Preview

Nursing Assessment

Best Essays
Open Document
Open Document
2963 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Nursing Assessment
Element: Prevention of pressure ulcers

This essay is going to explore the nursing process with regard to the prevention of pressure ulcers.
Pressure ulcers are a widespread and often underestimated health problem in the UK. They occur in 4-10% of patients admitted to hospital (Ward et al, 2010).
This essay, using case study 4, will explore the holistic nursing process, and also the biological, sociological, psychological and ethical issues regarding the prevention of pressure ulcers.
Lily is frightened due to her shortness of breath (dyspnoea), and as lying down exasperates her ability to breath effectively, has been sleeping in a chair. This is the primary concern of Lily. There has also been recent weight loss. The aim of any nursing interventions will be to improve Lily’s breathing and nutritional status; allowing her to mobilise more effectively and relieve pressure on her sacral area. Dyspnoea is a common and debilitating symptom of heart failure. Patients frequently become distressed and frightened by their breathlessness, which can worsen their symptoms (Currow et al, 2009).
Any nursing interventions to improve Lily’s health and well-being will need to take into account the patients perspective of her health and what goals she wants to achieve. Collaboration and negotiation with the patient will help them identify their problems and/or goals (Field & Smith, 2008).

The nursing process is a structured, systematic approach to care, based on evidence and the individual needs of the patient (Holland K. 2008). There are four main stages to this process; assessment, planning, implementation and evaluation. When Lily is admitted to hospital she will be assessed to identify her health and social needs. The main aim of the assessment process is to identify problems then design a realistic plan of nursing care to meet the individual needs of the patient and improve their health status (RCN, 2004). This individualised assessment examines



References: Bernard M. (1998) Backs to the Future? Reflection on Women, Ageing and Nursing. Journal of Advanced Nursing, 27, 633-40. British National Formulary (2011) http://bnf.org/bnf/bnf/current/2455.htm Accessed on 05/04/11. Brooker C. & Waugh A. (2007) Foundations of Nursing Practice: Fundamentals of Holistic Care. Mosby. London. Chamanga E T. (2010) A critical review of the Waterlow tool. Wound Management. Journal of Community Nursing. Volume 24; Issue 3. May 2010. Churchouse W Currow DC. Agar M. Smith J. Abernethy AP. (2009) Does palliative home oxygen improve dyspnoea? A consecutive cohort study. Palliative Medicine 2009; 23: 309-44. Defloor T. De Bacquer D. Grypdonck M (2005) The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. International Journal of Nursing Studies. 42, 1, 37-46. Denny E. Earle S. (2005) Sociology for Nurses. Cambridge. Polity Press. Elliott J. (2010) Nursing Older People; Strategies to improve the prevention of pressure ulcers. Issue: Volume 22(9), November 2010, p 31–36. Royal College of Nursing Ltd. EPUAP (2010) Pressure Ulcer Prevention; Quick Reference Guide. http://www.epuap.org/guidelines.html Accessed on March 22 2011. EPUAP (2009) Pressure Ulcer Treatment: Quick Reference Guide. http://epuap.org/guidelines/final_Quick_Treatment.pdf Accessed on April 4 2011. Field L. & Smith B. (2008) Nursing Care; an Essential Guide. Essex. Pearson Education Ltd. Girot E. (1990). Discussing Nursing Theory. Senior Nurse 10: 16-19. Hall C. & Ritchie D. (2009) What is Nursing? Exeter. Learning Matters Ltd. Harris H (2009) Tissue Viability Nurse Specialist; Policy and Procedure for the Prevention and Management of Pressure Ulcers. November 2009. Bristol and North Somerset NHS. Holland K Katz AM. Konstam MA. (2008) Heart failure: pathophysiology, molecular biology, and clinical management, 2nd edition. London: Lippincott Williams & Wilkins, 2008. Mitchell M (2005) Anxiety Management in Adult Day Surgery NICE (2005) The management of pressure ulcers in primary and secondary care; A Clinical Practice Guideline. Royal College of Nursing. http://www.nice.org.uk/nicemedia/pdf/CG029fullguideline.pdf Accessed on March 25 2011. NICE (2003) Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 5. London: NICE, 2003. www.nice.org.uk NMC (2008) The Code O’Connor M. (2002) Using the Roper, Logan and Tierney Model in a Neonatal ICU. Nursing Times. May 1st 2002. http://www.nursingtimes.net/nursing-practice/199604.article Accessed on April 4th 2011. Ogden (2004) Health Psychology Papanikolaou P. Lyne P. Anthony D. (2006) Risk Assessment Scales for Pressure Ulcers: A Methodological Review. International Journal of Nursing Studies, Volume 44, Issue 2, Pages 285-296. February 2007. Perry L (2009) Using Nutritional Screening Tools to Identify Malnourished Patients. Nursing Times. January 6 2009. London. EMAP Ltd. Pridmore JA. Murphy F. Williams A. (2010). Nursing Models and Contemporary Nursing 2; Can They Raise Standards of Care? Nursing Times; 106-24, June 21st 2010. RCN (2004) Nursing Assessment and Older People; A RCN nursing Toolkit Roper N. Logan W. Tierney A (2002) The Roper-Logan-Tierney Model of Nursing; Based on Activities of Living. Edinburgh. Churchill Livingstone. Royal Marsden Hospital (2008) Manual of Clinical Nursing Procedures. Seventh Edition. Blackwell Science Ltd. London. Rungapadiachy D (2005) Interpersonal Communication and Psychology for Health Care Professionals; Theory and Practice. Elsevier Ltd. London. Teasdale K (1995) The Nurses Role in Anxiety Management. Professional Nurse 10: 509-512. Thompson D (2005) An Evaluation of the Waterlow Pressure Ulcer Risk Assessment Tool. British Journal of Nursing 14 (8): 455-459 April 28 2005. Ward L. Fenton K. Mahor L. (2010) The High Impact Actions for Nursing and Midwifery 4; Your Skin Matters. Nursing Times; 106; 30; 14-15. Waterlow J. (2007) Pressure Ulcer Care and Pressure Ulcer Risk Assessment. www.judy-waterlow.co.uk Accessed on April 02 2011. Waterlow J (2005) The Waterlow Pressure Prevention Manual. Taunton. Newtons.

