Maintaining professional healthcare standards

MOD001576

Management of the care of an individual with a venous leg ulcer in the community: A care study
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Word count: 4800
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Table of contents
Introduction……………………………………………………………………………………3
Patient Presentation……………………………………………………………………………3
Venous Leg Ulcers…………………………………………………………………………….4
Nursing theory and models……………………………………………………………………5
Chosen model of Nursing: Roper, Logan and Tierney’s Activities of living model………….6
Nursing Process………………………………………………………………………………..7
Assessing……………………………………………………………………………………8-10
Plan……………………………………………………………………………………………11
Interventions………………………………………………………………………………….12
Evaluation…………………………………………………………………………………….13
Recommendations for practice……………………………………………………………….14
Conclusion……………………………………………………………………………………15
References……………………………………………………………………………………16
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Introduction Venous leg ulcers and venous insufficiency are of high prevalence in older people, it is a condition that can be both complex and chronic, with acute consequences. Many aspects of nursing care must be considered. When caring for patients with venous leg ulceration, promoting wound healing and maintaining health and quality of life is important. The aim of this care study is to demonstrate the effectiveness of collaborative, comprehensive and evidence-based care planning in the healing of a wound in the community. Drawing on recent failures such as the Mid Staffordshire public inquiry (Francis, 2013) it is of paramount importance that strong nursing values are demonstrated throughoutWith the aim of showing the nurse’s considerations in assessing, planning, implementing and evaluating individualised care, a nursing model was used. The chosen model of nursing is Roper, Logan and Tierney’s Activities of Living Model which is used as a framework throughout the nursing process. This care study will follow the management of a patient with a venous leg ulcer while receiving care in a community setting, over a period of three weeks.
Patient Presentation Roy is a 75 year old retired painter and decorator. He lives in a comfortable two storey townhouse with his wife, and together they are independent of their basic needs. They have a daughter nearby that helps with the food shopping. Chronic osteoarthritis causes Roy discomfort on movement, which has recently resulted in reduced mobility. He reports that he takes 1g oral paracetamol every evening before bed and in the day when he is uncomfortable, but that sitting in his armchair and refraining from exertion helps the most. Due to underlying venous insufficiency, he currently has a venous leg ulcer to the medial supra-malleolar region of his left leg, following a non-healing wound, caused by knocking his leg on a wall in the garden. After presenting to his practice nurse regarding his wound, Roy has been referred to the local community nursing team who will visit him at home to treat his leg ulcer. Roy’s vital signs were taken during admission to community services and are within normal limits. A Body Mass Index (BMI) of 24 places him in the “healthy” bracket and he is a nonsmoker.For the purpose of this care study the focus will be on Roy’s venous leg ulcer as it is the most prominent active problem. However, a holistic approach to his care ensures that his other morbidities are considered.
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The Nursing and Midwifery Council (NMC) (2008) state that every individual has a right to confidentiality and that this is to be respected. To maintain patient confidentiality, a pseudonym is used throughout.
Venous leg ulcer Venous leg ulcers are defined as an open wound in the skin of the lower leg due to hypertension in the leg veins (British Association of Dermatologists, 2014.) They are caused when the valves in the leg veins are insufficient or become damaged. The damaged valves can cause blood to pool resulting in hypertension in the legs which can lead to oedema, inflammatory changes and eventually skin breakdown. Venous ulcers are known to occur on the supra-malleolar and infra-malleolar regions of the leg and foot. However, they can occur at the malleolar region both on the medial and lateral parts of the ankle (Raffetto, 2010.) It is estimated that 1-2% of the adult population will develop a venous leg ulcer in their lifetime, as a result of chronic venous insufficiency. Worryingly, venous ulceration can often become a chronic condition with up to 70% of ulcers recurring within 3 months if no active treatment is implemented. (Finlayson et al, 2011.)
Treating patients with venous ulcers has cost the National Health Service (NHS) at least £168-198 million per year through services provided in primary care and community settings (Posnett and Franks, 2008) and with the population of older people rising, there is potential for the problem to increase due to old age being a contributing risk factor. Recent reports on the rise of obesity and type 2 diabetes (DoH, 2011; Public Health England, 2014) highlight cause for concern, as these conditions can be pre-disposing factors of venous insufficiency. It has been well documented that living with chronic leg ulceration can have a huge impact on quality of life. One study exploring people’s experience of living with chronic venous leg ulcers identified the impact of psycho-social wellbeing. Feelings of depression, frustration, social isolation and a loss of self-worth were identified in patient verbatim collected in unstructured interviews (Bryne and Kelly, 2010.)A widely used and effective treatment for venous insufficiency and the healing of venous leg ulcers is compression bandaging. Other treatments, both surgical and therapeutic can be used, for example; elevation of the leg, debridement, skin grafting, vacuum therapy and surgery of the veins.

