Insight into Adult Nursing for Mental Health Nursing students

This insight package is designed to introduce you to the specialist area of adult nursing and to help students studying other fields of nursing to develop the knowledge and clinical skills that will help them to meet and understand the physical care needs of their patients whilst taking a holistic approach to care.

Faculty of Health, Social Care & Education
BSc (Hons) RN
Insight into Adult Nursing
for
Mental Health Nursing students

INTRODUCTION:
Welcome to your adult insight placements.
“Adulthood is a period generally characterised by self-reliance which centres on occupational and family interests. There
is, of course, great diversity in the lifestyle and behaviour exhibited by individuals in this stage of life” (Alabaster, 2006).
The Specialist Area of Adult Nursing
This insight package is designed to introduce you to the specialist area of adult nursing and to help students studying
other fields of nursing to develop the knowledge and clinical skills that will help them to meet and understand the physical
care needs of their patients whilst taking a holistic approach to care. It is aimed at increasing your knowledge and
awareness of what services are provided in the adult sector both within acute and community settings. Use this workbook
alongside your clinical skills learning log.
In many areas of adult nursing you may find that the emphasis of care is placed on the physical needs of the person
being nursed. However, a more holistic approach that promotes individualised, seamless care for patient and family is
widely used.
As with all fields of nursing, caring for the ill adult takes place in many settings. Nearly all of us have, at some time, been
‘consumers’ of health care. This workbook follows a patient’s journey through the health care system and includes
activities designed to help you gain insight into the adult field of nursing.
Whilst on placement work with your mentor to select 1 and ideally 2 patients to follow their journey from
admission to discharge (these are referred to as patient 1 and patient 2 in the activity boxes). This will enable you
to enhance your knowledge and undertake many of the skills in your clinical skills learning log on a number of occasions.
Try to undertake at least 2 different skills in your skills learning log, each week. Make notes to reflect upon what
you have learnt and discuss them with other students in your tutor group so that you can learn from each other. Do not be
concerned if other students have undertaken skills that you have not been allowed to do (since this will depend on the
individual organisation’s policies) or if all of the skills in your skills log cannot be completed on your adult placement. If
there is something that you particularly wish to achieve on a placement include this in your action plan (appendix 2) and
ensure that you have your mentor’s agreement that this is a skill that you can undertake on that placement.
Using this workbook
Each section will include a number of activity boxes:
ACTIVITY BOXES
These are sections in which you are asked to undertake a specific activity
or reflection. Your answers should ideally be discussed with your mentor
and included in your portfolio where appropriate.
Each section identifies a list of resources that you will need to undertake the activity(s).
NB. Many of the activities require the use of the Internet.
Boxes with red borders relate to the first patient identified.
Boxes with blue borders relate to the second patient.
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SECTION 1:
Beginning the journey
This section looks at the beginning of the patient’s journey into an adult setting.
To help you complete this section you will need:
 Internet access
 Discussions with patients and staff
If patients are admitted to hospital, they reach the start of their admission by many different routes.
ACTIVITY BOX
List the routes by which patients are admitted to an acute hospital; does this differ to admissions into in-
patient mental health services?
 Encounter with the general practitioners
 General practitioner outside office hours
 112 ambulance
 Self –referral
Emergency department Admission / Geriatric rehabilitation care.
Student Signature…………………………………………………
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Some patients need longer-term physical nursing care, which often takes place in the independent sector.
ACTIVITY BOX
List the routes by which patients are admitted to a longer-term nursing care setting e.g. Nursing home;
does this differ to admissions into longer-term mental health services?
Which route of admission was used for the patients you have identified?
Patient 1: (dementia) Community
Adult services Acute care Liaison
Memory assessment
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Patient 2 (cardiovascular accident)
Student Signature…………………………………………………
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SECTION 2:
Assessment and care planning
To complete this section it will be useful for you to have:
 This workbook, you will find a nursing care plan form for you complete at Appendix 1.
 An anatomy and physiology textbook
 Access to the Internet
 A foundation nursing practice book with a section on pain assessment.
 Pharmacology textbook
 Research articles
ACTIVITY BOX
At this point you should revise:
The anatomy and physiology of the musculo-skeletal system.
The anatomy and physiology of the pancreas.
Pain assessment.
People require healthcare for a variety of reasons and initial contact with health services may be via a number of
routes. Regardless of the mode of entry to the healthcare system it is important to reassess the patients holistically to
allow for individualised care planning.
Assessing a patient with a physical condition is equally as complex as assessing those with a psychological or mental
health difficulty. People do not fit neat categories. All branches of nursing need to consider the physical, psychological
and social dimensions of those in their care and to recognise the strong interrelationship between mental and physical
health. People with mental health issues have a vulnerability to physical illness and those with physical disease are
susceptible to mental health problems.
