The focus of this assignment is the continuing care needs of a patient, Mr. Steve Brown (56) with multiple sclerosis. Mr. Brown is being cared for at home by his partner. Multiple sclerosis (MS) is a complex, chronic, degenerative disease of the nervous system. Mr. Brown has recently been experiencing difficulties swallowing and may require nutritional support to ensure he receives adequate nutrition and hydration. Hill and Pollard (2004) remind us of the social impact of chronic conditions such as social exclusion and isolation, from losing their job, which leads to a loss in income and status; role and relationship changes; and transportation problems.
This assignment will discuss nursing models, care planning, assessment, and implementation.
The Roper Logan and Tierney Model of Nursing.
Using Roper et al. (1998) model of nursing, an individual profile of a patient can be created based on their ability to carry out the twelve basic activities of living. The assessment also considers the impact of the patient’s level of autonomy/reliance, life expectancy and natural, mental, sociocultural, politico monetary and ecological factors on every activity. This is laid out in the NHS patients individual care records where nursing remarks are connected to every one of the activities of living recorded at the front of the notes. A better understanding of the patient’s present well-being can be developed through the identification of actual/potential problems, making this model appropriate to the care planning process and the most popular throughout NHS in the UK (Timmins and Oshea, 2004; Potter et al.2016).
The decision to use Roper et al. (1998) model of nursing is based on its relevance to the aims of nursing and providing holistic care. The model was developed based on the practice experiences of nurses who have worked in UK healthcare system, making it relevant and easy to use, unlike the complex natures of some other nursing models, and can be easily applied in both the clinical and community setting (Alexander et al. 2000). The Roper, Logan, and Tierney model has an individualised approach, but also places emphasis on the information gathering, assessment stage of the nursing process (Potter et al., 2016. Barrett et al. 2014). Chilton and Bain (2018) recognise that assessment is a core skill for nurses as any subsequent care is based on this, any inaccuracies in the process can lead to inadequate care.
Using the RLT model provides a framework to guide health professionals to coordinate and follow the same criteria of care (NMC, 2015; Wood, 2003; Williams, 2015). The framework was designed to ensure patient assessment gathers appropriate data, not just health data but also includes the activities of living. This is critical to giving person-centered care (NMC, 2015). Individualized care at that point is given all through the efficient nursing process.
Chilton and Bain (2018) also state it is worthy to note that if the whole RLT model is not used and only the ADL’s the assessment can just become a checklist type assessment which leads to the information gathered being superficial.
The indication that Mr. Brown has symptoms of dysphagia is the focus of the nursing assessment and particularly relates to the sufficient intake of food and water. Other elements of his MS condition would also be considered within all the activities of daily living.
If a patient is not tolerating adequate diet and fluids, several problems may occur, for example, loss of appetite and poor nutrition due to reduced ability to swallow but there is also the risk of dehydration and increased risk of pressure ulcers, respiratory infections, reduced mobility, and depression.
After all the relevant information has been given, an initial assessment of the patient’s needs is required. The initial assessment, according to Mosby (2002), is defined as “a collection of data and information relating to a patient and their healthcare needs.” Kozier et al. (2012) state that assessment is primarily undertaken to identify risk and highlight general problem areas to provide a basis for possible future intervention and revaluation if their condition changes. Ogden (2000) discusses how the assessment of a patient can help the professional understand the patient’s own opinions and perceptions of their healthcare needs. This knowledge can also help to plan patient-centered, evidence-based care with clear rationales (Balzer-Riley, 2000).
According to the NICE clinical guidelines for managing multiple sclerosis (NICE 2017), and for nutritional support it is essential to screen for the risk of malnutrition. BMI and unintentional weight changes are monitored, and the ‘Malnutrition Universal Screening Tool’ (‘MUST’) nutritional assessment tool (BAPEN.org) should be used to identify if nutritional support is required.
The NHS use the MUST screening tool which uses Body Mass Index (BMI) and levels of unintentional weight loss to determine if a person is at risk of malnutrition. The MUST guidelines request that a person’s weight be taken at intervals of 7 days to allow early escalation if required.
