Introduction within the care of a patient

IntroductionThis case study will look intoa patient’s journey from primary care into secondary care and the partnershipworking of different trusts and multi-disciplinary teams. This case study willexplore the physical and psychological impacts on the patient and her family,while looking at tools used during her care. For reasons of confidentiality thepatient’s name has been changed to Mrs Light. Under the National Health Service( NHS) constitution everyone has the right to confidentiality and privacy. Forthis case study the identity of the patient, staff and the identity of theprimary and secondary care settings involved in the care of Mrs Light have beenanonoymise . All information regarding them and their care is to be kept safeand secure (NHS constitution 2013).

This patient was chosen due to thecomplexity of the case which involved clinical, physiological, social, andpsychological and the emotional elements involved in her care . Yura and Walshdescribe the nursing process as a problem solving approach where nurse andpatients working in partnership undertake four steps within the care of apatient these include identifying problems together and the causes that requireintervention, making plans that remedy the identified problems, taking steps toevaluate the problems and to reflect on what has happened. The principals ofnursing practice are of high importance within person centred care and havemany different aspects which includes patient dignity, respect, privacy andcommunication (Department Of Health 2006, Royal College of Nursing 2008).All ofthese aspects will be discussed and identified within this case study .

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Thereare eight Principals of nursing care these are identifies as nursing staff totreat everyone in their care with dignity and humanity, they need to showcompassion and sensitivity in providing patient care while treating everyonewith equally, Nursing staff are to take responsibility for the care that theyprovide and are accountable for their own actions. Nursing staff must managerisk and help to keep everyone safe, Nursing staff to promote person centredcare ensuring patients  and theirfamilies/carers help patients make informed choices regarding their treatmentand care, Nursing staff are to assess, record and report the treatment of a person’scare and handle information confidentiality and sensitively and are required todeal with complaints effectively, Nursing staff must have up to date knowledgeand skills and use these to have an understanding with the needs of patientswithin their care. Nursing staff are required to work closely within their ownteam and with other multi-disciplinary teams ensuring best outcome for patients.Nursing staff are to lead by example and to develop themselves and othernursing staff and influence the way care is given.  BackgroundMrs Light attended the localurgent care service in the community during the week for a routine dressingchange as her GP practice was unable to offer an appointment. The Urgent CareCentre is a walk in and wait service whereby patients are called for a triageassessment shortly after arriving. The assessment is an interactive processthat underpins all aspects within nursing care (Heaven and Maguire 1996)  this looks at focusing on patient’s responsesto health rather than disease process and pathology (Wilkinson 2007).

TheManchester triage group was first identified in 1994 with developing systems toensure patient care is defined according to patient needs within a timelymanner using algorithms and national targets .It is a tool used in walk incentres and Accident and Emergency Departments as a system of patientprioritisation. Within this system questions regarding patient presentation tothe urgent care centre can be identified. As part of the initial assessment reasonsfor attending the service are taken including patient history including patient’slifestyle, family history and the presenting complaint of illness or injury(Crouch and Meurier 2005 ). An assessment is understood by Holt 1995 as the individualisationof a person’s care while understanding the uniqueness of each patient  andrecognising this within the care process. The effectiveness of the assessmentis a starting point a vital part in monitoring patient care, ongoing assessmentand 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 developedto given practitioners a structure in order to identify the analytical andproblems solving skills that are required for effective patient assessment andongoing care.

In order to determine which Nursing modelling tools should beused within patient care the approach should be sensitive in order not todiscriminate between patient’s different clinical needs. Mrs Light had incision and drainage to anabscess at the base of her neck at local secondary care trust three day priorto arriving at Urgent care. Patient’s medical history is taken (currentmedication, allergies, any medical history relating to care and also any socialaspects) the patient had no previous medical history; she had recentlycompleted Course of antibiotics for the abscess which was started prior tosurgery from her GP prior to surgery she had been prescribed pain relief of         co-codamol 30/500mg (30/500–60/1000?mgevery 4–6?hours as required; maximum 240/4000?mg per day( BNF however patientstated 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 housewife with 3 grown up children .Patient stated since operation she has beenfeeling very tired and was advised to rest but has been completing normal dailyhouse hold cleaning .This information was obtained from the patient and isimportant 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 andoxygen saturations all reported as within’ Normal limits’.

