Nursing Care of an Orthopaedic Patient - Case Study Example

Nursing Care of an Orthopaedic Patient Contents Objective 2. Ethical Considerations 3. Introduction 4. Background 5. Nursing Interventions 5 Preoperative Nursing Interventions 5.2. Postoperative Nursing Interventions 5.3. Health Promotion as Part of Nursing Intervention in the Discharge of a Patient. 6. Conclusion 1. Objective: The objective of this assignment is to describe and discuss the care and nursing interventions that a particular patient received while in an acute orthopaedic ward. 2. Ethical Considerations: The patient’s permission was sought and granted in order that I could use this incident for my essay. Within the essay the patient will be called “Mrs. Willow”, so that her real name is protected and that her confidentiality is maintained according to the Nursing and Midwifery Council Code of Conduct (NMC 2004). 3. Introduction: Mrs. Willow is 67 years of age .Se is married and has two children and three grandchildren. She and her husband live in a bungalow in a small village in the Southwest of England. They are both retired, but active in their community. Mrs. Willow had a fall at home. An ambulance was called and the paramedics on arrival found her in extreme discomfort due to pain in her left hip and leg. They assessed Mrs. Willow, immobilised the left leg and gave her an analgesic injection to reduce her discomfort. The ambulance brought her to the local hospital and Mrs. Willow was presented to the Accident and Emergency department of a local hospital. The attending doctor examined her. He found her in extreme pain, and the left leg could not sustain her weight and there was abnormal mobility of the left leg, raising a suspicion of a sub-trochanteric femur fracture (McRae 1989). The abnormal; immobility was identified, as the left leg could be externally rotated and abducted at the hip. (Santy & Macintosh 2002). X-rays of the left leg were ordered for confirmation of the suspicion and the X-ray images confirmed the sub-trochanteric femur fracture of the left leg. In such a case acute pain is experienced by the patient and according to Cooper et al effective treatment of acute pain should be the priority in the care of the patient. (Cooper et al 2006). In this assignment the care and nursing interventions received by the patient will be studied. 4. Background: Advances in the medical intervention strategies have led to increased lifespan in populations around the world leading to growth in the elderly population. Decreased physical attributes required to cope with the demands of daily life is a common feature of elderly people and according to Kelly & Dowling nearly one third of people over the age of 65 will experience a fall (Kelly & Dowling 2004). A majority of these falls do not lead to death or serious injury. Yet they are among the major causes for disabilities seen in the elderly. To cope with this the National Service Framework for Older People has set an objective aimed at reducing the fall incidents in the elderly and should it occur, provide effective treatment and rehabilitation (DoH, section 6, 2004). This needs to be implemented as the disability could have a significant impact on the elderly victims. The consequences of the disability lead to psychological effects that result in self-restriction to physical activities and a dependence on others. Fuller (2000). Mrs Willow’s fall is a common example of physical activities involved in daily activities leading to falls in the elderly leading to painful consequences. She had gone into the conservatory carrying some boxes, when she tripped over a threshold and fell. She could not get up because of the excruciating pain in her left leg. Her husband was not around and as is the case in the social set up of families, children are seldom present to provide assistance in the case of a crisis. So assistance took time in coming. It indicates the difficulties that the elderly face in the case of disabilities arising owing to a fall. Hearing cries for help, her neighbour found her an hour later. The ambulance service was called for and they transported her to the Accident and Emergencies department of the hospital, where further investigations and care was provided. This included besides the x-ray imaging other investigations like electrocardiogram (ecg), baseline bloods such as full blood count (fbc), urea and electrolytes (u&e) as well as blood type and cross-match. Baseline observations of temperature, pulse, respiration and blood pressure help to monitor signs of shock and possible hypothermia. She was also assessed for any other injuries that might have occurred. These investigations enable assessment of the condition of the patient and also ruling out any other injuries that may have resulted from the fall and require treatment. In addition, an intra venous (IV) access was started and she was transferred to the ward with the diagnosis of fracture neck of femur (NOF), of the left leg. 5. Nursing Interventions 