A Critical Appraisal Of Nursing Assessment And Interventions For Samara

Strengths of the Nursing Assessment

Part 1

Nursing assessment is the first step towards the care journey of a patient which requires the nurse to collect objective and subjective health information from patient and use the data in a meaningful way to formulate best nursing care plan for patient (Lewis et al. 2016). It deals with the systematic collection of information, which is relevant to patient’s health related problems and thereby helping to predict the present and future healthcare needs of the concerned patient (Wood and Garner, 2012). According to Wilson et al. (2014), a nursing assessment must be conducted in a logical and careful manner and demands frequent accumulation, management and tabulation of information in order to generate a detailed medical history and care plan of the patient. The medical history of the patient must encompass cognitive, physiological and psychological needs of the patients along with cultural and spiritual requirement in order to promote quality of life and well-being (Ingram, 2017; Nursing and Midwifery Council [NMC], 2015). The main purpose of this essay is to critically appraise strength and weakness of a nursing assessment done for Samara, a young woman with mild-moderate learning disability and discuss about any good practice or missing points from the assessment. It also discusses about relevant nursing intervention for Samara arising from assessment and provides a detailed discussion on one specific intervention can be applied for health and recovery of Samara.

After reviewing the nursing assessment of Samara, the strength or good point identified in the assessment process is that it targets holistic care of patient. The assessment not only focussed on present nursing issues of Samara but also focused on other aspects such as lifestyle, communication, safety, oral health and mental health needs of the client. The nursing assessment also takes in consideration the strengths and weaknesses of Samara. According to Berridge and Liddle (2010), this which will in turn help the nursing professionals to spot the domains that can be examined on in order to promote health and well-being of Samara. The capacity assessment has been done in a comprehensive way and this is crucial for proper planning of Samara’s care. This critical judgment of Samara’s capacity provides opinions and views of Samara that must be taken into consideration. However, from the nursing assessment it is clear the Samara is not always allowed to take informed choices. However, the existence of this documentation notifies that Samara can take part in decision making process about her healthcare requirement but the assessment has also highlighted that she generallyfails to understanding of the consequences of such health related decisions (Department of Health UK, 2012). The presence of this documentation at the time of nursing assessment helped multi-disciplinary team (MDT) members to at once detect that Samara’s present mind set lacks the required intellect of taking part in decision making process as she is not well-ware about the outcomes (Department of Health UK, 2012).

Missing Information from the Assessment

The nursing assessment highlighted that Samara prefers to have reminders and/or visual clues about any discussion that have occurred during the process of her care or MDT meeting time so that she can comprehensively access the data that was shared. Both Samara and her father proposed that one of the best ways of achieving this is via employing pictures and symbols. The identification of this requirement will help to facilitate suitable adjustments. It also highlights the all-inclusive nature under which the entire assessment has been conducted while making Samara felling involved with her process care while making her understand that it is going in the right direction (Lewis et al., 2017). However, the use of the visual reminders or any other suitable adoptions which may be important for Samara must be discussed with her in details and included in the assessment. According to Wheeler (2012), this kind of approach helps the clients (Samara) to understand the entire information that is being conveyed to them.

Samara’s father was present throughout the assessment. This is indeed a good practice because Samara has previously stated that she wants her father to remain present during any assessment or during the MDT meetings. According to Wahlin and Idvall (2009), including the trusted person, as per clients preferences helps to make the client (Samara) feel well supported and safe. Moreover, this also helps in the protection of self-worth and privacy (Wahlin and Idvall, 2009). Moreover, she will also feel that she is being listened and her needs or the demands are given priority (Berridge and Liddle, 2010). Another good practice about this nursing assessment is, ethnicity, ways of life, culture and communications have also been considered in details in this nursing assessment as this is as per the regulations of NMC (2015). This highlights the Samara is treated as an individual while procuring care. Although Samara and her father belong to the Muslim community, none of them practices the religion and mostly communicates in English.  According to Andrews and Boyle (2016), the differences in language, culture and spiritual needs can define the needs of the patients and hence it is vital that these requirements are considered at the time of nursing assessment.

