Throughout this piece the writer will discuss the fundamentals of nursing (primary,secondary and tertiary care) when assessing Mr Murphy who is a seventy two year old gentleman recently discharged home from hospital on oxygen, post an exacerbation of his chronic lung disease. The assessment setting takes place within the commuity where the comunity nurse plays a pivotal role in assessing both Mr Murphy and Mrs Murphy within their home. This is appropriate due to Mr Murphy not being the only person who will suffer from psychological and physical hardship during this time in life.
Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow obstruction worsening exercise performance, and contributes to general deterioration in health (Smith et al. 2008). When asssessing the patient on a local level, the implementation of care plans (primary, secondary and tertiary; including assessment and challenges), the continuous expansion in the role of the community nures, multi diciplinary team and the rationale for the use of the wellness/illness continuum is aslo discussed within the assignments (Telford 2006; Buswell (2000) cited in Porche 2004).
Utilising models by Hoeman community based rehabilitation nursing 1996 purple book seen in fig 1. 0, adaptation of Roach (2002): caring, the human mode of being in juxtapose with Barnhill’s system theoretical circular model of healthy family dynamics (Barnhill 1979) fig 2. 0 and an adaptation of Roper Logan and Tierneys model of nursing (2004) fig 3. 0/3. 1, the writer will begin to elaborate on each individual assessment stated above. Assessment Utilising an adaptation of Roper, Logan and tertiary model of nursing (2004) and other models of assessment including rehabilitation within the community and family dynamics.
The topics which the writer wishers to discuss are, rehabilitation into the community, maintaining a safe environment, care of the primary carer, breathing and oxygen therapy and anxiety. According to Chalmers (1992) and Appleton and Cowley (2008), assessing individuals within their community setting of the family home requires the ability to uncover needs and issues that are potentially harmful to the patient and strength of charactor to stimulate awareness of health needs of the individuals being assessed. When Mr Murphy is discharged into the community he and his family face rehabilitation into the community.
With the aid of Hoeman’s community based rehabilitation nursing 1996 purple book seen in fig 1. 0 the writer willl elaborate on the importance of rehabilitation into the community. Fig 1. 0 Adaptation of Roach 2002: caring, the human mode of being. Negotiate with client Caregiver to etsablish Goals and interventions To ada. t to changes The stressor in which Mr Murphy is suffering from is the degeneration of his lung capacity caused by lifestyle factors and or results from his past employment (Mc Kenzie et al. 2006).
Utilising the aid of health promotion staff (community health nurse and the multi diciplinary team), establishing a therapeutic coping mechanisms can be achieved. Such a coping mechanism may include, the patient and carer keeping a diary of events that have happened or exacerbated their conditions (Bandura 1986, Prochaska et al. 1992, Battersby et al 2003). By keeping a journal of events (Battersby et al. 2003), the community nurse and others health professionals can indentify issues that contribute to tachi-apnoea (rapid breathing) or dyspnoea (shortness of breath).
When the care is critically analysed in a holistic manner, and found to be ineffective, the community nurse can assist by modifying the current health promotion tools; for example, re-evaluating the topics discussed on the benefits of self care and importance of good inhaling techniques of pulmonary medications (Robinson et al. 2008). Although further empowerment and negotiation with the patient may be seen to work initially, the benefits will not last if the patient does not abide by the information given (Robinson et al. 2008).
Utilising the method of benchmarking or illness/wellness continuum (Kendall 2002) in juxtapose with community rehabilitation and health promotion, allows all involved parties to identify the compliance and effectiveness of the care being administered. Fig 2. 0 Adaptation of Roach 2002: caring, the human mode of being in juxtapose with Barnhill’s system theoretical circular model of healthy family dynamics (Barnhill 1979) According to Boykin and Schoenhofer (2006), the role of the community nurse is to educate individuals in a manner which encompasses the individuals continuous growth in a caring environment.
Due to exteral factors effecting individuals and families alike within societial dynamics, radical changes of family dynamics occur when a member is diagnosed with an illness, wheather self inflicted or not. When this occurs, role exchanges with in the family develop for example the bread earner becoming the dependant (Kelly and Symonds 2003). On assesment, the community nurse should encourage self management of their condition (Battersby et al. 2002), explaining the rationale through health promotion.
