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This essay will discuss the importance of needs assessment in nursing practice. In relation to case study 2 about a 68 years old Afro Caribbean retired bus driver male called Carl, who has being married for 45 years with 5 grown up children and 8 grand children. He smokes 20 a day and enjoys nightcap before sleep. His latest vital signs observation are respiratory 20 rpm, blood pressure 168/105, pulse 92bpm, Spo2 95% and BMI 32kg/m2 and he is on statin, betablocker, aspirin, frusemide medication. Currently his wife has notice Carl seems to have forgetfulness, he couldn’t remember his way home from the super market and keep losing items. He is getting frustrated and taking it on his wife and grand children, especially when he cannot read them a story.
This essay will discuss the importance of needs assessment in nursing practice. It will identify a service users needs base on a scenario and the appropriate assessment tools required for his care. And from the tools identified, one will be prioritised and apply on his condition. Finally the essay will summarise the experience of using the assessment tool and how it will help in future learning.
Patient’s assessment is the collection of data about an individual’s health state that identifies and defines patient problems in order for solutions to be planned and implemented in line with their preferences (Roper el at 2000 p 124). Therefore, a clear idea about health is important because this determines which assessment data should be collected. The world Health Organisation (WHO) (2001) defines health as a state of complete physical, mental and social well being and not merely the absence of disease or infirmity. Whiles this is a broad definition, it implies that the nursing approach to health care is holistic in nature and therefore health assessments should reflect that philosophy with it focus on the whole person and their context. Nurses are obliged to take in to consideration patient’s physical, emotional, spiritual, social and intellectual needs when making an assessment (Department of Health 2004). `
Therefore, when nurses are conducting health assessment on a person it may requires acknowledgement of techniques of collecting and analysing subjective data which is what the person says about them self’s during history taking. And objectives data which is what nurses observe by inspecting, percussion, palpating, and auscultation during physical examination (Department of Health 2003). Potter and Berry (2005) argue that if inaccurate, incomplete or inappropriate data is recorded then the overall care of the patient may be affected, including wrong diagnosis and even wrong treatment. NMC (2002), code of professional conduct, urged all nurses to work in a professional manner and abide by the policies set out by the trust they work in. it suggest that the recording or documentation of information is essential and any deviation could lead to potential consequences for the individual if their standards are not met. The purpose of health assessment is to make judgement or diagnosis because all health treatments and decisions are based on the data gathered during assessment; it is paramount that the assessment is factual and complete, providing the foundation for clinical decision making (RCN, 2007). This gathered information provides a comprehensive description of the patient. It focuses on the patient’s needs at that moment in time and possible needs that may need to be addressed in the future (NMC, 2007). It’s a fair and accurate account of the individual and their life. Overall assessment is a way of delving deeper into a patient’s illness and preventing more problems from arising.
In relation to case study 2 about a 68 years old Afro Caribbean retired bus driver male called Carl, who has being married for 45 years with 5 grown up children and 8 grand children. He smokes 20 a day and enjoys nightcap before sleep. His latest vital signs observation are respiratory 20 rpm, blood pressure 168/105, pulse 92bpm, Spo2 95% and BMI 32kg/m2 and he is on statin, betablocker, aspirin, frusemide medication. Currently his wife has notice Carl seems to have forgetfulness, he couldn’t remember his way home from the super market and keep losing items. He is getting frustrated and taking it on his wife and grand children, especially when he cannot read them a story.
