B740 Adult Nursing : Professional Development in Nursing Practice

Introduction:

The essay focuses on the clinical scenario of a patient with stroke and having the symptoms of aphasia and dysplasia. The first part of the essay describes the barrier faced in communication with the patient and the technique used to improve communication and interaction with patient. On the other hand, the second part discusses about the challenges faced in care of patients, planning of care and the implementation process to address the problem. Finally, a reflective account gives detail on how participation in care of patient during clinical placement facilitates personal and professional development in nursing practice.

Task 1: Communication with a patient in clinical placement:

Communication in nursing practice

Communication is the process of interaction between one or more people for the successful completion of task. The communication process is achieved by several means such as interpersonal communication, non-verbal, written and oral communication. Verbal communication involves the use of words to deliver intended messages. It is also done by written means, face-to-face contact, video conferencing or other medium. The effectiveness of oral communication depends on speech, volume, tone, voice modulation, body language as well as visual cues. On the other hand, non-verbal communication is achieved by sending wordless messages in the form of gestures such as tone of voices, touch, pointed fingers, facial expression, emption and style of speaking (Little et al. 2015).

Good communication is an important part of nurse patient relationship to engage in individualized care of patient. The communication process begins with the first interaction of the patient and the consideration of the rights of patient in care facilitates the delivery of high quality of care (Kourkouta & Papathanasiou 2014, P. 65). Hence, excellent communication skill is necessary to build therapeutic relationship with patients, prevent medical error and provide high level of care. According to Peplau’s Interpersonal Relations Theory, the communication between nurses and patient proceed in three phases. The first phase includes the orientation phase in which patient is engaged in treatment by two way of communication- asking questions and receiving detail on treatments process. It promotes trust in nurse-patient relationship. The second phase includes the identification phase in which mutual understanding is developed and active participation of patients is seen in treatment. This is followed by the exploitation phase in which relationship is further nurtured by addressing treatment goals. The final phase is the resolution phase in which complete independence of patient is achieved and all health care needs are met. This results in the culmination of an effective therapeutic relationship (Hagerty et al. 2017, pp. 160-167).

Communication process with patient and barrier to communication in clinical placement

In one of the nursing clinical placement, Mark (pseudonym), a 55 year old man was admitted to the hospital suffering from stroke. He was admitted to the hospital after sudden onset of aphasia (muteness) and central paralysis. He had sustained stroke 9 months back and since then has been struggling with difficulty in speech, sudden numbness of the body and lack of coordination. To prevent further risk to patient, Mark was scheduled for an elective surgery. His assessment revealed aphasia and impaired sensation on the right side. Due to this, he was also having difficulty in mobility and swallowing foods and liquid.

In clinical practice, effective communication is necessary to cooperate with multiprofessional health care team and enhance physiological and functional status of patient. However, many factors act as barrier to communication process and disrupt the ongoing process of care (Norouzinia et al. 2016, p. 65). During the clinical care of Mark, he was found to have many difficulties in communication post stroke. Aphasia is the main reason for which speech and language impairment is seen in post stroke patient. This form of acquired language impairment affects almost one-third of stroke patient (Mazaux et al. 2013, pp 341-346). The same was witnessed in Mark during the clinical assessment of patient. As Mark had suffered paralysis on the right side of the body, the condition had affected his ability to speak (expressive aphasia). Secondly, stroke had affected the muscle that controls movement of lips, mouth and tongue (dysarthria) (Bahia & Chun 2014, pp. 353-359). He was having extreme difficulty in expressing word and speaking full sentence. Apart from nurse, mutliprofessional health care team of occupational therapist, physician, neurologist and psychologist was also involved in care of Mr. Mark. Before the assessment of patient, speech language pathologist informed the nurse about the speech difficulty in patient and that he could only respond to ‘yes’ and ‘no’. Communication of this fact from the multiprofessional team helped to the nurse to modify the communication process with patient.

Hence, challenges in communication with patient were observed due to the symptom of aphasia and dysphasia. In such situation, it was very difficult for nurse and health care team to interpret whether Mark understood messages or not. Secondly, the process of guidance for nutritional care before surgery also became difficult. Hence, the oriental phase of communication was compromised while interacting with Mark.

In addition, NMC code of conduct require nurses to act in the best interest of patient by means of respecting their right to accept or refuse treatment and getting properly informed consent from patient before any medical procedure (Council, 2008). However, as a nursing student, breaches in consent process within the multidisciplinary team. Consent process requires taking voluntary and informed consent from patient. In case of patient with disability, it is necessary to take consent from family members. However, it was found that despite knowing the Mark was unable to give voluntary consent for treatment, the multi-professional health care team took consent from Mark breaching legal and ethical aspects of care (Mamo 2014, p 510). Therefore, Mark was not regarded as an autonomous agent through the process of informed consent.