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Nursing Theories and Models Since Florence Nightingale’s first acknowledgment of nursing as an art, the profession has remained somewhat hard to define in its entirety. In 1966 Virginia Henderson quoted that the function of the nurse is ‘unique’ and also mentioned the role of teaching and advocacy. The World Health Organisation (2000) defined nursing as holistic, collaborative and personcentred: skills that are emphasised in contemporary nursing. It also states how nursing requires a set of social and professional skills alongside scientific knowledge to provide care for individuals and their families. Most recently the Royal College of Nursing (2003) created a publication specifically for defining the nursing role, stating how nurses aim to aid patients to achieve ‘the best quality of life.’ Fawcett’s metaparadigm of nursing (1978) is used to explain the links between theory, philosophy and science used in the study and practice of the profession. The nursing metaparadigm has four components; The Person, Environment, Health and Nursing. These concepts can be used globally for the nursing profession, to distinguish what it is that nursing involves (Fawcett and Desanto-Madeya, 2013.)
Within the study of nursing theory and philosophy are the derivation of nursing models, or frameworks. Nursing models were created with the intention of developing nursing as a distinct profession separate from medicine, and to assist with the defining of what is a broad and complex role. They offer a set of values and beliefs that can be used to guide nurses through the stages of problem solving involved in caring for patients. Orem’s Self Care Model (2001) provides a framework for a holistic assessment. Intrinsically criticised for its academic and ‘flowery’ language the model uses 8 ‘universal self-care requisites’ as the basis for assessing a patient’s needs. Other ideas underlying the model continue to support the theory of holistic assessment and patient centred care which is paramount in contemporary nursing. Peplau’s theory of interpersonal relations (1997) stresses the importance of effective nurse-client relationships. Using psychological theories, Peplau’s therapeutic approach has good relevance to mental health nursing.
Neuman’s System Model (1972) was developed with the philosophy of moving away from a focus on ‘illness’ and rather on promoting ‘wellness.’ Neuman suggests the person is a system that strives for stability and when ‘stressors’ occur that effect stability, nursing care helps the individual to regain that stability. While the model is celebrated for its interdisciplinary approach, Neuman’s Model could prove difficult for student’s and novices,
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as like Orem’s, the language used is academic and at times confusing. Murphy et al. (2010) discusses the criticisms faced by all nursing models, debating the relevance to contemporary nursing practice. Intrinsic factors include the use of complex terminology from American academics and their transferability to British nurses. Extrinsic factors for nursing models such as lack of training on use of the models, and a resistance to change, provoke special consideration for British nurses whom work within a National Health Service (NHS) and face realities such as government funding. The cultural differences between nurses working in the US and in Britain provided a gap in the market for modern British theorists Roper, Logan and Tierney, and their publication of the Activities of Living model in 1980.
Chosen model of nursing Roper, Logan and Tierney’s Activities of Daily Living Model (2000) was the chosen model of nursing for the care of the discussed patient. The reason for this was because of the benefits of the holistic nature of the model for both patients, and the staff implementing it. In addition, rationale for choosing this model was also due to its compatibility with patient management and documentation within the trust in which Roy was being cared for. Many of the documents used to communicate with other members of the multidisciplinary team were based around the theorist’s ideas. Furthermore, Timmins and O’Shea report that the model is the most commonly used in Europe (2004), suggesting it may be most recognisable. Roper, Logan and Tierney identify 12 behaviours that all people carry out each day, these are named ‘the activities of daily living’ (ADL.) Some of these behaviours are essential for us to live, and in healthy individuals are involuntary. The others relate to our quality of life and despite contributing to our psychological wellbeing, are not essential (Barrett et al, 2012.) The aim of the model is to promote independence along a ‘lifespan continuum.’ It is suggested that that each person goes through certain stages in their life, in which their levels of dependence change. However, the ways in which the activities of living are carried out varies from person to person. Therefore, identifying biological, psychological, environmental, socio cultural and politico economic influences on a person’s life is encouraged. The effects these may have on a person’s ability to carry out the activities of living will help to identify their level of dependence (Walsh, 1998 cited by Barrett et al, 2012.)
