Nursing Process And Assessment: A Case Study Of Mrs. Julie Frank

Situation and Background

Nursing process refers to the systematic procedure that is used by nursing professionals for ensuring appropriate quality of care that is delivered to patients. This approach takes into account the clinical judgment of nursing staff for striking a steadiness of epistemology between research evidence and personal interpretation of critical thinking. Nursing process is usually classified into different stages namely, the assessment phase, diagnosis phase, planning phase, implementation phase, and the evaluation phase (Yildirim & Ozkahraman, 2011). The nursing process has also been defined as an ongoing and a cyclical process that can culminate at any phase, if the clinical problem gets resolved. The nursing process has been found to exist for almost all kinds of physical and mental problem that are encountered by an individual, family, and the entire community. The process not only emphasises on methods to advance physical needs, but also elaborates on the emotional and social needs as well. Some of the key characteristics of the process are namely, (1) cyclic and dynamic nature, (2) client centred and goal directed, (3) collaborative and interpersonal, (4) systematic, and (5) universally applicable (George, 2011). This assignment will utilise a nursing process for elaborating on the case study of Mrs. Julie Frank and will provide adequate examples to elucidate on the ways by which all the components of the process can be put to use, for meeting the needs of the patient.

Nursing assessment refers to the process of collecting relevant information about the physiological, sociological, psychological, and spiritual condition of a client, and is usually performed by a registered nurse. This forms the first phase of a nursing process and encompass collection of data by conducting an interview of the client, besides undertaking a physical examination, taking references from the patient history, and noting down the general observations (Lewis et al., 2016). During the handover, upon finding Julie sitting up on her bed and clutching her chest tightly, it should be immediate noted that there lies a probable danger of Julie suffering from a heart attack and/or suffering an injury due to fall from the bed. These circumstances also have the capability of creating chaos and commotion among the other patients who are being offered care, along with this client, thus adding to their distress. The primary responsibility would be to make her seated in an appropriate position on the bed to prevent any injurious falls (Ward et al., 2015). Furthermore, the event requires taking assistance from a mentor RN as well. Her statements indicate the presence of an obstruction in the airways that have resulted in poor breathing (Bausewein & Simon, 2013). Furthermore, her vital signs were taken eight hours earlier. Thus, it would be difficult to ascertain the presence of any abnormality in her circulation and breathing from the previous records. Beginning with the focused assessment, it is imperative to assess and order her cardiovascular system, owing to the fact that she was found to clutch her chest. Her medical history suggests that Julie had previously suffered from hypertension, heart failure and hypercholesterolemia, and was currently being administered medications for the conditions. The pain in the chest and difficulty in breathing could serve as essential indicators for blockage in blood vessels, or other potential disease (Benetos et al., 2012).

Assessment Phase

Hence, the assessment should begin with evaluation of the cardiovascular system. Due to the fact that Julie is experiencing shortness of breath, and reported slightly increased respiratory rate and low levels of oxygen saturations at 2330 hours, conducting an assessment of the respiratory System is also crucial, with the purpose of identifying all the underlying factors that might have resulted in the abnormal breathing (Luctkar-Flude, Wilson-Keates & Larocque, 2012). Moreover, taking into consideration the fact that Julie underwent a hemicolectomy, a thorough assessment of her alimentary canal also needs to be conducted, for identifying potential complications and adverse effects of the surgery (Morris et al., 2011). Previous history of depressive symptoms and anxiety disorder also make it necessary to evaluate Julie’s neurological system. If left untreated, such underlying psychological and neurological conditions can lead to severe complications that have the potential of affecting different areas of life such as, physical, emotional, mental, and behavioural. These might also contribute to suicidal ideations and make a person more susceptible to cardiovascular diseases (Park et al., 2013). Neurological issues act as potential markers for presence of electrical, biochemical or structural abnormalities in the never, spinal cord and brain.

