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Introduction within the care of a patient

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Introduction

This case study will look into
a patient’s journey from primary care into secondary care and the partnership
working of different trusts and multi-disciplinary teams. This case study will
explore the physical and psychological impacts on the patient and her family,
while looking at tools used during her care. For reasons of confidentiality the
patient’s name has been changed to Mrs Light. Under the National Health Service
( NHS) constitution everyone has the right to confidentiality and privacy. For
this case study the identity of the patient, staff and the identity of the
primary and secondary care settings involved in the care of Mrs Light have been
anonoymise . All information regarding them and their care is to be kept safe
and secure (NHS constitution 2013).This patient was chosen due to the
complexity of the case which involved clinical, physiological, social, and
psychological and the emotional elements involved in her care . Yura and Walsh
describe the nursing process as a problem solving approach where nurse and
patients working in partnership undertake four steps within the care of a
patient these include identifying problems together and the causes that require
intervention, making plans that remedy the identified problems, taking steps to
evaluate the problems and to reflect on what has happened. The principals of
nursing practice are of high importance within person centred care and have
many different aspects which includes patient dignity, respect, privacy and
communication (Department Of Health 2006, Royal College of Nursing 2008).All of
these aspects will be discussed and identified within this case study .There
are eight Principals of nursing care these are identifies as nursing staff to
treat everyone in their care with dignity and humanity, they need to show
compassion and sensitivity in providing patient care while treating everyone
with equally, Nursing staff are to take responsibility for the care that they
provide and are accountable for their own actions. Nursing staff must manage
risk and help to keep everyone safe, Nursing staff to promote person centred
care ensuring patients  and their
families/carers help patients make informed choices regarding their treatment
and care, Nursing staff are to assess, record and report the treatment of a person’s
care and handle information confidentiality and sensitively and are required to
deal with complaints effectively, Nursing staff must have up to date knowledge
and skills and use these to have an understanding with the needs of patients
within their care. Nursing staff are required to work closely within their own
team and with other multi-disciplinary teams ensuring best outcome for patients.
Nursing staff are to lead by example and to develop themselves and other
nursing staff and influence the way care is given. 

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Background

Mrs Light attended the local
urgent care service in the community during the week for a routine dressing
change as her GP practice was unable to offer an appointment. The Urgent Care
Centre is a walk in and wait service whereby patients are called for a triage
assessment shortly after arriving. The assessment is an interactive process
that underpins all aspects within nursing care (Heaven and Maguire 1996)  this looks at focusing on patient’s responses
to health rather than disease process and pathology (Wilkinson 2007). The
Manchester triage group was first identified in 1994 with developing systems to
ensure patient care is defined according to patient needs within a timely
manner using algorithms and national targets .It is a tool used in walk in
centres and Accident and Emergency Departments as a system of patient
prioritisation. Within this system questions regarding patient presentation to
the urgent care centre can be identified. As part of the initial assessment reasons
for attending the service are taken including patient history including patient’s
lifestyle, family history and the presenting complaint of illness or injury
(Crouch and Meurier 2005 ). An assessment is understood by Holt 1995 as the individualisation
of a person’s care while understanding 
the uniqueness of each patient  and
recognising this within the care process. The effectiveness of the assessment
is a starting point a vital part in monitoring patient care, ongoing assessment
and detecting any emerging problems that should arise. Nursing models  such as self care models (Orem el at .2001),
the activities of daily living (Murphy et al 2000) have been introduced and developed
to given practitioners a structure in order to identify the analytical and
problems solving skills that are required for effective patient assessment and
ongoing care. In order to determine which Nursing modelling tools should be
used within patient care the approach should be sensitive in order not to
discriminate between patient’s different clinical needs.

 Mrs Light had incision and drainage to an
abscess at the base of her neck at local secondary care trust three day prior
to arriving at Urgent care. Patient’s medical history is taken (current
medication, allergies, any medical history relating to care and also any social
aspects) the patient had no previous medical history; she had recently
completed Course of antibiotics for the abscess which was started prior to
surgery from her GP prior to surgery she had been prescribed pain relief of         co-codamol 30/500mg (30/500–60/1000?mg
every 4–6?hours as required; maximum 240/4000?mg per day( BNF however patient
stated taken 2 tablets as prescribed made her feel more tired and constipated.
The patient lives at home with her husband who works full time. She is a house
wife with 3 grown up children .Patient stated since operation she has been
feeling very tired and was advised to rest but has been completing normal daily
house hold cleaning .This information was obtained from the patient and is
important as we are focusing on the person as a whole including mind, body,
spirit, emotion and environment which was first introduced by Florence nightingale.
Observations were taken including blood pressure, heart rate, temperature and
oxygen saturations all reported as within’ Normal limits’. Observations is a
term which refers to the physical assessment of a patient , Vital signs are a
collection of hearth rate, blood pressure, respirations, temperature and pulse
oximetrey. Taking these as a part of the assessment process act as a baseline
to determine a patient’s normal range (Bickley and Szilagyi 2009) It is important
to understand if vital signs are outside the normal range as this would
indicate the patients deteriorating condition and the need to alert the
registered nurse and document the results (Keisiel and Perkins 2006 ).

