Assessing the Patient with an Aspect of Care: Wound Care Management - Case Study Example

ASSESSING A PATIENT ASSESSING THE PATIENT WITH AN ASPECT OF CARE “WOUND CARE MANAGEMENT” ASSESSING A PATIENT 2 INTRODUCTION: The essay describes the aspect of care chosen for the patient who has undergone “knee replacement surgery”. The details of the patient show that the patient had undergone replacement surgery in both the knees. Above all the patient is an 83 year old lady, Lymphoma in Right leg, affected by myeloproliferative disorder and suffering from recurrent anaplastic disorder. While reviewing the body condition and the financial status of the patient, the aspect of care that was found out to be suitable for her condition was wound care management, as that appears to be the suitable care that should be given to the patient. Further reasons for choosing the wound are that 1. Both the knees have been replaced 2. the patient is very old and she requires a healthy person or service provider to assist her in dressing the operated places 3. she already has myeloproliferative disorder, which might result in increased number of red blood cells and increased number of platelets 4. she has recurrent anaplastic cutaneous t-cell lymphoma, which as a result of the surgery has aggravated the t-cell lymphoma, forming red patches in the skin and produces itching sensation in the skin. 5. though the surgery wounds have healed , it has triggered the t-cell lymphoma, and as a result smell started to come out from the decay and infection 6. the aspect of dressing was palliative one, as she is almost in the path of her last days ASSESSING A PATIENT 3 7. Based on the reasons it is finally decided that wound care management will be the suitable for this patient. As her skin is sensitive to other diseases, the dressing and medication given to the spot in which the replacement surgery had been done have to be carefully analyzed. The process of wound care, management involves the following steps: The first and foremost step would be assessing the patient and the wound, but in the case of this patient there is not real wound but an operation had been done in both her knees. 1. “It is widely accepted that a warm moist wound environment encourages healing and prevents tissue dehydration and cell death”[1] 2. an ideal dressing condition should maintain [2] a. a moist environment at the wound surface b. provide thermal insulation 3. And in general a dressing should :[3] a. “provide mechanical protection b. protect secondary infection c. be non-adherent and easily removed without trauma d. leave no foreign particles in the wound e. remove excess exudates without allowing “strike through” to the surface of the dressing f. be cost effective g. offer effective pain relief “[4] ASSESSING A PATIENT 4 The type of dressing that is chosen is aquacel and redressing suggested is aseptic technique. This is a kind of palliative dressing, which is usually suggested as the final or last or end of life dressing, done only with the aim of giving a timely relief to those patient who show very less or no progress in curative dressing. Since the patient has developed infection and smell in the right leg, and other defects and disorders also has more chances to aggravate further the wound, the wound care management is highly recommended in order to reduce further risk of skin damages while the patient is under the medications for osteoarthritis and also to give her comfort as she had expected to spend her last few days in her home. Before going through the care management is it highly recommended to have a view on the disease called osteoarthritis and its effects on the patient from a sociological and psychological point of view. Osteoarthritis is found out to be one of the frequently identified arthritis, occurring particularly in older people. “Osteoarthritis is a joint disease that mostly affects the cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint”[National Institute of Arthritis and Musculoskeletal and Skin Diseases] More over the institute has to say the following on the effects of osteoarthritis. People with osteoarthritis will develop limited movement and joint pain. The effects of the disease includes various kinds such as financial, lifestyles effects [which includes sociological and psychological aspects also] ASSESSING A PATIENT 5 “The financial effects include: 1. The cost of treatment 2. wages lost because of disability”[ National Institute of Arthritis and Musculoskeletal and Skin Diseases] and the life style effects includes : “Depression Anxiety Feelings of helplessness Limitations on daily activities Job limitations Trouble participating in every day personal and family joys and responsibilities” [National Institute of Arthritis and Musculoskeletal and Skin Diseases] The aim of this aspect of wound care management is to bring out the patient from a hospitalized atmosphere to a homely one, with out being affected by other external sources of the society such as finance and disability. Wound care management is found out to be the moderate care or service that could be provided, of course to an older patient. And as per the NMC code of conduct the patient’s name has not been specified, it has been kept confidential, but the health problems have been specifically mentioned in order to justify the aspect of care management chosen. The NMC code of conduct has the basic rules that are to be followed by the nursing people, they are, ASSESSING A PATIENT 6 “Respect the patient or client as an individual Obtain consent before you give any treatment or care Protect confidential information Co-operate with the others in the team Maintain your professional knowledge and competence”[The NMC code of professional conduct: standards for conduct, performance and ethics. 