Mr Rajit Singh 79 season old practising Sikh gentleman and British is his second dialect. He recently endured a mild heart stroke and made a good recovery but his freedom is slow-moving and he is occasionally unsteady and mobilises with a Zimmer framework.
Mr Singh was admitted to the acute medical ward three days ago carrying out a stroke. He's a rather obese gentleman who smokes twenty cigarette smoking each day and has a right sided hemiplegia. Mr Singh lives with his seventy five time old wife, child and little princess in legislation in a first floor flat. His partner and girl in regulation are his main carers.
Since his admission to the medical ward Mr Singh is becoming incontinent of urine failing to tell personnel he needs the toilet. He is alternatively unwilling to mobilise and wants to stay in bed and his urge for food is poor. He reluctantly accepts support along with his personal cleanliness only hoping either his partner or little princess in law to aid him.
Two days and nights after admission when being showered, a tiny red area was noticed on his right hip that was brought up during patient handover but was not implemented through by nursing staff. By day four a big cavity of about 10cm by 9. 8cm and 3cm deep developed on his right hip and was filled up with soft yellowish slough. He's complaining of pain in his wound.
This reflective case study will provide an account of the nursing management of a Mr Singh a 79 year old gentleman who developed a pressure sore whilst a clinic inpatient. The purpose of the research study is to enhance the reader's understanding of the importance of a structured approach to the management of the sophisticated problems he reveals with. The factors that affect wound curing will be reviewed; the medical process the use of analysis tools and good practice rules may also be explored. The good care delivered will be analysed and honest considerations will also be revealed. A rationale may also be given for the decision of dressings used in managing his treatment.
It is hoped that the acquisition of knowledge and skills obtained undertaking this research study and following representation on the health care provided, that effective strategies will be suggested in my place of work to ensure that future practice can be better.
With a sizable body indie and governmental proof supporting the necessity for post heart stroke diagnosis and management for the secondary protection of cerebrovascular situations (Team of Health, 2007; Royal University of Medical doctors, 2008; National Institute for Clinical Brilliance, 2008; Price and Keady, 2010; Furie et al. , 2011) it is an important part of the diagnosis process for factors that raise the risk of further health issues to be discovered and managed. Essentially it is vital for medical care providers to not only deal with and evaluate the impact of the original stroke but there's a necessity for even more evaluation and interventions to be identified to aid individuals to maximise their vascular health to lessen the chance of future vascular situations (Price and Keady, 2010).
For Mr Singh the nursing assessment has outlined three main conditions that increase the threat of further health complications and they are his advancing get older, his smoking and his weight. In respect of his age this isn't an element that may be addressed through nursing or medical intervention as it is something that is not modifiable; nevertheless the two main health difficulties of his smoking and weight can be evaluated and strategies carried out in an attempt to maximise his health probable.
In regards to the smoking concern there are medical and medical tools open to assess the impact and degree of dependency; including the Cigarette Dependence Questionnaire (Huang, 2010) provides a theory based approach to assessing a smokers level of dependency on tobacco so that they can develop cessation ideas, regrettably the validity of the particular tool is difficult to evaluate as the test size was relatively small (N = 256) and it was predicated on a Taiwanese inhabitants where transferability to United kingdom culture may have an effect on outcomes.
From a nursing perspective it is important to understand the smoking behavior and gain understanding of the individual's belief and description of their own smoking patterns so that involvement strategies can be utilised for maximum impact. Ridner et al (2010) identifies that the issue of smoking is becoming far more complicated than individuals being a cigarette smoker or non cigarette smoker; individuals may only smoke cigars 'socially' or smoke cigars without the data of family or friends and inability in understanding genuine smoking behaviour may effect on the nurses' potential to provide effective smoking cessation health promotion.
Once a nursing assessment has taken place of Mr Singh's smoking practices and degrees of dependency then nursing interventions may be tailored appropriately; for example whilst on the ward Mr Singh could be offered first lines treatment such as nicotine alternative therapy to aid with the physiological drawback of smoking as it is recorded by Aveyard and Western world (2007) following a meta-analysis of more than 100 randomised handled trials that all forms of nicotine replacement remedy are roughly similarly effective in aiding long-term cessation.