Newson (2001) suggests that, for a process to commence a model of assessment is utilised and this model needs to be holistic in all aspects of patients needs. Therefore proper attention needs to be paid to the biological, psychological and social situations of the patient. It is important that the health assessment includes a thorough examination of the patient’s ‘activities of daily living’ (Department of Health, 2002) .The twelve activities of daily living (ADL) are communication, safe environment, breathing, eating and drinking, elimination, washing and dressing, temperature, death and dying, mobility, working and playing, sexuality and sleep (Roper, Logan and Tierney model 1985). Although, the Roper Logan Tierney model has being criticized for the use of activities of living as a simple checklist and emphasis only on the physical aspect of patient care( Reed and Robins 1991). This contrasts with Newton (1991) who suggests that the description of the Roper Logan Tierney model (1985) have been varied over the years and describe the model as a system model. Also Pearson (1983) describes it as a systems/development-based model incorporating certain concepts of Dorothy Orem’s model and the conceptual framework of Henderson’s model (Henderson, 1969). It is important to remember that all ADLs about our individual life activities are interlink and when one or more activities is affected due to illness then most of the activities can become compromised. (REF)
After a thorough nursing assessment, the ADLs that are appropriate to meet Carl’s needs are communication breathing, eating and drinking, elimination, safe environment, mobility, working and playing. Communication is essential for building nurse – patient relationship (Robinson, 2002). For Carl due to his state of forgetfulness, memory loos, out of character behaviour and frustration especially when he cannot read for his grand children, he may need referral to see opticians for eye check, and the MMSE tool can be use to assess his state of dementia.
Breathing is the first sign every health professional look for during patient assessment. Being able to breathe normally ensures that we can attempt other activities without any difficulties for example running. For Carl his breathing can be affected by smoking for 20 pack years as well as his higher BMI can cause shortness of breath. Referral to the NHS stop smoking service or radiographs for chest x-ray to check for infection will be essential. Also regular vital signs check up and the use of the peak flow meter for checking oxygen level in the lungs or nebuliser will help.
Ensuring adequate hydration and nutrition is essential if health is to be maintained and in Carl’s case he has a higher BMI and he is in a state of confusion. There is a difference between dying from nutrition and dying with nutrition. And in Carl’s case he is dying with nutrition as being over nourished with higher cholesterol level. Fanning H, (2003) suggests that Dehydration as well as UTI can contribute to his state of confusion. Both the (MUST) tool and the (MMSE) tool for assessment of possible dementia can be used (NICE 2012). Referrals can be made by nurses for Carl to see the dietician and also physiotherapist for physical exercise regime and dipstick for UTI.
Elimination is very important, and in Carl’s situation review of his medications will be important since some may cause constipation or frequent urination e.g. furosemide. Higher BMI as a result of being Obese as well as chronic chest problems and constipation can cause urinary incontinent (Kamm, MA1998). Also In male, disease of the prostate may lead to the obstruction of the flow of urine (Abrams el at 2002). The Bristol stool chart can be use to assess constipation, the dipstick tool can also be used to check for infection or UTIs and the fluid balance chart can be use to assess for dehydration by checking input over output.
Mobility can be a problem since Carl has a history of forgetfulness and the need to urinate frequently. Fear of not being able to find his way home, been incontinence in public and even fear of falling in a new environment may but him off from mobilising. Human assistance will be needed as well as the assessment of risk of fall. Carl may need assessment on Working and playing since he is retired, have memory impairment and get upset when he cannot read for his grand children. Socialisation seems impossible for him now due to his condition. Referral to psychologists for self worth exercise and also going to day centres to meet other people will help.
According to the RCN (2004), nurses will always need an assessment tool to guide their daily nursing practice in terms of their professional accountability and responsibility. For any tool to be effective it must be integrated into daily activity – as a standalone initiative it is unlikely to have a significant impact.
In Carl’s condition the as human beings the capacity to sustain life is dependent on our ability to address biological needs including breathing, maintaining blood flow to all our major organs, eating and drinking, elimination waste, protecting ourselfes from injury or disease, exerciseing and resting. All these activities can be monitored through nursing observations of patient in our care, enabling us to decide whether any intervention is necessary to help them maintain their vital functions. In order to make accurate observations we need to learn the correct techniques and how to use relevant equipment. To appreciate the significance of the observations, we need a good understanding of relevant anatomy and physiology, and how to distinguish normal from abnormal functioning. We then have to decide whether our observation require further action, which might include double checking results, increasing the frequency of observations, reporting changes to the clinical managers,
Universal Screening Tool (MUST) will be appropriate for his health. The reason being that, been over weight or having a higher BMIcontribute to a whole range of health problems such as heart conditions, high blood pressure, type 2 diabetes, stroke, sleep apnoea, cancer, gallstone, weak pelvic muscles and osteoarthritis (Department of Health, 2004). Heart disease for instance, is one of the most widespread main health risks of being overweight. Being overweight increases the probability of heart malfunction and blood circulation problems and may result in congestive heart failure (Miller el at 2006). He continued that, losing weight in this situation may not only avoid the above-mentioned ailments but as well assist normalize blood pressure, cholesterol levels and triglyceride and diminish inflammation in the body.
