Patient Care Study Essay

INTRODUCTION
This is a nursing care study of people with physical illness. For the purpose of this study a single patient’s care was focused on. The patients name is Adam and he is a middle aged man who is separated from his wife and lives with his mother. Adam is an alcoholic who was referred to hospital against his wishes, by his G.P. He presented with heel ulcers secondary to vasculitis, a groin skin infection and cellulitis secondary to poor hygiene. This study looks at how Adam felt about being in hospital and what he hoped to gain from his treatment. The role of the multi-disciplinary team in treating Adam. The areas seen as problematic for Adam and the plans made to overcome these problems. Also described is my relationship with Adam and the role I played in his care. In conclusion the different needs of patients in general hospital and mental health care settings is looked at.

HOW ADAM CAME TO BE IN HOSPITAL

Adam came to be in hospital as a result of his G.P. referring him to accident and emergency. His mother whom he lives with had summoned the G.P. to the house as she was worried about his general state of health and in particular about open wounds on his heels that had begun to smell. His condition was deteriorating rapidly but he did not want the doctor called and this led to a significant delay in his receiving treatment.

Adam has a history of alcohol abuse (C2H50H) and in the weeks prior to his presentation at A&E. he had taken to sitting and sleeping in a chair in front of the television and consuming alcohol. According to his mother he was urinating and vomiting on himself but refused to look after his personal hygiene needs. He was also refusing to take his Librium which was prescribed to him by his doctor. Adam’s G.P. called an ambulance and he was brought to A&E on a stretcher. His presenting features were G.P. referral due to bilateral breakdown both heels, oedematous and exudates, pain and rash in groin area. Adam had a history (HX) of asthma, peptic ulcer disease (PUD), Appendectomy, alcohol liver disease, obstructive jaundice and cellulitis. Cellulitis-: (inflammation of the cellular or corrective tissue of the body.) PUD-: Peptic ulcers consist of areas of erosion of a mucosal surface bathed with acid gastric juice. They are located typically in the stomach and a major causative is excess alcohol.

His confirmed diagnoses was (1) Bilateral heel ulcers (pressure sores) secondary to vasculitis. (2)Groin skin infection and cellulites due to poor hygiene. He was noted as an infection control risk due to open wounds and poor hygiene. Also noted as a problem for alcoholism and alcohol neuropathy. His right heel wound was open and clean but his left heel wound was necrotic. It is worth noting at this stage that apart from his alcohol problem there is no mention of his diagnosis of psychiatric problems or referral for psychiatric assessment.

HOW ADAM FELT ABOUT BEING IN HOSPITAL AND WHAT HE HOPED TO GAIN FROM HIS TREATMENT

Adam was very unhappy about being in hospital although this was tempered with great praise for doctors and nurses and the general care he was receiving. He was a very compliant and pleasant patient but seemed to be totally unconcerned about his physical condition or his personal hygiene.

Adam at first was completely immobile and as part of his treatment regime was a daily shower, it offered a good opportunity to communicate with him. However when his physical needs were dealt with Adam spent most of the day in a chair beside his bed with his legs raised. His main complaints were that he was very bored and that the hospital did not serve alcohol. He had a good rapport with both staff and other patients and would often ask if somebody was going to the shop as he did not seem to get any visitors. He disclosed that he had been married for ten years but had been separated for two years and that he was a professional painter by trade but had been unemployed for four years due to his health. When asked if he attributed his bad health to his abuse of alcohol he replied “yes” but he had no intention of stopping. When asked what he hoped to gain from his treatment programme his only reply was that he could once again be mobile so he could go home and “have a few drinks”.

THE ROLE OF THE MULTIDISCIPLINARY TEAM IN TREATING ADAM

There were many different disciplines needed to give Adam the best possible treatment. Although his primary problem was a surgical matter i.e. open wounds to his heels, there were many other conditions requiring attention. Together these disciplines are known as a multidisciplinary team. The following are some of the roles of this multidisciplinary team. The surgical team-: consisting of a surgical consultant, registrars, interns and student doctors. As stated they treat the surgical needs of the patient e.g. open wounds.