Many informations were missing from the assessment considering the scenario of Samara. Comprehensive record-keeping is a vital aspect of any nursing assessment. Inadequate tabulation of data or poor-record keepingmay cause errors and this in turn and adversely impact the care plan of Samara (Wheller, 2012). Numerous portion of the assignment like the contact details of the general physicians (GP), next kin of people in Samara’s life and immediate point of contact are required to complete in more comprehensive manner (like full name, address and contact details) as this will help to dodge mistakes or confusions. This will ensure the information is not communicated to other people who are not directly linked with Samara’s life and thereby helping to avoid the ethical consequences of privacy (Blightman et al., 2014). According to Wheeler (2012), it is best to have more the one immediate point of contact or the next of kin when completing one nursing assessment this is because if the first point of contact cannot be reached then the immediate second point of contact will be notified about the progress or change in the care plan about the client (Samara). Though it is well-stated that the Samara was not cooperating during the process of tabulating the vital signs (for example pulse), but such gaps in the information, decreased the quality of the nursing assessment. The respiratory rate was however tabulated and noted-down in the assessment this might be because, Samara was not displaying any aggressive behaviour during the the tabulation of respiratory rate. It also mentioned that the diet plan of Samara is predominantly composed of fat rich and high sugar content food and hence there might be a risk of appearance of glucose in urine (diabetes mellitus) (Mitchell, Thomas and Langlois, 2013). The nursing assessment lacks the family history. According to Kelly (2011), family history is an effective tool towards the detection of any underlying cause behind the disease development and thus can be employed to personalised screening of the disease, risk stratification and other targeted hereditary services.

Nursing Interventions for Samara

The nursing assessment of Samara also lacks an updated risk assessment. According to National Patient Safety Agency [NPSA] (2004), risk assessment is an important piece of documentation of nursing assessment and must be completed as soon as possible. In case of Samara, there are numerous risks and hence risk assessment is important in order to comprehensively handle the behaviour of Samara appropriately. Although the learning disability of Samara has been highlighted as “mild to moderate” there are many risks linked with her behaviour which has been stringently highlighted by the people in her closed peers. Samara’s case study has also identified that she has a tendency to become physically and verbally aggressive and this is mostly triggered by conversations centring her abnormal diet and uncontrolled weight. Moreover it is being highlighted that Samara can become physically violent towards others, issues in the domain of safety are not adequately accessed in the assessment. These highlighted issues along with the risk interlined with Samara’s lack of proper observance of hygiene and strong reluctance to observe healthy diet must be analysed and incorporated on both Samara’s safeguarding and risk assessment documents (Department of Health UK, 2006).

Samara’s hearing and vision problems has not been analysed in detail however assessing thesewould have benefited her. According to Lewis et al. (2017), hearing and visual problems can generate frustration and hopelessness among the individuals particularly people with learning disabilities. However, Holmstrom (2014) and McClimens, Brennan and Hargreaves (2015) has opined that these two major issues are ignored and these two issues can specifically help in explaining individuals apparent gap in understanding and reluctance to cooperate with the plan of care. Hence, the nurses should have acknowledged these issues and carried out a detailed person-centred care approach. This is important because, Samara lacks proper mental capacity and it noted that she has sudden difficulties in seeing and hearing (Lewis et al., 2017).

Nursing assessment of Samara has identified numerous nursing interventions. The first one is related to personal hygiene. It has been recognised by nurses, care givers and Samara’s father that Samara suffers from poor personal hygiene. Her fingernails have faeces and the condition of her skin has been noted as “visibly dirty”. The principal nursing intervention here is to generate personalised hygiene schedule for Samara’s dental care and skin care (Carnaby and Cambridge, 2006). According to Carnaby and Cambridge (2006), this is one of the most fundamental and yet possibly most difficult intervention for Samara.

Another nursing interventions for Samara would be referral and regular follow-up from numerous members of the multidisciplinary teams. This will mainly include a dietician for an evidenced-based diet plan in order to support with the weight management (MacDonald-Wicks, 2015); an occupational therapists (OT) for getting accustomed with home and this will facilitate proper management of personal hygiene (Symbol charts, walk-in shower and shower chair/stool) (Soderback, 2015); a GP for regular health check-ups as this will enable early detection of the risk factors associated with the disease development (Raines, 2010). Other member of MDT team will be behavioural psychologists in order to detect and simultaneously resolve the difficulties that Samara might have been experiencing while getting separated from her mother at an early stage age of her life (Ogden and Simmonds, 2014). A learning disability nurse (LDN) and a professional physiotherapist should also be included in MDT of Samara. A referral to these professionals will enable proper weight management, comprehensive vital signs monitoring and proper assessment of Samara’s mental and physical sate.