According to Elia, (2003) MUST is a screening tool that has been devised for application to all adult patients across all health care settings. Malnutrition adversely affects physical and psychological function (Elisa, 2000; Stratton et al. 2003b) and impairs patients’ recovery from disease and injury, thereby increasing morbidity and mortality.
BMI (body mass index) is an easy, inexpensive method of predicting the percentage of your body weight that is due to fat mass. BMI is found by dividing your weight (in lbs.) by your height squared (in inches) and then multiplying by 703. In adults, a BMI below 18.5 is considered underweight, 18.6 to 24.9 is considered healthy, 25.0 to 29.9 is considered overweight and above 30.0 is considered obese.
Respiratory function has been studied extensively in relation to BMI. For those with lung diseases, including emphysema, chronic bronchitis, asthma, and interstitial and vascular lung diseases, respiratory function is moderately to severely compromised. This compromise can be exacerbated by being overweight or having a BMI over 25.0. However, even in those with normal airway function, high BMI can impair respiratory function.
Obesity and Chronic Obstructive Pulmonary Diseases (COPD)
Chronic Obstructive Pulmonary Diseases include emphysema, chronic bronchitis and asthma. COPD causes a decrease in elastic recoil of the lungs so that excess air becomes trapped in the chest. This stretches the muscles involved in respiration and compromises their function. The respiratory muscles must then work harder even at rest, increasing oxygen demand on an already taxed respiratory system.
At a certain point during physical activity, COPD patients reach a level when increased effort does not further increase the amount of air that they can expire. Having a high BMI means having more weight for your muscles to support during mobility. Thus, if you have COPD, the level at which increased effort no longer provides an increase in expiration comes much faster since you are working harder to support your own weight. In addition, having a high BMI means having more weight on the chest for the respiratory muscles to work against.
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Underweight and COPD
Although a high BMI can further impair respiration in those with COPD, once COPD progresses to a severe level, weight loss becomes problematic. Because of lower oxygen levels in the blood, blood becomes shunted from the abdomen into the heart and lungs. This causes malnutrition because the gut is not getting enough blood flow to properly digest foods. Additionally, severe impairment of the lungs causes the respiratory muscles to work so much harder that metabolism greatly increases, even at rest. Typically, severe COPD patients who are underweight have a worse prognosis than those who are overweight because they are essentially starving.
High BMI in Healthy Individuals
According to a 2005 study by Jones et. al., high BMI can severely impact respiratory function even in non-diseased individuals. The study found that both Functional Residual Capacity–the volume of air in your lungs after passive exhalation–and Expiratory Reserve Volume–the volume of air you can expire after passively exhaling—decreased exponentially as BMI increased. Subjects who were morbidly obese were actually breathing close to their Residual Volumes–the amount of air in your lungs after forced exhalation. Another 2005 study by Medarov et. al. Supports Jones’ findings and also found that Total Lung Capacity—the maximum amount of air you can inhale–decreased with increasing BMI.
According to the American College of Sports Medicine, being overweight has mechanical effects on respiration, due to increased weight on the chest wall and diaphragm. Being overweight also causes an increase in energy use at the same workload compared to a leaner person, so the respiratory muscles fatigue at lower intensities in heavier people. These effects may contribute to the decreases in Functional Residual Capacity, Expiratory Reserve Volume and Total Lung Capacity.
Lung Diseases Caused by Obesity
There are two types of lung disease for which obesity is a primary cause. The first is Obesity Hypoventilation Syndrome, also known as Pickwickian Syndrome. Obesity Hypoventilation Syndrome involves chronic hypoxemia—too little oxygen in the blood—and hypercapnia—too much carbon dioxide in the blood. The second lung disease obesity can cause is Obstructive Sleep Apnea. This disease involves periodic airway collapse and increased airway resistance during sleep. As both of these diseases progress, pulmonary hypertension may occur and eventually cause cor pulmonale–failure of the right side of the heart.