5.1. Pre-operative Nursing Interventions: Nursing assessment and care continue at the ward. (Collins, 1999). Managing the pain experienced by Mrs. Willow and preparing her for the surgical procedure were the primary objectives of the nursing care. Pain is recognised for its diverse and personalised nature. It is also subjective. To assess the pain experienced by Mrs. Willow a pain assessment chart in the form of the numerical rating scale (NRS), which was the norm in the ward, was employed as the assessment tool. (Alexander et, al 2000). The scale uses a 0-3 rating of pain and is a subjective analysis. Mrs. Willow kept indicating a high level of pain, which represents a rating of 3 on this scale. To address this issue, she was settled in her bed and skin traction employed as a conservative measure. The benefit of traction is that it helps to reduce and immobilise the fracture, reduce muscle spasm, besides the aspect of providing relief for pain, (Jamison, et al 2000), which was acute in the case of Mrs. Willow. Symptoms of depression, such as lack of sleep and low morale can make a persons pain tolerance lower and thus can be a factor in effective pain management. Mood states can negatively influence the way pain is perceived and lower the body’s threshold (Russell, 1999). Communication with Mrs. Willow indicated that she was in a depressed mood, as a result of the incident and so communication to elevate her depressed state was used as a part of the nursing care to manage her feeling of pain. The nursing care provided in the form of the traction and the comforting communication made Mrs. Willow to come to a state where the surgical procedure she was due for could be discussed with her. The anaesthetist and the consultant arrived and discussed the operation procedures and the post-operative pain relief option available. Mrs. Willow understood the information that was given to her and agreed to surgery and signed the consent forms. This visit helped the anaesthetist to make a full assessment of her needs and it also helped reduce Mrs. Willow’s anxiety (Rodgers 2000). Dean and Fawcett (2002) explain that fasting before surgery is necessary to prevent aspiration of stomach content which can be potentially fatal, however, there is debate on the length of time a patient needs to be starved and according to Bateman and Whittingham (1982) since the actual time it takes food to pass through the stomach is variable as the stomach is never truly empty (cited by Woodhouse, 2006). In the case of Mrs. Willow, the nursing care preparation prior to surgery, in this aspect, was to keep her nil by mouth from midnight prior to the surgery the next day morning. 5.2. Post-operative Nursing Interventions: Mrs. Willow’s fracture was repaired and she returned to the ward following her recovery, she was drowsy but able to communicate. The nursing care in post-operative patients has a significant impact in bringing about successful outcomes. Nursing care norms require close observations during the immediate post-operative period in order to detect any potential complications promptly. One of the most important nursing interventions is the observation of temperature, pulse, respirations and blood pressure. These were monitored every half hour for the first hour, then hourly for the next four hours and then two hourly for the next 8 hours. Nursing care intervention requires these to be monitored every 4 hours, provided there were no complications. Following major surgery, a raised temperature is observed in 40% of patients, according to Davidson et al (1999), this is a normal response in the first 24 hours following surgical trauma. Another area of concern was to ensure that Mrs. Willow’s blood pressure was monitored and adequately controlled to prevent reactionary haemorrhage at the wound site. Additional nursing care interventions for Mrs. Williams included checking of the wound site, as hypovolaemic shock can occur due to a slowly bleeding vessel, this loss of fluid can be detected on the wound dressing. (Wilson and Basket 1992). Dressings were checked on each shift and changed every other day or as needed. Initially, post-operative pain control is the responsibility of the anaesthetist. Mrs. Willow returned to the ward with a patient-controlled analgesia pump (PCA), this allowed her to administer small boluses of morphine. The PCA is a special infusion pump that is set to give a specific volume of solution when the patient presses a hand-held button. The pump is programmed to administer the bolus after a certain length of time has lapsed with a maximum number of boluses over a timer period. However it is nursing intervention that is responsible for assessing, delivering and monitoring the effectiveness of the pain management. For assessing pain the numerical rating scale (NRS) was handy and used on Mrs. Williams during the post-operative period of acute pain. Mrs. Williams was instructed on how to use the PCA and she understood the instructions well, which