You May Also Find These Documents Helpful

  • Good Essays

    Nvq3 Unit 4222

    • 999 Words
    • 4 Pages

    5. Mobility has a significant role to play in the prevention of pressure ulcers. By facilitating the residents’…

    • 999 Words
    • 4 Pages
    Good Essays
  • Best Essays

    Holistic Practitioner 2

    • 3345 Words
    • 14 Pages

    Byrne, O. and Kelly, M. (2010), Living with a Chronic Leg Ulcer Journal of community nursing, Vol. 24, No. 5, pp. 46-54…

    • 3345 Words
    • 14 Pages
    Best Essays
  • Best Essays

    Ebt Task 1

    • 2000 Words
    • 8 Pages

    | |patients in whom pressure ulcers do and do not develop and to identify prevention strategies associated with a |…

    • 2000 Words
    • 8 Pages
    Best Essays
  • Good Essays

    Pressure Area Care

    • 1008 Words
    • 5 Pages

    Some of the interventions that can be taken to help minimise the risk of pressure ulcers occurring in those that are at risk, one method is to that the individuals is position is changed on a regular basis, another is to use a pressure relieving device such as a special mattress, bed frame, seat…

    • 1008 Words
    • 5 Pages
    Good Essays
  • Good Essays

    Waterlow Essay

    • 744 Words
    • 3 Pages

    The scoring system consists of areas that are all deemed to be factors that may contribute towards a patient’s risk of developing pressure ulcers. These include a patient’s build, tissue viability, sex, nutritional status, continence, mobility and other special risks such as co-morbidities and medications. The theory is, the higher the patient scores within each area and overall the higher the patient is at risk of obtaining pressure ulcers (Judy-waterlow.co.uk 2007).…

    • 744 Words
    • 3 Pages
    Good Essays
  • Satisfactory Essays

    Pressure Ulcers Stage 4

    • 148 Words
    • 1 Page

    Having pressure ulcers especially on stage 4 give impact to individual’s life. Impact may vary from person to person where some patient may feel having pressure ulcers is the worst thing can happen and some can live normally with the ulcers. First impact on having pressure ulcers is on quality of life. People who suffer from pressure ulcers experiencing excruciating pain while doing daily activities such as dressing changes.Individual who suffer from pressure ulcers also suffer from financial problem where they need to deal with expensive healthcare such as medical care charges, medication, trips for appointment and home modification. Next, patients may experience social isolation. Patients may feel isolated when they do the treatment. For…

    • 148 Words
    • 1 Page
    Satisfactory Essays
  • Powerful Essays

    Cited: Fleck CA. Pressure ulcers: risks, causes, and prevention. Extended Care Product News. 2005;105:32-40. Available at: http://www.extendedcarenews.com/article/4968. Accessed February 6, 2008.…

    • 1804 Words
    • 8 Pages
    Powerful Essays
  • Good Essays

    Knowing the prevalence, one could consider the actions leading up to the good and bad outcomes, compare the two to determine contributing factors, then put together a plan of action to prevent bad outcomes from occurring. The data collected on the unit could then be shared throughout the hospital to have better outcomes and a greater patient satisfaction score overall. Through this process, healthcare workers could learn to prevent nursing-sensitive indicator, such as pressure ulcers, by turning or repositioning patients at least every two hours. Being proactive throughout the hospital will reduce the number of hospital acquired pressure ulcers and help the healing process of those that were present upon admission. This also aids in a better patient satisfaction…