It is very important to the nursing examination to consider the effect Mr Singh's smoking behavior has already established on his vascular health insurance and consideration also needs to be made to how his smoking behavior prior to the stroke and following admission to hospital will effect on his treatment whilst an inpatient. A factor for example is the immediate relationship between air flow (ventilation) and blood circulation (perfusion), normally there is a balance between these two factors nevertheless the balance can be impaired significantly through a history of smoking or pulmonary problems, overweight or prolonged periods of immobility (Tortora and Grabowski, 2002); conditions that are all relevant in the case of Mr Singh.
With restricted blood flow (perfusion) there is a reduction in oxygenation and diet to cells within the body and if this isn't monitored carefully by nursing personnel then this can result in harm to muscle and organs which can impact significantly on Mr Singh's already affected health. It is also important to recognise also that oxygenated cells are essential factors in the healing process and the control of disease (Whitney, 1999).
From a medical perspective the medical staff should develop a care plan to maximise perfusion to Mr Singh's essential organs; even though he has factors that may impact on effects, this may involve the nursing staff monitoring blood circulation and oxygenation levels, monitoring epidermis integrity, monitoring the quality of peripheral pulses and the supervision of air if required.
Further medical assessments require conclusion to explore Mr Singh's current weight issues. It's been identified that he's obese and NICE direction (2006) indicates a medical evaluation must identify patients who are in risk of weight problems related medical issues. This assessment should include a careful record, physical exam (including dedication of BMI) and lab tests to recognize eating and activity behaviours, weight history and past weight loss endeavors, obesity-related health risks, and current obesity-related medical illnesses.
One key concern is the ethnical, language and customs that may effect on the nursing staff's ability to implement medical care and attention. Mr Singh is a Sikh of Indian source which is noted that British is not his main language for communication. This might present some issues particularly if the nursing team comprises predominantly of English speaking practitioners. If information is not disclosed and comprehended by Mr Singh this might effect on his recovery and ability to be pro effective in his care and treatment.
This issue is backed in the literature with studies highlighting that we now have five main social relate communication issues, which are thought as being; differences in the explanatory types of health and health issues, differences in ethnical values, cultural dissimilarities in tastes (guy/female carer, doctors and nurses), racism and perceptual bias and finally linguistic obstacles (Schouten and Meeuwesen, 2006). All these factors have a substantial part to experience in how treatment is delivered to an individual who is culturally different to the care company and literature helps that treatment providers; such as nurses, find vocabulary barriers a way to obtain stress within the work area (Bernard et al. , 2006).
In addition to the clinical features identified pursuing Mr Singh's post stroke entrance there is documentary evidence a 'red area' on his hip have been identified but no further action have been taken. Four times later a sizable cavity or pressure sore had developed which was combined with Mr Singh reporting pain.
Baronoski and Ayello (2007) claim that the procedure of quality wound treatment should commence on the patients entrance, unfortunately in this instance although an area of concern had been identified no more action have been taken which has led to Mr Singh developing a significant wound to his hip.
The evidence bottom part acknowledges that epidermis integrity issues are common place after stroke particularly if there have been impairments in ability to move (Sackley et al. , 2008) and that one-tenth of hospitalized stroke patients will develop pressure sores (Stein, 2008).
Schultz et al (2003) suggests that in chronic wounds the occurrences that lead to repair may become disrupted, the situation of Mr Singh can be an example of this, what began as a tiny area of redness highlighting an issue regarding pressure and the prospect of change to the integrity of the skin became a far more serious issue as the healing process is impaired possibly by factors such as Mr Singh's weight and poor mobility, perfusion to the region credited to vascular problems, his capacity to understand that which was going on; all contributing factors that predispose his vulnerability to the integrity of his epidermal and dermal tissue (Bowler et al. , 2001).
The management of pain in wound treatment is an important factor in the healing process as it's advocated that there are harmful ramifications of unrelieved pain which might include increased pulse, blood pressure and cardiac workload (Taylor, 2010); factors that are not appealing for Mr Singh specifically as he has experienced a stroke.
Pediani (2001) shows that from a report of 5150 clinic patients 61% of the population suffered pain anticipated to wounds and the degrees of pain were ranked to be either modest or severe in 87% of the population, from this comprehensive study it has been figured pain serves as a defensive function generally as it warns the patient of problems and will draw attention to the need for even more assessment.
