This assignment will focus on the widely used Roper-Logan-Tierney model for nursing based on the activities of daily living, as well as the nursing skills used and assessment tools in place for the assessment of a patient whilst on placement in an acute medical respiratory ward.
The Roper-Logan-Tierney model for nursing, initially designed as an elementary teaching tool for new nursing students and tutors is now widely used as the building blocks for nursing care and practice, and teaching and learning. The model seeks to define what daily living means, with the activities of daily living being key to the process. The model focuses on a human’s 12 activities of daily living, namely maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying.
The activities of daily living assess an individual’s ability to carry out these normal daily activities of living, ranging from complete independence to complete dependence, and to determine what interventions or support will contribute to aiding the patient to be more independent in carrying out these activities. The application not only applies to the admission stage of a patient on to a ward, but that the holistic approach be continued long after the patient’s discharge, so that they can learn to cope with, adjust and improve their own heath challenges. The resulting end goal of assessment, and its recommended interventions, is the advocation of maximum independence for the patient concerned. According to the Roper-Logan-Tierney model, there are 5 influencing factors on daily living, namely biological, psychological, sociocultural, and environmental and politico economic.
The impact that injury or illness has on overall health can be determined as the biological factor, whilst the influence of a person’s ability to know, think, hope, feel and believe can be associated with the psychological factor. An individual’s experience of the impact society and culture has on their life is implied in the sociocultural factor, including expectations and values based on class and status. Expectations, beliefs and values upheld by an individual can be associated with culture as an influencing factor, as well as by others in relation to their ability to carry out their activities of daily living, and their independence as a whole. The environmental factor covers the impact the environment has on the activities of daily living, while also examining the reverse of the influence or impact the activities of daily living has on the environment. The politico economic factor examines the impact the government, politics and the economy have on the activities of daily living, addressing issues such as war/conflict, state benefits, funding, policies and interest rates amongst others.
To make an accurate assessment of any patient, a detailed account of their activities of daily living, or ADLs, must be examined. Montague et al, 2005 states that all ADLs about individual life activities are interlinked and when one or more activity is affected due to illness, then most of the activities can become compromised. When assessing Alice in conjunction to all the 12 activities of daily living, I found it necessary to concentrate on 4 of the 12 aforementioned to assess Alice’s needs, namely breathing, personal cleansing and dressing, sleeping and dying. The remaining ADLs of maintaining a safe environment, communicating, eating and drinking, eliminating, controlling body temperature, mobilising, working and playing and expressing sexuality were important and will be covered, but were not an obstacle for, or requirement of Alice’s at that time of my assessment. As a precursor to my main assessment of Alice’s activities of daily living, I took readings of her vital signs, as per the National Early Warning Score (NEWS) tool available to me. This tool was developed by the Royal College of Physicians and subsequently launched by the National Health Service in 2012, to improve the detection and response in an adult patient who is clinically deteriorating. It is a key component to improving patient outcomes and safety.
Alice’s clinical observations had a NEWS score of 7, mainly due to a decreased reading in her blood oxygen saturation levels (SpO2) of 88%, a heartrate of 117 beats per minute and a respiration rate of 24 breaths per minute. Her blood pressure was within range 100/64 mmHg and her body temperature read normal at 36.7 degrees Celsius. Alice’s pain level was recorded as a 5, due to her shoulder and back pain. I also tested her blood glucose level as she was taking steroids, and it was also within normal range of 6.4 mmol/l.
Maintaining a safe environment is vital to an individual’s safe existence, therefore allowing them to carry on with their other activities of daily living. Alice’s environment was noted to be safe. She was independent at ward level, requiring no assistance with walking and no safety requirement for bed rails. She maintained an orderly, tidy environment.
It was obvious that Alice was alert and orientated to time, place and person. She did not appear confused or drowsy and her good spirits lead to easy interactive communication between us. I found Alice very easy to communicate with, and her understanding of the nature and object of my interviewing, provided me with clarity and honesty in her answers. It was obvious that Alice had no difficulties with her speech or language. There was no evidence of slurring or use of sign language.
