Acute Care Nursing

Question: Describe about the Report for Acute Care Nursing. Answer: 1. Osteoporosis is mainly a disease of aged people and it occurred due to the more bone resorption as compared to the of bone formation. The central cause of occurrence of osteoporosis is deficiency of gonadal sex hormone like estrogen. Estrogen represses receptor activator of nuclear factor- B ligand (RANKL). RANKL is responsible for the osteoclast differentiation and survival, when it binds to the RANK on the cell surface of osteoclast cells. This RANKL is generally expressed on the osteoblast precursor cells and inflammatory cells like T B cells. Also, estrogen stimulates the expression of osteoprotegerin which binds to RANKL before it binds to RANK and prevent capability of RANKL to promote ostoclast formation and bone resorption and hence suppresses its ability to increase bone resorption. Deficiency of vitamin D and calcium also leads to the bone loss. In response to low calcium levels, parathyroid glands secret more amount of parathyroid hormone and this hormone promotes bone resorption by increasing more absorption of calcium in the blood to maintain optimum level of calcium in the blood. Trabecular bone are present at the end of long bones and vertebrae which plays role in bone turnover and due to the microcrack in the trabecular bone, it replaced by weaker bones (Raisz 2005; Drake et al., 2015). Open reduction and internal fixation (ORIF) is used correct as a bone break. In this open reduction means restoring fractured bone in the original position and internal fixation means steel rods, screw and plate are used to fix bone fracture. A total hip replacement (THR) is a surgical procedure used in osteoporosis in which deformed cartilage and bone of the hip joint is substituted with plastic, ceramic and metal. In THR there is more percentage of ambulation reported after discharge. In case of ORIF there is more morbidity, less compliance in terms of inhibited weight bearing and inferior outcome. In osteoporosis, due to bone loss there is the reduced possibility of plate fixation in case of ORIF. There were more number of patients already underwent ORIF, tried to move to THR (Boelch eta l., 2016; Archdeacon et al., 2013; Daurka et al., 2014) . 2. Hip replacement (THR)/arthroplasty surgery requires anesthesia for long duration. There is significant loss of blood during surgery of the patient. Reported loss of blood in THR patient is around 1500 ml with hemoglobin around 4.0 g. In Gianna also almost same amount of blood loss occurred. However there were confounding results available for the loss of blood in general and local anesthesia. Few studies showed there was no difference in the blood loss in general and local anaesthesia, on the other hand few studies showed there was more blood loss in general anaesthesia as compared to the local anaesthesia (Rozario et al., 2008; Durasek et al., 2010; Singh et al., 2012). Anaesthesia and THR leads to the hypotension in the patients undergoing surgery. Average blood pressure less than 95/50 was reported in THR surgery. In case of Gianna also blood pressure observed was 95/50. In case of THR, different studies gave different definitions for the hypotension. Hypotension considered in different studies for THR were fall in blood pressure more than 30 % systolic blood pressure, 33 % overall blood pressure, 40 mmHg and 20 % fall from the baseline (Bigler et al., 1985; Berggren et al., 1987; Davis et al., 1987). Even though, there was different criteria for hypotension in different studies, overall it has been observed that fall in blood pressure was more observed in regional anaesthesia as compared to the general anaesthesia (Couderc et al., 1977). It has been reported that blood transfusion in THR over the preoperative and postoperative period in case of regional anaesthesia was in the range of 230 to 260 ml. In case of Gianna, blood transfusion was 200 ml. In case of general and regional anaesthesia number of patients required transfusions were same however volume of transfusion required in the regional anaesthesia patients were higher as compared to the general anaesthesia patients (Valentin et al., 1986; Bredahl et al., 1991; Juelsgaard et al., 1998). Most of t he available data in case of blood transfusion was heterogeneous. There was less percentage of O2 in the blood of patients undergoing THR. In such scenario, administration of oxygen is necessary to prevent hypoxia. This condition occurred in almost 98 % patients. Oxygen saturation (SpO2) between 90 to 95%, considered optimum in case of THR surgery patients. This SpO2 correspond to the oxygen tension (Pao2) of 6080 mmHg. Oxygen saturation observed in case of Gianna was 93 %. This volume was in the adequate range considering age and THR surgery of Gianna. In earlier studies few patients were