This essay is an episode of care analysis that aims to discuss the role of adult nurses in the assessment and planning of care. It also highlights how clinical decisions and interventions are influenced by the assessment of patients in healthcare settings, including how various types of knowledge are utilized in making clinical decisions and care plans for such patients. The analysis is based on a case scenario of a 60-year-old female patient who transferred from a nursing home and was admitted to the placement facility for colonoscopy, management of her type 2 diabetes, and hypertension. At the time of admission, the patient had symptoms of a high glucose level of 240mg/dl, high blood pressure of 145/85mmHg, bowel incontinence, and imbalance in nutrition, as exhibited by episodes of constipation and diarrhea, including being fatigued and weak.
In line with the Nursing and Midwifery Council (NMC) code of practice on upholding patients’ privacy during nursing care, the patient will be referred to as Mrs. J (NMC, 2018). For the episode of care analysis, the essay will focus on a twenty-four-hour shift care process that aimed at managing the problem of bowel incontinence and imbalanced nutrition for Mrs. J. Since the patient was not critically ill, Mrs. J was evaluated based on the Activities of Daily Living (ADL) assessment tool to determine the level of care she needed. For this care shift, the goal was to ensure that the patient had a regular bowel movement and regained strength within the twenty-four hours of the care process.
Considering that Mrs. J was diabetic, her bowel incontinence problem was likely caused by the medical condition. Type 2 diabetes is a chronic condition that affects the body’s ability to use insulin properly, resulting in elevated blood sugar levels (Benson et al., 2019). The medical condition may result in chronic kidney disease, nerve damage, and decreased blood flow to the intestines. These effects can cause a disruption in the nerves and muscles of the bowels, causing problems with the digestive process and leading to bowel incontinence (Bharucha et al., 2022). The high blood sugar levels can also damage the nerves in the large intestine, making it difficult for the muscles to contract and relax as needed for proper elimination, which consequently results in loose stools, incontinence, and constipation.
Besides, some medications used in diabetes treatment, like Metformin, can also affect the nerves that control the rectal muscles, resulting in decreased rectal tone and decreased control of bowel movements contributing to constipation (Liu, Xie, and Or, 2020). This reaction was evident with Mrs. J, who, at the beginning of the care process, had difficulties with her bowel movement, as observed through the stool chart. The patient recorded no bowel action for about four hours, between 2pm and 6pm; when given a solution of the Laxido orange and Dulcolax Laxative, she recorded a small hard stool indicating that she was constipating. Two hours later, the patient’s stool became watery, with increased frequency of bowel movement, indicating that she was experiencing incontinence. Hence, there was a need for the patient to undergo a colonoscopy to determine the exact cause of the bowel symptoms.
Nurses generally play an important role in the healthcare provision of patients admitted to hospitals and care homes. They act as the main liaison between physicians and patients by assessing and updating patients’ current status, which helps physicians and other healthcare practitioners to take necessary actions (Lawler et al., 2019). According to the National Institute for Health and Care Excellence (NICE), nursing is an evidence-based practice (EBP) profession guided by a five-step care process that entails assessment, diagnosis, planning, implementation, and evaluation (NICE, 2019). The primary functions of a nurse are to identify patients’ needs and develop an appropriate care plan that meets such needs. At the initial assessment stage, the point of admission, nurses are mandated to evaluate both objective and subjective data of a patient prior to the commencement of their treatment (Colley et al., 2023). Objective data include information on physiological processes such as blood pressure, temperature, and blood sugar test. In the case of Mrs. J, the patient’s blood sugar and pressure were tested, having recorded a medical history of hypertension and diabetes.
As dictated by the NMC, a nursing process in healthcare facilities aims at offering patient-centered care to ensure that the patients obtain healthcare services that align with their needs (Musuuza et al., 2020). Considering that various health and social care service seekers have varying needs, which may be influenced by factors such as gender, religion, or culture, nurses have a duty to determine the care process by involving the patients directly or through their dependents. This approach ensures that all the steps undertaken in the care process do not infringe on the patient’s rights to privacy and confidentiality as required by the code of practice (Cheng et al., 2019). Besides, the systematic nature of the nursing process, which is iterative in nature, ensures that patients’ needs are met holistically for better healthcare outcomes. According to the Care Quality Commission (CQC), evaluation of nursing interventions implemented for various patients is essential in ensuring that patients are getting the right medical care based on their physiological and sociopsychological needs (Correia et al., 2019). Therefore, conducting routine assessments is essential in ensuring that such needs are met from time to time.