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The model encompasses nursing needs that are common to all patients, for example, ensuring comfort and hygiene. However, the broad nature of the 12 terms means assessment can be individualised to ensure a person-centred approach to care. This benefits the patient by having their daily living taken into consideration, as well as the condition that presents itself foremost. Salvage (2006) identifies how the model is not set in stone and instead was designed to be open to refinements, much like the ever-changing process of modern nursing. However, criticisms have been made that the model is too often used as a ‘checklist,’ scrutinising the simplicity of the model (Walsh 1998Barrett et al, 2012.) In community settings, it is paramount to consider how the patient will continue with their day to day life and within their own environment. Roy is independent and so for him, being able to continue his life in the way that he had been is important to him.
Nursing Process The nursing process was first introduced in 1967 by Yura and Walsh. Abbreviated to A.P.I.E, it consists of four stages; Assess, Plan, Implement and Evaluate. The process was created in a bid to move away from intuitive and ritual-based practice, to a systemic, evidence-based approach that would create consistency in patient care. The first element of the process is assessment and it is important to say that a good assessment is comprehensive, holistic and ongoing. It is used as a starting point and enables the professional to get a detailed representation of the patient in order to proceed with the process. However, throughout the patient’s treatment, an assessment of their needs should reoccur routinely and as things change and develop.Planning extends from assessment and involves consideration of the information during the first stage. Using evidence-based clinical judgement to prioritise and plan interventions is paramount. It is in this stage of the process that goals and targets can be set
The next element in the process is implementation. The actions taken during this stage vary hugely depending on many factors aside from just the preferences and needs of the patient. Local and national policies, law, cost, availability, personal and professional choice, best evidence and consent are just some of the factors that contribute to the collaborative decisionmaking that takes place before actions are implemented. Finally, the fourth stage in the nursing process is Evaluation and again, this is an ongoing process. Based on feedback from
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patient, staff and family/carer, conclusions can be made to establish whether goals have been met. Subjective feedback such as attitudes and patient experience are considered, and by referring to baselines collected during the assessment stage, comparisons can be made to show whether the condition has improved or not.
Recognised as having been moulded and developed over the years (Castledine, 2011) the nursing process continues to be relevant despite development in healthcare. However, criticisms of its transferability to modern nursing practice have led to a new pneumonic being proposed. Recognising, Connecting, Partnering and Reflecting (Turkel et al., 2012) suggests moving away from the medical language used to communicate with patients and instead adopting a ‘language of caring’ highlighting the ethical responsibility expected from the nursing profession. Barrett et al. (2012) propose expanding the four stage process to A.S.P.I.R.E, incorporating ‘Systematic nursing diagnosis’ and ‘Recheck’ in reflection of the role of nurses in today’s admission and care planning process. Systematic nursing diagnosis differs from medical diagnosis, as it considers the patient’s needs in a holistic way with considerations that do not always directly involve disease. Recheck refers to the immediate confirmation that the intervention has been or will be safe and effective. Using A.P.I.E, the nursing process is explained further in the form of a care study, following Roy’s care over a period of 3 weeks.
Assessing
Nursing assessment is a process that aims to identify needs and problems so that solutions can be planned and implemented in a way that is specific to the patient’s preferences (Howatson-Jones, Standing and Roberts, 2013.) Consent must be gained so that patient autonomy is encouraged and deprivation of liberty is avoided. Collaboration with the patient assesses their mental, physical, cultural, social, spiritual and personal needs holistically. Competence in skills such as directing conversation, observing appearance, measuring vital signs, inferring and filtering information is vital. As Roy was a new referral to the community nursing team the first stage of the assessment was to gather necessary information that was not yet held. This included confirming his name, date of birth, contact details, allergies and next of kin. During Roy’s first home visit, a range of objective and subjective information was gathered about his health and wellbeing. This information was received verbally during
