My patient

For the purpose of this essay I shall attempt to identify the issues brought up in the assessment I previously completed on my patient on her arrival to the surgical ward. I will explain in this essay that the planning is for, what I will do for my patient in regards to her care, why I am doing this for my patient, where this will all take place and most importantly when this will take place. I will be using the process of planning throughout my essay to work out the solutions to my Patient’s needs. I will refer to the workings of the SMART (Specific, measurable, achievable, realistic and time orientated) principle. Hinchcliff, S, 2004). The Smart principle is used to make planning simple, more effective and more efficient. It divides the planning process into five different categories, which helps us cover ‘planning’ in greater detail.

With this principle in place, I will be able to show a good understanding of my patient’s needs, and the best way to achieve their set goals. Egan explains that ‘a helping model is like a map that helps you know what to do in your interactions with clients. At any given moment, it also helps you orient yourself, to understand ‘where you are’ with the client and what kind of intervention would be most useful’. G. Egan, The Skilled Helper: A problem Management Approach to Helping 6th Edition).

I have used a pseudonym to comply with my patient’s confidentiality as stated in the NMC (Nursing and Midwifery council) guidelines (NMC Code of Conduct 2004). My patients name will be changed to Rachel; she is 35-year-old lady who has been admitted to have a bilateral breast reduction. She has been admitted to a surgical ward within the local trust. Rachel is married with two children who are two and four. She lives with her husband and children in the local area, with her husband being her next of kin.

In order to plan Rachel’s care holistically I need to take into account the physical, psychological, environmental, socio-cultural and politico economic factors that will affect the care given. But for the purpose of this essay I will only focus on the physical and psychological factors because they are the most important in the accordance of planning. This is because physically, Rachel’s figure is going to change due to her operation where her breast size will be reduced. Psychologically, this operation will alter the concept of her body image and the way others look at her.

Before I started the planning of Rachel’s care, I decided that I should inquire to see what type of care plan would be best suited to Rachel. A care plan is important as it identifies the needs that my patient has. A care plan also informs other members of the multidisciplinary team what the specific plan of action is, and what action is to be taken regarding the care of the patient. It is highly important for me to access the right care plan for Rachel’s needs and to see how I can accomplish these issues by setting the correct care planning.

Throughout her planning, I will need Rachel to be seen by other health professionals within my local trusts multidisciplinary team, such as the breast care nurse. Because of her specialist knowledge in the area, she is a vital input towards the planning of Rachael’s care. This is expressed in the NMC code of conduct 4. 1. I feel that by leasing with my ward mentor and the breast care nurse specialist on a regular basis, this will help the planning of care for Rachel, as every member involved will need a regular update of progress in order to achieve long and short term goals. The complexity and specialisation of nursing today makes it more necessary than ever for the elements of nursing to be identified and understood” (N. Roper, W. Logan, A. Tierney – Learning to use the process of learning, 1981). I will have to take into account that I must recognise and respect the role of the patient as a partner in their own care and contribution they can make. (NMC code of conduct 2. 1. 2004) This is why I have discussed with Rachel what she would like to achieve in her care plan and whether she has any ideas on her care.

After some discussion with my ward mentor, the breast care specialist and Rachel these are the goals we have come up with. “Individuals are primarily social beings and a major part of living involves communicating with other people in one way or another” (Roper et al applying the model in practice 1996) As I have stated I will be using the workings of SMART to recognise and help me achieve my patient’s goals. I will start by recognising the ‘specific’ goals that my patient will need. These are to make sure Rachel is ready for theatre and has a theatre checklist completed before she has her bilateral breast reduction.

Bilateral relating to or affecting both sides of the body or of a tissue or organ or both of a pair of organs, e. g. breasts. ” (Oxford Concise Medical Dictionary 2003). This will ensure that the patient’s time in theatre will run smoothly and according to plan, and will allow theatre nurses to double check that the legal document is correct and completed. The ‘specific’ part of planning will also confirm that Rachel has an understanding of what will happen and whether she is physically and psychologically ready for an operation to reduce breast size and a nil by mouth status when appropriate.

Also I will try to prevent infection, refer her to the breast care nurse, attempt to prevent pressure sores and keep her pain under control. “Pain is what the patient says it is, existing when he says it does”. (M. McCaffery, Nursing the patient in pain, 1983) During the planning process, my ‘specific’ goals are to attempt to educate Rachel in regards to checking her own breasts for swelling and leakage. This will be a good idea because I feel that if Rachel’s breasts were to get an infection, then she may be able to help us identify it more quickly.

