The Importance Of Nursing Standards In Providing Quality Care: A Case Study Of Total Hip Replacement

Thinks critically and analyses nursing practice

Engages in therapeutic and professional relationship

Provides safe, appropriate and responsive quality nursing practice

Evaluates outcomes to inform practice

Effectiveness of empathy in general practice: a systematic review. British Journal of General Practice,

Intermittent Pneumatic Compression for the Prevention of Venous Thromboembolism after Total Hip Arthroplasty.

Effect of training problem-solving skill on decision-making and critical thinking of personnel at medical emergencies.

Nursing Standards and Legal Requirements in Providing Quality Care

During my last clinical placement, I encountered one case that I believe was very significant in my studies. I was placed in a medical ward where my role was to take care of a patient who was undergoing a total hip replacement (THR). My main role was to follow the standards of nursing in conducting complete assessment and administering medications to the patient. From the studies, the Standard -1 urges that RN should consult various

critical thinking strategies and apply best available evidence to come up with practical decisions.  In addition to these standards, we are also required to master the provisions of the legislations and law applicable to practice and the Code of Conducts. In the state of Australia, the professional code of conduct is outlined in the national standards of nursing conducts for the nurses (Nursing and Midwifery Board of Australia & Nursing and Midwifery Board of Australia[NIMBA], 2016). Besides, one must also comply with the

Health Professionals (ACT Nursing and Midwifery Board Standards) Approval 2006 (No 1) who oversee the application Code and Standards as well as the nurse practitioners’ competency.

For instance, the Australian nursing practice must comply with legal provisions from other legislations such as the civil laws, criminal laws, common laws and statutes (Atkins, et al., 2017). For example, nurse who can be guilty of murder or manslaughter if he or she causes the death of a patient intentionally either through administration of wrong drug or other faults. Other law in nursing include the principles of common law and statutes. Law provisions in Australian Consumer Laws and the Therapeutic Goods Act 1989 (Cwlth) also may apply among others

As a registered nurse, I recognized that I have a duty to care to the community and accountability in the delivery of the highest standard of care. I also recognized my duty to promote the quality of safe.

The field of nursing also requires critical thinking skills. There are situations that come outside the scope and may require nurses to think critically and employ problem solving skills (Shahbazi & Heidari, 2016). Other areas that nurses are also required to advance in is the embracement the rapid development in technology that are changing different approaches to health practices (Veer, et al., 2011).

During my placement, I learnt how THR has become the most frequent and successful cases in orthopaedic surgeries. I was also able to connect that with the various studies that are providing proof that the procedure is reliable and has a significant socioeconomic effect. From what I leant, THR operations are effective, and they are preferred where patients are experiencing pain with less mobility as a result of severe osteoarthritis of hip joints. According to (Ilchmann, 2014), this procedure should only attract a short hospital stay yet delivering a quick recovery. In addition, patient satisfaction and the overall functioning of the hip should be the ultimate goal, and the practitioners should be aiming for a high percentage of patients going back to their lives without any effects of the procedure. The work of (Behrend, et al., 2012) terms this as a “forgotten joint replacement.”

The Role of Critical Thinking and Technology in Nursing Practice

Again, I got much knowledge to explain the prevalent cases of readmission in THR. There are various reasons for readmission. Some of these included joint dislocation, bone fracture, or any other mechanical complications with signs and symptoms such as swelling, stiffness, pain, etc. (Mnatzaganian, et al., 2012). According to (Mnatzaganian, et al., 2012) readmission is connected to comorbidity and some complications while in hospital.

Even though, one of the major complications that come after THR is Venous thromboembolism (VTE). This incident can occur as asymptomatic, symptomatic deep-vein thrombosis (DVT) or the pulmonary thromboembolism (PE). Incidences of DVT and PE are a bit rare though there have been reports of their occurrence in both cases of hip and knee replacement (Fang, et al., 2018). While investigating the standard of practice in THR,

While handling my patient (Mrs.White), I started conducting a complete and adequate assessment of the patient case to determine the best care plan. Mrs. White had undergone a right THR through spinal anesthesia.  This operation was necessitated by osteoarthritis problem on her right hip joint. The psychosocial and physical assessment revealed that Mrs. White was overweight with as she weighted 80 Kg, the height of 166 cms, and BMI of 29.03 kg/m2. Mrs. White took low amounts of alcohol, did not smoke, had hypertension, high levels of cholesterol, old myocardial infarction, and reflux gastritis.  She was under HT, high cholesterol, and heart disease medication. Some years back she also had a total knee replacement operation and surgeries for hysterectomy and appendectomy.  

