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Geriatric Nursing Care Plan and Intervention Measures

Introduction

Mr. Pluto (not the patient’s real name. We do not use the patient real name to protect his identity and maintain confidentiality according to NMC Code 2008) is 86 years old patient admitted to the Ward Gold of Hollywood Hospital with problems of mobility, temperature, and urinary elimination. Mr. Pluto is a widower who lives in a small flat in an impoverished area near a factory. Mr. Pluto also stays alone.

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The temperature of the patient serves as the most important sign nurses use to monitor the health status of the patient. The normal body temperature should be 37 0C. However, Mr. Pluto has a case of high fever (39 0C as the thermometer indicated) that prompted his admission to the hospital.

Mr. Pluto also needs a care plan because of clinical problem of physical mobility. Thus, admission aims at providing a safe place, maintaining the ability to move, and reducing further deterioration of the patient’s physical abilities. Thus, nurses must design a care plan and implement so as to meet the needs of Mr. Pluto. The care plan will aid in reducing risks of deterioration and enhancing mobility, assisting Mr. Pluto to walk, and providing assistance if Mr. Pluto is in need.

The care plan shall also ensure that Mr. Pluto remains clean and dry with healthy skin. Nurses shall also turn Mr. Pluto as a way of avoiding cases of soreness. Mr. Pluto shall also engage in various forms of exercise so as to reduce problems of stiff joints and enhance muscle activities and develop strength.

Mr. Pluto also has urine elimination problem (incontinence). This is due to physical abilities challenges, inactivity, and old age. These factors prevent Mr. Pluto from normal urination. Care plan must manage cases of feeling isolated, possible depression, and other needs Mr. Pluto will require.

Nursing models provide systematic methods of offering nursing care. The chosen model in this case is The Roper, Logan and Tierney model. This model is common in the UK and Ireland. The model works by “assessing the ability of the patient to conduct twelve activities of living in relation to his position on the lifespan, and his or her level on the dependence/independence continuum and nurses, family and the patient identity aims in care” (Roper, Logan and Tierney, 1996, 14).

In the twelve activities of the model, “safe environment, elimination, controlling temperature, drinking and eating, dressing and washing” (Roper, Logan and Tierney, 1996, 14) relate to Mr. Pluto clinical problems. The Roper, Logan and Tierney model offers systematic and logical way of providing care, documentation, enhancing consultation among key stakeholders, acting like a source of primary care in ensuring continuity of care. The Roper, Logan and Tierney model also provides “clarity and consistency, and a holistic approach in the care plan” (Roper, Logan and Tierney, 1996, 12).

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An overview of The Roper, Logan and Tierney model

The Roper, Logan and Tierney model is a theory of care plan in nursing developed from daily living. This model gained recognition in the UK and Ireland. This model provides us with the definition of living. Consequently, it uses categories of its findings and classifies them into different activities of living through an assessment.

Consequently, nurses can develop intervention measures that can provide independence to patients in situations where patients may find hard to manage on their own. Therefore, the model aims at developing a care plan that offers ultimate independence for the patient (Roper, Logan and Tierney, 1996).

Mr. Pluto has urinary elimination (incontinence). This condition affects his physical health, mobility, and general cleanliness. Thus, main aim is to enhance continent at all times. Temperature also affects Mr. Pluto body conditions. The care plan must include intervention to ensure long-term maintenance of constant body temperature.

Mr. Pluto cannot move normally. The care plan aims at designing interventions that must restore Mr. Pluto’s ability to move normally. The Roper, Logan and Tierney model must include assessment, goals, and intervention. These conditions of living affect Mr. Pluto independence and have general impacts on his daily life activities. Thus, the model plan shall enhance Mr. Pluto’s independence (Roper, Logan and Tierney, 1996).

Nurses look at possibilities of dependence and independence situation of the patient. This continuum enables nurses to identify the kind of interventions that are necessary for the patient to enhance complete independence, and various ongoing supports that can eliminate dependency of the patient.

According to the model, daily living activities are not sources of checklist for the patient’s continuum of dependence and independence. Roper and colleagues note that daily living activities should act as a “cognitive approach to the assessment and care of the patient, not on paper as a list of boxes, but in the nurse’s approach to an organization of her care” (Roper, Logan and Tierney, 1996, 19). This enables the nurses to increase understanding of the model and how to apply it.

The Roper, Logan and Tierney model has many living activities such as “communications, the provision of safe environment, elimination, mobilization, sleeping, controlling temperature, working and playing, breathing, eating and drinking, washing and dressing” (Roper, Logan and Tierney, 1996, 14). In addition, the model also includes death and sexuality activities. However, these two depend on the setting and conditions of an individual patient (Roper, Logan and Tierney, 1996).

