Osteoarthritis is a case of hip, spine and forearm fractures and injuries which is predominantly found in older people, unless otherwise. There is an increase in these fractures, injuries, morbidity and mortality rates in older people. In the 1990s, these numbered around 1.7 million worldwide and with rapid increases in the years that followed, it has been estimated around 8.2 million cases by 2050 (Cooper, 2006). Yaban (2006) made the staggering conclusion that 95% of hip fractures or injuries in old age people are caused by falls. Supporting these views, Arinzon (2007) went a little further by stating that post hip fracture disability among patients that initially survived hospitalisation is between 32-80% and that those in need of long term caring by skilled Nurses is 6-60%.
MeeK et al (2002) and Abudu et al (2002) noted the series of complications that usually develop in patients after hip fracture or injury due to old age and that 10-35% of such patients died within the first year after an injury and 30% do suffer another fracture within a year. Mitigating these appalling problems, surgery is usually recommended for a total hip replacement (THR), especially in primary and secondary Osteoarthritis. Following surgery, many patients encountered problems, especially in their activities of daily life (ADL) as they are no longer able to climb chairs, lie down in bed, and get on and off transportation without the help of someone. As a result of this dependency, after discharge, total hip replacement patients need a proper arrangement of their home settings.
The home setting is in conjunction with their new model of living (TML), which Roper in 1976 defined as those activities of living performed by individuals and care being provided throughout their lives. As Murphy et al (2002) admonished, the model did not only emphasis on individualism but also facilitates the planning of the care as a whole and the achievement of realistic and accessible goals in care.
Holistic assessment of Ms Jane.
On admission to the ward, Ms Sutcliffe is given a thorough assessment that involves the collection of her data regarding age, sex, chronic medical conditions, pre-fracture functional status, her type of fracture and operation, weight, pain perception and cognitive status. The assessment takes into account her psychological, physical and social preparation as all will play a major role in her recovery after surgery.
The psychological assessment/preparation allows her to understand what she will experience during the acute phase of the surgery and during the process of recovery. This gives her ample time to prepare ahead and come to terms with whatever follows. Banduru (1997) made mentioned of self-efficacy beliefs, which are making exercises in order to achieve good outcome after surgery. There is also the provision of verbal and written information by Nurses to her before the surgery.
Ayers et al (2004) regards physical preparation as a major life event and affects the outcome of the operation. This process underscores the point that patients that are more depressed before the surgery to have poorer pain relief after operation. On the other hand, Holman (2005)maintained patients with positive expectations before a hip operation have better physical outcomes and that those that work hard help the multidisciplinary team in achieving such outcomes.
Social assessment looks at Ms Sutcliffe’s home circumstances and her ability to manage after the hip replacement operation. Chow (2001) refers to the patient’s home environment as very crucial in the recovery process and that there is no need for Jane to struggle in getting up from a chair, a bed, visiting the kitchen, going to toilet during the period her muscles are healing. There is a need for support in the areas of shopping, cleaning, cooking, laundry as there are no relatives or friends around her on daily basis.
Escobar et al (2007) purported that the whole pathway of care from patients being listed for surgery, to the time of surgery and the recovery process are very complex and involves a lot of health professionals. Normally, before a patient is referred for hip replacement, should have some understanding of what the surgery entails. This gives them the chance to consider it or not. Some GPs do ensure that patients are physically fit before making a referral to an Orthopaedic Consultant. In the event the patient’s hip pain can no longer be managed, as in the case of Ms Jane, the Consultant can now refer to an Orthopaedic Surgeon.
The preparation for surgery at the preoperative assessment clinic is considered to be long and should be undertaken earlier. That is, just when a patient’s name is added to the waiting list (Krouse, 2001). Normally, the process involves giving out a comprehensive booklet to Ms Jane to read at home to enable her understand what is required along the care pathway. In some instances, videos or DVDs containing details of the surgery provided for watching at home as well.
The final stage of assessment is the preoperative assessment in the ward. It is a form of educational assessment, whereby the Nurse or any professional ensure earlier conditions do not change. They will screen for MRSA to check for infection and to see whether Ms Jane can cope with the surgery (Losina, 2008). According to Rowley (2001), Nurses in the unit/ward are to make sure that Jane is safely prepared for surgery through the help of a surgical safety checklist.
A Medical condition
With regards to the care the patient requires for Osteoarthritis, as the case with Ms Jane, is derived from the Integrated Care Pathways (ICP), which are structured multidisciplinary care plans that describe in detail each step in the care process. Zander (1998) looked at such care plans and concluded that they usually entail treatment protocols with the aim of standardising care. Inputs are not only from Nurses, but from paramedical and administrative staff as well. Parker et al (2002) maintained that in-hospital care for right hip replacement is a team effort, though Nurses are seen to be playing an all-embracing role throughout this period. In brief, Nurses are involved in assessment, emotional support, involvement of family members, technical and physical care, co-ordination and communication and therapy integration. This therefore made Kirkevold (1997) to conclude that the need for Nurses to work effectively within the multi-professional team is becoming increasingly vital, just as their contributions towards rehabilitation leading to the patients’ independence living.