In relation to the difficulty faced by nurse in communicating with Mark, the strategy of SOLER model of communication was employed. This was necessary because of Mark’s inability to express due to symptoms of aphasia. A study also revealed that therapeutic communication in stroke patient is achieved by means of gestures instead of verbal and written communication. Nurses mostly apply informal strategies to communicate with patient (Souza & Arcuri 2014, 292-298). Therefore, the facial expression of the patient was the main mode of communication with health care team. The concept of SOLER is “S: Sitting at comfortable Angle, O- Open posture, L-Lean towards the other, E- eye contact and R-relax”. The attention and response of Mark was gained through the SOLER mode of communication and the use of compassion and empathy in care. This non-verbal strategy identified by SOLER ensures that patient feel they are being paid adequate attention and this encourages two-way communication with patient. Secondly, another strategy was not to rush the communication and use short sentence to make patient comprehend easily (Rousseaux et al. 2010, 1099-1107). The speech therapist also explained to health care team that soft tone should be used with patient and only one idea should be communicated at a time.  Accordingly, the nurse gave instruction regarding meal time for Mark and then paused to tell he would have to change his dress.

By means of non-verbal communication skill, Mark’s approval or disapproval for any clinical process was received by means of gesture, facial expression and eye contact. Secondly, the concept of empathy and respect in care was employed to empower patient and make him feel valued. According to the patient-centric communication technique, empathy is a two stage process which includes clarifying about the patient situation or feeling and communicating in supportive way with patient (O'hagan et al. 2014, 1344-1355). Hence, nurse and other staff engaged in emotional and compassionate interaction with patient by encouraging Mark to feel free to share his concern at any time. His gestures helped me to understand his concerns and different things around the patient were used to ensure that patient’s message is easily understood by all.

Task 2: Challenges in nursing care with patient:

Introduction:

The holistic care process of nursing care begins with patient assessment process of nurses. It promotes understanding of complexity and problem in patient. With this knowledge and insight, development of care priorities of patient is simplified. The judgment regarding most appropriate intervention and care plan helps to optimize patient outcome and deliver high quality care (Fawcett & Rhynas, 2012, pp. 41-46). To make the nurse care planning process easier, use of appropriate nursing model of care facilitates evidence based care process. For example, the power of environmental adaptation is nursing care is given by Nightingale’s environmental theory. This is based on the concept that restoration of normal health of patient is facilitated by the modification of external environment of patient (Jacobson 2017). On the other hand, the Ropar, Logan and Tierney’s activities of daily living model is a practice oriented nursing theoretical model that explain different factors that influence daily living in patient. This model is specific to the nursing process and knowledge about the factors influencing daily living facilitates nurse to engage in effective assessment and care planning process. It applies a guide to holistic patient assessment process by means of assessment, diagnosis, planning, intervention and evaluation process (Williams 2017, pp. 17-20). This essay applies the Roper, Logan and Tiernet’s (RLT) model of care to identify the problem in care of specific patient during placement and develop a care plan process by means of assessment of patient, short and long term goal for patient, care and implementation process for target patient.

Nursing problem according to the Roper, Logan and Tierney’s Activities of Living model

The RLT model of nursing supports a nurse to assess how a patient’s life and activities of daily living is affected by illness. The assessment of activities of daily living in patient is an approach to complete assessment that leads a nurse to specific intervention to support independence of patient in those areas. According to the RLT model, the 12 assessment areas in activities of daily living includes communication, nutrition, elimination, washing and dressing, mobilization, safe environment, working and playing, sleeping, controlling temperature expressing sexuality and death and dying. Changes in these areas may be seen in patient as a result of illness.

Problem 1: 

During my clinical care of Mark (pseudonym), a stroke patient with right side paralysis, symptoms of aphasia and dysarthria wereobserved. He was having difficulty in understanding words, expressing and in moving lips and tongue. Due to this, the activity of mobility and nutrition was impaired in the patient. It occurred because the condition of dysarthria affects the muscles of vocal tract, throat or mouth. This creates swallowing difficulty for patient and lead to poor nutrition in patient. Apart from nutritional deficit, such patient is most likely to suffer from the risk of pneumonia (Sura et al. 2012, pp. 287-298). In such condition, meeting nutritional needs of patient is a challenging process.

Plan of care for nursing problem 1:

The plan of care of Mark is influenced by the nursing process of APIE, which are assessment, planning, implementation and evaluation. This framework enables critical thinking and accurate decision-making process for well-being of patient (Hill 2015, p.197). Secondly, SBAR framework helps to analyze the background and situation of patient to assess and recommend appropriate intervention.

