Nursing Assessment

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Element: Prevention of pressure ulcers

This essay is going to explore the nursing process with regard to the prevention of pressure ulcers. Pressure ulcers are a widespread and often underestimated health problem in the UK. They occur in 4-10% of patients admitted to hospital (Ward et al, 2010). This essay, using case study 4, will explore the holistic nursing process, and also the biological, sociological, psychological and ethical issues regarding the prevention of pressure ulcers. Lily is frightened due to her shortness of breath (dyspnoea), and as lying down exasperates her ability to breath effectively, has been sleeping in a chair. This is the primary concern of Lily. There has also been recent weight loss. The aim of any nursing interventions will be to improve Lily’s breathing and nutritional status; allowing her to mobilise more effectively and relieve pressure on her sacral area. Dyspnoea is a common and debilitating symptom of heart failure. Patients frequently become distressed and frightened by their breathlessness, which can worsen their symptoms (Currow et al, 2009). Any nursing interventions to improve Lily’s health and well-being will need to take into account the patients perspective of her health and what goals she wants to achieve. Collaboration and negotiation with the patient will help them identify their problems and/or goals (Field & Smith, 2008).

The nursing process is a structured, systematic approach to care, based on evidence and the individual needs of the patient (Holland K. 2008). There are four main stages to this process; assessment, planning, implementation and evaluation. When Lily is admitted to hospital she will be assessed to identify her health and social needs. The main aim of the assessment process is to identify problems then design a realistic plan of nursing care to meet the individual needs of the patient and improve their health status (RCN, 2004). This individualised assessment examines the patients’ current medical condition and identifies potential and actual problems affecting the patient (Hall & Ritchie, 2009). Through discussions with Lily, an understanding of her perspectives and needs will be gained. The primary source of information will come from Lily, and any other data will be a secondary source e.g. Lily’s GP. The nurse will also observe Lily to collect data during the assessment. Physical signs and a patients’ appearance can be observed. Touch can also give the nurse information. Temperature of skin, rate of pulse and signs of dehydration can be gained through touch (Brooker & Waugh, 2007). To ensure that the assessment is systematic and does not miss out anything, nursing frameworks (models) are often used. Models lead nurses to focus on a holistic assessment of the patients’ needs from the patients’ perspective, directing the nurse towards meeting the needs of the individual in a systematic and organized manner (Pridmore et al, 2010). The Roper-Logan-Tierney model is extensively used within the UK as a framework for nursing care and practice (Holland K, 2008). The model has been criticised for being too simplistic (Girot, 1990), although it could be argued that the simplicity has contributed to the popularity of the model (O’Connor, 2002). The nurse will use this framework to establish Lily’s ability to fulfil the Activities of Living (ALs) (Roper et al 2002), these include breathing, eating and drinking, mobilising and sleeping. Many aspects of ALs interlink. Lily’s worsening heart failure and dyspnoea are preventing Lily from sleeping in her bed, and may make it difficult for her to eat, drink and mobilise effectively. Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation (NICE, 2003). Causes of dyspnoea in heart failure include the inability of the weakened ventricle to...
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