Depict the care received by apatient during his recent stay in hospital.
The aim of this study is to depict the care received by a patient during his recent stay in hospital. In accordance with the NMC Code of professional conduct (2002) "to respect patients' autonomy, and treat information about patients as confidential" names have been changed and the patient will be referred to as "Kit". The study will look at pre and post operative care, evaluation of the nursing model used, cultural issues, multi disciplinary team roles, health promotion and services available. Kit consented fully to being the subject of my study knowing his anonymity would be maintained.
PATIENT BACKGROUND
Kit aged 54 lives locally with his wife and teenage children. Until 2 years ago Kit was a self-employed builder. Mobility problems and restrictions imposed by his present condition, together with long periods of absence have forced him to leave his occupation. Kit is diagnosed as having osteoarthritis of the hip. "Oesteoarthritis is a wear and tear arthritis that affects weight bearing and highly stressed joints such as the hip and knee". (Palmer 1999).
Prior to the onset of osteoarthritis Kit had enjoyed good health, was physically fit and active, he had minor eye surgery 7 years ago, and his appendix removed at 19. Kit and his wife enjoy social dancing, mobility problems and pain have prevented this for the past 18 months, and their social life has consequently decreased. Prior to surgery Kit said he felt himself to be a "Liability, unable to work and support his family financially, unable to enjoy himself socially, he felt worthless and incompetent with little positive future for himself". The psychosocial effect upon his quality of life made him feel constantly nervous and anxious. Jackobson (2002) states " There is an increasing risk with age of being affected by osteoarthritis, and therefore pain and decreased quality of life as a result".
Creamer (1997) suggests "Depression, anxiety and fatigue are significantly related to pain". Gradually his symptoms worsened, increasing pain, decreasing mobility and constant sleep disturbance. He was prescribed Ibuprofen NSAIDS (Non Steroidal Anti-Inflammatory Drugs) and Tramadol, a centrally acting analgesic which helped relieve the pain but only partially, following X-Ray examination and several consultations Kit was advised to consider a total hip replacement.
Palmer (1999) states "Total hip replacement is an elective procedure to remove deteriorating bone and cartilage in a joint and replace the joint with an artificial component known as a prosthesis". Kit felt he needed time to consider if he should have surgery and not rush into it without exploring other options. Naidoo (2000) states it is important that "People should make their own decisions about their own health".
PRE ASSESSMENT SCREENING
After electing to undergo surgery Kit attended for pre-assessment screening. A detailed medical history was taken, together with CBC (Complete Blood Count) ECG (Electrocardiogram) and a chest X-Ray. His blood pressure and weight were measured, he was screened for MRSA (Methiclin Resistant Staphloccus aureus) as Makoni (2002) states "MRSA is now endemic in many UK hospitals".
Kit was informed he was fit for surgery and given a date for admission.
ADMISSION AND NURSING ASSESSMENT
Kit was admitted the day prior to his surgery. He was oriented to the ward and introduced to his named nurse. The principle of named nursing is that the allocated nurse should plan and evaluate all care for the named patients, ensuring the patient and his relatives have a main and consistent point of contact for information. The concept was introduced in the Patient's Charter by the British Government in 1992. "It is the responsibility of the named nurse to make herself known to the patient and work in partnership with the patient". (Department of Health)
The idea in principle is an excellent one, Kit did not really benefit however, as his named nurse was on holiday shortly after his admission. Dooley (1999) states "Continuity of care is a key issue in named nursing."
The medical history from his pre-assessment visit was checked and updated, his social history and nursing assessment were carried out. The assessment concentrated particularly on the daily activities of living as the ward care planning is based on the Roper-Logan-Tierney Model of Nursing. This model is based on a model of living and links nursing with living, Tierney (1998) suggests "Health and ill health are inextricably linked to lifestyle" and suggests that generally the need for nursing is usually only for a short period, a major aim of nursing care should be "Minimal disruption to a patient's established and normal lifestyle".
It was identified that the activities of living Kit had difficulty with were: mobilizing, eliminating (difficulty getting to the bathroom quickly enough and getting on and off the toilet), work, play and sleeping. Roper (2000) describes the specific function of nursing as "Assisting the individual to prevent, alleviate, solve or cope positively with problems related to the activities of living." This statement is particularly applicable to Kit as it identifies the exact areas of difficulty. A nutritional and moving and handling assessment completed the process and his basic care plan was formulated.