Assessment:

 In relation to the problem of nutritional difficulty in patient with dysphagia, the patient data related to the abnormality was assessed and validated by the enrolled nurse. The nursing intervention for basic swallowing of patient was identified by testing patient with a small amount of water. The enrolled nurse observed the signs in patients and student nurse gave the fluid for testing. The assessment and observation regarding coughing gurgling sound and wet voice in patient gave the indication of swallowing difficulty. The symptom of dysphagia was validated by the enrolled nurse, if the patient was coughing and had to put effort while drinking milk or water. Processed sour milk was used for swallowing difficulty assessment instead of water as thick consistency is easier to swallow for patient with stroke-induced dysphagia (Westergren et al. 1999, 274-282). This means of bedside assessment of patient is beneficial for nurse as it can be easily done and promote observation at regular intervals.

According to NICE recommendation for initial management of stroke, it emphasizes on recognizing symptoms rapidly. This was done by means of Airways, Breathing, Circulation, Disability and Exposure Assessment (ABC). This was important for patient because dysphagia and aspiration are linked to each other leading to variety of maladaptive feeding and swallowing patterns. Abnormal coordination between breathing and swallowing may lead to respiratory problems in patient. Hence, ABCDE assessment was important. The airway obstruction and respiratory distress in patient was observed by means of signs like sweating, cyanosis, abdominal breathing, and other signs. The color of hand and temperature of limbs was checked for circulation problem and risk of hypovolemia. Finally, disability in patient such as hypoxia and hypercapnia was identified by means of breathing and airway assessment (Hsieh et al. 2014). The patient was having little difficulty in breathing normally and had clear airway (Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance and guidelines | NICE 2017). 

Goal:

The goal of care for Mark with dysphagia was as follows:

The short term goal was to identify level of swallowing difficulty in patient and take measures to adapt alternative eating habits in patient. The long term goal was to ensure that nutritional needs of patient is met, swallowing of patient is managed by means of therapies and safe swallowing process is facilitated by managing posture and position in patients.

Care and implementation: 

According to NICE recommendation, swallowing screening should be done on patient and supplemental hydration and nutrition should be considered (Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance and guidelines | NICE 2017). In accordance with the recommendation, my senior nurse gave me the advice to the student nurse to give smaller but frequent meal to patient to meet his nutritional requirement as well as reduce fatigue in patient. The most important feeding requirements consideration for Mark was to provide him cold and liquid food to avoid extra complications while eating. Secondly, dietician of Mark adjusted his meal time according to the peak medication time and the student nurse was explained this was meant to improve muscle function. After this, the student nurse gave the medication to patient in crushed form in juices or dissolvable gel caps (Geeganage et al. 2012). However, the enrolled nurse emphasized that in case the patient suffers from severe challenges in eating, feeding tube will be used to meet his primary and secondary nutritional needs. 

After implementing appropriate nutritional option for patient with dysphagia, the care plan was to facilitate short term adjustment to patient, food and environment to ensure that patient nutritional and hydration needs of patient is met until he becomes independent in this activity. In addition, compensatory mechanism of swallowing maneuvers was taught to patient to promote continue safe oral intake of food and nutrients. Patient was also taught to change body and head posture to reduce aspiration. This is also beneficial in altering the speed of bolus and protecting airways (Sura et al., 2012, pp. 287-298). This form of simple adjustment will improve the quality of life of patients.

Evaluation:

The swallowing screening of Mark revealed extreme difficulty in swallowing food. He was facing problems in swallowing thick fluids like soup and medications too. Hence, the intervention of providing liquid and cold fluids to Mark relieved him a lot during feeding as he could easily swallow them without any difficulty. The patient also reported that he felt better after his position as altered from time to time as he could not move his body due to paralysis. The patient was also slowly acquiring the long-term goal of learning swallowing maneuvers. Hence, this intervention addressed swallowing problems in patient and he could take food in required amount. This eliminated the risk of nutritional deficit in patient too.

Problem 2:

In relation to delivering nursing care to Mark, a patient with stroke and right side paralysis, his independence in mobility was compromised. This made patient dependent for mobility needs, toileting and changing clothes. In such situation, many challenges were faced in managing care of patients and assisting them in activities of daily living (Dean et al. 2012). All this problem was experienced by patient because of the condition of hemiparesis which affects movement in one side of the body and reduces muscular strength in that part (Darekar et al. 2015, p.46). In such case, managing motor skills of patient will be necessary. Hence, the condition of stroke will dramatically alter the lifestyle of patient due to loss of functional independence, particularly decrease in mobility.