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conversation. He remained alert and orientated showing that Roy had no problems with the ADL ‘communication.’ This clarified that a face to face collaborative assessment was suitable, with no need for further involvement from the multidisciplinary team at this stage.
A previous medical history was established in which Roy reported his longstanding osteoarthritis. This has affected his mobility due to the stiffness in his joints. During assessment a number of actual and potential problems were identified, relating to Roy’s health and wellbeing. However, it would be impossible to discuss each of these at length. For the purpose of this care study, the problems highlighted will be; pain, skin integrity and mobility. Using Roper, Logan and Tierney’s model, the activities of daily living that are considered to have been affected are; ‘maintaining a safe environment’ due to the leg ulcer causing a change in homeostasis, and ‘mobilising.’ A study revealed that for the majority of patients living with leg ulcers, pain was considered the most important problem associated with the condition and controlling pain prioritised wound healing or any other aspect (Briggs and Fleming, 2007.) The British Pain Society (2007) state, that assessment of pain in older people should contain 5 key components; direct enquiry about the presence of pain, observation of signs for pain, description, measurement and cause. Roy reported that the pain he suffered with was mostly present in his left leg and described it as ‘a sharp stabbing feeling that comes and goes’ and was ‘generally sore.’ He appeared relaxed whilst sitting in his chair but was showing signs of tension and anxiousness when the dressing on his wound was later removed for observation. Using the Numerical Rating Scale (NRS), Roy was asked to score his pain out of 10, 1 being ‘no pain’ and 10 being ‘the worst pain imaginable.’ Roy scored his pain as 6/10.
To assess Roy’s skin integrity an assessment tool known as the TIME framework (Fletcher, 2007) was used. TIME is an acronym for Tissue, Infection or Inflammation, Moisture imbalance and Edge of the wound non-advancing. The tool is a systematic, evidence-based approach to wound observation and the headings are used to prompt observation and coordinate the information that is gathered. Tissue type is defined by assessing the condition of wound bed. Roy’s leg ulcer was documented as presenting as 80% sloughy and 20% granulating. Slough is a term used to describe non-viable adherent tissue that is fibrinous, protein and/or pus. It is creamy-yellow in appearance and can be either soft or firm in texture. (Dowsett and Newton, 2005) Granulation is the new healthy connective tissue, due to the blood vessels at the surface it is red and often bumpy in appearance.The surrounding skin appeared dry but intact. There was no oedema, heat or erythema, however, other sings of
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clinical infection such as moderate exudate levels and acute pain were present. Using nontouch technique, the wound was exposed and measured to provide a reference of size for future visits. It presented at, 3cm at the longest part, 2.4cm at the widest and approximately 0.5cm in depth.
A study by Coleman et al. (2013) found that poor mobility, poor skin condition, poor perfusion and age are some of the indicators for being at high risk of pressure ulcer development. As Roy is suffering from these influencing factors a pressure ulcer risk assessment was conducted using the waterlow tool. The waterlow tool was chosen as it is the most widely used pressure ulcer prevention tool in the U.K (Waterlow, 2014.) It is used to determine the risk status of the patient to developing a pressure ulcer and can be used in all hospital and community settings. Roy scored a waterlow of 14, putting him in the ‘at risk’ category. For Roy, mobilising was not something he had considered to be relevant to his needs. However, during the nursing assessment he had said that he often felt stiff and that sitting in his armchair relieved the aching in his joints and the pain in his legs. Roy uses a stick to mobilise around the house and outside. He is able to transfer safely and independently from sitting to standing and vice versa. Although he stated that it is ‘uncomfortable’ to mobilise, he is able to do so without any problems.
Planning The purpose of setting goals is ‘to solve or alleviate problems…and avoid potential problems from becoming actual problems’ (Barrett et al., 2012.) In relation to the ADL model, it is at this stage that the nurse makes goals to move the patient along the dependence-independence continuum. A valuable way to set goals is to use a tool such as the acronym SMART. Each letter stands for an objective that must be met when setting a goal; Specific, Measurable, Achievable, Realistic and Time-based. Kerridge (2012) discussed the use of the tool in service improvement and expressed that the tool can be invaluable when each stage is fully understood and adhered too.With the findings documented, a plan could be established. Roy’s pain was a priority as it was causing him discomfort. It was also impairing his mobility which was resulting in him sitting in his chair for long periods, putting him at risk of developing pressure ulcers, and reducing the circulation to his leg, impairing wound healing. Using a baseline of Roy’s 6/10 pain on admission, an immediate goal was set to reduce the
