Hmh2007 Person Centred Care; Case Assessment Answers

Evelyn Goldstone

Answer:

Introduction:

Case of Evelyn Goldstone is chosen for the care plan. Interest in providing care to the complex cases and expertise in the similar cases made to choose case of Evelyn Goldstone. This case is about the orthopaedic old female patient who is also having psychological problems like short term memory loss and confusion. For Evelyn Goldstone, it is necessary to provide person centred care because involvement of family members is necessary in her care. Usually, patient need to be incorporated in the person-centred care; however, due to age factor it would be difficult to involve Evelyn Goldstone in her care (Moore et al., 2017).

Jane, Evelyn Goldstone’s daughter need to be at the centre of her care and she need to work alongside healthcare professionals in the decision making for care of Evelyn Goldstone. Involvement of Jane is important in the care of Evelyn because along with providing medical care to her psychological and emotional intervention need to be provided to her. Psychological and emotional intervention is necessary because she is not cooperating for treatment and reluctant to take food also (Ross et al., 2015).

From the collected objective data like left hip fracture, osteoarthritis and osteoporosis and subjective data like pain; it is evident that acute pain is the most significant problem for Evelyn. As a result of pain, she is also having problem of mobility. Left hip fracture, pain and orthopaedic condition might increase chances of fall in her. Hence, risk of fall is another problem for Evelyn. Hence, pain, mobility and risk of fall are the three problems for Evelyn. Since, she is having very severe pain, care plan for pain would be written in this assignment. Confidentiality about name and health condition of Evelyn would be maintained. Maintaining confidentiality of patients is important because dignity and self-respect of the patient would be maintained (McHale and Tingle, 2007).

Discussion:

Person-centred care : Framework of person-centred care (PCC) comprises of structure, process and outcome. Structure is related to components of health-care system, deliverables to the patient, health-care resources and organisational characteristics. In the hospital, it is necessary to build person centred culture to provide PCC to Evelyn. Health education, health-promotion and prevention plan need to be established for Evelyn and opportunity need to be given to Jane for these establishments. Hospital need to support staff members for implementation of PCC. For the promotion of PCC, it is necessary to provide health information to family members. Hence, health information technology needs to be established in the hospital. It is necessary to provide supportive and accommodating environment for PCC implementation. Applicability of PPC in case of Evelyn, need to be evaluated.  Hence, hospital need to adopt established structure to measure and monitor PCC. PCC process includes communication between healthcare professionals and Jane. Communication in PCC include cultivating communication, respectful and compassionate care, engagement of patients in their own care and integration medical care with psychological and social intervention (Kennedy, 2016; Stickley, 2011).

Outcome exhibit benefits of PCC implementation and interaction among patient family members and healthcare providers. There should be relationship and alignment among structure, process and outcome of PCC. Different aspects like medical, social, cultural, psychological and emotional are being considered in PPC; hence, it is considered as multidimensional concept. As a result, it is useful in providing holistic care to Evelyn because she also needs intervention for medical, emotional and psychological aspects. It indicates complexity of concept of PCC. Hence, it is necessary to use established framework for assessment of patient in PCC (Ross et al., 2015).

PCC promotes self-determination for Evelyn and Jane. It also establishes mutual respect and understanding among nurses and Evelyn and Jane. It is also helpful in providing power to Jane and giving responsibility to her. It would be helpful in improving her self-esteem and her involvement in her mother’s care. It is also helpful in establishing common therapeutic goals in concordance with the Evelyn. It would provide more comfort to both Evelyn and Jane (Moore et al., 2017). Nurse need to establish interpersonal relationships with patient and family members to implement PPC. John Heron's six-category intervention analysis is useful in understanding interpersonal relationships and providing effective clinical services to the patients.  These six categories are classified into authoritative and facilitative. Authoritative type of nurse should provide information, challenge the other person, play a dominant role and should take responsibility on behalf of client. Authoritative categories include prescriptive, informative and confronting. In facilitative model, nurse should draw ideas, find solutions, and build self-confidence. Facilitative categories include cathartic, catalytic and supportive. This model is also useful as supervision model and improving clinical competency of nurse in implementing PPC (Heron, 2001).  

