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Margaret an 84 year old lady was admitted to the surgical unit following emergency repair of a perforated duodenal ulcer. The following assignment aims to illustrate how, through assessment, a problem pertaining to Margaret’s health was identified and how an appropriate plan of care was planned, implemented and evaluated with reference to this problem, to facilitate maximisation of Margaret’s health. Margaret remained on the surgical unit throughout placement and hence a wide knowledge of her case and strong relationship was built with her. This and personal interest in Nutritional support is rationale for choosing this particular case. In accordance with the NMC (2002) Code of Professional Conduct and maintenance of confidentiality, the name Margaret is a pseudonym. The nursing process of assessment, planning, implementation and evaluation is facilitated using specific models of nursing. The Roper, Logan and Tierney ‘model of living’, is a model designed around 12 activities of living. The basis of the model provides nurses with a way of viewing patient problems holistically in relation to everyday living activities (Roper et al 1982). When using the model within the nursing process an individualised plan of care can be structured around the patients needs relating to current or potential problems within each or all of the activities of living (Roper et al 1982). A thorough assessment aims to ascertain a patient’s current and potential needs. This data establishes the patient as unique enabling individualisation of care. The nurse can achieve a thorough patient assessment by use of her communication skills, empathy, knowledge and astute and skilful use of the senses. (Carroll et al 2000). Assessment provides a baseline to which further, continuous assessment and evaluation of care can be compared and acts as an instrument to facilitate continuity and safety in patient care (Heartfield 1996, Allen 1998). A patient’s initial assessment, usually undertaken on admittance to the ward is the first opportunity for introduction and communication between the nurse, the patient and their family. It is the initial stage of the forming of the nurse- patient relationship (Carroll et al 2000). When Margaret was admitted to the surgical unit, she was still drowsy and recovering from the effects of her general anaesthetic. It was the nurse’s discretion to only complete the areas of the assessment where the necessary information could be drawn from either observation of medical notes, allowing Margaret to recover further before continuation. She introduced herself to Margaret and explained that when she was feeling better they would discuss her care needs, but if she needed anything in the meantime just to ask.
Approximate Word count = 1616
Approximate Pages = 6.5
(250 words per page double spaced)
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