Holistic Healthcare for Acute Patients

Background

In the mentioned case study scenario Daniel who is 70 years old man and was admitted to the hospital for resection of the bladder tumour. The whole surgical process was great and being the nursing member of the hospital I was assigned to take his care during operation and also during post-operative scenario. As the surgery was carried out in the morning he was recovering in the day surgery unit, he was fine at that time. He was inserted with catheter and a mild presence of blood cell in his urine (haematuria) was observed but just an hour later it was observed that the catheter bag was full and excessive haematuria was occurred. He was suddenly got drowsy and I rushed to check all the vital parameters. I observed that respiratory rate was 26 breaths per minute at that time, oxygen saturation was 90% on the room air, pulse rate was 124 beats/unit, blood pressure systolic was 90 and diastolic was 60 mm Hg, the refill time for capillary was 4 sec and the body temperature was 36 degrees. It was found at that time all the vitals are above or below normal level in human. Pulse rate is too high whereas the blood pressure fall down, so I decided to take critical care for this complex unpredictable situation of Mr. Daniel. In the following section of the essay I am going to discuss the holistic healthcare and the priorities of care by following the nursing assessment for this acutely unwell patient for first 24 hrs following admission to hospital, in the light of knowledge based on physiology, pharmacology and anatomy for this certain condition.

Holistic healthcare of adult of acute unwell condition by variety of health setting

To take proper care of this patient who is suffering from complex and unpredictable situation the proper knowledge for this disease pathophysiology, pharmacology and anatomy of human body were needed. Resection of bladder tumour also termed as the trans-urethral resection (TURBT) is the first line of treatment for the patient who was diagnosed to have bladder cancer. In the first stage the surgeon will remove the tumour from bladder through the urethra which is the urinary tract (Mostof, et al, 2012). To do the TURBT firstly the bladder cancer was checked by cystoscopy where the clinician checked the urinary bladder lining and the urethra with the help of apparatus known as cystoscope having a lens and got inserted into the bladder (Richterstetter, et al, 2012). He was given spinal anaesthesia and after that TURBT was done. When the lens detects the tumour cell a surgical instrument just flowed by the lens will cut out the whole lesions. Other methods are also there to detect bladder cancer and which will followed by the TURBT, these are imaging by using narrow band, here different colour of lights are used which will pass through the tissue and will enter into the bladder region which is affected. Another such technique is photodynamic diagnosis (PDD), where surgeon treats the patient with dye before TURBT and this blue dye is sensitive to light, during the surgical time it will shine and show the proper lining of bladder that will make the resection easy (O'Brien, et al, 2013). The whole surgery takes 15 to 20 minutes. After the surgery the patient mat treated with chemotherapy after 6 hrs to remove any residual cell to reduce the risk of bladder tumour. A nurse like me, who was taking care of such patient must be aware of the anatomy of bladder tumour/cancer as well. Basically the bladder cancer starts when uncontrolled cell growth was observed into the urinary bladder, which is situated in the lower part of pelvis, works to urine store and passes the urine through the urethra. Thus during the cancer the tumour cell formed within the urethra and bladder. Urinary bladder has many layers, the carcinoma condition starts from the innermost layer for bladder lining and spread very rapidly to other layers. So in first place the removal of tumour lesion was needed for this patient. As a nurse holistic care of this adult of complex situation was needed. When Mr. Daniel arrived for pre-assessment before operation about 2 weeks ago I took his care, by doing the measurement of height, weight, oxygen saturation as well as the blood pressure measurement for that time, also the body temperature and pulse rate were checked. I noted it down at that time as I need to compare the values after the operation, to check how much it would change and varied time to time which was unpredictable situation for acute unwell patient. I instructed him regarding the method and mode of operation after consulting with the Doctor, and told him what he had to bring during the time of operation. I suggested him to bring the bag having things for overnight stay, if the situation would arrive where I need to check him thoroughly due to post-operative symptoms got unpredictable. When he arrived in the hospital on the operation day I again checked all his vitals before the operation starts and took him to the operation theatre. After the successful operation I applied some local pain relief in the injected area for anaesthesia. Then I inserted the catheter to collect the urine and observed small amount of blood cell in the urine, which was quiet normal, but the need of critical care arise when after one hr when the bag was full with urine and excessive haematuria took place. From this point a critical care was needed for the patient. His vitals also got changed rapidly in an unpredictable manner. Then the holistic approach along with discussion among the whole operation team was needed. I managed to call the authority to arrange an emergency meeting to discuss this patient’s health condition by starting to give him proper care.