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pain to a lower score so that Roy is ‘maintaining a safe environment.’ Improving the integrity and hydration of Roy’s dry skin on his legs, within a week, was a further goal. Due to the percentage of slough in the wound bed, healing is being prevented and therefore a goal to aid debridement of the wound and promote healthy granulation tissue was set. To achieve this, a longer timeframe should be expected and in this instance, 100% wound granulation was aimed to occur within three weeks. Roy was visited twice a week on a Monday and Thursday and advised to call the community nursing team if the dressing needed changing in-between the allocated visits.
Implementing
There are two categories of intervention. Those that are pharmacological (involving the use of medication) and those that are non-pharmacological (therapy not using medication.) Roy received interventions that were pharmacological and therapeutic. National guidelines on gaining consent outline the importance of establishing whether the patient has capacity and the legal principles surrounding consent and accountability (DoH, 2009.) Roy was fully informed of the reasons for each intervention and gave informed consent before each intervention took place. The World Health Organisation (WHO) analgesic ladder is a threestep systematic approach to the management of pain. It is recommended, when prescribing and administering analgesia, to start at the bottom of the ladder and take steps up if there is no improvement. Starting at the bottom, a non-opioid such as paracetamol or non-steroidal anti- inflammatory drugs (NSAIDs) are recommended to treat mild pain. For moderate pain, a weak opioid such as codeine can be used alone or alongside a non-opioid. Severe pain can be treated with strong opioids such as morphine. As Roy had not been taking his prescribed 1g of paracetamol 4 times a day, the management of his pain had not been successful. For this reason, discussion and education on the importance on taking regular pain relief to control symptoms was implemented. Roy was advised to contact his G.P if he felt regular paracetamol was not sufficient.
Therapeutic interventions for the management of pain, should not be underestimated. Roy was advised to elevate his legs by resting them up on a footstall when he is sitting in his chair, it was explained to him that this would promote blood flow back to the heart and reduce the pressure in his legs, and that elevation may also help with the pain. Prior to
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admission to community services a Doppler was done by the Practice nurse. The result of the Doppler was a diagnosis of chronic venous insufficiency, therefore, the use of compression therapy was considered. However, in keeping with plans to debride the wound, compression will not be discussed during this essay. Discussion will be on the primary dressing choice.
The British National Formulary (2014, p.1017) states that for skin to heal, the ideal dressing needs to ensure the wound is moist, free of infection, excessive slough, chemicals and debris and keeps the wound at optimum temperature and pH level. As well as these, Bryant and Nix (2012) consider other factors when describing the ideal wound dressing, such as; cost effectiveness, shelf-life and availability. During Roy’s first visit from the nursing team, a swab of his wound was taken to test for infection, the results of which were negative. In line with local guidelines, hand-washing was performed pre and post care, the wound was dressed using appropriate non-touch technique, wearing personal protective equipment (gloves and apron) to prevent infection and cross contamination. The plan was to debride the wound of slough, therefore reducing exudate and promoting granulation. A hydrofibre dressing called ‘Aquacel’ was cut to shape and moulded into the wound bed. Due to the moderate amount of exudate, a hydrocolloid ‘ActivHeal’ adhesive dressing was placed over the wound. Hydrocolloids are recommended for moderate-high level exuding wounds (BNF, 2014.)
Dry skin can impair wound healing and lead to skin breakdown. The use of simple, low-cost interventions such as emollient creams can improve wellbeing and maintain skin integrity in older people (Cowdell, 2012.) Roy’s G.P prescribed an emollient which could be applied daily to the skin on both legs and any other dry areas to prevent further breakdown.Patient education is an invaluable intervention that involves health professionals providing patients with a knowledge base that empowers participation and a collaborative approach to managing health. Wingard (2005) discusses patient education within the nursing process, concluding that by educating patients, positive attitudes can be built and outcomes, improved. From assessing Roy’s coping strategies and knowledge on his condition it was apparent that he was unaware of the negative effects of remaining sitting for long periods. As recommended by NICE guidelines (2014) Roy was provided with verbal advice to regularly reposition every 4 hours and intermit sitting in his chair with walking and laying in his bed to prevent developing pressure ulcers. Information leaflets, published by the trust, on pressure ulcer prevention and leg ulcer management were also provided for reference. To further prevent
