Hip Replacement Surgery of an 80-Year-Old Lady - Essay Example

Abstract I will discuss in the following paper, how I was involved in caring for an 80-year-old lady. Using a case study, I will detail this elderly lady’s patient history, the surgery she underwent, her current medication and side effects and preoperative and postoperative monitoring. In addition to the case study, I will describe the operation she underwent and the associated postoperative effects. Highlighting the multidisciplinary team involved in her care and the policies under which this care was provided. I will also concentrate on my role as a professional nurse and my contribution to this elderly lady’s preoperative and postoperative care. I will also explain the specific guidelines and codes of conduct used when dealing and communicating with this patient. I will attempt to demonstrate my nursing model using the Roper-Logan Tierney ADL nursing model. How from the time of admission to discharge, from a professional standpoint, I provided a vital contribution to the patient’s care while being part of her healthcare team. Case Study Of An 80-year-old Lady - Admitted for Hip Replacement Surgery This lady is an 80-year-old diabetic who was admitted to the hospital for hip replacement surgery. During time of admittance she was noticed to have hypertension. She was admitted on 15/1/2007 at 08.00 AM, was taken to the operation theatre at 10.00 AM and brought back to the ward at 13.030 PM. Upon admittance, I showed the patient to her bed, asked preoperative OBS questions and prepared her for the operation theatre. Postoperatively, as per NMC guidelines I monitored and recorded the patient’s organic brain syndrome (OBS), bowel movements (BM), input and output, and provided her with anti-embolic stockings. Currently, she is on medication for diabetes and hypertension, consisting of Insulin for diabetes and Doxazon for hypertension. Insulin in used to treat Type 1 and Type 2 diabetes mellitus and is usually administered through a subcutaneous injection or a pump. Insulin works to increase glycogen synthesis thereby lowering blood glucose levels. The most common side effect of insulin is hypoglycaemia in rare cases insulin triggers allergic skin reactions. Doxazon falls into the class of alpha-blockers and is used to treat elevated blood pressure. Doxazon decreases blood pressure by blocking norepinephrine from constricting the muscles of small arteries and veins, which results in improved blood flow. Side effects of Doxazon include sudden drop in blood pressure, which can cause dizziness and fainting. Other side effects can include pounding heartbeat, fatigue, nausea and weakness. In very rare cases it can cause a drop in white cell counts. Hip Replacement – Postoperative Care Hip replacement is a surgery, by which a diseased or worn out hip joint is replaced with artificial parts. Hip replacement surgery is usually carried out to improve function of the joint, relieve pain and increase mobility. Elderly patients who undergo hip replacement require special care as they face postoperative issues such organic brain syndrome, embolism, dehydration and pain. Since this patient was on medication for high blood pressure and diabetes, she also had to be monitored for signs of hypotension and hypoglycaemia. People who undergo hip replacement surgeries have to be monitored and care should be provided for several days after surgery. This includes draining fluid from the hip via a drain, frequent changing of position in the bed to prevent formation of bed sores and fluid in lungs, and placing an anti-embolic stocking to prevent blood clots. In addition to this several precautions have to be taken to ensure that the wound does not get infected and the hip does not get dislocated. Multidisciplinary Healthcare Professionals and Policies “In reality, differences between professional roles are small leading to the potential for shared role boundaries” (Hope 2004). A number of multidisciplinary healthcare professionals are involved in the care of this elderly lady. These professionals include doctors, physiotherapists, occupational therapists, dieticians, district and community nurses, Chiropodists, tissue viability nurses and pharmacists. Doctors were involved in diagnosing the patient and performing the surgery. A physiotherapist helped the patient before and after the operation by assessing her range of motion and prescribing a set of exercises which could be completed in bed, at home or on stairs. “A systematic review on the efficacy of occupational therapy for community-dwelling elderly, showed strong evidence for the efficacy of occupational therapy on functional ability and some evidence for decreasing incidence of falls” (Steultjens et al. 2004). Occupational therapists are involved in getting the patient to perform everyday tasks after surgery. In this case the therapist demonstrated to the patient how to complete a toilet transfer while adhering to proper hip precautions. This is essential as the patient has to learn how to use the new prosthesis in the proper manner to minimize future complications. A dietician instructed the patient on how to maintain a proper diet of three meals a day, limit the intake of empty calories as this would lead to weight gain, and lessen the intake of Vitamin K rich foods. “Nurses are mobile and can provide care and comfort needs that fall within the province of independent nursing diagnosis and treatment” (Barry 1996). District and community nurses are usually attached to GP offices. In this case, they