The medical team-: consisting of a medical consultant, registrars, interns and student doctors. They treat the medical needs of the patient e.g. rash, infections and a later diagnosed jaundice. The nursing team-: consisting of Clinical Nurse Manager, primary nurse, staff nurses and student nurses. The nurses take a holistic approach to caring for a patient and his family. They carry out the administering of medications, wound dressings, removal of sutures and certain other medical procedures that maybe prescribed by the consultant. Nurses also make their own care plans by assessing, planning, implementing and evaluating care. They use the Roper, Logan & Tierney (1976) activities of daily living (ADL’s) nursing model. This model as the name suggests covers the activities associated with everyday living and are listed under 12 headings.  In Adams case he relied heavily upon nurses to perform the ADL’s. As nurses usually work closest with patients and their families they are often central to the multidisciplinary team and have great influence over the type of care given. Nurses also do most of the discharge planning and further referrals to social workers, public health nurses etc. Physiotherapists-: They build up the muscle tissue so a patient regains mobility. They also assess the need for any mechanical assistance e.g. walking frames, walking sticks that may be required for mobility. Dieticians-: Assess and recommend the dietary needs of the patient. Social workers-: Assist with social and financial needs of the patient and their families. They also arrange such services as home help and meals on wheels.

They also advise of entitlements such as social welfare. Public Health Nurse-: They carry out follow up visits when a patient has been discharged. They deliver treatments in the home and take account of the living conditions. Care Staff-: They assist nurses in carrying out ADL’s and can monitor patients for dietary intake and hygiene. They also assist with and encourage mobilization. Catering Staff-: Provide meals and drinks and fulfil and special diet requirements. Cleaning Staff-: Keep wards, showers and toilets clean and safe. They undertake special cleaning requirements where there is a risk of infection.

Although on this ward there was no official multidisciplinary team meetings the different disciplines were in close contact throughout the day. They all shared a common goal of providing the best possible service for the patient.

AREAS INDENTIFIED AS PROBLEMATIC FOR ADAM AND NURSING PLANS MADE TO OVERCOME HIS DIFFICULTIES There were many areas identified as problematic for Adam upon admission. These were alcohol dependency, alcohol neuropathy, infection control risk, he could not perform many of the activities of daily living and on the Medley Score Pressure sore prevention risk assessment he scored 16 which put him in the medium risk category for pressure sores.

HOW NURSING PLAN WAS IMPLEMENTED AND HOW EFFECTIVE/HELPFUL THE PLAN WAS

Each day a nurse would be assigned usually to 6 patients. At the hand-over all nurses were brought up to date on the progress and requirements of each patient. The nursing progress notes would be read out and this detailed any difficulties and interventions used by the previous shift. A printed hand-out was supplied to each nurse listing details of patients name, age, doctor, diagnosis, medical history, mobility, dressings, diet and remarks. A progress report was filled out on each patient and this was kept at the nursing station. Each nurse would familiarise themselves with the details of their 6 patients and would know exactly what was to be implemented and when. Adam’s plan was very effective as there were vast improvements to all areas in need of attention. His physical condition improved immensely and at the time of writing he is due for discharge.

MY RELATIONSHIP WITH ADAM AND THE PART I PLAYED IN HIS CARE

It is fair to say that Adam had good relationships with all the staff and other patients. He has a good sense of humour and puts complete trust in the capabilities of the nurses who provided his care. When I first met him I introduced myself as a student nurse and informed him that I would be working in this area for the day and that if he required anything he should let me know. I noticed that for a long time after this he was closely observing me as we went about the general ward duties. When the time came for his daily shower I asked if he had any objections to me assisting the staff nurse and his reply was “no, you seem to know what you’re doing”. This remark put me at ease and I felt confident when dealing with Adam. Over the following days I had many conversations with Adam, some to do with his condition and others about general topics. I also assisted in his care and I felt that he liked and trusted me. He showed a good interest in what I was studying and I took this opportunity to explain what I knew about pressure sores and personal hygiene in terms that he understood. I must emphasize that this was done in a natural and informative way and I explained that he was helping me with my studies.

