NUR2300 Evidence Based Nursing Practice

Task 1

Admission to the Intensive Care Unit Places Patients at Greater Risk of Developing Pressure Injuries

The intensive care unit is a special section of hospitals in which patients who are extremely ill are kept under constant observation (Opgenorth, Stelfox,  Gilfoyle, Gibney, Meier, Boucher, McKinlay, Job McIntosh, Wang, Zygun & Bagshaw 2018, pp. 8). The patients with life threatening illnesses that require close monitoring are kept in the intensive care units to facilitate constant care, close monitoring and the use of specialized equipment an medication to ensure that the body functions of the patient comes back to normal.

The critical care units are meant to handle adverse illness stages, however, in some occasions the multiple life saving technology might have adverse effect on the patient. Among the adverse effects on Intensive care is the development of pressure injuries. The medical practitioners handling the patient should therefore ensure a skillful balance of the adverse effects which often take precedence in the situation of intensive care of patients (Papadopoulos, Cummings, Marraffa, Aldous, & Ahmad 2017, pp 773). This essay gives a critical evaluation of the scholarly articles on the connection between intensive care unit and pressure injuries. It further goes ahead to elaborate on the nature of the pressure injuries and how to manage them.

According to Cox (2017), it is a common believe among some of the medical practitioners that pressure injuries are unavailable in once a patient is in the intensive care unit. However, it is vital for the nurses in charge of the patient to take the necessary precautions to manage the pressure injuries that come as a result of the use of various medical technology that are used in the intensive care unit to support the various body functions of the patient. The study further elaborates that the occurrence of pressure injuries among the patients in intensive care units is statistically dominant despite the fact that there are evidence based techniques and procedures to help in the prevention of the pressure injuries. The critical care nurses have developed an attitude towards pressure injuries overtime as it has become a common occurrence in the intensive care unit patients (Cox 2017, pp 51).

 Even though the pressure injuries is common, some of the nurses still believe that the pressure injuries could actually be prevented while some exhibited the attitude that the interest in the prevention of the pressure injuries equal to the interests in the treatment of the illness that brought the patient into the intensive care unit. Despite the findings of the study, the patients in the intensive care unit require not only constant but also adequate care for their chronic illnesses. However, with the knowledge of the pressure injuries it is vital for the medical practitioners taking care of the patient to take necessary precautions to prevent the pressure injuries in the process of administering intensive care medication (Waugh, SM 2014, pp. 352). On the other hand there are a number of factors that may contribute the development of pressure injuries in the process of intensive care.

Factors that contribute to development of pressure injury among intensive care unit patients

The better understand the factors that contribute to the development of the pressure injuries, it is vital to have the understanding of the nature of the pressure injuries. The pressure injuries manifest themselves on patients as breakdown of the skin which is accompanies by continuum of ischemic etiology tissues damage that comes about as a result of external pressure. The pressure, in most cases, occurs over bonny prominences (Jackson, McKenney, Drumm, Merrick, LeMaster, & VanGilder 2011, pp 44).

The pressure injuries are therefore manifested as a result of two sets of factors. There are intrinsic factors as well as extrinsic factors that contribute to the manifestation of the pressure injuries. The intrinsic factors are the internal factors that expose patients admitted to the intensive care units to the pressure injuries. They include chronic diseases like cancer and diabetes mellitus, use of steroids by the patient, old age of the patient, poor nutrition, cognitive deficit and immobilization. On the other hand, the extrinsic factors, which affect the patient from the outside include; share force, humidity, pressure and friction (Dukes, Maupin, Thomas & Mortimer, 2018, pp. 33). An evidence point out that pressure is a crucial factor when it comes to pressure injuries. Pressure of 70mmHg if exerted over a bonny prominence for about two hours or even more has the capacity to cause ischemic wound (Dukes, Maupin, Thomas & Mortimer, 2018, pp. 33). The medical practitioners overtime have come up with different ways of measuring the risk factors. One of the most commonly used scale in the measurement of the burden scale.