Due to the communication and ethnical issues it's important that a complete assessment of Mr Singh's pain is completed and this can be achieved by utilising specific pain dimension scales such as pain observation tools like the CNPI (Feldt, 2000) or tools where Mr Singh can indicate a score graph or even to drawn encounters highlighting degrees of pain (Hockenberry, 2005); the outcome may then determine the level of involvement required so that medications and analgesia can be recommended to lessen the pain experienced by Mr Singh.
The use of evaluation tools in wound attention is not strange as a format to obtain a standardised take on what the clinical issues are; examples of such tools used in wound good care include; the 2001 Bates-Jensen Wound Examination Tool (Harris et al. , 2010); the Waterlow Report (Waterlow, 2005) as well as the Applied Wound Management Continuums (Grey et al, 2009). The books indicates that there surely is no clear evidence that assessment tools presently used accurately predict risk (Lomas, 2009) however nurses specialized medical judgement should be viewed as more effective than analysis tools by themselves (Gould, 2004; RCN/NICE, 2005).
Most analysis tools are reported to be of low quality in respect of methodological rigour, sample sizes and populations, and outcome measurement, resulting in them being vunerable to bias (McGough, 1999); in conclusion examination tools should be utilised as an aide memoire and really should not replace scientific judgement (Royal School of Medical, 2001).
NICE (2005) suggest that the use of modern dressings support restorative healing and types of these interventions include; alginate dressings, hydrocolloid adhesive dressings, hydrogel and foams in preference to basic dressing pads and gauze which do not support restoration in the same way.
For Mr Singh; the standard of his wound may require a higher absorbency dressing to ensure that the dressing can absorb the exudates levels rather than allow any further pass on to peri- wound epidermis (Wicks, 2007) and also the nursing team should send for advice from experienced experts such as a wound health care specialist nurse to ensure interventions are information based and effective.
The Wound - Professional, Ethical and Legal Issues
Mr Singh was not admitted with a wound and the evidence suggest that it developed as a result of the serious medical center environment and staff members perhaps not conducting a thorough analysis of the risk factors (fatness, perfusion and vascular complications, poor mobility) that could determine if Mr Singh was at high risk of developing complications with his pores and skin integrity.
Record keeping and communication is also to be analyzed in cases like this review. The NMC (2010) provide listed nurses with concise guidance regarding their responsibility and accountability to patients in making sure record keeping and documentation is of a higher standard. Record keeping ensures there is certainly documentary information that assessments, care and attention planning, relevant information, the care and attention continuum which affordable steps have been taken to provide look after the individual have happened (Real wood, 2003).
It is observed in the case research that Mr Singh has portrayed a inclination for his partner and Daughter-in-Law to provide personal care, therefore a chance for the professional to determine and screen the integrity of Mr Singh's skin area has been removed by this delegation of care and attention; communication should be increased between the gatherings to ensure there is nothing missed.
The nurse might well have asked Mrs Singh if she seen and grades or red areas on her husband's skin when she was supporting him to improve his Pyjama's; If communication is difficult because of ethnic and language barriers then meetings and conversations with family should be performed with interpreter support to ensure information is transferred and received with understanding.
For Mr Singh to have developed such a substantial wound in such a short period of time raises the problem of medical negligence and when scrutinised it is ultimately the responsibility of the professional nurse to justify why they may have or have not taken a particular course of action (Hardwood, 2003).
Consequentialist theory in moral reasoning recognizes that the rightness or wrongness of the work should be judged entirely on whether the implications produces more benefits than cons (Seedhouse, 2005). In cases like this example it is obvious that the results of the medical staff not evaluating and conversing on the issue regarding Mr Singh's pores and skin integrity has resulted in the introduction of a big and agonizing wound, the consequences of the (absence) actions have recommended health compromises for Mr Singh, increased treatment needs and intervention, possible prolongment of clinic admission, threat of infection in addition to the professional results to be experienced by the nursing personnel and the NHS Trust as employers.
