Patient care is the major concern for health care professionals where nursing intervention is mandatory. Attending to patients during a long stay in hospitals involves a lot of expertise. This is better addressed by nurse care in an evidence base practice approach. Patients suffering some acute conditions are often a challenge to nurses due to the difficulty involved in taking care of them which means that nurses are to ensure that these people move enough, stay with their dietary changes, adapt to environment well, etc. However, with proper investigation of the problem and implementation of nurse care models, the issue can be solved. Nursing models have been devised by many experts in the area. Some of these are Health Belief model, Adaptation model of nursing, Roper–Logan–Tierney Model of Nursing, etc (Nursing Theories 2012). These models enable the investigators to better understand the problem and provide a standardized framework of nurse care. In the present context, three different clinical problems have been highlighted, so there is a need to provide an efficient nurse care plan based on the available literature for solving these problems. The initial problem is “risk of falling due to increased frailty of the patient”. This condition in nursing care settings is considered as a frequent event as it predisposes individuals, especially of older age, to morbidity and mortality. It was described that multifactorial interventions would minimize the risk of falls in hospitals which could be better adapted by nursing care facilities through Vitamin D supplementation (Cameron et al. 2010). As such, this multifacotrial intervention requires the application of Health belief model, a nursing model.
This is a psychological model that allows to predict health behavior of a patient while enhancing the nurse’s proffession through a significant impact on the emotional and intellectual growth (Application of Health Belief Model 2012).
Therefore, the model for this specific nurse care plan is able to provide a solution to the problem of falls. According to the study analyzing 41 trials that involved 25,422 participants, fall rate and risk of falling were investigated. Although there were inconsistencies with the effect of vitamin D supplementation and supervised exercise on risk of falls, the model has implications that could modify the behavior of patients (Cameron et al.2010).
For example, a patient could learn what to do, how to behave and whom to call for a help once he or she falls by chance, or a person could be taught about the simple adaptive methods to overcome the fall situation. This approach has supported a previous randomised controlled trial study where falls were minimized through structured multifactorial intervention in psychogeriatric nursing home. Through combining a fall risk evaluation tool and general medical assessment, the nursing professionals were able to determine the type of fall prevention strategy specific for a given individual (Neyens Jacques et al. 2008). Older patients discharged from Accident and Emergency Department after falls require a great nurse care. This has been accomplished in a randomized controlled trial carried out in a large teaching hospital. The patients were followed up at home by assessment task where modifiable risk factors for falls were being checked. This involved emphasis on feet and footwear, mobility, balance, vestibular dysfunction, visual acuity, cognition, blood pressure, ECG and medication (Lightbody et al. 2002). The patients could be aware of home safety through education and suggestions (Lightbody et al. 2002).
Patients suffering from falls require a mandatory assessment after hospital discharge.
It was revealed that patients who were enrolled in the intervention group of the study had fewer falls indicating the need for assessment of various factors following the discharge.
Thus, such patients need to be carefully monitored for certain complications of functional decline that put them at risk. It was reported that screening is the primary step to be considered while identifying the patients for the functional decline since it enables better treatment plans. As such, nurses could implement this strategy and anticipate a change in the behavior of old patients. For this purpose, in the care plan approach, nurses need to apply functional decline predictors that help to recognize the older patients at risk. This is better accomplished through well-devised clinical user-friendly instruments. These could be Care Complexity Prediction Instrument, Identification of Seniors at Risk and Hospital Admission Risk Profile (Hoogerduijn et al. 2007). These instruments help the nurses be aware of cognitive impairment, lower functional status, age, etc. Extensive support of the caregivers is required for the patients suffering from falls. Moreover, if these hospitalized patients are elderly people, then the functional decline will be frequent thus affecting the quality of life. It was found out that these patients exhibit increased dependency on nursing home placement and a prolonged hospital stay, and have more adverse condition mortality (Hoogerduijn et al. 2007). To better manage the fall patients, Hendrich Fall Risk Model was implemented in the nurse care strategies. This involves complete information on assessment parameters that are considered risky for all patients with fall risks (Henrich, Bender & Nyhuis 2003). There were standardized instruments regarding mandatory for studying the clinician assessments and physical attributes. The risk factor model developed in this context may provide the nurses with better insights on the interaction among the risk factors. Mobility is important for such patients. In addition, several other assessments are also required for increasing the quality of life of these patients.