Mrs. White has been using a stick as a walking aid. The recording of such factors are essential for as they are critical to the planning of mobility after the operation and the rest of the postoperative care (Blythe & Buchan, 2016). The history of Mrs. White’s medical plans shows that she had the prescription of some several medications such as the naproxen (NSAID), fentanyl PCA (narcotics), enoxaparin (VTE prophylaxis), Oxycodone (Opioid), paracetamol (analgesic), and rosuvastatin (for regulating the cholesterol). She also had a symptomatic treatment that was given for the management of gastric reflux. These were metoclopramide, ondansetron, and domperidone.

Regarding her social life, she was widowed, and his son Mr. X was helping in the routine care though Mrs. White preferred an independent life. Mrs. White owned a house, and she was sure that she could manage a self-care.  In the case of co-morbidities, Mrs. White had issues with overweight, alcoholism, old myocardial infarction, mild malnourishment, reflux disease, and knee replacement. It is paramount to understand these factors as they can also affect her recovery despite having self-care and confidence level positive. These facts were also presented by (McHugh, et al., 2013) that previous joint involvements and co-morbidities can affect the patient’s outcomes in the cases of hip replacement. Oher factors that can affect the outcomes are a mental disorder, some diseases such as diabetes mellitus, aging, anxiety, obesity, and malnutrition among others.

The Case Study of Total Hip Replacement

According to (Lasater & Mchugh, 2016), nurses should make sure that they are forming positive relationships with patient while at the same time keeping professional boundaries. Guided by such nursing principles, I started with developing trust with Mrs. White. I understood that she did not know me, and she did not understand her sickness. Also, I understood that Mrs. White did not know how we as the healthcare professional would approach her problem. By understanding these facts, I understood that I needed to ascertain her attitudes to the problem she had, and the condition of the treatment that she was yet to understand. Therefore, while I was taking the initial assessment, I explore her thoughts and the attitude she had towards the treatment procedure. I did this by asking her some few questions and being attentive to the responses that that she gave. In this way, my therapeutic relationship with Mrs. White was able to progress from a foundation of the established empathy.

My approach for establishing the position of empathy was focusing on three main areas. The first one was my obligation to acquire accurate and relevant information from Mrs. White to inform any risks that might connected to her case. According to (DeLaune, et al., 2016), nurses are required to conduct an accurate physical examination to the patients. Also, a study carried out by (Derksen, et al., 2013) on the impacts of empathy during patient consultation showed that there is a an established correlation between health professionals empathy and the patient satisfaction. The study showed that empathy creates positive relationship which lowers the patient’s distress, anxiety and enables the nurse to get correct data during for assessment. As I knew my other roles involved assessing the patient’s neurovascular dysfunctions and I was supposed to even assess other risks such as peripheral neurovascular dysfunction which the work of (Yang, 2014) says that they may come after THR, I understood that empathy would play a major role. The second reason why I first focused on empathy was to be able to manage the patient’s confusion associated that would have come with the treatment like possible challenge of accepting the change of circumstances. Thirdly, was helpful in justifying care measures and procedures.

As a nurse, I also understood my role in using culturally competent communications skills both which should be verbal and nonverbal. I also understood that these skills should be guided by the identification of the patient’s values, practices, beliefs, perceptions, and her unique health needs. According to  (Miller, et al., 2008), a nurse efficacy in cultural communication is one way of demonstrating the preservation of the patient’s human rights, dignity and respect. Apart from just being familiar with Mrs. White culture, I also comprehended her

Factors Affecting Patient Outcomes in Total Hip Replacement

health care needs by listening to her effectively, being attentive to her body language, and I carefully used eye contact. Other non-verbal communications that I used were the perceptions of space and time. From what I understood of Mrs. White, she was a woman who wanted to be independent. I therefore tried to maintain the best space that made her comfortable such as helping her reach only the things that are far from her hands. She wanted to handle close objects without help. I also paid attention to other nonverbal communications such as silence, touch, dressing, and provider gender.

