Mr Valentine attended an appointment with his optometrist who refereed him to the Eye Centre at a local hospital stating that he was suffering from a cataract. The eye centre is an ophthalmic day case unit which serves both ophthalmic surgical and medical patients. When Mr Valentine was seen at the eye centre by an ophthalmologist consultant, further investigations revealed that he was suffering from a nuclear age related cataract. The treatment deemed appropriate for this condition was a cataract extraction and the insertion of an intra ocular lens under a local anaesthetic. This treatment was discussed between Mr Valentine and the Consultant and a pre operative assessment was then made in line with Department of Health Guidelines (2000). Brooker et al (2007) state that the aim of a pre operative assessment is to ensure that each patient receives holistic planning for a safe and dignified surgical experience. Informed consent was obtained from the patient for a nursing assessment to be made (NMC 2008). A nursing assessment was used to obtain and record his past and present history in a holistic manner. The following information was taken and recorded.
The patient Mr Frederick Valentine, is a Caucasian 79 year old male. Mr Valentine used to be an engineer and worked for the same company for over 50 years. He retired almost 14 years ago and misses his job very much. Fred has been a widow for 8 months now and finds it very difficult to talk about his wife. Fred feels that he is slightly depressed and his doctor has prescribed him some medication for depression which he takes when he remembers. He lives alone in a bungalow rented from the local council and receives a state pension on a weekly basis. He has two daughters whom he has very little contact with. This is due to the eldest daughter living in Scotland and the younger daughter living in Canada. They telephone him occasionally but he has not seen them since their Mothers funeral. Fred has a dog that he describes as his best friend. Fred suffers with poor mobility and uses a Zimmer frame to walk.
Due to this lack of mobility he misses taking his dog for walks. Since the age of eleven Fred has been deaf in his right ear and wears a hearing aid in his left ear. In 2008 he suffered from two myocardial infarctions. Mr Valentine describes himself as being in good health apart from his current condition with his vision and lack of mobility. Mr Valentine attends his local Church and is a practising Catholic. He attends luncheon clubs at his church on a Tuesday afternoon and enjoys reading novels and watching wildlife programmes and sport on the television. Due to the lack of visual acuity he has been struggling to read and watch television and feels unsafe when walking around outside of his home. Fred is on medication for high blood pressure and is a non smoker.
Upon Mr Valentines admittance to the eye centre the nursing assessment used was an adaptation of the Roper, Logan and Tierney model (RLT). Nursing models provide guidance for nursing practice which leads to enhanced quality care for the patient (Mooney et al 2006). Aggleton et al (2000) also states that a nursing model gives direction to nurses to guide them in decision making. This should enable a continuity and consistency of care. The RLT model is used in conjunction with the nursing process. The nursing process consists of four stages. These are assessing, planning, implementing and evaluation (Seaback 2006). See Appendix 1. The first stage in the nursing process is assessing the patient as an individual. The most important aspect of nursing assessment is taking a full holistic history of the patient (Lloyd et al 2007).The RLT model is extremely prevalent throughout the United Kingdom (Healy et al 2003) and is based around five interrelated areas which create the model of living (Holland et al 2008)
These are the individual, the activities of living, lifespan, levels of dependence and independence and factors influencing the activities of living. Individuality of living is the way in which the individual will experience and carry out the ADLs differently (Marriner et al 2006). This will be affected by the other four remaining areas mentioned. There are twelve activities of daily living (ADL) which Roper et al (2000) states are essential for survival. See appendix 2. These are maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, working and playing, mobilising, sleeping, expressing sexuality and dying. These activities are not exclusive but many interlink with each other (Roper et al 1996). Upon assessment not all of the ADLs were presenting with any obstacles. The ADLs which were seen to need intervention were maintaining a safe environment and mobility due to his decreased sight, difficulty with hearing and problems with walking. The communication ADL is appropriate as hearing and non verbal communication in the form of eye contact is diminished (Rawlings 2004).
The lifespan on the continuum is linked to age. Beginning with infancy and moving through to old age. As Mr Valentine is 79 years old he moves along the continuum into old age. Age is closely linked with the dependence and independence continuum (Dingwall 2010). Newborn babies or young children are dependant on adults due to their age, but adults could also become dependant due to mobility problems requiring a wheelchair or requiring specialised equipment such as artificial ventilation required for survival (Roper et al 2000). As Mr Valentine relies on a walking frame to help aid in his mobility this is seen as dependence. The factors influencing the ADLs are biological, psychological, sociocultural, environmental and politicoeconomic Once the information is recorded a care plan based around the pre operative assessment can be created using the next step in the nursing process, the planning of care (Pearson et al 2005).