These issues can be better addressed through the instruments like ‘Timed Up and Go Test’ for Mobility, walking, transferability, gait, balance; SPICES for evidence of falls, confusion, incontinence, problems with eating or feeding and sleep; Functional Independence Measure with FIM for problem-solving, sphincter control, communication, locomotion, self-care; Lawton Instrumental Activities Daily Living Scale for laundry, managing finances, shopping, transportation and medication; 2 Minute Walk Test for Exercise tolerance and exercise capacity, etc. (Kleinpell et al.2008).
As per the evidence based on a practice approach, the following changes need to be amended in order to avoid falls and related outcomes to facilitate mobility. Falls are regarded as a geriatric syndrome that is experienced mostly by senior adults due to the extrinsic and intrinsic risks, and precipitating causes like dizziness syncope, etc. (Kleinpell et al.2008). Fall condition is reported to occur mostly in patients in departments of Neurology and Medicine (Hitcho et al.2004). Major fall cases of nearly 75% are reported to occur at nursing homes, thus making this condition a leading cause of unintentional injury in countries like the United States, etc. (Rose, 2008). This can be better accomplished by checking the environment for ensuring the safety screening or assessing the multifactorial risk factors, documentation, interdepartmental communication, and facilitating enhanced mobility like routine walking. Once a patient gets discharged from the ward, the nurses need to discuss the fall risk factors with the caregivers, family members and the patient to avoid falls at home. In addition, nurse care should also involve referral programs related to fall prevention, which emphasize the importance of low-rise beds, call light access, proper glasses to ensure smooth walking, etc. These safety approaches are paramount for nurse care to render precise fall management. The next issue in the nurse care plan is Hypothermia. This condition occurs when there is abnormal body temperature affecting the nervous, respiratory and circulatory systems. It was described that for the elder population, geriatric trauma is interconnected with falls and injury as a result of alterations in coordination, motor strength, balance and postural stability. Therefore, it is essential to monitor a variety of changes like physical changes of aging, reduced physiologic reserve, and some morbid conditions. These factors serve as an index during patient transfer to an intensive care setting and injury (Wright and Schurr, 2001). As such, fall traumatic individuals may be at risk for complications that alleviate their resistance to fight against injury. In this context, hypothermia is a usual problematic condition resulting from postoperative care, surgery and resuscitation (Sedlak, 1995). Nurse care plays an important role in identifying and performing therapy to rectify the potentially dangerous hypothermic condition like enabling or modifying environmental sources for inducing warmth to restore the body temperature (Sedlak, 1995). The nurse care plan should focus on clinical decision-making where all the important symptoms of the patients may have been taken into consideration without fail. In most cases, a patient’s temperature is not recorded in hospitals. This may increase the chances of exposure to hypothermic conditions at a serious rate. Nurses need to develop an awareness of the issues related to hypothermia with regard to defining the poor methods to alleviate the heat loss or maintain warmth conditions in patients. Further, related complications of hypothermia, like metabolic acidosis and coagulopathy, are not precisely recognized by the hospital staff. The main reasons include limited access to patients, poor awareness of the condition and problems with the temperature measuring devices. Hence, the nurse care plans should implement the education intervention programs and algorithms that present improvement of the patients suffering from falls with regard to temperature monitoring and management. They could minimize the hypothermic conditions (Ireland et al. 2006). The practices implemented for managing hypothermia caused by surgery may be to prevent further complications. As warmth conditions are essential for patients, there is a need for putting up forced-air warming systems and carbon-fiber blankets and circulating-water garments. They ensure proper maintenance of normothermia (Ireland et al. 2006). For this purpose, the nurses are supposed to review the conditions met in the surgical units. Database studies have provided information that during the intraoperative period, cutaneous warming systems play an influential role, and therefore, these approaches may become reliable sources of hypothermia management for patients suffering from falls. Care plans in this context should have a precise awareness of experimental trials carried out in various settings as this may enable the nurses to attain the success rate of the strategy implemented for controlling hypothermia (Galvão et al. 2009). Nurse-led intervention programs robust influence on thermoregulation care. Protocol development and practice through implementation for understanding the variety of patient requirements are vital in such a case. In the form of a flow chart, information on patient temperatures and an outline that depicts improvement in the interventions to minimize hypothermia will be obtained. Prior to the admission of the patient, care area preparation is mandatory for the nurses. Documentation of patient profiles and questionnaires for staff is very important in the evaluation of practice or care plans (Galvão et al. 2009). Nursing staff would feel much satisfied if they knew that the care plan enables them to easily recognize hypothermia, thermal care documentation and appropriate treatment. Hence, temperature control is an essential component for both moderate and severe hypothermic patients (Block et al. 2012). Roy’s