NURS 3046 Nursing Project

1. Planning Person-Centred Care

Priority problem selected: Lower back pain associated with chronic osteoarthritis

Identification of the health assessment

There were no significant health assessments conducted during my SIM experience which is relevant to the chosen problem. The only thing highlighted in the case study is, Sam Shepherd is complaining about the lower back pain and is given Panadol/Panadiene along with repositioning and heat packs. Panadol/ Panadiene are a paracetamol group of drug, which helps to manage mild to moderate pain. It is a non-steroidal anti-inflammatory drug which reduces the intensity of pain signals in brain via decreasing the secretion of prostaglandin (Palmer, 2016). According to Latimer, Chaboyer and Gillespie (2015) repositioning is frequently used for management of pain management. This is done via elevation of the head of the bed (1 to 45 degree). In the domain of heat treatment, Cruz-Almeida and Fillingim (2014) highlighted that heat treatments like heating pads or warm baths helps in vasodilatation thereby helping in the relaxation of the smooth muscles via increasing the blood circulation and promoting pain relief.

However, all these are interventions for pain management and not health assessment. The main health assessment for lower back pain includes detection of the chronicity of osteoarthritis (OA). This is done via radiographic assessment of the knees (Park et al., 2013). According to Mobasheri and Batt (2016), in advanced OA, features are visible on plain radiology reports which highlight narrowing of the joint space (occurring due to cartilage loss). The most common method for the radiographic evaluation of OA is osteophyte-based Kellgrean-Lawrence joint scoring system that grades the change in the structure of joint in five different levels (0 to 4; where 0 represents healthy joint). Kellgren-Lawrence mainly denotes narrowing of the joint (Park et al., 2013). According to Mobasheri and Batt (2016), the main morphological change observed in OA includes cartilage erosion and inflammation. Erosion of the cartilage causes narrowing of the joint space and thereby generating chronic pain. Radiographic plate analysis will help to analyse the extent of joint space narrowing and its subsequent treatment planning.

Additional health assessment required

Additional health assessment data that should have been collected during the episode of care include pain score as Sam Shepherd is suffering from lower back pain. According to Abdulla et al. (2013), pain assessment is crucial for pain management. The pain assessment should be conducted via taking into consideration the pain history of the patient, location of pain, intensity of pain and cognitive development and understanding of pain. Swift (2015) stated that pain affects patient emotionally and physically and thus, successful management of pain based on pain score is key component of recovery. Accessing proper pain score helps in determining the dosage of painkillers (NSAIDs) and thereby helping to provide relief to patients.

Proper physical assessment of Sam Shepherd must be collected in order to note down additional health-assessment data for pain management. This physical assessment includes detection of swelling, warmth and tenderness at the site of pain, detection for bony knobs (osteophytic changes) on joints (Palmer, 2016).

Goals for Care: Independent nursing actions

Nursing action one: The analysis of the case study highlighted that Mr Shepherd had head injury following a fall. As a result, he is unable to ambulate independently with the aid of a wheelie walker. This fall might have caused his lower back pain. According to National Safety and Quality Health Service Standards (NSQHSS) (2012), it is the duty of the nursing professionals; it is the duty of the nursing professional to implement fall prevention plans and effective management of fall. This can be done via employing equipment and other fall prevention devices and implementing fall prevention strategies to at risk patients. According to Kruschke (2017), individualised fall prevention program helps in accessing specific fall. According to the Nursing and the Midwifery Board of Australia (NMBA), development of person-centred is effective in getting quality outcome. NMBA code also highlights use of evidence based practice for the potential improvement of patient. In case of Mr Shepherd, person-centred fall prevention plans will mainly include use of wheel chair, as he is unable to ambulate freely via wheelie walker. Another effective management of fall include constant assistance while moving (going to bathroom or get down from bed), visual alerts, patient education and bed exist alarms (Hempel et al., 2013).

Nursing action two: According to NSQHSS (2012), extended bed rest might cause pressure injuries causing immobility. Since Mr. Shepherd is unable to ambulate freely post encountering fall, chances are high of getting affected with pressure injuries. NSQHSS highlighted conducting comprehensive skin inspection under defined time frame set will be helpful in reducing the chance of pressure injuries. Results of the skin assessment will be help in repositioning of Mr. Shepherd (Miles, Nowicki & Fulbrook, 2013). Santamaria et al. (2015) highlighted use of soft silicone multi-layered foam bed in preventing pressure injuries.