I realised that behind the sense of humour Adam is a lonely man who does not see much of a future for himself. I also realised that although the physical care which Adam was receiving was of the highest quality his psychological needs were not being considered. This I again stress is not a criticism of his care but perhaps in the very busy and very task orientated environment of a general surgical ward there is not the required time to really get to know the person. The benefits of getting to know Adam are that he allowed me to trim his beard and hair which were very overgrown and he now asks for his daily shower. With the help of the physiotherapists and a walking frame he takes a daily walk around the ward and he feels that his mobility is improving. As a consequence of this he has had his Foley Catheter removed and he is delighted about that. This progress was to be expected of Adam but maybe the relationship we formed enabled the process to progress a little faster. In addition I assisted with the daily dressing of his wounds, the process of building up his body i.e. encouraging food and water and assisting in dispensing his medications. In particular I would give him his clexane injections. This is an anti-coagulant and is given sub-cutaneously normally in the stomach area.

CONCLUSION

There are many similarities and some important differences in the needs of patients in a general hospital setting and those in a mental health care setting. The underlying needs of patients in any setting are that they receive the best possible care and attention in a dignified and professional way with a goal of returning to full health or to a level of functioning which is the best their capabilities will allow.

Patients in general hospital are there due to some physical condition. These conditions can be surgical or medical and the symptoms are usually visible e.g. broken bones, open wounds, heart conditions, respiratory problems or cancers. The patient needs a diagnosis, a treatment regime, a prognosis and a time frame for discharge. During their treatment the patients needs can differ. The needs are medication for pain relief or injections, high or low temperatures or blood pressure. They may also need help with their activities of daily living due to immobility or weakness but this is usually on a temporary basis as their condition is generally improving. The patient understands the need for being in hospital and usually co-operates with the treatment programme. There are exceptions to this as patients become anxious or depressed from being in hospital but in my own experience the focus still remains on the physical condition and needs associated with this. In a mental health care setting the needs of the patient may not be so obvious. In some cases the patient may not want to be there or they may feel that they are not ill at all. Their condition may not be understood and therefore there is no prognosis or time frame for discharge. Often they have been very damaged a long time before they present for treatment. Unlike physical illness which is socially acceptable the mental health patient may have been shunned by society.

Their needs are for acceptance; understanding, caring and a genuine interest on behalf of the nurse for the person themselves. They especially need to be able to trust the nurse so as to hand over the reins of their lives when things are particularly difficult for them. To this end they need to form a very special relationship based on mutual understanding, trust and respect. The patient also has need of medication and assistance with activities of daily living but as their stay usually is a long one they need as much as is possible to feel safe and at home in their surrounds. The mental health patient may also have no home, no friends or family who are interested in them, no job and no social skills. Their needs may be for someone to show them a reason to go on living, to make them feel valued and to offer a place of sanctuary. On my own placement I calculated that at any given time at least 40% of the patients needed psychiatric care but only on two occasions were patients transferred to mental health settings. As these general settings are very task orientated, fast passed condition focused places, the idea of holistic care can not be a reality at this time.

REFERENCES
Barker, P. (ed) (2003). Psychiatric and Mental Health Nursing: The Craft of Caring. Arnold: London. Bloom, A. (1978). Medicine for Nurses. (12th ed.) Churchill Livingstone: Edinburgh. Fish, E.J. (1974) Surgical Nursing. (9th ed) Boilliere Tindalc: London Roper, N. Logan, W.W. Tierney A.J. (1996). The Elements of Nursing: A model for nursing based on a model of living. (4th ed) Churchill Livingstone: Edinburgh

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Care study

Care Study

I recently completed a placement in the community, and decided it appropriate while there to focus my care study assignment on leg ulcers as I witness various chronic wounds being assessed and dressed and wished to acquire more knowledge on the subject. Chambers et al, (1996) suggests that chronic leg ulcers present a large problem to nursing today. My care study will focus on one particular lady who was suffering from a venous leg ulcer. For the purpose of this case study I will call that patient Miss. A, as a nurse has a legal, professional and ethical duty to protect all confidential information concerning patients by recognizing the primacy of the patient and practice in an ethical and legal framework (NMC, 2002). The patient gave informed consent and agreed to be involved with the care study after being given adequate information and given time to decide whether or not to agree to be written about. It was discussed and explained that the care study would involve the condition of the patient, assessments, prioritise the needs which arise and contribute and develop a plan of care. This would be done by assessment, planning, implementing and evaluating which is the constant cycle of the nursing process. (Alexander et al, 2000).