adaptation model is considered ideal for hypothermia care by nurses. This information obtained from the post-operative hypothermia condition was reported to provide a framework for nurses to take care by rectifying the temperature problems in Hypothermic patients. This model is based on a person-adaptive system where environment stimuli and promotion of adaptation are the main objectives. The changes induced by nurse care for hypothermia may be received by patients who may respond positively. The patients may get adapted to the system brought forward by the environment through warmth conditions which may be identified as adaptive mechanisms in this context of nurse care. This adaptive system comprising of parts is better reflected in the variety of temperature correction conditions mentioned previously. The circumstances and the conditions provided by the nurse care may affect the person’s behavior with the objective of ensuring the quality of life. Taking into account the above-mentioned strategies, hypothermia could be controlled in patients. The nurse could monitor temperature more frequently with the help of temperature measuring devices. Supporting clothes like warmth-producing blankets and warm drinks thus can be provided to the patients. It was described that ECG monitoring connected with routine electrolyte observation is important since hypothermia evokes potassium uptake at the cellular level to avoid reversion on re-warming that results in ‘overshoot hyperkalaemia’. Hence, ECG monitoring of patients with hypothermia is mandatory for nurses. People at risk of a variety of complications,
discharged from hospital, need increased home security in the form of care or medical attention. This will not solve the problem unless a standardized nursing framework is established. Hypothermia conditions could be easily reverted by exercising various strategies mentioned above. Warmth conditions are feasible not only in hospital wards or intensive care units but also at home. Nurses should be aware of intervention programs in this context to train home attendees. As such, home care interventions are necessary for keeping the old frail patients warm. Generally, the mechanisms to maintain warm environments often become inapplicable for elderly people that resulting in a risky condition at home. Healthy elder individuals are able to provide themselves with extra clothing and switch on the thermostat. In contrast, frail individuals, especially, elders with physical discomfort, poor awareness about the environment, communication defects need the assistance of caregivers who can provide the required condition (Worfolk 1997). However, the problems associated with thermoregulation for the elderly hypothermic individuals have not completely been attended to due to the caregiver’s lack of knowledge. Taking care of elderly individuals at risk of hypothermia, regular methods are not totally effective as they induce some cold discomfort conditions and deteriorate the temperature in the care of elderly individuals (Worfolk1997). Hence, nurse care should be targeted at reducing the negative outcomes by providing advice for nursing priorities, and innovative solutions that are currently accepted randomly appreciated and further explored. So, the main tasks for nurses include cultural competence in the delivery of services, allocation of resources, and the organization’s continuous service. These employ promoting healthy aging, assistive technology, increased use of telemedicine, interaction with families, focusing older adults at high risk and intensive case management programs (Young 2003).
The next issue is about the nutrition defect/impairment. To gain insights in this area, there is a need to collect data on patient records from the hospital. These records should be analyzed for primarily imbalanced nutrition, low body requirements, infection risk among elderly patients who have a minimum duration stay in hospitals for 14 to 17 days. Care need should emphasize sticking to a certain diet as it might encourage eating.
This also helps the nurses to have free assess to the dietary history of the patient and tolerance to certain food items (Almeida Mde et al.2008). Generally, elderly individuals are predisposed to undernutrition which is associated with morbidity and mortality. This problem is more urgent for patients with increased frailty who are physically dependent. Weight loss is common for these people, and food intake is affected by decreased appetite (Dylan et al 2005). Nutrition screening may offer reliable tests examining the following parameters like Body Mass Index (BMI), Skinfold thickness, arm circumference, serological markers like serum albumin, Transferrin, low total lymphocyte count, low total cholesterol assessment of vitamin and trace element status( Dylan et al 2005).
In order to get information on the nutritional requirements of patients and be aware of the causes of their reduced weight by the time of discharge, there is a need of implementing Malnutrition screening tools. These are the Malnutrition Universal Screening Tool (MUST) based on acute illness effect, history of unexplained weight loss and BMI, and Mini Nutritional Assessment (MNA) for estimating the malnutrition risk in the elderly at hospitals, nursing homes and home-care programs (Dylan et al 2005).
Both these assessment tools are based on scores obtained from components like mobility, body mass index, neuropsychological problems, low food intake in the previous three months, acute disease or psychological stress or acute disease and finally weight loss in the previous three months (Dylan et al 2005). Most elderly people are prone to constipation. The causative factors being identified are the neglect of the calls to defecate, defects in anorectic sensation, underlying diseases, medications and loss of mobility.
Nurse care may address this problem by seeking data on the medication history, co-morbid problems and meticulous digital rectal examination (Rao and Go, 2010).
