The author presents a person-centred care (PCC) plan for Mr David McDermott. The case scenario has been chosen due to the interests of finding out how to develop a care plan in the community for a person who potentially is an alcohol dependent. The issues addressed in the care plan are pain, risk of falls and alcohol abuse.
Mr David McDermott is 70-year-old gentleman who suffers from worsening pain due to arthritis, and frequent episode of gout caused by drinking heavily. For further detail refer to appendix 1.
According to the NMC Code of Conduct as nurse or midwife maintain the confidentiality of the patient is an owe (NMC, 2015). Therefore the patient personal details cannot be shared without his/her consent. Since this case scenario is fictitious, the author did not change the name of the patient. However, if the personal details of the patient were real, in the interest of the patient’s confidentiality the author must have replaced them.
Before starting the care plan, the writer will explore the concept of PCC to provide a better understanding of the care plan created for Mr McDermot. PCC is defined as the delivering of individualised and respectful care using a holistic (bio-psychosocial-spiritual) approach that will enable to establish a therapeutic relationship between practitioner and service users by allowing the patient to be empowered in health decisions. (Morgan and Yoder,2012 p.8)
The author has ensured that the care plan is person centred by following the guiding values of people framework which are:
· Respecting Mr McDermott values and beliefs and listening and supporting him to express his needs ensuring that he feels comfortable expressing his feelings.
· Promoting autonomy and independence by aiding Mr McDermott participation in his care plan and decision-making.
· Including life experience of Mr McDermott to understand his needs based on his past and present life experience and his hope for the future.
· Understanding how important is a good relationship between the practitioner and Mr McDermott and his family to support the creation of a quality care plan.
· A responsive support which includes a regular contact between practitioner and Mr McDermott, regularly review of the care plan making adjustments if it is required, used a language that is understandable for McDermott and bespoke care service to meet McDermott outcomes. (Valuepeopleframework,2017 pp.19-29)
According to McCormack and McCancer PCC framework prerequisite, care environment, person centre and outcomes need to be account to provide an effective person-care to Mr. McDermott.
Prerequisite characteristic of a nurse which include being professional competence to analyse the best care option using a holistic approach. Having develop interpersonal skill which are the ability to communicate effectively using an appropriate language that is easy to understand for Mr McDermott. Commitment to the job which emphasis the dedication of proving the best care. Clarity of belief and values stand out the importance of nurses to keep away their own views when they are delivering care to avoid that nurses’ opinions influence Mr McDermott decisions. Moreover, knowing self to avoid that any emotional life experience of the nurse might influence the care provided to Mr McDermott. (McCormack and McCance, 2017 pp.42-47)
The care environment must contain an appropriate skill mix of staff with different backgrounds. A work environment that facilitate sharing decision and power within the team. A physical environment that provide privacy and dignity to patient and promote relaxation and healing. A supportive organisational system in which staff feel empowered by promoting initiative, creativity, freedom and safety among staff and potential for innovation and risk-taking.
Person-centre process is the delivering of care using a person-centred approach including values and belief of Mr McDermott in the care plan, sharing decision about his care plan, engaging with Mr McDermott to build up a trusty relationship, having sympathetic for the situation that Mr McDermott is going though and providing physical care if the person required.
Lastly, the outcomes expected from effective person-centred process are McDermott is satisfied with the care plan since he feels involved, also he is feeling wellbeing. Moreover, a therapeutic culture has been created based on making decision shared with patient and collaborative relationship among staff.
The writer respects the principles of McCormack and McCance however in the actual nursing climate they are totally unrealistic. Now NHS is suffering a staff crisis due to a short of 42000 nurses, midwives, physiotherapist and occupational therapist. Moreover, in the recent years the aging population has growth and created a high demand of care.( Denis Campbell,2017) Therefore, to achieve PCC in the actual work environment would be almost impossible, since nurses have many patient through the shift to take care and unfortunately it is difficult to focuses on person centred approach due to the short time that nurses can expend with a patient. To overcame this issue and achieve person centred more staff are required to delivered a care that fulfil all the principles of McCormack and McCance framework.
