Rehabilitation and Intermediate Care Needs of a Patient with Fracture Neck of Femur - Assignment Example

Rehabilitation and intermediate care needs of a patient with fracture neck of femur Intermediate care was specified as one of the eight standards of the National Service Framework for Older People (DoH, 2001:41). As stated - Older people will have access to a new range of intermediate care services at home or in designated care settings, to promote their independence by providing enhanced services from the NHS and councils, to prevent unnecessary hospital admission and effective rehabilitation services, to enable early discharge from hospital and to prevent premature or unnecessary admission to long-term residential care. Earlier, rehabilitation had been defined by the World Health Organization (WHO) as "a process aimed at enabling persons with disabilities to reach and maintain their optimal functional levels." In May 2001, however, WHO adopted the International Classification of Functioning, Disability and Health where the new classification has modified the concept of disability to recognise that personal and environmental factors directly influence the experience of people with disability. Rehabilitation is the combined and co-ordinated use of medical, social, educational and vocational measures for training and retraining the individual to the highest possible level of functional ability (WHO, 2001). Rehabilitation then is seen as a coordinated process that enhances "activity" and "participation." This paper is on rehabilitation and ensuring effective treatment to prevent further falls to a patient with fracture neck of femur. According to the DOH (2001), falls in older people aged 75 and over are major causes of disability and in most cases these lead to death due to injury. In accordance with the NMC Code of Professional Conduct (2004), one is to protect confidential information. For this purpose then, the patient's name in this report will be called Sydney. Sydney is a 75 year old man who weighed 110 kg and has a past medical history of Osteoporosis, hypertension, high cholesterol and falls. Osteoporosis is a condition with reduction in bone mass and density and can increase the risk of fracture when an old person falls. The fracture occurs mostly in the hip area (DoH. 2001). Sydney lives alone in a three bedroom house since his wife died four years ago. He is normally self-caring and independent in his house in all activities of daily living. He goes out when accompanied by one of his two daughters who live locally. He usually mobilises with a walking stick when outdoors. Sydney suffers from osteoporosis and hypertension. Sydney had a fall in his house one day and the ambulance was called by one of his daughters who happened to be there. He was taken to one of the south west London hospitals and at A&E an x-ray revealed that Sydney had fracture neck of femur. In view of that he was transferred to a trauma orthopaedic ward, and was to have an operation (Dynamic hip screw was done) to repair the fracture. Sydney was already advised on admission that he will be spending a maximum of 10 days depending on his condition and progress. After first day post operation Sydney was already mobilised by the physiotherapist. Later on, discharge planning for Sydney had been agreed by the doctors and the multi-disciplinary team, since physiotherapist assessment shows he was making progress, and no longer needed an acute bed. With Sydney's consent the occupational therapist had arranged to look at Sydney's home situation and assess his needs. His needs will involve raised toilet seat, raised bed and chair, bed lever to help him pull himself up from bed, pouching stool to assist him with kitchen skills. It had been decided that intermediate care will be appropriate for rehabilitation for Sydney. As mentioned earlier, the National Service Framework for older people (2001) intends to prevent unnecessary hospital admission and to effect rehabilitation services. Intermediate care comprises of the physiotherapists, occupational therapists, nurses and general practitioners. The fracture neck of femur pathway was in place. Sydney was assessed using the single assessment to bring him into intermediate care team, and also following his suitability for rehabilitation. When it was time for discharge the nurse decided that it will be in Sydney's best interest to go to one of the rehabilitation centres used by the intermediate care for a couple of days before going home finally. He declined the offer maintaining that he can manage at home, and that he would rather go home than stop anywhere. Though Sydney seemed anxious at the prospect of going back home, fear that he might not be able to cope showed in his eyes. On the day of Sydney's return to his home from hospital the nurse went in to assess him and present was his two daughters, and of course, the nurse. I knew it was my responsibility to be knowledgeable about specific nursing care of a fracture neck of femur. For pre-operative nursing care, I gave the patient a full bed bath and saw to it that the operative limb was marked by the orthopaedic. Throughout my watch, the patient was nursed with the thought of the immediate future: minimizing his risk of postoperative wound infection, and maintaining his skin integrity related to immobility, secondary to pain and temporary restrictions. This included reducing pressure sore formation. One of the guidelines for nurses in caring for this kind of patients is to prevent complications of deep venous thrombosis or pulmonary embolus. I took it my role to reduce patient anxiety related to the type of anaesthesia to be used, i.e., spinal or general, by explaining the difference. He had needed one for his operation. I kept reflective notes and developed them as the case progressed. At Sydney's old age, it is difficult to be requesting him to turn from time to time as he felt discomfort each time he was asked to. However, frequent repositioning of the patient is required to alleviate pain and discomfort and to prevent anatomical misalignment. I made sure a thorough skin assessment was carried out each time I repositioned the patient. Of all the problems of Sydney, it was in the aspect of elimination that proved to be difficult. It was the most challenging part that I had to do some extra readings on the topic. A rehabilitation nurse, I understand, has to educate the client on urinary health and bladder management techniques and strategies, and implement strategies to promote urinary health and decrease the risk of urinary complications. This included recognizing manifestations of infection, routine voiding, hydration, and perineal hygiene. When it came to assessing bowel function, I had to consider among others his awareness of the need to defecate, including cultural beliefs