Nurses have the liberty to adopt various assessment frameworks depending on a patient’s care needs at the time of admission. For patients who are critically ill such as victims of accident, the ABCDE assessment model could be used to manage their life-threatening condition based on the hierarchy of their needs (Siegel et al., 2020). For patients who are not in critical conditions, which could be life-threatening, but unable to perform their activities independently, the nurses could adopt the ADL assessment model to meet the nursing care needs for such patients. In the case scenario, Mrs. J was assessed based on the ADL model since she was admitted for a colonoscopy and management of her hypertension and diabetes, which were not life-threatening (Cheng et al., 2019). However, she was unable to perform her duties normally due to her symptoms,had episodes of bowel incontinence, constipation, and abdominal distention. The patient was also fatigued and weak but was breathing normally and conscious. Thus, the ADL assessment framework was appropriate in developing a care plan that would ensure the patient is stable and able to perform her activities of daily living, such as dressing, eating, and bathing (Garcia-Molina et al., 2020).
Following the ADL assessment at the beginning of the shift, it was established that Mrs. J was generally sluggish and fatigued. Physical observation of the body showed that she had pale and dry skin with dull and brittle hair, including a swollen red tongue. Besides, the patient had decreased attention span, which was associated with poor nutrition. Her referral sheet from the nursing home indicated that Mrs. J had not emptied her bowel for the last two days, having been given Pepto Bismol medication following an episode of diarrhea that lasted for two days. Mrs J, the single parent, was taken to the nursing home by her 28-old daughter living and working in a nearby town after she complained of experiencing an episode of incontinence that would see her involuntarily urinate or defecate on herself.
She noticed this symptom two weeks before her admission to the nursing home and often felt embarrassed before she shared the problem with her only daughter, who took her to the nursing home. This symptom indicated that the patient had a bowel incontinence problem, which may have been caused by her diabetes or the medication for the health problem (Nikitara et al., 2019). Thus, based on the assessment, the two nursing problems identified were bowel incontinence and imbalanced nutrition. For the incontinence problem, the nursing goal was to ensure that the patient attained a regular bowel movement pattern within twenty-four of nursing care before being subjected to a colonoscopy procedure. For the imbalanced nutrition problem, the nursing care objective was to ensure that the patient regains energy and is able to move independently within the twenty-four hours of nursing care.
Based on this assessment, a patient-centered care plan, in line with NICE requirements on EBP, was developed to help stabilize the patient before she was subject to the coloscopy test, which would determine the cause of her bowel symptoms (NICE, 2019). As indicated under the NMC code of practice, the Mrs. J was involved in the planning of care through a consultative process in which she was given various options in managing her managing her incontinence. The patient was given the option of removing fecal impaction manually or through nutritional and laxative medication which she chose the latter (NMC, 2018). Upon seeking her consent, the patient was fed green peas, bananas, and 8-ounce glass of prune juice at the beginning of the shift, at 2pm, to help relieve her constipation. Green peas and ripe bananas are good sources of fiber, which help in stool bulk, softens stool, and promotes regularity (Gröndahl et al., 2019). On the other hand, prune juice is a natural laxative due to its high concentration of sorbitol, which helps to draw water into the intestines to soften the stool, which helps in relieving constipation (Kerr et al., 2019). However, the patient did not record any bowel movement, and two hours later, at 6pm, he was given 1 sachet solution of Laxido orange and 15mg of Dulcolax laxative taken orally with a lot of water.
Laxido Orange is a type of osmotic laxative that works by drawing water into the intestines and increasing the amount of stool produced. This working mechanism helps to soften and bulk up the stool, making it easier to pass. By contrast, Dulcolax is a stimulant laxative that works by stimulating the muscles in the intestines to help speed up the passage of stool. When taken together, these two laxatives help to provide faster relief from constipation and abdominal distention (Calabrese et al., 2023). This intervention enabled the patient to initially record a small hard stool, and after another three hours, at 9pm, she recorded a soft, medium stool. The patient was further given more fiber-rich food, including broccoli and black peas, with an 8-ounce glass of Apple juice, which made her record a large loose stool at 12am midnight. Like green peas and ripe bananas, Broccoli and black peas are both high in fiber, which helps to promote regularity and reduce constipation. Fiber helps to add bulk to stool, which helps to move food through the digestive tract more quickly. Additionally, both broccoli and black peas are high in water content, which helps to soften stool and promote healthy digestion (Hämel et al., 2019).