For elderly individuals, the problem is frequent and needs a multifactorial treatment approach at the personal level. The use of osmotic laxatives like polyethylene glycol and novel approaches like peripherally acting μ-opioid receptor antagonists (alvimopan and methylnaltrexone) for opioid-induced constipation, 5HT4 agonist (prucalopride), guanylate cyclase agonist (linaclotide), chloride-channel activator (lubiprostone) are recommended for avoiding constipation (Rao and Go, 2010). The other reasons for constipation include decreased physical activity and low fluid and fiber consumption. Therefore, the primary nonpharmacological strategies include high fluid intake, daily physical activity, consumption of high fiber products, etc. Nurses could provide reliable care to evaluate, plan and manage constipation in elderly patients. Bulk-forming laxatives are essential for frail elderly patients as they ensure good hydration. Osmotic agents like polyethylene glycol serve as alternatives. Stimulant laxatives are other options in elderly patients who exhibit poor responses to osmotic laxatives. It is important to note that day-to-day emerging interventions for treating constipation in elderly patients need to be carefully monitored as their application is limited and needs exploration. Nurses’ experience and beliefs are contributing factors to constipation management in the elderly population (Ross, 1993). Bowel elimination is a problematic issue for the elderly. Well-known nurse care strategies focused earlier on this issue include information with regard to bowel elimination pattern(s) (BEP). This was addressed by collecting the data from the patients through questionnaires. It was found that regular eating habits are essential for the hygienic life of elder patients. Patient education was considered important for the investigations led by nurses (Ross, 1993). To ensure an efficient nurse care plan for the management of altered eating habits, there is a need to focus on electronic health records. It was reported that investigation on characteristics that reflect patient and support system related to altered eating habits would be beneficial. It was revealed that a system of electronic health record collection was done for implementing the approaches; Omaha System interventions and Outcome and Assessment Information Set (OASIS) structured assessment form (Westra et al. 2011). When patients were discharged, there were improvements in bowel incontinence. This nurse care plan has indicated that nurses need to be aware of the type of patient-supporting systems for ensuring the precise management of bowel incontinence (Westra et al. 2011). A model known as the clinical nursing leadership model was described as the one that could increase the continence among older adults. There are 3 practice initiatives that were employed. They include a standardized paradigm for enhanced discharge care of patients with incontinence; a novel method for the management of bowel elimination and nursing assessment forward-based nurses setting up an improved role to extend clinical assistance to patients and staff members for incontinence management (Ostaszkiewicz, 2006). These approaches ensure much satisfaction with regard to discharge care of patients who could become dependent on someone’s help, thus indicating the sustainability of the nursing initiatives in the absence of clinical attendees like nurses.
These strategies may ensure frequent stools making patients avoid the problem of constipation.
They also enable the patients to gain knowledge of the recommended measures that they could rely on. Thus, it may indicate that precise application of assessment tools is important in nurse care for effective screening of the outcomes.
Taking into account the above information, nurse care plans deal with the management of frail elderly patients where nursing models serve as a basic foundation. These patients face risks both at the hospital and at home. However, the major challenge is how the elderly patients upon discharge manage to continue to live their routine life without the clinical assistance of nurses. Fall complications put these individuals at risk making their mobility an important issue. Nurse care plans have addressed the problem by examining standardized methodologies through the knowledge gained from the evidence-based practice and application of nursing models. As such, the patients could easily adapt to a new atmosphere or environment and begin standing, walking, using assisting devices like call bells, side rails and bed control panels. Ultimately, the patient could avoid injuries both at the hospital and upon discharge at home. Hypothermia is common for elderly people, that is why temperature correcting devices have been suggested for these patients. These include carbon-fiber blankets and circulating-water garments that induce a warm environment. Nutrition imbalance or malnutrition may be addressed by screening tools that reflect the levels of trace elements, vitamins serological markers like albumin, cholesterol and ferritin. It is essential for the nurses to assess the outcome of the interventions applied for the care of the patients at nursing homes, so the steps to correct the errors would take into account. This ensures confidence among the nurses and assures the increased quality of life of patients at home. Finally, the problem of constipation was also better addressed by nurse care by various interventions like recommending a high fiber diet, laxatives, and enhanced physical activity. Hence, nurse care offers reliable management of elderly patients with frailty who are at risk of aging complications that lead to injury.
References
Almeida Mde A, Aliti GB, Franzen E, Thomé EG, Unicovsky MR, Rabelo ER, Ludwig ML, Moraes MA, 2008, ‘Prevalent nursing diagnoses and interventions in the hospitalized elder care’, Rev Lat Am Enfermagem, vol.16 no.4,pp.707-11.