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The model highlights five conditions that control activities of the living. These factors include “environmental, biological, politicoeconomic, sociocultural, and psychological” (Roper, Logan and Tierney, 1996, 14). Roper and associates note that analysis that disregards these factors results into a flawed and incomplete evaluation. These five factors are useful in determining the patient’s “dependence and independence in relations to daily activities of living” (Roper, Logan and Tierney, 1996, 16).

The biological factor in the model accounts for issues concerning “overall health of the patient such as the current situation like injuries, illness, anatomy, and physiology” (Roper, Logan and Tierney, 1996, 14). The psychological factor looks into areas concerning the patient’s emotion, comprehension abilities, spiritual beliefs, and cognition. Roper and colleagues note that psychological factor entails “knowing, thinking, hoping, feeling and believing” (Roper, Logan and Tierney, 1996, 14).

Sociocultural l factor relates to how patients experience issues that concern society and culture. These issues entail values and expectations that relate to culture, status, and class of the patient as they relate to dependence or independence of conducting daily activities of living. The environmental factor looks at effects of the environment on the daily living, and consequences of daily living activities on the environment. This makes the model “green”.

Finally, politicoeconomic factor accounts for “consequences of the economy, government, and politics, and their influences on daily living activities” (Roper, Logan and Tierney, 1996, 14). Politicoeconomic factor accounts for issues relating to government funding, policies, welfare programmes, reforms, war, conflict, private influences, and benefits, among other factors.

Developers of this model do not want the model to serve as a checklist. They attribute this tendency to nurses who are reluctant to discuss certain issues with patients, and assume that patients too do not want to discuss such issues. As a result, nurses do not assess and address patients’ preferences. Roper and associates insist that instead of deleting or disregarding daily living, nurses can use it to help patients by analyses of the five factors in line with the daily living activities. The area where the patient receives the care is not relevant in this situation (Roper, Logan and Tierney, 1996).

Murphy and other authors note that the usefulness of such models has generated debates (Murphy, Cooney and Casey, 2000). Murphy and these scholars question the usefulness of the Roper, Logan and Tierney model beyond general areas of nursing. Aggleton and Chambers provide an analysis of different models in their attempts to identify value of these models to users (Aggleton and Chalmers, 2000). These models empower nurses during decision-making processes (Aggleton and Chalmers, 2000).

On the other hand, Fraser notes that the Roper, Logan and Tierney model, with its daily living activities, offers a physiological or physical method of evaluating patients (Fraser, 1996). Thus, it must encompass all the elements and the five factors that affect the activities of the patient. These factors should not hinder nurses from focusing on their assessment of the patient, but provide opportunities for a holistic assessment of the patient.

However, some of these factors may draw the attention of nurses leading to disregarding other factors and conditions of the patient. Some studies indicate that physical assessment of the patient may dominate psychological assessment. However, they note that these depend on observations of nurses applying the model instead of the model itself (Cormack and Reynolds, 1992).

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Cormack and Reynolds established that many nurses have challenges understanding different models of care plan (Cormack and Reynolds, 1992). As a result, such nurses do not apply models in their care plans. However, the Roper, Logan and Tierney model is simple to understand. This has led to its popularity across Europe (Newton, 1992).

Fraser notes that there is no existing research to support the validity of the model. This is because models should be “reliable, tested, and valid” (Cormack and Reynolds, 1992). However, this model has the potential to generate research and areas of further studies as Tierney notes (Tierney, 1998).

Adopting a problem solving approach: a Care Plan

Mr. Pluto is 83 years old man who has mobility, temperature, and urinary elimination problems. He is in Ward Gold for care under these three clinical problems. Mr. Pluto care plan includes his clinical problems, assessment, expected goals, and needed interventions.

Clinical problem: Mobility

Assessment

  • Physical assessment (timing the patient to determine risks of falling)
  • Balancing the legs for a given duration.
  • Structured evaluation: Get up, go, and come back.
  • A thorough and detailed assessment of gait, loss of strength and balance during the procedure

Goals

  • Mr. Pluto shall have a steady gait while in the Ward Gold before discharge.
  • Mr. Pluto shall not fall during his stay at the hospital.
  • Mr. Pluto shall engage in skill transfer and exercise while in hospital.
  • Mr. Pluto shall perform resistive exercise three times a week.

Intervention

  • Training the patient on gait
  • Introducing walking assistive device
  • Introducing exercise and balancing to enhance strength of the muscles.
  • Training and exercising to enhance balancing and skills transfer.
  • Changes to Ward Gold to fit Mr. Pluto mobility requirements such as installing grab bars.
  • Mr. Pluto shall exercise to strengthen muscles in arms, legs, knees, ankle, elbow, and knees. The patient shall use resistive bands.
  • Medication shall include muscle relaxant therapy such as Flexeril.
  • At discharge, Mr. Pluto showed reliance on adaptive devices for enhancing mobility, and minimal chances of developing mobility complications.
  • Steady postural control movements (Tinetti, Baker, McAvay and Claus, 1994).