Thomas (2002) is of the view that the human body is always susceptible to physical, traumatic and medical situations that do adversely affect the breathing process. As a result of this, airway and breathing must be managed quickly and effectively to enable the continuous flow of oxygen, thereby preventing deaths. Airway management is the physical process which ensures the airway is open and clear to allow respiration to occur. Mastering or becoming proficient in the methods and tools for airway management by health professionals enhances the patient’s (Ms Sutcliffe) chances of survival after surgery. Nurses should observe for coughs, inspiratory crackles, and shallow respirations and decreased chest expansion. In addition, observe for pale mucous membrane as they are signs of pneumonia that usually create ineffective airway clearance.
Breathing involves the process of air (oxygen) entering the body and then (carbon dioxide) expelled back into the environment. The conduit for such a process is through the airway. Such complex ways of managing airways by health professionals involves the opening, cleaning and delivering of supplementary oxygen for artificial ventilation-in cases of ineffective breathing by Jane after the surgery.
Post-operative observation in relation to circulation normally looks at the main signs and symptoms of bleeding as soon as Ms Jane is brought to the ward after the surgery. There are tendencies for patients to be at risk after undergoing surgery. Problems such as hypovolenic shock as a result of loss of blood and fluids. Right hip replacement surgery requires bed rest post-operatively and normally places the patient at risk in relation to developing blood clots in the legs. When this occurs, the decreased volume within the circulating system cannot provide the much needed oxygen and nutrients to the tissues and can sometime results to death if not solved. As a care, the Nurses or health professionals should administer intravenous fluids to replace the lost volume and if blood is lost, packed red blood cells and platelets must be ordered for Ms Jane immediately.
Helme and Gibson (2001) asserted that pain and its consequence, especially functional limitations that interfere with individual daily activities and leading to poorer life, afflict about 25%-88% of elder people within communities worldwide. For pain management to be effective there must be accurate pain assessment. Many held the view that self-reporting of pain is an individual’s subjective perception and this may provide enough information for its management. With the elderly, their pain is usually undetected due to severe cognitive impairment.
Sheppered et al (2010) argues that effective post-operative pain management relieves suffering and leads not only to shorter hospital stay but at the same time reduces hospital costs as well as earlier patient mobilisation. One goal many believe in the management of post-operative pain is to actually reduce the dose of medications in order to lessen side effects.
Opioids are seen to be the first-line treatment for severe acute post-operative pain and the same scenario should apply to Ms Jane after undergoing the surgery. They are drugs use to lessen pain and use often to titrate against pain relief and to minimise unwanted effects to the patient. Other common methods use to manage post-operative pain include the taking of Codeine, Ibuprofen, intravenous narcotics like Morphine Sulphate, Paracetamol and even Opiate Fentanyl.
According to Sheppered et al (2010), some of the side effects of Opiopds include vomiting, respiratory depression, constipation and itching which are mostly common. In such situations, healthcare professionals can reduce the effects by changing the dosing schedule of the patients, in this case Ms Jane, maintain constant blood levels through checking the manner in which drugs are given out and addition of other drugs to counteract any effects.
Davidson et al (2008) are of the view that normally when psychological care is addressed in hospitals, entails what health professionals expect the patient to need rather than from the perspective of the individual and illness experience. Such a care should focus on assessments of Ms Jane’s understanding of her illness and the effect it will have on her life. Supporting this view, one is to draw his or her attention to the assertion that assessment of the patient’s illness beliefs as a daily practice can significantly increase his or her sense of wellbeing on discharge (Lau-Walker et al, 2008).
After the surgery, hip replacement patient immediately start physical therapy as part of the psychological care. This is normally a minor exercise, involving sitting in a chair, the day after the surgery. What follows is stepping, walking, and climbing, with supportive devices like crutches. In this case, Ms Jane pain is being monitored during these exercises, as most often, there is some degree of discomfort. As Van den Akker-Scheek et al (2007) pointed out, psychological needs of hip replacement patients like acute pain after surgery can be addressed during the period of psychological care. At the pre-operative stage, the patient some time has already planned about such a pain and come to terms with it at this stage.
Discharge is a process and not an isolated thing and in this regard, must be planned for at the earliest opportunity. According to the Department of Health (2003), the above view is to ensure that patients and their carers understand and feel involved in the discharge arrangements. For any discharge to be detailed, the planning must involve communication, education, patient participation and collaboration and coordination. All such detailed planning must be instituted for Ms Jane.