enabled the PCA to become an effective means to assist in reducing the pain. Assessment of Mrs. Williams’ pain levels enabled discontinuation of the PCA after 24 hrs, subsequent to which she was prescribed oral pain medications that included Paracetamol 1gm and Ibuprofen 400mg every 4 hours as well as Oromorph 10-20mg as needed. The medication was explained to Mrs. Williams and her compliance assisted through monitoring. In order for successful treatment, a good relationship between patient and nurse is important to instil that trust and confidence. This not only reassures the patient but can also have a placebo effect that complements analgesia. (Santy and Mackintosh 2002). Good communication levels were maintained with Mrs. Williams. This enabled locating other possible reasons for pain like position, deep vein thrombosis or pulmonary embolism, wound site, urinary retention and take measures to remove or reduce their impact. (Alexander, et al. 2000). There were factors that affected the administration of analgesics to Mrs. William, which is commonly encountered in the nursing intervention to manage pain and treatment requirements. In the study by Santy and Mackintosh (2002) they highlight several factors that influence a nurse’s decision to administer pain medication. Some of these factors included time, organisation of care and influence of shift worked, impact of the multidisciplinary team (MDT), concerns of the use of opioid analgesia and in giving and collecting information. In some of the case studies there was the impression that pressure of work meant not enough time was given to write care plans or spending time with patients, thus making evaluation of analgesia more difficult. Frequently administration of analgesia seems to be controlled by drug rounds and ward routines, rather than the needs of the patient. Shifts also influence the administration with morning and evening shifts being discharge oriented compared to safety oriented at night. (Santy and Mackintosh (2002). To reduce the impact of these factors on the pain management of Mrs. Williams, several measures were initiated. She was repeatedly asked if the medication being provided was effective and her response noted and heeded. In addition her pain levels were assessed by the means of the NRS to provide a better understanding of the effect of the pain medication being given to her. All this information was made available to the multi-disciplinary team responsible for her care. To improve the nursing effort of her care, the administration of the analgesic medicines was separated from the routine drug round, making pain management truly a part of the individualised nursing care provided to her. (Santy and Mackintosh (2002). 5.3. Health Promotion as Part of Nursing Intervention in the Discharge of a Patient. Different people use the term health promotion to mean different things. For instance, the use of the term by the government when they apply it to screening clinics in primary health care is very different from the holistic and political perception of the World Health Organization: “health promotion has come to represent a unifying concept for those who recognize the need for change in the ways and conditions of living in order to promote health. Health promotion represents a mediating strategy between people and their environments, synthesizing personal choice and social responsibility in health to create a healthier future” Accordingly there are three overlapping spheres to of activity: health education, health protection and prevention. These different approaches relate to each other in an overall process termed health promotion. (WHO. 1984). Government policy makes it clear that timely discharges are an important element to a patients’ hospital experience (DoH, 2004). Planning for discharge from hospital begins on admission and in order to help Mrs. Willow return home, discharge plans were made in such a manner as to ensure a smooth transition from hospital to home for continued patient care, ensuring that proper assessment by the multi-disciplinary team was incorporated, as well as all their recommendations. The importance of involving Mr. Williams in these discharge instructions were give due weight and he was present at the time of this information being given to Mrs. Williams. Effective multidisciplinary working ensured Mrs. Willow with an excellent chance of recovery and a good quality of life. To ensure that such an injury does not occur again the ways and means to avoid a repetition were given to Mrs. Williams. Falls are by far the most common type of accident in people of 65 yrs of age. The National Institute for Clinical Excellence (NICE) guidelines on falls (NICE, 2004) calls for person-centred care, where patients and carers are involved in decision making about falls prevention strategies. These guidelines are relevant to those older people who have fallen or are at risk of falling, family and carers of older people, healthcare professionals who share