– Experiencing Long-term Care, Rehabilitation & Recovery (BSc Adult Nursing)
Assessment Title: CASE SCENARIO ESSAY
This assessment is a 2500-word essay
Scenario 1
Roger Palmer, who is 40 years old, has a history of shortness of breath and chest pain. He was admitted to the Emergency Department, where he was diagnosed with Myocardial Infarction. After the initial assessment, he received a stent and underwent outpatient cardiac rehabilitation
Roger lives with his wife and two young children in a rented house. His wife is not working, as she is solely responsible for looking after the children. Roger has become extremely anxious in relation to his life expectations, particular in relation to paying all the bills. He is severely depressed and is not engaging in any activities with his family.
In relation to Roger’s circumstances, discuss two of the following themes of care:
• Continuing Care
• End of life & palliative care
• Quality Of Life Issues
• Health promotion / lifestyle modifications
In relation to the chosen scenario and using the relationship-centered framework, critically discuss the role of the nurse and other health care professionals in providing evidence-based care for adults with long-term conditions. Consider how the relevant sense/s of relationship-centred care model (RCC) influences the care requirements of the person and critically evaluate two of the themes of care for people with long-term conditions
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Assessment Specification
1. Using the case scenario as an example, you should critically discuss how one of the six senses (from the relationship-centred care model) identified in the case scenario influences/underpins the care given to the person.
2. You should also consider two themes of care & discuss why they may be relevant to the provision of care to the person in the scenario and to people with long-term conditions.
3. The assignment should be structured in essay style & subheadings may be used. The introduction should include a brief description of what you propose to discuss in relation to care & how you will consider some of the themes that may be relevant to the person’s scenario (& how they may relate to other people with similar long-term needs).
4. Draw on theory and peer-reviewed literature to critically discuss what is known about the issues around long-term management (e.g. what is known about long-term catheterization; drug concordance/compliance). You should consider this in relation to the needs of the person in the scenario and in the context of their condition. Critically reflect on the implications of the evidence from the literature – how it might influence practice and support of people with long-term conditions.
The following list contains some suggestions for your discussion:
• Overview of assessing the person’s care needs (& those of others with long term conditions).
• Consideration of environmental aspects (e.g. housing; finances) and how these may impact on the person’s quality of life & care-delivery.
• Consideration of assessment tools, decision-making skills & multidisciplinary approaches to supporting the person and their family.
• Consideration of relevant policies, frameworks, benchmarks that impact on the care of the person.
• A review the recent health care initiatives/guidelines and how they may have impact on the patient in the scenario and their families (for example Gold Standards Framework; Expert Patient Programme, etc.).
• Reflection on current service provision and recommendations for improvement/change & examples of good practice.
Pass Mark
You are required to achieve the minimum pass mark in each assessment – The pass mark for this assessment is 40%.
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Assessment Criteria
Please consult the grade related Assessment Criteria below, for descriptions of the level of skills, knowledge or attributes you need to demonstrate in order to achieve a certain grade or mark in this assessment – the assessment criteria indicate the proportion of marks allocated and feedback on your work will be based on these.
Assessment Criteria: In relation to the chosen scenario and using the relationship-centered framework, critically discuss the role of the nurse and other health care professionals in providing evidence-based care for adults with long-term conditions. Consider how the relevant sense/s of relationship-centred care model (RCC) influences the care requirements of the person and critically evaluate two of the themes of care for people with long-term conditions. Proportion of marks (optional)
Clearly presented & Structured to follow a logical and coherent order:
You will use
• Same font (Arial, size 11) used throughout
• 1.5 line-spacing
• Clear Introduction, body & conclusion
5%
Correct citation practice is used throughout the essay. An accurate and completed reference list is presented.
You will have:
• Used Harvard system of referencing
5%
Considers how one of the six senses of relationship-centred care model (RCC) influences/underpins care requirements.
You will have:
• Clearly identified which of the six senses you have chosen to discuss
• Made clear links between the chosen sense and the care requirements
10%
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Critically discusses key policy frameworks which influence care (within the chosen scenario) for people with long-term conditions and their carers.