Mr Valentines ADLs the mobility aspect and maintaining a safe environment interlink with each other as his unsteadiness on his feet can create an unsafe environment. Due to this Mr Valentine was informed that a nurse will assist him with moving around the area. Also all obstacles were moved from around the bed area. Mr Valentine was given the call bell and asked to press the bell for assistance. As Mr Valentine has sensory obstacles due to his lack of hearing and poor sight he asked the nurse to speak to him either straight on or to his left side to aid with communication.
To show how the nursing process works in practice the author is focusing on the nursing intervention of the instillation and application of ophthalmic medication in the form of drops. Mr Valentine was admitted to the ward by the State Registered nurse and was made to feel welcome. The nurse began to complete a pre operative assessment and place an identity band on Mr Valentines wrist. He was then shown to the waiting area to be seen by the Surgeon for the procedure to be explained again and for consent to be obtained. Mr Valentine had been prescribed three different ophthalmic medications which were all mydriatic drugs required for cataract surgery (Steinert 2004). The nurse in the waiting room confirmed with Mr Valentine his name, date of birth, the procedure he was undergoing and which eye the surgery was on. These details were checked against the patients case notes and the identity band including the patients hospital number on Mr Valentines wrist to check that the correct medication was being given to the correct patient (Rosdahl et al 2008).
The nursing assessment had been made confirmed that this was the correct patient and the observations indicated that the pupil needed to be dilated ready for surgery. The planning stage in the nursing process was for the nurse to explain to Mr Valentine that ophthalmic drops were required to dilate his pupil and why this was necessary. Mr Valentine was also informed at this point that he must ask for help if he needed to mobilise such as going to the toilet as it had been documented in his pre operative assessment that his mobility was poor and the need to maintain a safe environment was of the upmost importance. The implementation stage in the nursing process is the instilling of the drops. The nurse explained to Mr Valentine that they may sting and can also leave an unpleasant taste in the mouth (Stollery et al 2005). The nurse proceeded to wash her hands as set out by the World Health Organisation guidelines. The expiry date was checked on the eye drops to make sure that they were in date (Dimmond 2003). Mr Valentine was then asked to gently tilt his head back and look up towards the ceiling. The nurse positioned her hand holding the bottle just above the patients forehead.
This helps prevent the bottle touching the eye if Mr Valentine was to blink or move his head. With the nurses other hand Mr Valentines lower eye lid was gently held down with a tissue. As Mr Valentine is looking up this ensures that the drop will fall into the lower fornix and not onto the cornea which will cause discomfort and the reaction of blinking. The ophthalmic medication bottle was squeezed to allow one drop to fall into the lower fornix towards the outer canthus. If the drop is instilled to close to the inner canthus then it will drain down the tear duct before it has had any therapeutic value. Once the drop has been instilled the eye lid is released and Mr Valentine was asked to gently close his eye without squeezing it and hold closed for one to two minutes. This allows time for the drops to be absorbed and helps prevent systemic absorption (Dougherty et al 2004).
The excess drops were wiped away using a tissue for Mr Valentines comfort and to prevent any irritation of the skin from the drops. The tissues used by the nurse and Mr Valentine and the ophthalmic medication containers were discarded in the clinical waste bin. The pre operative assessment sheet was signed to indicate that the medication had been administered and the nurse washed her hands again to prevent infection. The evaluation stage in the nursing process was to establish if the implementation stage of the intervention of instilling the ophthalmic medication had the desired outcome, and if there had been any undesirable reactions. In this case Mr Valentines pupil had dilated to the required size and there had been no adverse reactions. Therefore the intervention did not need to be repeated. In conclusion, this assignment has demonstrated the use of the RLT model in conjunction with the Nursing Process. The case study which was discussed has shown that by making an holistic assessment using the RLT model and using it alongside the nursing process this will lead to the planning of person centred care. It is extremely important when assessing and planning care of a patient that they are seen as a whole person and not just an illness. roper logan and tierney