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PART 1

This assignment will focus on a case study of one individual who was an 80 year old
gentleman who lived in a senior citizen care home. Although he had quite a few healthcare
issues, the major diagnosis he had been given by his consultants was that Jim (not his real
name) suffered from chronic obstructive pulmonary disease (COPD) and as a result of this
Jim has had re-occurring chest infections. Another major health issue recently was that he
had lost a significant amount of weight and he was also finding t sometimes difficult to walk
about unaided. The reason why I have chosen Jim as my case study is because it appeared to
me his health issues were varied and very interesting. While I was at my primary care
placement I had the opportunity to undertake an initial assessment on Jim¶s health. I surmised
that visiting Jim at the care home would be an on-going process and would offer me a great
opportunity to follow Jim¶s health concerns throughout the duration of my placement. The
assignment will discuss the theory put forth by Roper, Logan and Tierney (1985) which
concentrates on the activities of daily living. This was chosen because the assessment forms
used by this particular Primary Care Trust used this model to guide all assessments. The
second half of the essay will focus in more detail on the nutrition needs that Jim requires. I
have chosen the Malnutrition Universal Screening Tool (MUST) (Malnutrition Advisory
Group, 2005) to discuss further any medical interventions Jim may require.
According to Walsh (1998) an assessment schedule derived from a model has the strength of
being as comprehensive as possible because the author will have thought a great deal about
the assessment and tried to ensure that the nurse has the logical and consistent framework of
knowledge necessary to plan care consistent with the model. However, some notes of caution
are needed. Firstly, the nurse must see the assessment form as a tool which will enable staff
to make the model work, it is not just another form-filling, box-ticking exercise. The
assessment should therefore reflect the aspirations of the model (Walsh, 1998).

Newton (1991) suggests that the term µassessing¶ is used in the Roper-Logan-Tierney model
to describe the first stage of the nursing process, emphasising that this is an active process,
and not a once-only event. It consists of collecting and reviewing information about the
patient and identifying any problems, actual or potential, which are amenable to nursing
intervention.

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It may be fair to suggest that assessment is arguably the most important stage in nursing,
however it is often poorly carried out (Walsh, 1991). In particular, systematic ongoing
assessment, which is vital to monitor the success of care and to detect the emergence of new
problems is rarely achieved (Batehup & Evans, 1992).

According to Dougherty & Lister (2008) medical assessment is a systematic, deliberate and
interactive process that underpins every aspect of nursing care (Heaven & Maguire, 1996). It
is the process by which the health care professional and patient together identify needs and
concerns and is seen as the cornerstone of individualised care.

Assessment therefore forms an integral part of patient care and should be viewed as a
continuous process (Cancer Action Team, 2007). Indeed, careful, individualised clinical
assessment of health is a necessity to provide the best available planned medical care.
Clinical assessment is undertaken in varied ways depending on the specific health needs of
the individual, their stage on the illness trajectory, and their social or institutional context
(Bennett & Closs, 2008).
Assessment of older people requires a comprehensive collection of information about the physical,
biological, psychosocial, psychological and functional aspects of the older person. It will enquire into
physiological functioning, growth and development, family relationships, social networks, religious
and occupational pursuits. (Department of Health, 2002). It is vital that the health assessment
includes a thorough appraisal of what are commonly referred to as µactivities of daily living¶. The
Royal College of Nursing believes that this must be linked to the overall health assessment. .Nurses
should relate the person¶s ability to undertake daily living activities to an assessment of health status,
which is linked to medical diagnosis. The key throughout is the individual¶s biography and personal
circumstances.

Newton (1991) suggests that description of the Roper, Logan and Tierney model have been varied
over the years. The model has been described as a system model (Aggleton & Chalmers,
1987), as an eclectic model incorporating multiple theories (Thibodeau, 1983) and as an
µactivities of living¶ model based on human needs (McFarlane, 1980); Farmer (1986)
describes it as having a functional approach. Pearson (1983) describes it as a
systems/development-based model incorporating concepts of Orem¶s model and the
conceptual framework of Henderson¶s model (Henderson, 1969).