‘It is common to feel sad or discouraged after a heart attack, a cancer diagnosis, or if you are trying to manage a chronic
condition like pain. However, there are some risk factors directly related to having another illness. For example, conditions
such as Parkinson’s disease and stroke cause changes in the brain. In some cases, these changes may have a direct
role in depression. Illness-related anxiety and stress can also trigger symptoms of depression.’ (National Institute of
Mental Health) https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/index.shtml
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ACTIVITY BOX
Explain what the terms ‘Holistic Care’ and ‘Individualised Care’ mean to you.
Holistic care- Holistic care involves assisting the patient in the healing of the mind, body and souls of the patient.
Individualised care- An individualised care is the care planned to meet the individual or the specialised needs of
each patients (Morgan and Yoder 2012).
Student Signature…………………………………………………
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Many adult nursing care settings use the Activities of Living model developed by Roper, Logan & Tierney (2000) to guide
assessment.
The Activities of Living (ALs) are:
 Maintaining a Safe Environment
 Communicating
 Breathing
 Eating and Drinking
 Eliminating
 Personal cleansing and dressing
 Controlling body temperature
 Mobilising
 Working and Playing
 Expressing Sexuality
 Sleeping
 Dying
ACTIVITY BOX
Consider each of the ALs and how they relate to a patient you are caring for on the ward (Patient 1)? Use
this to identify patient focused problems on the attached care plan (appendix 1)
Patient 1- This patient had been suffering from progressive dementia and has poor mobility having high risk of
falls.
 Maintaining a Safe Environment- Provision of environment modifications to prevent falls
 Communicating- Communicating using simple and short sentences that can be understood by the
patient.
 Breathing- Encouraging deep breathing exercises and teaching relaxation techniques.
 Eating and Drinking- Encouraging the patient to consume nutritious food and fluids timely
 Eliminating- Providing physical assistance during bowel clearance.
 Personal cleansing and dressing- Assisting the patient in self care activities
 Controlling body temperature- Daily check up of the body temperature
 Mobilizing- Assisting the patient with physical exercises to improve mobility.
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 Working and Playing- assisting the patient in incidental exercises.
 Expressing Sexuality-Allowing the patient to spend quality time with her partner. Cuddling and
affection are sometimes considered as the basic needs of the elderly people.
 Sleeping- Assisting the patient to maintain sleep cycle by exercises or by medicines.
 Dying- Respecting the wish of the patient while in a palliative care
ACTIVITY BOX
Consider each of the ALs and how they relate to a patient you are caring for on the ward (Patient 2)? Use
this to identify patient focused problems on the attached care plan (appendix 1)
Patient 2 : Patient 2 had undergone a cardiovascular accident and is now under rehabilitation.
The Activities of Living (ALs) are:
 Maintaining a Safe Environment- Providing side rails in beds and accompanying the patient in the
bathroom to prevent fall.
 Communicating-Communicating the patient in a comprehensive, culturally safe language.
 Breathing- Assisting the patient is shallow breathing exercises.
 Eating and Drinking- Providing in the patient with semi solid food and abundant fluids.
 Eliminating- Assisting the patient in bowel clearance, laxatives can be given.
 Personal cleansing and dressing- Assisting the patient in self care, dressing , grooming
 Controlling body temperature- regular checking of the vital signs.
 Mobilizing- Mobilizing the patient to prevent venous thrombosis.
 Working and Playing- promoting no work or playing.
 Expressing Sexuality- Allowing the patient to spend quality time with her partner. Cuddling and
affection are sometimes considered as the basic needs of the elderly people
 Sleeping- Relaxation exercises and providing calm environment to facilitate sleep.
 Dying- Providing a culturally safe care, respecting patient’s wish or the religious or the spiritual
beliefs to facilitate a dignified death.
Study the assessment documentation used at your placement to admit a patient and note if all of the ALs are
included. Reflect on how this compares to assessment carried out in your own discipline.
Student’s reflection
What ?
In my own discipline of mental health sector and other sectors, less importance is given on maintaining the
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dignity of the patient. In this ward, assessment is mainly done on the basis of interviews with the patients; the
vital signs are not assessed first. In patients suffering from physical illness, the primary assessment consists of
assessment of the airways or chest or neurological assessments, but in case of mental health disorders, much
importance given on the mental state examination and interview with the patient.
So what?
I believe that this difference between the type of assessment is due to the difference in the pathophysiology or
the symptoms.
Now what?
The mental assessment of the mental health patients has to be more robust.
Student Signature…………………………………………………
Mentor Signature…………………………………………………..