Assessment: For effective assessment, nurse and patient collectively need to identify needs and concern of patient. Patient assessment need to be patient focused. Patient assessment is useful in obtaining information which is required for planning intervention, achieving goals and facilitating evaluation of the care plan. McCormack and McCance’s framework is useful for the patient assessment. Patient assessment should be respectful and individualised, permitting negotiation, and allowing patient and family members to participate in the decision making. Steps involved in patient assessment are observation, data collection and clinical judgement (Wolstenholme, et al., 2017; Thim et al., 2012).

Assessment of Evelyn need to be performed for both subjective and objective data. Objective data comprises of observable and measurable data. It also includes data related to lab and diagnostic tests. Objective data include BP- 121/73, Pulse- 96, Saturation Level 98%, Temperature- 37.6 and VAS pain score 10/10 on movement. Objective assessment data also include concurrent health conditions like gastric reflux, osteoarthritis, osteoporosis, Alzheimer’s Disease and short-term memory loss. X-ray examination revealed fracture in her left neck of femur. Subjective assessment data include pain, moaning and disorientation. Roper, Logan and Tierney assessment tool need to be used for assessing daily activities of living. In case of Evelyn, Roper, Logan and Tierney assessment tool would be useful in assessing mobilisation, communication, breathing, eating and drinking. McCormack and McCance framework is useful making PCC more tangible for implementation in the actual practice (McCormack et al., 2017; McCormack, B. and McCance, 2016).

This framework uses empirical data for the assessment of patient. Hence, it is considered as valid method for the assessment of patient. This framework is useful in establishing caring relationship among service provider and recipient. Caring relationship is necessary in case of Evelyn because medical, psychological and emotional intervention need to be provided to her and her family members. Nurse need to acknowledge emotions and compassion of Evelyn and her daughter to establish mutuality in her care. According to this framework, it is necessary for the nurse use values like trust, involvement and humour in her care. Trusting relationship among the nurse and; Evelyn and Jane is important aspect because patients need to believe in the care provided by the nurses. Moreover, trusting relationship facilitate PCC (McCormack et al., 2017; McCormack, B. and McCance, 2016).  

Nursing Problems: Based on the collected subjective and objective assessment data; it is evident that Evelyn is having specific nursing problems. These problems include acute pain, mobilising, risk of falls, confusion and eating and drinking. It is essential to identify problems in the patient to provide care to the patient.

Goal: To maintain Evelyn comfort and pain to a level that is manageable for her.

Intervention: Comprehensive assessment needs to be performed to assess location, onset, duration, frequency and severity of pain. Bolton pain assessment tool need to be used for assessment of pain score in Evelyn. Nurse need to foresee pain relief and acknowledge pain report of Evelyn. Foreseeing pain relief can be useful in providing early intervention and reducing dose requirement for pain relief. Acknowledging immediate pain reporting is useful in reducing anxiety due to pain. Minimizing anxiety is necessary because anxiety can exaggerate pain sensation. It is necessary because it is useful in providing effective pain management to Evelyn. Nurse should observe for non-verbal signs of pain like moaning, guarding and facial grimace for Evelyn. In few instances, patient might not verbalise pain. These behaviours would be helpful managing pain in Evelyn. Evelyn’s vital signs need to be assessed because vital signs get affected due to pain. It is evident that tachycardia, hypertension, and increased respiration occur due to pain in patients like Evelyn. However, nurse need to be careful while assessing these vital signs in Evelyn for pain assessment because due to her older age also, there is possibility alterations in these vital signs (Foss et al., 2009; Thim et al., 2012).