provided this patient with nursing services at home after her surgery and discharge. A Chiropodist was also part of this team and helped the patient with issues regarding her foot. “While there has been a large amount of published literature regarding the treatment and prevention of pressure ulcers, very few studies have attempted to provide clear clinical guidelines” (Lewis, Pearson& Ward 2003). The tissue viability service is usually provided by nurses who have extensive knowledge in caring for acute and chronic wounds. A tissue viability nurse was an integral part of this team and helped take care of the patient’s wound. The pharmacist provided prescribed medications for the patient, followed the patient’s progress and reviewed the medication. These are the professionals involved in the care of this patient, only few of their many jobs are detailed in the above paragraph. Government and NMC Policy “Policies help to standardize patient care, which is another principle aim of evidence based practice”(Guvatt, Rennie & Haywood 2003). “Many lessons have been learned from this case and greater attention has been paid to ensuring that care services are more rigorously monitored, clinical governance frameworks act to prevent and monitor abuse, leadership is strengthened and that more carefully regulated standards of care are in place” (Department of Health 2005). The healthcare professionals mentioned above work under the rules and regulations set forth by the Department of Health. The Department of Health is a government organization and has many polices and guidelines which govern the treatment of the elderly in hospitals and their continuing care after discharge. The NMC is an organization set up by the parliament of the United Kingdom. Nurses operate under Nursing and Midwifery Council (NMC) guidelines, which include standards for conduct, ethics and performance. My Role in Caring For This Patient “Physically and emotionally vulnerable, the patients rely heavily on the nurses' ability to compliment the technical components of their role with the caring aspects” (McNamara 1995). As a professional nurse, I was involved in the care of this patient from admission to discharge. Providing a “. . . emotive, intimate, interpersonal relationship' that values the individuality of each patient” (Stein-Parbury 2000) was a priority. I collaborated with this patient and recognised her contribution in maintaining her overall health and well being. While doing so I also took in account the fact that I had to conform to Nursing and Midwifery Council (NMC) guidelines. I used these guidelines when recording the patient’s OBS, BM, input and output. I also used these guidelines when maintaining treatment records and the effectiveness of treatment. I also used the NCM code of conduct when dealing with this patient. When obtaining informed consent I respected the patient’s views and rights to accept or reject treatment. I treated this elderly lady as an individual, respected her dignity and considered her specific needs in detail. I respected her right to confidentially and informed her under what circumstances confidential information would be shared by caregivers. “When carefully implemented and consistently evaluated, evidence based practice achieves the most desired of all outcomes in health care, that is, cost-effective quality care” (Zeitz & McCutcheon 2003). I tried to adopt a proactive and modern approach to her treatment keeping latest nursing practices in mind. Keeping the above mentioned factors in mind, I proceeded to aid the patient during her stay in the hospital. Starting from the time she was admitted, I showed her to her bed and made her comfortable. “In elderly medical patients, five independent precipitating factors have been found to predict the development of delirium: immobility, malnutrition, more than three medications added, use of bladder catheter and any iatrogenic event during hospitalization” (Inouye & Charpentier1996). I then went ahead and completed a preoperative check list, asked her questions to determine her OBS, escorted her to the operation theatre and then prepared her bed for her return to the ward. Postoperatively, the patient was brought back to the ward, at that point of time she was being administered oxygen and IV dextrose drips. Oxygen and IV dextrose drips are normally administered after operations and I continued administering them as prescribed. I then checked the surgical wound for bleeding, charted and observed drainage from the wound, checked the patient periodically until she was stable, assessed her pain and need for analgesics and gave her prescribed medications. Among various other things I also applied an anti-embolic stocking and gave the patient food and liquids as per her diet. I made sure she was not suffering from dehydration and hypotension. I paid special attention to the patient’s sensations of pain and listened to her complaints, I then made sure that they were resolved in an appropriate manner. I also recorded the patient’s OBS again by asking several questions. One day postoperative, in addition to routinely checking her blood pressure, wound, checking her chest and shifting her position in her bed etc. I also assisted the patient in her personal hygiene needs, including helping her to a commode or bed pan. Over the next few days, I encouraged the patient to walk till the toilet with ambulatory aids and assisted her while she sat on a char. In addition to observing and helping treat the patient, I also helped her with day to day activities