Mrs Light is three days
post-operative following an incision and drainage to/of an abscess of her lower
posterior aspect to her neck. An abscess occur when an area of skin/ tissue
becomes infected, the tissue wall collects pus. This area develops into a lump
and people can become unwell with it (Patient.co.uk ). The procedure of
incisions and drainage of the infected area is an operation undertaken in
hospital under local or general anaesthetic depending on where the abscess is
located. An incision is made to allow the pus to drain from an infected area.
The area is then packed with a sterile wick and covered with a sterile dressing
to allow the surgical wound to heal.

 

Primary care visit

Mrs Light was discharged from
an acute hospital trust early the next day with what patient states as very
little discharge information hence why Mrs light arrived to us three days post
operation as the patient stated she was unaware of when a dressing change was
required . Patient was given a discharge letter to bring GP practice or Urgent
care setting when required a dressing change .After triage Mrs Light was called
in by a Health care assistant for a dressing change. The Treatment room and
dressing trolley had been already prepared prior to patient arriving in
treatment room. The Health care Assistant (HCA) introduced herself to the
patient and explained the procedure and asked the patient if she had any questions
prior to the procedure while also explaining to the patient what was going to happen.
The patient was anxious this was displayed by the non-verbally by the patient’s
body language, lack of eye contact and through verbal communication to the HCA
asking ‘will it hurt ‘, ‘ how long does it take to heal ‘. Patients can
naturally have an emotional response to an illness while in the care of a
health care professional; this can be reflected in a patient’s emotional
response to care (NICE 2004).Communication is both verbal and non verbal and is
important in developing relationships (Sale and Neale 2014) , non verbal
communication make up 85% of all communication as demonstrated by the patient
(Blazer and Riley 2007). Failings within communication between patient and
clinician are known to have detrimental outcomes and poor patient experiences
(Parliamentary and health ombudsmen 2001).The HCA responded to the questions
asked by the patient. The patient had not had any pain relief until seen in
triage 20 minute prior to being called for a dressing change. Verbal consent
was given by the patient for dressing change. Consent by law is a voluntarily
agreement with an action or task performed by another, this can be gained
verbally and non verbally, informed consent where patients have knowledge and
comprehension and the consent is given freely without duress or any undue
influence , the patient also has  the
right to withdraw from the procedure (Miller –Kane  2003). In order to give consent the person
must have capacity to be able to consent to the treatment and to have to
ability to retain the information given to them. A person is presumed to have
capacity unless it is established that they lack capacity, if there is any
doubt an assessment should be completed (Mental capacity act 2005 ).The Nursing
and Midwifery Code of conduct states that nurses and health care professionals
have a responsibility to gain consent prior to treatment, to respect and support
persons rights in accepting or declining treatment, to up hold the right of the
individual in decisions’ regarding a person’s care and be able to demonstrate
that they have acted in a person’s best interests.

 As patients pain score was 7/10 using the
Numeric pain system where  11-point numeric
scale ranges from ‘0’ representing one pain extreme (e.g. “no pain”) to ’10’
representing the other pain extreme (e.g. “pain as bad as you can imagine” or
“worst pain imaginable”).Pain is described as whatever the person experiencing
it says it is (McCaffery 1989) Due to the
patients pain score HCA offered the patient Entonox as per administration
protocol as unregistered the HCA wouldn’t be covered to give the Entonox to the
patient ,the HCA discussed this with a registered practitioner in order to be
prescribed for the patient to obtained the appropriate  pain relief for the patient . The patient was
asked to lie on the patient couch The HCA then preceded by using PPE and
Aseptic Non Touch Technique (ANTT). While patient was led on her side taking
instructions on how to use the Entonox and constant communication with the HCA
.The HCA started by removing the previous dressing and gently removing the wick
that had been used to pack the cavity this had become stuck due to the time the
wick had been in the cavity . The patient started to show signs of autonomic
response to the pain that she was experiencing . The patient started by
communicating to the Hca she felt tired, hot ,sweaty and the HCA notice the
patient became sweaty and pale . The Hca decided to stop the removal of the
wick where the patient then became unresponsive but breathing and not communicating
the HCA then called for help using the emergency button to alert the registered
nurses for assistance. The HCA’S intuition led them to call for help with the
‘gut feeling ‘ that the patient was unwell and the Hca needed assistance in the
patient care .Intuition has been described as the understanding without a
rational and without conscious use of reason (Schrafer and Fischer 1987) according
to Benner’s  novice to expert this is an
important theory within the nursing field. Intuitive experience can lead to
moral reasoning and personal knowledge. This is explained over the five steps
within the theory being novice, advanced beginner, competent, proficient and
expert.