reported with Pao2 less than 60 mmHg (Couderc et al., 1977; McKenzie et al., 1984; Brown et al., 1994). Fall in the oxygen tension was reported to be different at different time points for general and local anaesthesia. There was more fall in oxygen tension in case of general anaesthesia as compared to the local anaesthesia at one hour after surgery, however there was no difference in the oxygen tension between general and local anaesthesia one day after completi on of surgery. However, in few studies there was no difference observed in oxygen and carbon dioxide tension between general and local anaesthesia. To prevent hypoxia, it has been suggested that oxygen with flow rate of 5 L/min is sufficient in case of THR patients (Rozario et al., 2008; Singh et al., 2012). However, in case of Gianna oxygen was supplied with the flow rate of 6 L/min. This volume was sufficient for Gianna. Orthopedic theaters used in the THR surgery are generally cooler than any other operation theaters with temperature is in the range of 18-20C and humidity more than 55 %. With the weakened temperature regulatory system in the THR patients and mentioned cool orthopedic theater, in case of patients undergoing THR surgery, there is rapid decrease in the body temperature of patients undergoing THR surgery (Akca et al., 2002; Moretti et al., 2009). There was very less literature available for recording of temperature, hence threshold temperature is not available. In case of Gianna, recorded temperature was 36oC which is less than the normal temperature. It was reported in the literature that there is no difference in the temperature due to the general and local anaesthesia. Effect of analgesics on the vital signs mainly depends on the baseline values of the vital signs of the individual patient. In this case of Gianna, most of the vital signs were abnormal and there was no worsening effect on vital signs by the use of analgesics (Sporer et al., 2006). 3. Dischrge plan for the Giana was prepared by a team of discharge planner, resident nurse and physician. Consent of the Giana and her family was taken for her diachrge. A case of Gianna Rossi, 79 years old, female, was admitted to emergency department after collapse. In X-ray it was revealed that Gianna has fracture in the hip due to osteoporosis. She stayed in the orthopedic ward for four days and her daily activities like eating and drinking are normal. She can walk using four-wheeled walker under supervision. Her pain can be managed with paracetamol and tramadol. Subjective : Gianna was concerned about her independence after her discharge. Objective : Giana and her family were seen packing their items. Giana received instruction from the physician and surgeon. All the payments of the hospital were done. Complete Patient Assessment (Chin-Jung et al., 2012; Al-Maqbali, 2014): Dischrge needs : Giana is doing her daily activities normally and walk on her own using four wheeled walker under supervision and gradually there is progress in this. Screening: Vital signs of Giana, those were became abnormal during and after surgery are now normal. Complaints: Giana doesnt have any complaint as such and her pain can be managed using paracetamol and tramadol. Physical screening: Giana was evaluated for getting in and out of her bed, walking with walker under observation and walking to the bathroom. All these assessments showed promising outcome. Prioritize patient needs (Advise to patient and family): Visit hospital after 2 weeks for clinical follow-up. Change dressing twice a day and dont disturb the stitches. Referred to experienced physiotherapist after two weeks because rehabilitation and physical therapy is essential. Do not take shower upto 6 days after surgery because incision and stitches may get wet and this can lead to infection. Do not allow anybody to touch incision without washing hands with antiseptic. Take paracetamol and tramadol, if she feels pain otherwise she can stop it. Call to the hospital in following situations: More redness or drainage at the incision area. If pain is not decreasing even after taking painkiller. If temperature is increasing. After the approval of discharge plan of Giana by physician and the surgeon, Giana was discharged to her home along with discharge planner, visiting nurse, physiotherapist and her family members. References: Akca, O., Sessler, D.I. (2002). Thermal management and blood loss during hip arthroplasty. Minerva Anestesiologica, 68, 1825. Al-Maqbali, M. A. (2014). Nursing intervention in discharge planning for elderly patients with hip fractures. International Journal of Orthopaedic and Trauma Nursing, 18(2), 6880. Archdeacon, M., Kazemi, N., Collinge, C., Budde, B., Schnell, S. (2013). Treatment of protrusio fractures of the acetabulum in patients 70 years and older. Journal of Orthopaedic Trauma, 27(5), 256261. Berggren, D., Gustafson, Y., Eriksson, B., Bucht, G., Hansson, L.H., Reiz, S., Winblad, B. (1987). Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Anesthesia and Analgesia, 66, 497-504. Bigler, D., Adelhoj, B., Petring, O.U., Pederson, N.O., Busch, P., Kalhke, P. (1985). Mental function and morbidity after acute hip surgery during spinal and general anaesthesia. Anaesthesia, 40, 672-6. Boelch, S.P., Jordan, M.C., Meffert, R.H., Jansen. H. (2016). Comparison of open reduction and internal fixation and primary total hip replacement for osteoporotic acetabular fractures: a retrospective clinical study. International Orthopaedics, Aug 10. [Epub ahead of print]. Bredahl, C., Hindsholm, K.B., Frandsen PC. (1991). Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and general anaesthesia. Acta Anaesthesiologica Scandinavica, 35, 548-52. Brown, A.G., Visram, A.R, Jones, R.D.M., Irwins, M.G., Bacon-Shone, J. Preoperative and postoperative oxygen saturation in the elderly following spinal or general anaesthesia - an audit of current practice. Anaesthesia and Intensive Care , 22, 150-4. Couderc, E., Mauge, F., Duvaldestin, P., Desmonts, J.M. (1977). Comparative results of general and peridural anesthesia for hip surgery in the very old patient. Anesthesie, Analgesie, Reanimation. 34(5), 987-98. Chin-Jung, Lin., Shih-Jung, C., Shou-Chuan, S., Cheng-Hsin , C., Jin-Jin, T. (2012). Discharge Planning. International Journal of Gerontology, 6(4), 237240. Daurka, J., Pastides, P., Lewis, A., Rickman, M., Bircher, M. (2014). Acetabular fractures in patients aged 55 years: a systematic review of the literature. Bone Joint Journal , 96, 157163. Davis, F.M., Woolner, D.F., Frampton, C., Wilkinson, A., Grant, A., Harrison RT, et al. (1987). Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. British Journal of Anaesthesia, 59, 1080-8. Drake, M.T., Clarke, B.L. and Lewiecki, E.M. (2015). The Pathophysiology and Treatment of Osteoporosis. Clinical Therapeutics, 37(8), 1837-50. Durasek, J. (2010). Factors affecting blood loss in total knee arthroplasty patients. Acta Medica Croatica, 64, 20914. Juelsgaard, P., Sand, N.P.R., Felsby, S., Dalsgaard, J., Jakobsen, K.B., Brink, O., et al. Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia. European Journal of Anaesthesiology, 15(6), 656-63. McKenzie, P.J., Wishart, H.Y., Smith, G. (1984). Long-term outcome after repair of fractured neck of femur; comparison of subarachnoid and general anaesthesia. British Journal of Anaesthesia, 56, 581-4. Moretti, B., Larocca, A.M., Napoli, C., Martinelli, D., Paolillo, L., Cassano M, et al. (2009). Active warming systems to maintain perioperative normrothermia in hip replacement surgery: A therapeutic aid or a vector of infection? Journal of Hospital Infection, 73, 5863. Pesce, V., Speciale, D., Sammarco, G., Patella, S., Spinarelli, A., Patella, V. (2009). Surgical approach to bone healing in osteoporosis. Clinical Cases in mineral and bone metabolism, 6(2), 131135. Raisz, L. (2005). Pathogenesis of osteoporosis: concepts, conflicts, and prospects. Journal of Clinical Investigation, 115(12), 331825. Rozario, L., Sloper, D., Sheridan, M.J. (2008). Supplemental oxygen during moderate sedation and the occurance of clinically significant desaturation during endoscopic procedures. Gastroenterology Nursing, 31, 2815. Sporer, K.A., Tabas, J.A., Tam, R.K., Sellers, K.L., et al. (2006). Do medications affect vital signs in the prehospital treatment of acute decompensated heart failure? Prehospital Emergency Care, 10(1), 41-5. Singh, S., Singh, S. P., Agarwal, J. K. (2012). Anesthesia for bone replacement surgery. Journal of Anaesthesiology Clinical Pharmacology, 28(2), 154161. Valentin, N., Lomholt, B., Jensen, J.S., Hejgaard, N., Kreiner, S. (1986). Spinal or general anaesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients. British Journal of Anaesthesia, 58, 284-91. Acute Care Nursing Questions: 1. Identify factors that determine which healthcare professionals are required to be involved in a health care team? 2. Who should lead the health care team? 3. Who is the most important member of the health care team? 4. What further questions will you need to ask the nurse? 5. List specifically what further assessments you would complete when the patient arrives onto the ward? 6. Clinical Reasoning: Learning to think like a nurse, Frenchs Forests, NSW: Pearson? 