Assessment and care planning for pain.
Physical (and psycho-emotional) pain or discomfort is a common feature of many peoples experience of healthcare. Good
communication is essential in pain assessment. Consequently assessment of pain is critical in patient welfare and
wellbeing.
Pain affects patients physically and emotionally, so successfully managing the pain they experience is a key component
of their recovery. Swift, A, 2015 Nursing Times 11 (41):12-17.
ACTIVITY BOX
When pain is assessed as a high priority. Which of the ALs would be most affected?
Mobility, working and playing and personal cleansing and hygiene are the ADLs that will be affected.
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ACTIVITY BOX
What may be the psychological impact of a patient’s pain?
Some of the psychological responses to pain are anxiety, depression, imsomnia, demoralisation and fear.
Student Signature…………………………………………………
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ACTIVITY BOX
Read, and make notes from at least one research article that explores issues relating to pain
assessment e.g. the effectiveness of your chosen tool, how they can aid analgesic treatment or
discrepancies between nurses’ and patient’s perceptions of pain. Are there any disadvantages to this
tool?
Abbey pain scale is an important pain assessment tool for measuring pain in the elderly patient, who might have
communication difficulties. This toll might be helpful to rate the effectiveness of the patient controlled analgesia
for the management of acute pain.
In many cases the patient might not be able to describe the intensity of the pain. In such cases, factors such as
vocalisation, facial expressions, change in the body language, physiological change and physical changes helps
in assessing the pain. Each of the factors is rated within the range Absent, Mild, moderate and severe.
Disadvantages:
It cannot differentiate between distress and pain.
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Assessment and care planning for diabetes.
Before you begin the next section, you should complete the following activity:
ACTIVITY BOX
Access www.diabetes.org.uk .
What are the differences between Type 1 (Insulin dependant diabetes) and Type 2 (non-insulin
dependant diabetes)
Type 1 Diabetes- T1D occurs when the cells of the pancreas of a person produces no insulin due to the
destruction of the pancreatic cells by the body’s own defence system.
Type 2 Diabetes- In this type the beta cells of the pancreas either do not process enough insulin or the body
cannot use the insulin properly as the cells become insulin resistant and requiring a greater amount of insulin to
keep the blood glucose level within the range.
Using a pharmacology textbook, identify two drugs that may be prescribed to control Type 2 diabetes.
Metformin (Glucophage, Glumetza), Sulfonylureas
Identify your patient’s needs with regards to their diabetes and write them on a care plan (appendix 1).
 Controlling the blood sugar level
 Maintenance of skin integrity
 Nutritional needs maintenance of the fluid volume.
On the same document, record what care you would plan to meet these needs.
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 Controlling the blood sugar level- Assessing the signs for hyperglycaemia, monitoring the patient’s
HbA1c-glycosylated hemoglobin.
 Skin integrity- Use of moisturizers, inspection of feet for erythema, assessing skin integrity.
 Nutritional needs- Consultation with the dietician, provision of liquids containing nutrients and
electrolytes.
As you will have discovered, there are major differences between the two conditions. The only major link is that raised
blood glucose is a feature of both types of condition, and it is not surprising that for many years similar treatment was
prescribed for both. Glucose levels are now almost exclusively assessed by blood testing as opposed to the older
method of urine testing. As part of an initial assessment, patients who are admitted to the acute general sector of health
care are likely to have a blood glucose test performed as routine should they be identified as at risk of either Type 1 or
Type 2 diabetes. Any abnormal level (high or low) will be followed up by a laboratory analysis.
Patient assessment and user involvement in the care planning process
ACTIVITY BOX
Whilst on placement, assist a member of staff to assess patients following their admission to the clinical
area.
Reflect on the nature and outcome of this process and how it might differ from assessment in mental
health settings?
While caring for the patient with cardiovascular accident, the assessment that was made were-
Stroke (Face arm speech test), general appearance, vital signs (presence or absence of tachycardia or
tachypnea), physical examination for the presence of pallor abnormal bleeding, deafness, muscular oedema,
arrhythmia (Clarke and Forster 2015).
Whereas for a mental health setting the assessment consists of – a physical examination to detect presence of
any illness that mimics mental illness.
Laboratory tests- brain scan, urine test, questions on any drug or alcohol abuse (Clarke and Forster 2015).
Mental health history- The doctor will ask questions about family history of mental health issues.
Mental and cognitive evaluation- Question answering about the thoughts and the perceptions.
Student Signature…………………………………………………
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ACTIVITY BOX
Look at the documentation used with patient 1. Is there evidence that the patient was involved in the
planning of their care? Consider the patient’s ability, motivation and opportunities for involvement.
Discuss this with your mentor.