Moving on from the principles of PCC to be able to undertand what the patient needs the author will explain the principles of nursing process. The five steps that compromise the nursing process are assessment, diagnosis, plan, intervention and evaluation.
· Assessment is the stage in which nurse gather relevant information from the patient to identified needs or potential ones. It is a fundamental stage since all the care plan is built upon the assessment stage. Moreover, is an ongoing process since the nurse is continuously gathering information about the patient. There are many type of assessment depend on the context.
· Diagnose process where data from the patient is analyses and nurse develops a clinical judgment of patient’s actual and potential problems.
· Plan is the development of a goal for the actual problems prioritizing the one that need to be solve firstly. Furthermore, goals’ achievements are measured through implementation and evaluation stage. Goals must be SMART, which stand for specific, measurable, achievable, realistic and timed. Moreover, goals are decided with the patient, after negotiation making sure that they are person-centred.
· Implementation is the action plan to achieve the goals set in the care plan.
· Evaluation is the process in which goals are assessed to know whether has been met or not, therefore helps to evaluate the effectiveness of the intervention. (Catherine delves-yates,2015 pp.198-207)
The following care plan is related to pain managment; the author has assessed Mr McDermott pain using PQRST pain assessment tool, before to do the assessment the write has asked for consent to ask some questions to analyse his pain.
Association for Project Safety proposed PQRST mnemonic assessment to help clinician remember the element of the initial evaluation of patient pain. P stands for provocative which assesses the cause of pain. Q stands for quantity, assesses the quantity of pain the patient experiences. R stands for region, evaluates the location of pain. S stands for severity, determines the grade of pain. T stands for temporal which assesses the onset, course and fluctuation of pain. (B.McCarberg and S.Stanos,2008) The results from Mr McDermott PQRST assessment were the following:
P- Pain caused by worsening arthritis and frequent episode of gout.
Q- Burning pain that is persistent.
R- Joint ache, usually pain onset knees, however, pain onset toes during gout episode.
S- Pain scored 8 in NRS. Numeric rating scale(NRS) is used to assess pain intensity, the scale goes from 0 to 10, being 0 none pain, 1 to 3 mild pain, 4 to 6 moderate pain and 7 to 10 severe pain.
T- Daily pain that is sudden and gets worst at morning and night after the patient have walked during the day.
After analysed the data from PQRST assessment the diagnose is chronic pain mainly caused for worsening arthritis. The plan for Mr McDermott is to reduced pain to 2 in NRS scale within 48 hours and reassess using NR scale. Mr McDermott agreed with the set goal.
Moreover, the write has explained that chronic pain is a pain that last long than 6 months, it is caused by a disease or injury and continue when the cause has been treated. There are not remedies to cure chronic pain and can lead to depression due to the patient feeling restricted to do any life activity due to persistent pain. (Catherine delves-yates,2015 p.380). Mr McDermott is acknowledged what is chronic pain and understands that unfortunately cannot be cured but pain can be managed in order that cannot interfere in his life activities.
Before to discuss the intervention, the write has asked what method Mr McDermott uses to cope with the pain, he answered that he takes paracetamol, he added that paracetamol does not work and he is in a lot of pain.
After discussing some treatments to combat pain with Mr McDermott the intervention chosen is the following. The no pharmacological intervention is to apply alternatively cold and warm bags on the pain areas. Heat increases blood flow to the painful areas and relaxes muscles, cold lower swelling of the joints by constricting blood vessel. To manage pain, apply 2 to 3 times a day for 15 minutes heat, equally apply cold until pain and swelling has been lessen. ( Foltz-Gray D. …….,p.71)
Moreover, the write has encouraged Mr McDermott to get distract so it will help to focus on pleasant sensation instead of pain. (Catherine delves-yates,2015 p.391) Mr McDermott said that he enjoyed listening music so he will use it as a pain distraction when he feels a lot of pain.
