Introduction
The case study analysis a female patient with hypotension and Alzheimer’s disease who recently suffered a fall. The Nursing and Midwifery Council (NMC) code 2018 and Data Protection Act (DPA) 2018 require nurse-patient confidentiality. Therefore, in the analysis of this case, I will refer to the female patient as Elsie.
Pathophysiology and Treatment Option
Elsie was admitted from a fall at home. On her arrival to the hospital, her medical history was obtained by consulting her and retrieving patient records. The record showed that Elsie had hypotension and newly diagnosed with Alzheimer’s disease. Hypotension, also known as low blood pressure, is a health condition where blood pressure readings are less than 90/60 mmHg (National Health Service (NHS), 2020). When the blood pressure drops, the heart rate increases hence interfering with the functioning of cardiac system.
The patient presented symptoms such as pain and swelling on her right hip, inability to bear her weight, difficulties lifting her right leg, and her right leg appearing shorter and turning outwards. Alzheimer’s disease is a common type of progressive dementia that begins with mild memory loss leading to inability to hold conversations and respond to the environment (CDC, 2020). Elsie also reported Alzheimer’s disease symptoms such as memory loss, challenges in solving problems, and confusion with place or time. The patient presented femoral neck fractures, which prompted an X-ray and MRI scans, upon which results confirmed a diagnosis of displaced intracapsular hip fracture (NHS, 2019). Elsie also reported episodic blurred vision, confusion, and fainting, which might have contributed to the fall.
Following her unstable mental health resulting from Alzheimer’s disease, Elsie could not proper physical body function. Due to challenges in memory and confusion, among other symptoms, the patient could not perform activities of daily living such as cooking and cleaning (McCormack et al., 2021). The base level of Elsie is low, meaning that condition she was admitted could not allow her to do normal activities such as walking, cleaning or even gardening. After her fall, the various body inabilities, such as weight bearing or general body movement, reduced her physical functioning. Even if she could move, Elsie would have trouble recognizing and moving to the right places due to her inability to function properly. Following new diagnosis of displaced intracapsular hip fracture, Elsie’s most relevant form of treatment would be surgery.
A prosthetic replacement surgery should be done on the day or the day after patient admission to prevent increased mortality in neck of femur fracture patients. Before the procedure, Elsie must be assessed for correctible co-morbidities such as uncontrolled diabetes and uncontrollable heart failure must be treated upon detection (National Institute for Health and Clinical Excellence (NICE), 2017). When the candidate is ready for the surgery, she must be advised about her anaesthesia options. In this case, Elsie cannot opt for general anaesthesia because of her diagnosis of Alzheimer’s disease and the recent fall, which increases her health risks. The surgical procedure entails removal of femoral head from the socket joint, acetabulum, and the socket of the ball (femoral head) (Felton et al., 2019). A post-surgery recovery plan for the patient consists of physiotherapy and analgesia (NICE, 2009). Elsie would be given pain management medication including morphine, meperidine, and Percocet (NICE, 2009). Physiotherapy should be done once a day so long as the doctor proves Elsie medically fit for it.
Pain Management in Nursing Practice
Pain management consists of multiple strategies, such as administering pain medicines, physical therapies, and complementary therapies. A Nursing associate (NA) is responsible for observing and assessing the pain management process and reporting findings to colleagues, working in partnership with the multi-disciplinary team (NHS, 2022). In this case, Elsie would need a complex combination of pain management strategies which requires closer observation and pain relief assessment. The NA would work towards ensuring that Elsie is physically able to participate in physiotherapy sessions (NHS, 2022). Such duties ensure complementing registered nurses’ pain management procedures by advising on most patient-beneficial strategies for her recovery (Roland, 2018). Elsie would experience difficulties moving to and from the toilet hence would need help. However, in contrast contemporary quality improvement research in infection control recommends against the use of Urinary catheters to reduce the rate of post-surgical urinary tract infections (Thakker et al., 2018). Therefore, I would support her when she needs to move for convenience.