As an essential activity for survival, breathing plays a vital role in a person’s ability to carry out their activities of daily living. The act of breathing allows for an exchange of gases in the lungs, where the absorption of oxygen, used for sustaining the living body down to cellular level, is complemented with the expellation of unhealthy carbon dioxide gas back into the atmosphere, therefore sustaining a body’s homeostasis. For Alice, the daily activity of breathing was an increasing struggle. Assessment of breathing is paramount in carrying out a patient’s vital signs and monitoring observations. Her respirations were fast and laboured, above the normal range of 12-18 breaths per minute, a symptomology of her pleural effusion caused by the primary diagnosis of lung cancer. Oxygen therapy via nasal specs, along with nebulisers as required, were being used to manage Alice’s breathing and oxygen saturation levels – thus providing some effective relief to a distressing condition.
For good health to be maintained, adequate hydration of daily fluids, as well as the digestion of a well-balanced diet are essential. Despite Alice’s medical history and medications, she was eating and drinking well with no assistance, and was maintaining a good appetite. Her subsequent risk for malnutrition was evaluated using the Malnutrition Universal Scoring Tool (MUST tool) and this proved very favourable with a score of zero, due to her healthy BMI of 27, which was in keeping with her weight of 70 kilograms and height of 5 feet 4 inches. If Alice’s hydration and nutrition status were to change due to nausea or swallow impairments, the services of the available Dietician and Speech and Language Therapist would be on hand for advice. In assessing Alice’s skin and risk of pressure ulcers due to malhydration, the Braden tool was used. Alice’s satisfactory score of 23 put her in the no risk category.
Elimination of the body’s food and fluid wastes are key to maintaining the body’s homeostasis. Elimination is a private activity and nursing care should uphold a person dignity and respect when assisting a patient with this personal activity (NMC, 2015). There were no concerns with Alice’s ability to urinate or defecate, nor did she require assistance with toileting. Her well-balanced fluid and nutrition intake complimented a favourable elimination output, which was not a concern for the medical team, and therefore not being recorded on a daily basis. Alice’s medication did not interfere with her ability to eliminate successfully.
Alice was self-caring, therefore able to wash and dress herself without assistance on a daily basis. Roper et al (1996) chose to call this activity personal cleansing rather than washing, and included the activities of perineal hygiene, care of hair, nails, teeth and mouth, as well as hand-washing and bathing. There were no areas of concern noted.
Regulation of body temperature is essential for our body’s different biological processes. People have to avoid the hazards and discomfort of heat and cold through varying the amount of clothing they wear and regulating the amount of physical activity. The human body is programmed to control the temperature of our body for proper functioning. Extremes in temperature can disrupt our vital internal bodily functions. Alice had a normal body temperature of 36.7 degrees celsius. She was able to regulate her temperature by adding and removing clothing as required.
Alice was fully mobile and independent at ward level as well as in daily life outside of hospital. She did not require the use of walking aids and would regularly walk down to the hospital shop unassisted to break up her long days on the ward. No appraisal of her risk of falling was carried out.
Alice recently retired from her job in the Civil Service and now worked as a volunteer in her local charity shop. She was an active member of her church and up until her hospitalisation, she attended services, as well as extra-curricular events. Work and play are important daily activities for both mental and physical well-being, and Alice was still actively involved in these activities of daily living. Expressing Sexuality Alice disclosed that since her diagnosis of lung cancer, she has not taken much of an interest in her appearance and is conscious of her body image. She has been divorced for several years and is currently not in a relationship, mainly due to her illness.
Sleep is vital for existence and our body’s involuntary processes continue to be active during sleep. Sleeping for Alice can prove difficult from time to time, due to her shortness of breath and pain in her shoulder and back. Alice was independent and could manipulate her bed raising levels to suit her comfort. She told me her most comfortable sleeping positions were poised upright, using her electronic bed to raise her legs. This position made breathing easier for her. Alice was reluctant to add sleeping tablets to her list of daily medications.
As the final act of living, death is inevitable for us all, whether sick or healthy. Alice did not refer to her cancer diagnosis as being terminal, nor did she use the services of a palliative care team. I did not, therefore, approach the subject of dying or death with Alice.
Finally, the nursing process and ultimately the provision of nursing care, is provided with a systematic direction when a nursing model is incorporated. The Roper-Logan-Tierney model (1996) used in this patient’s assessment of her activities of daily living is a widely used and familiar assessment tool. The emerging care plan and its end goals should be a mutual agreement between the nurse, the patient and extended family members, where appropriate. The care plan should be open for revision as a patient’s needs or situation changes, even after discharge from hospital. It was a privilege to have met and engaged Alice in my assessment assignment and I wish her all the best with her future health.
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