Non-pharmacological interventions like relaxation exercise, breathing exercise and music therapy need to be provided to Evelyn. Non-pharmacological treatments would be helpful in augmenting release of endorphins which would be helpful in improving therapeutic effect of medications for pain relief. Optimal pain relief medication needs to be administered because different types of pain require different pain relief medications. Analgesic regime needs to be reviewed because patient-controlled analgesia pump is not favourable for her due to Alzheimer’s disease and short-term memory loss. Pain medication record need to be maintained which is useful in determining effectiveness of medication which is useful in alteration of the dose (Foss et al., 2009). Anti-inflammatory medication should not be given to her due to gastric reflux. Pain score need to be assessed pre and post analgesia. Pain score need to be evaluated every 24 hours. Nurse need to reduce or eliminate factors which are responsible for precipitation or potentiation of pain. These factors include fear, fatigue and monotony. Elimination of pain precipitating factors are necessary because pain is the subjective parameter which varies from person to person and external factors influence it.

Interventions for the pain management need to be planned according PCC framework. Structure, process and outcome aspects of the PCC framework are useful in planning interventions for pain relief. Structure of PCC framework states that pain interventions need to be planned at the organisational level. Structure deals with making availability of resources for pain intervention. Process of PCC framework states that pain interventions need to be planned at the patient and healthcare provider level. Process is related to action to be carried out to provide intervention. Outcome of PCC aspect states that pain intervention need to be planned at patient, healthcare provider and organisational level. Outcome is related to usefulness of the intervention (NICE Guidelines, 2012).

Roper, Logan and Tierney model would be used for assessing mobility necessary for performing daily activities. It would be useful in providing necessary intervention. Nurse should ensure positioning in proper alignment and reposition every two hours. Hence, Evelyn will not experience complex feeling due to immobility. Nurse should teach use of adaptive accessory for mobility. Mobility accessories would be useful in improving mobility. Nurse nee to identify factors facilitating safety in Evelyn and modify environment accordingly. It would be helpful in understanding whether intervention need to be provided for improving safe mobility. If environment is not familiar, there is possibility of fall of Evelyn. Patients like Evelyn who are disoriented or confused are at higher risk of fall. Nurse should ensure to put side trials up and put items necessary for Evelyn in her reach. If items are out of reach of Evelyn, she needs to stretch her body to get these items. Hence, there is possibility of losing balance and fall (Kenny et al., 2017; Greenwood and Oldmeadow, 2009).

Legal and ethical issues: According to Nursing and Midwifery Council Code of Conduct for the confidentiality nurse need to respect patient’s right to privacy and confidentiality. Information related to care of patient’s need to be shared appropriately. Patients should be informed about how information about their care would be shared and who will provide care. Information related to health of patient need to shared only with the permission of patients and when safety patients override need for confidentiality (NMC, 2015). Pain management is fundamental human right and healthcare providers are obliged to provide management to patient like Evelyn. Many international guidelines stated that pain management is primary ethical duty of healthcare provider. Hence, it is mandatory for the healthcare providers to be aware of multiple pain related ethics. One of the most important pain related ethics is patient’s appraisal in the decision making of their own pain relief. It is in alignment with the case of Evelyn because in her case, PCC need to be implemented. Patient and family members involvement in the decision making is of significant importance in case in PCC. In case of Evelyn, Jane should be encouraged to take part in decision making. Opioid crises are a significant ethical issue in case pain management. Hence, healthcare providers need to consider risks associated with the opioid administration because risk minimisation is the basic human right (NICE Guidelines, 2016).

Discharge plan: Pain need to be assessed during discharge for Evelyn. Sufficient time need to be given for preparing discharge plan for older person like Evelyn. Jane need to be involved in preparing her discharge plan. All the healthcare professionals involved in her care need to be informed about her discharge plan. Discharge plan for Evelyn should include her functional goals following her discharge and list of prescribed medications. List of prescribed medicine should also include dose, frequency and anticipated duration of medication consumption. For opioid medicines administered during hospitalisation, prescription plan and stopping strategy need to be mentioned in the discharge plan for Evelyn (Galvin et al., 2017).

