NURSING QUESTIONS.

Answer

Introduction

This paper discusses the placement experience of the student with Albert (pseudonym) a 73-year adult patient, who was admitted with late-stage dementia and Type 2 Diabetes. The first part of the paper focuses on communication barriers between the patient and the student, and how such barriers were addressed. This part also discusses the communication between the student and other members of the multidisciplinary team. The second part discusses the nursing acre for John in relation to the Roper-Logan-Tierney model for nursing. This part commences by explaining what the Roper-Logan-Tierney model entails and the proceeds to the development of a care plan for the patient. Some of the issues addressed in the care plan are nursing care problems and the reason for the selection of the nursing care issues, nursing process, assessment, and goals. The paper then concludes by providing a reflection on the contribution of the student’s involvement in the planning of the patient care to the student’s professional and personal development. Effective communication ensures the attainment of better patient outcomes (Pannick et al. 2019; Lyndon et al., 2015). Communication involves the exchange of information between individuals by sending and receiving such information through writing, speaking, or by employing any other medium (O’Hagan et al. 2014). The subsequent part discusses the concept of communication in relation to the student’s experience with the patient, patient’s family, and multidisciplinary team members.

Part A

As aforementioned, the patient was diagnosed with late-stage dementia and type 2 diabetes. According to Stevenson et al. (2016) and Takayanagi et al. (2014), dementia affects patients’ expressive and receptive communication abilities thereby making it more problematic for nurses to evaluate or assess their needs and delver necessary care. While interacting with the patient, the author established that the patient’s impaired capability to communicate complicated the nursing care. The patient demonstrated communication problems in comprehending and verbal expression, writing, reading, and repetition.  As such, the student employed various communication approaches or strategies in breaking these conversation barriers, and demonstrating dignity, empathy, and respect during the process of care delivery. The author commenced the care delivery process by introducing himself to the patient, and explaining the reason for him being there. Baddley (2018) argues that introducing oneself to the elderly patient serves as a sign of respect and serves as a vital step to the establishment of a rapport either patients and comfortable atmosphere for care delivery. When conversing with the patient, the student ensured that formal words were employed in addressing the patient, especially the use of Mr. before mentioning the patient’s name. The use author addressed the patient with his first name after the patient had become comfortable with him, and allowed the patient enough time to respond to issues.

According to Pannick et al. (2019), nurses should often pay attention to patients’ body language to identify communication difficulties and embrace necessary measures to facilitate conversations. As such, the author was attentive to the patient’s body language and in situations where the student identify that the patient had difficulties comprehending what was being spoken or asked, the author rephrased questions in ways that were easier to comprehend. Butcher (2018) asserts that patronisation happens to be among the major conversation drawbacks when it comes to effective communication with patients. Ellis and Astell (2017) add that a dementia patient may read the practitioner’s tone of voice and body language, and any detection of tense facial expression or agitated movements may upset such as patient, which in turn may complicate the communication process. In relation to this, the author ensured that any aspect of patronisation was eliminated from the conversation between him and the client. For instance, the student avoided putting his face inches from the patient’s face and using a high-pitched voice, as if cooing to a baby. Instead, the author gave the patient a warm smile, offered his hand, and spoke directly to the patient, as if speaking to any other adult.

O’Hagan et al. (2014) and Mulder et al. (2015) argue that non-verbal communication strategies contribute largely to the facilitation of verbal communication with dementia patients. Therefore, the student leveraged verbal communication approaches in facilitating the verbal communication with the client, with the aim of breaking the conversation barrier presented by dementia. Examples of verbal techniques that were employed during the interaction with the patient were maintaining eye contact, being at the same level as the patient, gently touching the patient’s arm during conversation, and allowing the patient to retain control. In circumstances where the patient was struggling to communicate particular information to the client, the author provided simple choices and used objects or pictures to assist the patient to convey the message, as the patient could not read.

Effective team communication is essential in ensuring patient safety, as well as high quality patient care. Intrapersonal communication played a vital role in triggering the need for interpersonal communication with patient’s family and other members of the interdisciplinary team. O’Hagan et al. (2014) and Gluyas (2015) define intrapersonal communication as a powerful nature of conversation that transpires within a person. This communication level is also known as self-talk, inner thought, or self-verbalisation (O’Hagan et al. 2014). The author engaged in self-talk by asking himself questions about certain issues about the patient’s history and symptoms that seemed unclear. For instance, the author asked himself about the possibility of cases of diabetes being reported by members of the patient’s family. Addressing this question compelled the student to communicate with the patient’s family about this issue and any other symptoms that the patient demonstrated while at home. Active listening was embraced as the patient’s family narrated his health history to the author. John’s family members, especially his wife, could also be consulted when the student and other nurses experienced problems interpreting certain aspects of the sign language from him. Besides, interpersonal communication was employed in communicating nurses and health practitioners from other health care fields including physicians, psychiatrists, and pharmacists. For instance, the student sought the help of other experienced nurses in interpreting non-verbal communication cues demonstrated by the patient. The author also consulted the hospital’s psychiatrist in interpreting certain behaviors that were demonstrated by the patient, especially in situations where the author felt that the patient was uncooperative. Such an undertaking enabled the student and other nurses to avoid communication hitches that made the patient uncomfortable. Other members of the multidisciplinary team such as doctors or physicians were consulted in the form of writing, and in circumstances where clarification was needed the student was forced to converse verbally with the physicians about the patient’s condition. Embracing these approaches contributed significantly to enhancing the effectiveness of multidisciplinary communication in the planning of the patient’s care. 