Moreover, Julie has a temporary stoma site and is also being subjected to wound dressing regularly. The most common complications that are associated with stoma include vascular compromise, improper sitting, peristomal irritation in the skin, retraction, fistula, and early postoperative bowel obstruction (Chen et al., 2011). Hence, Julie must be assessed for abnormalities in her cardiovascular, respiratory and digestive system. Julie is short of breath and reports pain in her chest. Thus, all efforts will be taken to frame the interview questions in a close-ended manner that will allow her to provide answers by simple ‘yes’, or ‘no’, and would not require much thought or analysis (Covell, Sidani & Ritchie, 2012). Some of the questions that I would ask, while assessing the cardiovascular system are as follows:

• Does anyone in your family have a history of heart disease?
• Do you show compliance to your medications on a regular basis?

Non-compliance to cardiovascular medications might have resulted in her condition. Furthermore, a family history of cardiovascular complications increases the likelihood of a person to suffer from angina, coronary heart disease, heart failure, heart attack and stroke (Mosca et al., 2011). Some of the questions related to her respiratory assessment would be the following:

• Did you experience shortness of breath in the past?
• Does anybody in your family have a history of asthma?

I would ask the following questions for assessing her hemicolectomy:

• Are you experiencing pain?
• Have you observed bleeding?

This will be followed by performing physical assessments. Rapport in nursing refers to the process of establishing emotional affinity with the clients, by demonstrating a feeling of harmony, empathy and responsiveness (Tremayne, 2014). This will act prove imperative in establishing an effective nurse-patient therapeutic relationship. Demonstrating respect and safeguarding the confidentiality of the client will be another essential step (O’lynn & Krautscheid, 2011). This will be achieved by respecting Julie’s privacy, both emotionally and physically. All the assessments will be conducted by taken her approval for the same. A pain assessment will also be conducted since Julie has been administered the semi-synthetic alkaloid, oxycodone.

Recommendation Phase

The ABC system primarily encompasses the process of patient prioritization and comprises of assigning each alphabet to a patient problem, depending on its severity.

Shortness of breath requires prioritisation in Julie. This condition commonly refers to circumstances referred to as dyspnoea that make it difficult for the air to enter into the lungs. Not only is this condition dangerous, but also acts as an indicator for hypoxia or hypoxemia. Furthermore, shortness of breath might also lead to a loss of consciousness in the patient (Kinjo, 2018). The fact that Julie had 92% Sp0₂ provide an indication for the need of supplemental oxygen. Tightness in the chest would be another patient priority. This condition most commonly occurs when the internal organs such as, the heart, thorax and oesophagus are affected. Besides, chest tightness is also attributed to an anxiety, stress, and abnormalities in the muscles and bone (Shen et al., 2013). Thus, efforts must be taken to address this condition, for preventing further cardiovascular problems. Abdominal pain and constipation due to hemicolectomy would be the third care priority. The procedure commonly involves removal of a segment of the human colon for treating obstructive bowel disease. Abdominal pain is associated with leaking of the bowel at the anastomosis, following the surgery, which in turn reduces mobility of the patient (Radhi, Ramsay & Boutross-Tadross, 2011). Furthermore, Julie is also anxious that she will not be able to care properly for her husband, who has been diagnosed with Alzheimer’s disease. Hence, addressing all the three care priorities would help in her easy recovery.

Supplemental oxygen- This medical treatment, also referred to as oxygen therapy is commonly administered on patients reporting carbon monoxide toxicity, cluster headache or low blood oxygen. Considering the fact that her oxygen levels are quite low (92%), a nasal cannula will be used for the purpose. The nasal cannula is a device that delivers external oxygen for increasing the airflow to a patient in want of respiratory aid. This device comprises of a lightweight pipe, which splits into two prongs that are inserted in the nostrils, from which oxygen and air flows (Sztrymf et al., 2012).  Most cannulae are able to deliver oxygen at low flow rates such as, 5L/min, at a concentration of 28–44%. Efforts will be taken to maintain the oxygen rates not more than 5L/min to prevent any discomfort or epistaxis to the patient (Peters, Holets & Gay, 2013). Furthermore, under hypoxic conditions, oxygen therapy has been found effective in reducing cell death and infection, thus maintaining tissue viability. Observation of a state of eupnoea in the patient, manifested by normal and unlaboured breathing will indicate absence shortness of breath, thereby proving efficacy of the intervention.

