An update on the Mead model and nursing care plan

An update on the Mead model and nursing care plan

lnfmsivr andCtitical CanNursing ( 1994)10,127-132 0 Lonpan Group Ltd 1994 An update on the Mead model and nursing care plan Bridget A. McClune An up...

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lnfmsivr andCtitical CanNursing ( 1994)10,127-132 0 Lonpan Group Ltd 1994

An update on the Mead model and nursing care plan Bridget A. McClune

An update

and Karen L. Franklin

and some clarifying points on the Mead model and nursing care plan.

Confusion of the model with the care plan

INTRODUCTION Since the development of the Mead model (McClune 8c Franklin 1987) and care plan format (Franklin & McClune 1987) a number of units have adopted them and we receive many enquiries for information and advice. An update and clarification of some points now seems overdue, although we hope that nurses will continue to contact us if they need more information. The issues to be discussed are: 1. 2. 3. 4.

5. 6. 7. 8.

confusion of the model with the care plan the flexibility of the model documentation of care issues related to patients’ needs - the relative importance of different needs and the subdivision in the care plan of physical needs and not psychological and social/cultural needs goal setting involvement of relatives with care care of relatives staffeducation and experience.

Bridget A. McClure RGN, DipN, ENBlOO, MSc, Parttime Staff Nurse, Karen L. Franklin RGN, RSCN, ENBlOO & 998, DipN, Sister, Intensive Care Unit (Mead Ward), St Thomas’ Hospital, Lambeth Palace Road, London, SE1 7EH, UK (Requests for offprints to KLF)

Manuscript

eccepted 27 February

7994

It is important not to confuse the Mead model with the care plan format based on it - they are not the same thing. The Mead model was outlined in our first article (McClune & Franklin 1987). It is an adaptation of Roper, Logan and Tierney’s model for nursing (1985) and to be used effectively requires understanding of and familiarity with this model, in addition to knowledge and experience in intensive care; that article does not stand on its own as a comprehensive guide to intensive care nursing. The care plan format published (Franklin & McClune 1987) is merely the way we have chosen to design a care plan for one unit based on the Mead model. It is a structured framework to help intensive care nurses to apply the model in assessing, planning, implementing and evaluating their patients’ care, and to document this process concisely in a manner which helps other staff to find out about a patient’s individual care easily, without working through irrelevant information.

The flexibility of the model We believe that ideally nurses should be familiar with a range of models and should select the one which is most appropriate for each patient. 127

128

INTENSJVVEAND CRITICAL CARE NURSING

However

this is not practical

care units,

in most intensive

and thus if a unit decides

It

should

encourages

provide

nurses

as possi-

and skin condition

their patients’ scriptive,

a framework

to think

creatively

care and should

forcing

for a particular

about

cess and its documentation

patient.

is a distinction

worth

emphasising

process

is the

required

No matter

which

reflected planning. sheet

plan written each

philosophy

In an ideal world

of paper

which

Further

is used it should

be

in the care plan so that it is evident

that the model’s

should

from

reflects nurse’s

has guided perhaps

be used

patient’s

approach.

a blank care

in a format

uniqueness

In practice

have some type of preprinted

care

and the

the beginning

each

here.

known

and

most units

document

reduction

using some ventilated

patients

and parameters

their

nursing

related manual

should explain

checking

duction

of computerised

care

planning

the norm

there is usually scope for tailoring

care plans to

to write creative

care plans using their own phraseology salient

It can also be difftcult

points

about

documentation,

a patient

much

patient

bits which

are relevant.

may be irreleto find the

Our view is that care

be as unstandardised

and also reasonably

a mass of

but which never-

theless still has to be waded through plans should

is great-

to pick up the

from

of which

vant to that particular

stan-

and, whilst

as possible

brief so that only the mat-

ters which are relevant

to the patient

mented.

So the format

between

a blank

sheet

are docu-

and

a standard

care

ventilation

The

as part of

plan

of care

their ventila-

is to be used the ward exactly what is meant by

filling

the care

instructions

in that particular alarm

settings,

plan

to

This avoids

with a lot of basic

which should

in

unit; for

listening

such activities.

care

be known by nurses

working in that unit - if they do not understand at least the basic they should

care

of a ventilated

not be caring

quate supervision.

the patient must be written in addition itor ventilation’. shows the patient

patient

for one without

ade-

Any care which is specific For example,

to

to ‘mon-

if the assessment

has a collapsed

left lower lobe

then this should be written in the care plan with the

appropriate

Priorities ate.

care

to

help

can be stated where

In the

same

to correct

occasions

in ‘monitor

for a patient

also be stated. In principle

it.

