a critical study of a 100 year old

8/8/2019 A Critical Study of a 100 Year Old

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Implementation of the identied nursing care.The ongoing evaluation and nal conclusion ofthe care given.

The Roper, Logan and Tierney model

The Roper et al. (1980) nursing model is used atthe patients hospital as it is regarded as a generalmodel, adaptable to many areas and needs. Thestarting point for this model is the work of Abra-ham Maslow (1954) and his hierarchy of humanneeds, from the most basic to the most sophisti-cated. Maslow suggests that our basic biologicalrequirements (such as nutrition) must be met, be-fore we are able to satisfy higher psychologicalneeds.

The model is based on the theory that peopleare best understood by the activities of their lives(Aggleton and Chalmers, 2000 ), biological, socialand cultural. Some activities are essential and pri-marily biological in nature, while others are non-essential but enhance the quality of life. Theseneeds are therefore primarily social and psycholog-ical. This is a holistic view of the person and repre-sents a move away from the mechanisticperspective, of the traditional biologically centredmedical model ( Archibald, 2000 ).

The 12 activities of living identied by this mod-el are: maintaining a safe environment, communi-cating, breathing, eating and drinking,

eliminating, personal cleansing and dressing, con-trolling body temperature, mobilising, workingand playing, expressing sexuality, sleeping and -nally dying. Added to this concept are three com-ponents of nursing care based upon a balancebetween dependence and independence ( Kenwor-thy et al., 1996 ). The rst is the preventing compo-nent, here the object of nursing care is to prevent(or assist in preventing) a worsening of the pa-tients condition and the development of newproblems. The second component is that of thecomforting component, the object to provide andassist in physical, emotional and spiritual comfort.This component is difcult to dene as it is highlyindividualised relying heavily on the nurses inter-personal skills. The third and nal component isthe dependent component, this component recog-nises that the patient will be dependent upon thenursing staff for aid and it is this component thatrepresents the implementation of nursing care.

Although intended as a framework for caredelivery nursing models are often used as an assess-ment aid, with little inuence on the later stagesof the nursing process. The model is popular with

nurses and it is suggested this is because of itsresemblance to the medical systems model ( Archi-bald, 2000 ). There is a danger that any model usedmechanistically becomes mechanistic, as doeseventual care delivery.

The model is relevant to orthopaedic nursing asit recognises how injury can affect the patients

self-care ability ( Santy, 2005b ) in addition to themany serious medical complications. How the mod-el inuences care delivery, is best illustrated by abrief review of the care given. The factors thatthey inuence and are inuenced by, are broad inconcept and overlap.

Maintaining a safe environment

Due to the patients mild and intermittent confu-sion, an awareness of potential dangers to herwellbeing is vital. Care was taken that she couldmanage a hot drink and was supervised whenmobilising in the early stages of her stay. A fallsrisk assessment is carried out on all patientswithin this particular clinical area. She wasjudged to be of a high risk but was later reas-sessed as medium as her ability to mobiliseincreased.

Communicating

A two-way process in which the healthcare staffmust identify the patients needs using both verbaland non-verbal cues. Roper, Logan and Tierneyplace pain in this activity as the patient must ex-press their discomfort. Therefore, the alleviationof pain or the introduction of a coping mechanismis a nursing issue. Her pain was well controlled dur-ing her stay with no particular complaints beingmade post-operation, even with an unidentiedbroken arm.

Breathing

This also includes the cardiovascular system as awhole and several of the patients medical condi-

tions fall within this activity, including hyperten-sion, atrial brillation, anaemia and diabetes.The necessity of close observation is clearly re-quired in the early stages of care to prevent com-plications developing.

Eating and drinking

The patient was type II diabetic and therefore thechoice of correct menu was required. Her diabeteswas remarkably stable post-operation.

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Eliminating

The patient was occasionally incontinent, some-times doubly. Prior to her operation, she requiredcatheterisation but this was removed on the fourthday post-operation and incontinence pads pro-vided. She was by this time walking to the toilet

with a walking frame and the catheters removalgave her greater independence.

Personal cleansing and dressing

Due to her advanced age and her injury, the patientrequired assistance. Over a few short days how-ever, she was able to progress to washing her upperbody with less help. When assisting a patient withhygiene healthcare staff are in a privileged positionof intimacy, raising many issues regarding privacyand dignity. This time also affords an opportunityto inspect the patients skin integrity. It was whilstassisting with her morning wash that a suspicion ofthe injury to her right forearm came about.