Prioritization of Patient Problems

Bronchodilators- These are substances that play an important role in dilating the bronchi and bronchioles, thus reducing resistance in the airways and increasing flow of air to the lungs. Formoterol or salmeterol like long-acting bronchodilators will be administered to Julie. These long-acting β adrenoceptor agonists, commonly known as LABA have been designed with the aim of treating asthma and relax the smooth muscles present in the lungs, thus promoting dilation of the airways (Beier & Beeh, 2011). Daily dosing of 12 mcg formoterol (1 inhalation) should be administered after every 12 hours. Frequent administration of the drug will not be followed in order to prevent complications of chills, cough, ear congestion, nasal congestion and fever (Halpin et al., 2011). Observing that Julie is able to breath with ease and has a normal respiratory rate will prove the effectiveness of the intervention.

Vital signs- The four vital signs of pulse rate, body temperature, respiratory rate, and blood pressure provide healthcare professionals with a clear understanding of any abnormality in the physiologic system of the body and provide an indication about the life-sustaining functions of the human body. Early warning scores have often been proposed by clinical guidelines, which have elaborated on the process of combining all individual values into one score. Evidences have also established the fact abnormal vital signs act as an indication of deterioration of patient health status and often precede cardiac problems and/or admission to ICU (Johnson et al., 2014). At 2330 hours, Julie manifested three deviations from her normal vital signs namely, a respiratory rate of 24, 92% Sp0₂, and slightly increased systolic pressure. Continuous monitoring of her vital signs at an interval of two hours is required. These will help in determining success of the interventions that are implemented on her. Presence of a respiratory rate of 12-20, and Sp0₂ above 95%, and blood pressure of 120/80 mmHg, will indicate that the interventions that have been administered have proved successful in managing her health.

Surgical wound- Surgical wounds refer to incision or cut that are made on the skin with the use of scalpel during a surgery. These wounds are found to vary in their size and also occur when a drain is placed in the region during the surgery. Owing to the fact that Julie has undergone hemicolectomy where a segment of her large intestine has been removed, proper care must be given to heal the surgical wound. To facilitate wound care, the principles of TIME will be employed in the case (Leaper et al., 2012). The framework encompasses different aspects of T (tissue), I (inflammation), M (moisture balance), E (edge of wound). Furthermore, evidences also suggest that a person might not be able to resume daily activities for weeks, after the surgery. Infections can worsen the condition and impede the recovery process. A cloth or gauze will be dipped in saline water, followed by dabbing or wiping the skin with it. All drainage and dried blood must be removed, which have built up on the skin surface (Halim, Khoo & Saad, 2012). Adoption of these procedures and observing negligible infection at the surgical site will indicate that Julie has recovered from the surgical complications. Her ability to move properly and conduct activities of daily living with little assistance will also serve as an evaluation method.

Pain management- Pain management is most commonly simple or complex and depends on the underlying factors that have resulted in the condition. It is caused due to surgery, injury, muscular pain, and damage of the nerves. Abdominal pain reported by Julie will be managed by administration of Butylscopolamine (Buscopan). Hyoscine butylbromide is a common drug prescribed for treating abdominal pain, bladder spasms, renal colic spasm, and oesophageal spasms (Ryu et al., 2013). This drug is a quaternary ammonium compound and is synthetically derived from hyoscine hydrobromide or scopolamine. Scopolamine butylbromide has been found to effectively bind to the muscarinic M3 receptors that are present in the gastrointestinal tract. This results in a prevention of the binding of acetycholine to its receptors (Falch et al., 2014). Thus, the receptors fail to get activated and inhibit contraction of smooth muscles. The contraction inhibition reduces the abdominal spasms and associated pain, during stomach cramping. Evaluation will be conducted with the use of the 11-point Numeric Rating Scale for determining whether the pain killer has been operative in reducing abdominal pain in Julie.