The pharmacological intervention is prescribed anti-inflammatory drugs. Prostaglandins are hormones that causes inflammation of the joint, anti-inflammatory drugs limit the production of this substance reducing pain, swelling and stiffness of the joints (Tammi L. , M.D. Shlotzhauer
and James L. , M.D. McGuire,2003 p.136)
After 48 hours Mr McDermott has been reassessed, he stated that his pain has been reduced to 1 in NR. He is very satisfied with cold and warm therapy and listening to music; however, he is very concerned with the medical intervention since he does not want to rely on drugs every day to reduce pain. Therefore, the writer has suggested to Mr McDermott to stop to take medication and just take anti-inflammatory drug when they pain is unbearable.
The second potential problem identified was risk of fall, Mr McDermott has recently fallen over and has suffered a large cut on his head and leg. Moreover, Mr McDermott drinking habits are another potential factor for falling. A study conducted in Auckland (New Zealand) among working-age adults has identified that drinking 6 hours previously has a strong relationship with unintentional falls at home. (B. Kool,2008)
The author has assessed Mr McDermott using Fall risk assessment tool (FRAT). FRAT is divided in three sections: risk screen assessment, risk factor checks list and action plan to prevent falls. (Peninsula Health,1999) The scored from the risk screen was 13 which stand for medium risk of falls. The diagnosed for Mr McDermott is medium risk of fall and the plan is to minimize potential risk within two weeks.
The writer has used factor checklist and action plan section from FRAT as a framework to developed his intervention. To valorised accurately the potential risk the author has asked Mr McDermott if his wife could participate in filling up the check list, he agreed.
The factor considered as a potential risk of falls were:
-Impaired mobility due to Mr McDermott stated worsening arthritis and struggling to mobilised with walking stick.
– Miss McDermott reported that his husband is confused and disorientated most of the time since he drinks heavily.
-Mr McDermott reported trouble getting to the bedroom through the stairs.
-The write observed an unsafe footwear in Mr McDermott.
After shared decision-making with Mr McDermott the intervention to minimize risk of falls were the following.
A referral to a physiotherapist to assess his mobility and prescribe a proper walking aid.
A referral to an occupational therapist to evaluate any hazard in Mr McDermott’s house.
The write has suggested Mr McDermott to do some strength and balance training and has explained the benefit of it. These exercises allow the body to learn the correct response to maintain balance by doing a set of exercises that mimic change in balance experiences in everyday life. (The journal on active aging,2003) Mr McDermott was interested to do this training and the writer has found a programme nearby Mr McDermott house.
Lastly, a proper footwear has been advised to wear to prevent falls due to slippery. Regarding confusion and disorientation due to drinking problem the next care plan will address this issue.
The evaluation after two weeks of intervention was a success, Mr McDermott stated that after the physiotherapist has prescribed him with a Zimmer frame he feels more safe and confident when he walks. Moreover, he is very satisfied with the strength and balance training and he added that the training is even helping with his arthritis.
The last care plan is about alcohol abuse, the subjective data gathered from the case scenario is the following:
Ø Lost job because of drinking.
Ø Morose behaviour.
Ø Aggressive shouting and violent outburst toward his wife.
Ø A frequent episode of gout due to heavy drinking.
Ø Memory loss and recent fall.
The author has assessed his drinking problem using Alcohol use disorder identify test(AUDIT) which is an assessment tool developed by World Health organisation(WHO) to help health practitioner and other health setting to identify excessive drinking and its cause. (WHO ….p4)
Before to run AUDIT, consent has been gained from Mr McDermott also an explanation regarding what this assessment is for has been provided. The result from AUDIT was hazardous drinker due to scoring 10/20 in the test.
The diagnosed for Mr McDermott is hazardous drinker evidenced by AUDIT scoring 10 and the subjective data which indicated symptoms of drinking heavily. Aggressive behaviour, the risk of fall, memory lost and depression are some of the effects of drinking heavily. (…..)