In such scenario one of the most important part was drug dose calculation, which was administrate for the patient. In the nursing practice core skill is to manage the dose of medicine properly. Around 11% patient’s reports due to medication incidents got registered by ‘National reporting and Learning system’ in England in the report of 2012. Among them 90% did not affected in the extent which cause harm in the patient but few of them were critically suffered due to this. So management of drug dose was very important for the patient by doing the competent numerical calculations of drug dose. McMullan and co-workers observed that 45% and 55% of the registered nurses and students respectively failed the test of numerical analysis on the other hand 89% and 92% of nurses and students respectively failed the drug calculation test. Older participants with age of 35 years were found to be more able in performing numerical calculations, irrespective of their status or level of experience. There was almost no significant difference in terms of statistics between the nursing students and the registered nurses in terms of their ability of overall calculation of drug. However, nurses have significantly more ability over the students in terms of basic calculations regarding numerical detection for oral liquids, solids and injection during anaesthesia. Both student and nurses were found to be able to perform numerical calculation for solid, liquids and injection than the calculation for percentage of drug, rates of infusion and drip. They have prescribed that registered nurses should practice and fresh-up their skills for drug calculations in a regular basis. More emphasis to be given on the learning of numerical calculations by the student nurses (McMullan, et al, 2010). Eastwood et al. showed that poor mathematical skill among the registered and pre-registered nurses due to major error in conceptual, numerical and computational understanding. These problems have made them poor during calculation of formula and equations and sorting of mathematical errors (Eastwood, et al, 2011). Kohtz et al, checked the extent of incorrect calculation by the pool of senior undergraduate and nursing student using two approaches namely dimensional and conventional analysis. They mainly focused on the accuracy in conceptual level (Kohtz, et al, 2010). McMullan et al, in another study found that students with e-learning and learning by receiving handout have different skills of drug calculations. It was found that students guided with e-packages and efficient in calculation. The e-learning process was based on cognitive load theory and they showed more improvement than the students supplied with handouts. It was also found that the e-learners were more satisfied about their study pattern (McMullan, et al, 2011). Coyne et.al, figured out that the main factor that influences the student nurses ability of medicinal calculations precisely and their skills of identification of errors. These abilities include mathematical aptitudes of multiplications with decimal figures and are mainly abilities of doing mathematical calculations, using medication formulas and medication dose conceptualizations (Coyne, et al, 2013). This evidence based supports proves that this patient’s dose of medication must be strictly regulated and after the conditions he was facing due to post-operation must be took under control by proper medication.

Priorities of care by nursing management

To take the immediate action for individual care, here in the case of Mr. Daniel I check the priorities by following the ethics of professional practice according to the Nursing and Midwifery Council’s regulation of code (NMC code, 2018). First and foremost duty was to check what was happened after the surgery. As I was aware of the risk after the resection of bladder tumour by TURBT. Those were mainly the excessive bleeding, blood clotting in the urine and extreme pain during urine pass, even constrains during passing the urine. Complications arose due to infection when excessive urine is passing out and stored in catheter. His pressure was falling low and the body temperature reduces as a consequence. I immediately consulted with the ward manager, he then contacted with the doctor to know whether his bladder got injured during the resection. Doctor assured that there is a feeble chance of injury of urinary bladder and that can be settled down with insertion of catheter in the patient. Saline and drips were introduced to the patient for the time being until and unless he is in the condition of taking food properly. I asked him about the pain he was feeling and according to his body weight and other vitals after consulting with the doctor I gave him a painkiller drip by patient controlled analgesic (PCA). So thereafter a pain management was needed, which had further arranged by the line manager of the ward. Also then a local anaesthesia was introduced by a thin tube into his back portion to get relief of the pain. I found that there was no need to administration of other drugs as all the other vitals are under control but this patient needs a thorough observation for 24 hrs after the operation. Being a cancer patient there was an immediate need to give a chemotherapy after this surgery. Palou-Redorta et al, suggested that immediate chemotherapy is needed just after the TURBT of the ‘non-muscle invasive bladder cancer (NMIBC)’ patients in Europe. He suggested that there was a huge discrepancy among the need of use of chemotherapy after resection of bladder tumour but overall the cases of re growth of this tumours diminishes after the therapy (Palou-Redorta, et al, 2014). In contrary in a recent study Do, et al, suggested that overnight administration of saline reduces the chances of recurrence of bladder cancer (Do, et al, 2018). In other way Stroman, et al. suggested that 39% of the patients after the TURBT faces the recurrence of those tumour tissue due to the re implantation of resected tumours cells inside the bladder wall, thus the intra-vesicular chemotherapy technique will inhibit the DNA synthesis, so tumour propagation will stalled (Stroman, et al, 2016). Here also the patient was decided to treat with chemotherapy and that would be after the haematuria problem get recovered.

Here comes the theories of ethics in nursing practice, a series of ethics should be followed by nurse while handling such cases of complex and unpredictable situation (Holt, et al, 2012). According to the NMC standard, before doing any actions the nurse first ask consent from the patient or his family. The nurse should keep the case confidential and respect of the individual should also be conserved. The nurse should consider about the communication skills to communicate properly and respectfully with the patients of multiple ethnicity and linguistic background (NMC code, 2018).