Through health promotion and encouragement to abide to the care plan provided the individual suffering from the degenerative disease can decrease levels of depresssion,frustration and dependancy on the primary carer/family (Williams 1994; Fraser et al. 2006 ) Elimination of unwanted data collection allows the assessor community nurse to focus on the environment in question (the family home/dynamics). The aim of the analyse, is to monitor the medical treatment and social status of the persons involved in order to re-evaluate care being administered. Shaw et al. 2010) highlight that, due to the lack of shared objectives, poor communications and hierarchical structures contributed to barriers (physical and psychological barriers), hindering the development of effective team working. With the aid of the activities of daily living (Roper, Logan and Tierney 2004), assessment tool the community nurse can highlight needs to be adressed as seen in fig 3. 0/3. 1. Fig 3. 0 Assessment of patient suffering fromm COPD in the community Adaptation of Roper, Logan and Tierney modelPrimary Care (assessment of care)Secondary Care (implementation of care)Tirtary Care (evaluation of care)
Illness/ Wellness Continuum. Education of O2 therapyAssessed/educated on assessmentRe-educated Technique improvingDiscussed and analysed Mobility in home environmentAssessed/educated on ambuation and 02 titrations. Restricted by anxietyAmbulation improving Discussed and encouraged Medication management/ thechniqueAssessed/education giveneducated/difficulty in technique skillsReassessed good technique Discussed Anxiety and sleepAnxiety reduces rest periodsEducated/anxiety persists No change Discussed Washing and dressing No issues No issuesReassessed no issues Not discussed
Nutrition/ hydrationGood intake of nutrition/fluidDietry intake assessedReassessed no isssues Not discussed Safe enviornmentNeeds for refurbishmentYes with difficultiesRequires OT review Awaiting assessment Fig 3. 1 Assessment of the primary carer in the community Adaptation of Roper, Logan and Tierney modelPrimary Care(assessment of care)Secondary Care(care implemented)Tirtary Care (reassessment of care)Illness/wellness continuum) Understanding O2 therapyAssessed/education given Re-educatedRetaining good knowlegdeDiscussed and analysed
MobilityRestrictedRestricted YesDiscussed Medication management/ thechniqueAssessd/Educated on the importanceReeducated with difficultyReassessed good knowledge Discussed Anxiety and sleepPresence of anxietyAnxiety persistsReassesssed Persistant Discussed Washing and dressing Independant No issuesReassessed no issues Not discussed Nutrition/ hydration Independant No issuesReassessed no isssues Not discussed Safe enviornmentNeeds for refurbishmentAssessment requiredOT assessed Awaiting feedback Maintaining a safe environment.
When discussing the concept of, transforming our public health service into one that services quintessential and holistic to both the economy and service users, public in a holistic there appears an abundance of barriers to be hurled (Turnock 2007). Due the ever rising cost of caring for patients suffering with chronic disease being gargantuan, a study by Gravil et al 1998(cited in hospital at home) found that, caring for patients in their home environment, post exacerbation of their chronic lung disease was seen to beneficial to all parties involved.
This finding was further backed by studies carried out by Ojoo et al. (2002) stating that the utilisation of hospital support systems from a home setting to be beneficial and more financially sound for both parties involved. A therapeutic relationship is of vital importance within community nursing. This relationship according to Grady (2007), implements a positive impact upon treatment with home care of patients suffering with chronic pulmonary diseases. According to Hare (2004), nursing within the community plays an imperative role in supporting both patient and carer in the community.
Ambulating is an innate yet a complex skill used in everyday life especially in patient whom is suffering with a chronic lung disease; increasing the fear of falling with patients suffering from this disorder is not uncommon. (Mode and Unsworth 2003) Falls in the older generation is continuously a topic of great discussion. According to Hess et al (2010), the task of ambulating requires additional effort for the older generation especially when these concerns are intrinsically merged with chronic lung disease.
According to Courtine and Schieppatin (2003) an ambulation and gait assessment within a home setting should be carried out by a member of the multi disciplinary team. The purpose of this is to assess the individuals’ ability not only to ambulate safely, but also focusing on the ability to walk around corners or around furniture. This system of assessment is known as the figure of eight walk test (Hess et al. 2010). Breathing, oxygen therapy and anxiety According to Rozenbaum (2008), dyspnoea is one of the most common symptoms of chronic pulmonary disease.
The exacerbation of the chronic lung disease has major impacts on the quality of life of all members of the family especially the primary carer Mrs Murphy. According to Rozenbaum (2008), ambulatory oxygen therapy is the favoured treatment concerning chronic pulmonary disease. Although mobile oxygen therapy improves the survival for patients with severe pulmonary diseases and decreases the incidences of repeat hospitalisation; it does come with potential hazards, such as possible inadequate oxygen titration leading to tachiapnoea in the patient (Dunne 2009).