The author has explained Mr McDermott diagnosed and the impact of alcohol on his wellbeing if he carries on drinking. He is aware of the side effect and is willing to stop drinking. After a discussion with Mr McDermott a set goal and intervention were decided. The goal is to cease drinking within a month and visit Mr McDermott within two weeks to check if the intervention is effective. Mr McDermott is motivated by the plan however he is very concerned about failure due to withdrawal symptoms.
A hazardous drinker who has gone through withdrawal symptoms are more prone to experience the side effect of ceasing alcohol intake. Withdrawals can be either physical such as a headache, nausea, vomiting or sweating and psychological such as irritability, agitation, fatigue or anxiety. (G. Hussein Rassool,2011 p p58-60).
The pharmacological intervention is a referral to a doctor to prescriber some medication to aid with the withdrawal symptoms. During alcohol detoxification patients suffer from withdrawal symptoms that can last for five days. Therefore, pharmacologic intervention through the process help to relief those signs. (G. Hussein Rassool,2011 p.62).
The no pharmacological intervention is to suggest Mr McDermott to join a Cognitive Behavioural therapy (CBT) for problem drinking, he has agreed to star the treatment. CBT teach people with drinking problems how to control the response to the stimulus of drink through improving social coping and problem-solving skills. (G. Hussein Rassool,2011 p.64).
After two weeks, Mr McDermott stated that he did not drink and the medication prescribed to treat withdrawal symptom is helping him a lot. Also, he added that the CBT is very helpful and is teaching him many techniques to cope with the desire to drink. Further, his wife said that he does not have any violent outburst and he is less morose and forgetful. Therefore, the intervention so far has been achieved.
After the care plan has been achieved successfully the writer will board the discharge planning.
Community Care Act 2003 states that NHS body should communicate community care service prior to the discharge if the patient is unlike to be safe to discharged.
The writer has used NHS Continuing Healthcare Needs Checklist as a tool to referral Mr McDermott for a full assessment for NHS continuing healthcare. Mr McDermott and his wife were acknowledged that a referral to NHS continuing healthcare services does not mean that he will be eligible to get a package of care. Before to complete the checklist, consent has been gained.
The write has explained the checklist and has offered Mr McDermott to have a representative present when the checklist was complete to advocate in his behalf. Moreover, Mr McDermott was involved during the completion of the checklist. (Department of Health,2012 pp5-15)
For an example of the Checklist refer to appendix ….
Unfortunately, Mr McDermott was not eligible for NHS continuing healthcare service, the writer provided the documented which explained why his application was not successful. Mr McDermott understood the reasons about the rejection of his application.
The author has suggested Mr McDermott and his wife to employee a cleaner to help them with the house, they agreed since they said that they are struggling mostly with household choices and they can afford to pay a cleaner.
Since Mr McDermott is medically fit, the writer has discharged him. However, the write has suggested Mr McDermott to go to the GP if his pain is unbearable using the techniques provided. Moreover, the author has recommended to join Alcoholic Anonymous group so he can share his experience and meet people with the same issue.
In conclusion, the essay has helped the author to have a better understanding of the concept of PCC by appraising how important is to knowing patient belief, values or life experiences and including patients in any decision to their care plan. Also, supporting them to express any feeling making them feel listened and keeping an ongoing evaluation of the care plan ensuring that meet patient’s needs.
Moreover, through applying the nursing process to the care plan made, the author has learned how to assess a patient using assessment tools, how to set SMART goals and find innervations to solve the problem identified.
Lastly, through Mr McDermott care plan the author has found out how to create a care plan for a person who has problems with alcohol and has gotten to know AUDIT assessment and some interesting interventions use to stop drinking. Also, the author has learnt some techniques to reduce pain that does not involve any drugs. Furthermore, the author has found very interesting strength and balance training which used as an action plan for treating the risk of fall.
Therefore, in the future when the write should make a nursing care plan will keep on mind that PCC is core principle to develop a care plan which fulfils the needs service .Also the author will follow the stage of ADPIE nursing process,