Clinical Problem: Controlling Temperature

Assessment

  • Assessment of skin conditions, swellings in the ankle and feet.
  • Assessment of abnormal dizziness, nausea, sweating, and thirst.
  • Reviewing cases of heat stroke, confusion, and fainting.

Goals

  • Mr. Pluto shall have a steady gait while in the Ward Gold before discharge.
  • Mr. Pluto shall not fall during his stay at the hospital.
  • Mr. Pluto shall engage in skill transfer and exercise while in hospital.
  • Mr. Pluto shall perform resistive exercise three times a week.
  • Maintain Mr. Pluto’s body temperature with the normal range of 37 0C while under care.

Intervention

  • Maintain body fluid (avoiding dehydration for maintain steady temperatures)
  • Recommend suitable body temperature regulating medicine

During hot weather

  • Drinking water
  • No alcohol
  • Taking cool baths/showers
  • Staying indoors
  • Using cooling systems in the room
  • Medication include administration of antipyretics and antibiotics (if recommended) to reduce fever to normal body temperature

In a cold weather

  • Reducing body heat loss through warm clothing and showers.
  • Treatment shall include warm meals and soups
  • Appropriate means of generating and conserving heat in the room (Larry and Thayne, 2003).
  • At discharge, Mr. Pluto body temperature presented challenges due to fluctuation in the environment, thus, the patient shall rely on antipyretics and antibiotics for controlling temperature.

Clinical Problem: Urinary elimination (Continence)

Assessment

  • Assessment that covers “fluid consumption, cognitive ability, cases of mobility, and any existing case of urologic surgery, and use of medication” (Abed and Rogers, 2008).
  • Physical assessment of Mr. Pluto should cover prostate gland, abnormalities and enlargement in rectal.
  • Assessment of rectal condition to determine any condition of impaction.
  • Objective urinalysis can determine possibility of glycosuria, or infection.
  • Measuring urine volume after urination (Postvoid Residual Urine Volume) and classifying them as follows: Normal volume (50 mL, and below), 100 mL and above indicate abnormality (requires tests), and any volume above 200 mL indicate serious abnormality.

Goals

  • Mr. Pluto’s Postvoid Residual Urine Volume shall range below 50 mL while in the Ward Gold.
  • Improve continent of urine at all times
  • Mr. Pluto shall develop confidence and accept his condition.
  • Mr. Pluto shall engage in exercise three times a week.
  • Improve convenience for Mr. Pluto by placing a portable commode nearby. This reduces cases of rush, possible injuries, and mobility challenges.
  • Enhance social acceptance within the first week of Gold Ward placement.
  • Improve the cleanliness and general environment of the room.

Intervention

  • Lifestyle changes such as changes in diet and improving hygiene.
  • Training the bladder (behavioural technique)
  • Continent help
  • Psychosocial support
  • Kegel exercise
  • Medication shall include anticholinergics, or estrogen, progesterone.
  • Corrective surgery (as the last resort) (Abed and Rogers, 2008).
  • At discharge, Mr. Pluto was continent after waking hours, and at all times.

Implementation of the Intervention measures and the NMC Code (2008)

The Nursing and Midwifery Council (NMC) published the NMC Code of 2008 to act as a guide for performance, ethics, and conduct benchmark for nurses (Nursing and Midwifery Council, 2008). It has some clauses that relate to dignity, respect, and partnership among others. Mr. Pluto shall receive care from the district nurse while receiving care at Ward Gold.

The care plan has to promote dignity of the patient during implementation of the intervention measures (Nursing and Midwifery Council, 2008). The care plan strives to provide positive physical environment to reduce vulnerability of the patient while engaged in daily living activities. The nurse shall offer assistance where the patient needs it.

At the same time, the nurse shall ensure that the patient is comfortable with the level of care he receives. Some of the procedures and supports that may compromise Mr. Pluto’s dignity include support with elimination, support with hygiene, exposing procedures, and mobility exercise, and physical procedures (Nursing and Midwifery Council, 2008).

Partnership in this care plan involves teamwork and collaboration with other stakeholders. The nurse shall also collaborate with patient and others who provide support to the patient so as to enhance quality of care, improve, and maintain health status (Nursing and Midwifery Council, 2008).

The care plan also ensures that the patient receives utmost respect especially confidentiality. Mr. Pluto will also understand why the nurse will have to share his information with others who will provide care to him. The nurse shall ensure that he has the patient’s consent before performing any medical procedure or care. The nurse must recognise that Mr. Pluto has the right to decline or accept any care procedure (Nursing and Midwifery Council, 2008).

