CASE STUDY:

CASE STUDY
ON

Positive Health Care for Individuals

2008

By ::

MOTILAL DASS
Registered Nurse (India)
HNC Health Care (Scotland)

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 CASE STUDY:

CASE STUDY
Positive Health Care for Individuals
Motilal Dass

In order to a complete case study for the unit of Positive Health Care for Individuals
(DR3R34), I chose a patient who had undergone a colostomy operation. To comply with
the Data Protection Act and also to ensure patient’s confidentiality the patient’s name is
not disclosed through out the case study, as Nursing and Midwifery Council states that
you must treat information about patients and clients as confidential and use it for the
purpose for which it was given (NMC-2004). The Data Protection Act (1998) declares
that all the records about client which are filled will be seen as data, whether electronic or
paper and individuals are given rights which include the right to confidentiality- that the
information should not be accessible to unauthorised people.

The patient is Mrs. ‘X’ a 78 year’s old lady and she was transferred from Ayr General
Hospital to the residential care home. On admission various assessment tools were being
used to find out base line physical parameters. The assessment tools were Modified Early
Warning Score, Waterlow scale (pressure ulcer risk assessment tool), menu planner and
body mass index calculator. Her base line data’s were obtained as temperature 36.9
degree Celsius, pulse rate 76 beats/minutes, respiratory rate 16 beats/minutes, blood
pressure 110/70 mm of Hg (mm of Hg means millimetre of mercury), body mass index
16 and it was calculated using the formula: patients weight in kilogram divided by her
height in meter squared. General risk assessment was also done by removing unnecessary
objects from the patient’s room and only the useful things were kept inside the room. I
used the facilities provided by the employer to facilitate the quality patient care. This
helped to minimise the risks as Manual Handling Operations Regulations (1992) states
that make proper use of equipment provided to minimise the risk of patient injuries.

The patient had to undergo a colostomy operation and this was the choice of surgical
treatment because of the clinical manifestation of the carcinogenic condition of colon this
surgical intervention was performed. Colostomy means a surgical opening into the colon
for the purpose of creating the diversion for eliminating the faecal matter. Tortora et al
(1996) states that the large colon has three parts called ascending colon, transverse colon
and descending colon. As a result of this procedure her dependence continuum got
hindered. In this context of case study, while viewing the patient’s disease condition, the
treatment regime is appropriately suited.

To implement the appropriate care to this patient the Roper Logan Tierney model of care
plan is being used. Roper Logan-Tierney Model of care includes twelve activities of daily
living. Due to existing treatment regime this patient was not being able to carry out the
Activities of Daily Livings by herself. The activities in which she required assistance
were identified as eating and drinking, eliminating need, personal cleansing & dressing,
maintaining a safe environment, controlling body temperature, mobilising, working and
playing and also expressing sexuality.

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To ensure that the patient gets the holistic nursing care, the nursing process was followed.
The nursing process is being defined as the systematic planning of care using the steps
assessment, diagnosis, planning, implementation and evaluation. Nursing process is the
vicious cycle where if the goals and objectives fail to produce satisfactory outcome then
the whole process is revised until positive outcome is received by the patient. To this
patient the holistic nursing care was implemented. The holistic nursing care means the
combination of physical, mental, social and spiritual needs are being met during the care
process.

The care process was formulated by respecting the patient’s beliefs and finding out her
preferences and at the same time depending on the scientific rationale behind each
component of the care process. The patient was directly involved in this planning process
regardless her existing disease condition. Eventually the involvement of the patient into
the planning process made the care much effective. The care plan was done on the basis
of Maslow’s Highrerchy of need, here patient’s needs are prioritised accordingly and the
three most Activities of Daily Livings have been explained in details:

Eating & Drinking:

Assessment: In this phase, information collected from the patient and nursing history,
thereby the potential and actual problems were identified accordingly. From the existing
condition, it was assumed that the dietary pattern of this patient has been altered
drastically. The patient was no longer capable of eating solid diet as bulk portion at times
she had to procure only semi-liquid and liquid diet. There was loss in body weight and
appetite reduced. Her BMI was 16, which suggests she was underweight.