Samara also required proper assessment and periodic monitoring for her vital signs along with urinalysis. The support staffs in the support care home are required to complete a detailed food chart in order to develop a healthier diet plan of Samara. A comprehensive support from the psychological and LDN will help Samara to indentify the reasons behind her violent outburst. The issues with communications that were highlighted in Samara’s case study will also require certain interventions. According to Holland et al. (2008) both verbal and non-verbal communications are an important pillar of individuals’ healthy living. It seems that Samara is struggling with her communication and hence adjustments to facilitate smooth communications between Samara and the nurse must be given prime importance in order ensure adequate support to Samara. While the use of symbols and pictures will help to improve Samara’s communications (Holland et al., 2008). Mistry and Barnes (2013) have also identified other means of communication support like via employing Makaton or signing.

Part 2:

The second part of the essay focuses mainly on behavioural problem based on nursing assessment data of Samara and provides rationale for focusing on this area for identifying one suitable intervention for client. Behavioural issues like physical aggression and poor personal hygiene could be negatively affect both physical and mental health of Samara. Sridevi et al. (2015) states that in people with learning disability, deficits in brain function leads to deficits in learning which eventually contribute to psychological or behavioural consequences. Hence, finding the best intervention to address behavioural issues found in Samara is critical for her health and recovery. The essay provides a comprehensive discussion on the intervention of positive behavioural support (PSB) and the rational for choosing the intervention for Samara. It also discusses about the strategies and tools needed by a learning disability nurse to easily apply the intervention on client.

Based on critical review of Samara’s nursing assessment data, behavioural problem is one major issue that needs to be addressed as it is posing risk to Samara’s health and safety, creating health and safety issues for other housemates at the supported living facility and leading to obesity related problem too. The review of Samara’s case scenario and nursing assessment revealed that due to her verbal and physical aggression, her housemates and support staffs are having an unpleasant time. She even gets aggressive when she is asked to wash hand. Evidence shows that physical or verbal aggression are common in adults with learning disability and behavioural interventions are effective in reducing aggression (Richardson 2013).The nursing assessment also reflects Samara’s anti-social attitude as she dislikes anyone talking about her weight and eating habits. Physical and verbal aggression and antisocial and disruptive behaviour are termed as challenging behaviour in people with learning disability and such people are at risk of inappropriate care, deprivation and social exclusion. It also poses significant challenges for staffs, friends or other carers working with such individual (Bigby and Beadle?Brown 2018). Hence, Samara’s  behaviour needs to be targeted first to reduce challenging behaviour and achieve good outcome for client.

Another rationale for prioritising behavioural issues for care of Samara is that she is gaining weight and eating lots of sweets foods like chocolate, cakes and biscuit. However, changing her eating habit or asking her to maintain her weight is difficult because she does like people to talk about her weight or question about food. She becomes verbally and physically aggressive when anyone tries to educate her about healthy eating habits. Hence, due to such behavioural challenges too, identifying the best behavioural intervention is necessary for Samara to prevent obesity and reduce negative effect of obesity on health. Biswas et al. (2010) suggest that obesity is more prevalent in people with learning disability compared to general population and this may lead to additional health risk in people. Hence, planning appropriate intervention to address Samara’s attitude towards food and appearance is necessary so that she can easily follow healthy lifestyle and response to weight management care plan.

There are many behavioural interventions to treat and reduce physical aggression and other challenging behaviour in people with learning disability such as mindfulness therapy, counselling and cognitive behavioural therapy. However, in relation to Samara’s case scenario, the positive behavioural support (PSB) intervention has been chosen to address behavioural issues and reduce her physical and verbal aggression. PBS is a type of behaviour management system that specifically targets challenging behaviour and offers holistic approach that considers all factors that has an impact on a person’s behaviour and attitude This approach resolves the problem behaviour in an individual (LaVigna and Willis 2012). Since, Samara also exhibited problem behaviour like aggression, social exclusion and poor ability to listen to other people, PBS is considered as the most suitable intervention for her. Hieneman (2015) also explains that PBS resolves behavioural challenges, improves independence and social participation of people with behavioural challenges. Therefore, PBS can be beneficial for the improvement of overall quality of life of Samara while living at the supported care living.

The uniqueness of PBS is that this intervention emerged to manage behaviour of clients for inclusive home, work and community for individuals with living disability. It facilitates taking individualized problem solving approach by following five process. This includes identification of broad goals and behaviours of concern in client, gathering information related to factors affecting behaviour, selecting strategies and integrating them in comprehensive plan and implementing them across setting. PBS also supports carer in engaging in patient-centered care planning as strength and weakness of client is identified to establish action steps for achieving particular goal (Freeman et al. 2014). Functional behavioural assessment is also a necessary element of PSB as it gives carers clear understanding about the events triggering problem behaviour in client. The final process of PBS is to assess and monitor achievement of new skills and lifestyle outcomes in people like Samara (Kincaid et al. 2016).  Hence, such care process is likely to improve social interaction and address aggressive behaviour of Samara too and improve her quality of life.