The patient 1 was suffering from progressive dementia. In spite of the cognitive impairment, the patient was
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involved in the planning of care. Such as patient was asked each time whether he needed any assistance in
toileting activities and dressing. Autonomy was given to the patient in terms of self care activities. The patient
was discussed with the entire treatment regimen in front a trusted member of the family and consent was taken
from patient before carrying out the treatment.
Student Signature…………………………………………………
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ACTIVITY BOX
Look at the documentation used with patient 2. Is there evidence that the patient was involved in the
planning of their care? Consider the patient’s ability, motivation and opportunities for involvement.
Discuss this with your mentor.
The patient 2 had suffered from a cardiovascular accident.
The patient was involved while chalking out the rehabilitation procedure. The patient was given the opportunity
to choose the type of rehabilitation, any nutritional preferences while making the diet plan. The patient was
encouraged to do mild exercises on her own. Furthermore, patient consent was considered before carrying out
any procedures.
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ACTIVITY BOX
Whilst on placement note the type of specimens that are collected, the procedures for collecting those
specimens, the required documentation and how results are recorded. Make some notes below.
Blood, sputum, urine and stool specimens are often collected by the nurses for testing. Specimen should be
collected at the best time possible. Appropriate collection devices like sterile, leak proof specimen containers
should be used. All the containers should be labelled and the test request form has to be filled. Nurses are also
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responsible for the timely transfer of the samples. The results are sent electronically from the pathology lab and
the nurse transfers it over to the specialist.
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Factfile
Patients with diabetes are at higher risk of mental health disorders — including depression and psychotic disorders — than
the general population (2015) http://www.thelancet.com/diabetes-and-mental-health-disorders
“For both first and second generation antipsychotics the incidence of diabetes increased with the number of prescriptions.
Additionally, the incidence of diabetes increased with the number of combined antipsychotic drugs. (Kessing, Thimson,
Mogensen & Anderson, 2010)
Research has shown that diabetes can increase the risk of developing both Alzheimer's disease and vascular dementia.
https://www.alzheimers.org.uk/info/20053/research_projects/753/investigating_the_relationship_between_diabetes_and_dementia
SECTION 3: Implementation and Evaluation of care
To help you complete this section it will be useful to have:
 A pharmacology textbook
 Access to the Internet
 NMC The Code
The next stage of the nursing process requires that the problems identified at assessment and the associated care
planned is implemented. As you have seen these problems, particularly the pain, affect the Activities of Living and so to
restore equilibrium the problems prioritised must be treated.
ACTIVITY BOX
Using the pharmacology text book, identify one drug that is used for severe pain.
 What are the actions and interactions of this drug?
 How long is its duration of action?
 What are its possible side effects?
Opioids (Morphine)
Actions and interactions
Morphine acts by acting on the receptors located in the neuronal cell membrane. It inhibits the release of the
neurotransmitters thus inhibiting pain.
Morphine may interact with the drugs such as opioid agonist like pentazocine, naltrexone.
Duration of action
Effects of Morphine taken orally stays for 4-5 hours
Effect of subcutaneously applied morphine takes place for 4-5 hours.
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Side effects
Shallow breathing, dizziness, allergy
Now identify two drugs that may be prescribed for moderate pain.
 What are the actions and interactions of these drugs?
 How long is the duration of action?
 What are their possible side effects?
Ibuprofen, Acetaminophen
Action and interactions of Ibuprofen
Ibuprofen is a non selective inhibitor of the enzyme cyclooxygenase that is necessary for the synthesis of
prostaglandin. Blocking the release of the prostaglandins prevents the sensation of pain and swelling. Ibuprofen
should be avoided with aspirin, warfarin as it would increase the risk of stomach bleeding.
Duration of action
400 gm of Ibuprofen is effective for at least 6 hours.
Side effects
Mild heart burn, nausea, dizziness, bloating.
How can the effectiveness of the drugs on the patient’s pain be assessed?
Effective follow up and gathering data about any evidence of adverse effects and then tallying them with the
desired goal can be helpful in assessing the effectiveness of drugs.
Student Signature…………………………………………………
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In many areas of health care, the health care professionals function as a multi-disciplinary or inter-professional team.
During hospital admission this team could consist of the following a
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ACTIVITY BOX
Identify a similar inter-professional team for patient 1 whose journey you are following on your placement. What is
each person doing for your patient?
Interprofessional team for treating the dementia patient
A neuropsychologist-
A mental health nurse- They monitor the clinical manifestations, responds to any medication issues and provides
education to the patient.
A psychiatrist-Provides mental support to the patient and applies psychotherapy
Occupational therapist- They help the patients to adapt to their diminished ability to face the chalanges in daily
living.