7. Using your knowledge and experience of various patient allocation models? Answers: 1. Factors to determine the involvement of health care professionals The health care professionals are involved to determine the care and needs of the service users. The needs vary from patient to patient like diagnosis, emotional, psychological and functional level of the patient (Okuyama, Wagner Bijnen, 2014). This also includes the social, functional status of the patient, treatment type and the preference of them. In addition, needs of care and multidisciplinary team involvement should be changed as per the progression of disease and the symptoms that are present. According to Lgar et al., (2014), the important part is the involvement of multidisciplinary team and information exchange through the communication. The multidisciplinary team members should have the ability of the proper communication so that the patients get proper treatment. All the expertise people should have the utilizing power of the clinical judgement. 2. Leader of the health care team The multidisciplinary team should be led by the case manager. In some cases the care coordinator manages the team (Grol et al., 2013). Each member has individual responsibilities to achieve their job goal. They have some common goals that they need to perform in collaboration (Al-Balushi et al., 2014). According to the fact sheet, the team leader needs to motivate other staffs so that there will fewer difficulties to achieve the goal (MND Australia 2013). He needs to maintain the healthy environment of the caring home. 3. Important member of the health care team Every member of the multidisciplinary team is important to give their best performance and achieve the best outcome. The treatment procedure should be effective and the focus should be given to the patient only. The patient should get efficient and effective treatment. The team members should provide the central focus and care to the patient. They should communicate properly and collaboratively. Salminen et al., (2014) mention that all he member of multidisciplinary team should respect each other and participate in the decision making for the wellbeing of the patient. They need to communicate with the patient on regular basis and make rapport of the patient assessment. The responsibilities of different doctors and staffs are different. For example, the role of Psychologist is different from the physiotherapist. Key issues: Leg injuries and mild head injury due to motor vehicle accident. Admitted for six months Suffering from depression Need long term rehabilitation Health care team involved in treatment Physiotherapist helps to assess and manage the mobility Psychologist helps to stable the mental condition and bring back to normal life Social worker supports patient and his family members to adapt the situation and return to the normal lifestyle The occupational therapist helps Grant Thompson to improve the skills and day to day activities. As the team leader, the treating doctor should take the concern of the patient and the family members of the patient to know their opinion. Rehabilitation unit will help to motivate the treatment procedure of Grant Thompson. They will help to speed up the recovery of Grant Thompson so that he can return to his normal lifestyle as soon as possible. 4. The medication time and the procedure of medication If the patient has any allergic problem or any kind of irritation from a particular food The type of injury and time period of admission The function of drugs and injection, which the nurse does not know 5. List of the necessary and specific patient assessment The nurse should go through the patient history very carefully and examine the patient. The nurse needs to identify that if the patient is able to bear with the treatment procedure. Therefore she must modify the procedure according to the patient needs. The nurse needs to spend more time with the patient to know more details about him and make rapport. The nurse should know about the presence of the systemic diseases, previous hospitalization, allergies, past anaesthetic events, drug or alcohol use, medication and family history. The nurse should discuss the test reports with the patient as the patient has the right to know about the reports (Alomar, 2014). The patient also should not hide anything from the nurse and provide all information to the nurse. Moreover, the nurse needs to know about the psychological, spiritual, physiological and sociological status of the patient. 6. Levett- Jones Clinical Reasoning Cycle Consider the patient situation What current information do you have on this pt.? What new information have you gathered? 