Prevention and management strategies need to be mentioned for probable side effects of medications. All the contact details need to be given for the person to whom Jane need to be contacted if pain relief is not adequate post-discharge. Contact information about follow-up appointments, referrals for outpatient and community-based rehabilitation need to be given to Jane. With the consent of Jane, discharge plan needs to be given to the residential aged care facility. It is necessary to send Evelyn to residential aged care facility because it is a suitable place to take care of her. Jane alone could not take care of Evelyn alone; hence, in aged care facility service providers would take care of her. Moreover, social isolation can exaggerate pain in Evelyn. Hence, in aged care facility Evelyn can socialize with other older people and it would minimize pain sensation in her (Couturier et al., 2016).

Personal values: It is necessary to maintain personal values of the patient and family members while planning care for the patient like Evelyn. It is also in alignment with the person-centred care. Nurses and healthcare professionals need to give respect Evelyn and Jane by understanding their feelings and by encouraging them to contribute in decision making of Evelyn’s care. In case of Evelyn, autonomy is not possible because due to her age and health condition, it is difficult to expect independence in her. Life-experience of patient is useful tool for providing intervention to the patient. However, in case of Evelyn, life-experience cannot be considered because her age and psychological condition like confusion and dementia would not give accurate outcome. In this case, Jane’s help need to be taken to understand life-experience of Evelyn because she cannot provide life experience due to her dementia. Understanding relationship of care provider and carer with patient is important aspect in providing nursing intervention for pain management. In case of Evelyn, nurse need to establish both personal and therapeutic relationship with Evelyn. It is evident that change in the environment of care for patient with pain is useful in reducing dose and duration of pain medication. Quiet environment is useful in minimizing pain perception (Addario et al., 2018).

Evaluation: Evaluation of pain intervention in Evelyn should not be only focused on medical treatment but also it should focus on biochemical, physiologic, functional, and quality of life measures. In evaluation, pain relief need to be assessed which is useful in reducing duration of hospital admission and hospital readmissions. Pain relief in Evelyn need to be evaluated by reviewing pain score and analgesia regime. Pain score would be reviewed every 4 hours and analgesia regime would be evaluated every 24 hours. Mean pain score need to be evaluated after 24 hours. Evaluation also need to be performed for stabilization of the biochemical parameters and vital signs. All the subjective and objective parameters need to be stabilized to assess pain relief (Addario et al., 2018).

Conclusion:

In this assignment, case study of Evelyn was described. Evelyn is a 92 years lady admitted to orthopaedic ward with fractured left neck of femur. Person centred care was implemented for Evelyn. Mccormack and Mccane framework was used for implementing person centred care. Established frame work was used for the assessment of Evelyn. Both the subjective and objective parameters were assessed during her assessment. After the completion of assessment, she was diagnosed with left hip fracture. Relevant to her diagnosis, three problems were identified for Evelyn. Pain was considered as the major problem and motility and fall risk were considered as the other problems for her. After the identification of problems, goal was set for her. For Evelyn goal was, ‘To maintain Evelyn comfort and pain to a level that is manageable for her’. To meet the goal set for her, interventions necessary to reduce the pain were implemented. Interventions provided for Evelyn were with reference to the person-centred care framework. Nurse and other healthcare professionals made sure that legal and ethical implications were considered while providing interventions to her. Personal values of Evelyn and Jane were considered while providing intervention to Evelyn. Person-centred care discharge plan was prepared for her and referral was made for the outside treatment and care. Different strategies were implemented to the evaluation of the care plan for Evelyn. Evaluation was directed to assess whether goals were met for Evelyn.

This assignment benefited by providing more insight into the person-centred care of old patient. This assignment gave experience of following step-wise and systematic approach for providing person-centred care to the old patient. It also helped to understand impotence of personal, legal and ethical issues while providing care to the patient. This assignment would definitely help in future to implement this approach in the actual practice. It would give more confidence to use person-centred approach in the old patient.