Another factor that I paid attention to was the patient participation. I needed to recognize that Mrs. White was an expert of her lived experience.  According to (Vahdat, et al., 2014) patient participation is the involvement of the patients while making decision to get their opinions regarding the treatment approach. For instance, during the pain management approach, we wanted to use a low-dose of analgesic infusion in Patient-controlled analgesia (PCA) devices. This approach also avoids high levels of does concentration as it can cause respiratory depression. In epidural analgesia, PCA works effectively and has greater autonomy to the patients (Kuchalik, et al., 2013). On the other hand, PCA has side effects such as vomiting, nausea, sedation, confusion and respiratory depression (Min, et al., 2016). With this, we needed I consulted Mrs. White before administering PCA and she very much appreciated my communication about it. She said that it was good that I was recognizing her rights in health care appreciated my communication. I also advised her to take rest and use other mechanisms like a Charnley pillow between legs which helps in leg abduction.

One study conducted by (Pape, et al., 2013) showed that interprofessional collaboration diminished patients stay in the hospital after THR. With this, I involved other professionals in the assessment of Mrs. White, an action that really impressed the hospital administrator. Further, I also recognized my duty in reporting any cases of persistent neurovascular dysfunction to the physician after the interventions.

Overall, both Mrs. White and her son Mr. X were very impressed with the way I took care of her. Without my knowledge, they decided to write a cheque to me as their appreciation of my service. However, I politely told them that I was not going to take it and they understood. This was one practice that went ahead to impress my supervisor and other colleagues.

Establishing Empathy in Nursing Care

According to (DeLaune, et al., 2016), nurses are required to conduct an accurate physical examination to the patients. In my placement, the examinations included especial manifestations such as urine analysis and blood pressure tests. I understood that cases of hip surgery required me to examine the patient’s cognitive level, sight and hearing abilities, balance and coordination, weight and BMI, pain scale, osteoporosis and muscular strength.

Another assessment that I needed to take was the neurovascular dysfunctions. Here my role was to examine other risks such as peripheral neurovascular dysfunction which may come after THR (Yang, 2014). Practices in this area included examining the motor functions, pedal pulses, capillary filling-time in the patient’s toes and others as also found in (White, et al., 2012). Measures of preventing neurovascular dysfunction are such as adjustment of devices, straps, proper alignment, prevention of dislocation, swelling reduction of swelling, prevention of bleeding (White, et al., 2012). Further, I also carried out my other duty which was to always inform the physician in case there was any persistent neurovascular dysfunction but it never happened.

Like as mentioned above, VTE is one of the observed risks that can come immediately after THR. The management of VTE is accomplished using VTE prophylaxis whose targets is minimizing any risk of THR. Thus, I knew I was introducing Mrs. White to medication. Even though Mrs. White was well known to me since she was my first client in the placement, I did not assume that I know everything. I still had to follow the “five rights” that apply to medication as told in (Gutkowska, 1987). These rights are the the right patient, the right drug, the right time, the right dose, and the right route.

The work of also (Zhang, et al., 2015) suggests using oral anticoagulants or low molecular weight heparin (LMWH) in VTE prophylaxis. My patient Mrs. White’s care plan included Clexane (enoxaparin) as single s/c injection that was to take 35 days.  The disadvantages of using Heparin therapy are facilitation thrombocytopenia and inconvenience.  Despite that, enoxaparin, an LMWH is safer and works better than warfarin (Budhiparama, et al., 2014). I informed these choices as a practice of including her in the decision.  For VTE prophylaxis administration, Mrs. White care included knee ted stocking, pharmacological and compression device. The compressive device was to be used on the affected limb which I advised Mrs. White to use it for 18 hours in a day as explained in (Solayar & Shannon, 2014). According to (Toker, et al., 2011) DVT and PE are fatal complications that can come immediately following orthopaedic surgery. The work of (Solayar & Shannon, 2014).states that mechanical prophylaxis which is the use of foot pumps with pharmacological are effective strategies in the management of VTE prophylaxis. The work of (Toker, et al., 2011) also advice on the pneumatic compression devices which are also effective in swelling reduction, microcirculation, and early mobilization

The main causes of pain in THR are a muscle spasm, previous joint problems, and surgical procedure. The patient's recovery both on health and mobility depends on the level of pain. (Min, et al., 2016) Through the direction of the physician, I administered a low-dose of analgesic infusion in Patient-controlled analgesia (PCA) devices is recommended because it works effectively and has been programmed for rapid functioning.  This approach also avoids high levels of does concentration as it can cause respiratory depression. In epidural analgesia, PCA works effectively and has greater autonomy to the patients (Kuchalik, et al., 2013). On the other hand, PCA has side effects such as vomiting, nausea, sedation, confusion and respiratory depression (Min, et al., 2016). Before administering PCA to Mrs. White, she received information about it. The procedure worked, and she was advised to use to rest, and use other mechanisms like a Charnley pillow between legs which helps in leg abduction.