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It seems fair to suggest that the model has had its fair share of criticism over the years. Indeed, the
model has been criticized for the use of the activities of living as a checklist (Reed & Robbins
1991), the emphasis on the physical aspects of patient care (Minshull ñ

1986, Walsh
1989), and the simplistic nature of the model (Walsh 1991). The first two problems indicate
an inappropriate introduction and implementation of the model in practice. The model clearly
delineates the need to address the psychological, socio-cultural, environmental, politico-
economic factors as well as the physical factors which influence the activities of living
(Bellman, 1996).

I shall now examine Jim¶s nursing history based on the assessment that was completed when
I first came into contact with Jim. Emphasis will be placed on the main issues for Jim,
namely, breathing, diet and mobility. There will also be a discussion of any initial nursing
care that Jim had received prior to me doing this particular assessment.

Jim¶s greatest health issue at the time of the assessment would have to be his COPD which
when I carried out his assessment, he had just recently been diagnosed by his consultant at
the out-patient¶s chest clinic he went to at his local hospital. However, he had been required
to carry with him oxygen cylinders and was using a nose cannula if his breathing appeared to
deteriorate throughout the day. He also was prone to developing chest infections on quite a
regular basis.

As mentioned in the introduction, Jim had lost a significant amount of weight recently and
also that there had been a significant decrease in food and fluid intake. I discussed Jim¶s
situation with my mentor and it was decided that a nutrition evaluation must be undertaken to
determine if he was indeed suffering from malnutrition. After I had examined Jim¶s medical
notes it did appear that he had lost significant amounts of weight, put the weight back on and
then lost it again in the past. The staff in the care home discussed this with me and they stated
that when Jim had a chest infection he was always µoff his food¶.

The issue of Jim¶s mobility appeared also to be a concern as the assessment I completed
determined that Jim was a fall and moving and handling risk. I discovered from Jim¶s son
(who was Jim¶s carer before he began living at the care home) that Jim had a previous history
of falls and now used a walking frame all the time. He is not independent however, even with
the walking frame and requires assistance to move around and stand from a seated position.

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There also appeared to be concerns for Jim when he used the toilet as he was having
problems with diarrhoea one minute and constipation the next. I did not discuss it at the time,
but I was thinking that perhaps he would benefit from a colonoscopy to determine if he was
suffering from a health issue concerning his bowels. Perhaps in future cases like Jim¶s I could
talk a bit more about my concerns to other medical staff and see if they agree with me or not.

A list of other health issues can be found in the list of nursing diagnoses:
À‘ Communication impaired/decreased
À‘ Confusion ± at times
À‘ Coping
À‘ Diarrhoea ± at times
À‘ Fluid volume deficient
À‘ Falls, risk of
À‘ Memory
À‘ Mobility ± walks with aid
À‘ Nutrition, imbalanced
À‘ Pain, varying amount
À‘ Pressure ulcers, varying grades
À‘ Problems with decision making
À‘ Self-care Deficit: Dressing/Grooming
À‘ Self-care Deficit: Toileting
À‘ Skin integrity slightly impaired

According to the Royal College of Nursing (2006) systematic and sensitive assessment has been
a key requirement of government policy in primary health and community care. A multi-agency and
multidisciplinary partnership enhances patient care, prevents the waste of valuable resources, and
could have a positive impact on the whole of the health and social care system for older people.

In general, outcome measurement has focused on a health gain or health maintenance score, or an
overall wellbeing result (French, 1997). However, because quality of life is difficult to define and
even more difficult to measure - particularly with physically and mentally vulnerable people -
outcomes from nursing in continuing care are not easily articulated (Royal College of Nursing, 2004).