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pressure ulcers, and improve comfort and circulation, in line with local and national guidelines, a repose pressure relieving cushion and mattress were ordered.
Evaluating Roy’s care was evaluated twice a week, during each visit from the nursing team. By referring back to the original assessment, any changes in his condition could be established. Using RLT’s model, the aim was to help move Roy along the independence continuum in the ADL that he required nursing involvement for. These were; mobilising and maintaining a safe environment. Following the advice given to Roy about taking regular analgesia, during the next visit he reported he had been taking 1g paracetamol, as prescribed, 4 times a day with positive effect. Using the NRS, he scored 2/10 which he reported was the achiness which came from his wound. It was discussed that as the wound began to heal this may improve, however, during each following visit his pain was assessed to ensure that the pain had not increased. The goal of reducing Roy’s pain was successful and no further action was required during the next three weeks. When evaluating Roy’s wound, a thorough wound reassessment was documented during each visit using the TIME framework. During the three weeks, infection was successfully avoided due to the implementation of infection prevention measures. A successful decrease in percentage of slough, and an increase to 80% granulation tissue could be seen. Emollient cream was applied to surrounding skin daily with help from Roy’s wife. It was established that with Roy’s and his wife’s concordance to pharmacological intervention and advice on mobility and leg elevation, there was an improvement in wound and skin integrity. The implementation of patient education had therefore been invaluable. By reducing and managing the pain, and improving skin integrity, homeostasis had been regained.
Recommendations for practice
Leg ulceration is a condition seen often in the community. Therefore, applying use of the nursing process is valuable in gaining a systematic and consistent approach to wound healing. Although research and literature on the management of venous leg ulcers exists in high quantity, there are currently no national guidelines for their treatment. With most diseases of high prevalence being covered by NICE guidelines and pathways, some may question the logic behind having a lack of set guidelines for the treatment of leg ulceration.A patient-led
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approach to wound healing can be beneficial, as this encourages patient involvement and adherence to treatment (McNichol, 2014.) By educating patients on the interventions used to encourage healing, such as leg elevation and mobilising, care planning can be collaborative between patient and professional.It is encouraged that community nurses consider pain when planning care for patients with leg ulcers, not just on admission but also during healing (Vandenkerkhof et al, 2013) as this has been recognised as being a priority for patients (Briggs and Fleming, 2007.)
In this study, accurate wound assessment was able to provide a baseline of observations that were useful in the evaluation stage of the nursing process. The TIME wound assessment tool has been proven to make significant improvements to wound care in the community (Dowsett, 2009.) Competency in the evidence-based strategies used in the care planning and management of leg ulcers is paramount to providing excellent care.
Conclusion
As demonstrated in this care study, patients with venous leg ulceration can benefit hugely from comprehensive, holistic assessment, as it is a condition which can affect a person in many ways. Application of a nursing model, such as RLT’s, can sign-post assessment of an individual and ascertain that all patients receive the same standard of excellent care planning. Nursing values are at the heart of the work that nurses carry out, therefore, competency in compassionate, honest, person-centred care planning is required to achieve excellent and consistent standards. It is by practicing these unique values that the art of nursing, first acknowledged by Florence Nightingale, continues to provide reassurance, guidance and support to those in need.
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References
Barrett, D., Wilson, B. and Woollands, A., 2012. Care Planning: A guide for nurses. 2nd ed. Pearson: Harlow
Briggs, M., and Flemming, K., 2007. Living with leg ulceration: a synthesis of qualitative research. Journal of Advanced Nursing, 59 (4) pp.319-328
British Association of Dermatologists, 2014. Venous Leg Ulcers. [online] Available at: <http://www.bad.org.uk/for-the-public/patient-information-leaflets/venous-legulcers#.VEqNEPldU_o> [Accessed 10 October 2014] British National Formulary, 2014. 66th ed. BMJ Group: London
Bryant, R. and Nix, D., 2012. Acute and Chronic Wounds: current management concepts. 4th ed. Mosby: USA