Dietary modifications- Stomach cramps and frequent diarrhoea are quite common after hemicolectomy. Eating the correct food after a bowel surgery is utmost essential to prevent dehydration. During the phase that involves healing of the colon from the surgery, all kinds of food that are easier to digest must be given to Julie, to help her recuperate from the condition. She will initially be given only intravenous fluids for providing the colon the adequate time to heal. This will be followed by a clear transition to a liquid diet. Some of the major dietary modifications that she will be made to adhere to include apple sauce, boiled white rice, bananas, peaches, melons, spinach, potatoes, low-sugar cereals, and yoghurt (Feroci et al., 2013). Further efforts will be taken to prevent her from consuming foods that have a risk of increasing infection and/or inflammation rates such as, non-pasteurized soft cheese, undercooked meat and uncooked fish. Making her consume smaller assortment of foods, at an interval of three hours will prove beneficial to her digestive system and also reduce her constipation. She will also be advised to drink more water. Observing a regain in her bowel patterns will indicate usefulness of the treatment.

Constipation treatment- This condition is characterised by changes in the digestive system that makes it difficult for a person to expel faecal matter. The condition most commonly occurs due to absorption of more water from food that has been consumed. Tumours in the rectum or colon also restrict the intestinal passage and cause constipation. Furthermore, administration of narcotic pain drugs like opioid might have also contributed to the condition. Julie will be prescribed Prucalopride (Resolor), a 5-HT₄ receptor agonist for normalising her bowel movement and reducing constipation. This dihydro-benzofuran-carboxamide is a high affinity, selective serotonin (5-HT₄) receptor agonist, and has enterokinetic activities (Ke et al., 2012). The drug changes the motility patterns of the colon, by stimulating the serotonin 5-HT₄ receptor, thus resulting in colonic mass movements. These have been found most effective in providing a propulsive force for excretion. Reports from Julie’s assessments that indicate absence of stomach ache or cramps, reduced bloated feelings, and gain in appetite will prove the usefulness of the treatment.

Discharge care planning- Discharge planning encompasses the process of involving the carer, patient, family and all staff who are involved in ensuring delivery of proper care to a patient for ensuring a smooth and safe release from the hospital, to home or residential care locations. Her friends and family will be asked to provide her help with the errands and chores, while she recovers from the surgery. She will be asked to walk on a regular basis, by gradually increasing the distance. She will be instructed not to lift any objects that are heavier than 10 pounds. She will be referred to occupational therapists who will assist her in mobility and also help her conduct the activities of daily living. Referrals for hand delivering meals such as, meal-on-wheels will be provided that will help her, her husband diagnosed with Alzheimer’s and their children get their adequate nutritional intake (Zhu & An, 2013).  Home health aide will also be sent to Julie’s home in order to provide care to her as well as her husband. She will be asked to seek consultation with a dementia specialist, the primary role of whom would be to keep her husband safe in the home setting. Trained caregivers will also facilitate Julie to care for herself, as well as her diseased husband. She will also be provided with certain bowel movement softeners that will prove effective in preventing further constipation in home settings. Blood thinners will also be prescribed in the discharge plan for preventing clot formation at the site of surgery. These clots might result in heart attacks, strokes and subsequent death. She will also be asked to watch for bruising or bleeding while showing compliance to the prescribed thinners (Agko et al., 2012).

Julie will also be asked to return to the hospital for tests or removal of the staples and/or stitches at the site of surgery. Her discharge plan will also include consultation with a dietician who will formulate a diet plan that has low fibre content and is easily digestible. She will also be asked to contact at the hospital if symptoms of fever, vomiting, burning sensation during urination, and pus appear. If she shows signs of recovery at her home, with due help from necessary support network and is also able to care for her husband, the intervention will be considered operational.

Conclusion

Thus, it can be concluded that primary assessment of a patient is imperative in initially examining the patient for recognising and managing all life-threatening conditions. Conducting the assessment of the patient Julie was essential in order to ascertain the triage. This component of the nursing process helps in assigning specific degrees of urgency to illness and/or wounds, thus providing assistance in determining the treatment that will be provided to the patient. Primary assessment is enormously significant in both non-emergency and emergency patient situations. Besides, the nursing process has been recognised as an exceedingly convenient tool that permits nursing staff to prioritise the care that is intended to be administered upon patients. The steps of nursing process have been implemented in the case of Mrs. Julie Frank throughout the assignment. This helped in prescribing different useful interventions in treating her signs and symptoms.

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