References:

Addario, B.J., Fadich, A., Fox, J., Krebs, L., Maskens, D., et al.  (2018) Patient value: Perspectives from the advocacy community. Health Expectations. 21(1), pp. 57-63.

Clarke, C. (2014) Promoting the 6Cs of nursing in patient assessment. Nursing Standard, 28, pp. 52-59.

Couturier, B., Carrat, F. and Hejblum, G. (2016) A systematic review on the effect of the organisation of hospital discharge on patient health outcomes. BMJ Open. 6(12):e012287. doi: 10.1136/bmjopen-2016-012287.

Foss, N.B., Kristensen, M.T., Palm, H., and Kehlet, H. (2009) Postoperative pain after hip fracture is procedure specific. British Journal of Anaesthesia, 102(1), pp. 111-6.

Galvin, E.C., Wills, T. and Coffey, A. (2017) Readiness for hospital discharge: A concept analysis. Journal of Advanced Nursing. 73(11), pp. 2547-2557.

Greenwood, K. and Oldmeadow, L. (2009). A 4-item falls-risk screening tool for sub-acute and residential care: The first step in falls prevention. Australasian Journal on Ageing, 28(3), pp. 139-143.

Gregory, J. and Richardson, C. (2014) The Use of Pain Assessment Tools in Clinical Practice: A Pilot Survey. Journal Pain Relief, 3(140). doi: 10.4172/2167-0846.1000140.

Heron, J. (2001) Helping the Client: A Creative Practical Guide. SAGE Publications. London.

Kennedy, C.J. (2017) What is person-centred care and can it be achieved in emergency departments? Emergency Nurse. 25(2), pp. 19-23.

Kenny, R. A., Romero-Ortuno, R. and Kumar, P. (2017) Falls in older adults. Medicine, 45(1), pp. 28–33.

McCormack, B. and McCance, T. (2016) Person-Centred Practice in Nursing and Health Care: Theory and Practice. John Wiley & Sons.

McCormack, B., Dulmen, S., Eide, H., Skovdahl, K. and Eide, T. (2017) Person-Centred Healthcare Research. John Wiley & Sons.

McHale, J. and Tingle, J. (2007). Law and Nursing. Elsevier Health Sciences. New York. United States.

Moore, L., Britten, N., Lydahl, D., Naldemirci, Ö., Elam, M. and Wolf, A. (2017) Barriers and facilitators to the implementation of person-centred care in different healthcare contexts. Scandinavian Journal of Caring Sciences. 31(4), pp. 662-673.

NICE Guidelines. (2012) Patient experience in adult NHS services: improving the experience of care for people using adult NHS services.  Retrieved from https://www.nice.org.uk/guidance on 04.12.2018.

NICE Guidelines. (2011) Patient experience in adult NHS services: improving the experience of care for people using adult NHS services.  Retrieved from https://www.nice.org.uk/guidance/cg124 on 04.12.2018.

NMC. (2015) Professional standards of practice and behaviour for nurses, midwives and nursing associates. Retrieved from https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf on 04.12.2018.

Rakatansky, H. (2013) Pain management: Considering the medical, legal aspects in patient care. Rhode Island Medical Journal. 99(4), pp. 10-1.

Ross, H., Tod, A.M. and Clarke, A. (2015) Understanding and achieving person-centred care: the nurse perspective. Journal of Clinical Nursing. 24(9-10), pp. 1223-33.

Stickley, T. (2011)  From SOLER to SURETY for effective non-verbal communication. Nurse Education in Practice, 11(6), pp. 395-8.

Ross, H., Cobb, M. and Bowen, S. (2017) Participatory design facilitates Person Centred Nursing in service improvement with older people: a secondary directed content analysis. Journal of Clinical Nursing. 26(9-10), pp. 1217-1225.

Thim, T., Krarup, N.H., Grove, E.L., Rohde, C.V. and Løfgren, B. (2012) Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine, 5, pp. 117-21.