The on to the discussion on the

The purpose of this essay is to analyse and reflect on a scenario of patient identified as Samara. The essay will begin by defining the process of nursing assessment and moving on to the discussion on the negative and the positive aspects on Samara’s assessment. Also identify any missing data from the nursing assessment and rationale the support in relation to the care that Samara received. Further to emphasis on one specific area of the nursing assessment, with a critical examination of the advanced therapeutic interventions that could be implemented in this area. Finally, the essay will conclude with a brief examination on Samara’s nursing assessment to consider whether the proposed interventions would be helpful and suitable for future recommendations. Confidentiality will be maintained throughout the essay as required by Nursing and Midwifery Council (NMC, 2015).
Samara Ahmed is a 22-year-old woman with a mild-moderate learning disability and is overweight. Samara loves sweet foods, especially chocolate, cakes and biscuits. Recently she moved into a supported living environment, in which shares with 2 other people, Samara has gained more weight since moving and does not like discussing it. Also, she has been refusing personal care causing unpleasantness for her housemates and support staff. These raises concerns as she wants to prepare her own food and refuses to wash her hands and her nails are dirty with faeces. Samara becomes physically (slapping or scratching) and verbally (screaming and swearing) aggressive if she is challenged or questioned about the food intake and personal care.
The term nursing assessment defines as the procedure of gathering, validating and recording of data to detect and predict the patient’s current and forthcoming health needs in daily practice (Berman et al, 2010; Wilson, 2014). A nursing assessment is the first phase of the patient being diagnosed in a nursing process, to form the foundation of the care plan (Oxford dictionary for Nurses 2017). This is a systematic approach that supports the values that is outlined by the 6Cs of nursing (DOH 2012). Therefore, a strong knowledge about health is significant as it ascertains which assessment information would be gathered. Health is defined by World Health Organization as “state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (WHO, 2001). An all-inclusive assessment allows healthcare professionals to ascertain and implement nursing interventions to improve the patient’s health such as their well-being and quality of life (Wilson et al, 2014). This will involve the patient’s mental, physical, psychosocial and spiritual, along with cultural needs (DOH, 2003; NMC, 2015; Ingram, 2017). This approach is known as holistic, which signifies best practice in nursing assessment. Also, this method of care is where the patient is considered as person and not merely treated due to the physical condition or symptoms of a disease (Blair, 2012). This will be used as the basis for evaluating the comprehensive nursing assessment for Samara.
Samara’s nursing assessment covers her communication levels and social needs along with her current nursing issues. Also reflects on her strengths and weaknesses that will help the nurse to recognise areas that can be worked on in terms of health promotion (Berridge and Liddle, 2010). Effective communication is multi-factorial phenomenon and essential aspect which improves nurse-patient relationship that are shared in patient care. Also, it has a profound effect on the patient’s perceptions of health care and treatment.
(Li, Ang and Hegney, 2012; Davies, 2012). In addition, Samara’s capacity assessment has been fully completed to signpost the significance in the planning of her care. This decision on her capacity gives consent for her opinions and views of Samara to be considered. The existence of this documentation suggest that a complete assessment has taken place, this shows that Samara can contribute in decisions about her own healthcare needs. However, this means that Samara lacks full capacity to make informed choices and shows lack of capability to fully understand the consequences of such decisions (DoH,2012). This documentation allowed the multi-disciplinary team (MDT) to quickly identify Samara’s capacity throughout the nursing assessment (DoH, 2012).
The nursing assessment identified Samara preferences in visual cues to help her as reminders on any discussions in MDT meetings or her care. Both Samara and her father have proposed use of symbols and pictures. This explains the nature in which the assessment was carried out, in terms of Samara’s involvement with her on-going care (Wheeler, 2012; Lewis et al., 2017). Samara’s father was present for the assessment process; as she had previously wished her father to be present for any assessments or MDT meetings. This is good practice, as this will help Samara feel safe and supported, as well as her self-worth and privacy are protected (NHS ENGLAND, 2014: Wahlin and Idvall, 2009). Also, it will help to remain calm and feel like someone is listening to her (Berridge and Liddle, 2010). The nursing assessment considered Samara’s ethnicity, culture and communication. Although Samara and her father are Muslims, (not practising) and they mostly speak English (NMC, 2015). This is good nursing assessment practice, as it signifies that Samara is treated as a person in provision of care. Differences in culture, spiritual needs and language varies, often means the patient’s needs are unlike those that are first predicted, therefore, so it is vital that these needs are considered during nursing assessment (Andrews and Boyle, 2016).