Thomas and Bishop (2007) however feel that a diet history can assess nutrient intake.
The MS Society (mssociety.org) also states the importance of a healthy diet, the impact on health and cite special diets which may improve the condition. A review by the British Dietetic Association (BDA) found insufficient clinical evidence that exclusion of foods or gluten improve the symptoms but could compromise nutritional intake leading to changes in bowel habits, fatigue, pressure ulcers and infection (BDA,2015).
A sound adjusted eating regimen and ideal sustenance assumes a significant part for those living with MS. Thusly, education on the sort of nourishment, and amounts, for example, those in the Eatwell Guide (2017) created by the public health department is essential. It has additionally been recommended by the Scientific Advisory Committee on Nutrition (2016) that since Vitamin D has a part in keeping up and supporting the central nervous system, and hard to accomplish the day by day prerequisites through nourishment, that a daily supplement ought to be taken.
Notwithstanding the MUST assessment, it is advantageous to complete a 3-day total intake chart (NHSG, 2018) to screen Mr. Brown’s calorie and liquid intake and to assess whether further referrals may be required to Speech and Language Therapy, concerning his dysphagia, or a referral to the community dietician.
There are a variety of dietary changes that can be made to suit Mr. Brown’s needs, whether mashing or pureeing the food will make it more manageable or introducing fortified foods.
Chronic disease management focuses on patient empowerment and user involvement in decision-making, and good information is needed for this to happen. Dunphy et al. (2015) also, the NMC Code (2015) suggest that patient education and health promotion is an essential element of the role of the nurse, as it has a critical impact in empowering the patient to deal with their particular illness. However, effective management also additionally relies upon the patient’s eagerness and capacity to adhere to the suggested therapies and routines.
Mr. Brown would benefit from a multidisciplinary approach to his care (Bell et.al.2017). A referral to the OT could assess whether he requires adapted cutlery, look at posture, eating position, seating or any other aids to optimise his nutritional intake. Speech and Language therapists are the experts in the assessment and diagnosis of dysphagia, and any eating or drinking disorders linked to difficulties swallowing (RCSLT,2005). The dietician can use expert knowledge and implement an individual nutritional care plan and ensure the nutritional adequacy of any texture modified diets.
Complete the 3 Day intake chart and suggest other adaptations such as having several smaller meals, snacks, and encouragement to maintain a balanced diet. Ojo and Brooke (2015) emphasise the importance of the environment to be conducive to meal consumption, seated upright in a quiet room with few distractions, and meals should be unhurried.
Fluid Balance charts are to be completed daily initially to ensure the patient is not dehydrated/overhydrated.
Nelms and Sucher (2016) support providing oral adaptations to diet currently in the plan, including adaptations to the type, quantity or consistency of food and the nutritional content in foods or snacks between foods. However, if these parenteral changes prove unsuccessful, or if the patient’s condition worsens enteral feeding may have to be considered.
The MUST assessment and measurement of weight would be repeated after four weeks. Sole et al. (2013) states that evaluation of the patient, and changes in tolerances to foods, eating habits, changes in weight and any indications of dehydration or overhydration are a basis of ensuring the patient is meeting the goal of nutritional support. Goals not being met would require a reassessment of the care plan, and decisions would need to be made regarding changes to the plan to ensure the required outcome. Howatson-Jones et al. (2015), also emphasises the importance of monitoring clinical assessment information in conjunction with that from nutritional assessments to ensure the effects of the nutritional care plan can be evaluated over time.
Summarising it is evident, that there is a requirement to use appropriate assessment and care planning tools to ensure continuity and individualised care. The Roper Logan and Tierney model provides a framework to ensure continuity and supports this process. However, the process of carrying out the care plan highlights the importance of building the therapeutic relationship, health promotion and the inclusion of the patients and their families in decisions regarding their care.
Dealing with any long-term health condition provides a challenge to nurses, as well as drawing on previous experience and knowledge, it may also create a requirement to develop skills and gain expertise to meet the patient’s needs. It is also essential to remember care planning is only as effective as the assessments that underpin them.