EVALUATION AND COMPARISON OF NURSING MODELS
Aggleton (1986) indicates when comparing models of nursing "All are likely to have something to say about seven aspects of patient care". Newton (1992) suggests "The Roper-Logan-Tierney model is based on ideas derived from practice and may be seen to be useful in practice for real nurses, nursing real people."
The model has attracted much criticism, Murphy et al (2000) suggest "The model concentrates on physical aspects of care rather than other areas", a view embraced by Fraser (1996) who cites "Overly physically/physiologically oriented". Mitchell (1984) implies "The overly ...
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EVALUATION AND COMPARISON OF NURSING MODELS
Aggleton (1986) indicates when comparing models of nursing "All are likely to have something to say about seven aspects of patient care". Newton (1992) suggests "The Roper-Logan-Tierney model is based on ideas derived from practice and may be seen to be useful in practice for real nurses, nursing real people."
The model has attracted much criticism, Murphy et al (2000) suggest "The model concentrates on physical aspects of care rather than other areas", a view embraced by Fraser (1996) who cites "Overly physically/physiologically oriented". Mitchell (1984) implies "The overly complicated documentation is a main concern". Further criticism is offered by Fletcher (2000) who suggests "It is not appropriate for the management of patients with wounds" When changing Kit's dressing I discovered the omission of a wound care chart as no reference had been made to this in his care planning. This I feel is a valid and appropriate criticism.
In defence of the model, Tierney (1998) suggests "It is positively balanced, and has been one of the most popular in the United Kingdom". Wimpenny (2001) agrees stating "It is certainly the best known and most widely used model in this country". Generally the model worked well as a basis for Kit's care planning. Excellent in relation to most physical aspects of care, social aspects although referred to did not seem to be as important, therefore his psychosocial needs were not properly addressed.
A more suitable model perhaps is Orem's model for nursing as the universal self-care requisites upon which the model is founded "Embrace the essential physical, psychological, social and spiritual elements of life" (Cavanagh 1991). Salvage (1990) suggests "When using Orem's model individual responsibility is valued and health education is seen as an important aspect of care". Kit has very low self esteem, needs to feel valued as an individual, and would benefit from health education.
POST OPERATIVE CARE AND POSSIBLE COMPLICATIONS
Following his surgery Kit was closely monitored, observations were taken half-hourly, and recorded together with early warning scores to identify any potentially developing problems. The early warning scoring system was introduced on the unit to identify at risk patients as early intervention "May reduce the number of cardiac arrests and intensive care admissions" (Alcock 2002). Mercer (2000) states "After major surgery hypoxia (lack of oxygen) can occur for up to for 3 days". Kit was given oxygen therapy 2L/ min to prevent this.
A closed vacuum drain was inserted, Thomas (2001) states "It is believed that the negative pressure assists with removal of interstitial fluid, decreasing localised odema and increasing blood flow". O'Brien (1997) argues "Recent studies demonstrate that wound drains offer little advantage in the outcome of primary total hip replacements". Alexander (2000) states "The femoral bone tissue has an excellent blood supply blood drainage may in some cases therefore be excessive compared with other forms of surgery". Kit's blood loss was estimated at 350 mls and I feel in this case insertion of a drain was correct.
Daily care for Kit continued as per his care plan, he remained on bed rest for 48 hours following surgery, his observations were monitored 4 hourly, particular attention being given to pain, pressure areas, care of the operated hip, and prevention of complications, he was prescribed Paracetamol and Tramadol every 4 hours for pain relief. Tate (1998) suggests "Infection is probably the most devastating complication of joint replacement surgery" as a precautionary measure Kit was given an IV antibiotic Ciprofloxacin 200mg b.d. (twice a day) to reduce the risk.
One of the main complications arising from total hip replacement is the risk of developing DVT (Deep Vein Thrombosis) which may occur during the first 3 months post-operatively. Miller (1996) suggests an "increased incidence of thromboembolic disease can be expected with osteoarthritis" In line with the Trust policy Kit was measured and fitted with anti-embolism stockings as a preventative measure. Agu (1999) states "Graduated compression stockings reduced the relative risk of DVT by 57% following total hip replacement". Kit was prescribed Clexane (Enoxoparin) 2000 units pre-surgery and 2000 units daily for 7/10 days post-operatively. Hopkins (1999) defines Clexane as a "Low weight molecular heparin used for the prevention and treatment of venous thromboembolism". A study of 200 patients by Warwick (1995) revealed "The prevalence of calf thrombosis to be 15.4% in the group prescribed Enoxoparin and 32.1% in the control group."