Physical therapist- This can help the dementia patients to optimise their physical condition and maintain a safe
mobility (Grand, Caspar & Macdonald, 2011).
Nutritionist- Cognitive impairment places the patient under the risk of malnutrition. A nutritionist should prepare a
proper diet chart for the patient.
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Adult Insight Sept 16
PATIENT
AND FAMILY
Nurse
Doctors
Dietician
Physiotherapist Radiographer
Plaster
technician
Diabetes nurse
specialist
Laboratory
Scientist
13

ACTIVITY BOX
Identify a similar inter-professional team for patient 2 whose journey you are following on your placement. What is
each person doing for your patient?
A cardio- nurse- Assessing the vital signs, clinical monitoring, medication administration and overall management
of the rehabilitation procedure.
A nutritionist-Assesses the nutritional requirement of the patient.
An occupational therapist- Helped the patient to cope up with the ADL, teaching the patient with eating, dressing
and toileting and use of assistive devices (Grand et al. 2015).
Speech and language therapy- speech therapist assesses all the aspects of communication and also assesses
the difficulties in swallowing.
Student Signature…………………………………………………
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SECTION 3: Evaluation of care
The final phase of the nursing process is evaluation. Evaluation is about reviewing the effectiveness of the care that has
been given, and it serves two purposes. First, the nurse is able to ascertain whether the desired outcomes for the client
have been achieved. Second, evaluation acts as an opportunity to review the entire process and determine whether the
assessment was accurate and complete, the diagnosis correct, the goals realistic and achievable, and the prescribed
actions appropriate.
ACTIVITY BOX
List the ways in which different aspects of your patients’ nursing care can be evaluated.
 The nursing care can be evaluated by the determining the behavioural response of the client to the
nursing interventions
 By comparing the response of the client with the predetermined outcome criteria.
 By appraising the extent to which the goals of the client were attained.
 Identification of the errors in the plan of care
 Monitoring the quality of the nursing care.
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NB You may wish to enter these in the evaluation section of the nursing care plan at Appendix 1 of this workbook.
Reflect on how this compares to evaluation carried out in your own mental health discipline.
In the mental health discipline, the evaluation stage of the nursing care is almost similar to that of the
generalised steps. At first it is necessary to identify the criteria and the standards, then collection of the
evaluation data (such as rate of violent or suicidal episodes, rate of depressive episodes), followed by
interpretation and summarisation of the findings and finally revision of the care plans.
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 Formal evaluation of care planning is a vital step in the performance of the nurse’s duty of care towards their clients. Writing
an evaluation down is the proof that the nurse has, by reviewing the care plan, complied with the professional Code. The
documentation could be produced in court should it ever be needed.
 There are also other ways to evaluate care on a less formal basis. Nursing handover is a useful opportunity to discuss a
patient/client’s progress and the effectiveness of treatments. Reflection also plays a vital part, whether the nurse delivering
care is a student or a clinician of many years standing.
 Evidence tells us that supporting patients to be actively involved in their own care, treatment and support can improve
outcomes and experience for patients. Person-centred care supports people to develop the knowledge, skills and confidence
they need to more effectively manage and make informed decisions about their own health and care.
https://www.england.nhs.uk/ourwork/patient-participation/
 True patient/client centred care will also allow the care receiver to play a part in their own care. Take for example pain; once it
has been assessed using the visual analogue score, recorded on a care plan, and a suitable drug prescribed it is a natural
action for the nurse to ask their patient whether the drug has been effective or not – so the patient will play a large part in
evaluating their own care.
ACTIVITY BOX
Look at the documentation used with patient 1; has their care been evaluated? Is there evidence that the patient
was involved in the evaluation of their care? Discuss this with your mentor.
Yes, as per the documentation, the care has been evaluated. This was done by tallying the outcomes with the
perceived goal. The patient displayed improved mood and orientation. The subjective data was evaluated with the
objective data. The patient was involved in the evaluation process as feedback was obtained from the patient.
Student Signature…………………………………………………
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ACTIVITY BOX
Look at the documentation used with patient 2; has their care been evaluated? Is there evidence that the
patient was involved in the evaluation of their care? Discuss this with your mentor.
The nursing care for the patient 2 was being evaluated. The patient displayed improved sensory perception, with
an improved speech and mobility. Feedback was also taken from the patient to obtain the subjective data for
evaluation (Parry et al 2015).
Student Signature…………………………………………………
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SECTION 4: Journey’s End
To complete this section you will need:
 Internet Access
In the next activity you need to explore the implications of discharging someone from hospital.
ACTIVITY BOX
Where possible, participate in both a simple and complex discharge of your patients.