2004] Nursing Interventions: Considering the wound care management from a biological aspect of view : As far as the patient is concerned she has osteoarthritis, lymphoma in right leg, both knees have been replaced, having myeloproliferative disorder, recurrent anaplastic t-cell cutaneous lymphoma. And the surgery had aggravated her infection in her right leg, giving way for smell and pain. It is better to have a view on what is a cutaneous t-cell lymphoma is A cutaneous t-cell lymphoma is a or CTCL “is a particular type of lymphoma that begins in the skin. Cancerous T cells grows within the skin…… and there are 4 main stages of this condition Stage 1. the disease is only affecting the skin Stage 2. lymph nodes are enlarged, but there is no sign of cancer inside them Stage.3 there are lymphoma cells in the lymph nodes Stage .4. the lymphoma has spread to the body organs”[Cancer Research UK] ASSESSING A PATIENT 7 The treatment suggested is chemotherapy, electron beam therapy, etc. The patient should be judged on the basis of in which stage she really is and according to that treatment should be suggested. Osteoarthritis as has been already discussed that it will lead to limited movement and disability in the patient. The treatment also includes exercises, Surgery, rest and joint care, pain relief techniques, medications and alternate therapies etc. As the patient has undergone a surgery already the biological factors needed to be considered in order to gain the recovery. The exercises, or therapies will not work, as the patient depends on a wheel chair even at the time sleeping. Then only option would be wound care management with palliative dressing technique, though many research reports have released facts regarding the effects of osteoarthritis, like the one suggested by Mayo Clinic site, “There is no cure for osteoarthritis, but available treatments can relieve pain and help you remain active. In addition, how well you live with osteoarthritis often depends on your behaviors and attitude.If you are actively manage your osteoarthritis, you may be able to gain control over pain” says [MayoClinic.com. Osteoarthritis] . It further gives hope in a joint replacement surgery is done, and it will help in recovering “an active , pain free lifestyle . In smaller joints, it also can improve your joint’s mobility”[Mayo Clinic.com. Surgical or other procedures: Joint replacement. Osteoarthritis] Though hopeful cases exists even after surgery, and even at the very old age , but in the case of this patient the other commanding diseases such as the myeloproliferative disorder and Cutaneous t-cell lymphoma, or the cancer on her leg have already reduced the ASSESSING A PATIENT 8 hope of recovery. The only thing aimed at this aspect of wound care management is to give her comfort as possibly as possibly so that she could get at least a timely relief. The smell that comes out from the infected portion or the leg affected by the cancer, paves the way for her being dependent. The biological aspects show quiet a little hope for the patient to recover from the smell and infection from mental point of view since her age and other lymphoma disorders might influence or interfere the treatments that will be given in future. At the same time the literatures show some ambiguous results such a risk of complications after the replacement surgeries such as “1.Thrombophlebitis 2.Infection in the joint 3. Stiffness of the joint 4. Loosening of the joint”[A patient’s Guide To total Knee Replacement Surgery] But these being the common complications there seem to be other risky complications also. So these factors need to be considered while the patient undergoes the treatment after the surgery has been done. As far as the sociological aspect of the patient is concerned the financial background, the level of disability, the family support etc are to be considered. In the case of this patient the smell that comes out from the decay and infection in the right leg, that has been ASSESSING A PATIENT 9 aggravated by the surgery needs more care from the sociological point of view. Her infection should not affect or spread to others has to be noted. And moreover she should not develop the feeling that she might become a reason for the infection or smell that might disturb others in the family and society. The reaction of the patient and her cooperation with the selected aspect of care is also to be considered. The patient seems to be friendly, approachable and she has not approached this