Care plan for the problem 2:

To address the problem in daily living activity of mobility in patient with stroke, the care plan for Mark is made on the basis of APIE nursing process framework. This will help to systematically assess and collect data related to abnormalities in patient, prepare realistic goal to achieve desired outcome in care and direct care according to promote independence in activities of daily living (ADL) (Hill, 2015).

Assessment

To analyze level of difficulty in mobility in patient, the enrolled nurse did assessment in the area of motor control by observing the function of upper and lower extremity of the body. As toileting, bathing, dressing and grooming was difficult for Mark, mobility assessment and monitoring was critical to prevent fall and support patient. The enrolled nurse used Barthel Index and Functional Independence measure test was done in patient to measure mobility and ADL (Hong et al. 2016). Balance test was be done to evaluate performance in basic task of natural stance, tandem stance, stance with right and left leg only, stance with eyes closed and on toes. To test the adaptability to walking, gait assessment tool was utilized to measure variables of gait such as walking velocity and stride length (Balasubramanian et al. 2014).

Goal:

To address the problem of mobility in stroke patient, the goals of care are as follows:

The short term goal was to improve support for patient in activities like bathing, dressing and showering, minimizing risk of fall and injury in patient, providing assistive device to patient for mobility and modifying patient environment to prevent risk of fall. In addition, the long term goal was to engage patients in range of motion exercise to improve mobility and gait patterns.

Care and implementation:

To improve mobility and prevent deformities in patient, student nurse provided  positioning intervention  with the instruction of senior nurse to maintain good body alignment and prevent compressive neuropathies due to continues period of rest. This exercise had the potential to encourage patient in successive position changes and this had the advantage of shifting patient back to their original kinaesthetic. Side-to-get up intervention was also be taught to patient. The senior nurse explained to student nurse that this is done to encourage patient to get up from bed step by step to improve spatial orientation of patient. The improvement in functional measures can be evaluated from time to time by means of the Extended Barthel Index. This is a validated tool to measure functionality in patient in rehabilitation setting (Imhof et al. 2015).

Another important care plan was be to establish daily exercise program in patient at least four times day to improve motor control, maintain joint movement and prevent contractures particularly in paralyzed areas. The goal was be to engage patient in range of motion exercise to prevent long-term problem in mobility (Morris et al. 2014, pp.956-967). Dean et al. (2012, pp. 1046-1057) reveal that exercise interventions are useful in enhancing mobility post stroke as well as prevent fall. The goal of exercise intervention is to prevent fall, increase physical activity and enhance mobility. Typical exercise for this may include sideways stepping and walking, sit-stand and step-ups exercise. This will also increase the patient walking capacity.

Evaluation:

Through the intervention of providing support in activities of daily living (ADLs), the short term goal of risk and injury due to fall was minimized. Secondly, attempts to move patient back to original kinaesthetics promoted his rapid recovery from movement related disability. Secondly, the long term goal of improving mobility in patient through exercise proved to be beneficial for Mark as his walking and strides had improved significantly.

Reflection on personal and professional development during planning patient care:

After being involved in the activity of planning patient care during my clinical patient, I got the opportunity to learn many things in nursing care process. It not only enhanced my professional skill in my job but also my personal confidence in handling patients with range of clinical issues. From the exercise of identifying barrier in communication process with patient in clinical placement, I learnt about the importance of communication in nursing practice. The nursing theory on communication enlightened me with the approach needed to initiate communication with patient, inform them about care and actively involved them in care process. With this knowledge, I am now aware about the systematic process of interaction with patient. Secondly, in the second exercise of identify problems in nursing care, I realized the importance of RLT for realizing factors that may affect independence of patient due to affect of illness. This has enabled me to engage in practice-oriented care by taking guidance from APIE nursing process. With this knowledge gained in nursing skill, I can implement patient centered care to achieve positive clinical outcome for patient.

Conclusion:

The essay summarized the process of planning care for patient in nursing practice by means of evaluation of a patient during clinical placement. The first exercise of exploring communication related challenges in a 55 year old post stroke patient with right side paralysis revealed the difficulty in communication process due to symptoms of aphasia and dysphagia in patient. As communication is an important element in nursing care, the essay proposed use of Peplau’s Interpersonal Relations Theory to engage patient in care process. In relation to the issues in communication process, the use of SOLER model of communication and emphasis on respect and empathy while delivering care gave direction to overcoming the issue. In accordance with NMC standard of nursing care, the nurse also monitored ethical and legal practice within multi-professional health care team to preserve the anonymity of patient in care. Finally, the exercise of identifying barrier in ADL in patient according to TDL model of nursing care helped in identifying factors that influence independence of patient due to disease. This exercise guided in making systematic care plan of patient by using the APIE framework of nursing process.

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