Evaluation

Evaluation methods should identify process outcomes and means of measuring them for Mr. Pluto. Exploratory technique in qualitative approach will enable the process discover the underlying causes of errors and failure model in provisions of care to Mr. Pluto. Exploratory analysis can reveal factors related to processes steps, ways in which the process steps can go wrong, causes, and methods of detection. The responses will enable the process locate ineffective areas and causes and how stakeholders can avoid such problems in the future.

Outcomes related to mobility goals shows that the patient engaged in exercise three times a week to improve his gait. Mr. Pluto restored his posture while in Ward Gold.

Mr. Pluto’s Postvoid Residual Urine Volume shall range below 50 mL while in Ward Gold. This goal outcome was possible due constant monitoring of intervention and record keeping. However, this model consumes a lot of time when documenting the patient’s outcome. Thus, continuous documentation during procedures is the best approach.

Maintaining body fluid (avoiding dehydration to maintain steady temperatures) was challenging due to different factors such as changes in the environment, the patient’s ability to take fluids, and frequency of elimination.

Conclusion and Reflection

The Roper, Logan, and Tierney model is popular in the UK than other models. However, models should be universal to guide different people who provide care to patients. Models assess various activities the patient can perform independently or with support from others.

Nurses must comply with the NMC Code (2008) while formulating goals for the patient. At the same, it is crucial to involve the patient, and family members while during decision-making processes. It is only an effective evaluation that explores all outcomes, which can determine whether or not the process has achieved the care goals. In case, there are deviations, then the nurse can revise the goals (Nursing and Midwifery Council, 2008).

Models and codes shall influence the future of care delivery through influencing professionalism, teamwork, and collaboration. This shall ensure that patients receive primary and continued care, and reduce the old model of allocating tasks to others, and poor practices (Nursing and Midwifery Council, 2008).

Mr. Pluto uses the Roper, Logan and Tierney model. It enabled the nurse to provide a logical sequence of designing a care plan. It also allowed the nurse to include various aspects related to the patient’s health problems such as environment, psychological, physical, and social factors. Models with dependent and independent continuum enable nurses to identify specific areas where the patient needs improvement. In addition, models can provide a quick understanding of conditions that exist, and enable nurses shift their emphasis to different areas that require support.

Models should offer clarity, simplicity, and consistencies in order to enable nurses provide a holistic approach to care provision, and promote the importance of care provision. Future models must reduce problems associated with documentations and keeping of records. This is among the reasons why some nurses find care models difficult to apply in real situations.

There is a widespread negative attitude with regards to use of care models among nurses. Nurses can avoid such difficulties by choosing a simple care model like the Roper, Logan and Tierney model. Thus, future practice can incorporate this model in handling various activities related to care provisions. At the same time, nurses must also get continuous education on various care models so as to enable them adapt different care models within different situations.

Reference List

Abed, H and Rogers, R 2008, ‘Urinary incontinence and pelvic organ prolapse: diagnosis and treatment for the primary care physician’, Med Clin North America, vol. 92, no. 5, pp. 1273-93.

Aggleton, P, and Chalmers, H 2000, Nursing Models and Nursing Practice, 2nd edn, Macmillan, London.

Cormack, D and Reynolds, W 1992, ‘Criteria for evaluating the clinical and practical utility of models used bynurses’, Journal of Advanced Nursing, vol. 17, no.12, pp. 1472-1478.

Fraser, M 1996, Using Conceptual Models in Practice: A research-based approach, Harper Row, London.

Larry, K and Thayne, M 2003, ‘Invited Review: Aging and human temperature regulation’, Journal of Applied Physiology, vol. 95, no. 6, pp. 2598-2603.

Murphy, K, Cooney, A, and Casey, D 2000, ‘The Roper, Logan and Tierney (1996) model: perceptions andoperationalization of the model in psychiatric nursing within a health board in Ireland’, Journal of AdvancedNursing, vol. 31, no. 6, pp. 1333-1341.

Newton, C 1992, The Roper, Logan and Tierney Model in Action, Macmillan, London.

Nursing and Midwifery Council 2008, The code: Standards of conduct, performance and ethics for nurses and midwives, NMC, London.

Roper, N, Logan, W, and Tierney, J 1996, The Elements of Nursing: A model for nursing based on a model for living, 4th edn, Churchill Livingstone, London.

Tierney, A 1998, ‘Nursing models: extant or extinct?’, Journal of Advanced Nursing, vol. 28, no. 1, pp. 77-85.

Tinetti, M, Baker, I, McAvay, G, and Claus, B 1994, ‘A multifactorial intervention to reduce the risk of falling among elderly people living in the community’, N Engl J Med., vol. 331, pp. 821–827.

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