Because high BMI decreases lung function in both diseased and healthy individuals, an unfortunate domino effect often occurs. Since being overweight makes it harder to breathe, those with respiratory problems may become less physically active. Decreased physical activity causes your muscles, including your respiratory muscles, to weaken and break down, which in turn makes breathing even more difficult. A downward spiral begins, in which inactivity begets further respiratory problems and respiratory problems beget more inactivity
Read more: http://www.livestrong.com/article/84685-bmi-respiratory-function/#ixzz2I54s1yvb
The Health Risks of Overweight and Obesity
Dr Jeremy Sims MB BS MSc MRCGP FRIPH FRSH PGDipHI DipN&H MRNT
Obesity isn’t just a cosmetic problem; it’s very much a health problem as well. You may be reading this today because you are, or have been, very unhappy about your physical appearance.
However, losing weight isn’t just about looking good, it is about feeling good; it’s about being healthy and living a productive and comfortable life. Above all, it is about avoiding the terrible health consequences of carrying around excessive weight.
The growing evidence shows that if you are overweight you are more likely to develop health problems, such as heart disease, stroke, diabetes, certain types ofcancer, gout (joint pain caused by excess uric acid), and gallbladder disease. Being overweight can also cause problems such as sleep apnoea (interrupted breathing during sleep) and osteoarthritis (wearing away of the joints); and the more overweight you are, the more likely you are to have these health problems.
In comparison, healthy and steady Weight Loss can help improve the harmful effects of being overweight. The latest studies show that by losing as little as 10 to 20 pounds you can dramatically improve your overall health status, whilst significantly diminishing your risk of disease.
The Risks To Your Health
Heart Disease and Stroke
Heart disease and stroke are the leading causes of death and disability for both men and women in the Western World. Overweight people are more likely to have high blood pressure, a major risk factor for heart disease and stroke, than people who are not overweight. Very high blood levels of cholesterol and triglycerides (blood fats) can also lead to heart disease and often are linked to obesity. Being overweight also contributes to angina (chest pain caused by decreased oxygen to the heart) and sudden death from heart disease or stroke without any signs or symptoms.
The good news is that losing a small amount of weight can reduce your chances of developing heart disease or a stroke. See dietitian, Juliette Kellow’s Healthy Heart Diet feature.
Reducing your weight by 10 percent can decrease your risk of developing heart disease by improving how your heart works, reducing your blood pressure, and reducing the levels of blood cholesterol and triglycerides.
Noninsulin-dependent diabetes mellitus (type 2 diabetes) is the most common type of diabetes in the Western World. Type 2 diabetes reduces your body’s ability to control blood sugar. It is a major cause of early death, heart disease, kidney disease, stroke, and blindness.
Statistically, overweight people are twice as likely to develop type 2 diabetes as people who are not overweight.
You can reduce your risk of developing this type of diabetes by both losing weight and by increasing your physical activity.
Furthermore, if you have type 2 diabetes, losing weight and becoming more physically active can help control your blood sugar levels. If you use medicine to control your blood sugar, Weight Loss and physical activity may make it possible for your family doctor to decrease the amount of medication you need
Mohammed, MA (2009) Improving accuracy and efficiency of early warning scores in acute care. British Journal of Nursing. 18(1) 18-24
This article is a report on an experimental study to compare the effectiveness of hand held early warning computer system with the traditional pen and paper method
Johnstone C, Rattray J and Myers L (2007) Physiological risk factors, early warning systems. British Association of Critical Care Nursing. 12(5) 220-231
This article is a general article that provides background information on the topic of why early warning systems can improve patient care
Hughes LL (2009) Implementing a patient assessment framework in acute care Nursing Standard 24(3) 35-39
This article describes a service improvement initiative to improve patient assessment using an early warning score system over a4 month period at a Hospital in Birmingham
Wheatley I (2006) The nurses practice of taking level 1 patient observations. Intensive Critical Care Nurse 22(2) 115-21
This was a survey conducted to discover the nurses practices of taking clinical observations in acute settings. It uses an observation data collecting tool (words 470)
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Weight-control Information Network.” Do You Know The Health Risks Of Being Overweight?. Nov. 2004. U.S. Dept. of Health and Human Services. 23 Oct 2006
“Diabetes Statistics.” Total Prevalence of Diabetes & Pre-diabetes. 2005. American Diabetes Association. 23 Oct 2006
“The Nutrition Source.” Healthy Weight. 2006. Harvard School of Public Health. 25 Oct 2006
Obesity causes many of the most common diseases in the world. Being overweight can cause insulin resistance, which leads to Type II Diabetes. A diet high in fat and lack of exercise causes cardiovascular disease and congestive heart failure. Excess weight can cause sleep apnea and respiratory illnesses. Many top scientists believe the increase of average weight directly corresponds to the increase of cancer cases, including kidney, breast, colon and prostate cancers.
