Administering Appropriate Care to Patients - Case Study Example

Case Analysis Student’s Name Institutional Affiliation Introduction According to Kirschner, Smith and Donnelley (1994), Troy was involved in a road accident and as such, sustained severe injury of the abdomen and the spinal cord. He underwent insertion of the tracheostomy after two weeks. Thereafter, he was transferred to a rehabilitation unit. He got weaned from ventilators, but the status of his pulmonary remained fragile. Also, he had a cough that needed frequent assistance as well as suctioning for management of secretions. Anesthetic and the closure of the ileostomy had to be conducted after an improvement in the respiratory function as has been stated in Turley (2013). However, Troy exhibited violent tendencies and reluctance to receive medical attention. He was emotionally fragile and opposed care from staff allowing only his two favorite staff to attend to him. In addition, he demanded to smoke despite his fragile respiratory status. Improved clearance of secretions made it possible for the tracheostomy to be removed. This led to placement of a button in the last stage of completing decannulation. After evaluation by the resident on call regarding the button, it was established that there was an increase in the respiratory rate and mild traces of hypoxemia in his blood gas (Barnett, 2006). In addition, he had difficulties in the management of his secretions in spite of oral suctioning and coughing assistance. This required immediate replacement of the tracheostomy tube although he was adamant about this procedure. This paper aims at conducting an analysis on the selected patient scenario with a description of evidence that the patient has received appropriate care. In addition, the paper will identify areas where the safety or well being of the patient may have been compromised or where policy, guidelines and professional standards were breached. Thereafter, the paper will provide a discussion on the recommendations for optimal care of the patient. An Analysis of the Scenario and Evidence of Appropriate Care Tracheostomy refers to a surgical opening in the wall of the neck made at third or second cartilaginous ring and kept open with the use of a tracheostomy tube (Woodrow, 2002). The upper airway is bypassed by the tracheostomy preventing humidification, warming and filtration of air. In Intensive Care Society (2008), tracheostomy is used in several situations such as; in maintenance of an airway where normal mechanisms have been permanently compromised by obstruction of the upper airway, facilitation of support in the long term respiration as a result of failure resulting from mechanical ventilation, clearance of secretions from poor cough, emergency procedure for the neck and head trauma and to minimize airway aspiration risk that results from swallowing ambiguity or reflex absence. Therefore, nurses are required to deliver appropriate care in a safe and effective management of residents (Suiter and Leder, 2007). This may entail the removal and cleaning of the tube without a disturbance of the site in cases of blockage of the inner tube (Barnett, 2005). Staff taking care of the patients needs to know why the tracheostomy was inserted. Also, they need to know the size and type of the tube as has been pointed out by Russell (2005). This information should be clearly documented and made readily available in the nursing notes and care plan. Ward (2007), states that important aspects to look out for in caring for patients with tracheostomy includes maintenance of patient safety, provision of care based on evidence, facilitation of effective communication and prevention of tracheostomy related complications. In addition, individuals discharged to nursing care homes are in need of full assistance to manage and care for their daily needs and tubes (Feber, 2006). Nursing care staffs are required to demonstrate understanding, empathy and psychological support to help patients accept their conditions and body images that have been altered. This may also need the help of dieticians, language and speech therapists and physiotherapists. However, complications can develop as a result of accidental displacement or obstruction (Intensive Care Society, 2008). Settings in nursing homes need to have procedures for management of such events in place and the staff caring for patients with tracheostomy should know the right procedures, in addition to receiving proper training. According to Barnett (2005), other complications that may develop include tracheal secretions, infection of the stoma site and bleeding as a result of trauma from suction or change of tubes. Staffs need to know the procedure of resuscitation of tracheostomy patients and equipment to be used that must be available at all times. Evidence of appropriate care in Troy’s case included the insertion of a tracheotomy to aid in mechanical ventilation (Donnelly and Wiechula, 2006). Also, transferring him to a rehabilitation unit ensured proper recovery. In addition, educating him regarding his medical care helped in taking care of himself in situations such as engaging in different motions, caring for the bowel and bladder, moving from the bed into the wheelchair and how to self administer medication. Additionally, when the patient got frightened, emotionally fragile, depressed and anxious, refusing to have staff attend to him, the staff understood what he was going through as it was a normal feeling for patients in that state (Barnett, 2005). This understanding allowed him to have his two favorite staff attend to him. Appropriate care of the patient requires allowing them to make decisions regarding medical attention. In National Health and Medical Research Council (2011), patients make the best decision regarding their health, and they expect their carers to respect these decisions. This may also include refusal to have additional treatment. However, justice has to be applied regarding putting into consideration the needs of concerned parties such as nursing staff, family members and other parties involved in caring for the patient (Feber, 2006). Carers and patients can discuss death inevitability and decisions to withdraw burdensome treatments and any disagreements are acknowledged and discussed cooperatively. Areas Where Safety of the Patient was Compromised Despite the evidence that the nurses took good care of Troy, they also erred in breaching policy, guidelines or professional standards thereby compromising safety of the patient. This is evident where the skin around Troy’s stoma was in most circumstances excoriated as a result of spill from faecal fluid in cases when emptying of the appliance was done late. In addition, his nutrition had been neglected leading to the inability to adequately control pulmonary toilet. In this case nurses were required to manage the nutritional status of the patient as a way of containing the stoma as pointed out by Dennis-Rouse and Davidson (2008). Adequate