Byrne, O. and Kelly, M., 2010. Living with a chronic venous leg ulcer. Journal of Community Nursing, 24 (5), p.46, Available through: Gale Cengage [Accessed 12 October 2014] Castledine, G., 2011. Updating the nursing process. British Journal of Nursing, 20 (8), p. 131, Available through: EBSCOhost Cinahl [Accessed 12 October 2014] Coleman, S., Gorecki, C., Nelson, E.A., Cross, S.J., Defloor, T., Halfens, R., Farrin, A., Brown, J., Schoonhoven, L., and Nixon, J., 2013. Patient risk factors for pressure ulcer development: a systematic review. International Journal of Nursing Studies, 50 (7) Available through: Elsevier ScienceDirect [Accessed 1st October 2014] 16
Cowdell, F., 2012. Maintaining skin health in older people. Nursing Times, 108 (49)
Department of Health, 2009. Reference guide to consent for examination or treatment. Second edition. Department of Health. [pdf] Available at: <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_1 03653__1_.pdf> [Accessed 12 October 2014] Department of Health, 2011. Healthy Lives, Healthy People: a call to action on obesity in England. [pdf] London: Department of Health. Available at: <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213720/dh_1 30487.pdf> [Accessed 12 October 2014] Dowsett, C, 2009. Use of TIME to improve community nurses’ wound care knowledge and practise. Wounds UK. 5(3) pp.14-21 [pdf] Available at: http://www.woundsinternational.com/pdf/content_9293.pdf [Accessed 30 October 2014] Dowsett, C. and Newton, H, 2005. Wound bed preparation: TIME in practice. Wounds international [pdf] <http://woundsinternational.com/pdf/content_86.pdf> [Accessed 18 October 2014] Fawcett, J. and Desanto-Madeya, 2013. Contemporary nursing knowledge: analysis and evaluation of nursing models and theories. 3rd ed. Philadelphia, Pa: F.A Davis.
Finlayson, K., Edwards, H. and Courtney, M., 2011. Relationships between preventative activities, psychological factors and recurrence of venous leg ulcers: a prospective study. Journal of advanced nursing. 67(10) pp.2180-2190. Available through: EBSCOhost Cinahl [Accessed September 23 October] Fletcher, J., 2007. Wound assessment and the TIME framework. British Journal of Nursing, 6(8), pp. 462-466.
17
Francis, R., 2013. Mid Staffordshire NHS Foundation Trust: Public Enquiry. [online] Available at: <http://www.midstaffspublicinquiry.com/report> [Accessed 26 October 2014] Howatson-Jones, L., Standing, M. and Roberts, S., 2013. Patient Assessment and Care Planning in Nursing. Sage: London. p.1
Kerridge, J., 2012. Leading Change 2 – planning. Nursing Times, 108(5) pp.23-24.
Murphy, F., Williams, A., Pridmore, J.A., 2010. Nursing models and contemporary nursing 1: their development, uses and limitations. Nursing Times, 106 (23) pp. 18-20.
Neuman, B. and Young, R.J., 1972. A model for teaching total person approach to patient problems. Nursing Research, 21, pp.264-269
Nursing and Midwifery Council, 2008. The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC
Orem, D., 2001. Nursing: Concepts and Practice. 6th ed. St Louis, MO: Mosby
Peplau, H., 1997. Peplau’s Theory of Interpersonal Relations. Nursing Science Quarterly
Posnett, J. and Franks, P.J., 2008. The burden of chronic wounds in the UK. Nursing Times.
104(3) Available through: Journals@Ovid [Accessed 30th October 2014] Public Health England, 2014. Adult obesity and type 2 diabetes. [pdf] Available at: <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adul t_obesity_and_type_2_diabetes_.pdf> [Accessed 15 October 2014] Raffetto, J.D, 2010. Definition of a venous leg ulcer. Journal of Vascular Surgery, 52, pp. 4649. Available through: Elsevier ScienceDirect [Accessed 28th September 2014] 18
Roper, N., Logan, W., and Tierney, A., 2000. The Roper-Logan-Tierney model for Nursing: based on the activities of living. Edinburgh: Churchill Livingstone.
Royal College of Nursing, 2003. Defining Nursing. RCN [pdf] Available through: http://www.rcn.org.uk/__data/assets/pdf_file/0003/78564/001983.pdf [Accessed 30th October] Salvage, J., 2006. Model Thinking. Nursing Standard, 20 (17), pp.24-25
Timmins, F. and O’Shea, J., 2004. The Roper-Logan-Tierney (1996) model of nursing as a tool for professional development in education. Nurse Education in Practise, 4(3) pp.159167. Available through: Elsevier ScienceDirect [Accessed 9th October 2014] The British Pain Society, 2007. The assessment of pain in older people: National Guidelines. Royal College of Physicians [pdf] Available at: <www.britishpainsociety.org/book_pain_older_people.pdf> [Accessed 15 October 2014] Turkel, M., Ray, M. and Kornblatt, L., 2012. Instead of Reconceptualising the Nursing process let’s rename it. Nursing Science Quarterly. [online] Available at: <http://nsq.sagepub.com/content/25/2/194>
Vandenkerkhof, E., Hopman, W, Carley, M., Kuhnke, J. and Harrison, M., 2013. Leg ulcer nursing care in the community: a prospective study of the symptom of pain. BMC Nursing, 12. Available through: Gale Cengage [Accessed 17 October 2014] Waterlow, J., 2014. The Waterlow Score. [online] Available at: <http://www.judywaterlow.co.uk/waterlow_score.htm> [Accessed 28 September 2014] 19
Wingard, R., 2005. Patient education and the nursing process; meeting the patient’s needs. ephrolog nursing ournal ournal of the erian ephrolog urses’ ssoiation, 32(2) pp.211-214
World Health Organisation, 2014. Nursing. [online] Available at: <http://www.who.int/topics/nursing/en/>
Yura, H. and Walsh, M., 1973. The Nursing Process: assessing, planning, implementing, evaluating. 2nd ed. Appleton Century Crofts