Read more: Effects of Being Overweight | eHow.com http://www.ehow.com/about_4596213_effects-being-overweight.html#ixzz2I57jKX6t
Advances in the recording of vital signs make it possible for nurses to monitor patients continuously, be it their heart function, arterial blood pressure, central venous pressure or oxygen saturations. The recordings generated by this equipment must be interpreted according to the patient and in conjunction with other observations. The concern is that nurses may become too reliant on using technology to carry out assessment. Burman et al (2002) describe how staff who are used to equipment can feel insecure assessing patients without this equipment to validate their findings.
Within the competencies are skills such as venepuncture, cannulation, arterial blood gases (obtaining and analysing), and recording and obtaining ECGs. Docherty (2003) identifies the recording and interpretation of the 12-lead ECG as being pivotal in the assessment and management of patients who are experiencing chest pain. This is further supported by Harvey (2004) who discusses the assessment and management of patients suffering from angina. However, it is further complemented by accurate physical assessment of the patient.
‘Basic’ is a term that is frequently used to describe blood pressure, pulse, respiratory rate and temperature. However, I would argue that this undervalues these observations. Breakell (2004) identifies respiratory rate as ‘one of the most important signs and yet one of the most frequently omitted clinical observations’. Carberry (2002) also found this to be a problem in clinical practice.
The objective of observation is to monitor patients’ progress, thus ensuring the prompt detection of adverse events or delays in recovery (Stevenson, 2004). Respiratory rate is pivotal to assessment. Many scoring systems incorporate respiratory rate, such as:
– APACHE – Acute Physiology and Chronic Health Evaluation Score;
– SIRS – Systemic Inflammatory Response Score;
Neiderhauser and Arnold (2004) identify the importance of assessing the health risk status of patients, and the indications for intervention. A wide variety of assessment tools are in use to facilitate assessment and ensure the reliability of the process.
For example the EWAS/MEWS tool can be use to check vital signs and avoid patient’s deterioration. EWAS is use for the assessment of unwell hospital patients, using 5 simple physiological parameters, mental response, pulse rate, systolic blood pressure, respiratory rate and temperature.
It scoring system can be calculated at the patient’s bedside, using a simple and inexpensive equipment to measure any parameters. Of all the parameters respiratory rate is said to be the most sensitive indicatory of a patient’s physiological well being. Breakell (2004) identifies respiratory rate as ‘one of the most important signs and yet one of the most frequently omitted clinical observations’. Carberry (2002) also found this to be a problem in clinical practice. This is logical because respiratory rate reflects not only respiratory
function as in hypoxia or hypercapnia, but cardiovascular statusas in pulmonary oedema, and metabolic imbalance such as that seen in diabetic ketoacidosis (DKA)( REF).
Department of Health (1999b) Making a Difference:
Strengthening the Contribution of Nurses, Midwives and
Health Visitors. DH, London
the health problems that stem from being overweight go way beyond the ones we usually hear about, like diabetes and heart disease. Being overweight can also affect a person’s joints, breathing, sleep, mood, and energy levels. So being overweight can impact a person’s entire quality of life.
Dangers of being Overweight
Some of the dangers of being overweight include developing:
High Blood Pressure: When you have excess body fat, your body retains sodium. When your body retains sodium, blood volume increases and blood pressure rises. High blood pressure causes your heart to work harder, which is dangerous for the heart.