Using your own knowledge of healthcare who should be notified of the discharge? Consider the physical care
needs of the patients based on your assessments – think about possible social care issues, emotional support as
well as more specific issues such as wound care, medication and follow up appointments
At the time of the discharge, the discharge nurse should notify to the multidisciplinary care team, the specialist
doctor, occupational therapist, Medicare services (if present). Before the discharge it is necessary to assess their
physiological, physical and the social needs. For example, patients having financial constraints should be referred
with community care services providing Medicare services, providing home support in less cost. Social care needs
like confidentiality should be maintained during the paper work, referrals to podiatrists for wound management.
Who will be responsible for informing and liaising with other professionals and what will they need to be
told? Talk to the people organising the discharge.
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A discharge liaison nurse is responsible for the informing and liaising with other professionals. A discharge nurse
use a discharge checklist and see whether any such needs of the patient in unaddressed. It provides all the
information regarding the current health status of the patient and assists in discharge planning.
Reflect on any differences between this and discharging someone who has been an in-patient in a mental health
setting.
Student’s reflection
What?
I have noticed a difference between the admission procedure of these patients and someone who had been an in-
patient in a mental health setting.
So what?
I feel that the follow up care in case of mental health patients needs to be more robust than the normal wards.
This is because there lies a high chance of remission or certain environmental and emotional triggers might cause
remission. Furthermore, patients with mental health illness often face from withdrawal symptoms, that needs to
be followed up.
Now What?
Hence, it is recommended that a proper discharge planning involving a thorough consultation with the MDT, the
family and the patient is necessary.
Student Signature…………………………………………………
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One of the first important questions regarding your patient’s discharge is; how are they going to get home? In most cases
a relative or friend will be happy to help out, but they do need to be contacted to make sure that they are willing and able
to do so. Think about any equipment that may be required? Have they got basic provisions at home? Are they going to be
by themselves?
The General Practitioner (GP) may also need to provide a certificate of sickness for your patient to produce to an
employer or to the Department of Work and Pensions.
Although in many ways discharge home means the patient has reached the end of their ‘Patient Journey’ within the acute
hospital setting, in other ways the journey is just beginning.
Diabetes
A potential problem for some patients under the AL of Eating and Drinking is weight. In order to help control Type 2
diabetes some patients need, in the long term, to reduce their weight. This weight reduction forms a potential problem in
the AL of Eating and Drinking,
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During their stay in the acute general hospital, it will not have been practical to meet in full this identified potential
problem. Nursing care will have begun the process, but patients will be outside their own socio-cultural environment and
in ‘artificial’ surroundings where their dietary intake can be closely controlled.
ACTIVITY BOX
Access www.diabetes.org.uk
Why is weight management an issue for people with Type 2 diabetes?
Weight management in pre-diabetes can be beneficial for not developing diabetes in future. Excess body fat may
lead to insulin resistance (Feinman et al. 2015).
What type of diet is recommended?
Complex carbohydrates like whole wheat, oatmeals, fruits, vegetables, lentils and beans, low fat dairy products.
Processed carbohydrate and sugar should be avoided (American Diabetes Association 2014).
.
How might lifestyle and employment affect a patient’s ability to maintain a healthy diet?
Sedentary life styles and job roles allowing less mobility can lead to diabetes. Unavailability of healthy food in
close proximity, large number of take- away stalls, lack of time compels people to live on unhealthy and ready-
made food (American Diabetes Association 2014).
Student Signature…………………………………………………
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ACTIVITY BOX
What patient education interventions might a patient with Type 2 diabetes require prior to discharge?
Prior to discharge the following education should be provided to the patient:-
 The patient should be taught to check the blood sugar level regularly and to maintain a logbook
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 A diet chart should be made and the patient should be educated about the importance of diet in Diabetes
management (Frassetto et al. 2015).
 Regular physical exercises.
 Wound management. In case of any prolonged chronic wound, the patient should immediately contact
with the doctor.
Student Signature…………………………………………………
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ACTIVITY BOX
Look at the documentation used with patient 1. Is there evidence that the patient was involved in their discharge
planning? When did discharge planning start? Who has been informed of their discharge? Discuss these issues
with your mentor.
The patient was involved in the discharge planning. The patient was educated about self care, about the
importance of adherence to medications, keeping remainders to avoid medication misses. The criteria for the
discharge that has been used are-
 Independence in mobility, washing and dressing.
 Patient displayed no symptoms of depression or anxiety.
The discharge planning starts soon after a patient has been admitted in to the hospital and several days before
the planned discharge. The patient’s family is generally informed of their discharge after a MDT meeting. Social
care community services can be referred to for facilitating socialisation of the patient.