. 48 hours post operatively blood tests were performed to check his full blood count and Urea and Electrolyte balance. Jenkins (2002) believes this indicates "The measure of general health, kidney and lung function, metabolism, fluid and minerals". It is a useful indicator as to the progress of a patient. His drain was removed, the wound re-dressed, and an x-ray taken to check alignment of the new joint. Following assessment by his consultant of the x-ray Kit was visited by the ward physiotherapy team to assess and prepare him for mobilizing.
Early mobilization is essential as a study by Cockey (2000) suggests "Prolonged bed rest may actually be more harmful than helpful". He was helped to stand with the aid of two people, and shown how to use a walking frame to transfer from bed to chair. Kit was assessed by his consultant on a regular basis and continued to work with the physiotherapy team doing bed exercises to strengthen his leg muscles and gradually increasing the number of steps he was able to take using his walking frame.
CULTURAL ISSUES
Kenworthy (2002) defines culture as "Observable factors, food, dress, language, values and beliefs". It is important to understand a patient's social and cultural background in order to provide holistic nursing care. Kit was aware that his weight had increased steadily, partly due to immobility but mainly due to "comfort eating". He remembered his mother using food as a form of comfort when he was younger, and had adopted this practice more and more during his incapacity. Helman (1990) suggests "Food consumption is patterned by culture, and is part of the accepted way of life of that community". When filling menus in Kit always ordered large portions, his locker was full of sweets and chocolate biscuits. I suggested a referral to the Dietician who spent time with Kit advising him about healthy eating options. Carter (2002) states "Assisting patients to eat and drink and helping them make the right choice from the menu is important".
One area which concerned Kit was discussion with the doctors, he felt inferior because he could not make any decisions without first being given an explanation by the nursing staff to help him understand the "jargon". Miller (2002) states " There are many potential barriers to effective communication". Having spent much time alone at home he felt he was loosing his conversational skills. I suggested balancing his time between the ward and dayroom. This ensured his private time and also the opportunity for social interaction with other patients. Pearce (2002) suggests "An added complexity to the nursing role is trying to balance the need for dignity and privacy",
Several days after surgery Kit began to refuse pain medication, he held the belief that men should be "strong" and he should be able to manage now. Helman( 2) suggests "Pain is private data, for us to know whether a person is in pain we depend on that person signaling the fact to us, verbally or non-verbally". It was obvious Kit was in pain when he was mobilizing, the charge nurse discussed this with him and gave the reassurance he needed.
MULTIDISCIPLINARY TEAM
Kit's daily care continued under the guidance of the MDT. Doherty (2000) states "The overall standard of nursing care can be greatly improved through collaborative working". Heinemann (1995) implies " Multi Disciplinary Team working members benefit from the supportive and nurturing environment it creates." Team members included Ward Sister, Charge Nurse, Staff Nurses grades D and E. Nursing Students and Auxiliary Nurses, Physiotherapists, Occupational Therapists, Dietician, Pharmacist, and Doctors. The sharing of information to ensure continuity of care is vital. The Multi Disciplinary Team share information by a weekly team meeting to discuss and evaluate patient care and progress, and by a column section in Kardex, fax or telephone when necessary.
ROLES OF TEAM MEMBERS
The grade E nurse is team leader, also running the ward in the absence of the Charge Nurse and Ward Sister. The Physiotherpist's role is to promote physical activity ensuring safety, and re-educating the patient following trauma or illness. Felson (1997) states "Physical activity is essential to optimizing both physical and mental health, and can play a vital role in the management of arthritis". In promoting physical activity the overall aim of the physiotherapist is to return the patient to a degree of mobility equal to or better than prior to illness of surgery.
The Occupational Therapist's role is a functional role primarily aimed at promoting and ensuring safety within all aspects of the daily Activities of Living. The aim being to allow the patient to live as independently and safely as possible in their home environment.