Other care management strategies would entail informing the responsible doctor or specialist nurse about the patient’s needs. For example, if the patient finds difficulty drinking or eating due to nausea, I would provide mouth care and other necessary support. Upon the doctor’s review, I would communicate Elsie’s changed fluids needs, especially if she is no longer nauseated. Nursing demands continuous communication with and from the patient’s other attending professionals (NHS, 2020). Communication would bridge the gaps between registered nurse observation and assessment and general reporting. For example, I would ensure that Elsie gets sufficient IV administration by communicating to the nurse in charge because she may be dehydrated due to low blood pressure and general interference of cardiac system. Additional duties would demand increased supervision of Elsie to monitor and record what is observed (NHS, 2020). The NA would also undertake medication administration, dressing, and liaising within the multi-professional team.
The nursing implications of the case study should be the promotion of clinical effectiveness to ensure patient welfare and safety. The National Health Information Service (2022) provide that effective pain management interventions involve a personalised care plan, including patient counselling and psychological support. The NA could develop and deliver patient support by making conversations to inform and know the patient. The NA constantly notes the patient’s preferences in the treatment process and informs colleagues, showing effective working within the multi-Disciplinary team. (Kuru and Oscar, 2020). Effective pain management practice requires a combination of support from multiple professionals, such as the Pain team. Working with various professionals to relieve Elsie’s pain would help her to regain energy and speed up the recovery process.
Offering high-quality care to the patient entails encompassing the pain management process with the promotion of well-being, prevention of other illnesses, and meeting the patient’s changing care needs. As she continues to recover, Elsie will need less medication and psychological support, especially due to her Alzheimer’s disease (Scheltens et al., 2021). Therefore, complementary therapies would also consist of helping retrieve her memories. Nelson et al. (2018) provides that physiotherapy after hip operation could be challenging especially for older people. Elsie who is 60 years may face difficulties undergoing physiotherapy and that may delay her healing process. Nursing level of care delivered to Elsie is critical and increased compared to caring for a person of younger age. People of older ages requires more time to heal because their body systems are slower to recovery (Nelson et al. 2018). However, it is still important to help her where possible physically and mentally to ensure her well-being.
Benefits of Various Parts of Caring Processes
Appropriate assessment is beneficial in establishing patient needs for delivering quality care. Effective assessment entails gathering health information about the patients from them, caregivers, and their family members (Care Quality Commission, 2022). The assessment process is done through verbal and non-verbal communication and observation. Combining these care pathways ensures that the assessor collects all patient’s health-related issues (Hollins, 2021). The assessment process is also critical to determine the most life-threatening complications that need an immediate solution (Yura and Walsh, 1978). Using the ABCDE approach in assessment is excellent in identifying issues that might need reassessment during treatment (Resuscitation Council UK, 2021). The process is also beneficial in identifying a patient’s abnormalities requiring the care provider’s attention.
Implementing the caring process is essential in delivering a patient-centered care plan. It entails acting on or delivering the planned nursing interventions. According to Brooker and Waugh (2013), the implementation process is a critical and holistic approach for improving the quality of nursing care. In the process, the nurses carefully follow all the care plan steps to ensure they handle all patient’s health needs (Stonehouse, 2017). Omitting any step in the implementation process would lead to less optimal nursing care.
The appropriate evaluation of the caring process is vital because it supports evidence-based practice delivery. According to McCormack et al. (2021), evaluation is continuously done throughout the care delivery process to ensure that the assessment is correct, diagnosis was accurate, set realistic and achievable goals, and the prescription actions are well-informed. In other words, the evaluation process is beneficial in telling whether or not the care process is a success. The evaluation process is critical in deciding whether the evidence of the practice could be applied in future nursing care (Stonehouse, 2017). It highlights care delivery mistakes and offers to resolve suggestions during the continuing care process.
Working in partnership with the patient, their caregivers, and family members involves thorough consultation about patient needs. The most effective method to meet patients’ needs is consulting and identifying them (Marie Curie, 2018). The NA can build rapport by starting and maintaining conversations with the patients and family members. These conversations aim to know the patient and get information that indicates the patient’s treatment preferences and needs. Using the obtained patient preference information, the NA can develop a personalised environment and meaningful activities for the patient (Marie Curie, 2018). Working in partnership also involves continuously discussing the patient care plan with the patient and concerned caregivers or family members. Such partnership strategies promote the patient’s well-being, preventing recovery-related psychological illnesses for successful healing.