Part B

Roper-Logan-Tierney Theory

Holland and Jenkins (2019) defines the Roper-Logan-Tierney model as a nursing care theory based on daily living activities, which are always abbreviated as ALs or ADLs. The Roper, Logan, and Tierney’s activities of the living model take into consideration sleeping, working and playing, mobilisation, washing and dressing, elimination, controlling temperature, breathing, communication, drinking and eating, and maintaining a safe setting (Nursing Theory 2016; Williams 2015). This theory endeavors to define what living entails by categorising the discoveries into living activities via complete assessment or evaluation, which result in interventions that back independence within areas that may present problems to patients when it comes to addressing them alone. O’Hagan et al. (2014) assert that the ability of older adults to manage themselves in their daily lives happens to be a major issue for the health and safety of this population owing to the inability of their memories to recognise their routines and surroundings. In relation to The Roper, Logan, and Tierney’s activities of the living model, the problems selected for John (pseudonym), who was a different patient attended to by the author, were eating and drinking, and bathing and dressing. These problems are selected because they are among the five Activities of Daily Living (ADL). Besides, the inability to offer these basic forms of care for oneself is considered a regular cause of institutionalisation (Elia, 2015). These problems were also selected owing to the fact that the patient appeared tired, feeble, and untidy. Moreover, the patient was smelly. The next step involved the assessment of the patient for these problems.

Nursing Process, Assessment, and Outcomes

According to Butcher (2018), the nursing process plays a significant role in guiding nurses in the processes of individualizing, contextualising, and prioritizing problem areas. These steps involve assessment, nursing diagnosis, intervention, planning, and evaluation. These processes were taken into consideration during the establishment of a care plan for John. The first process involved assessment. Thorarinsdottir et al. (2019) and Hadjistavropoulos et al. (2014) assert that assessment serves as a key aspect of nursing practice needed for planning and delivery of patient, as well as family-centred care. In relation to the problems that the patient was experiencing, the student chose to conduct the subjective and objective assessments, with the aim of establishing a precise diagnosis of the patient’s condition. The subjective assessment was executed to gather subjective data or verbal statements that are offered by the patient. This form of assessment was accomplished by embracing the problem-focused nursing diagnosis whereby the eating and drinking assessment process involved asking the patient questions concerning whether he experienced problems or difficulties eating and bathing, lack of appetite, and inability to execute daily activities such as dressing. Besides, the author questioned the patient whether he had issues such as lack of energy, poor concentration, lethargy or tiredness and special dietary needs such swallowing difficulties or dysphagia. The outcomes of subjective assessment revealed that John was suffering from inability to dress and bathe, loss of appetite, poor concentration, and lack of energy or tiredness, as well as poor skin integrity. The student then proceeded to perform subjective assessment to ascertain whether the patient was suffering from under-nutrition or not.

Objective assessment focused on the collection of objective data or signs that are detectable, measurable, and testable against an accepted measure or standard. The objective assessment was conducted using the Malnutrition Universal Screening Tool (MUST) screening tool. This tool has been reviewed frequent since its establishment in 2003 and is supported by several governmental and non-governmental agencies including the Royal College of Nursing (RCN), the Registered Nursing Home Association (RNHA) and the British Dietetic Association (BDA) (Sandhu et al., 2016). It is significant to note that MUSA is the common screening tool within the UK and other European countries when it comes to assessing patients for eating and drinking. The MUST toolkit takes into consideration five steps. The first step involves the measurement of the patient’s weight and height to get the Body Mass Index (BMI) score. The second step involves the establishment of the percentage of unplanned loss of weight and score. The third step focuses on the establishment of the effect and score of the patient’s acute illness. The fourth step involves the addition of the scores realised from the first, second, and third steps to obtain the aggregate or overall malnutrition risk (Sandhu et al., 2016). The fifth step involves the employment of management guidelines to establish a care plan for the patient. The student followed the five steps of the MUST toolkit when assessing the patient for malnutrition and the outcomes of the assessment revealed that the patient was suffering from under-nutrition. The next step involved the development of a care plan for the patient. However, prior to the establishment of the care plan, the author focused on setting SMART goals for the patient in relation to addressing issues of dressing and bathing, and eating and drinking.

