept nil by mouth from food for at least 6 hours and clearliquid for at least 2 hours, so that under general anaesthesia there is aprevention of pulmonary aspiration of the stomach content, this is so you don’tvomit 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 tosee if it’s working.
Furthermore, Josephson (2004) indicates the importance tocheck the site of the cannula to ensure it is free from phlebitis. According to Bland (2009) one of the main reason forfluid 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 wasonly allowed small sips of water and once he could tolerate this, then he wasallowed a little more. After a while you can start taking food if there is novomiting. Alex’s’ urine output was measured and checked with the normal urineoutput range for a 14-year-old which is 1 ml/kg/hour (Ricci 2008), it was foundthat he had little urine output.
Gallagher (1995) indicates that little urineoutput 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 bebecause of anaesthetic or due to morphine given during surgery. I was monitoring Alex’s fluid input and urine outputon a fluid balance chart. I was doing this to see if he is taking enough fluidsto 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 hadnot urinated as much as he should have, if he continues to drink fluids he willbe able to soon.
I was also checking to see if Alex was having anypost-operative vomiting or bleeding on the surgical site. As he didn’t have anyin the two-hour post-surgery, there was no need to contact the surgeons. Forpatients to be discharged they need to pass urinate and can tolerate food anddrink.
As Alex is currently stable, his temperature has gone down, he will havehis 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 mustgo through preoperative checklist with nurse and surgeon and have a generalanaesthesia clearing. To stabilise and prevent any further damage to thefracture, Alex had plaster of Paris cast applied (Al-Hadithy and Panagiotidou,2012). General anaesthetic is a drug that is used to putyou asleep during surgery (Nimmo 1994). The anaesthesitic surgeon looks afterthe patient the entire surgical procedure and monitors patients breathing andoxygen levels. Raitt (2013) states that the anaesthesia has sections;unconsciousness, analgesia and muscle relaxant.
General anaesthetic (GA) isusually administered via IV or inhaled. It works by preventing nerve receptorsreaching the brain to keep you asleep. There are several effects of having GAas this could lead to cardiovascular depression and hypothermia. Furthermore,patient controlled drugs such as morphine is administered during surgery tohelp with pain post-surgery, this also has many side effects such as vomiting,headache and decreased urination.
Fromundertaking this care study of an acutely unwell patient as a student nurse, Ihave gained imperative knowledge, understanding and skills in caring forfractured orthopedic patient. I now know the hospital policy for admission andmanagement of the condition. As a student nurse, it is vital that I understandthe 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 haveimproved my skills in doing neurovascular observation. In addition to this, I have learnt to documentneurovascular observations confidently as well as understanding the importanceof information needed for effective care and care plans. Effectivetime keeping is another skill I will be taking on and implementing in my futurepractice.
As nurses, you are expected to deliver short term and long-term careeffectively, to do this, time management is key. As a result, planning yourshift out and looking through the notes/ documentation will help in givingeffective care as you will be up to date with the care of the child. Time keeping results in good holistic carebeing given which is one of the main tasks of a nurse. Additionally,the importance of the multi-disciplinary team I will remember in my futurepractice.
As health care professionals work together such as the doctors,physios and dieticians alongside nurses, the best care can be delivered to anypatient. Likewise, it is important to include the family, especially the maincare giver because they know their child better than anyone else and knowwhat’s the best option would be. In addition to this, if parents/ carers areinvolved in care at hospital then they will find it much easier to transitionthe same care but at home in their comfort. Furthermore, effectivecommunication with multi-disciplinary team and parents are vital so informationpassed on is accurate, it makes the patients and their family/carers feelvalued, at ease and in control of the care as well. Inconclusion, I have become confident in my clinical skills after observing,taking part in practice, working with patients and families/ carers alongsidewith multi-disciplinary team. Using a nursing model to provide care forpatients it allows care plan to be made successfully keeping in mind thepatients preferences and independence.
Furthermore, using models effectivelyhelps to identify risks early on, preventing them or if patient deterioratingit allows the best care to be provided till the end. The skills that I haveobserved and the knowledge that I have gained, I will be implementing inpractice for holistic care.