The ward Pharmacist offers a variety of services including current information on medications, dosage, drug interactions or adverse effects. The pharmacist may teach a patient directly how to use their drugs, or assist when necessary with any special dosage calculations. Stephenson (1997) advocates "A Pharmacist on the team offers invaluable knowledge and expertise to enhance the team's delivery of comprehensive care".
The Dietician plays an important role in assessing a patient's nutritional requirements and intake. This was particularly useful for Kit who needed advice on healthy eating, and the encouragement to change his eating habits.
It is sometimes easy to forget that the client is also "An equal member of the team" Whitehead (2001). Kit felt at times he was overlooked, and was presented with information and decisions regarding his care, rather than being actively involved in the decision making.
DISCHARGE PLANNING
7 days after surgery at the weekly team meeting Kit's discharge plan was activated. Rudd (2002) suggests "Discharge planning begins on admission". This early discharge planning is necessary both for the patient in terms of having a goal to work towards, and the Multi Disciplinary Team in order to plan transport, and any aids or services which may be required. A study by Holle (1995) suggests that until recently "Post discharge care was planned from the perspective of service providers rather than patients perceptions of need." This was not true in Kit's case as he underwent a home visit to assess his home environment with regard to carrying out the Daily Activities of Living.
It was agreed that items needed were, a walking frame/trolley with wheels to move drinks/snacks from the kitchen to the living room safely, a raised toilet seat, a seat for use in the shower and a "helping hand" dressing aid. These items were requested from the Community Loan Stores and delivered in readiness for his discharge.
HEALTH PROMOTION
Engel (1980) suggests "Illness is often caused by a combination of factors that can be biological - a virus, psychological - behaviour and beliefs and social - employment". If we look at the psychological elements of illness there is much behavioural change we can effect, this is known as health promotion. A study by Johannson (2002) revealed that "56% of the patients interviewed following total hip replacement considered identification and prevention of potential complications as extremely important prior to hospital discharge". Patient education before discharge is very important in order for patients to manage self-care at home. Health promotion activities were explained to Kit and he was given a booklet reinforcing this information. Drake (2002) advocates the importance of post operative positioning to "avoid dislocation of the new hip". Kit was given instructions to prevent this including bending from the waist, crossing legs or ankles, keeping knees below the level of hips when sitting by avoiding low chairs, the use of an elevated toilet seat and to sleep on the back placing a pillow between the legs tot keep the joint in proper alignment. Kit was advised to shower rather than take a bath for the next 12 weeks, again to prevent flexion of the hip above 90o Ewles & Simnett (1995) suggest "Much health behaviour develops without conscious decision making" Kit agreed with this but realised he now needed to think about his movements to promote his health. A study by Metules (2001) advocates the "Importance of exercise to prevent the incidence of ADL (Activities of Daily Living) disability and prolong autonomy". Kit was advised by the physiotherapist to exercise regularly once his recovery was complete. This would not only help his general fitness and mobility but also encourage him to reach his target weight loss. The Dietician gave Kit a diet sheet to follow at home in order to assist with this.
The discharge facilitator referred Kit to the Community Nursing Team for nursing visits to be arranged following his discharge. A fax was sent to his G.P. informing him of Kit's progress and impending discharge. The wound closing staples would need to be removed after 14 days, and his overall health and progress monitored. He was discharged 12 days after his operation and given an appointment to return to the outpatients clinic in 6 weeks time. Kit was eager to return home and I suggested he use the "man in the van" scheme for his take home prescription. Under the scheme his prescription would be collected from the ward and delivered to his home, preventing delayed discharge. I advised him that Age Concern would do shopping for people over 50 years of age following discharge from hospital, and gave him the telephone number of Arthritis Care, a national voluntary organization for people with arthritis. Their aim is to promote health, well-being and independence and I felt this could be a useful service for Kit.
CONCLUSION
In conclusion, Kit felt he was very lucky to have been assessed and admitted so quickly. His young age and general good health meant he was passed fit for surgery and put on the waiting list superceding many older people who had been waiting for longer but who were not medically fit for surgery at the time of assessment. He was looking forward to the time when he could be independent and self caring again. Orem (1991) defines self care as "the ability of an individual to manage all the activities needed to live and survive". Often this is something we take for granted until illness forces the issue. Kit's surgery and stay in hospital were largely uneventful and with little complication, but following a period of recovery will allow him to return to an independent and active life.
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