The burden scale measures the pressure factor taking into consideration the duration of the pressure and the tolerance level of the tissues upon which the pressure is being exerted. The tolerance level of the tissue maters a lot and therefore if the pressure has to be exerted on the tissue beyond the time duration within which the tissue can handle then result is a pressure injury. The injuries become another cost center for the patient. While the patient may successfully get out of the intensive care unit, he or she might get out of the unit with pressure injuries that will definitely need treatment. Since pressure injuries has been reported as a common phenomena among patients admitted into the intensive care units, it contribute to a high amount medical expenditure on the side of the patent especially after getting out on the intensive care unit. Research shows that the treatment of the pressure wounds is costly and that patients spend up to $ 1.35 billion yearly on the treatment of pressure wounds (Walker, Gillespie, Thalib, Higgins, & Whitty 2018, pp. 145). It is therefore vital for the medical practitioners to take adequate precautions to help in the prevention of the pressure injuries. There are well stipulated standard practices to help in the prevention of such injuries while the patient is under intensive care. The practices are aimed at reducing the impact of the pressure exerted by the medical machines that are used in the intensive care unit.

The best practice in handling pressure injuries

The standard practice of handling pressure injuries beginning before the patient goes in the intensive care unit. The fast step involves of the assessment of the risks involved if the patient goes into the intensive care unit. The information is vital for the intensive care planning for the patient. This stage is vital because the pressure injuries might develop and deteriorate within a short period of time (Sharp, C, Burr, G, Broadbent, M, Cummins, M, Casey, H & Merriman, A 2015, pp.153). The fast development and ease of deterioration is mostly common in patients with diabetes or limited mobility as well as those who are malnourished. The major aim of the assessment is to adequately come up with a way of reducing the likelihood of the development pressure injury. While it is possible for the medical practitioners involved to use their professional judgment in the assessment, there are structures risk assessment tools that help the practitioners to come to conclusions. It is important to note that the risk assessment must be carried out within the shortest time possible depending in the needs of the patient and the care setting. The criterion for the assessment is as follows;

Age appropriate and relevant risk assessment tools should be used to give support to the   assessment by the medical practitioners (Elliott, 2010 pp.32). Younger children are at a higher risk of being affected by pressure injuries. The social care staff should make assessment and document the risk of pressure injuries within eight hours of admission of the patient to the hospital or within twenty four hours of admission to any other health care setting. The assessment should include; inspection of the patients skin with special focus on the areas with bony prominences and the areas that will be in direct or indirect contact with the medical equipment, the assessment of other risk factors such as nutrition and drug abuse, the personal needs of the patient as well as making identifications of the self management strategies for the patents. The assessment should also include a planned review of the care plans and the reassessment of the risks (Elliott, 2010 pp.33). In case the assessment is not taken at the correct time, the practitioner should indicate the reasons, the discussions with the patients or the close relatives in case of children and the agreed actions.

The second part of the procedure is the reassessment of the risk. The reassessment is vital in that it takes into consideration any changes that might have occurred in the condition of the patient between the time of the assessment and the time of the reassessment. The changes that the practitioners might look for at this stage include any changes that might have occurred in the health condition of the patient. For instance, the patient might have become acutely unwell. The reassessment is taken and adjustments made in the existing care plan when changes are notices by the practitioners or reported by the representatives of the patients. In the event that the care plan has not been followed up to this point, the reasons should be recorded to there with the discussions with the patient of the representative as well as the agreement. The care plan is solely based on the outcomes of the risk assessment of the patient (Elliott, 2010 pp.34). It also takes into consideration of the risk factors involved as well as the personal choice of the patient. Additionally, the health and the social care professional judgment should also be taken into account. Furthermore, it should entail the treatment for any existing pressure injury, the frequency of the positioning as well as the requirements for the equipments and the devices.

The last part of the procedure involves the care planning for prevention and treatment. A person centered care plan is developed and then implemented to reduce the risk of pressure injury that may have been developed during the intensive care as well as managing the existing pressure injuries. The care plan should include the agreement with the patient or the representative of the patient.

Conclusion:

The pressure injuries are common among patients of intensive care. While different medical practitioners have different views of handling the injuries there is a standard recommended practice for the prevention, cure and management of the pressure injuries. it is not enough for the medical practitioners to focus on the acute illness of the patient and not take precautions to prevent the possibility of the occurrence of pressure injuries. It is therefore vital that step by step standard procedure is followed to minimize the possibility of the patient incurring pressure injuries as well as managing the existing pressure injuries.

References:

Cox, J 2017, ‘Pressure Injuries in Critical Care: A Survey of Critical Care Nurses’, Critical Care Nurse, vol. 37, no. 5, pp. 46–56, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=125112055&site=ehost-live>.