Controlling body temperature

There is always a risk of potential infection follow-ing an operation and monitoring of the patientstemperature is necessary. The patient also re-ceived a blood transfusion peri-operatively andtherefore required close monitoring at that time.

Mobilising

The patient was able to walk on the second daypost-operation. Her walking distance and indepen-dence increased until she was able to walk to thetoilet without assistance, although she could notget in or out of bed or raise herself from a sittingposition without assistance. Increased mobility isdesirable, as it lessens the risk of complicationssuch as venous thromboembolism and aids therecovery of pressure areas.

Working and playingHer leisure interests centred around reading andwatching television. Her family, who visited daily,provided books and newspapers as necessary to re-lieve the boredom of her hospital stay.

Expressing sexuality

The use of the word sexuality within this contextcauses some confusion. This activity includes both

sexuality and gender issues relating to hygiene,self-image and self-awareness. Patients need toexpress individual and self-perceived needs relat-ing to hair, make up, washing and shaving (facialif male and lower limb if female). On one occasionafter bathing, her hair was put in curlers.

SleepingLack of sleep and sleeping in a strange environmentcan have detrimental effects upon an individualsmental state. Promoting good quality sleep andrest in hospital is difcult as the wards are alwaysbusy and very often noisy. Limiting the number ofvisitors to each bedside and monitoring noise levelscan help. Providing comfortable and the right num-ber of pillows may help. Unfortunately, there arestill difculties and, although necessary from ahealth and safety position, ward night lights donot promote rest.

Dying

People die everyday but an individual does not.However, a patient and his or her relatives mayhave concerns about the possible worsening of anillness. Patients with a terminal illness or the el-derly may live with the prospect of death andthe nurse should handle these concerns with care.The documentation of who to contact if the needarises should be made. In dealing with anxiety,the nurse may need to contact distant friends, aspiritual advisor or even a neighbour.

Roper, Logan and Tierney model withinorthopaedics

Many nursing models are unnecessarily compli-cated, yet the Roper Logan and Tierney nursingmodel may be regarded by some nurses as beingsimplistic. This is a mistaken view as the modelhas depth that will only become apparent with reg-ular use by the practitioner. This is particularlytrue when exploring the component factors relatedto dependency. Here it is for the practitioner touse their own judgement, as to when to step backand allow the patient to do more.

There is no ideal nursing model and in practice,the nurse may subconsciously use a combination ofmodels. Each nurse may carry their own nursingtheory or philosophy, in their head. The modelhas the balance of being relatively easy to becomefamiliar with, together with the depth to allowadaptation in variable settings.

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Balcombe (1994) with Davis and Lim attemptedto adapt the model to orthopaedics by placingthe patients desired health state at the centre ofnursing care; giving eleven areas for considerationwithin the assessment criteria; mental state, diet,self-concept, sleep and rest, breathing (and cardio-vascular state), home environment, pain, move-

ment (and mobility), behaviour, hygiene andaspirations.Davis (2005a) takes this one-step further by

adapting the activities of living model ( Roperet al., 1990 ) to orthopaedics. By centralising mobil-ising, the Davis model shares some characteris-tics of the Balcombe model. Incorporated into theDavis model are the activities of living from Roper,Logan and Tierney, together with the lifespan andthe dependenceindependence concepts fromthe same model.

The possible advantage of the Davis model isthat it recognises the value of other models andbuilds upon them. Added to the above is a self-empowerment framework, an area representingindividualised nursing that includes assessmentand nally an other category. This area calledfactors inuencing is the framework for factorsnot necessarily covered by the others.

By placing pain within communicating Roper, Lo-gan and Tierney give the impression that the activ-ity of communicating is something of a catch-all.Balcombe has the advantage of recognising theimportance of pain as a factor in its own rightand not merely as a sub-factor. Davis is honest en-

ough to have an other category and links pain tomobilising, as it is on movement that orthopaedicpatients tend to have most pain.

