The following essay will demonstrate an understanding of the nursing process; which is a logical, structured approach to planning and delivering nursing care (Holland et al. 2008). Although the process is composed of four main stages namely: assessment, planning, implementation and evaluation (Peate et al. 2014), the focus will mainly be on the final two phases. The author will explore the postoperative care provided to a single patient during one shift of duty in relation to the nursing process. This inquiry will provide a focus on the nurses’ involvement in respect of physiological, pharmacological, and psycho-sociological aspects of their care of that particular patient. In order to conform to the guidelines of the Nursing and Midwifery Council (NMC 2015) on patient confidentiality, any names that could lead to the patient being identified have been altered. Thus, for the purpose of this assignment, the patient will be referred to as Mrs. C. In addition, the name of the ward and/or hospital will not be mentioned in the essay.
Mrs. C; a 53-year-old woman with a history of type 2 diabetes mellitus (T2DM) and severe peripheral vascular disease (PVD); was admitted to the vascular unit after presenting with non-healing ulcers over the lower aspects of both legs. In view of poor mobility, infection and chronic pain associated with the ulcers, it was agreed to amputate both legs below the knee. Following the procedure, the surgeons employed a combination of patient-controlled analgesia (PCA) and intravenous morphine to provide Mrs. C with adequate acute pain control. In the first 24 hours after the surgery, Mrs. C described her pain as continued, moderate to severe, in the stump area. With each passing day; however; the pain decreased in the verbal numerical pain scale (Dillon, 2016). As a result, the PCA was discontinued and oral analgesia was initiated. With regards to the assessment and planning phases of the nursing process, the patient’s needs were assessed as soon as she arrived back on the ward from recovery. Her vital signs as well as her level of consciousness and pain were routinely monitored and the epidural site was also checked regularly for swelling. Goals were set to reduce Mrs. C’s pain levels, help her mobilise and be independent enough to be able to carry out activities of daily living (Cedar 2012).
In his paper “A Theory of Human Motivation”, Maslow (1943) outlined a hierarchy of needs that all human beings must fulfil to be content. On the lowest level of this hierarchy are physiological needs (i.e. food and water) which are required by every individual to sustain life (Peate et al. 2014). Maslow (1943) suggested that these physical requirements have greater priority over other needs located at the top of the pyramid. Using this theory, Treas and Wilkinson (2014) listed “physical activity” as one of the physiological needs that must be met by all humans to maintain optimum health. According to Oglesby et al. (2017), physical activity comprises any bodily movement; including activities of daily living (ADLs). Thus, with regards to Mrs. C, this need became a tremendous challenge considering she now had a mobility impairment. Losing both of her legs meant that she was no longer able to walk as she did previously without some form of assistance. In addition, she now struggled with basic but vital needs like positioning herself in bed. Thus, to help enhance her mobility and general strength, the nurses worked closely with physiotherapists and other healthcare professionals. This idea of working together is strongly supported by the NMC (2015) in its Code. This is because collaborative practice improves the quality of care and health outcomes for the patients (Swanwick and McKimm 2017). The nurses assisted the physiotherapists by implementing various measures; such as promoting bed mobility; to meet Mrs. C’s activity needs. She was encouraged to change positions at least every 2 hours while she was awake and the need for this was explained to her clearly so that she would comply. It was also decided to keep Mrs. C’s bed rails up not only for safety reasons but also to help facilitate independent movement. These interventions were performed to increase Mrs. C’s independence in bed mobility as well as to prevent complications of immobility such as skin breakdown and pressure ulcers (bedsores). The effectiveness of these implementations was evaluated by observing Mrs. C’s skill performance. By the end of the shift, her mobility had somewhat improved as she demonstrated the ability to reposition herself regularly using the bed rails. Skin assessment is another evaluative measure that was performed. The student nurse gained consent from the patient to inspect all areas of her skin, with particular attention paid to the bony prominences subject to pressure. The absence of non-blanchable redness on Mrs. C’s skin indicated that she had followed the repositioning schedule and mobilised. This progress in bed mobility was documented in the patient’s notes so other health professionals would know about it. This demonstrates compliance with the NMC (2010) guidelines which highlight record keeping as a fundamental part of nursing.
Pain avoidance is another physiological need that is viewed by Maslow (in Nevid and Rathus 2016) as a priority. Individuals who undergo amputations are known to experience painful sensations either in the stump area (stump pain) or in the missing limb which is referred to as phantom pain (Benzon et al. 2014). Studies have shown that phantom pain is experienced by approximately 60 to 80% of patients following an amputation (Benzon et al. 2014). Given that the incidence has been reported to be higher in patients with pre-amputation pain (Tsui et al. 2010), it comes as no surprise that Mrs C. also experienced this type of pain. It limited her ability to mobilise in bed; at times; for instance, during the changing of bed linen where she had to roll over to the other side. Thus, to help alleviate this pain, the nurses implemented pharmacological and nonpharmacological interventions. Mrs. C was provided with optimal pain medication; as prescribed by the doctors; to help manage the pain. The student nurse also used distraction techniques like talking to draw the patient’s attention away from the pain she was feeling. This method is supported by Allred et al. (2010) who state that the redirection of attention makes the awareness of pain disappear. The effectiveness of these pain control measures was evaluated by asking Mrs. C to use a pain rating scale of 0 to 3. Following the pharmacological interventions, she verbalised that her pain was tolerable at 1, as it only presented whenever she moved. Observation skills were also used to evaluate effectiveness of care provided. The student nurse regularly checked up on the patient to see if she was showing non-verbal signs of pain or discomfort. Overall only the pharmacological interventions were successful in relieving Mrs. C’s pain as she still insisted on having analgesic medication during the nonpharmacological technique tried by the student.