Impaired mobility results from musculoskeletal damage due to pain, surgery procedure, discomforts or restrictions.  In a successful procedure and care, patients of THR should be able to walk independently with some supports about 10 meters, rise from a chair, come out of bed, and the capacity to engage in physiotherapy after their discharge from the hospital (Holm, et al., 2013).  The work of (Šponer, et al., 2017) states that nurses should advise patient regarding pressure sores. To avoid all these issues, I advised Mrs. White to avoid frequent re-positioning. Nevertheless, Mrs. White could walk with no problems on the affected leg, but she was using some walking aid. No pressure sores noticed in her early mobility. In terms of nutrition, the work of (Ellsworth & Kamath, 2016) states that malnutrition is a possible risk in THR, and it reduces the body’s defence mechanism.  Mrs. White had no much issues with malnutrition. However, supplementation was suggested for boosting essential elements like amino acids.

Assessing patient outcome is one of the main standard practices in nursing. In THR, assessment is relevant for monitoring the patient outcome and a major nursing standard of practice. In my case, Mrs. White assessment report showed that all standard procedures were followed, and I had handled all the nursing concerns appropriately. My report showed that I had taken comprehensive and accurate measures when taking her history, her assessments, and all her physical examination. Mrs.White also had no postoperative problems. My evaluation demonstrated that the entire postoperative phase went well and had no complications.

Also, I noticed no incidences of dislocation, confusion, bleeding, bed sore or even infection. In addition, the report affirmed that the practice met all the significant expectations of the nursing interventions something that my supervisor appreciated. The necessary approaches to reducing pain also worked efficiently. Mrs. White reported that the pain was mild, which was manageable and less distracting.  On the part of the neurovascular assessment, there were no problems. Everything was normal meaning that she had a full recovery. Similarly, all other vital signs were healthy.  Mrs. White said that she was feeling comfortable with only a little pain. While taking the assessment, she was cooperating fully and started walking with some aid on the first postoperative day. The procedure also reduced PCA slowly. Other determinants such as mobility, physiotherapy, ADLs, and walking with the aid of a stick were encouraged step by step.

The work of (Peters, et al., 2015) explains that the improvement in the modern surgery particularly the key-hole incision method is less invasive. This work extends to say that the surgery does not have many impacts on the muscles due to shorter anaesthetics. With this, the patient can be encouraged on earlier mobilization. However, patient education is also advised to make sure the patient is aware of the measures to be taken.  Some of these measures were advised in (Peters, et al., 2015). According to the authors, patients should avoid supine positions while sleeping in the first eight weeks. They should also not put a pillow between their legs.  Avoidance of such restriction has various benefits such as high satisfaction, improved sleep experience, and fast recovery. The work of (Modi, et al., 2012) affirms that sleep deprivation from restriction causes patients to develop anxiety and contributes to patient dissatisfaction. As this information was necessary for Mrs. Whites, I made sure she understood it, and also explained its importance to Mr. X.

In the case of the intermittent pneumatic compression device (IPCD), there are recent studies that have shown the efficacy of these portable devices in prophylaxis. For instance, in (Kwak, et al., 2017), the authors were evaluating the effects of IPCD in preventing VTE in patients who had undergone hip surgery. The results showed that only three patients who got VTE while still using IPCD. On the other hand, the control group had six patients who developed VTE. In other words, the incidences of VTE were higher in people who did not have the IPCD than those who had it. Despite that the noted variation was very small, the results of this study is a solid proof that IPCD can reduce chances of the occurrence of VTE.

The mechanism of IPCD works by compressing the veins to push blood to the heart. The device features a garment and an inflation pump (Zhao, et al., 2014). It is this garment which the patient fits the foot or calf. When air is pumped, the garment inflates compressing any blood that is stuck in the vein hence pushing it to the heart. The deflation happens after a few seconds, and the entire action looks like veins squeezing exercise. The benefits of IPCD devices are that they offer the pressure gradient which facilitates the blood flow (Zhao, et al., 2014). Another advantage is that they also create a cyclical flow which prevents the stasis of the blood in the femoral vein. In addition, a patient can still use IPCD while still in operation. This is one of the main advantage of IPCD over pharmacological prophylaxis. The use of pharmacological prophylaxis is not often advised for the patients who have not spent more than one day after an operation since they are seen to induce the bleeding.

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