One possible way of combining all that is bestfrom the above models would be the continueduse and development of integrated care pathways.Care pathways are documentation and care plan-ning tools, following agreed guidelines and proto-cols while based upon evidence based practice(National Electronic Library for Health, 2004; San-ty, 2005b ). Care can be documented and any devi-ations recorded as a variance ( Bayliss and Salter,2004).The UK government has identied the useof the integrated care pathway as having signicantbenets to patient care ( Davis, 2005b ). However,less than fty percent of trusts actually use them(House of Commons, 2004 ). Each care pathwayshould be tailored around the unique needs of eachclinical area ( Bayliss and Salter, 2004 ), so recognis-ing their inherent speciality. A key feature of theDavis model, in being different from the Balcombemodel, is the recognition that orthopaedic nursingis a speciality and therefore deserves a specialisednursing model.

UK policy

There is today a wide spread professional and gov-ernment support for the concept of patient centredcare ( Price, 2004 ). Current thinking has a focus onbenchmarking and clinical governance. The aim isto provide a structured approach to the comparison

and improvement of clinical practice ( Bayliss andSalter, 2004; Burton, 2004 ).UK government policy directives provide the

structure for future planning in healthcare ( Martin,2001). There are a number that inuence currentthinking, including The NHS Plan ( DOH, 2000), var-ious National Service Frameworks and The Essenceof Care ( Parkin and Bullock, 2005 ).

It is generally accepted by many that age discrim-ination can and does exist within the UK NationalHealth Service ( DOH/SNMAC, 2001; Coombes, 2001and Kmietowicz, 2001 ). There is however, some dif-ference of opinion as to whether age discriminationis endemic or an aberration from normal practice.Forster (1993) quoted Eric Midwinter the formerdirector of the Centre for Policy on Ageing as saying,Discriminationby ageis asviciousas discriminationby race or sex and is not borne out by medical evi-dence. The suggestion is made that discriminationmay be unintentional and that health care profes-sionals are unaware that the older person can bene-t from many procedures.

The National Service Framework for Older Peo-ple (DOH, 2001a,b ) has been interpreted as a planto end age discrimination within the National

Health Service ( Kmietowicz, 2001 ). The objectiveof the NSF is to guarantee fair and equal care forthe older person. Concerns as to the differencesin care across the country were summed up byBowling (1999), who wrote of evidence of age beingused as a factor in health care provision and in theinvitation of joining screening programmes. All pa-tients have the right to be treated with dignity andrespect ( Williams et al., 1999 ) and this includes theright to privacy.

Standard six of the NSF is of relevance withinorthopaedic nursing, as it highlights preventativemeasures regarding falls. Research suggests thatthe strongest predictor of having an osteoporoticfracture, is having had a previous one ( Minnset al., 2004 ). Although it is important to preventthe rst fall, we must recognise that once a fallhas taken place, prevention of further falls isequally important.

Although it may be tempting to think that wherethe NSF for older people ends, the Essence of Care(DOH, 2001a,b ) begins, this is not strictly true. Forexample, both publications share the same originalyear of publication.

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Originally, the Essence of Care consisted of eightcore aspects considered crucial to the quality ofthe patients experience of care ( Bayliss and Salt-er, 2004 ). A ninth aspect was later added focusingon communication ( Burton, 2004; ModernisationAgency/DOH, 2003 ).

The nine patient focused benchmarks are:

Continence, bladder and bowel care.Personal and oral hygiene.Food and nutrition.Pressure ulcers.Privacy and dignity.Record keeping.Safety of patients with mental health needs inacute mental health and general hospitalsettings.Principles of self-care.Communication between patients, carers andhealthcare personnel.

Conclusion

The patient was well cared for and she made aremarkable recovery and was discharged, pain freeand mobile. The introduction of a change ofemphasis, such as a greater focus on mobilisingwithin the framework of care delivery, coupledwith the clearly set standards of the Essence ofCare, may yet prove benecial to our patients.The time has come for orthopaedic nursing to haveits own nursing model.

References

Aggleton, P., Chalmers, H., 2000. Nursing Models and NursingPractice, second ed. Palgrave, Basingstoke Hampshire (Firstpublished as: Nursing models and the nursing process (1986)Palgrave. Basingstoke Hampshire).

Andrews, C., Smith, J., 1992. Medical Nursing: A Concise NursingText, 11th ed. Bailliere Tindall, London.