    • 740 Words
    • 3 Pages
    Good Essays
  • Powerful Essays

    For the purposes of this assignment, the patients name will be referred to as Mr S. Mr S was admitted from a care home onto our ward as a bed bound patient with a grade four sacral pressure sore which was severely bleeding and at high risk of infection. NHS Choices (2012) shows that this grading is the most severe type of pressure sore. The skin was severely damaged and the surrounding tissue beginning to die (tissue necrosis). The underlying muscles or bone may also be damaged. Pressure sores are a serious problem in health care systems. They cause pain and suffering and can lead to infection, and if not prevented or managed effectively can result in fatality. Nazarko (2005) Current research shows that Pressure sores are a common and often underrated health problem. Focus on disability (2012) estimates in the UK that between 4%-10% of all patients admitted to hospital will form at least one pressure sore. For elderly people with mobility problems, the figure can be as high as 70%. Pressure sores are an area of localized injury to the skin and underlying…

    • 1978 Words
    • 6 Pages
    Powerful Essays
  • Good Essays

    Diabetic Foot Ulcers

    • 695 Words
    • 3 Pages

    Nursing practice is always changing with new research findings. Nurses have to use current evidence-based practice methods available to ensure that the patients receive quality care through best practices. This research paper will review a growing problem in today’s healthcare field that needs to be addressed: Diabetic foot ulcers. To ensure quality patient care, current evidence based research has to be an important part of this process. With every new research proposal, a solid foundation has to be the basis for that specific research. This paper will discuss why diabetic foot ulcers are a growing problem in healthcare, methods used to improve outcomes (negative pressure wound therapy versus moist wound therapy),…

    • 695 Words
    • 3 Pages
    Good Essays
  • Better Essays

    Pressure Ulcers

    • 987 Words
    • 4 Pages

    According to Moore and Price (2006), the incidence of pressure ulcers has not improved and with the surge of older patients, this will exacerbate the situation. Registered nurses working in the acute care facilities encounter many patients with pressure ulcers. Alteration in skin…

    • 987 Words
    • 4 Pages
    Better Essays
  • Powerful Essays

    Either adding new techniques or finding new techniques to prove prevention. Several studies that have been conducted with the use of mapping devices that display pressure monitoring to help with pressure ulcers. The studies are to show how effective these methods are towards pressure improvement. The research question consists if there is a significant effect in preventing pressure ulcer with the use of these mattress mapping devices compare to not using the mapping devices. Pressure ulcer prevention is very important in nursing because it provides the patient with a better quality of life after hospitalization. The pressure ulcers can reduce quality of due to bring more pain, additional treatment, longer hospital stay and in some patient this can lead to premature mortality. Hence, researching the effect of mapping device can help with the prevention of pressure ulcers which can lead to improved quality life for patient and reduce cost of pressure ulcer care or treatment. Also a benefit for nurses is the knowledge of where not to reposition the patients and possibly learning of other areas in the body that are prone to…

    • 1561 Words
    • 7 Pages
    Powerful Essays
  • Good Essays

    Therefore, identification is the most current best practice recommendation. The most common tool used for identifying patients at risk for developing pressure ulcers is the Braden Scale. However, “quantification of the relationship between Braden Scale score and nursing interventions indicates the need for a more comprehensive and fundamental approach” (JAN, 2010). The Braden Scale is divided into six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A score of 18 or less indicates that the patient is at risk for pressure ulcers. The rationale for these recommendations is that identifying a patient upon admission for being at risk allows the nurse to begin a prevention plan as soon as identified. The nurse needs to implement interventions to prevent the formation of a pressure ulcer. If the practice of identification upon admission is not followed, prevention is delayed and pressure ulcer formation begins. This causes the patient unnecessary pain, increases their risk for infection, and extends the hospital stay. Pressure ulcers are easier to prevent than to…

    • 636 Words
    • 3 Pages
    Good Essays
  • Powerful Essays

    Reflection-Leg Ulcers

    • 2209 Words
    • 9 Pages

    de Laat, E.H. et al (2005) Pressure ulcers: diagnostics and interventions aimed at wound-related complaints: a review of the literature. Journal of Clinical Nursing; 14: 4, 464-472.…

    • 2209 Words
    • 9 Pages
    Powerful Essays
  • Best Essays

    Kozier, B., Erb, G., Berman, A., Sndyer, S., Lake, R. & Harvey, S. (2008) Fundamentals of nursing: concepts, process and practice. Essex: Pearson Education Limited.…

    • 3155 Words
    • 13 Pages
    Best Essays

Related Topics