Miss A is an elderly lady who has lived with her sister for many years; she has limited mobility and relies on her sister for most of her care. Miss A is a very private woman and required encouragement from her sister for the nurse to attend to assess her wound which was thought to be a leg ulcer, she also felt generally unwell.cocf cfr secfcfw orcf cfk incf focf cf.

Leg ulcers cost the NHS approximately £400m per year and is estimated that at any one time 100,000 individuals will receive treatment for this condition in the community, which remains to be the most frequent encountered wound that community nurses are called upon to treat (Williams, 1996). A leg ulcer is defined as a loss of skin below the knee on the leg or foot which takes more than six weeks to heal, the occurrence of leg ulcers increases with age and is most common in women (Watson, 2002).

The underlying cause of a venous leg ulcer is poor venous return which can be recognized by oedema, skin pigmentation and are usually flat (Watson, 2003). It is important that this type of ulcer is assessed by the use of a Doppler test (Maylor, 2002). The nurse must check that the patient is complying with recommendations: elevation of the limb to prevent oedema and aid venous return, exercise and compression bandages/stockings. Chair bound patients are encouraged to strengthen the calf muscles by moving the feet up and down, this action also helps to pump the blood up the vein. On no account should the patient stand or dangle the limb for long periods without moving (David, 1986).

The management of leg ulcers is divided into three stages: assessment, treatment and prevention, the most important being assessment, as it is a vital first step in treating all types of leg ulcers as the district nurse is the primary nurse and has sole responsibility for deciding which type of ulcer is present and what dressing to use (Pudner, 1997). Primary nursing care is when the nurse has total responsibility for the planning, delivery and evaluation of care for the duration of the patients care (Pearson, 1988). Visit coursework bf in bf fo bf for bf more writing bf Do bf not bf redistribute

The District Nurses I was working with used a care pathway which had been modified for community use; care pathways are holistic multidisciplinary plans which predict the course of events in the treatment of patient's problems. These events must be specified on a timescale, and all incidents, actions and interventions must be identified (Reinhart 1995). The Roper Logan and Tierney's Activities of living model of nursing was used as a basis for her assessment of the patient. This can be viewed as the first stage of the Nursing Process; assessment, planning, implementing and evaluating. This assessment sheet outlines the client's actual and potential problems with regard to daily activities; the assessment is also about collecting data and communicating with the patient. It is widely used as it is looked upon as a holistic model and suggested that it is not merely a checklist but a guide to enable a nurse to care for a patients needs effectively. (Gilling, 1996) However all information documented is confidential and nurses are accountable for any entries made by them (NMC, 2002) Documentation is often targeted by nurses because of the increasing amount of paperwork involved, which nurses feel is limiting the amount of time a nurse can spend with each patient (Brindle 1998). However nurses must always bear in mind the reasoning for this as litigation with regard to health care is not uncommon (McHale 1998). Any nursing document can become a legal document, if requested by a court of law therefore it is essential that medical staff follow legislation and good record keeping (Young, 1995). The NMC (2002) has a booklet entitled 'Guidelines for records and record keeping,' designed to guide nurses in their documentation. The NMC (2002) also has booklets on professional code of conduct highlighting the importance of responsibility and accountability. This gives nurses guidelines ensuring they understand the implications of their actions and working within their own limitations. Therefore whatever intervention a nurse is using she must be able to justify the rationale for its use, have evidence based knowledge about intervention and be able to react in a professional manner if adverse effects occur.