Opgenorth, D, Stelfox, HT, Gilfoyle, E, Gibney, RTN, Meier, M, Boucher, P, McKinlay, D, Job McIntosh, CN, Wang, X, Zygun, DA & Bagshaw, SM 2018, ‘Perspectives on strained intensive care unit capacity: A survey of critical care professionals’, PLoS ONE, vol. 13, no. 8, pp. 1–13, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=131361529&site=ehost-live>.

Papadopoulos, EA, Cummings, KR, Marraffa, JM, Aldous, KM, Li, L & Ahmad, N 2017, ‘Reports of adverse health effects related to synthetic cannabinoid use in New York State’, American Journal on Addictions, vol. 26, no. 8, pp. 772–775, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=126404455&site=ehost-live>.

Jackson, M, McKenney, T, Drumm, J, Merrick, B, LeMaster, T & VanGilder, C 2011, ‘Pressure Ulcer Prevention in High-Risk Postoperative Cardiovascular Patients’, Critical Care Nurse, vol. 31, no. 4, pp. 44–53, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=63645439&site=ehost-live>.

Dukes, SF, Maupin, GM, Thomas, ME & Mortimer, DL 2018, ‘Pressure Injury Development in Patients Treated by Critical Care Air Transport Teams: A Case-Control Study’, Critical Care Nurse, vol. 38, no. 2, pp. 30–36, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=128488215&site=ehost-live>.

Waugh, SM 2014, ‘Attitudes of Nurses Toward Pressure Ulcer Prevention: A Literature Review’, MEDSURG Nursing, vol. 23, no. 5, pp. 350–357, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=98979531&site=ehost-live>.

Walker, RM, Gillespie, BM, Thalib, L, Higgins, NS & Whitty, JA 2018, ‘Foam dressings for treating pressure injuries in patients of any age in any care setting: An abridged Cochrane systematic review’, International Journal of Nursing Studies, vol. 87, pp. 140–147, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=132491046&site=ehost-live>.

Sharp, C, Burr, G, Broadbent, M, Cummins, M, Casey, H & Merriman, A 2015, ‘Pressure ulcer prevention and care: A survey of current practice’, Journal of Quality in Clinical Practice, vol. 20, no. 4, pp. 150–157, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=5521595&site=ehost-live>.

Elliott, J 2010, ‘Strategies to improve the prevention of pressure ulcers’, Nursing Older People, vol. 22, no. 9, pp. 31–36, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=55761823&site=ehost-live>.

Task 2

Patient Transfer Care Plan

Introduction

Transitional care includes a wide range of activities and steps outlined to oversee the safe handover of patients from one facility to another across different levels of health care setting. Acute health care facilities are important for patients with chronic illnesses. In such settings the patients receive specialized care from a multiplicity of health care professionals. Transferring the patient from such as setting to a community based or home based care center transfers the roles of providing medication and diet from the health professionals to the caregivers and the family. A significant rise in the risk of adverse events is observed in patients during the period of transition from acute care in the hospital to the home setting. According to Eassey, McLachlan, Brien & Smith (2017), potential risk factors for adverse effects are attributable to patient specific and organization-specific factors that can be facilitative of the patient’s safe transition or could hinder the transfer process depending on how they are executed. This paper proposes a number of strategies to be implemented in order to oversee a successful patient transition from an acute care hospital to a community based care setting.

Goals and Courses of Action

Wibe, Ekstedt & Helles (2015) report on a number of plans that may be deployed in the care of patients after discharge from the acute care hospital to the home based care setting. Generally, the approaches give focus to the patients and to less extent, family caregivers. The study was targeted at improving the action plan for community based care and has received much critical acclaim even informing the design of community based models of transitional care in the US. Sato, Ikebuchi Anzai & Inoue (2012) posit that the unique needs of older adults recovering from pressure injuries in acute care can only best be taken care of within the home based care models like the “hospital at home”. In the study, they signed up patients living within the community with selected chronic illnesses in a quasi-experimental study where the eligible patients received care from physicians, nurses and other health practitioners. The outcomes of the clinical trial showed better results as compared to the acute care setting and shorter periods of stay were recorded.

Wibe, Ekstedt & Helles (2015) also explored the Day Hospital Model as an alternative in community based transitional care. This approach is a model that borrows from the British health care system and targeted older adults in acute care who were at risk of adverse outcomes. The patients enrolled were given access to medical and palliative care from health practitioners including nurses, physicians and counselors. The results of the clinical trial showed high levels of patient satisfaction with the community based care.