Deontological theorists would claim that what counts most in this example was not the resulting wound experienced by Mr Singh however the proven fact that the medical team acted corresponding to a recognized work or responsibility; however this moral standpoint cannot be adopted as Mr Singh did not develop the wound irrespective of all nursing policy and method being followed but rather as a direct result of what was not done alternatively than what was done.
Patient Health Promotion and Education to Prevent Future Wound Development
Downie and Tannahill (1996) suggest that health promotion consists of efforts to improve positive health insurance and reduce the risk of ill health insurance and for Mr Singh which means that support and education for him and his family to maximise their knowledge and understanding of what is required to support the recovery of his current wound and also to be aware of measures that may be adopted to reduce the chance of him developing wounds and pressure sores in the foreseeable future.
Patients with pressure ulcers and wounds are to be actively inspired to mobilise or change their position frequently to market therapeutic (RCN and NICE, 2005) and ensure other areas of the skin continue to be intact. If Mr Singh encounters difficulty mobilising or must remain in foundation for long periods then it is advocated that regular making and movement, recognized with a pressure minimizing mattress maximises skin area potential and is an efficient method in protecting against ulcers and skin wounds from developing.
Nutritional advice and diet education should be provided to Mr Singh as optimising the structure environment for wound treatment by encouraging dietary balance is advocated (RCN and NICE, 2005); this might entail a referral to the specialist dieticians. Mr Singh is obese and part of the assessment process should include the completion of a verification tool like the MUST (Malnutrition General Screening Tool; MAG, 2003) that will identify under or higher nutrition and following that nutritional strategies for weight loss involving nutritional supplements, nutrient limited diet and energy limited diet can be viewed as (Shewmake and Huntington, 2009).
It is important for health promoting advice and health education to be communicated to Mr Singh and his family to guarantee they are able to make the best choice about health behaviours and also develop a knowledge of what their role is; therefore steps must be studied to facilitate this technique by maximising understanding by including a translator to be present during these exchanges. And also the transition from medical center to community should supply the opportunities for support to be established on discharge for Mr Singh and his family to ensure any health issues needing ongoing interventions are dealt with and that any more health campaign and education is prolonged throughout the healing process.
Wound Attention - Developing Clinical Practice
Once Mr Singh has been assessed to be medically stable and discharged home then ongoing support would be provided by the city nursing service in an attempt to continue the dressing and diagnosis of Mr Singh's wound.
Community nurses visit patients at home, nor have access to the resources and materials that a hospital founded nurse may have and in light of current slashes within the NHS nurses are under higher pressure to provide the best standard of care for the cheapest cost. Additionally it is important to recognize that wound care products are costly and are sometimes available to patients on the prescription only basis locally thus incurring a financial fee to the patient.
It is with this at heart that a literature review was conducted to obtain a clearer point of view of whether tap water could be utilized by nurses for wound cleaning locally setting rather than pre packed sterile water currently; plain tap water is commonly found in the community anticipated to help ease of availability and low priced, however this is not extensively advocated and controversy surrounds this practice (Fernandez et al. , 2007).
It has been recommended that there surely is less risk to the individual of contamination when plain tap water is used compared to saline drinking water (Fernandez, 2008) however this data was developed by the analysis of chronic wounds and did not emphasize the difference in severe wounds.
The evidence basic identified centered mainly on quantitative rather that qualitative data with the use of convenience sampling (Teddlie and Yu, 2007) undermining reliability and the test groups used composed of greatly readily available wounds (Valente et al. , 2003) which also impacts on rigour and stability. In light of the review however the evidence does indeed support the benefits of using plain tap water for cleaning wounds however with the primary bodies of research being conducted in the hospital preparing more qualitative data is necessary in a community based mostly environment.
Wound treatment is a sophisticated and time consuming concern which requires high levels of assessment and knowledge specifically with regards to good practice in nursing look after wounds. It really is imperative that nursing practitioners take part in good practice that inhibits the occurrence of wounds and pressure sores in the beginning. In developing understanding of contributing factors to the introduction of wounds and the sophisticated nature of the patients' health needs facilitates the idea of preventative wound treatment.
If wounds do develop then nurses knowledge surrounding management and treatment should echo criteria of good practice and professional medical advice to ensure patients receive evidence based interventions so that they can solve and treat wounds efficiently and effectively.
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