and values. Perhaps because he is male and the nurse and those around are females, the patient failed most of the time to properly eliminate. I had discovered later on that problems of hemorrhoids came in the way and shame and loss of face was preventing the patient to call for assistance most of the time. Part of my functions was also to assess the patient's normal bowel elimination pattern. At times, though, the patient had urinary incontinence that a Foley catheter had to be inserted. At his old age, physiologic changes could result in decreased bladder capacity, incomplete emptying and increased residual urine. These had to be reported accordingly as urine is said to contaminate the wound in the post-operative recovery. Whenever I had the chance, I explained to him to be drinking enough liquid to prevent dehydration and to prevent electrolyte imbalance. The patient was given access to a mouth rinse to prevent drying of the mouth. Now and then, the patient was reassured and allayed whenever he got anxious. Using the Gibbs (1988) model to facilitate and guide my reflection, I could then focus on the experience of learning from the incident and on my individual action. As the model encourages a clear description of the situation, analysis of feelings, evaluation of the experience, analysis to make sense of the experience, conclusion and reflection upon experience, it could enable me to examine what I would do if the situation arose again. In general, I find that not only do rehabilitation nurses generally work on multidisciplinary teams, but enact their philosophical principles of maximizing their potential, their learning, and their ability, among others. In dealing successfully with personal-functional disability and societal handicap, I learned that it requires more than just common goals. Rehabilitative success requires interaction among the disciplines where their boundaries are regularly crossed in service to client care. In this case, this means the involvement of the physiotherapists, occupational therapists, nurses, as well as the general practitioners. I found too, that it is the rehabilitation nurse who educates the client and family about skills for self-management of care. This would include self-medication, activities of daily living, home safety, and understanding of disability, medications, and memory aids. When it comes to motivating the patient for life ahead, it is difficult to tell that life will not be the same again. As a patient, he would be banking on my word for expectations. There would still be the depression and grief associated with living without a spouse when one loses self-esteem and body image and at his age. By force of habit, I taken the cognitive functions of judgment, attention and memory among the aged to be automatically impaired, as is the level of consciousness. Perhaps this was a judgment I had picked up over the years from socialization, but it was not totally so with Sydney. Age, after all, does not determine what happens to people. Somehow, he had managed to stand strong with these faculties to act like some 10 years younger than his age. According to Choong, Langford, Dowsey & Santamaria (2000), patients susceptible to osteoporotic fractures are in an age group which commonly has cognitive difficulties. In this case, Sydney seemed to be an exception as he was cognitively better than generalized. The findings of Clemow & Seah (2006) reveal that patient-focused and collaborative care management enabled more patients to return to their usual place of residence following fractured neck of femur. This is proof enough that all the efforts towards treating patients with the concerted effort of teams contribute a lot. After Sydney's operation especially at the point of discharge, I knew it had to be pain that he would have to face, and would then have to know about coping strategies. As a rehabilitation nurse, my role was to educate him on strategies in managing pain even through alternative therapies. This was not easy to do as he had now an altered body image and Sydney seemed to care less. It is difficult enough when geriatric people have to depend on other people for their mobility. Nevertheless, having family members around is some comfort compared to those without family. I found that communication won't be much of a problem if the patient and family were primed about effective use of communication devices, tools and strategies based on their abilities. The patient has to have easy contact with his carers in case of emergency. If ever this thing happened next time, I would know that elimination would be the greatest challenge with this kind of patient; that some problems may not be easily seen if the patient has some hidden problems that he does not readily communicate out of shame; that one's thinking must be open to change as circumstances require; that the nurse will not be depending on doctors and other medics totally to give the patient coping strategies on pain and other difficulties. In sum, rehabilitation is not the domain of just one discipline, but of a team that has to contribute their individual skills to make the patient whole. References Choong, P. F. M., Langford, A.K., Dowsey, M.M. & Santamaria, N.M. Clinical pathway for fractured neck of femur: a prospective, controlled study. MJA 2000 172: 423-426. Clemow, R. & Seah, J. Collaborative working to improve the return of patients to their usual place of residence following fractured neck of femur. Journal of Orthopaedic Nursing Vol. 10, Issue 1, February 2006, Pages 33-37. doi:10.1016/j.joon.2006.01.002. Davis, S. & O'Connor, S. (1999). Rehabilitation Nursing, Foundations for Practice. Bailliere Tindall: RCN, London. Department of Health (200I) National Service Framework for Older People. London: DoH. Derstine. J. B. & Hargrove, S.D. Comprehensive rehabilitation nursing. Philadelphia, PA: W. B. Saunders, 2001. Gibbs, G. (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit, Oxford Brookes University, Oxford. National Service Framework for Older People. Department of Health. London. February 2001. NMC (2004). The NMC Code of Professional Conduct. Standards for Conduct, Performance, and Ethics. London. NMC. Smith M. (Ed.). (1999) Rehabilitation in Adult Nursing Practice. Churchill Livingstone, Edinburgh. Vaughan B & Lathlean J (1999) Intermediate Care: Models in Practice. London: King's Fund. Wade, S. (2003) Intermediate Care of Older People: Whurr Publishers, London and Philadelphia, ISBN 1-86156-356-6. Chapters 1, 2, 8 & 9. Walker, A. & Mollenkopf, H. International and Multi-Disciplinary Perspectives on Quality of Life in Old Age: Conceptual Issues. 2007. Springer Netherlands. Vol. 31. DOI10.1007/978-1-4020-5682-6 World Health Organization. International Classification of Functioning, Disability and Health. Geneva: WHO, 2001. Read More