You will have:
• Identified at least two policies/frameworks (e.g. NICE guidelines; National Service Frameworks; Expert Patient Group)
• Made clear links between these policies/frameworks and the chosen scenario, in relation to the provision of care.
15%
In relation to the chosen scenario, critically discusses two of the themes of care for people with long-term conditions.
You will have:
• Clearly identify which themes of care you have chosen and stated their relevance
• Critically discussed care-provision in relation to the theme and the scenario.
40%
In relation to the chosen scenario, considers recommendations for improvement/change and implications for practice.
You will have:
• Made recommendations for practice improvement.
15%
Draws upon a broad range of contemporary (peer-reviewed) literature to reflect a depth and breadth of reading.
You will have:
• Used current, peer-reviewed literature to underpin the provision of care for the chosen scenario.
10%
can you correct the one I wrote below according to the instructions above
Proportion of
mark available
Proportion of
mark awarded
Comment
Clearly presented & Structured to follow a logical and coherent order
5%
3% You have attempted to present this clearly, although your essay did not always flow in parts.
Correct citation practice is used throughout the essay. An accurate and completed reference list is presented.
5%
2% You need to refer to the University guidelines there are errors both in you essay and your reference list, for example there is no need to have the author first name initial in your text and in your reference list you need to cite all the authors not just et al.
Considers how one of the six senses of relationship-centred care model (RCC) influence care requirements.
10%
3% It appears that you have discussed two significance and purpose from the 6 sense framework. While you have recognised the importance of these and the effect on the patient it was sometime lost in what you were trying to say.
Critically evaluates key policy frameworks which influence care (within the chosen scenario) for people with long-term conditions and their carers. 15% 2% There is no evidence that you have critically evaluated key policy frameworks or even in fact considered any, you briefly mention the Gold Standard framework, but this is not developed, although you do allude to some frameworks
In relation to the chosen scenario, critically evaluates two of the themes of care for people with long-term conditions. 40% 12% You have identified health promotion and continuing care. In both themes you do have some valid and interesting points however they were largely underdeveloped and much of your discussion was descriptive, for example, components of a healthy diet and self-help groups. You need to consider and understand cardiac rehabilitation programmes as they are in fact quite short not long; you needed to use the research to support your discussion on depression and patient post MI. He would not be referred to an urologist if he had difficulties in his physical relationship, you would need to consider first the psychological effects and possible drugs that he might be on. A financial advisor possibly would charge for this service, how else do you think this could have been managed?
In relation to the chosen scenario, considers recommendations for improvement/change and implications for practice. 15% 4% Your recommendations appear to come in your conclusion, while you have made some recommendations they are quite generic.
Draws upon a broad range of contemporary (peer-reviewed) literature to reflect a depth and breadth of reading. 10% 3% This is very limited. There is literature that you could have used to support your discussion more.
100%
0.00%
29
Overall comment (referring also to the grade related criteria):
unfortunately this is a fail you demonstrated limited understanding and it appears that you have not grasped the key issues. There was limited development of ideas and you could have used the literature more to support you. Presentation is not always that clear.
Please can you seek tutorial before you resubmit this work.
Scenario 1
Introduction
Mr Palmer Roger is a forty years old man who had a Myocardial infarction .After receiving a stent he underwent cardiac rehabilitation. A stent is a wire mesh stainless steel tube that holds an artery open and keeps it from closing again therefore improving the blood flow. A good blow flow will reduce the chest pain and the probability of a blood clot forming. Cardiac rehabilitation is a program advised by NICE (2005) for people who had a myocardial infarction and their goal is to help them resume a normal life as soon as possible. It provides good quality essentials care that should improve the quality of life and implement long term lifestyle changes. In this essay will show how by using a person centre approach, his rehabilitation can enhance his sense of purpose and significance, giving him back his dignity by focusing on him as an individual. The emphasis will be on the sense of significance as he seems to be struggling with his role within his family will also focus on the continuing care theme that then lead to Health promotion and lifestyle changes. How cans a nurse, using the resources available and in collaboration with other health professional, provide a full package containing the necessary requirements to achieve the goals stated above: A fairly normal life after a myocardial infarction.