As a result of Jim¶s assessment being taken it was determined that other members of the
multi-disciplinary team should be contacted. Therefore, the incontinence nurse was contacted
as it was felt that this issue needed investigation immediately. There was a referral to a pain
management nurse, as this particular nurse worked in the same office as the district nurses
that I was shadowing. It was felt necessary to contact a dietician to get the ball rolling with
regards to talking to Jim and Jim¶s carers about using supplement drinks on top of the diet he

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already was being given in the care home. Although Jim had pressure ulcers, it was felt that
these could be treated by the district nurses themselves and if necessary a tissue viability
nurse would be contacted if the ulcers were to deteriorate further.

The assessment that I completed appeared to go reasonably well. There was only a short time
in which to complete the assessment as the district nurses had a lot of visits on the day I did
the assessment. I would have liked to spend more time with Jim ton discuss his care. I also
felt that some of Jim¶s characteristics did not always fit neatly into the boxes of the Roper,
Logan and Tierney assessment tool.

This is echoed by Walsh (1998) who states that the nurse must be free to explore detailed
areas with patients that do not have headings on the assessment plan. It may well be that
patients want to talk about things that do not neatly dovetail with the headings devised by the
author of the model. The model does not seem to take into account any spiritual or sexual
matters and does not bring the issue of the patient possibly dying into the assessment. I take
the stance that one must not automatically assume that a patient doesn¶t want to talk about
dying or sexual matters with a nurse. They may feel that the nurse is easier to talk to than
perhaps, the patient¶s family or a doctor and because of how the assessment form is
constructed, that opportunity may be lost for the patient (Clark, 1992).

PART TWO

The second part of the assignment focuses on the nutritional assessment that was undertaken by me.
This was done by using the Malnutrition Universal Screening Tool (MUST). According to the
Malnutrition Advisory Group (2005) it is estimated that, at any one time, at least two million
adults in the UK are affected by malnutrition. The more vulnerable at risk groups include
those with chronic diseases, the elderly, those recently discharged from hospital, and those
who are poor or socially isolated. Malnutrition in the older person is a frequent and serious
problem (Chen et al, 2001) and often goes unnoticed, mistaken for signs of ageing symptoms
of underlying disease (McLaren et al, 1997). Untreated it will lead to increased mortality,
morbidity and influence overall well being.

I think that it is important to understand a little about an older person and their nutritional input and to
ask oneself so questions when carrying out an assessment using the MUST tool to determine nutrition.

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For example, the older person is likely to have lower activity levels and lead a more sedentary
lifestyle than younger people. They are also likely to be receiving medication that may cause
side effects (e.g. nausea, constipation and altered appetite) (Holland, et al., 2003). Another
possible issue could be a decrease in the ability to handle food and cutlery perhaps due to
arthritic hands or mental capacity, difficulty with shopping and cooking, declining oral health
and ill-fitting dentures, as well as loss of senses such as taste and smell, can contribute to
malnutrition in the older person.

In addition, I think that it is important to have in the back of one¶s mind that assessment of
individual eating and drinking needs will obviously depend very much on the patient¶s health
problem(s) or medical diagnosis(es). Past history of their patterns of eating and drinking are
an essential part of the nursing assessment.

As the MUST questionnaire used in the assessment was split into five different stages I
thought that using the MUST document was relatively easy and was set out in an algorithm
that could be followed with relative ease by any nurse or health care professional who used it.
However, as mentioned previously the assessment that I carried out was fairly rushed and I
would have liked to have spent time talking with Jim about his concerns and also perhaps
have a conversation with his carers or his son who, I am sure could have enlightened me
about Jim¶s health issues better than if I were to just fill in a form about the patient myself. I
also thought that the MUST tool did not offer much scope into the depths of understanding
the medical issues that were brought forward during the interview. The MUST algorithm was
handy to use, but I felt at the time of the assessment that it did not offer a thorough picture of
the patient¶s health issues. This may work well in the community as the assessments there I
found were done very quickly, but the MUST tool may fall short in providing a full picture as
to the patient¶s needs and does not take into account previous history of malnutrition.

 



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