Miss As initial assessment showed that she required support for her medical condition (leg ulcer), emotional support and encouragement of independence. It was also established at this point that Miss A had some years ago been admitted to hospital after suffering from a Myocardial Infarction, and continued to suffer from angina. Although this was not a priority at this point as her angina was stable I felt it appropriate to gain knowledge on this subject.

More than 1.4 million people suffer from angina and 300,000 have heart attacks each year, which makes Coronary heart disease (CHD) one of the biggest killers in England (DoH 2000). For this reason The National Service Framework for Coronary HeartDisease (DoH 2000) introduced 12 standards to ensure that patients would receive equal access to services and equal standards of care, regardless of postcode. Also when providing care for patients it is important to work in accordance with the Public Health Strategy. The Department of Health (1999) document, Saving lives: our healthier nation is a government action plan to tackle poor health and inequalities in health. One of the targets in this plan is to reduce the death rate for coronary heart disease in people under the age of seventy five by two fifths by the year 2010. An effective cardiac rehabilitation programme can reduce mortality rates by lessening the risk of problems reoccurring and can significantly improve patients' quality of life (Jones & West, 1995).

Myocardial Infarctions occur when one of the coronary arteries which supply the heart muscle is blocked by a clot. As a result, part of the heart muscle is starved of blood and oxygen which causes it to become damaged. Myocardial refers to the heart muscle and infarction to the blockage, The narrowing of the coronary vessels is often a gradual process which could have been going on for years and is often linked with 'risk factors' such as smoking, high blood pressure, high blood cholesterol, physical inactivity and being overweight.
Research has also shown that people who have a family history of coronary heart disease (CHD) are at a greater risk of developing CHD. (BHF, 2002).

Miss A did indicate that she had never exercised much throughout her life, and leading a busy life she was not always able to stick to a healthy diet. Early health promotion and education is essential to change people's lifestyle in order to reduce the risk of coronary heart disease (Naidoo & Wills, 2000). However Miss A still did not participate in any exercise and ate an unhealthy diet.

On examining Miss As wound it presented generalized oedema, exuding and was shallow with diffuse edges. It was recommended for Miss A to lie down on her bed for one hour and the nurse and myself would come back to carry out a Doppler test. A Doppler ultrasound assessment is usually performed after the initial assessment, when it is thought that the ulcer is venous but confirmation is needed that the arterial circulation to the leg is not impaired. Maylor (2002). Other baseline observations and blood tests were also carried out by myself, these observations are essential as they might indicate the presence of infection, deterioration in a patient's condition and many other disorders. For this reason it is essential that they are measured accurately so that when detected nursing intervention can occur. Watson (1998). After taking the required measurement the results need to be interpreted, taking into account what the patients normal measurements usually are. A patient's body core temperature is maintained close to 37 C although 36.4° and 37.2° C are within normal limits. Watson (1998) In a healthy person, blood pressure increases from 120/75 at age 30, to about 140/90 at age 40 and over. Blood monitoring was also carried out as to eliminate diabetes. All information was recorded accurately in Miss As care pathway. cal1966, please do not redistribute this coursework. We work very hard to create this website, and we trust our visitors to respect it for the good of other students. Please, do not circulate this coursework elsewhere on the internet. Anybody found doing so will be permanently banned.

Miss As temperature was normal at 36.8° and her blood pressure slightly high at 160/110 which I pointed out to my mentor; however Miss A was extremely anxious which can contribute to an increased reading. Her BM was also within normal range. These findings were explained to Miss A and we left in order for her to lie on the bed.