37years old male patient faced MVA before six months Pt. is recovering day by day Pt. is depressed Collect Cues/Information What further cues and information would be useful? Why? Pt is a truck driver and faced accident before six months. Recovery time is slow and relies on the wheelchair. However, he can walk for short distance with the help of walker. Process Information What changes do you notice in the cues and information provided? Which changesare significant for this patientand why? What do you think these changes could indicate and why? What could be the outcome of these changes? The health condition of the patient is improving since the last six months. The significant changes are that the patient can walk to cover short distance. The patient is gradually depressed as he is the only earning member in the family and he is hospitalised. The patient needs rehabilitation. The patient got depressed. Establish Goals Describe what you want to happen. Who do you want to be involved and what do you want them to do? In what timeframe? The nurse needs to involve herself in the treatment of the patient so that he can recover soon by following the guidelines and can collaborate with multidisciplinary team. Take Action What nursing actions will you take? What will be your nursing priorities? The nurse needs to consult with the doctor and help the patient in medication and walking. Evaluate Outcomes What do you expect to achieve from the actions have taken? The nurse then needs to take proper action to reduce the problem and needs to observe the patient, if any noticeable changes like improvement or decline happen (Matziou et al., 2014). Reflect on Process and new learning What have you learnt from this exercise? The nurse can learn various things from these evaluated outcomes, which she needs to understand and learn. This clinical reasoning cycle will help the nurse to develop her skills. 7. There are one RN, one EN and three AIN in the ward with me and we work in the afternoon shift. There are total twenty two patients, in which 14 need post operative treatment and 8 need pre operative treatment. To ensure the skills, techniques, experience and knowledge the total patient care model is chosen to discuss the module. Patient allocation model: Total patient care The registered nurse is allocated for the total patient are as she has the registered licence of total patient care. Delany and Golding (2014) mentioned registered nurse as the primary nurse. Two AINs are also appointed with the RN for the help. The RN has various responsibilities to perform like medication, administration and dressing changes. The patient who went for the surgery in morning, are very sensitive. Therefore, they needs to be handled with sensitivity and deserves more caring. The necessary needs of the surgical patients are dressing of the wounded place, provide proper medication and injection. According to Urden, Stacy and Lough (2015), as the type of surgery is different for various patients, therefore the nurses need to provide different care to different patients. The room should be cleaned and well ventilated for the post operative patients. Team nursing A team of three people of RN, EN and AIN is formed for the acute caring of the pre operative patients, who needs to know about the all circumstances of the operation. They will explain the patients about the risks and curing chances of the patients. They need to give proper medication to the patient. The RN should lead the team but as she is busy with the post operative patients therefore, the EN should lead the team and guide the AIN. The team is responsible to handle all the eight patients who are going for the surgery. The team needs to work in collaboration and no one should be ignored (Delany Golding 2014). All the members of the team should input their skills and also can learn new knowledge from the patients. Task allocation There are one RN, one EN and three AIN in the ward with me and we work in the afternoon shift. There are total twenty two patients, in which 14 need post operative treatment and 8 need pre operative treatment. Due to the huge patient load of the pre and post operative patient two teams are made, which include one registered nurse, one enrolled nurse and one AIN. In the other team, there are one RN and two AIN that will handle the pre operative patient. As the AINs do not have the licence of giving antibiotics and performing intravenous access, therefore I and the other RN will handle this. Both the AIN will do the other formalities in case of pre operative patients like filling up the formalities and dress up. In case of post operative patients, the EN will help the other RN that is responsible for the medication and injection and the AIN will take care of dress up and controlling infection. References Al-Balushi, S., Sohal, A. S., Singh, P. J., Al Hajri, A., Al Farsi, Y. M., Al Abri, R. (2014). Readiness factors for lean implementation in healthcare settingsa literature review.Journal of health organization and management,28(2), 135-153. Grol, R., Wensing, M., Eccles, M., Davis, D. (Eds.). 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Lavin, M., Harper, E., Barr, N. (2015). Health information technology, patient safety, and professional nursing care documentation in acute care settings.OJIN: The Online Journal of Issues in Nursing,20(2). Urden, L. D., Stacy, K. M., Lough, M. E. (2015).Priorities in critical care nursing. Elsevier Health Sciences.