If she is not educated in any way, and it does take us longer to notice the infection, then this will set back the discharge date for Rachel to go home. (JL Day. Writing articles for publication. Online 2004. ) Stated that “Education/empowerment is critical if successful self-management is to be achieved. ” After discussing with my ward mentor it was decided that Rachel’s care would have to be measurable so we can see how her progress is getting on. For example, we will have to do her hourly post observations for four hours then reduce it to once every four hours after that.

She will also need hourly dressing checks at the same time as the observations. Depending on the amount of discharge from her dressing, we could reduce the dressing checks when we reduce the observations to every four hours. Also we would have to give Rachel analgesia every four hours to keep her pain under control as stated on her drug chart. For the plan to be ‘achievable’, we need to make sure the plan can be carried out and fully completed. Setting goals that are impractical will not make your plan achievable.

In order for one of Rachel’s goals to be achievable a care plan will need to be put into place. The one I have picked will be to make sure the patient will be safely prepared for theatre both physically and psychologically. I feel this one would be the most important because the operation that Rachel will have, will alter her body image and I want to make sure Rachel is fully prepared. The continuing care of Rachel is an ongoing process and for goals to be accomplished then I must update her care plan and identify all issues and problems.

A copy of Rachel’s assessment and care plan is attached in the appendix at the back of this essay. In order for the process of planning to be ‘realistic’ I will try to avoid setting a goal that is too difficult for the patient to achieve. The patient may become, discouraged, depressed, and apathetic if she is unable to achieve an expected outcome. This is why I have made sure that the blood pressure, pulse, temperature, respiratory rate and Rachel’s dressing checks are performed at the same time so they are more likely to be carried out.

If they were to be performed separately on Rachel, then there is a high possibility that either one of the observations or dressing checks maybe missed or forgotten. Not many of these goals would work that effectively unless they were time orientated. So I will put them into three groups which are short term goals, mid term goals and long term goals. Having these three different time groups ensures that there is a clear time divide to when the goals are expected to be worked on and completed. The short-term goals I have chosen for Rachel’s care plan are to take place before she goes to theatre for her bilateral breast reduction.

These are to make sure she will be nil by mouth, prepare her for theatre both physically and psychologically and to confirm that she knows what is going to happen to her before, after and during operation. This is of great importance to Rachel, as she is required to sign a consent form which is a legal document stating that she knows and understands what is going to happen and why, and that she is happy and consented for treatment to go ahead. Results from several research studies have shown that information given to, and understood by, patients prior to operations and investigations can help to reduce anxiety and aid recovery. J. Boore, Prescription for Recovery, 1978. ) I thought that Rachel’s mid term goals could be set for her after theatre in which they will include observations of her temperature, pulse, blood pressure, her respiratory rate and her dressing checks using the time frame already given. The long term goals best suited for Rachel will be for her discharge a week after surgery, also for her to attend an out patients clinic so her dressing and staples can be removed.

A long term goal is usually spoken in terms similar to those in which the problem is expressed; whilst the short term goals are expressed as observable and measurable signs that can be used to evaluate the extent which the long term goal is being achieved. (C. Newton, The Roper – Logan – Tierney, Model in Action 1991) In conclusion I have found that by using the SMART principle in the planning process, and the 12 activities of living by Roper, Logan and Tierney (Roper, N et al 2001) in the initial assessment, it has been very helping in guiding me towards what I think will be an achievable goal to planning Rachel’s care.

I have addressed all my patients needs regarding planning out the best possible care, I feel that I have used the SMART criteria effectively during this essay when addressing Rachel’s needs. I have learned from this planning essay that I could not have achieved the goals that I set out to accomplish on my own without the help and advice that I will accept from other members of the multidisciplinary team and they will help me achieve my last goal, the discharge of Rachel.

When Rachel is ready to be discharged from the ward I will advise her that if she has any problems after her reduction, that she should contact her local GP or the National Health Service help line as they could give her advice on any questions or queries that she may come across. I feel that I have involved Rachel in as much of her own care as possible, and believe that this will help her effectively achieve her goals set and speed her recovery after operation.