Nonetheless, at 7am, the following morning of the nursing care shift, the patient started recording watery stool, which came involuntarily, indicating that Mrs. J was still experiencing episodes of incontinence as exhibited by the diarrhea. The patient was left for observation for about two hours, until 10am, during which she was not given any medication but was cleaned and washed around the perineal area with soap and water and glycerin applied. As required by the NMC code privacy, the patient was cleaned in a private secluded area in the ward, during which the curtains were closed to ensure her privacy (NMC, 2018). However, when the diarrhea persisted, Mrs. J was given an oral liquid dose of 30ml Kaopectate medication to help control the diarrhea. The medication works by coating the stomach and intestines to reduce the symptoms of diarrhea, nausea, and heartburn (Siegel et al., 2020).
Kaopectate also contains bismuth subsalicylate, which helps reduce inflammation in the stomach and intestines. The active ingredients in Kaopectate work to relieve these symptoms by reducing the amount of excess water in the intestines and stomach while also helping to reduce inflammation. Kaopectate also contains ingredients to help reduce symptoms associated with stomach upset, such as cramping and bloating (Berke et al., 2019). Consequently, upon being given the medication and the nutritional support, the patient’s bowel movement was stabilized, as observed between 12 noon to 2pm when the shift ended. The patient was then prepared for the coloscopy procedure, which would further determine the cause of her bowel symptoms for which she was admitted at the facility. According to the National Health Service (NHS) guidelines on clinical interventions, symptom control is a crucial aspect of the care process as it ensures that a patient is stable enough to undergo further medical procedures for holistic healthcare delivery (Hailu, Moen, and Hjortdahl, 2019).
In dealing with the problem of nutrition imbalance, the Mrs.J’s glucose level was constantly evaluated to determine the appropriate food for her medical condition at every given moment. Diabetes UK, a charity organization targeting people living with diabetes in the UK, diet assessment is an important part of diabetes management. Eating a healthy and balanced diet is a key part of managing diabetes which reduces the risk of diabetes-related complications. Diet assessment ideally helps to identify any nutritional deficiencies or imbalances that may be contributing to the individual’s diabetes symptoms (Siegel et al., 2020). This also helps to identify any foods that may be causing blood sugar spikes or other problems. Additionally, diet assessment provides an individual with personalized advice on how to plan meals that are both healthy and tasty (Tamura et al., 2020). This can help individuals make better food choices and be more successful in achieving their diabetes management goals. Thus, in dealing with her nutritional problem, Mrs. J was first engaged in conversation to determine her diet at home, which would inform the clinical decision and the most appropriate food to reverse her nutritional problem (NMC, 2018). The assessment showed that the patient had limited vegetable intake in her diet, which was the probable cause for her nutritional problem.
On the first day of the nursing care shift, Mrs. J was given a snack of 1 small pear and 1 low-fat cheese stick at 3pm. Pears are a nutritious, diabetes-friendly fruit that is rich in dietary fiber, vitamins, minerals, and antioxidants. The fruit has high fiber content that helps in slowing the digestion of carbohydrates, which can help to regulate blood sugar levels (Wranik et al. 2019). Besides, pears have a low glycemic index, which implies that they will not cause large spikes in blood sugar. Additionally, pears are a good source of essential vitamins such as vitamin C, vitamin K, and potassium. The antioxidant elements in the fruit may help to reduce inflammation and improve overall health (McLendon, Wood and Stanley, 2019). An FSBG test of the patient’s blood glucose level at 3.30pm showed 140mg/dl, which was a normal range, and the patient was given a glass of water. Subsequently, at 18:00. The patient was served with dinner that included backed salmon, 1 cup of steamed asparagus, and ½ cup of brown rice, and 1 glass of water. At 18:30, Mrs. J recorded an FSBG test of 150mg/dl (slightly off the normal range). Therefore, the patient was given a 1000mg dosage of Glucophage taken orally for the day. Glucophage, or Metformin, is a medication used to treat type 2 diabetes. It works by decreasing the amount of sugar produced by the liver and increasing the body’s sensitivity to insulin, which helps the body use insulin more effectively. Glucophage also decreases the amount of sugar absorbed from food and helps the body to use stored fat for energy (Suzuki et al., 2021). By decreasing the amount of sugar released into the bloodstream, it helps to keep blood sugar levels in a normal range.