such as dressing. I also made sure the patient had seen the physiotherapist and liaised with him and ensured that the patient had been doing her exercises and was recovering as per plan. Nearing her discharge date, I completed her discharge plan and gave her written advice to be followed after discharge. I also explained the discharge advice to her and made sure that she understood it. “Continuing problems are reported with the transfer of information and communication between acute and community care, suggesting that seamless discharge appears to remain problematic” (McKenna et al. 2000). Keeping this in mind I discussed future hip precautions and I also organised a district nurse to check on the patient. “A multidisciplinary approach to the provision services for patients following discharge is now viewed as a best practice” (Department of Health 2003). Fully aware of the fact that I was only one part of the care pathway which was treated this patient and current government suggestions, I spoke to the patient about this. I also discussed the fact that she might need additional care provided by multidisciplinary professionals after discharge from hospital, and I enquired if she knew how to obtain it. I also explained what additional social care could be provided to her and what she was entitled to receive given present government regulations. Roper-Logan Tierney Nursing Model “It is an indisputable fact that people who are in need of the nursing part of the health service, for whatever reason and wherever they are located, have to go on ‘living’; therefore our model of nursing is underpinned by the model of living” (Roper, Logan & Tierney 2000). I will attempt to demonstrate my nursing model using Roper-Logan Tierney ADL model of nursing. The Roper-Logan Tierney model was originally published in 1980 and subsequently revised. It is based upon the five components, namely activities of daily living (ADLs), lifespan, dependence/independence continuum, factors influencing ADLs and individuality in living. This popular model of nursing has the same components as the model of living. In fact the model of nursing is based on the model of living. “Individualising nursing is accomplished by application to practice of the concept of the process of nursing comprising four phases” (Roper, Logan & Tierney 2000). The Roper-Logan Tierney model of nursing assists the nurse by helping with the four stages of the nursing process namely assessing, planning, implementing and evaluating. Aiming to individualize nursing and hence cater to the needs of the individual. 1) Assessing includes collecting information about the patient, reviewing it, identifying the patient’s problems and prioritizing them. 2) Planning refers to solving actual problems, preventing identified problems from becoming real ones, alleviating problems which cannot be solved, helping the patient to cope with problems in a positive manner and administering palliative care in cases where death is inevitable. 3) Implementing among other things involves listening, talking, observing and helping. 4) The evaluating stage includes observing, questioning, examining and measuring. “However even more importantly, the person who comes in contact with the nursing service is central to the model, and the nursing required can be tailored to the individual’s circumstances and not imposed by the nurses” (Roper, Logan & Tierney 2000). I used the Roper-Logan Tierney nursing model to care for this elderly lady by paying attention to her needs all the while listening, watching and learning about the patient. Understanding this patient’s needs was paramount as I knew that only once I had understood her needs would I be able to address them in a proper fashion. I started paying attention to this patient’s specific needs when she was admitted to the hospital for hip replacement surgery. I was able to further understand her needs when questioning her for OBS. During the preoperative and postoperative period I further used the Roper-Logan Tierney nursing model to cater to the medical needs of this patient. I understood that as an individual she had unique needs and that as an elderly individual these needs would be complicated by her age. I paid specific attention to the OBS “Also, subsyndromal delirium has been linked to poorer hospital outcomes such as longer acute hospital care and increased post discharge mortality” (Cole et al. 2003) as I knew that in her case delirium would significantly impact her recovery from the surgical procedure. “Nurses should take the lead in developing interventions to increase detection of delirium and in developing and promoting non-pharmacological approaches for the prevention and management of delirium” (Irving, Fick & Foreman 2006). In addition I concentrated on the fact that she had diabetes and hypertension which could complicate her recovery. I took this into consideration and made sure that her blood sugar and blood pressure levels were within normal. In cases where I could not answer the patient’s questions or fulfil her medical needs in a proper manner, I immediately notified the attending physician. Knowing that my understanding of the surgical procedure and its implications would directly effect the quality of care I was able to provide, I familiarised myself with the procedure. I then applied this knowledge when speaking to the patient, explaining the surgical procedure and obtaining her consent for it. I also impressed upon the patient that her assistance was needed to ensure that she recovered well from the