type of wound or care management before. It has become very easy to proceed with the treatment. The effects of osteoarthritis in many cases has lead to change in shape due to the result of bone damage, and this in turn will, make their movements limited within their family and within the society. In the case of this patient she could not move independently and completely depends on others for any routine work. Even for sleeping she uses her wheel chair, her leg being the cause for this, since her leg hurts her so much. As a nurse, the duty not only includes dressing and therapy but also includes counseling regarding the effect of the knee replacement surgery, the effects include the positive effect of complete cure and relief from pain, and gaining back the structure and the risks include loosening of the joints or stiffness of the joints etc. Details of the effects should be explained in order to make the patient aware of what she should do to get well soon. As a nurse the information regarding the patient’s family background, the breadwinner of her family, issues if she has any are to be gathered so that she might get the full support during times of pain and disability. And counseling is also given on what kind of diet restriction ASSESSING A PATIENT 10 should be followed. Generally obesity is also another reason leading to osteoarthritis. So diet plays an important role reducing the risk of the disease. Some scientists suggest a macrobatic diet, such as the following “50% of whole grains[ brown rice, barley, millet, oats and buckwheat, 20 percent seasonal vegetables [cooked or rae], 10 percent protein foods [legumes, soy products or fish], 5 percent sea vegetables[ sea weeds like wakame, agar agar, atc., 5 percent soups [ miso soup, , a broth made with soy bean paste, soups from vegetables, grains, seaweed, or beans etc], 5 percent fruits, seeds, nuts and drinks “[ Diet: Macrobiotic Diet. Remedy Find. http://www.remedyfind.com/treatments/20/2392/] These are suggested to the patient for reducing further risks in the disease. Suggestions are also given to her family members to give the most possible food items that are affordable for them and at the same time food items such as meat , chicken , eggs are recommended to be avoided. But in the case of this patient the risk further extends to the extent of the end of her life. So the only thing that has to be concentrated is palliative dressing and the medications to avoid smell and pain and finally to give her most possible comfort. Assessing from the psychological aspect: ASSESSING A PATIENT 11 The study about osteoarthritis says that the patient might develop risk of depression, anxiety, feeling of helplessness, unable to move with the rest of the society etc. A Depression might lead to serious as well as variable effects such a change or imbalanced mood, “loss of interest or pleasure”[a], feelings of overwhelming sadness or fear[b], changing appetite[c], disturbed sleep patterns[e], feelings of guilt anxiety, or fear [d], etc. But as far as this patient is concerned she doest seem to express any of these signs. She had been friendly and approachable through out and never showed any disapproval also. Her approachable and friendly nature helped a lot in the process of making her understand the health situation of her. And moreover she was cooperative through out the counseling session on the health issues of osteoarthritis. The ordour that comes from the infection gives her the feeling that she could not be independent and this makes her feel that it would be better if she spends her last days at her home. The aspect clearly shows that she is absolutely dependent, and feels more comfort in the palliative dressing , and further believes that the nurse will not ignore her from taking care. Activities involved in the wound care management: First step was dressing done to the patient. In the beginning Mepitel , a soft silicon primary wound dressing was done and it was changed weekly then with aquacel, eclipse x2, dressing pad cella band, bandage and yellow tubi net was applied and sterile water was appliednto keep the operated area moist. Presently the dressing is done twice a day with 400mcg of alfentyal. And dressing was removed with the instruction given without removing the mepital and cleaning should be done with gentle saline .And finally application and ASSESSING A PATIENT 12 reapplication of aquacel to the rest of the leg, and surgi pad x2, then clinisorb the mesorbx2 was done after that allevyn heel and the portion was covered with K band bandage and yellow tubi net. And weekly changes was suggested to the family members of the family such as giving a bath with tree oil to soak off dressing redress with mepital and continue with current dressing techniques. At the time of pain alfentyal 400mcg is suggested.. Analyzing the wound care management: This aspect of wound care management works very well for this patient, as she had been cooperative from the beginning in the sense she believed the nursing care as giving more comfort and she could depend and relay over the care at least in her last days of her life. Usually the patient who