this is appropri-

way, on the rare

when care usually included tion’ is not appropriate

used is a compromise

their

this so that it is clear what care is included

the chest and other

intro-

by

For example,

documented

tion. If such phraseology

example

ly reduced.

care

is achieved

to this will be to ‘monitor’

care plans. With the increasing

ability

the

first assessing

phrases.

assessment.

dardised

nurses’

-

without

will have

mode

many cases these take the form of largely stan-

degree,

is perhaps the nursing

thing

in writing

ventilation’

some

pro-

which ‘Doing’

‘shorthand’

‘monitor

is becoming

Also

- but writing it down may need to

and in

dardisation

later.

the nursing

be done later, albeit as soon as possible.

of care model

between

important

is not

and planning

Documentation

to be assessed

there

not be too pre-

resuscita-

aspects such as urine output

which

them down rigid paths which

may not be appropriate

the plan will be to commence

tion, leaving other

one model only it should be as flexible ble.

then

to adopt

ventila-

this should

it is like writing ‘bed

plan. It encourages each nurse caring for a patient to work through the nursing process

bath’ in the care plan for a patient in a general ward. Nurses are expected to know the basics of

and identify priorities

bed-bathing

Basing ensure

for care.

the care plan on the model that patients are and no needs

helps

comprehensively are overlooked.

to

assessed However, in an emergency, patient assessment will obviously be concerned with determining the immediate priorities and will not be comprehensive. For example, if assessing the patient shows he is in ventricular fibrillation

before

being

allowed

therefore

all the care involved

not

out in the

spelt

care

to do one,

in a bed bath is

plan;

for example

using a clean bowl, which order of washing follow to reduce spread of bacteria, when

to to

change the water. However anything specific to a particular patient would be documented, for example if he does not like soap on his face. The care plan format

designed

was intended

INTENSIVE AND CRITICAL CARE NURSING

to produce

concise

plans for practice

and busy unit, where

patients

in a large

with a very wide

Subdividing

helpful.

social/cultural

of problems and ages are admitted with change rapidly. which often conditions

since

However,

ble needs

range

as long

as the care

plan provides

useable

practice

include

as much or as little detail as the nurses

on

a unit

(bearing

tool it can take any format

a

consider

appropriate

in mind

see UKCC

1993).

assess patients accordingly

and

professional The

thing

should

this but the documentation

is to

help with

of the process

nurses

can

was not

are

so

helpful

individual

for

in

the variety and combination

seemed

in these

better

areas

to leave

and

likely

nurses

it for

care

are

not

provided

that

in the psychological

and

care of intensive

this is discussed

that

open

Aspects of psy-

to be overlooked

are educated

of possi-

this section

social/cultural

social/cultural

us

these

is so diverse

to tailor to each patient.

chological more

and plan their care

- using a model

be done in any number

helpful

requirements,

important

as individuals

and

respects;

and

psychological

needs

patients

1%

further

under

care patients

-

staff education

and experience.

of ways.

Goal setting Issues related to patients’ It has

been

suggested

needs happen

that

The continuum

needs

because

in the Mead

physical

to be listed first in the model and

care plan format

they are therefore

regarded

most important,

and that because

psychologi-

cal and social/cultural

factors are not subdivid-

ed they are considered

less important.

els

care

and

preprinted

plan

designed

to apply to a range

decision

has to be taken

enormously but

this

of patients’

over quite should

be

short

evident

All mod-

sheets

of patients

about

which things are to be printed. ative importance

as

statements patient The

about

continua

how each

needs

may vary of time, their

care

(full-health cating

our

care

plan

social/cultural needs

factors.

as is appropriate

how

to

to physical, The

and

continua far

the

the criteria

the

goal

is being

written

specifically

helpful.

Individual

achieved.

for stages on the continua

in a general

and

dependence/

are a broad way of indi-

way to help

assess where to put patients,

physical

and possible

the criteria

for each

patient

patient objectives,

nurses can be

if this is which are

they are necessarily

less

more

arti-

written into the care plan as part of the planned

& Franklin

factors

1987, p 103). Putting

first on the list was merely

that the reason

intensive

after

dependence

as already stated in our original

cle (McClune physical

needs

fact that, in

psychological

are listed

does not mean

important,

reflect

format, needs

several

The

are our

is to help them regain as much

for them)

are defined

Very often

moves from

and social/cultural

independence

in order

importance.

the

& Law 1982).

over time in relation

independence

Although

of priority.

general

and/or

in the care plan format

goal for patients

plans, even if the needs are not actually printed will be of equal

(Heath

of setting

are

what the nurse

patient

psychological

periods

Coals

goal setting system and a broad way of showing

and a

In reality the rel-

goals.