Diagnosis: Her nutritional status altered and this was less than normal requirement of her
body’s need.

Planning: Periodic record of her body weight. Encouraging the patient to take feeds
regularly. Vitamin supplementary could be given as per the advice of the dietician.
Consult a dietician or a doctor. Motivate to consume food.

Implementation: There were adequate resources available to carry out the plans which
were mentioned. It was not possible by me alone to deliver all the care which was
planned, so I needed help from other carers and nurse to make the plan effective and this
helped me in reaching the positive outcome at the end. During my placement each week I
checked the weight of this patient and maintained an accurate record of this. This was
very much helpful to me to compare the progress of the patient. During my placement,
most of the time I carried out the nursing actions and implemented them according.
Whenever I felt I needed to consult the staff nurse I did it so. At time to time I motivated
patient to consume food.

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Evaluation: Evaluation is an ongoing process and it helps to deduce conclusion

pertaining to the care implemented to the patient. K.Holland et al (2004) states that when
evaluating the care plan, you will need to establish if the goals have been completely met
partially met or not met at all. I evaluated the care plan and found that it was effective
and patient gained weight in last two months.

Eliminating Need, personal Cleansing and Dressing:

Assessment: This patient had to undergo a colostomy operation due to the carcinogenic
condition of the descending portion of colon. She could not defecate normally and as a
result of this she has got a diversion of eliminating faecal matter through the colostomy
opening. She also needs assistance in cleaning and emptying this bag and more
appropriately maintaining her hygiene.

Diagnosis: Abnormal elimination pattern and maintenance of hygiene noted. Particular

concentration was given on hand hygiene as the Postnote (2005) states that probably the
single most effective way of combating health care associated infections is to improve
hygiene in healthcare settings, in particular hand hygiene.

Planning: Prevention of infection, hand washing, regular changing and emptying of the
colostomy bag, bathing the patient, dressing her up with the clean dress, and regular
changing of sanitary pad, preventing the risks of infection and care of the stoma.

Implementation: The colostomy bag was emptied regularly. The bag was changed in
every two subsequent days. Patient was given bed bath and tub bath as well. Patient’s
privacy and dignity was always maintained by keeping the door shut and not exposing the
private areas without patient’s awareness and the patient was treated as an individual as
Nursing and Midwifery Council (2004) states that respect the patient or client as an
individual. The site of the stoma was cleaned with antiseptic solution. Whenever the bag
was changed it was discarded in a plastic bag and send for incinerating it. The sanitary
pad was also changed whenever found them wet and they were discarded in bins and
disposed. Appropriate hand washing technique was followed before and after giving care
to this patient.

Evaluation: All the cares which were planned were implemented. There was little
redness and rash observed around the site of the stoma but this was notified to the nurse
in charge. The redness indicated there was initial sign of infection as its one of the
component of inflammation. As result of the planning step was revised and care
implemented accordingly and later on there was not sign of infection noted.

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Maintaining a Safe Environment

Assessments of patient’s ability to maintain own safe environment was done on the basis
of clinical observations and previous medical history. This patient was vulnerable to falls
as she could not support herself while she tried to walk or sit on a chair. She always
required assistance in almost every area of daily living activities.

Diagnosis: The medical history reveals that there were high risks for falls and injuries.
As without assistance she could hardly walk or sit or even move from one side to the
other. There was also high chance of getting weakness and fragile due to confinement
and prolong bed rest and these were identified as potential factors which aggravated the
physical condition of this patient. Psychologically this patient was agitated and depressed
as her body image was altered from normal. As a result she had low self-esteem. She was
concerned about her family members and friends so she kept on asking their well being
from time to time. She was interested to go to pubs and clubs to meet her friends, share
her views and feelings but she could not do this due to the existing condition, as a result
of this her social life is not well balanced. This patient was experiencing the restricted life
style so she always looked gloomy but I kept her assuring.

Planning: At the planning stage I made sure to use the hoist and adequate assistance
from other carers or nursing staffs, use of bed rails, wheel chair was provided to take
patient whenever required, use of strap was ensured and patient was never left alone
unattended, care of pressure areas.