Student Signature…………………………………………………
Mentor Signature…………………………………………………..
ACTIVITY BOX
Look at the documentation used with patient 2. Is there evidence that the patient was involved in their discharge
planning? When did discharge planning start? Who has been informed of their discharge? Discuss these issues
with your mentor.
Yes, the patient was involved in the discharge planning. She was educated about the use of assistive devices,
maintenance of correct posture while bending or toileting, breathing exercises, medication adherence.
The discharge planning started right after the patient has been admitted (Shepperd et al. 2015).
The patient’s family, the physiotherapist and the occupational therapist have been informed about the discharge
such that home care services such as physiotherapy and occupational therapy can be continued even after the
discharge for coping up with the Daily activities of living (Gonçalves‐Bradley et al. 2015).
Student Signature…………………………………………………
Mentor Signature…………………………………………………..
Adult Insight Sept 16 19

Primary Care:
Primary Care Trusts, and other community based organisations, are responsible for consulting with local communities on
health care needs as well as delivering care to those living within a specified area. They work in conjunction with the
acute sector, social services and other organisations.
Some patients will require considerable follow up care once they have returned to their own home and community. Health
promotion and education, care and support will take place within the local community; and at the G.P.’s surgery in nurse
led clinics.
Many G.P. practices have nurse-led diabetic clinics. On your next visit to the G.P. see if your G.P. practice offers this
service. What other nurse led services are available at G.P. practices near to your home or the hospital where you are
placed?
ACTIVITY BOX
What follow-up services does patient 1 require after discharge?
Follow up services for the dementia patient:
 Visiting nurses
 Volunteer services
 Adult protective services
 Community resources
 Counselling
Student Signature…………………………………………………
Mentor Signature…………………………………………………..
ACTIVITY BOX
What follow-up services do patient 2 require after discharge?
Follow up services for the patient with Cardiovascular accident:
 Follow up home visits by a physician and a nurse
 Standard aftercare
 Provision of a home support to help the patient in ADLs.
Adult Insight Sept 16 20

Student Signature…………………………………………………
Mentor Signature…………………………………………………..
Section 5: Conclusion
This workbook has concentrated on the patient journey of patients within your placement area, following the nursing
process of assessment, planning, implementation and evaluation.
The psychological effects of sudden change from independence to dependence can have a profound effect on an
individual and their capability to maintain their own safe environment.
Diabetes has also been explored. The condition may be detected on routine examination by other professionals, for
example, opticians while they are examining a client’s eyes. This is an increasingly common condition, which is to some
extent preventable. Type 2 diabetes tends to develop slowly, especially in those with a high BMI or a family history of the
condition and is often found on assessment when a client is admitted for other reasons. It is widespread and affects
patients and clients of all disciplines within nursing. By visiting the Diabetes UK website and/or reading about the topic
and exploring the diet and drug therapy for this condition you have gained an insight into how the condition may be
controlled in order to prevent the side-effects that can develop.
The prevention and treatment of Type 2 diabetes is a high priority nationally. The politico economic implications of this
condition have led to the development of a National Service Framework (NSF) for Diabetes in which standards for the
prevention and treatment of both Type 1 and Type 2 diabetes are outlined.
By undertaking the activities outlined you should have gained some knowledge of how to assess, plan, implement and
evaluate care within an adult care setting. By assisting in the care of patients and discussing the activities with your
mentor you should have gained knowledge and understanding of physical aspects of care that will enable you to deliver
holistic care within your own field of nursing care.
I hope that you enjoy your adult placements and that you feel more confident when performing physical care
skills.
Useful Reading
Delves-Yates C, 2015 Essential Skills for Nurses; Step by Step London Sage
Howatson-Jones, L, Standing, M, Roberts, S 2012 Patient Assessment and Care Planning in Nursing London Sage
May, A 2015 Adult Nursing at a Glance Wiley and Sons Chichester
Peate, I.; (ed) 2010 Nursing Care and the Activities of Living Wiley Chichester
Peate I, Wild K, Nair M (eds) 2014 Nursing Practice Knowledge and Care Wiley Chichester
Roper, N., Logan, W. & Tierney, A.J., 2000. The Roper-Logan-Tierney model of nursing: based on activities of living.
Edinburgh: Churchill Livingstone.
Adult Insight Sept 16 21

Adult Insight Sept 16 22

APPENDIX 1: CARE PLAN
Dementia
PROBLEM / ISSUE PLANNING IMPLEMENTATION EVALUATION
Disturbed thought process
(in the dementia patient)
Assessing the ability of the person for the
processing of the thought, observing the
patient for the cognitive functioning, memory
changes.
This can be done by
directly observing the
patient
By taking feedback from
the patient and tallying
with the decided goals.