However when returning at the lady's home Miss A had not complied with the nurses wishes and had declined to lie on her bed for the Doppler test to be carried out.Although she had complied with all the information required for her initial assessment, she had suggested to her sister that she did not need any help from nurses and would feel better tomorrow. This I felt was an ethical dilemma as it was important for the test to take place for treatment to commence, however a nurse must respect a patients choice of treatment or refusal of it. Therefore the relationship between beneficence and respect for autonomy often conflict when caring for patients. However literature suggests that there are many reasons why patients do not comply with treatments, unfortunately these patients are often viewed as bad patients and gain the reputation as being awkward. Although Lambert (1992) suggests that it is more likely that the patient had misunderstood the information, forgotten about it or received inappropriate advice. Parry (1970) identified certain factors that could affect a person's ability to understand the information; these can sometimes include such things as poor attention due to being anxious, language barriers or confusion due to pain. Therefore it is vital for the patient that the nurse uses effective communication skills (Wilson, 1998). For this reason it is felt that a nurse should follow best practices in their working day. It is essential that the nurse listens carefully, does not talk down to a patient and always respect the patient's wishes by keeping the patient fully informed and include them in all decision making (Wilson, 1998) Visit coursework gd in gd fo gd for gd more dissertation gd Do gd not gd redistribute

It was felt by the nurse and myself that maybe the importance of the test has not been explained appropriately to Miss A, and that Miss A had been told to lie on her bed and not asked to. My mentor apologized to Miss A and her sister suggesting that she herself was at fault and stated this communication problem would not happen again. Communication comes in many forms, not just spoken, therefore it is essential that a nurse understands communication concepts and delivers and receives the correct message to patients and other healthcare professionals. The nurse and patients relationship should always involve equality, for the nurse and patient to gain a rapport and trust, the nurse must understand the behavior of the patient and act upon this. Example. Some patients may feel uncomfortable if a nurse is standing too close to them, whereas other patients may feel more secure the closer the nurse, this is proximity behavior. A Language barrier may prove to be a problem; this may be because of a strong accent, which could be difficult to understand, age, culture and gender may also come within this category. Facial expressions, heads shaking, nodding and hand gestures may be used to get the message understood (French, 1994).

For this reason a nurse must be able to use effective verbal and non verbal communication skills, there are many different ways of expressing ourselves, Argyle (1972) suggested there were nine nonverbal behaviors that we use to communicate, some of these include such things as gestures, appearance, proximity and facial expressions. Miss A had felt some what confused as to what a Doppler test was and thought it may have been a painful procedure which was the reason for non compliance.cobd bdr sebdbdw orbd bdk inbd fobd bd.

Miss A felt much happier after this discussion and happy for the nurse to continue with her treatment. It is also important for a nurse work within an empathetic attitude and develops a therapeutic relationship with her patient to ensure the patient feels at ease with the nurse as trust is an important aspect of care.

During the implementation of a wound dressing, it is essential for a nurse to bear in mind the recommended ideal environment for healing to take place. The literature that I referred to about this ideal environment all list similar properties: The notion of a 'moist' healing environment is a fairly new concept, and is often not readily accepted by some health professionals. However, all of the literature that I consulted mentioned a moist environment as extremely conducive to healing. (Miller, 1996) states that George Winter introduced the notion of moist healing, after performing trials on pigs: Superficial wounds dressed with polythene healed twice as quickly as those exposed to air only. Miller goes on to mention that clinicians were critical of moist healing, stating that it led to a greater risk of acquiring infection. However, Hutchinson and Lawrence (1991) discredited this argument.

The size of the wound was monitored on each dressing change, in order to record the progress or deterioration of it, especially as there were other health care professionals tending to the wound on different occasions; this ensures continuity of care. Miss As care plan was also always kept up to date for this reason; including any change with her sister as carer's needs must also be considered and documented in accordance with the Trusts strategy for carers. (Strategy for Carers, 1999).

However the relationship with Miss A and her sister was often strained, it was felt that Miss A resented her sister going out and leaving her on her own, it was also felt that her sister was at breaking point as Miss A had recently fallen and was more demanding than usual. It was suggested that a specialist service would be beneficial for a short period of time, Miss A and her sister agreed and a referral was made to Responsive Integrated Assessment and Care Team (RIACT). This is a specialist service that provides immediate care to families in the community which are in crisis for one week; they also prevent admission to hospital for older people who are medically stable to be maintained at home (RIACT Newsletter, 2003). Therefore it is important that all healthcare professionals understand the network of services available within the community setting which can be accessed by the district nurse and the patients. The nursing staff suggested that services such as NHS Direct have helped to reduce calls to the district nurse for advice, therefore leaving more time to spend with patients. Community care uses a framework for the provision of all health and social care services, there aim is to meet the needs and deliver the services required. Community health professionals are at the for front of new initiatives dealing with many people in diverse setting and community services can also provide a lifeline for isolated people suffering with a chronic disorder Audit Commission (1996).