operation. All the while I understood my place with regard to the patient understanding that I was in a “Profession whose focus is to help the client to prevent, solve, alleviate or cope with problems associated with the activities he or she carries out in order to live” (Roper, Logan & Tierney 1990). How I Worked As Part of a Team I worked as part of a multidisciplinary team to ensure that when the patient left the hospital she would be at “The optimum level of independence in each activity of living which enables the individual to function at his/her maximum potential” (Roper, Logan & Tierney 1990). Knowing my place in the care pathway, recognising my role and responsibilities and performing them to the optimum level were my contribution to this team. Realizing that I would serve the patient best by being part of a multidisciplinary team I worked hard to keep in touch with the various members of the team. I liaised with other team members ranging from the doctor, physiotherapist, occupational therapist, dietician, district and community nurse and pharmacist to make sure that this patient received the best possible care we could provide. “Effective discharge planning is a vital link in the continuity of care for older people” (Bull & Roberts 2001). Giving due importance to my role and recognising the value I could add to the overall health of this patient, I planned the patient’s discharge with care and made sure that all aspects of discharge protocol were adhered to. Quite aware that my discharge plan and the patient’s adherence to it would determine her health in future, I made sure the patient and her caregiver were fully briefed about it. I also set up appropriate appointments with her community nurse, so that the patient’s health would be monitored once she left the hospital. I strongly felt that it is my ethical and moral responsibility to provide the patient with all the care and information needed, so as to allow the patient to care for herself up to a certain extent. Taking into consideration that this elderly patient would be increasingly vulnerable after discharge, I felt necessary to provide the maximum level of personal and professional assistance to the patient so that she would understand the hip precautions she had to maintain and how she could avoid falls and dislocation of her hip. Adhering to current NCM guidelines, the Roper-Logan Tierney Nursing Model and government rules and regulations and using an individualised nursing method I feel that a nurse can provide patients with levels of care which are both effective and superlative. Ultimately, I am of the opinion that a nurse’s performance depends on his or her own ability to learn on the job, use modern methods of nursing and constantly adapt to each patient’s requirements. References 1. Hope, R. 2004, The Ten Essential Shared Capabilities. : Sainsbury Centre for Mental Health/National Institute for Mental Health. 2. Steultjens, E. M. J., Dekker, J., Bouter, L. M., Jellema, S., Bakker, E. B. & Van den Ende, C. H. M. 2004, Occupational therapy for community dwelling elderly people: a systematic review. Age and Ageing. 3. Barry P. Nursing diagnosis and care planning. In: Barry P (ed.) 1996, Psychosocial Nursing: Care of Physically Ill Patients and their Families. : Lippincott. 4. Lewis, Pearson & Ward 2003, Pressure ulcer prevention and treatment: transforming research findings into consensus based clinical guidelines International Journal of Nursing Practice 9 (2), 92–102. doi:10.1046/j.1322-7114.2002.00405.x. 5. Guvatt G, Rennie D, Haywood R. 2003, Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. American Association Press. 6. Department of Health 2005, No Secrets: Guidance on Developing and Implementing Multi-Agency Policies and Procedures to Protect Vulnerable Adults from Abuse. Department of Health. 7. McNamara SA. 1995, Perioperative nurses' perceptions of caring practices. AORN Journal. 8. Stein-Parbury J. 2000, Patient and Person: Developing Interpersonal Skills in Nursing, 2nd edn. : Harcourt. 9. Zeitz K, McCutcheon H. 2003, Evidence-based practice: To be or not to be, this is the question! International Journal of Nursing Practice. 10. Inouye S. & Charpentier P. 1996, Precipitating factors for delirium in hospitalised elderly medical persons: a predictive model and interrelationship with baseline vulnerability. Journal of the American Medical Association. 11. McKenna H., Keeney S., Glenn A. & Gordon P. 2000, Discharge planning: an exploratory study. Journal of Clinical Nursing. 12. Department of Health 2003, Discharge from Hospital: Pathway, Process and Practice. Department of Health. 13. Roper, Logan, W., Tierney J. 2000, The Roper-Logan-Tierney model of nursing. Elsevier Health Sciences. 14. Roper, Logan, W., Tierney J. 2000, The Roper-Logan-Tierney model of nursing. Elsevier Health Sciences. 15. Roper, Logan, W., Tierney J. 2000, The Roper-Logan-Tierney model of nursing. Elsevier Health Sciences. 16. Cole M., McCusker J., Dendukuri N. & Han L. 2003, The prognostic significance of subsyndromal delirium in elderly medical inpatients. Journal of the American Geriatrics Society. 17. Irving, Fick, Foreman 2006, Delirium: a new appraisal of an old problem International Journal of Older People Nursing 1 (2), 106–112. doi:10.1111/j.1748-3743.2006.00017.x. 18. Roper, Logan, W., Tierney J. 1990, The Elements of Nursing. 19. Roper, Logan, W., Tierney J. 1990, The Elements of Nursing. 20. Bull M.J. & Roberts J. 2001, Components of a proper hospital discharge for elders. Journal of Advanced Nursing. Read More