wish to achieve

independence

in

is not a means

measurable

are

the order

from

specific

of dependence/independence model

and measurable

care - to separate

objectives

than goals,

repetitive

are admitted

to

they have problems

of

to wean down a patient’s adrenaline 1 mg per hour providing his mean

and unhelpful.

are

and plan can be

to

patients

care is because

specific

An example

might be

infusion by blood pres-

a physical nature, and was not intended to imply that these necessarily outweigh or are

sure remains at 70mmHg or above - this is both a plan and an objective. In this and many

always more important

other

Subdividing compromise

physical between

than their other needs

needs.

was part of the

a standard

care plan and

a blank sheet of paper. The headings are useful for most of our patients and nurses find them

instances

example

setting

a time

to have the adrenaline

objective,

for

off in 4 hours,

is neither realistic nor helpful. The reason for devising the goal-setting system in this way was to avoid writing goals which

130

INTENSIVE AND CRITICAL CARE NURSING

have little value or use. For example, if a patient is assessed and found to be dehydrated because of not receiving suEcient fluids, in our view setting a goal of ‘rehydration’ is worthless - it is obvious and does not give sufficient information. This kind of goal setting was common when our system was developed, and it appeared more practical and useful to put in the care plan instead what the nurse plans to do and the goal to be achieved; for example, ‘give colloid until the central venous pressure reaches +5 mmHg on ventilation’.

involvement

of relatives

with care

It is vital to include the needs of patients’ relatives and friends in their care plans and whenever appropriate to involve them in giving care. The nursing history sheet was replaced 18 months ago by a nursing information sheet. This has headings derived from the model and

Name:

Mr Cyril Higgins

an example is shown in the Figure. Its purpose is to record the one&f information which is specific to each patient (e.g. pet name, hearing aid, sleep pattern) and to each relative (e.g. wheelchair bound, needs accommodation in the hospital, family dynamics) which will improve or enhance their care. At the very least relatives and friends should be involved in psychological and social/cultural care and taught and encouraged to communicate appropriately with the patient. However, there is usually no reason why they cannot also help with aspects of physical care, and if they do wish to they should be taught the necessary skills. Some relatives may not want to help, and they should not feel under pressure to do so. This is a complex issue since it has to be borne in mind that not all patients will want their relatives helping with their care, and if at all possible the patient’s consent should be obtained. Whenever relatives and friends wish to be

CB No: Z 123456

Mead Ward

Nursing information 1.

Physical Is allergic to perfumed soap and deodorant Wears a full set of dentures. Wears spectacles for reading and watching television. Having managed a pub for many years normally goes to sleep between and gets up at 9 am.

2.

Psychological

1 and 2 am

and social/cultural

Patient: Likes to be called Fred not Cyril. Was exceedingly apprehensive about having redo coronary artery bypass grafts but felt his quality of life was so poor that the risks of surgery were worth taking. Relatives: Mrs Ann Higgins is Fred’s second wife. They have one daughter called Joan who is currently studying at university. Fred’s first wife Mary does not keep in contact but their two sons Peter and Daniel do and knew their father was having surgery today. Information 7/12/93 2130

given to patient and or relatives

Mrs Higgins and Joan were spoken to by Dr Roberts shortly after Fred’s return from surgery. The gravity of his condition was explained. They were told that Fred’s condition was stable although he was very sick. He was needing very strong drugs to support his heart and blood pressure and a special machine called a balloon pump. The family were very upset but understood how important the next 24 hours would be. They also accepted the offer of accommodation in the hospital.

Fig. The nursing

information

sheet.

K. Franklin

131

INTENSIVE AND CRITICAL CARE NURSING

involved in care this is documented relevant

part of the care

plan,

they wish to help with bed-bathing under

goals

wound

and plan

care’.

The

involvement evaluation

in the most

for example

if

this is stated

of relatives

of any help

is documented

in the relevant

in aspects of care relevant

or

Secondly, to make is meant

members

and friends

of patients’

and any relevant

family

informa-

tion about them is documented

on the nursing

information

already.

specific

sheet

care

on

as indicated

a daily/shift-by-shift

part of the patient’s

psychological,

cultural

is

care

patient’s

and

basis

is

social

and

in

the

documented

care plan under

Their

this heading.

Thirdly,

this job is to orientate

knowledge

Student

format.

Once

experienced

member

Sister also monitors

patients’

required

not yet acquired

in inten-

and even qualified in intensive

care

care,

for patients

how comprehensive is and and

care,

on and

accountability rienced

(UKCC

and

1992a,b)

plan,

expert.