Archibald, G., 2000. A post modern nursing model. NursingStandard 14 (34), 4042.

Balcombe, K., 1994. Using a nursing model: a model fororthopaedic nursing. In: Davis, P. (Ed.), Nursing the Ortho-paedic Patient. Churchill Livingstone, Edinburgh and London.

Bayliss, V., Salter, L., 2004. Pathways for evidence-basedcontinence care. Nursing Standard 19 (9), 4552.

Bowling, A., 1999. Ageism in cardiology. British Medical Journal319 (7221), 13531355.

Burton, F., 2004. Benchmarking and wound care in A& E. NursingStandard 18 (45), 6772.

Coombes, R., 2001. Same old story about elderly care. NursingTimes 97 (14), 12.

Davis, P.S., 2005a. Why move?. In: Kneale J., Davis, P. (Eds.),Orthopaedic and Trauma Nursing, 2nd ed. Churchill Living-stone, Edinburgh and London, pp. 76104.

Davis, P., 2005b. A critical exploration of practice improvementin orthopaedic nursing with reference to venous thrombo-

embolism prevention. Journal of Orthopaedic Nursing 8 (4),208214.

Department of Health, 2000. The NHS Plan, A plan for Invest-ment, A Plan for Reform. HMSO, London.

Department of Health Standing Nursing and Midwifery AdvisoryCommittee, 2001. Caring for older people: a nursing priority.In: Practice Guidance: Principles Standards and Indicators, AResource Tool. HMSO, London.

Department of Health, 2001a. National Service Framework forOlder People. HMSO, London.

Department of Health, 2001b. The Essence of Care. HMSO,London.

Doppelt, S.H., 1980. The sliding compression screw-todays bestanswer for stabilisation of intertrochanteric hip fractures.Orthopaedic Clinics of North America 11, 507523 (cited inHarrington et al. (2002)).

Fawcett, J., 1984. Analysis and Evaluation of Conceptual Modelsof Nursing. F.A. Davis, Philadelphia (cited in Kenworthy et al.(1996)).

Forster, P., 1993. The fortysomething barrier: medicine and agediscrimination. British Medical Journal 306 (6878), 637639.

Harrington, P., Nihal, A., Singhania, A.K., Howell, F.R., 2002.Intramedullary hip screw versus sliding hip screw for unstableintertrochanteric femoral fractures in the elderly. Injury 33(1), 2328.

House of Commons, 2004. Committee of Public Accounts: Hipreplacements an update. 17th report. HMSO, London (citedin Davis (2005b)).

Jacobs, R.R., McCain, O., Armstrong, H.J., 1980. Internalxation of intertrochanteric hip fractures: a clinical andbiomedical study. Clinical Orthopaedics 146, 6270 (cited inLorich et al. (2004)).

Jenson, J.S., Tondevold, E., Sonne-Holm, S., 1980. Stabletrochanteric fractures. A comparative analysis of four meth-ods of internal xation. Acta Orthopaedica Scandinavica 51,811816 (cited in Harrington et al. (2002)).

Kenworthy, N., Snowley, G., Gilling, C. (Eds.), 1996. CommonFoundation Studies in Nursing, 2nd ed. Churchill Livingstone,Edinburgh.

Kmietowicz, Z., 2001. Plan to end age discrimination in NHS islaunched. British Medical Journal 322 (7289), 751.

Koval, K.J., Zuckerman, J.D., 1998. Hip. In: Koval, K.J.,Zuckerman, J.D. (Eds.), Fractures in the Elderly. Lippincott,Philadelphia, USA, pp. 175192.

Kunkler, C.E., 2002. Fractures. In: Maher, A.B., Salmond, S.W.,Pellino, T.A. (Eds.), Orthopaedic Nursing, third ed. W.B.Saunders Company, Philadelphia, USA, pp. 609649.

Lorich, D.G., Geller, D.S., Nielson, J.H., 2004. Osterporoticpertrochanteric hip fractures: management and currentcontroversies. The Journal of Bone and Joint Surgery 86a(2), 398410.

Martin, V., 2001. Service planning and governance. NursingManagement 8 (2), 3236.

Maslow, A.H., 1954. Motivation and Personality. Harper andRow, New York (cited in Aggleton and Chalmers (2000)).