Implementation: I have provided care to maintain her life and to prevent deterioration
by focusing on the physical status of this patient. Each time I attended this patient I made
sure to keep the side rails well fixed and head was supported by extra pillows and even
special care was provided to bony prominence areas to avoid pressure sores. I always
summoned help from other carers and nursing staffs when I needed to turn the position of
this patient.

Evaluation: This was effective care which was rendered to this patent and patient’s out
come was satisfactory. There was no evidence of developing pressure sores or history of
falls noted during the period I took care to this patient.

The patient was given all the choices about receiving the care. Prior to implement any
care a formal consent was taken from the patient, as NMC (2004) states that you must
seek consent before giving any care to the patient or client. I maintained patient’s dignity
by being polite to her during the conversation; I used the term ‘madam’ to make her feel
happy. Due to colostomy bag attachment, at times there was foul smell in her room but I
ignored this, adjusted with the existing environment and provided care.

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Her socio-economic history revealed that she was from middle class family but I did not
go for class stratification while providing care to this patient I adhered to anti-
discriminatory practice, where richness or poverty have insignificant role to play. Once I
took this patient for bath, suddenly I was told by one of the carer that the patient needs to
have her hair wash done; this was not mentioned in the care plan. I got interrupted and
went to the staff nurse to get it clarified. I was told by the staff nurse that hair wash is not
mentioned in care plan on Thursday; but it was mentioned to be done on each Sunday. I
met the carer who told me but she apologized for coordinating inappropriate information.
This was the most conflict situation that I faced during implementing care to this patient
but I reacted positively.

To establish and maintain a positive health environment for the this patient each team
members worked in well coordinated manner with other team members and everyone of
us portrayed professional skills by the standard of care the patient was given. I was also
integral part of this team. The way I have delegated care to this patient, sought and got
support from the members of the care team was beneficial to me. I have developed a
professional understanding during this case study which I had to do. I have shown
effective co-ordinating skill along with other team members. Everyone in this team
played a vital role and I could relate this role theory to the Belbin’s Team Roles Theory.
Dr. Meredith Belbin (1994) stated that team workers make helpful interventions to avert
potential friction and enable difficult characters within the team to use their skills to
positive ends; they tend to keep team spirit up and allow other members to contribute
effectively. There was a good reciprocity and mutual understanding among the team
members. To ensure the optimum quality of patient care I worked in collaboration with
the team members. Through out this case study I kept patient as a central point of
receiving care. All the care given to this patient was recorded properly and got them
countersigned by the nurse on duty.

At each stage of intervention, I respected patients autonomy as NMC (2004) states that
you must respect patients’ and clients’ autonomy – their right to decide whether or not to
undergo any health care intervention-even where refusal may result in harm or death to
themselves. I demonstrated effective communication skills while I interacted with this
patient. I preferred to use the non-verbal method of communication and I mostly used
actions to convey messages to this patient as Kenworthy et al (2002) states that actions
speak louder than words. The patient could easily understand me and co-operated well. In
conclusion, an effective patient care strategy was demonstrated by me while the care was
being given to this patient.

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References:

Belbin’s Team Role Theory [online] 1994, London; available on: www.srds.co.uk and
accessed on April 23rd 2008.

Holland K, Jenkins J, Solomon (2004): Applying the Roper Logan Tierney Model in
Practice, 2 ed. Edinburgh: Churchill Livingstone. p. 195

Kenworthy N, Snowley G, Gilling C (2002): Common Foundation Studies in Nursing 3rd

ed.Edinburugh: Churchill Livingstone. p. 258

NMC code of professional conduct: standards for conduct, performance and ethics
(Nursing & Midwifery Council) London, p.3, 5

Occupational Therapy Training [online] 2007, London; available on: www.otdirect.co.uk

and accessed on April 25th 2008.

Tortora GJ, Grabowski SR (1996): Principles of Anatomy and Physiology 1st ed.
Biological Sciences Text Books, Inc. and Sandra Reynolds Grabowski. p.793

The Postnote (2005) Infection control in health care setting, London. [Online]: available
www.parliament.uk [accessed on April 27th 2008]

Author:
Motilal Dass 
Registered Nurse (India) 
HNC Health Care (Scotland) 

E-mail:
motilald@hotmail.com

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