Olsen and Wagner (2000) maintained that effective communication is needed between Ms Jane, the patient, and the healthcare professionals for any meaningful discharge to take place. This kind of communication normally involves asking questions to her or relatives and getting answers. Through this process, inconsistencies are brought to light and clarified. At this stage of discharge planning, which may be verbal or written, information like the patient’s functional status, social support and environment status, are all addressed (Neuman, 2004). Bull and Roberts (2001) viewed communication as a complete circle as it involve community team in the arrangement of outpatient appointments, the GP and connecting again with the district Nurse.
Education is all part of communication but Lin et al (2005) believed that the provision of instruction leaflets to the patient or the family sums the entire process. Garratt (2009) said of such leaflets to contain specific information of the patient’s needs and at the same time how to manage their ongoing care at home.
Patients’ involvement and collaboration in their discharge is very essential and according to Pearson et al (2004) includes their practical arrangements for physically getting back to their homes, management at home and health professionals making them feel they are in control of their health. Such information is vital and discussing it jointly with Ms Jane makes the discharge planning very successful.
All what has been discussed above will be meaningless without proper coordination. Therefore, Atwal (2002) purported that a key aspect of successful discharge planning is coordination and that without it, the entire process cannot be effective. For Atwal, there should be inter-professional working relationship between the Nurses and the Doctors for a successful discharge planning. Watts et al (2007) are of the view that there are normally disputes as to who does, and who should, carry out the discharge planning process. But where there is coordination, normally it is the bedside Nurse or primary Nurse that is responsible for coordinating discharge planning process (Gardner (2005).
The issue of discharge is to be dealt with in the right manner just as Young et al (2005) warned, shorter hospital stays can result in older people experiencing right hip replacement being discharged in a state of incomplete recovery. They went on to suggest for a proper time table for such an activity and to be agreed upon by both the hospital authorities and the patient.
Immediate care of the patient in the community.
Contemporary health and social care policy across Europe and in the UK in particular, is focused on the provision of care in the community for older people with chronic illnesses and eventual surgery (DH, 2001). To this end, Themessl-Hubber et al (2007) suggested that awareness, expectations and perceptions of community services are steadily increasing in older people. According to Stoltz et al (2004), research has shown more responsibility for care provision is now placed on informal caregivers-unpaid family members, friends or neighbours. This is because older people perceived this informal segment as their best option as compared to formal support-services provided by health and social care in the community. However, Mahoney et al (2008) caution this claim as they pointed out that older people living alone and infrequently visited by family members are more likely to have poor outcomes following discharge. Relating this to Ms Jane, proper arrangement should be made for community care so as to avoid the situation of having a poor outcome. One is to take not of the fact that she lives alone and not frequently visited by her children relatives and friends.
Deniz et al (2005) warned that after hip replacement surgery, patients normally encounter problems such as climbing stairs, lie down in bed, walk and so on and thereby affecting their activities of daily living. As a result of these problems and many more, Bilik (2006) asserted that continuity of care is to be provided in their homes or communities. Such a community care emphasised on individualism so that Ms Jane can acquire independence in her activities of daily living. The Model of Living, according to Roper (1976), can be used to acquire this independence. In brief, the model focuses on eating and drinking, personal cleansing and dressing, mobilising, working and playing, breathing and control of body temperature. Where this model is properly used by those caring for her in the community, will not only allow her to live independently, assist in focusing on those problems she often experienced while recovering but complications can also be prevented.
The removal of the sutures depends which ones are used in Ms Jane’s operation. If buried ones are used by the Surgeon, no need to be removed as they would dissolve in the body. The dressing also depends largely on whether the Surgeon uses stitches or staples. In any case, the wound needs to be kept covered and in the case of leakage from Ms Jane’s covered wound, the community worker should inform the appropriate authorities.
Post-operative care of elderly patients with hip fracture both in hospitals and in their communities can be carried out effectively when they are identified immediately at admission as high-risk patients. With this achieved, planning for their discharge to be done early and communicated well to all those involve in the care process. This is to allow them to move back confidently to their communities.
Nurses’ role in the entire process of care appears to be extensive and always in a position to influence patient care. This is why it is expected of them to make a thorough assessment of patients, including their physical, mental and social conditions as soon as possible. Such a clinical history would help Nurses to transform care from defensive status to a more advanced care. However, even though assessment is a vital part of caring for hip replacement, majority have considered it to be of less importance wherein Nurses who carry it out do not inform their superiors in the care planning process.
Moving away from the hospital environment, the importance of support provided by other family members and the community during post-hospitalisation, more so in the dispensation of medication should be considered highly.
Notwithstanding the above, total hip replacement is becoming increasingly common. All that is required from those undertaking it is physical, psychological and social preparation.