Discuss the care pathway of an adult patient who has undergone a surgical /acute procedure. Critically examine one aspect of this pathway.

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Care pathways aim to assist care delivery, by providing guidance, milestones and expected outcomes over a set time period (Herring, 1999). Throughout this assignment, the care pathway for women undergoing a full abdominal hysterectomy will be discussed. To do this the term hysterectomy will be defined, and some common conditions resulting in the procedure will be identified. As will recent trends relating to hysterectomies in the United Kingdom. Care pathways will then be discussed, in relation to the nurses’ role at each stage. The short comings and advantages of using such frameworks will also be identified. In doing this legal and ethical considerations, along with the principals of holistic care in a surgical environment, to meet the needs patients from a diverse society will be addressed. Within this the focus will turn to post operative pain, and the tools used in its assessment. Some common tools used in the assessment of pain will be identified, compared and critically analysed.  

Hysterectomy refers to the surgical removal of the uterus; this may or may not involve the removal of the ovaries, fallopian tubes and cervix depending on the nature of the patients condition (Castledine & Close, 2006). This is a major operation and is usually carried out as an elective procedure.  The procedure may be carried out abdominally, using a horizontal incision on the lower abdomen, or vaginally, where the uterus is reached by making an incision around the top of the cervix (Santoso & Coleman, 2001). Less common are laparoscopic hysterectomies, which involve smaller abdominal incisions and the uses of a small telescopes, this approach is often referred to as keyhole surgery (Walsgrove, 2001). The type of hysterectomy a patient receives is often determined by the condition. There are a number of conditions that may result in a patient requiring a hysterectomy including, gynaecological cancers, fibroids which are benign tumours, endometriosis an inflammatory condition, painful and heavy bleeding, uterine prolapse caused by weakening of the muscle and ligaments, allowing the uterus to move into the vaginal canal and pelvic inflammatory disease a long lasting chronic infection (Tortora & Derrickson, 2006).  Surgery is normally only carried out as a final resort, after other treatments options have been explored. However, in the case of malignancy a hysterectomy may be a critical aspect of treatment (Walsgrove, 2001).

Dysfunctional or heavy uterine bleeding is the most frequent indicator for a hysterectomy, accounting for forty-six percent of hysterectomies (Donaldson, 2006). 31898, women were admitted to hospital in 2005/6 for an abdominal hysterectomy, using 184907 bed days. 182 of these took place at a local hospital (Hospital Episode Statistics 2007). Ninety percent of all hysterectomies that were performed nationally where performed for benign conditions (Edozien, 2005). The Chief Medical Officers Report highlighted hysterectomies as an extremely common procedure, with one in five women having a hysterectomy by the age of sixty (Donaldson, 2006).

Care pathways are most suited to routine elected procedures such as hysterectomies, as common responses to interventions may be accounted for (Guezo, 2003). Care pathways are designed to insure that there is a clear auditable trail,  evidence based practice, an improvement in risk assessment, less time in spent in hospital for patients and improved financial planning (Hinchliff Etal, 2003). This is achieved by providing all members of the multi disciplinary team with a framework on which care can be based (Herring, 1999).  However, it has been argued that care pathways are not compatible with patient centred care, and that the use of care pathways reduces the nurses critical thinking and clinical judgment, because it may be felt that the pathway has to be followed exactly (Hood & Leddy, 2003).  The care pathway of a patient that is to undergo a full abdominal hysterectomy begins with the General Practitioners referral to the Consultant. The nurse involvement with such a patient would begin in the pre operative assessment clinic.

The pre operative assessment clinic facilitates, a multi disciplinary approach to care, allowing the coordination of skills and knowledge to provide a comprehensive assessment of patients needs (Manley & Belman, 2002). With the aim of identifying the patients’ suitability for surgery, minimise the risk to patients, provide information, allowing valid consent to be obtained and reduce patient anxiety. The nurses’ role in a pre assessment clinic would involve, carrying out a holistic assessment of the patients physical, social and psychological fitness for surgery (Walsgrove, 2006). A full set of base line observations would be recorded, to measure all future observations against. Patient education would take place with the nurse providing information about, what to expect before, during and after the procedure. Within this health promotion issues will be addressed, such as the benefits of stopping smoking before surgery (Pudner, 2005). During the physical assessment the nurse will take the patients medical history and record any medications both prescribed and over the counter including herbal remedies, that the patient takes on a regular basis. As these may have contra indications for surgery, for example, a patient that takes aspirin on a regular basis may be advised to stop prior to surgery due to its antiplatelet properties (Davey & Ince, 2000). The types of investigations that are carried out in the pre assessment of a patient may vary, depending on the type of surgery that is to be carried out. Common investigations include blood tests, it is important to note that Afro-Caribbean and Mediterranean women may also require electrophoresis, to rule out sickle cell disease and β thalassaemia. Electrocardiograms will be required for women over sixty, to identify any underlying cardiac problems (Pudner, 2005), urinalysis, scans and lung function tests, all of which are carried out to confirm the patients fitness for surgeries (Jolley, 2007).

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In the case of a hysterectomy, the nurse would need to be aware of the social and cultural implications. A hysterectomy may mean different things to women from different cultures for example; the woman’s role in Muslim communities is often directly linked to her fertility and can be destroyed by a hysterectomy. Some West Indians view menstruation itself as a cleansing act. In such cultures a hysterectomy may result in the women being viewed as inadequate (Walsgrove, 2001). Uncovering fears and misconceptions by giving clear advice and information is a vital part of the nurses’ role (Hughes, 2002). It ...

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