The significance of record-keeping is key in all aspect of the nursing assessment process. For example, inadequate record-keeping causes errors therefore can have a negative impact on the care Samara will need. In the assessment, contact details for the general practitioner (GP), next of kin and other people that are involve in Samara’s life needs to be completed. Evidence in literature suggests that it is best practice to have more than one next of kin in case the named person cannot be reached when completing a nursing assessment, for emergency purposes (Wheeler, 2012). To complete more comprehensively assessment; full names and full addresses, along with telephone numbers postcodes to avoid any mistakes. As such confusion could lead to personal information is sent to the wrong person; this may lead to legal issues with confidentiality (Blightman et al., 2014; NMC, 2008).
The document shows obvious gaps in the nursing assessment which have not been recorded, such as Samara’s vital signs (blood pressure, temperature etc). However, the respiratory rate was recorded in the assessment, possibly Samara was not presenting with any aggressive behaviour at the time of the assessment. Moving on to the importance of urinalysis; this test will enable the nurse to examine Samara’s urine sample, such as its colour and odour. This will provide valuable information about various illnesses, such as urinary tract infection(UTI), diabetes mellitus and kidney diseases (Steggall, 2007; Dreyer, 2010). Furthermore, given that Samara’s dietary is mostly made up of sugary foods and high in fat, there is a chance that glucose may be present in the urine (Mitchell, Thomas and Langlois, 2013). In addition, family history can be an effective tool to detect any underlying disease which has not been recorded in the nursing assessment. This can be used for risk stratification and personalised screening for diseases for hereditary services or interventions (Hu -Genet,2013; McClellan, 2013).
Moreover, Samara’s nursing assessment signposted uncompleted up-to-date risk assessment. Another missing piece of documentation that is crucial and must be completed as soon as possible. In reference, to Samara there are numerous risks present and the risk assessment is essential in terms of managing Samara behaviour properly (National Patient Safety Agency, 2004). Although Samara’s learning disability (LD) recognised as ‘mild to moderate’, there have been various risks identified in relation to her behaviour. It has been found that she can become verbally and physically aggressive to others, and this is regularly triggered by discussions regarding her dietary and recent weight gain. Despite this being identified that she can be violent towards others, safety measures have not been completed in her nursing assessment. Such issues, along with the risks related with her lack of management over her personal hygiene and refusal to follow a healthy diet, must be reassessed. Further to be included in Samara’s risk assessment and safeguarding documents (DoH, 2006). These documents will be used by staff and MDT as an ongoing guide at her supported living. Also, this will ensure any concerns to those who come in contact with Samara, therefore aware of the risks and how to manage these risks.
Another beneficial assessment to Samara, is her vision and hearing which have not been assessed. These two areas are mostly ignored, leading to non-compliance to her care plan and lack of understanding (Holmström, 2014; McClimens, Brennan and Hargreaves, 2015). Lewis et al (2017) suggest that hearing and vision difficulties leads to frustration and confusion, predominantly in people with learning disabilities. Therefore, such issues should be considered before carrying out comprehensive person-centred nursing assessment. Particularly when Samara lacks mental capacity and has communication difficulties with hearing and seeing (Lewis et al., 2017).
The nursing assessment has proposed several nursing interventions that should be implemented to help Samara. The first intervention is related to Samara’s personal hygiene; as noted by carers, nurses and Samara’s father, even the people at her dance class. Samara’s skin has been described as dirty and have been observed to have faeces underneath her fingernails. The key nursing intervention here is to generate an individually-tailored personal hygiene routine for Samara, to ensure that her personal hygiene, such as oral and skincare can become a daily priority (Carnaby and Cambridge, 2006). This is clearly the most essential and most complex intervention that Samara needs.
The various members MDT needs to make a referral and follow-up for Samara. would be and follow up from various members of the MDT and These will include an Occupational Therapist (O.T) to make an adaptation to facilitate management in personal hygiene, such as walk-in shower, handles, shower chair handles and visual cues (Soderback, 2015). A visit to the GP for an annual health checks and screening, as this will indicate early discovery and adjustment of risk issues for disease and illness and a dietician for support with weight loss and management (Raines, 2010; MacDonald-Wicks, 2015). Also, psychologist to resolve and identify any difficulties or experiences Samara may be suffering due to separation from her deceased mother and behaviour management (Ogden and Simmonds, 2014). Finally, a learning disabilities nurse (LDN) to act as an advocate to support and empower her and physiotherapist to assist and support an increase in muscle tone