Having understood the rationale and effectiveness of PBS for addressing behavioural problems of Samara, this essay provides a discussion on the strategies that a learning disability nurse can use to easily apply the PBS intervention for solving behavioural issues of Samara. The first step that will be necessary for nurse to implement PBS will be to build a behavioural support team of individuals who are most involved in the life of Samara and then collaborate in different ways to engage in behavioural support planning process (Hawkins, Catalano and Kuklinski 2014). Although PBS process is implemented by a person having knowledge and experience with behavioural principles, however support teams like nurse and family members are essential for goal setting, assessment, planning, implementation and evaluation of outcomes (Hieneman 2015). Potential team members could be client’s parent or families and other members like program consultant, support staff, therapist and resource professional. Nurse can collaborate with these people to develop behaviour support plan for Samara. Family is the most vital part for the fidelity and success of plan as they are the source who can explain why their child show problem behaviour and give better idea about problem solving approach to support the child (Erbas  2010).

Challenging behaviours like physical or verbal aggression can traumatic for carers increases risk of harm for people with learning disability. A nurse can apply PBS intervention to help Samara to express herself in different ways. The nurse can conduct functional assessment of client and the main rational for this is to understand what a person is trying to achieve through challenging behaviour. This indicates that there is a cause behind each behaviour and it can support nurse to develop link between events and circumstances that trigger and maintain problem behaviour (Horner and Sugai 2015). Observation is the main strategy by which nurse can obtain data related to the functional behaviour assessment process. A nurse can do so by taking notes while observing Samara at the supported living environment. Nurse should also determine antecedents that trigger aggressive behaviour in client. Nurse can constantly collaborate with the main stakeholders regarding the behaviour observed so that effective patterns of problem behaviour are understood (Beadle?Brown et al. 2012). Based on this discussion, it can be said that PBS is a data driven process and nurse plays a role in collaborating with family to perform functional assessment and engage in decision making with potential team member at every stage.

For a learning disability nurse to effective apply PBS for Samara, it is also necessary that they have appropriate value for implementing PBS. Values are one of the core components of PBS and the main PBS coordinator should training nurse regarding core values and principles of PBS. The main values include prevention of challenging behaviour within the context of quality of life, participation and inclusion and using constructional and collaborative approach to build stakeholders skill and avoid restrictive practices (Crone, Hawken and Horner 2015). A nurse should also have competence in three areas to effectively implement PBS. This includes having the skills to create high quality care environment for client, conduct functional, contextual and skill based assessment and apply evidence based strategies to implement and develop behavioural support plan (Skillsforcare.org.uk. 2018). Moskowitz et al. (2017) supports the fact that identifying specific antecedents that evoke problem behaviour and manipulative antecedents events can reduce problem behaviour in people with intellectual disability. Hence, nurse can also use the PSB process and skills to collaborate with key stakeholders and reduce existing behavioural challenges for client.

Apart from basic competencies, values and knowledge of PBS process, a nurse also needs many tools to apply PBS for the optimal health of Samara. Functional behavioural assessment is the main foundation of PBS and nurse can enhance the process by the use of many observation tools like behavioural rating scales or other behavioural checklist to find link to the context in which a person engages in challenging behaviour. Behavior rating scales have parameter that describes set of behaviours like social skills, inattention or anxiety in a client (Dunlap and Kern 2018). Another advantage of using such tool is that nurse can compare the outcome of the scales by comparing it with perception of other close family members or friend of client. In the context of Samara, the nurse use the data to compare it with response received from her housemate and support staffs. This can further strengthen the functional behavioural analysis process and improve the fidelity of the behavioural support plan. Such tool is also useful for evaluation of outcome and examining progress towards goals (Leaf et al. 2016).

The essay summarized the good practices and missing information in relation to the assessment done for Samara, a client with mild-moderate learning disability. Based on evaluation of her assessment data, many interventions were proposed for the health and well-being of Samara, however PBS was take as a choice of intervention after identifying behavioural problem as the main issue for client. PBS model incorporates science of applied behavioural analysis to support people with challenging behaviour like aggression and by the discussion on strategies to apply PBS for Samara, it can support development of positive behaviour in her through teaching and reinforcing prosocial behaviour by alterning her environment and attitude of people surrounding her (Tolisano  Sondik and Dike 2017). From the discussion, it can be concluded that PBS approach is beneficial for addressing challenging behaviour in people with learning disability and its effectiveness is enhanced because it adapts patient-centered and holistic care approach to formulate behavioural support plan for client (Hieneman, 2015).

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