SMART Care Plan Goals

The SMART model plays a vital role in the development of care plan goals for patients and attainment of better care outcomes (Furze 2015; Turner-Stokes et al. 2015; Jennings et al. 2017). This model serves as an acronym for specific, measurable, attainable, realistic, and time-bound. As such, effective care plan goals are often established in relation to the SMART model. This model was employed in the establishment of short-term and long-term goals for John. Considering the outcomes of the assessment it can be noted that the patient experiences problems associated with daily activities of life such as eating and drinking, and dressing and washing, which are outlined in the Roper-Logan-Tierney model. The author developed the following SMART goals for the patient in relation to addressing these problems:

• To reduce the patient’s under-nutrition scores on the MUST toolkit by 25% in the next 2 months
• To subject the patient to bathing at intervals adequate to sustain skin integrity and hygiene in the next 2 months and handover this duty to different practitioner when the duration of patient elapses
• To subject the patient to changing clothing upon retiring and rising in the next 2 months and handover the duty to a different practitioner when the placement duration elapses

The student embraced certain interventions to develop a care plan for the accomplishment of the above SMART goals. These interventions are discussed in the subsequent section.

Care Plan and Implementation

Osborn et al. (2014) define care planning as the process of establishing an agreement or contract between the patient and practitioner concerning the problems established, outcomes to be accomplished, and services to be sought in support of the accomplishment of goals. Care planning serves as the link between service delivery and assessment, whereby facts concerning the patient gathered in the process of assessment are analysed and translated into areas of problem. Establishing problem areas enables practitioners to describe desired outcomes and suggest a service package that will help the patient to accomplish such outcomes. According to (), the patient and the patient’s significant others are often engaged or involved in the process of care planning. Good care planning integrates a cautious consideration of all probable service alternatives prior to the attainment of a decision concerning the best alternatives for the client.

In relation to the problem area of eating and drinking, several measures were embraced to accomplish the care plan goal of reducing the patient’s under-nutrition scores on the MUST toolkit. The author commenced by assisting the patient to make appropriate choices of meal such as easy-to-chew and soft foods, as recommended by Relph (2016). The author also sought the views of the patient’s family in relation to the patient’s preferred foods as advised by Pilgrim et al. (2015). The author then proceeded to develop a suitable meal timetable for the client with the help of the hospital’s dietician or nutritionist. The student then embarked on a dedicated process of helping the patient to eat. Prior to the commencement of the process, the author explained to the patient that he was going to assist him to eat his meals, as suggested by Relph (2016). Prior to helping the patient to eat, the student often dressed in an apron and washed his hands and those of the patient to minimise the risk of cross infection, as argued by Pilgrim et al. (2015). The author then proceeded to help the patient to sit uprightly in a chair by the bed, as this helped the patient with the swallowing and protected the airway. The author then ensured that the patient’s mouth was clean and moist and cut the food into portions that could be eaten easily by the patient. The author supplemented this processes with a glass of the patient’s preferred drink and water, as recommended by Hooper et al. (2014). As the patient progressed through the meal, the author encouraged and praised him. The details of what the patient ate and drank during every meal were recorded on appropriate charts for measurement against the MUST toolkit. Apparent changes in the patient’s fluid intake and appetite were reported to the supervisor.

In relation to bathing and dressing the patient, the author embraced several measures suggested in the body of the existing nursing literature. In relation to bathing, the student discussed the bathing with the patient in relation to the patient’s preferred bathing time and whether the patient preferred being washed by a person from the same sex or an individual from the opposite sex. Since the patient was ambivalent about the method of bathing, the author chose bath as a safer option than shower, as recommended by Gale et al. (2014). The author then established a routine bathing pattern and stuck to it to maintain a healthy hygiene as suggested by Freedman and Spillman (2014). The student employed a gentle wiping in cleansing the patient’s skin and used a clean towel to pat the patient’s skin dry. Dougherty and Lister (2015) recommend this approach owing to the fragility of the older adults’ skin and their vulnerability to bruising or tearing. In relation to dressing, the author commenced the care process by discussing with the patient about his style of dressing and the level of assistance the patient needed when it came to dressing. The author then provided the clothes in order in which they should be dressed and ensured that the patient had plenty of changes of preferred items, as argued by Freedman and Spillman (2014). Furthermore, the student provided a couple of choices of clothing so that the patient could maintain some dignity and control, as recommended by Whitehead et al. (2015). These measured were embraced throughout the student’s placement period. 

In conclusion, the student’s involvement in the patient’s care delivery plan contributed to his personal and professional development in effective communication in many ways.  The first placement plays a significant role in the development of the student’s basic skills such as conversing with patients and other members of the multidisciplinary team. In relation to this, placement subjected the author to a series of self-talks aimed at comprehending the message delivered by the patient, which in enhanced the development of the patient’s intrapersonal communication skills. Clinical placement provides student placement provides student with an opportunity to apply theoretical knowledge acquired in class in real world health care settings. By interacting with the patient and other multidisciplinary team members, the author managed to employ various communication strategies and interpersonal communication skills in conversing and addressing care and communication issues associated with the patient, which in turn contributed to the student’s personal and professional development. The involvement in the care delivery plan also enhanced the student’s confidence when it comes to interacting with patients and other health care practitioners. While in the hospital the student managed to establish links or connections with other health care professionals, which in turn contributed to the author’s professional development. Nonetheless, despite these achievements, the student will have to improve in areas such as addressing questions directly to patients, use of short sentences, and patience when communicating with dementia patients in the future.