2. Effective communication

Situation (S): I am a nurse working in Happy Valley Nursing Home. I am caring about Mr Sam Shepherd. I am corned that his lower back pain along with chronic OA might hamper his quality of life and free ambulation. Besides, his vital signs include deterioration like irregular pulse, disorientation, and partially high blood pressure (130/90).

Background (B): Mr Sam Shepherd is a resident at Happy Valley Nursing Home since January. He as returned to the unit after spending 2 nights in PA hospital to investigate ongoing confusion post fall 3/7 day ago. The last set of observation include accidental fall 30 minutes ago while he was trying to get up to visit bathroom. The injury has hit his head and he experienced abrasion and bruising over his right forehead. He was under 15-minute neuro observation post accidental fall and his GCS score is 14. He is however, suffering from chronic back pain.

Assessment (A): I think at present his problem is inability to ambulate freely without any support or by the use of wheelie chair. I have advised a detailed assessment of his OA pain via the use of radiography. I have also advised physical assessment in order to detect swelling or presence of bony knobs. I have also advised the person centred care plan in order to prevent accidental fall. This will be done via use of visual alerts, patient education and bed exist alarms. I will also personally assist Mr Shepherd while his is going to bathroom and will also organise wheel chair in order to reduce the chances of fall prevention.

Recommendation (R): I think in order to manage irregular pulse proper monitoring of the vital statistics through pulse oximetry is also important. If oxygen saturation was found low (due to Atrial fibrillation) upon monitoring then, external supply of oxygen will help to regularise the pulse and oxygen saturation.

References

Abdulla, A., Adams, N., Bone, M., Elliott, A. M., Gaffin, J., Jones, D., … & Schofield, P. (2013). Guidance on the management of pain in older people. Age and ageing, 42, i1-57. DOI: 10.1093/ageing/afs200

Cruz-Almeida, Y., & Fillingim, R. B. (2014). Can quantitative sensory testing move us closer to mechanism-based pain management?. Pain medicine, 15(1), 61-72. https://doi.org/10.1111/pme.12230

Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., … & Ganz, D. A. (2013). Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4), 483-494. https://doi.org/10.1111/jgs.12169

Kruschke, C. (2017). Fall Prevention for Older Adults. Journal of gerontological nursing, 43(11), 15-21. https://doi.org/10.3928/00989134-20171016-01

Latimer, S., Chaboyer, W., & Gillespie, B. M. (2015). The repositioning of hospitalized patients with reduced mobility: a prospective study. Nursing open, 2(2), 85-93. doi:  10.1002/nop2.20

Miles, S. J., Nowicki, T., & Fulbrook, P. (2013). Repositioning to prevent pressure injuries: evidence for practice. Australian Nursing and Midwifery Journal, 21(6), 32. Retrieved from: https://search.informit.com.au/documentSummary;dn=727936843693314;res=IELHEA

Mobasheri, A., & Batt, M. (2016). An update on the pathophysiology of osteoarthritis. Annals of physical and rehabilitation medicine, 59(5-6), 333-339. https://doi.org/10.1016/j.rehab.2016.07.004

National Safety and Quality Health Service Standards (NSQHSS (2012). National Safety and Quality Health Service Standards. Access date: 3^rd September 2018. Retrieved from: https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf

Nursing and Midwifery Board of Australia. (2016). National competency  standards for the registered nurse. Access date: 3^rd September 2018. Retrieved from: https://www.nursingmidwiferyboard.gov.au/search.aspx?q=national+competency+standards+for++++++registered+nurse.+

Palmer, G. M. (2016). Pain management in the acute care setting: Update and debates. Journal of paediatrics and child health, 52(2), 213-220. https://doi.org/10.1111/jpc.13134

Park, H. J., Kim, S. S., Lee, S. Y., Park, N. H., Park, J. Y., Choi, Y. J., & Jeon, H. J. (2013). A practical MRI grading system for osteoarthritis of the knee: association with Kellgren–Lawrence radiographic scores. European journal of radiology, 82(1), 112-117. https://doi.org/10.1016/j.ejrad.2012.02.023

Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., … & Knott, J. (2015). A randomised controlled trial of the effectiveness of soft silicone multi?layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International wound journal, 12(3), 302-308. https://doi.org/10.1111/iwj.12101

Swift, A. (2015). The importance of assessing pain in adults. Nursing times, 111(41), 12-4. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/26647478