Mary had previously always opted to wear skirts but since the operation was very aware of her altered image and although she said it took her along time to get used to wearing trousers this is what she now preferred. Although Mary was insistent that she had come to terms with the amputation she felt that wearing trousers avoided awkward responses from strangers. Mary was also very concerned about the effects the amputation would have on her relationship with her son, she felt that she was a burden to him as he was already having to take care of his wife and was absorbed with guilt.
Mary revealed to me that although she was extremely keen to get home to be able to recuperate in familiar surroundings, she was quite apprehensive before her discharge from hospital but had not discussed this with anyone as she didn’t want to bother anyone and knew that the multidisciplinary team were all working hard towards getting her home. Although Mary had been on a home visit with the occupational therapists, she had not received her specially adapted wheelchair at the time so had gone in a standard chair which was somewhat slimmer than her own. During this home visit some of the problems that had brought Mary back into hospital were therefore not anticipated. A recent project in the Norwich area aims to assess the patient in their own home in overnight stays when their functional performance is potentially at its lowest and the patient is most vulnerable (Stevenson 2004). Although the trial is still in it’s early stages it is hoped the project will cut re-admission rates and boost the confidence and capability of older people when they are discharged from hospital (Davis 2004). The extended home trial involves supporting the patient overnight and aims to give the patient, carers and nursing staff the confidence to proceed with the discharge. Although setting up a scheme of this nature may be considered expensive, the cost of re-admissions is not only financially costly but can be a devastating blow to the patients morale.
Although Mary’s flat was on the ground floor, there was no wheelchair access into and out of the flat and once inside the flat Mary was unable to manoeuvre her wheelchair adequately, she was unable to turn around in the hall or the kitchen and could not even enter the bathroom. The work surfaces in the kitchen were still of a standard height so Mary was unable to prepare refreshments for herself as and when required. Mary felt trapped and isolated in her flat, reliant on others for everything she needed or desired. Mary described her day as consisting of getting up in the morning when the home care arrived, waiting for her meals to be delivered and then waiting again for the home care so she could get back into bed. Although Mary had a commode next to her bed, she felt unsafe transferring on her own at night so would prefer to wait for help from the home care, this was also the case during the day.
When a patient is admitted to hospital it is the role of the professional nurse to begin the nursing process. The nursing process is a systematic approach to the planning and delivery of nursing care and provides a framework for organising individualised nursing care (Richards and Edwards 2004). Yura and Walsh (1983) identified the four main stages of this process as assessment, planning, implementation and evaluation. A plan of care should be formulated to address the actual and potential problems that are identified in the course of the patients assessment (Alexander et al 2001). To plan a patient’s care accurately it is crucial that a full assessment has been carried out (Alfaro-LeFevre 2002), the assessment of the patient should be holistic and as in depth as possible to make sure the plan of care and therefore the implementation of this care meets the patients needs. A complete care plan is a detailed plan for nursing action and provides a direction for the implementation stage of the nursing process and enables evaluation of the patient’s response to nursing actions (Potter and Perry 2002).
A care plan was formulated which addressed the stump wound on Mary’s leg. I discussed the core care plan with Mary and it was agreed that the main aims were to promote the healing of the wound, to prevent infection and to maintain her comfort. The nursing interventions which were put in place were to refer Mary to the wound care nurse for a more thorough assessment of the wound, so he/she would be able to advise on the most appropriate treatment for the promotion of healing, to give analgesia's on a regular basis (as prescribed) and to monitor the wound for further signs of infection/adverse reactions.
It is beneficial for the patient and has been shown to enhance their compliance to be seen by a specialist so an appropriate plan of care can be written up, rather than the patient being seen by different professionals who are constantly changing their wound care (Gethin 2002). The fact that Mary was a diabetic complicated the healing process, consideration when planning care should be given to risks associated with impaired circulation and sensation, increased risk of infection and delayed healing (Alexander et al 2001).
Leg ulceration may have a significant impact on a patients quality of life, with patients experiencing pain, depression, anxiety, fear, social isolation, and disruption to their daily and social activities (Franks et al, 1994). Leg-ulcer management requires a multidisciplinary approach involving the patient and carer, the patient's family, the patient's GP and both community and hospital nurses. It is important that the nurse sees the patient as a co-worker - working as a team and treating the patient as an equal. While the management of leg ulceration can be based on the best possible evidence, if it is not acceptable to the patient then it will fail. Previous negative experiences of poorly managed wound pain can leave a lasting impression and decrease the patient’s compliance. Patient involvement in wound care is a practical and effective strategy for relieving pain. It is essential to take time to listen to patients and explore their experiences. Many patients, particularly older people, prefer not to complain it is therefore essential that nurses be sensitive to patients' needs and have a positive regard for the individual.