Diabetes: Obesity is the leading cause of type 2 diabetes. Excess fat makes your body resistant to insulin. When your body is resistant to insulin, your cells can’t get the energy they need.
Abnormal blood fats: A diet high in saturated fats increases the level of LDL (bad) cholesterol.
Osteoarthritis: Excess weight adds pressure to joints and wears away at the cartilage that protects them.
Sleep apnea: The more overweight a person is, the greater more severe the sleep apnea will be.
Cancer: Men and women who are overweight have a higher risk of developing many different kinds of cancer.
Gallstones: Gallstones are more common in people who are overweight. The connection between gallstones and weight is unclear.
Weak Pelvic Muscles
Physical Discomfort: As fat accumulates, it crowds the space occupied by yourorgans. People who are overweight may have difficulty breathing, walking or sitting.
Heart disease is 1 of the most widespread main health risks of being overweight. Being overweight to a great extent increases the probability of heart malfunction and blood circulation problems and may result in congestive heart failure, heart attack, angina (chest pains), abrupt cardiac arrest or unequal heartbeat. Weight loss in this situation may not only avoid the above-mentioned ailments but as well assist normalize blood pressure, cholesterol levels and triglyceride and diminish inflammation in the body.
Cancer is one of the foremost causes of death in the United States, and is frequently a result from fat cells that affect cell growth and multiply beyond capacity. Colon, esophagus, and the kidney are the most affected regions of the body. Being obese has also contributed to uterine as well as postmenopausal breast cancer in females.
Sleep apnea, Osteoarthritis plus other Health Difficulties
In sleep apnea the sufferer experiences short lapses of breaths during nighttime. This in turn makes the person tired right through the day, making it hard for him to concentrate on work. In some cases, heart failure has also been noted in patients suffering from this ailment. The lapse of breath happens due to the increased size of the cells of the neck, obstructing the windpipe at certain intervals. Dropping weight may decrease the size of the neck and diminish the pressure on the windpipe and make breathing easy.
Osteoarthritis is another health risk of being overweight. In this particular ailment, the joint bone and the tissue that protects joints (cartilage), wear away. The joint bone of numerous parts of the body like the hip, knees, plus lower back are the main targets of Osteoarthritis. Being overweight places a lot of heaviness on the joints, which might lead to this condition in the long run. Dropping weight will let down the body fat and lessen the aches and pains.
Excess fat accumulates in the liver cells and causes the organ to inflate, leading to injuries. This results in Fatty Liver diseases. This disease can lead to severe liver injury, built-up of scar tissue that blocks the proper blood flow to the liver (cirrhosis), and complete liver breakdown. It is relatively similar to alcoholic liver damage but does not inevitably mean that it cannot affect those who do not consume alcohol.
Taking communication for instance, it is essential for building nurse – patient relationship (Robinson 2002). It is important, for example for nurses to know during assessment whether a patient can hear, understands the language in which a question is being asked or can answer by speaking or sing language. And if they cannot hear, do they wear hearing aids, if so in which ear. Language barrier can be a major problem during assessment, but interpreters, family and friends can contribute and help. However, very often accurate information will not be given, preventing full assessment of patients needs. The use of braill and flashy lights is also important during assessment for patients who are blind or deaf.
Newton (1991) suggests that descriptions of the Roper, Logan and Tierney model (1985) have been varied over the years. The model has been described as a system model (Aggleton & Chalmers, 1987), as a model that incorporates multiple theories (Thibodeau, 1983) and as an ‘activities of living’ model based on human needs (McFarlane, 1980). Farmer (1986) has described it as having a functional approach. Pearson (1983) describes it as a systems/development-based model incorporating certain concepts of Dorothy Orem’s model and the conceptual framework of Henderson’s model (Henderson, 1969).
It seems fair to suggest that the Roper, Logan and Tierney model has had criticism over time. Indeed, the model has been criticized for the use of the activities of living as a simple checklist (Reed & Robbins 1991), the emphasis on solely the physical aspects of patient care (Minshull et al 1986, Walsh 1989), and the simplicity of the model (Walsh 1991). Bellman (1996) suggests that the first two problems indicate an inappropriate introduction and implementation of the model in practice.
We have done nursing assessment and for Carl the ADLs that are a
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