Continuing care
The nurse must also thrive to establish a trusting relationship and establish a good communication with the patient as she/he is the first point of contact after the discharge from hospital. A sense of purpose is important for Mr Palmer as he is so anxious about providing for his family that he is sinking into depression. A sense of purpose is about setting yourself achievable goals (Nolan M.,2006) Nice guidelines recommend cardiac rehabilitation after myocardial infarction as soon as possible to help patients to resume their usual life to as quickly as possible(Nice,2007). A cardiac nurse can help by assessing his needs and abilities to make a personalised program after consulting with him on his availabilities. Helped by “The stepped care model”(NICE, 2009a) a nurse role is to identify, access the most effective interventions and make it available for the patients (Haddad M.,2009).It is a step by step intervention based on the least disruption that can be cause to the patient life. Transport, location, the person like and dislike and even routine are taken into account. This enhances his sense of significance as he has a voice and power of decision on his care. A sense of significance is about feeling that you matter as a person. The nurse should also keep in contact with Mr Palmer even after referring him to a different specialists and professional bodies. This will served two purposes: for the nurse to be up to date with Mr Palmer progress and reassess his priorities when needed but also to treat Mr Palmer with the respect and dignity he deserves as he is not just a number but a person that matters(Significance). As the cardiac rehabilitation is a long term process, Mr Palmer should continue with his program which involve being screened for anxiety and depression, tailored made exercises, education about the medications as well as the lifestyle changes that might needed to be implemented. An emphasis should be put on treating his depression as that can lead to a lot of complications such as:
? Medication compliance, which is the extent to which the patient follows medical or health advices concerning his medication (Pinikahana et al., 2002), necessary to his recovering. That can be him not taking his medication or not implementing the necessary lifestyle changes. The nurse, by actively listening to Mr Palmer and his fear for his future and family can reach a common ground where a shared decision concerning his medication can be reached, if not she can refer him to other professional such as a psychologist. Sometimes expressing and communicating your concerns might help you feel more in control of the situation and not just being a patient or transparent (BHF,2013). Talking can help with his sense of significance. Mr Palmer can go to his GP who can then refer him to a counsellor via the NHS. There are also independent organisations that provide help and support such as:
Samaritans which offer confidential, emotional support for anyone who wants to talk to someone supportive and non-judgemental. Call the helpline (24 hours): 08457 90 90 90 or email Samaritans Anxiety UK helpline if you want to speak to someone about your anxiety. call 08444 775774 (open 9.30am to 5.30pm, Monday to Friday) Mind Infoline for information on mental health problems and treatments, call 0300 123 3393 or email Mind Relate for relationship and family counselling and advice: in person, online and by phone. Call 0300 100 1234. There are also a lot of patient group on the internet or around his area with a same shared experience where he can get tips on how to cope after a myocardial infarction, make new friends and stars to interact again with others.
? Depression can create a big rift with his family as he is not engaging with them. After being assessed by the nurse, he can be referred to a specialised counsellor or a psychologist for a Cognitive Behaviour Therapy. The aim of this therapy is to treat depression and low perceive social support. It is thought to improved depression and social isolation. Cognitive behaviour therapy is made of personalised counselling sessions fitted to solve specific needs such as behavioural and social skill deficits, perceived or real therefore the therapy is based on the professionals’ opinion but on Mr Palmer’s needs, opinion, availabilities and abilities. By engaging him in his care and addressing his needs served his sense of significance. This type of therapy also addresses the social interaction or lack of it, and encourage the development of new relationships as well as the strengthening of the old ones. In Mr Palmer case, it take into account his family situation with the aim of making the relationship with his family more functional, supportive, and satisfying (JAMA, 2003).The cognitive behaviour therapy focus on short term, practical and small achievable goals on keys areas. That can boost Mr Palmer confidence and enhance his sense of purpose as the task at hand is less daunting and he is only asked to change the aspect that he can control.
? If Mr Palmer is experiencing some physical problems in his relationship that affect his love life, the cardiac nurse can also refer him to an urologist who can determine if the cause is physical rather than psychological.