When help arrived the patient
had started to respond at approx 30 seconds after becoming unresponsive, blood
pressure, heart rate and blood oxygen saturations were taken recorded and
documented. The patient became less responsive for a 2nd time witnessed by the
registered nurse an ECG and Blood glucose test was taken as per NICE guidelines
to rule out a cardiovascular event and low blood sugar levels. With support
from the registered nurse the HCA was able to look at the wound and repack and
redress the wound. The wound appeared pink and healthy tissue with no signs of
infection. Signs of a wound infection would include erthymea (redness),
swelling, heat from wound area, fluid or slough and mal odour from wound. Once
patient had started to respond the HCA and registered nurse were able to slowly
sit the patient up and offer her some water. The Hca asked the Registered nurse
whether a lying and standing blood pressure should be taken as part of the
assessment however it was discussed a with the patient and felt due to the
patient feeling unsteady it would not be appropriate . The lying and standing
blood pressure would give evidence regarding a postural drop in blood pressure.
Under NICE guidelines when a patient lies down blood pressure is recorded and
taken again once patient is standing. If the difference of lying to standing is
20mmcmg further assessment is required. The patient’s husband arrived in to
room and patient felt she was able to sit on the edge of the patient bed. While
the HCA was communicating with the husband (consent from patient was given for
this to happen) regarding the wound and dressing changes the patient started to
stare and became floppy, the  emergency
bell was pulled and the patient was led back on the bed and further
observations were taken. Once the patient had 
started to respond after approx 30 seconds the HCA  noticed that the patient  had been incontinent of  urine and discretely informed the registered
nurse and offered the patient clean clothes 
ensuring patient privacy and dignity was maintained at all times by
demonstrating empathy and compassion towards the patient. Empathy is a
multi-dimensional concept of emotional and behavioural aspects within nursing
care. It involves the ability to understand the patient’s perspective and
feelings while in the  nurses care .
Compassion is another key concept within the nursing process (Johnson 2008)
However in over  time it has been
expressed  that health care professionals
have witnessed a decrease in the caring and compassion due to other task that
have taken priority over holistic care (Pearcey, 2007)

Due to the pattern recognition
of the patients symptoms along with the diagnostic reasoning this led the
registered nurse to deciding the clinical judgement of patient follow on care .
The registered nurse discussed with the patient and her husband that as we were
unable to investigate further into the vacant episodes the patient was
experiencing it was advised to attend the local Accident and Emergency
department. The Patient at first declined and wanted to go home but it was
explained it was in her best interest to attend via ambulance for her safety.
The patient agreed and it was her choice once the situation was explained to
her as she was unable to remember what had happened and was able to make an
informed choice regarding her care. When ambulance arrived the registered nurse
gave a verbal hand over using the situation, background, assessment and
recognition (SBAR method) this   is a tool used nationally to simplify and
standardised communication within local teams and multidisciplinary teams. The patient
was transferred to Accident and emergency department for medical diagnostics
test . The patient notes including a nursing diagnosis of  multiple vacant episodes with no obvious
underlying infection or cause identified. The nursing diagnosis provides a
focus for planning and implementing evidence based effective care and
identifying appropriate interventions. A nursing diagnosis has been described
as patient illness that can be managed by nursing expertise (Leih and Salentijn
1994) , while on route the patient had another vacant episode totalling 4
within a two hour timeline. This was communicated to the nursing staff when
paramedics arrived for another patient later in the shift. As an Urgent care
centre we were not able to routinely follow up  patient.

The patient had presented at
the Urgent care centre for a regular dressing changes first being 3 days after
being sent into hospital. The patient had reported that she was discharged from
hospital after 2 days, blood test and scans were taken and was medically
diagnosed to have a nerve damaged in her neck where the incision and drainage
operation had been. However if the test returned inconclusive the patient
physical response could have been due to poor pain management and other factors
including anxiety. The patient now needs follow at a local tertiary care trust
for epilepsy and has regular vacant seizers on a daily basis. This had led the
patients’ husband needing to give up full time work to be a carer for his wife.
This had effected there house hold income and in turn their lifestyle including
money for food and social event which has affected her psychologically and
physically.

Conclusion

In conclusion this essay has
looked at the journey of a patient self presentation into primary care into
secondary care with ongoing treatment and assessment at a local tertiary care
trust. The combination of the multidisciplinary team working from primary and
secondary care and the team working, communication, documentation and
appropriate referral from within the urgent care centre led to promote a
positive outcome of care for the patient. Local and national policies along
with screening tool have been included. Improvements identified within this
case were the lack of practice nurse appointments, Lack of information to
patient upon discharge  from a secondary
care trust; this led to the patient being anxious regarding her care, if the
patient had been given more information regarding her after care she may have
been less anxious and have been able to manage her pain better and have made
better informed choices regarding her care and ongoing management .

 

 

 

 

 

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