According to Rozenbaum (2008), the incorrect use of medications, such as bronchodilators, have contributing factors in the exacerbation of chronic pulmonary disease. Health promotion by the community nurse plays a pivotal role in empowering both the patient and the family on the correct administration of all medication prescribed. The global initiative for chronic obstructive lung disease (GOLD 2006), provides transparent standards for the management of such exacerbations in a home setting.
On the initial assessment the community nurse should stringently address issues such as hypoxemia, oxygen administration levels and avoidance of external factors being present in the home, for example cigarette smoking ( Tarpy and Celli 1995). Care of the primary carer An early assessment by the community health team on the physical and mental status of the primary carer plays a vital role in supporting the individuals’ needs and encompasses the role of family support within the community. In society, the role of the community nurse also encompasses the role of the primary carers’ confidante (Hare 2004).
Encouraging breaks away from the caring role helps to destress the individual reducing the risk of burnout. Role of the community nurse According to Porche (2004) the role of the community health nurse is one of an organised and defined position, which empowers the community with information and support. This work force is educated and trained in the integration of scientific evidence through a social, biological, behavioural, and an epidemiological aspect when concerning the population. Florence Nightingale in the 1800s denoted nursing deals, little with disease but more with the maintenance of health.
Within the early years nursing mainly concentrated on the medical model, looking at just the medical issue in hand not being concerned with the individual or family in a holistic sense (Simpson et al. 2003). Health promotion was an unseen phenomenon along with the aspact of holistic care until the commencement of community health nursing (Tablot & Verrinder 2005). The level in which information is readily available on issues such as hygiene, the importance of immunisations or even nutritional values was an unspoken agenda until this time (Tablot & Verrinder 2005).
The importance of community health nursing within the community is an immeasurable asset to everyday life. Community nurses provide not only support and information to each one of their patients but also the knowing that there is a person there who has their best interests at heart (Kemp, Harris and Comino 2005). Due to daily admissions of people suffering from chronic pulmonary disease mounting further strain upon the health sector been put upon the medical sector, draining financial and human resources (Casas et al. 2006).
Not surprisingly, challenges and strains arise in abundance due to new cases of chronic long term illnesses being diagnosed within the health sector (Wong et al. 2005). In all aspacts of nursing the most commonly used nursing too of assessing an individual is the model of nursing designed by Roper Logan and Tierney model (2004). This tool encompasses a wide array of nursing disciplines including the role of the community, enabling nurses to evaluate the overall condition and health of the patient into consideration in order to prioritise needs regardless of the setting.
The use of care plans in modern day nursing provide nurses with a tool to which allows a set frame work of care to be abided by. As a result, care plans are a way to guide and continue the care that should be provided by the nurses. (Fundamentals of Nursing, 2005). Within society today, the role of the community nurse encompassses an array of different roles, including being of assistance to clients and their primary carers givers, families and at times being a personal confidante to primary carers easing their burden.
Also included in the community nurses scope of practice is delivering information on self-management of their illness and the benefits of self care in the comfort of their home environment (Van Loon 2007). In today’s society of diversity ,the role of the community nurse is ever expanding. Due to the mass change of international diversity through the world including Ireland it is important for the community nurse to understand that the diversity of cultures, beliefs and values influence each person differs from one person to the next when assessing them as a ppatient or client regardless of the social surroundings (De Crespigny et al. 004 Conclusion With the aid of selected frame works the writer of this assignment described the dynamics of society, family and the role of the community nurse as an advocate for both the health system and individuals which the system cateres for. For assessing Mr Murphy who is a seventy two year old gentleman recently discharged home from hospital on oxygen, post exacerbation of his chronic lung disease, an array of different nursing models were utilised.
The rationale for using frameworks was due to Mr Murphy not being the only person his condition was affecting for example Mrs Murphy the family and the medical system catering for his needs. The assessment setting takes place within the commuity when the comunity nurse plays a pivotal role in assessing both Mr Murphy and Mrs Murphy with in their home. Due to the safety concerns of Mr Murphy and Mrs Murphy in the community, a community health nurse is required to assess the needs of the patient(plan,implement,evaluate and re-evaluate assessment of care by empowerment and education) in their home environment.