Action Plan for Discharge

This paper proposes a number of strategies for ensuring the successful transition of Mr. Russo from the acute care hospital to the home based care setting. According to Dyrstad & Storm (2017), professional patient partnership model is one of the tested and proven models for transitional care. The model was tested on older adult patients who had heart failure and incorporated their caregivers. In this model, the participation of the nurse and the social workers in the discharge plan is given a central focus. In Mr. Russo’s case, this paper proposes a scenario where the patient and the caregivers or family members fill out a questionnaire detailing their needs and expectations upon discharge. After this, the health professional can then avail relevant material to the family on care management. For instance, the health staff could show the caregivers a videotape of the care management that is expected post discharge. This process makes the family members and the caregivers to feel better prepared to take on the care management after discharge.

The paper also suggests care transition coaching as a strategy that should be incorporated in the care management plan. This strategy as contained in Peters (2017) encourages the patient and the family or caregivers to become more actively involved in the transitional care and suggests that an advance practice nurse may be selected to serve as the transition care coach. The responsibility of the advanced practice nurse would be to impart cross setting continuity care methods to the caregivers and the patients. This process of skill impartation would be recommended to be commenced while the patient is being prepared for discharge and continued for not less than a month after the discharge date.

Verhaegh, MacNeil-Vroomen, Eslami, Geerlings, Rooij & Buurman, (2014) posit that if carried out effectively, the model of transitions care coaching has a significant potential to reduce the rates of re-hospitalization among patients and in the long run lowers the medical costs. The finding of this study demonstrates that the shortage of knowledge and skills among family and caregivers raises a serious hindrance to the effective care of patients after discharge from acute care hospitals. They further point out that the identification of health complications and related problems arising from hospitalization at acute care hospitals is often beyond the scope of the family and the caregivers. This makes a strong case for the engagement of an advanced care nurse in the transition care plan who will give timely response to questions and concerns of the caregiver or the family.

The ethical Issues in Patient Transfer

The discharge staff most of the time is not in the possession of all information regarding all aspects of the patient. The caregiver is the expert when it comes to the history of the patient. As the patient is transferred to another setting, the caregiver should be involved in the discharge plan (Toles, Colón-Emeric Naylor, Barroso & Anderson, 2016, p. 8). The planners of the patient transfer should seek the opinion of the family members on their willingness to be involved in the care of the patient. It’s is necessary that the discharging officials understand the limitations of the family members with regards to caregiving capabilities be they of physical, financial or other nature. In Mr. Russo’s case it will be necessary for the transferring facility to understand the childcare obligations of his daughter which will to a large extent affect her involvement in the care of her father in home based care setting. Notwithstanding their abilities or availability, the discharge and care process should involve the family of the patient.

Cultural Acceptability

Naylor & Berlinger (2016) argue that at the core of safe patient transfer is the issue of tailoring each transition to the specific and unique needs of the patient as opposed to attempting to force conformity to the existing transfer process. This is the first of three basic underlying principles that ought to inform patient transfer from one setting to another. The other two are empowerment of the patient and the family and the flow of appropriate and relevant psychosocial information to the patient.

The empowerment of the patient and the family is premised on the observation that after transfer from the acute care facility, most of the functions that were previously carried out by the hospital staff will be handled by caregivers (Freeman et al, 2017, p. 466). The care plan must therefore include the empowerment of caregivers to enable them to identify any warning signs in the patient’s condition. In the course of patient transfers a number of ethical issues may arise. Freeman et al (2017) posit that the patient and the caregivers may not be adequately prepared to face certain changes that may be imposed as a consequence of the change of facility. For instance, medications and diets for the patient may be altered at short notice. To counter the ethical questions that ordinarily arise from such moves it is necessary that the transition care plan empowers the caregivers and the patient to understand the reasons why the changes are being made.

Another ethical issue that arises in transfer of patients is when the transferring facility assumes for instance that a specialized nursing facility is the best option for the patient. Lefebvre, Brault, Odette, Levert, Alarie, Proulx & Larivière (2016) assert that a transition plan must take into account the financial ability of the patient to pay for the services that will be provided in the new facility. Advance directives that are made by the patient should be followed by both the transferring and receiving facility as an ethical issue. For seamless transfer, Lefebvre et al (2016) portend that after the patient is sent to the community based care facility, the health professionals in the acute care facility should remain always ready and available to respond to any concerns and queries on the transfer order. They should help to oversee the transfer process until the primary care providers at the new facility have mastered clinical control of the patient (Lefebvre et al, 2016, p.104). In the same vein, the necessary medication should be placed on site by the time of the arrival of the patient in the new facility to avert the possibility of gaps in the treatment.