? As one of the causes of Mr Palmer’s anxiety is his uncertainty on being able to return to work or perform as before, the nurse or his GP can refer him to a financial advisor in his area where he will be advised on the different benefits and/or taxes he is entitled to. Some workplace have schemes like “gradual return to work programmes” to help employees who have suffered a long term illness to come back to work. It is a combination of psychological rehabilitation including confidence building, counselling or cognitive behavioural therapy (McCulloch A.,2013 )
The social service can also be approached by the nurse to look into his accommodation needs and help in that domain. Although the study was based on Multiple sclerosis sufferers, a new trend in the way health professionals and services users work hand in hand in a pro-active manner destined to provide needs to care services can be extended to all long term illness (RCN, 2009).Social services are nowadays part of the care package. The Gold Standard Framework underlines the importance of social care professionals working in partnership with health professionals in the delivery of a more suitable care even though it is mostly used in the end of life care.
Health promotion/Lifestyle modification
Health promotion is a normal continuation of the cardiac rehabilitation after a myocardial infarction. Stents help to prevent arteries from becoming narrow or blocked again after a percutaneous coronary intervention also referred to as coronary angioplasty. However, stents are not a cure for atherosclerosis or its risk factors such as a myocardial infarction. Making lifestyle changes can help prevent plaque from building up in your arteries again. Lifestyle changes can mean changing your diet, quitting smoking, being physically active, losing weight, and reducing stress. They are adapted to Mr Palmer and abilities in order for him to achieve the maximum possible outcome. There are guidelines but no standards lifestyle changes, each program is unique and tailor made. This will build up Mr Palmer confidence by reinforcing his sense of significance. You also should take all medicines as your doctor prescribes, for example taking statins, which are medicines that lower blood cholesterol levels. As the nurse role is also to educate, an exercise program combine with healthy diet with or without a combination of anticoagulant and statins can be implemented and taut. Statins are medicine that decreases the level of bad cholesterol in the blood (BHF, 2013).She can in the other hand refer Mr Palmer to physiotherapist and a dietician. Some aspects of the healthy diet that can be put in place are:
Fats
Do not have more than 200mg of cholesterol a day. Less than 35% of the daily calories should be fat. It is advisable to used preferably unsaturated fats such as olive oil, rapeseed oil, almonds, avocado, sunflower oil and vegetable oil, walnuts, sunflower seeds, unsalted cashews and oily fish as they are a healthier choice than saturated fats.
Fibres
Food high in fibre averts the gastro intestinal tract from absorbing cholesterol. They are starchy foods like whole grain cereals, brown bread, rice, pasta, oat, potatoes, etc…
Fruits and vegetables
Although it is recommended to avoid grapefruit and grapefruit juice, a minimum of five portions of fruits and vegetables a day is recommended. They can be eaten in any form, fresh, frozen, canned, as a juice or dried. Sterols, cholesterol lowering compounds are found in fruits. They act like soluble fibre.
Proteins
Non-dairy source of protein like meat, beans, eggs and fish are recommended also. They are good canned or fresh. Fishes rich in fatty acid and omega 3 reduce further the risk of another attack by reducing the probability of a blood clot and an inflammation.
Salts
Too much increase the risk of another heart attack. It is recommended to eat very little quantity. Also choose the option of no added salt or low salt content. The information about the quantity of salt included in the precooked meal can be found on the packaging under the heading Nutrition facts label.
Alcohol
Reduce the intake of alcohol at two glasses for men and one glass for women.
Be active
But the most important part is to choose the activities that you enjoy and do them at a time that suit you ,making the being fit an enjoyable experience rather than a chore. That also enhaces the feeling of being in control of your life and a more dignify way of dealing with your illness.
Stop smoking
Nicotine, which is a tobacco product, stimulates the release of inflammatory enzymes like catecholamine and the increase of fibrinogen, platelets by damaging the arterial endothelium. The continuous irritation of the endothelium can lead to atherosclerosis. The same pathogenesis is observed on passive smoker but at a lower degree so, enrolling in a stop smoking program, if he is a smoker, will not only improve his health but also his family. (Powell J., 1998).It will also help to improve his finance as smoking is an expensive habit. A lot of GPs and pharmacy offer this type of program free of charge.