While Miss A was receiving this care her medication was also assessed by her GP and was given extra medication for other medical problems which she was having. This medication increased her feeling of wellbeing and therefore she was more confident about the future. All information between the GP, react service and nurses were documented and discussed accordingly.

It was discussed with Miss As sister that Miss A was not just being awkward and that patients often suffer from anxiety when a wound is difficult to heal or they are in pain. Sleep patterns are often disturbed and pain is often perceived to be far greater at night, a disturbance of body image may also cause distress and may leave a patients feeling dirty or smelly (Lacey & Birchnell, 1986).

It was also recognized at Miss As initial assessment that she would need to be encouraged to carry out more tasks for herself by promoting her independence, this can be achieved by setting small goals ,the goals must be realistic and be within the patients own values and beliefs. The goals are implemented by the form of a care plan and nursing intervention used, the care plans are important for the documentation of the patient's health care needs, to determine patient's problems, priorities and goals. The progress towards the patient achieving these goals are constantly evaluated, revising care plans and reflecting on the patients behavior and change in condition (Potter & Perry, 1995).

On completing my placement Miss As leg ulcer was well maintained but not entirely healed, her independence had grown and she was going shopping once a week with her sister on the community bus which was accessed by the nurse, this service is provided free by the one stop shop, it provides free advice and information in many topics and is an organization concerned with the well being of the community.

In conclusion, there are many different aspects included in the assessment of a patient with a leg ulcer, all of which are vital in order to plan a sufficient recovery. The nurse must not assume that all patients with, e.g. A venous leg ulcer, can receive the same treatment, as, general health, lifestyle, social circumstance and psychological health can make a difference to the prognosis. In this way, the patient will be receiving holistic, individualised care. The nurse must also realise that she is not alone in the care of an individual, and that it is conducive to gain help and advice from relatives and other professionals in the multi-disciplinary team. Relatives and friends can offer a great deal of psychological support to the person. Some of the other professionals that the nurse may wish to contact are the vascular surgeon for severe vascular ulcers, the physiotherapist for advice on mobility, the dietician to assess nutritional deficit, the diabetic link nurse, as well as their other nursing colleagues. Once the patient and their wound have been assessed, obviously a choice of dressing will have to be made. If the wound has been accurately assessed, then the nurse can refer to research/literature which is available in the community; the BNF (British National Formulary), posters, information packs, policies, and books. If the nurse is still unsure about a dressing choice she could contact her local tissue viability link nurse for advice. Then, the dressing choice must be documented in the care-plan to allow for continuity of care. Also by improving the way healthcare professionals communicate with patients the problems of compliance and cooperation with leg ulcer treatment can be addressed. Patients are becoming increasingly knowledgeable about their condition and will challenge healthcare professionals on their knowledge and skills. It is no longer acceptable to present the patient with a leaflet and expect
compliance (Clements, 1998). There are also many legal and ethical implications concerning a nurse, as nurses today have increasing responsibilities, having to make important decisions in many situations. For this reason it is paramount for them to follow a framework of law and ethics. Legal and ethical judgments must be guided by legislation, professional code of conduct and their own moral and ethical beliefs, working within their own limitations. With any treatment informed consent is vital, this arises from the ethical principle of respect for autonomy, all patients have the right to be given adequate and accurate information regarding there treatment and should make there decision based on their own circumstances, values and beliefs with the support from the nurse. The nurse must highlight the benefits, possible harms and what the treatment will involve. It must also be recognised that consent is an ongoing process as care will change as the patient improves therefore continued discussions must take place (Norton, 1995). Medical staff also has a legal obligation to keep all information confidential, this means that a nurse cannot pass on any information to a third party without consent (Hendrick, 2000).

References

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