has undergone knee replacement surgery need to be careful till the legs become normal for walking and other acticvities. Wound management provides pain management, dressing that is required for fast recovery, and it is very moderate when compared to the other care management services. In the case of this patient the surgery wound had already healed but it had increased the scope of infection and bad smell. She has become totally dependent .And the patients’ friendly and approachable nature proves that the wound care management works very well for the patient. What an osteoarthritis patient would require is that they get relief from joint pain, and loosening of the joints, disability etc. the wound management will help them in reducing the pain, recover from the impact of surgery etc. These are the things they expect. If the instructions on diet, medications and exercises are followed regularly they might improve very fast. This could be achieved through wound care management. Here the palliative ASSESSING A PATIENT 13 dressing with the medication alfentail works well but to some extent giving a timely relief from the pain and prevents the ordour that comes out of the infection. Difference between wound healing and palliative wound healing: If a patient’s disease does not respond to wound healing or other curative treatment then they could be suggested palliative woundhealing. Generally the palliative wound healing is followed for a dying patient. The article on palliative versus wound healing says a lot on it. “the goal of palliative care is promote the quality of life, being supportive by focusing on managing and controlling patient’s symptoms and achieve the best possible quality of life for patient’s and the families neither hastening nor postponing death”[ World Health Organization , 1989. Palliative Care Versus Wound Healing] Evaluation: The alfentyal that is given works in such a way that it creates the moister required for healing of the wound and as a result it reduces the pain So if taken it helps in fast healing and patient gets a hope to survive with confidence and recovers very soon. As far as this patient is concerned she gets very nice pain relief so that she could react friendly with the nursing assistant. So it was very help full for the process of wound care management as well as the recovery of the patient. Conclusion: The wound care management has worked in such a way that the patient, in spite of the reason that she is very old, has developed friendly and approachable with the nursing assistant. The dressing was changed showing improvement in the healing of the wound The ASSESSING A PATIENT 14 aim of the wound care management was to make the patient recover from the psychological, biological and sociological factor such as depression, pain, disability respectively. The aim also includes giving the patient an affordable payment for the treatment that are to be given through out the process of healing. As suggested the main points were what were the positive results of knee replacement surgery and also the risks. Though the patient did not show any sign of depression or anxiety she has chances of developing a feeling of loneliness as she is found out to be completely dependent. She uses a wheel chair, sleeps in the chair itself, as her leg causes more pain and discomfort. She does not want to spend her last days of her life under hospitalization, rather would like to remain at home itself. The nursing care shown seems to have created a sort of comfort and faith in her towards the nurse, as she had never showed any kind of disapproval during the course of treatment. REFERNCES Palliative wound care at the end of life “World Health Organization , 1989”. Palliative Care Versus Wound Healing online. Available on http://www.ahrq.gov/about/nursing/palliative.html “ Diet: Macrobiotic Diet. Remedy Find. http://www.remedyfind.com/treatments/20/2392/] A patient’s Guide To total Knee Replacement Surgery .Complications of Total Knee replacement .online. available on Medical Multimedia Group, 308 Louisiana Avenue, Libby, Montana 59923. http://www.healthpages.org/AHP/LIBRARY/HLTHTOP/TKR/tkrparts.jpg [1], [2], [3], [4].Prescribing Nurse Bulletin. Modern Wound Management Dressing.online. Available from http://www.npc.co.uk/nurse-prescribing/pdfs/modWoundvol1no2.pdf [a], [b], [c], Depression.online Available on http://en.wikiepedia.org/wikie/Clinical _depression-118k Mayo Clinic.com.Article section: Treatment Surgical or other procedures: Joint replacement. Osteoarthritis.online.Mayo Clinic.com Tools for healthier lives Available on http://www.mayoclinic.com/health/osteoarthritis/DS00019/DSECTION=8 Cancer Research UK.Cutaneous T cell lymphoma. Online available on http://www.cancerhelp.org.uk/help/default.asp?page=3962#new ”[The NMC code of professional conduct: standards for conduct, performance and ethics. 2004 online. Available on http://www.nmc-uk.org/aDisplayDocument.aspx?/Documentid=201 National Institute of Arthritis and Musculoskeletal and Skin Diseases. Hand Out on Health: osteoarthritis. Online Available on http://www.niams.nih.gov/hi/topics/arthritis/oahandout.htm#1 Read More