8.
TAXA5006: Assignment 2 – Semester 2, 2015
Research Paper:
Due date: Monday 26 October 2015
Word limit 3,000 words: excludes Bibliography & footnotes
Marks: 30
Submit: Through the Turnitin link in Blackboard/Assessment
Citation Method: AGLC3 with Bibliography
Case Study: Xena Pty Ltd
Xena Pty Ltd is a subsidiary member of the Lawless Group Ltd (Lawless). The Group is consolidated for tax purposes. The Balance sheet for Xena shows the following balances at the end of the current financial year:
$ ,000
Assets
Cash 10
Loan to Lawless Ltd 140
Financial Assets 1,540 Note 1
Property 2,550 Note 2
Total Assets 4,300

Liabilities
Loan from external bank 3,200
Total liabilities 3,200

Net Assets 1,100

Represented by:
Share Capital 10
Retained Earnings 790

Note 1: Listed shares at current market value. The cost base is $800,000
Note 2: Current market value. The cost base is $1,500,000.
Gabrielle Pty Ltd is an unrelated company that pays substantial dividends. Xena has the opportunity to acquire a minority interest in Gabrielle, and is looking at methods to raise the necessary $500,000.
Required:
Assuming that all entities involved in these arrangements are Australian residents, discuss the income tax consequences to Xena, Lawless, Gabrielle and Gaby of each of the following alternatives.
Option A: Xena issues 500 convertible notes with a face value of $1000 that will convert to 10 ordinary shares in Xena in seven years. The coupon rate is 5% per annum.
Option B: Xena will issue the lender 5,000 preference shares with a face value of $100 each and a dividend rate of 5%. In 7 years they will revert to ordinary shares.
Option C: Immediately prior to issuing the preference shares, Lawless repays $40,000 of the amount it owes to Xena. This is used to reduce the bank debt. Does this make any difference to your advice in relation to Option B?
Option D: Lawless Ltd is not satisfied with Xena acquiring a minority interest and initiates a takeover bid for Gabrielle Ltd. It makes an offer to purchase all shares in Gabrielle, issuing a $10 share in Lawless plus $10 cash for each share in Gabrielle. It succeeds in acquiring 85% of the shares in Gabrielle. Gaby held 1,000 shares in Gabrielle Ltd., and her shares had a cost base of $5 each.
Option E: When undertaking the due diligence inquiries Lawless discovers that Gaby has been living in an apartment owned by Gabrielle Pty Ltd for the whole of this financial year, carried on the balance sheet at $460,000. She has been paying rent of $300 pw. Another apartment in the same building has recently been leased for $500 pw. Lawless also asks for advice on the consequences of this arrangement.

Assignment guidelines:

Submission: All assignments should be accompanied by a cover page (available through Blackboard) and lodged through the relevant Turnitin link on Blackboard. You will have the opportunity to review your work for inadvertant plagiarism and resubmit up to the due date.

Late Assignments: Refer to the Unit Outline for the policy regarding extensions and late submission of assignments.

Marking Criteria: A Rubric will be applied in marking this assignment. The rubric template will be published on Blackboard, and each student will be able to view their personalised rubric.
The following marking criteria will be incorporated in the rubric:
Content: Has the student identified and articulated the relevant content/legal issues/information in the answer? Has the student “researched” the topic, explored the relevant cases (where relevant)?
Structure: Has the material/content been presented in a cogent, logical, and thorough manner?
Relevance and Has the student answered the question? Have all the elements of the
Completeness: question been addressed?
Analysis: Has the student “critically analysed” and “discussed” the content?
Understanding: Has the student demonstrated an understanding of the content and the issues arising from an analysis of that content?
Communication: Has the answer been communicated (e.g. written) in a clear and concise manner? Is the English grammar and construction of a written paper at an appropriate and professional standard?
Conclusion: Has the student reached a conclusion and used appropriate evidence to justify this conclusion?
Referencing: Has the student properly referenced the sources used? The preferred method of citation is AGLC3. All assignments MUST include a bibliography.

Format of assignments
You will not be awarded marks for the following requirements – rather you will lose marks for failing to attain these requirements or you may have your assignment returned unmarked.

All assignments MUST be typewritten or word-processed, complying with the following format requirements. It is your responsibility to keep copies/backups of every assignment submitted.

Font: Times New Roman font – no smaller than 12 point in size.
Pages: Numbered in top or bottom margin.
Spacing: 1.5 line spacing and appropriate paragraph spacing.
Margins: At least 2.5 cm top, left, right and bottom.
Spellcheck: The document MUST BE CHECKED for SPELLING AND GRAMMAR before submission.
Word Count: The total word count for each assignment is set out in the assessment criteria. This excludes references. Please provide a word count on your cover sheet. If the assignment exceeds the word count, with a tolerance of +/- 10% (eg a 3000 word assignment should be between 2700 and 3300 words) then the failure to comply will be reflected in your mark. The marker has the discretion to stop marking at the point where the word limit is exceeded. Footnotes and bibliography are not included in the word count, but should be limited to references: they should not introduce new material that should be incorporated in your main essay.
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