in care for those who are vulnerable to or at risk of falling and those responsible for service delivery. `These guidelines are supported by the NSF for Older People (Doh, 2001). In keeping with these guidelines, a practice nurse contacted Mrs. Willows from her surgery unit, who specialised in elderly care. In addition she was invited to attend a Falls Prevention Day at a local community centre. Mrs. Willow was discharged home after being in hospital for 10 days. Her hip was now pain-free and she was mobilising without too much difficulty. Mrs. Willow took a great deal of credit for managing her own pain. The nursing staff, by listening and taking time with Mrs. Willow, enabled this empowerment. She was given a follow-up appointment at the fracture clinic and she felt comfortable in the instructions she was given by the nursing staff and other members of the healthcare team. Her recovery is ongoing and she has the support and encouragement of family to help her return to her normal routines. 6. Conclusion: The medical intervention strategy in the case of Mrs. Williams led to a successful outcome. The contribution of the nursing intervention was a key factor that led to this good experience of Mrs. Williams. She left the hospital with the minimal of disabilities and in a happy frame of mind with enough information on how to avoid such incidents again, and in the shortest period of time, owing to the efforts of the multi-disciplinary team that looked after her and by no mean measure to the nursing care provided. The nursing care took into consideration all the nursing theories and pain management theories, information and evidence that was available to it in the care of Mrs. Williams. This was a key factor to the successful outcome in the medical intervention for the injuries that Mrs. Williams sustained due to the fall. The nursing care was not limited to the time that Mrs. Williams spent at the hospital, but extended even beyond that. Instruction on proper total rehabilitation means to attain the physical capabilities so that she was self-reliant were provided to her. In addition Mrs Williams was also provided with information on the ways and means of avoiding a repetition of such an incident, as she went about her daily activities. All in all the nursing intervention took into account all aspects in the care of the patient that acme for assistance. There are hindrances to the nurses providing the required nursing care of their patients. The administrative authorities of the healthcare provider needs to take a look at these hindrances by holding discussions with the nursing team and other members of the multi-disciplinary team to arrive at the means to avoid these limitations that affect the efficiency of the nursing care efforts of the nursing team. Literary References References Alexander, M., Fawcett, J.N., Runciman, P.J. (2000) Nursing Practice Hospital & Home, in Duke, S (eds) Pain, London, Churchill Livingstone Alexander, M., Fawcett, J.N., Runciman, P.J,(2000) Nursing Practice Hospital & Home, in Jamieson, L., McFarlane, C.M., Brown, J. (eds) The Musculoskeletal System, London, Churchill Livingstone Alexander, M., Fawcett, J.N., Runciman, P.J. (2000) Nursing Practice Hospital & Home, in Rodgers, S. E (ed) The Patient Facing Surgery, London, Churchill Livingstone Collins, T (1999), ‘Fractured Neck of Femur’ Nursing Standard 13(23), 53-57 Cooper, J. G., Haetzman, M., Stickler, B.R. (on-line), January, 2006, ‘Effective Post-Operative Analgesia.’ http://www.rcsed.ac.uk. 10 August 2006 Davidson, B., Rakesh, Rai.(1999) ‘Postoperative care of surgical patients.’ Student British Medical Journal (on-line). http://www.studentbmj.com/back_issues/0499/data/0499ed3.htm. 03 January 2006 Department of Health (2004) Change Agent Team: Planning for Discharge. London: The Stationery Office Department of Health (2004) National Service Framework for Older People. London: The Stationery Office Fuller, G. (2000), ‘Falls in the Elderly’, American Family Physician 61(7) 2159-68 Kelly, A., Dowling, M (2004), ‘Reducing the Likelihood of Falls in Older People’, Nursing Standard 18(49) 33-40 McRae, R. (1989) Practical Fracture Treatment, 2e London: Churchill Livingstone National Institute for Clinical Excellence (2004) The Assessment and Prevention of Falls in Older People. London: NICE Nursing and Midwifery Council (2004) Code of Professional Conduct, NMC, London Russell, G(1999) Essential Psychology, London: Routledge Santy, J., Mackintosh, C., ‘A Phenomenological Study of Pain Following Fractured Shaft of Femur.’ Journal of Clinical Nursing 10(4) 521-527 (on-line) Gateway@OVID (12 January 2006) Wilson, I.H., and Basket, P.J.F.,(on-line), (1992) ‘The Diagnosis and Treatment of Haemorrhagic Shock.’ http://www.nda.ox.ac.uk. 06 July 2006 Woodhouse, A (2006) Pre-operative fasting for the elective surgical patient. Nursing Standard 20(21) 41-48 World Health Organisation, Ottawa Charter for Health Promotion. Copenhagen: World Health Organisation, 1984. Read More