Holistic care of adults with evidence based practice for complex healthcare

The best way to give the proper healthcare for this patient having complex problem is holistic care with evidence based practices (EBP). Being a trained nurse I always depends on the evidence based practice. In this case study of Mr. Daniel, first I took the evidence based approach after the treatment based caring (Melnyk, et al, 2011). Such evidence based practice in nursing care makes the case study easy by making the care redesigned by making it effective more confident and safe. This will ultimately make the nursing system education also effective by remodelling theories and the development of nationwide network for scientific research based on healthcare development. EBP gives the cumulative effect from the past studies and the practice by nurses to make the current case more realistic and the decision making ability gets improved for common care sector. The evidence-based practice underpins three kinds of high quality practices, like services with interventions, health outcomes with fulfilment of most desired target and a thorough consistency with the contemporary research-based evidences. This practice asserts a strong belief of practice which comes from reliable source of knowledge and makes a huge change in patient’s health status to get positive outcomes. EBP is a knowledge based input in profession and it goals towards best quality. It also removes illogical and irrelevant variations in care giving by standardizing the process with best pool of scientific evidences. It is an integration of evidence obtained from expertise of clinician and from the values of patient. Therefore, evidence based practice brings together research evidence and expertise to encourage individualized care giving through prioritization of preference of a patient. Initially the meaning of EBP was big distorted but with time it has immerged as most useful tool for nursing and at the same time it also aligns the nurses towards vast knowledge of clinical practice (Dogherty, et al, 2010). The originality of EBP lies in cultivation of knowledge through systematic enquiry. The experience of clinician and the values of individual synergise the process through endurance. This method in current days going beyond prototypical models of healthcare and nursing and also it is bringing forth new roles, new models, new interpersonal skills, new culture of practice and above all new form of scientific faculty. It is making a paradigm shift in health care and now the nurses are also becoming careful and aligned towards the research results. (Malloch, et al, 2010; Stevens, 2013; Mackey, et al, 2017)

These were implemented for the care of Mr. Daniel. As from evidence the bladder tumour resection surgery supports needs patients centre approach which considers patients’ emotional, psychological as well as social wellbeing. Better informational support and high level of involvement during the process of making decision and during treatment exercising choice can have pragmatic effect on the outcome. More over this practice of evidence and research gives significant input into the knowledge of clinical nurses and also allow them to harvest their knowledge among other. National Institute for Health and Care Excellence (NICE) has set forth quality markers on the experience of patients in the service of adult NHS (NICE, 2012). This aims towards the enhancement of patient’s satisfaction. Here it is important to allow the patient to take part in decision making. It is always important that the patient should discuss about the choices of treatment with their partners, carers or some other supporting person. This is very important as the pathway of treatment is sometime distressing and making a decision is very difficult (Clark, et al, 2013). There are various kind of treatment available which have different survival rate and impact on sexual health, body outlook and relationship (Blick, et al, 2010). Therefore the patient should always give a second thought of the mode of treatment. Here in our case we took the patient for 24 hrs observation and after that we would talk to the patient and his family regarding the chemotherapy that might be provided.

Interpersonal communication, team work for complex healthcare

As this case study is the complex one, a proper interpersonal communication and team work was therefore needed. Here it was important to communicate with the patient very carefully as he was suffering drowsiness after the operation, so it was utmost necessity to know that what he was facing. If this drowsiness is due to the effect of anaesthesia then I needed to communicate with the anaesthetist immediately and it was fully due to pain as the catheter was inserted, then I should communicate with the pain management unit after talking with the line manager of the ward. As mentioned in the SAGE handbook excellent interpersonal communication is always an advantage for complex healthcare treatment (Knapp, et al, 2011). Hence an excellent team work was needed, where I could talk to the doctor whenever I need for administration of drug, I could consult with the anaesthetist regarding the drowsiness and the management team of the hospital should take care of the patient’s needs whenever I informed them. McCulloch, et al, have discussed the importance of team work and communication to avoid errors in healthcare (McCulloch, et al, 2011). After the 24 hrs observation he needed a physiotherapist for making his movements easier as he was inserted with catheter.

Conclusion

In the current piece of report critical case study of the patient Mr. Daniel has been done using proper knowledge of physiological and pharmaceutical factors required for holistic care in complex situation. During the treatment an evidence based practicing method has been followed to achieve quality outcome. The norms and intricate details of drug-calculations, critical analysis, and delivery of safe ethical and professional practice were kept in mind and discussed in the report. From the reflection of the performance it has been concluded that holistic care with involvement of patient is always necessary to make a complex healthcare successful.

Reference

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