Applying the partnership strategies with Elsie would mean communicating with her and her family. Upon admission, the doctor and NA would inform the patient and their family members about Elsie’s health condition and what was needed for recovery. My role as a NA would be to provide further information that the patient and family may need. This would entail complementing nurses’ information by constantly reminding the partners about the patient health status (National Health Service, 2018a). I would answer questions within my range of knowledge and offer a relaxing space for the family. Developing a professionally healthy relationship with Elsie and her family would help me to gain their trust, thus allowing them to confide in me openly.
Partnering with Elsie and her family means consulting them in critical decision-making stages. Family members are essential in the care delivery process because they can help the patient to make an important decision (Care Quality Commission, 2022). For example, Elsie may be reluctant or give up on physiotherapy due to the pain involved. The NA could speak to the family members to tell her that the importance of undergoing such therapy would help her to recover from the surgery. A close relationship with the patient and family members would also help to deliver care that respects their religious and cultural practices effectively. I would know what topics to discuss with these partners regarding their cultures and religions (Rosa, 2018). For example, if Elsie is a Christian and wants a word of encouragement, I could refer to the hospital chaplain or provide a bible, thus making her feel spiritually considered. These are a few reasons for partnering with the patient and family members in care delivery.
Significance of Gaining Consent, Ethical, and Legal Care Aspects
Gaining patient informed consent is significant in involving them in the decision-making process and regarding their freedom to participate in an intervention. Informed consent entails a care provider educating the patient about the benefits, risks, and alternatives of a given treatment plan (Royal College of Nursing, 2017). The informed consent provisions demand that the patient be competent to make a voluntary decision about engaging in the proposed procedure. In surgery-related or complex procedure cases, informed consent is presented to the patient as a document (Brooker and Waugh, 2013). The care provider then discusses the details of the form with the patient.
Informed consent provisions provide that a mentally incapacitated patient cannot sign a consent document. Therefore, the care providers reach the closest family members or friends to decide for the patient (Younas and Quennell, 2019). According to Mental Capacity Act, a person with dementia may lack the required mental capacity to make right legal decisions (NHS, 2021). Elsie was assessed by a mental health professional through a series of structured interviews and reported unhealthy cognitive functioning because she lacks the ability to think clearly, learn, or remember things. In that case, the patient cannot make an informed decision, hence the need to reach her family. Elsie’s cares must be informed about the consent and sign it for her to undergo surgery. Some patients may choose to waive their rights to consent, thus leaving the decision-making process to the care provider.
Legal and ethical considerations also govern informed consent. The state jurisdiction provides three approaches to legally acceptable informed consent. The first approach is subjective standard reviewing and reviewing what the patients need to know and understand to make a decision (Nursing and Midwifery Council (NMC), 2015). The second element is a reasonable patient standard which entails what an average patient needs to know to be a sufficiently informed participant in the decision (NMC), 2015). Lastly, reasonable physician standard enquires about what a typical physician would say about the procedure (Osuji, 2018). Ethically, the caregiver is expected to promote patient autonomy, offer all necessary information and avoid all biases (NMC, 2015). In their good mental capacity, patients have the right to refuse medical treatments on religious or other grounds.
Knowledge, Behaviours, and Roles of a TNA
In the care delivery process, the NA must demonstrate knowledge, attitudes, and behaviours that support their roles. In Elsie’s case, the NA requires basic knowledge about fundamental principles of nursing practice and personalized care. Such principles include fidelity, commitment to ethics, compassion, and beneficence (NMC, 2018a). the NA caring for Elsie should show fidelity by remaining true to their professional duties and promises to deliver high-quality, competent, efficient, and safe care to the patient (NMC, 2018b). The NA should offer their professional knowledge to Elsie when needed and ensure her safety throughout the caring process. Commitment to ethics includes respecting Elsie, educating her about her rights, and offering her autonomy. The NA must respect the patient’s choices, whether or not they agree with them.