Firstly,

of

who have expertise

whilst

intended

questioning

High

which was largely a post-event

Fourthly,

both

the

to ask

model

and

and even expe-

planning

are staff in post

in the areas needed

in the

expanded

are used course,

covering variety

plans

purposes.

is the one used

at the bedside,

care plans are also written.

daily teaching

help and

care plan format

did not.

care

for teaching

more

of care.

on the intensive

and in the unit where sessions

but

These

and go into much

on the ‘whys’ and ‘wherefores’

They care

descrip-

to patients,

and for teaching

are greatly detail

planning

in a way that the old

tion of what had happened

in practice

On Mead Ward we have sev-

that there

kardex,

educational

professional

it is part of our manpower to ensure

lack of knowledge

deliver

eral ways of helping nurses assess and plan care which are outlined here. strategy

unmasks

who have

staff need help at times, since no one is

a universal

Care

based on it are used for educational

and nurses

part

for

care.

The published

when they need is

point

their

the

being

this

starting

about

are

this must be supervised.

able to recognise

excellent

nurses

experience

safety also lie in nurses

guidance;

Therefore,

care plans are not primarily

how precise

quality care and patient for

aid when working with a

after a patient.

an

patients

their

Teaching

by using the

to, give a nurse sufficient

skill

to assess

The

a good

a model

and evaluate

of staff.

care planning

and are

nurses,

it gives,

are

tool they do provide

their own. No matter prescriptive

new staff

and work with an

nurses at the bedside

not be planning

guidelines

orientated,

for a time

and care

basis for teaching

nurses who are inexperienced should

new staff, which includes

them about the Mead model

supernumerary

at a

Part of

as an educational

to plan care for a patient

sive care,

Sister.

on their own do not, and

articles

were never intended

‘monitor

all the sisters rotate for 1 month

nurse looking

Our previous

for example,

the role of Teaching

teaching

on

in more detail what

in a care plan.

care plan as a teaching

Staff education and experience

fields who

It gives guidance

and explains

if one writes,

time into

plan

of relevant

there is a ward manual which we try

ventilation’

The names and relationships

In this

are nurses with

for others.

research-based.

good practice

Care of relatives

to intensive

management.

that there

in a variety

can act as resources

under

section.

wound

way we try to ensure knowledge

for ‘hygiene/mobility/

outcome

expertise

care, for example

of about

there

are

half an hour

a wide range of topics and involving of lecturers.

Auditing

care

plans

a

can

to uncover nurses’ educational needs the teaching programme is planned

accordingly. Fifthly, matically

a knowledge highlighted

deficit

which

was dra-

when we first introduced

unit, for example including a neurology, paediatric or renal course in addition to an intensive

care planning ficulty nurses

care course. Nurses are also encouraged to attend courses and to develop more in-depth

patients’ psychological needs and care. It became

to replace the kardex was the difhad with assessing and planning and social/cultural evident that this care

132

INTENSIVE AND CRITICAL CARE NURSING

was often neglected or unsystematic. A series of educational sessions was organised to help to improve this and elements of it can be repeated as necessary. When other deficits are discovered teaching sessions are planned to cover those areas too.

the Mead model and care plan allow nurses to exercise their professional judgement and expertise and do not restrict them by being too prescriptive. The end result should be relevant and easy-to-follow care plans which help to ensure that patients get high quality individual care.

CONCLUSION

References

In conclusion we would not argue that the Mead model and care plan are perfect; they are 8 years old now, having been developed in 1985 when very few intensive care units were using care plans or a model of nursing. There are other models which would be appropriate for intensive care even if they too require adapting. If each patient is an individual each nurse is also, and units and colleagues too all have a uniqueness. Therefore using the same model in the same way in all units is unlikely to work. Adaptation and revision are likely to be necessary, as is allowing scope for each nurse to practice in her or his own unique way and to formulate care plans in his or her own style. We hope

Heath J, Law G M 1982 Nursingprocess-whatis it?A practical introduction. National Health Service Learning Resources Unit, Sheffield Franklin K, McClune B 1987 The Mead ward nursing care plan - based on the Mead model for nursing-part II. Intensive Care Nursing 3(4): 141-156 McClune B, Franklin K 1987 The Mead model for nursing -adapted from the Roper, Logan and Tierney model for nursing. Intensive Care Nursing 3(3): 97-105 Roper N, Logan W, Tierney A J 1985 The elements of nursing. Churchill Livingstone, Edinburgh United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) 1992a Code of professional practice. UKCC, London United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) 1992b The scope of professional practice. UKCC, London United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) 1993 Standards for records and record keeping. UKCC, London.