Observations is aterm which refers to the physical assessment of a patient , Vital signs are acollection of hearth rate, blood pressure, respirations, temperature and pulseoximetrey. Taking these as a part of the assessment process act as a baselineto determine a patient’s normal range (Bickley and Szilagyi 2009) It is importantto understand if vital signs are outside the normal range as this wouldindicate the patients deteriorating condition and the need to alert theregistered nurse and document the results (Keisiel and Perkins 2006 ).Mrs Light is three dayspost-operative following an incision and drainage to/of an abscess of her lowerposterior aspect to her neck.

An abscess occur when an area of skin/ tissuebecomes infected, the tissue wall collects pus. This area develops into a lumpand people can become unwell with it ( ). The procedure ofincisions and drainage of the infected area is an operation undertaken inhospital under local or general anaesthetic depending on where the abscess islocated. 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 dressingto allow the surgical wound to heal. Primary care visitMrs Light was discharged froman acute hospital trust early the next day with what patient states as verylittle discharge information hence why Mrs light arrived to us three days postoperation as the patient stated she was unaware of when a dressing change wasrequired .

Patient was given a discharge letter to bring GP practice or Urgentcare setting when required a dressing change .After triage Mrs Light was calledin by a Health care assistant for a dressing change. The Treatment room anddressing trolley had been already prepared prior to patient arriving intreatment room. The Health care Assistant (HCA) introduced herself to thepatient and explained the procedure and asked the patient if she had any questionsprior 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’sbody language, lack of eye contact and through verbal communication to the HCAasking ‘will it hurt ‘, ‘ how long does it take to heal ‘. Patients cannaturally have an emotional response to an illness while in the care of ahealth care professional; this can be reflected in a patient’s emotionalresponse to care (NICE 2004).Communication is both verbal and non verbal and isimportant in developing relationships (Sale and Neale 2014) , non verbalcommunication make up 85% of all communication as demonstrated by the patient(Blazer and Riley 2007).

Failings within communication between patient andclinician are known to have detrimental outcomes and poor patient experiences(Parliamentary and health ombudsmen 2001).The HCA responded to the questionsasked by the patient. The patient had not had any pain relief until seen intriage 20 minute prior to being called for a dressing change. Verbal consentwas given by the patient for dressing change.

Consent by law is a voluntarilyagreement with an action or task performed by another, this can be gainedverbally and non verbally, informed consent where patients have knowledge andcomprehension and the consent is given freely without duress or any undueinfluence , the patient also has  theright to withdraw from the procedure (Miller –Kane  2003). In order to give consent the personmust have capacity to be able to consent to the treatment and to have toability to retain the information given to them. A person is presumed to havecapacity unless it is established that they lack capacity, if there is anydoubt an assessment should be completed (Mental capacity act 2005 ).The Nursingand Midwifery Code of conduct states that nurses and health care professionalshave a responsibility to gain consent prior to treatment, to respect and supportpersons rights in accepting or declining treatment, to up hold the right of theindividual in decisions’ regarding a person’s care and be able to demonstratethat they have acted in a person’s best interests.

 As patients pain score was 7/10 using theNumeric pain system where  11-point numericscale 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 experiencingit says it is (McCaffery 1989) Due to thepatients pain score HCA offered the patient Entonox as per administrationprotocol as unregistered the HCA wouldn’t be covered to give the Entonox to thepatient ,the HCA discussed this with a registered practitioner in order to beprescribed for the patient to obtained the appropriate  pain relief for the patient .

The patient wasasked to lie on the patient couch The HCA then preceded by using PPE andAseptic Non Touch Technique (ANTT). While patient was led on her side takinginstructions on how to use the Entonox and constant communication with the HCA.The HCA started by removing the previous dressing and gently removing the wickthat had been used to pack the cavity this had become stuck due to the time thewick had been in the cavity . The patient started to show signs of autonomicresponse to the pain that she was experiencing . The patient started bycommunicating to the Hca she felt tired, hot ,sweaty and the HCA notice thepatient became sweaty and pale . The Hca decided to stop the removal of thewick where the patient then became unresponsive but breathing and not communicatingthe HCA then called for help using the emergency button to alert the registerednurses 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 thepatient care .Intuition has been described as the understanding without arational and without conscious use of reason (Schrafer and Fischer 1987) accordingto Benner’s  novice to expert this is animportant theory within the nursing field.