Weight reduction
For overweight people, a weight management plan is advisable. It does usually involve multidisciplinary professionals such as a cardiac nurse, a nutritionist, a physiotherapist and according to the patient condition a surgeon.(BHF,2009)
Conclusion
The nurse is like the centre place from where a patient is directed, helped, advised, educated, informed and supported in his journey to live a normal life as possibly can( RCN,2006). But a nurse working in collaboration with different services provide a better and more appropriated care by helping the sufferer only when needed, giving him more freedom to decide on his life. Some framework can be copied from one discipline to another. Certain employers have implemented a return to work scheme in the companies but it is mostly base on people with hearth disease on its own, it lack substances as the staff is not properly trained to deal with long-term illness such as depression. The stigma of being label is also still very strong and prevents the patient form being open about their illness. This points out the need to upgrade the role of the occupational health in the workplace, and provide them with broad range of training. A healthy diet can still be achieved on a budget because a balance diet is having most of the food group in your diet in reasonable proportion. By being educated on the food he can eat and involving the whole family in the care, the nurse can help mend the rift cause by the depression. By adapting all aspects of his after care to the needs of the service user, nurses and all the health professionals can provide a high standard of care that boost the sense of significance.
Combining exercise, diet and counselling have proven to reduce the reoccurrence of the myocardial infarction when compared to usual care. Keeping up with these lifestyle changes in patients after the cardiac rehabilitation has greatly decrease according to the statistics therefore we can assume that there is an issue that need to be address to keep the patients on the right track (Nice, 2007). I think putting the emphasis on the patient as an individual whose needs are unique can help a great deal but with the budget cut the NHS is suffering from, this task is very flawed at the present time as the Francis report exposed a lot of lacking. One victim of the cut is emergence of the medication lottery; some drugs availability is dependant of the area you live in as each trust make the recommendation base more on the cost effectiveness rather than its benefits (BBC, 2012). Nevertheless the dedication of nurses and caring nature of people enrolling in the on hands health care professional still succeed in providing person centre care despite the institutional restrictions.
References
? BBC,2012, Inside Out: Child cancer drug ‘postcode lottery’ revealed Available on http://www.bbc.co.uk/news/uk-england-london-20272912. Access on the 10/04/2014
? BHF, 2013, Cardiac rehabilitation, available on http://www.bhf.org.uk/heart-health/living-with-heart-disease/counselling.aspx. Access on the 15/04/2014
? Dr McCulloch A., 2013, Returning to work: The role of depression available at : http://www.mentalhealth.org.uk/content/assets/PDF/publications/returning_to_work.pdf?view=Standard. Access on the 15/04/2014
? Mark Haddad ,2009, Depression in adults with long term conditions 1: how to identify and assess symptoms available in http://www.nursingtimes.net/nursing-practice/clinical-zones/long-term-conditions/depression-in-adults-with-long-term-conditions-1-how-to-identify-and-assess-symptoms-/5009329.article. Access on the 15/04/2014
? NHS, 2006, Gold Standard Framework. Available at: http://www.goldstandardsframework.org.uk/patients-amp-carers. Access on the 22/04/2014
? Nice guidelines, 2007, MI: Secondary prevention in primary and secondary care for patients following a myocardial infarction. Available at http://www.nice.org.uk/nicemedia/pdf/CG48NICEGuidance.pdf. Access on the 25/04/2014
? Nolan M. et al, 2006, The Senses Framework: improving care for older people through a relationship-centred approach. Getting Research into Practice. Report No 2. Available from Sheffield Hallam University Research Archive (SHURA) at: http://shura.shu.ac.uk/280/. Access on the 25/04/2014. Access on the 6/03/2014
? Pinikahana et al., 2002, p. 514,Service users and carers perspectives on medication compliance in mental health services a qualitative study. Available at http://www.rcn.org.uk/__data/assets/pdf_file/0008/446597/2012_RCN_research_4.5.2.pdf. Access on the 15/04/2014
? RCN, 2006, Developing Integrated Health and Social Care services for long term conditions. Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0008/78704/003051.pdf. Access on the 20/04/2014
? Vascular damage from smoking: disease mechanisms at the arterial wall by Janet T. Powell Vasc Med 1998 3: 21. Available at .http://vmj.sagepub.com/content/3/1/21). Access on the 03/04/2014
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