The ideal dressing should ensure that the wound remains moist but not with an excessive amount of exudate or slough, free from infection, and at an optimum temperature to encourage healing and free from fibres released from the dressing. The choice of dressing not only depends on the type of wound but also on the stage of the healing process. To increase the patient’s compliance the dressings should also be acceptable to them, I discussed with Mary the effects that the dressing had on her body image. As Mary preferred to wear long trousers and was still able to wear her loose fitting shoe she currently had no concerns regarding her body image. Following the regime set out by the wound care nurse, the wound was then dressed with Aquacel which is a Hydrocolloid dressing, these are commonly used for moderate to heavily exudating wounds. A Hydrocolloid presentation absorbs wound exudate directly into the fibres, and has been shown to reduce pain in a range of wounds and is easy to change compared with traditional products (Robinson, 2000). A Clinisorb dressing was then placed over this, it’s purpose being to absorb any odour from the wound, odour and leakage can have a major effect on a patient's psychological state and could lead to social isolation. Odour control can contribute to relieving the psychological effects of wound pain. Malodour is often caused by micro-organisms which can be removed by the use of a hydrogel or hydrocolloid dressing (Hollinworth 2001). The dressings were then secured with a contour bandage which enables the dressing to be keep close to the wound without restricting blood flow or movement. It is important that the stump bandage is correctly applied to assist with the healing of the wound and to begin to shape the stump, which eases the fitting of a prosthesis (Alexander et al 2001). During the dressing change Mary’s responses were observed for other indications of pain which can be observed from a patient's reactions.
On admission to hospital it was apparent that Mary required further support to build on her confidence to transfer independently. On admission, Mary needed two nurses to safely transfer. The role of the nurse is to involve the multidisciplinary team where appropriate. Mary was referred to the physiotherapist, who assess the patients moving and handling needs and develop safe systems of manual handling and exercise programmes for the patient to follow. Mary was also referred to the Occupational Therapist (OT) who could assess her social situation and provide all the necessary equipment to enable her to be as independent as possible in her home surroundings. The registered nurse should follow the recommendations of the OT and physiotherapist and a care plan and moving and handling assessment should be completed, completion of such documents leads to continuity of care and an individualised plan of care consistent with the patients needs. Planning and implementing effective care relies on a multidisciplinary team who can support and compliment each others roles whilst empowering the patient (Naidoo and Wills 1998). By utilising the multidisciplinary team approach and combining clinical knowledge and skills, more holistic treatment programmes can be tailored for each patient's individual needs. When assisting Mary to transfer it was important that her surroundings were ergonomic to her needs, her wheelchair was positioned so that she was able to pivot on her right foot with ease, the side of the chair was removed to facilitate this. Mary was encouraged to position her foot correctly and to wear suitable footwear. With support and encouragement Mary’s confidence was gradually increased until she was able to transfer comfortably and confidently.
The nursing care plan should also include a plan for discharge or transfer of care, Holland et al (2004) feel that it is beneficial to begin this when the patient is first admitted into hospital, this is particularly so when complex care packages are required to facilitate a safe and effective discharge. A well managed discharge not only benefits the patient and their family or carers, but also health care professionals by preventing delayed discharges inappropriate re-admission's and is crucial for effective bed management.
In the past, quality issues were not considered a priority in the NHS (Gray and Donaldson 1996), this has since changed and the government has introduced national policies aimed at improving the quality of care through the use of clinical governance. Clinical governance aims to address underperformance, learn lessons from excellent organisations and improve the quality of patient care (Scally and Donaldson 1998). To support this process, a set of national service frameworks (NSFs) have been introduced, these are a set of evidence-based standards that organisations must meet. The National Service Framework for Older People (DoH 2001) is particularly relevant to Mary’s case, standard three of which aims to address issues in relation to patient rehabilitation, poor discharge planning and re-admission's.
During a meeting with the consultant and the ward sister, Mary and her son discussed some of the worries they had of the news of her soon approaching discharge. Although there had been additional OT input, they were unable to make any further adaptations to her accommodation, so the problems that had brought Mary back into hospital still existed. Mary and her son were concerned regarding the lack of access into and out of the flat, and rightly so, regarded this as a fire hazard. They also highlighted that Mary was still reliant on others to meet all of her social and nutrition needs. Although sympathetic of the circumstances, the consultant and ward sister were adamant that these were social issues and there was no reason to justify Mary occupying an acute medical bed. Mary had been placed on the waiting list for an accommodation transfer but had been told that this could take up to eight months. After the meeting with the consultant I discussed my concerns with the ward sister and questioned why Mary was not placed in a continuing care bed until her accommodation needs were satisfied, she informed me that if Mary was willing the funding was not available and she did not meet the criteria to receive such care. Although I felt concerned regarding Mary’s discharge I tried to remain supportive and positive as I felt that this may increase her confidence.
On reflection I feel that although Mary’s confidence and ability to transfer improved dramatically she would have benefited tremendously from further rehabilitation. I also feel an extended home trial would have been to Mary’s advantage as she would have been assessed in her own surroundings where the problems she was experiencing were present. This may have given Mary and her son the confidence to be able to live independently or could have highlighted any potential problems and therefore prevented another admission. During Mary’s stay on the ward I was able to spend time with her, listen to her views and plan care which was agreeable to her. Mary was very compliant and willing to listen to and consider all aspects of care suggested to her. Mary has been an inspiration to me, dealing with so much and with such dignity and courage. Her enthusiasm and positive outlook will remain with me throughout my career and I hope to be able to extend this learning experience to others in my care.
References
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