At night, before Mrs. J slept, she was given a snack of 1 small banana and 1 tablespoon of almond butter. The patient was given a banana to help in improving her digestion and almond butter which is a good source of healthy fats and proteins. Almonds are also a good source of magnesium, which can help lower blood pressure and improve insulin sensitivity (Siegel et al., 2020). Moreover, the almond butter is high in dietary fiber, which can help keep blood sugar levels stable. In the morning, at 7:30 am, which is the second day of the shift, Mrs J. was served with breakfast that included 1 cup of oatmeal with a tablespoon of peanut butter, 1 small apple, and 1 cup of back coffee. Oatmeal is a great breakfast option for diabetics, as it is high in fiber and low in the glycemic index. Eating fiber-rich foods such as oatmeal can help diabetics keep their blood sugar levels more stable since it digests slowly. The fiber in oatmeal also helps to slow down digestion, which helps to prevent rapid spikes in blood sugar levels (Whicher, O’Neill and Holt, 2020).
At 12:30 noon, the patient was served lunch that included 1 cup of mixed fermented vegetables (cauliflower, carrot, broccoli). Mrs J was also served with small baked sweet potato and a piece of grilled chicken breast, including 1 glass of water. Fermented vegetables are a rich source of probiotics that help control blood sugar levels and improve digestion. Probiotics are beneficial bacteria that live in the gut and can help regulate the absorption of sugar, making it easier for the body to process and absorb (Cheng et al., 2019). During this nutritional intervention, the patient was given a glass of water at an interval of 2 hours to enhance skin hydration. Consequently, at the time of handing over, at 2pm, the patient had significantly improved and was able to move around independently.
Overall, the nursing care activity for Mrs. J was a fascinating experience since clinical interventions that were based on the patient’s assessment were achieved. For this nursing care shift, the nursing problem of bowel incontinence and imbalanced nutrition was solved through medical and nutritional interventions. The NHS requires medical practitioners, which includes nurses, to offer care that is patient-centered and based on EBP. This mandate necessitates that health practitioners constantly asses patients’ needs and act accordingly while engaging them or their home caregivers on the significance of proposed interventions for better healthcare outcomes. The case scenario was based on clinical guidelines set by the NHS, and regulatory authorities like the NMC, CQC, and NICE. The nurses involved applied various clinical knowledge to ensure that the patient’s care needs were met before she would be subject to the colonoscopy test that would further determine problems associated with her bowel symptoms. Thus, at the end of the twenty-four hours shift, the patient had significant improvement, including having the energy to do her ADL independently, indicating that the nursing care goals were achieved.
References
Benson, G.A., Sidebottom, A., Hayes, J., Miedema, M.D., Boucher, J., Vacquier, M., Sillah, A., Gamam, S. and VanWormer, J.J., 2019. Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) telemedicine randomized controlled trial on diabetes optimal care outcomes in patients with type 2 diabetes. Journal of the Academy of Nutrition and Dietetics, 119(4), pp.585-598.
Berke, C., Conley, M.J., Netsch, D., Franklin, L., Goodman, E., Shephard, C. and Thompson, D., 2019. Role of the wound, ostomy, and continence nurse in continence care: 2018 update. Journal of Wound Ostomy & Continence Nursing, 46(3), pp.221-225.
Bharucha, A.E., Knowles, C.H., Mack, I., Malcolm, A., Oblizajek, N., Rao, S., Scott, S.M., Shin, A. and Enck, P., 2022. Fecal incontinence in adults. Nature Reviews Disease Primers, 8(1), p.53.
Calabrese, F., Poziello, A., Spiezia, G., Rotunno, T., Chervino, C. and Iannicelli, A.M., 2023. Nursing Management of Patients Dealing with Spina Bifida: from the Prenatal Diagnosis to Adulthood/Nursing Intervention for the Improvement of the Impact of Urinary and Fecal Incontinence on the Quality of Life of People Dealing with Spina Bifida.
Cheng, L.J., Wang, W., Lim, S.T. and Wu, V.X., 2019. Factors associated with glycaemic control in patients with diabetes mellitus: a systematic literature review. Journal of clinical nursing, 28(9-10), pp.1433-1450.
Colley, A., Finlayson, E., Zhao, S., Boscardin, J. and Suskind, A., 2023. High risk of complications after a “low risk” procedure: A national study of nursing home residents and older adults undergoing hemorrhoid surgery. Colorectal Disease, 25(2), pp.298-304.
Correia, J.C., Lachat, S., Lagger, G., Chappuis, F., Golay, A. and Beran, D., 2019. Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low-and middle-income countries: a scoping review. BMC Public Health, 19(1), pp.1-20.
