James was encouraged to perform regular deep breathing exercises and educated on the use of the incentive spirometer. Incentive spirometry is used to increase the depth of inspiration in a patient who may not be taking adequate inspirations by themselves (Boggs & Wooldridge-King, 1993). A chest drain placed into the fifth intercostal space as well as post-operative pain could all contribute to a decrease in the depth of inspiration James was able to take. Normal respiration will move any fluid that is accumulating in the lungs of a healthy individual, whereas fluid that is pooling in the lungs of an individual with inadequate respirations may be another avenue for bacteria to colonise leading to infection (Kidd & Wagner, 2001).James was educated on the correct way to use the incentive spirometer and initially needed reminding and encouraging to utilise it, however after a few days he needed no reminding and used it far more frequently than the suggested three inhalations, three times per day.
It is important to encourage patient’s to participate in their self-care activities and treatment regimes in accordance to their level of progress and activity tolerance. According to Thelan, et. al.
(1994), patient’s who take an active role in their own treatment regimes are less likely to feel like helpless or powerless victims. They go on to say that this greater sense of control over their illness will guide them more swiftly towards becoming as independent as possible.Pelvic injuries and fractures are associated with high levels of pain (Thelan, et. al., 1994). Macintyre and Ready (1996) go on to say that it was often thought that whilst pain was not considered good for the patient, it was thought to do no harm.
It is now recognised that this belief is incorrect and that the patient can indeed have harmful physiological and psychological effects if severe acute pain is undertreated (Macintyre & Ready, 1996). Macintyre and Ready (1996) state that the following conditions may result from undertreated pain. It may exaggerate existing pulmonary dysfunction leading to further pulmonary complications; cardiovascular effects include an increase in sympathetic nervous system activity leading to increases in heart rate and the workload of the heart which could result in myocardial ischemia due to a decrease in oxygen supply.People in severe pain often reduce their movements which increases their risk of developing deep vein thrombosis and pulmonary emboli, pain can lead to significant delays in gastric emptying and a reduction in gut motility as well as urine retention, and activation of the stress response is noted after surgery or trauma which results in the body releasing hormones. This hormone release may trigger a cascade of responses which leads to compromised wound healing as well as an impairment of the body’s immune reactions, which increases susceptibility to infection. Undertreated pain also causes patient anxiety, fear and sleeplessness.James had been seriously injured and it was important that his health was not further compromised by allowing severe acute pain to delay healing so he was given regular analgesia for his pain control. He was also attached to a patient controlled analgesia (PCA) machine that delivered a controlled dose of analgesia whenever James required it.
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Macintyre and Ready (1996) state that the patient is more likely to maintain a reasonably constant blood concentration of analgesia which is more likely to be kept within the “analgesia corridor” (p. 76) for each patient.The PCA enabled James to administer a dose of analgesic medication to himself when he was beginning to feel uncomfortable rather than wait until he experienced strong pain, request pain medication from the nurse, wait until it arrived and then wait longer until it worked. It gives patients a sense of control over their treatment, which as noted earlier assists them to recover and prevents feelings of hopelessness and powerlessness.James was encouraged to utilise his PCA machine when any essential cares were being performed for him (such as bed baths) that may require him to move thus causing him pain and discomfort.
The nursing staff were very prompt with the administration of the oral pain medication for James and they always evaluated the effectiveness of it within 30 minutes of administering it. The administration of medications is governed by the Medicines Act of 1981 and the Medicines Regulations of 1984, (Galbraith, Bullock and Manias, 2001). The legislation guides and controls the manner by which nurses conduct their practice of administering medicinal drugs. The nurses in the HDU were very aware of these regulations and appeared to act very correctly regarding their professional responsibilities concerning medications.When handling medications the nursing staff was extremely rigorous in upholding the five rights of medicine administration. Any medications that were added to fluids for intravenous administration were checked by two nurses, the empty containers were again checked by two nurses to ensure no errors had been made, before being administered to the patient. All bags of fluid and syringes containing added medications were labeled with a bright yellow sticker that stated what medications had been added, the date and time it had been added and then signed by the person who had added the medication.Any undated syringes with medications in them, that had been partially used and left on the patient’s trolley for later use, were discarded by the nurses coming on at the change of shift.
It was explained to the writer that although this may seem to be wasteful and expensive, nurses were not prepared to compromise the health of their patients by administering a medication that they had not prepared and did not know how long it had been on the patient’s trolley for.Other nursing considerations and interventions included regular position changes, oxygen administration, impaired physical mobility, neurovascular compromise, risk for development of compartment syndrome, fat embolism syndrome, sleep deprivation, altered tissue perfusion and high risk for fluid volume deficit. James received the nursing care he needed to ensure that these problems or potential problems were eliminated or managed effectively.Hudak, Gallo and Morton (1998), say that calamities alter a family’s sense of equilibrium, creating challenges that the family must respond to. The patient’s responsibilities must be assumed by other family members and the social role of the patient is altered or missing. The family’s reaction to the event is also dependent upon the nature of the event (Hudak, Gallo & Morton, 1998). According to Kidd and Wagner (2001), both the patient and their families want to be educated about their condition and the hospital.
This was achieved for James’s wife and family by educating them on his condition including the drains and external fixations protruding from James’s body. James’s wife was involved in decision making about his care – she signed all of his consent forms for surgery. Nursing staff advised her when doctors involved in James’s care, were available to discuss his progress with her.James did not reside locally and his family and friends had to drive from another town to visit him.
His wife, children and friends were frequent visitors, which James seemed to enjoy. However, frequent visitors, combined with regular nursing interventions and doctors visits, interfered with the amount of sleep James was able to get during the day, despite the fact that at times he seemed extremely tired. Visitors were limited to two people at a time and some of the nursing interventions were assessed by the nurses as being safe to leave until James awoke, thus ensuring that he was able to sleep undisturbed for periods during the day.
James did not identify any specific cultural or spiritual needs, he was visited by the hospital chaplain on her rounds but he did not express a need to see her again.According to Clochesy, Breu, Cardin, Whittaker and Rudy (1996), standards of practice “define the minimum level of care provided by a given profession that is considered adequate” (p. 25). The standards of care provided to James is determined by the Nursing Council of New Zealand (NCNZ), and at all times the nursing staff in the HDU upheld these standards. They acted in a manner that complied with legal requirements, upheld high ethical standards towards the patient and their colleagues, maintained high standards of practice, respected the rights of the patient and his family and inspired confidence and public trust in the profession of nursing.One person driving on the wrong side of the road had a huge impact on James’s life. Serious pelvic injuries saw him in surgery three times for repairs.
He will return home to live for approximately three months with external fixations protruding from his body, which will make life rather awkward for him. The nursing care he received in HDU is comparable with the latest and most up to date healthcare practices. James’s wife was included in discussions about her husband’s condition and care and this enabled her to learn about his injuries, which empowered her and helped her to cope. At all times nursing staff acted professionally and according to their legal requirements, upholding James’s ethical and cultural requirements. The nursing care James received in HDU was excellent.