nutrition is important in tracheostomy patients as it aids in the healing process (Brown, 2009) and helps in combating infection. The tube used in tracheostomy alters normal swallowing mechanisms and an inflated cuff may impair swallowing ability because the oesophagus is compressed (Phillips, 2005). Therefore, patients should avoid oral feeding and use the recommended tube feeding. To add on, inasmuch as Troy was educated about his body, he was not provided with adequate education and this in a way was a breach of his safety. In Brown (2009), the patient is required to take responsibility in monitoring himself and reporting any concerns or issues. The educative lessons need to include lessons on the care of inner cannula, care of the stoma, change of the Velcro tape, covering of the stoma, how to dress it and administration of normal saline (Cameron, 2006). Also, Troy should not have been allowed to smoke in his state as it interfered with his recovery process. Failure to prevent him from smoking breached his safety. In addition, he was weaned from the ventilator too soon. His pulmonary was still fragile and he had an ineffective cough requiring frequent assistance as well as suctioning in the management of secretions. This led to further complications needing a replacement of the tracheostomy tube. On the other hand, when Troy started developing respiratory distress, an evaluation was done that indicating an increase in the respiratory rate and traces of mild hypoxemia in his blood gas. This was a sign of danger requiring immediate replacement of tracheostomy tube (Nursing and Midwifery Board of Australia, 2008). However, he was adamant about having this procedure. Nurses were required to apply the several nursing models that provide for an orderly analysis approach to be used in ethical disagreements and offer an approach in implementation of ethical decisions in the care of patients. Johnstone (2004), provides that the process of making moral decisions entail a critical reflection on the assessment of the situation, identifying and diagnosing moral problems, appropriate planning measures of addressing identified problems, implementation of the planned action and evaluation of moral outcomes of the actions can be useful in clarification of the nature of the problems and ways of solving them. Advance Care Directives provide ways through which people can plan ahead of their situations (Australian Health Ministers’ Advisory Council, 2011). Inasmuch as Advance Care Directives are written by patients in providing medical direction regarding decisions made at the end of life, they can be used as documents for the management of life in communities, homes, institutions and hospitals. Nursing and Midwifery Board of Australia (2008), points out that when Advanced Care Directives are completed, the aim is not to control decisions on medical treatment but living well and dying with dignity and according to personal values. Conclusion In the case of Troy, the skin around the stone was in most circumstances excoriated as a result of spill from faecal fluid in cases when emptying of the appliance was done late. His nutrition was neglected, he was not provided with adequate education on how to take care of himself, he was allowed to smoke, and he was weaned from the ventilator too soon. Nurses should take the necessary steps in administering appropriate care to patients. In addition, staff caring for patients with tracheostomy should receive proper training on what needs to be done, and they should know the right procedures to be followed. However, complications may develop in the process of taking care of patients. The complications may include tracheal secretions, infection of the stoma site and bleeding as a result of trauma from suction or change of tubes. Evidence of appropriate care in Troy’s case included the insertion of a tracheotomy to aid in mechanical ventilation. However, there are situations where they may breach policy, guidelines, or professional standards. When this happens, the care to be administered to the patient is compromised. Recommendations The skin around Troy’s stoma was in most circumstances excoriated as a result of the spill from faecal fluid in cases when emptying of the appliance was done late. Health care providers are required to closely monitor patients to prevent any delays that would lead to complications compromising the safety of patients. There is the need of frequent ward rounds and monitoring their progress towards recovery in order to detect any changes. In that case, nurses also had the option of applying adhesion to the stoma to prevent further excoriation of the skin and containment of the stoma. Troy’s nutrition had been neglected leading to inability to adequately control pulmonary toilet. The rehabilitation unit needs to implement measures of ensuring dietary requirements for individual patients are met. This includes the nutritional components, feeding time, manner of administering the same and the health care professionals who are responsible for feeding the patients. In practicing proper nutrition, patients should avoid oral feeding and use the recommended tube feeding. Also, patients are required to be in a sitting or upright position during feeding. The patient was not provided with adequate education on how to take care of himself and this in a way breached his safety. The rehabilitation unit should prepare adequate information for the education of patients and ensure all patients admitted in the unit are provided with adequate information regarding their individual conditions. Education provided needs to entail the dos and don’ts to keep them informed and what is expected from them whether healthcare workers are around or not. In addition, Troy was weaned from the ventilator too soon. This is an indication that adequate tests were not conducted to establish whether he was really prepared for the same. Health care units should ensure health care professionals handling patients are highly qualified and follow the laid down procedures for taking care of patients. References Australian Health Ministers’ Advisory Council. (2011). A national framework for advance care directives. A Working Group of the Clinical, Technical and Ethical Principal Committee of the Australian Health Ministers’ Advisory Council Barnett, M. (2006). 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British Journal of Nursing, 14(8), 428-33 Suiter, D. M., and Leder, S. B. (2007). Contribution of tracheotomy tubes and one-way Speaking valves to swallowing success. Topics in Geriatric Rehabilitation, 23(4), 341–351. Turley, S. (2013). A challenging case study: Small bowel transplantation with a unique twist. Gastrointestinal Nursing, 11 (1), 24- 31 Ward, E. et al. (2007). Clinical consistency in tracheostomy management. Journal of Medical Speech Language Pathology, 15 (1), 7-26. Woodrow, P. (2002). Managing patients with a tracheostomy in acute care. Nursing Standards 16 (44), 39-46 Read More