Conclusion:

Systemic failures arising from the complex and fragmented nature of health care provision in most countries are to blame for the transition challenges. These challenges make the system discontinuous in a manner that impedes the safety of the patient during transfer from the acute care to home based care. The advancement of seamless care is necessary for correcting errors that occur during the transfer phase. Seamless care is used to refer to a transition process that guarantees a safe and smooth transfer of the patient from one setting to another. Seamless care emphasizes on the importance of the continuity of care from the acute care environment to the community based setting as the main factor in the success of patient transition. In coming up with a working care plan for the patient, proper communication between the care givers, the patient and  their families must be sought as crucial elements to the success of the comprehensive transitional care plan.

References:

Eassey, D, McLachlan, AJ, Brien, J? anne, Krass, I & Smith, L 2017, ‘“I have nine specialists. They need to swap notes!” Australian patients’ perspectives of medication-related problems following discharge from hospital’, Health Expectations, vol. 20, no. 5, pp. 1114–1120, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=125188941&site=ehost-live>.

Wibe, T, Ekstedt, M & Helles, R 2015, ‘Information practices of health care professionals related to patient discharge from hospital’, Informatics for Health & Social Care, vol. 40, no. 3, pp. 198–209, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=108376732&site=ehost-live>.

Sato, S, Ikebuchi, E, Anzai, N & Inoue, S 2012, ‘Effects of psychosocial program for preparing long-term hospitalized patients with schizophrenia for discharge from hospital: Randomized controlled trial’, Psychiatry & Clinical Neurosciences, vol. 66, no. 6, pp. 474–481, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=82503635&site=ehost-live>.

Karlsson, V, Bergbom, I, Ringdal, M & Jonsson, A 2016, ‘After discharge home: a qualitative analysis of older ICU patients’ experiences and care needs’, Scandinavian Journal of Caring Sciences, vol. 30, no. 4, pp. 749–756, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=119880667&site=ehost-live>.

Dyrstad, DN & Storm, M 2017, ‘Interprofessional simulation to improve patient participation in transitional care’, Scandinavian Journal of Caring Sciences, vol. 31, no. 2, pp. 273–284, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=123838173&site=ehost-live>.

Freeman, PA, Bayless, E & Terrell, K 2017, ‘507 – Transitional Care Management Guiding Process Improvement’, Biology of Blood & Marrow Transplantation, vol. 23, pp. S466–S467, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=121105019&site=ehost-live>.

Lefebvre, H, Brault, I, Odette, R, Levert, M-J, Alarie, S, Proulx, M & Larivière, M 2016, ‘Co-Developing a Knowledge Exchange Network to Facilitate Access to Clinical Best Practices during Care Transitions of Patients with Chronic Diseases: An Example in Oncology’, Journal of Current Issues in Media & Telecommunications, vol. 8, no. 1, pp. 97–112, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=ufh&AN=118805701&site=ehost-live>.

Verhaegh, KJ, MacNeil-Vroomen, JL, Eslami, S, Geerlings, SE, de Rooij, SE & Buurman, BM 2014, ‘CHRONIC CARE. Transitional Care Interventions Prevent Hospital Readmissions For Adults With Chronic Illnesses’, Health Affairs, vol. 33, no. 9, pp. 1531–1539, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=98256728&site=ehost-live>.

Peters, JS 2017, ‘Role of Transitional Care Measures in the Prevention of Readmission After Critical Illness’, Critical Care Nurse, vol. 37, no. 1, pp. e10–e17, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=120801697&site=ehost-live>.

Toles, M, Colón-Emeric, C, Naylor, MD, Barroso, J & Anderson, RA 2016, ‘Transitional care in skilled nursing facilities: a multiple case study’, BMC Health Services Research, vol. 16, pp. 1–14, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=115436137&site=ehost-live>.

Naylor, M & Berlinger, N 2016, ‘Transitional Care: A Priority for Health Care Organizational Ethics’, Hastings Center Report, vol. 46, pp. S39–S42, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=118225075&site=ehost-live>.

Toles, M, Colón-Emeric, C, Naylor, MD, Barroso, J & Anderson, RA 2016, ‘Transitional care in skilled nursing facilities: a multiple case study’, BMC Health Services Research, vol. 16, pp. 1–14, viewed 14 December 2018, <https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=115436137&site=ehost-live>.