Being compassionate to Elsie is another way of delivering holistic care. Showing compassion, in this case, would be understanding her level of pain and anguish during the procedure while being calm and polite even when aggressive. Following Elsie’s mental incapability, the priority is to ensure dignified care and respect for her privacy (Moore, 2020). Empathising with Elsie would allow the NA to develop a healthy relationship with her, strengthen their communication, and earn her trust to the point that she can report discomfort (Texas A&M International University, 2019). A NA should also show acts of kindness and charity by offering help to Elsie. For example, Elsie might say she likes reading a particular book, and the NA can offer to read the book for her. Such small yet meaningful acts demonstrate a higher understanding of patient’s needs, thus increasing their satisfaction.
The nurse attending to Elsie also needs communication skills and common knowledge of human relations. Effective communication skills allow the nurse to actively participate in multi-disciplinary teams delivering care to the patient (Rosa, 2018). Communication skills also help develop positive relations with the patient and other caregivers during the caring process (Rosa, 2018). If Elsie’s recovery process would not be effective, the NA should deliver end of life care including sensitive communication especially when talking to Elsie and her family. Common knowledge of human relations includes knowing when to talk and remain silent. Some patients, especially those undergoing chronic pain, prefer their caregivers to minimize their conversations (Phillips et al., 2013). In such a case with Elsie, the attending NA should know how to handle different situations depending on the patient’s mood better.
The role of a NA in the case study is to monitor and report Elsie’s caring process and offer the patient safe, personalized, and effective care. The National Health Service (2020) provides that NA would perform and record clinical observations, including temperatures, blood pressure, pulses, and physical respirations checks. Elsie has low blood pressure and would need continuous checking of her pressure before, during, and after the surgery. The surgery will also warrant frequent monitoring of body temperatures, heart rates, and pulses (The Royal College of Nursing, 2022).
Further responsibilities would include administration of medications and helping with dressing, and liaising team. Following the patient’s surgery, the NA will be required to closely monitor the wound’s dressing and report to the doctor when it needs changing (Simunovic et al., 2011). They will also be expected to contribute to continuous assessment and evaluation processes through the ABCDE approach. The NA should also be able to use various equipment for physiological observations and identify issues worth reporting to various caregivers.
The NA would also work with Elsie’s family and carers to welcome unexpected news and life-changing diagnoses. They are obligated to offer professional and emotional support to the patient and her family to deliver holistic care (Brooker and Waugh, 2013). Following the already-developed relationship with the patient’s family, they may wish to ask follow-up questions to the NA. The NA is mandated to offer full support by clearing any doubts about patient information (NHS, 2020). As the patient and their family constantly receive doctor updates, the NA will be expected to help the family consume and accept the news. Such strategies include reassuring the patient that she will be well and asking whether she needs anything. The NA also is responsible for checking and reporting any patient’s or her family’s needs within the hospital.
Conclusion
Elsie, suffering from hypotension and Alzheimer’s disease, fell at home and had her right hip fractured. A prosthetic surgery is recommended alongside a personalised and holistic care plan. Caregivers must obtain the patient’s consent to deliver the planned care. The NA uses fundamental principles of nursing practice to deliver the planned care.
Word count 3000.
Reference List
Brooker, C. and Waugh, A. (2013) Nursing Practice: Fundamentals of Holistic Care. 2nd ed [online]. Mosby: Elsevier.
Care Quality Commission (2022) Regulation 9: Person-centered Care [online]. Web.
Centers for Disease Control and Prevention (2020) What is Alzheimer’s disease? [online]. United States: Centers for Disease Control and Prevention. Web.
Felton, J., Slobogean, G.P., Jackson, S.S., Della Rocca, G.J., Liew, S., Haverlag, R., Jeray, K.J., Sprague, S.A., O’Hara, N.N., Swiontkowski, M. and Bhandari, M. (2019) Femoral neck shortening after hip fracture fixation is associated with inferior hip function: Results from the FAITH trial. Journal of Orthopedic Trauma, 33(10), pp.487-496.
Hogston, R. and Marjoram, B.A. (2011) Foundations of Nursing Practice: Themes, Concepts, And Frameworks. 4th ed [online]. Basingstoke: Palgrave Macmillan.
Hollins Lisa (2021) Transforming Care Pathways. Web.
Marie Curie (2018) What Are Palliative Care and End of Life care? Web.