Application of Health Belief Model: Nursing Theories 2012, Web.
Block, J, Lilienthal, M, Cullen, L & White, 2012, ‘Evidence-based thermoregulation for adult trauma patients’, Crit Care Nurs Q, vol. 35 no.1, pp.50-63.
Cameron, ID, Murray, GR, Gillespie, LD, Robertson, MC, Hill, KD, Cumming, RG & Kerse N 2010, ‘Interventions for preventing falls in older people in nursing care facilities and hospitals’, Cochrane Database Syst Rev, vol.1, CD005465.
Deanna Gray-Micelli, 2008, Nursing Standard of Practice Protocol: Fall Prevention, Web.
Dylan Harris, and Nadim Haboubi, 2005, ‘Malnutrition screening in the elderly population‘, J R Soc Med, vol.98 no.9, pp.411–414.
Galvão, CM, Marck, PB, Sawada, NO, Clark, AM. 2009, ‘A systematic review of the effectiveness of cutaneous warming systems to prevent hypothermia’, Clin Nurs, vol.18 no. 5, pp.627-36.
Good, KK, Verble, JA, Secrest, J & Norwood, BR, ‘Postoperative hypothermia-the chilling consequences’, AORN J, vol.83, no 5. pp. 1054-66.
Hitcho, EB, Krauss, MJ, Birge, S, Dunagan, W C, Fischer, I, Johnson, S et al. 2004. ‘Characteristics and Circumstances of Falls in a Hospital Setting: A Prospective Analysis’, Journal of General Internal Medicine’, vol.19 no.7, pp.732-739.
Hoogerduijn, JG, Schuurmans, MJ, Duijnstee, MS, de Rooij, SE & Grypdonck MF 2007, ‘A systematic review of predictors and screening instruments to identify older hospitalized patients at risk for functional decline’, J Clin Nurs, vol.16 no.1, pp.46-57.
Ireland, S, Murdoch, K, Ormrod, P, Saliba, E, Endacott, R, Fitzgerald, M and Cameron, P 2006‘Nursing and medical staff knowledge regarding the monitoring and management of accidental or exposure hypothermia in adult major trauma patients’. Int J Nurs Pract, vol. 12 no.6, pp. 308-18.
Kleinpell Ruth M, Fletcher Kathy, Jennings Bonnie, M 2008. “Reducing Functional Decline in Hospitalized Elderly”, in RG Hughe (ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Web.
Lightbody, E, Watkins, C, Leathley, M, Sharma, A & Lye, M 2002, ‘Evaluation of a nurse-led falls prevention program versus usual care: a randomized controlled trial’, Age Ageing, vol. 31 no.3, pp. 203-10.
Neyens Jacques, CL, Dijcks Béatrice, PJ, Jos Twisk, Schols, Schols Jos MGA,van Haastregt Jolanda, CM, van den Heuvel Wim J A.& de Witte Luc P 2008, ‘A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomized controlled trial (RCT)’, Age and Ageing, vol. 38 no. 2, pp. pp. 194-199.
Nursing Theories 2012, Web.
Ostaszkiewicz, J 2006, A clinical nursing leadership model for enhancing continence care for older adults in a subacute inpatient care setting’, J Wound Ostomy Continence Nurs, vol.33, no.6, pp.624-9.
Rose Debra J 2008, ‘Preventing falls among older adults: No “one size suits all” intervention strategy’, J RehaIbil Res and Dev, vol.45, no.8, pp.1153-1166
Ross, DG 1993, ‘Subjective data related to altered bowel elimination patterns among hospitalized elder and middle-aged persons’, Orthop Nurs, vol.12 no.5, pp.25-32.
Rubenstein, LZ and Josephson, KR 2006, ‘Falls and their prevention in the elderly: What does the evidence show?’ Medical Clinics of North American, vol. 90 no 5, pp. 807–824.
Sedlak, SK 1995, ‘Hypothermia in trauma: the nurse’s role in recognition, prevention, and management’, Int J Trauma Nurs, vol. 1 no. 1, pp.19-26.
Wright, AS & Schurr, MJ 2001, ‘Geriatric trauma: review and recommendations’, WMJ, vol.100 no.2, pp.57-9.
Worfolk, JB 1997, ‘Keep frail elders warm! ’Geriatr Nurs, vol.18 no.1, pp.7-11.
Young, HM 2003, ‘Challenges and solutions for the care of frail older adults’, Online J Issues Nurs, vol.8 no.2, pp.5.