Minns, J., Dodd, C., Gardner, R., Bamford, J., Nabhani, F.,2004. Assessing the safety and effectiveness of hip protec-tors. Nursing Standard 18 (39), 3338.

Modernisation Agency/Department of Health, 2003. The Essenceof Care Patient-Focused Benchmarks for Clinical Gover-nance. HMSO, London.

National Electronic Library for Health, 2004. www.nelh.nhs.uk/carepathways/icp_about.asp (cited in Davis (2005b)).

Orem, D., 1971. Nursing: Concepts of Practice. McGraw-Hill,New York (cited in Aggleton, P., Chalmers, H., 1985. Modelsand theories ve: Orems self care model. Nursing Times2(January), 3639).

A critical study of a 100-year-old patient receiving a dynamic hip screw 183
http://www.nelh.nhs.uk/carepathways/icp_about.asphttp://www.nelh.nhs.uk/carepathways/icp_about.asphttp://www.nelh.nhs.uk/carepathways/icp_about.asphttp://www.nelh.nhs.uk/carepathways/icp_about.asp


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Parkin, C., Bullock, I., 2005. evidence-based health care:development and audit of a clinical standard for researchand its impact on an NHS trust. Journal of Clinical Nursing 14(4), 418425.

Pellino, T.A., Preston, M.A.S., Bell, N., Newton, M.J., Hansen,K., 2002. Complications of orthopaedic disorders and ortho-paedic surgery. In: Maher, A.B., Salmond, S.W., Pellino, T.A.(Eds.), Orthopaedic Nursing, third ed. W.B. Saunders, Phil-adelphia, USA.

Price, B., 2004. Demonstrating respect for patient dignity.Nursing Standard 19 (12), 4552.

Riehl, J., Roy, C., 1980. Conceptual Models for Nursing Practice,2nd. ed. Appleton-Century Crofts (cited in Aggleton, P.,Chalmers, H., 1984. Models and theories: dening the terms.Nursing Times 5(September), 2428).

Roper, N., Logan, W.W., Tierney, A.J., 1980. The Elements ofNursing: A Model for Nursing Based on a Model of Living.Churchill Livingstone, Edinburgh andLondon (cited in Aggleton,P., Chalmers, H., 1985. Models and theories Six: Ropersactivities of living model. Nursing Times (February13), 5961).

Roper, N., Logan, W.W., Tierney, A.J., 1990. The Elements ofNursing: A Model for Nursing Based on a Model of Living,third. ed. Churchill Livingstone, Edinburgh and London.

Santy, J., 2005a. Care of patients with lower limb injuries andconditions. In: Kneale, J., Davis, P. (Eds.), Orthopaedic and

Trauma Nursing, second ed. Churchill Livingstone, Edinburghand London, pp. 470494.

Santy, J., 2005b. Orthopaedic nursing theory and concepts. In:Kneale, J., Davis, P. (Eds.), Orthopaedic and Trauma Nurs-ing, second ed. Churchill Livingstone, Edinburgh and London,pp. 3146.

Schoen, D.C., 2000a. Care of a patient with hip and femoralsurgery. In: Schoen, D.C. (Ed.), Adult Orthopaedic Nursing.Lippincott, Philadelphia, USA, pp. 271315.

Schoen, D.C., 2000b. Musculoskeletal trauma, immobility andambulation. In: Schoen, D.C. (Ed.), Adult OrthopaedicNursing. Lippincott, Philadelphia, USA, pp. 85112.

Unwin, A., Jones, K., 1995. Fractures and other musculo-skeletal injuries. In: Unwin, A., Jones, K. (Eds.), EmergencyOrthopaedics and Trauma. Butterworth-Heinmann, Oxford,pp. 1336.

Walsh, M. (Ed.), 1997. Watsons Clinical Nursing and RelatedSciences, Fifth ed. Bailliere Tindall, London.

Williams, L.S., Shannon, P., Catalano, J., 1999. The nurse andthe health care system. In: Williams, L.S., Hopper, P.D.(Eds.), Understanding MedicalSurgical nursing. F.A. DavisCompany, Philadelphia, USA.

Williams, M.A., Oberst, M.T., Bjorklyund, B.C., 1994. Posthospital convalescence in older women with hip fracture.Orthopaedic Nursing 13 (4), 5564.

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