Garcia-Molina, L., Lewis-Mikhael, A.M., Riquelme-Gallego, B., Cano-Ibanez, N., Oliveras-Lopez, M.J. and Bueno-Cavanillas, A., 2020. Improving type 2 diabetes mellitus glycaemic control through lifestyle modification implementing diet intervention: a systematic review and meta-analysis. European Journal of Nutrition, 59(4), pp.1313-1328.
Gröndahl, W., Muurinen, H., Katajisto, J., Suhonen, R. and Leino-Kilpi, H., 2019. Perceived quality of nursing care and patient education: a cross-sectional study of hospitalized surgical patients in Finland. BMJ open, 9(4), p.e023108.
Hailu, F.B., Moen, A. and Hjortdahl, P., 2019. Diabetes self-management education (DSME)–Effect on knowledge, self-care behavior, and self-efficacy among type 2 diabetes patients in Ethiopia: A controlled clinical trial. Diabetes, metabolic syndrome, and obesity: targets and therapy, pp.2489-2499.
Hämel, K., Toso, B.R.G.D.O., Casanova, A. and Giovanella, L., 2019. Advanced practice nursing in primary health care in the Spanish National Health System. Ciência & Saúde Coletiva, 25, pp.303-314.
Kerr, M., Barron, E., Chadwick, P., Evans, T., Kong, W.M., Rayman, G., Sutton‐Smith, M., Todd, G., Young, B. and Jeffcoate, W.J., 2019. The cost of diabetic foot ulcers and amputations to the National Health Service in England. Diabetic Medicine, 36(8), pp.995-1002.
Lawler, J., Trevatt, P., Elliot, C. and Leary, A., 2019. Does the Diabetes Specialist Nursing workforce impact the experiences and outcomes of people with diabetes? A hermeneutic review of the evidence. Human resources for health, 17, pp.1-9.
Liu, K., Xie, Z. and Or, C.K., 2020. Effectiveness of mobile app-assisted self-care interventions for improving patient outcomes in type 2 diabetes and/or hypertension: systematic review and meta-analysis of randomized controlled trials. JMIR mHealth and uHealth, 8(8), p.e15779.
McLendon, S.F., Wood, F.G. and Stanley, N., 2019. Enhancing diabetes care through care coordination, telemedicine, and education: Evaluation of a rural pilot program. Public Health Nursing, 36(3), pp.310-320.
Musuuza, J., Sutherland, B.L., Kurter, S., Balasubramanian, P., Bartels, C.M. and Brennan, M.B., 2020. A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers. Journal of vascular surgery, 71(4), pp.1433-1446.
NICE (2019). NICE | The National Institute for Health and Care Excellence. [online] NICE. Available at: https://www.nice.org.uk/.
Nikitara, M., Constantinou, C.S., Andreou, E. and Diomidous, M., 2019. The role of nurses and the facilitators and barriers in diabetes care: a mixed methods systematic literature review. Behavioral Sciences, 9(6), p.61.
NMC (2018). The Code Professional Standards of Practice and Behaviour for Nurses and Midwives Nursing and Midwifery Council. [online] NMC. Nursing and Midwifery Council. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf.
Siegel, K.R., Ali, M.K., Zhou, X., Ng, B.P., Jawanda, S., Proia, K., Zhang, X., Gregg, E.W., Albright, A.L. and Zhang, P., 2020. Cost-effectiveness of interventions to manage diabetes: has the evidence changed since 2008? Diabetes Care, 43(7), pp.1557-1592.
Suzuki, M., Kodaira, M., Suyama, K., Murata, T. and Kume, H., 2021. Continence status and presence of pressure skin injury among special elderly nursing home residents in Japan: a nationwide cross-sectional survey. Geriatrics, 6(2), p.34.
Tamura, Y., Omura, T., Toyoshima, K. and Araki, A., 2020. Nutrition management in older adults with diabetes: a review on the importance of shifting prevention strategies from metabolic syndrome to frailty. Nutrients, 12(11), p.3367.
Whicher, C.A., O’Neill, S. and Holt, R.G., 2020. Diabetes in the UK: 2019. Diabetic Medicine, 37(2), pp.242-247.
Wranik, W.D., Price, S., Haydt, S.M., Edwards, J., Hatfield, K., Weir, J. and Doria, N., 2019. Implications of interprofessional primary care team characteristics for health services and patient health outcomes: a systematic review with narrative synthesis. Health Policy, 123(6), pp.550-563.
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