Self-care deficit /Bathing
and hygiene
The patient will be able to do the self-care
activities like washing the body parts, obtaining
the bath supplies, combing and brushing.
This can be done by
assessing the
appearance of the
patient, body odour.
Ensuring that all the
items are present in
the bathroom before
the arrival of the
patients.
Patient will have all the
self-care needs met and
will be able to carry out
self- care program on a
daily basis.
Social isolation
The patient will be able to communicate, will
be able to access the support group,
counselling for assistance.
Provision of rest and
sleep periods,
permitting coping up
with the stimuli.
Patient will display
socialisation.
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Cardiovascular accident
PROBLEM / ISSUE PLANNING IMPLEMENTATION EVALUATION
Impaired physical
mobility
The patient will be able to increase the
strength and the function of the affected parts
Assessing the extent
of the impairment for
the identification of
the strength and the
deficiencies.
By taking feedback from
the patient and tallying
with the decided goals.
Impaired verbal
communication
The nurse will be able to establish the methods
of communication problems.
The degree of the
brain involvement
and the difficulty that
the patient has with
communication
process
Patient will be able to
communicate
successfully.
Self-care The patient will be able to do the self-care
activities like washing the body parts, obtaining
the bath supplies, combing and brushing
This can be done by
assessing the
appearance of the
patient, body odour.
Ensuring that all the
items are present in
the bathroom before
the arrival of the
patients.
Patient will have all the
self-care needs met and
will be able to carry out
self- care program on a
daily basis.
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APPENDIX 2: ACTION PLAN FOR ACHIEVING CLINICAL SKILLS
Date Areas identified for
development.
SMART
Outcome
1. Actions required
by student.
2. Learning
Resources available
to support student
in achievement.
3. Agreed time frame
Feedback
from mentor /
supervisor
regarding
achievement /
reasons for
non-
achievement
Student
signature
Mentor /
supervisor
signature &
date
 Communication
skills
 Leadership skills
 Accurate
assessment of the
symptoms
 Knowledge about
the accountability
of the patient
S-To develop
communication
and leadership
skills in nursing
M- To
demonstrate an
increased
communication
with the patient
and the their
families, as well
as the members
of the
multidisciplinary
team members.
1. Intensive evidence
based research,
reflecting on
personal practices,
consulting with the
seniors.
2. Learning
resources-
Nursing articles
and journals.
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A-to improve in
future
professional
practice.
R- To improve
the
communication
skills while
communicating
with patients who
are culturally
backward.
T- Within a time
frame of 2
months.
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References
American Diabetes Association, 2014. Diagnosis and classification of diabetes mellitus. Diabetes care,
37(Supplement 1), pp.S81-S90.
Clarke, D.J. and Forster, A., 2015. Improving post-stroke recovery: the role of the multidisciplinary health
care team. Journal of multidisciplinary healthcare, 8, p.433.
Feinman, R.D., Pogozelski, W.K., Astrup, A., Bernstein, R.K., Fine, E.J., Westman, E.C., Accurso, A.,
Frassetto, L., Gower, B.A., McFarlane, S.I. and Nielsen, J.V., 2015. Dietary carbohydrate restriction as the
first approach in diabetes management: critical review and evidence base. Nutrition, 31(1), pp.1-13.
Gonçalves‐Bradley, D.C., Lannin, N.A., Clemson, L.M., Cameron, I.D. and Shepperd, S., 2016. Discharge
planning from hospital. Cochrane Database of Systematic Reviews, (1).
Grand, J. H., Caspar, S., & Macdonald, S. W. (2011). Clinical features and multidisciplinary approaches to
dementia care. Journal of multidisciplinary healthcare, 4, 125-47.
Morgan, S. and Yoder, L.H., 2012. A concept analysis of person-centered care. Journal of holistic nursing,
30(1), pp.6-15.
Parry, G. J., Carson-Stevens, A., Luff, D. F., McPherson, M. E., & Goldmann, D. A. (2013).
Recommendations for evaluation of health care improvement initiatives. Academic pediatrics, 13(6), S23-
S30.
Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W. and Ferri, C.P., 2013. The global prevalence of
dementia: a systematic review and metaanalysis. Alzheimer's & dementia, 9(1), pp.63-75.
Rubio-Valera, M., Chen, T. and O'Reilly, C., 2014. New roles for pharmacists in community mental health
care: a narrative review. International journal of environmental research and public health, 11(10), pp.10967-
10990.
Shepperd, S., Lannin, N.A., Clemson, L.M., McCluskey, A., Cameron, I.D. and Barras, S.L., 2013. Discharge
planning from hospital to home. Cochrane database of systematic reviews, (1).
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