Intuitive experience can lead tomoral reasoning and personal knowledge. This is explained over the five stepswithin the theory being novice, advanced beginner, competent, proficient andexpert. When help arrived the patienthad started to respond at approx 30 seconds after becoming unresponsive, bloodpressure, heart rate and blood oxygen saturations were taken recorded anddocumented. The patient became less responsive for a 2nd time witnessed by theregistered nurse an ECG and Blood glucose test was taken as per NICE guidelinesto rule out a cardiovascular event and low blood sugar levels. With supportfrom the registered nurse the HCA was able to look at the wound and repack andredress the wound.

The wound appeared pink and healthy tissue with no signs ofinfection. Signs of a wound infection would include erthymea (redness),swelling, heat from wound area, fluid or slough and mal odour from wound. Oncepatient had started to respond the HCA and registered nurse were able to slowlysit the patient up and offer her some water. The Hca asked the Registered nursewhether a lying and standing blood pressure should be taken as part of theassessment however it was discussed a with the patient and felt due to thepatient feeling unsteady it would not be appropriate . The lying and standingblood pressure would give evidence regarding a postural drop in blood pressure.Under NICE guidelines when a patient lies down blood pressure is recorded andtaken again once patient is standing. If the difference of lying to standing is20mmcmg further assessment is required.

The patient’s husband arrived in toroom and patient felt she was able to sit on the edge of the patient bed. Whilethe HCA was communicating with the husband (consent from patient was given forthis to happen) regarding the wound and dressing changes the patient started tostare and became floppy, the  emergencybell was pulled and the patient was led back on the bed and furtherobservations 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 registerednurse and offered the patient clean clothes ensuring patient privacy and dignity was maintained at all times bydemonstrating empathy and compassion towards the patient. Empathy is amulti-dimensional concept of emotional and behavioural aspects within nursingcare.

It involves the ability to understand the patient’s perspective andfeelings while in the  nurses care .Compassion is another key concept within the nursing process (Johnson 2008)However in over  time it has beenexpressed  that health care professionalshave witnessed a decrease in the caring and compassion due to other task thathave taken priority over holistic care (Pearcey, 2007)Due to the pattern recognitionof the patients symptoms along with the diagnostic reasoning this led theregistered nurse to deciding the clinical judgement of patient follow on care .The registered nurse discussed with the patient and her husband that as we wereunable to investigate further into the vacant episodes the patient wasexperiencing it was advised to attend the local Accident and Emergencydepartment. The Patient at first declined and wanted to go home but it wasexplained 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 toher as she was unable to remember what had happened and was able to make aninformed choice regarding her care. When ambulance arrived the registered nursegave a verbal hand over using the situation, background, assessment andrecognition (SBAR method) this   is a tool used nationally to simplify andstandardised communication within local teams and multidisciplinary teams. The patientwas transferred to Accident and emergency department for medical diagnosticstest . The patient notes including a nursing diagnosis of  multiple vacant episodes with no obviousunderlying infection or cause identified. The nursing diagnosis provides afocus for planning and implementing evidence based effective care andidentifying appropriate interventions. A nursing diagnosis has been describedas patient illness that can be managed by nursing expertise (Leih and Salentijn1994) , while on route the patient had another vacant episode totalling 4within a two hour timeline. This was communicated to the nursing staff whenparamedics arrived for another patient later in the shift. As an Urgent carecentre we were not able to routinely follow up  patient.

The patient had presented atthe Urgent care centre for a regular dressing changes first being 3 days afterbeing sent into hospital. The patient had reported that she was discharged fromhospital after 2 days, blood test and scans were taken and was medicallydiagnosed to have a nerve damaged in her neck where the incision and drainageoperation had been. However if the test returned inconclusive the patientphysical response could have been due to poor pain management and other factorsincluding anxiety.

The patient now needs follow at a local tertiary care trustfor epilepsy and has regular vacant seizers on a daily basis. This had led thepatients’ 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 includingmoney for food and social event which has affected her psychologically andphysically.ConclusionIn conclusion this essay haslooked at the journey of a patient self presentation into primary care intosecondary care with ongoing treatment and assessment at a local tertiary caretrust. The combination of the multidisciplinary team working from primary andsecondary care and the team working, communication, documentation andappropriate referral from within the urgent care centre led to promote apositive outcome of care for the patient. Local and national policies alongwith screening tool have been included.

Improvements identified within thiscase were the lack of practice nurse appointments, Lack of information topatient upon discharge  from a secondarycare trust; this led to the patient being anxious regarding her care, if thepatient had been given more information regarding her after care she may havebeen less anxious and have been able to manage her pain better and have madebetter informed choices regarding her care and ongoing management .     


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