McCormack, B., McCance, T., Bulley, C., Brown, D., McMillan, A. and Martin, S. (2021) Fundamentals of Person-Centered Healthcare Practice [online]. Scotland: John Wiley & Sons.
Moore, R.L. (2020) Respect and Dignity. Web.
National Health Service (2021) Mental Capacity Act [online]. UK: National Health Service. Web.
National Institute for Health and Clinical Excellence (2017) Hip Fracture: Management Guidance [online]. UK: National Institute for Health and Clinical Excellence. Web.
National Institute for Health and Clinical Excellence (2009) Hip Fracture: The Management of Hip Fracture in Adults [online]. UK: National Institute for Health and Clinical Excellence. Web.
National Health Service (2019) Hip Fracture [online]. UK: National Health Service. Web.
National Health Information Service (2022) Palliative Care [online]. Scotland: National Health Information Service. Web.
National Health Service (2020) Low Blood Pressure (Hypotension) [online]. UK: National Health Service. Web.
National Health Service (2022) Trainee Nursing Associate Apprenticeship [online]. UK: National Health Service. Web.
National Health Service (2020) Trainee Nursing Associate (TNA) [online]. UK: National Health Service. Web.
Nelson, M.J., Bourke, M.G., Crossley, K.M. and Russell, T.G. 2018 Outpatient physiotherapy rehabilitation for total hip replacement: Comparison of current practice with clinical evidence. International Journal of Therapy and Rehabilitation [online]. 25(11), pp.613-622.
Nursing and Midwifery Council (2018a) Standards of proficiency for nursing associates 1 Standards of proficiency for nursing associates [online]. Web.
Nursing and Midwifery Council (2018) The code nursing and midwifery council [online]. Web.
Osuji, P.I. (2018) Relational autonomy in informed consent (RAIC) as an ethics of care approach to the concept of informed consent. Medicine, Health Care and Philosophy [online]. 21(1), pp.101-111.
Phillips, A.C., Upton, J., Duggal, N.A., Carroll, D. and Lord, J.M. (2013) Depression following hip fracture is associated with increased physical frailty in older adults: The role of the cortisol: Dehydroepiandrosterone sulphate ratio. BMC Geriatrics [online]. 13 (1).
Resuscitation Council UK (2021) The ABCDE approach [online]. Web.
Roland, J. (2018) What to Expect from Hemiarthroplasty. Web.
Rosa, W.E. (2018) Transcultural pain management: Theory, practice, and nurse-client partnerships. Pain Management Nursing, 19(1), pp.23-33.
Royal College of Nursing (2017) Principles of consent: Guidance for nursing staff. British Journal of Healthcare Assistants [online]. 11(10), pp.498–502.
Scheltens, P., De Strooper, B., Kivipelto, M., Holstege, H., Chételat, G., Teunissen, C.E., Cummings, J. and van der Flier, W.M. (2021) Alzheimer’s disease. The Lancet, 397(10284), pp.1577-1590.
Simunovic, N., Devereaux, P. and Bhandari, M. (2011) Surgery for hip fractures: Does surgical delay affect outcomes? Indian Journal of Orthopaedics [online]. 45 (1), p.27.
Stonehouse, D. (2017) Understanding the nursing process. British Journal of Healthcare Assistants [online]. 11(8), pp.388–391.
Texas A&M International University (2019) Why Empathy is Crucial in Nursing [online]. Minnesota: Texas A&M International University. Web.
Thakker, A., Briggs, N., Maeda, A., Byrne, J., Davey, J.R. and Jackson, T.D. (2018) Reducing the rate of post-surgical urinary tract infections in orthopedic patients. BMJ Open Quality. [online]. 7 (2). Web.
The Royal College of Nursing (2022) Trainee Nursing Associates: HCAS and APS: Royal College of Nursing. Web.
Younas, A. and Quennell, S. (2019) Usefulness of nursing theory‐guided practice: An integrative review. Scandinavian Journal of Caring Sciences, 33(3), pp.540-555.
Yura, H. and Walsh, M.B. (1978) The Nursing Process: Assessing, Planning, Implementing, Evaluating [online]. Washington: Catholic Univ. of America Press.