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1. Apply legal and ethical frameworks and evidence based practice principles to explore the complexity of person centred care in the medical-surgical setting.


2. Examine the use of technology to inform person centred nursing care within the medical-surgical setting.

3. Critically discuss communication patterns and process required to inform person safety and quality within the medical-surgical setting. 

Process of Surgical Procedure

The main focus of patient centered care is the patient and their particular medical, surgical, social, and psychological needs.  It shifts the attention of the physicians and medical personnel from diseases to the patients and their families .The masterminds of this idea were well aware of its moral implications to their work.  This had to do with the respect for patients as special and unique beings and their obligation to attend to them and care for them according to their various needs.  Patients need to be consulted and be sufficiently informed in cases in which fateful health care decisions are supposed to be made.  This also includes cases that the patient’s decisions and preferences may play little or no significance role. A typical example is a case where a surgery is necessitated by an acute case of appendicitis.  This makes the patients feel that their needs are honored and their rights respected.

In the case presented, I will ask Molly to change into the hospital gown.  Then, assign her a bed in the holding room and keep her belongings away from the operating room.  An intravenous catheter will then be inserted. It is a procedure with a mild pain but is essential in providing essential fluids necessary for the surgical procedure ahead.  After that, I will call in a team of physician assistants whom after introducing themselves will perform a history test on Molly.  The objective of this procedure is to examine whether anything has changed since the last medical visit ( Hinkle and Cheever, 2014)

Risks related to the surgical procedure will be explained to Molly so that she is prepared for the surgery.  Such risks may include infection of the wound, which may be managed by the use of antibiotics.  This may require another surgery should the infection be deep. There may also be damage to the nerve, artery, or ligament around the knee joint.  Deep vein thrombosis or blood clots may result due to reduced movement of the leg after the first few weeks of surgery.  The bone around the artificial joint may fracture during or after the surgery( Becker and Hirschmann, 2015)

Molly’s knee cap may also end up being dislocated .There may be excess bone forming and scar tissue forming, and restricted movement of the joint all because of the surgery.  Molly will undergo an anesthetic procedure.  This consists of a spinal, epidural as well as a femoral or a saphenous nerve block.  Spinal or epidural anesthesia will be administered through an injection in her lower back to make the waist downwards numb.  Thereafter, a plastic catheter is connected so that local anesthetic may be infused to reduce pain after the surgery. Saphenous nerve block involves injection of a local anesthetic around nerves going to the knee. The injections control pain up to 16 hours after the surgery.

A general anesthesia will also have to be used.  It involves being put into sleep for the surgical procedure and it is administered though the intravenous line.  The anesthesia will put Molly asleep until the surgery is completed. An endotracheal tube will then be fixed and connected to a ventilator such as an oxygen cylinders or oxygen compressor.  Molly will remain deep asleep until the surgery is over. Thereafter, she will start breathing normally. Once the surgery is through Molly will be taken in the recovery room and the surgeon will talk to her family (Kee, Hayes, and McCuistion, 2014)

Consent in Surgical Procedure

In the recovery room, one becomes fully awake from the sedation and is monitored.  With the numbness still there, a urinary catheter is inserted. Blood loss because of the surgery is also monitored by placing a drain in the knee.  Some blood samples will also be sent by the staff to see if there is need for any transfusion.  At this point, Molly’s legs will begin to have some sensations. A machine (Patient-controlled Analgesia) will be attached to the epidural catheter to provide more medication for the pain.  There is a button in the machine that helps the patient to control the rate of infusion of the pain medicine.  There is a calibration in the machine that will prevent Molly from harming herself as she administers the pain medicine.  Molly will then be taken to her room from where she will be monitored until fit for discharge.

Clinical research studies have shown that  surgical procedures induce sympathetic responses that in turn elevate production of hepatic glucose.  This may be a threat to Type2 diabetes patients.  The recovery period for her surgery may be longer so it may require an intravenous insulin infusion (Schipper and Jiang, 2014). This is done first on the morning of the surgery.  This should be continued until after the subcutaneous insulin is administered. Capillary blood glucose should be measured at least after every hour after insulin administration.  This will be done until the patient is seen to be stable (Kee et al., 2014). Thereafter, Molly will be advised to replace carbohydrates with sugary fluids and a lot of monitoring done to ensure that she does not turn hypoglycemic.

Consent is a vital and fundamental law upon each surgical procedure must be put through. It is a key clinical skill applied in patient care.  Consent acts as a legal permit to save the surgeon from accusations that may arise due to illegal touch (Hinkle et all.,  2014). Management of the patient’s personal data and disposal of their waste also forms part of the consent.  Surgical procedure, alternative methods, risks involved after the surgery, and even the effects of choosing not to take the surgery are explained in the consent (Gastmans, 2013)

Engagement with Molly in face to face conversation about the consent would be very important ( Gastmans, 2013). However, if she does not feel comfortable ,a third trusted party of her choice is to be involved in this discussion to offset any decisions based on arrogance and illiteracy.  Any other suitable method can be used if need be.  The consent should only  be done once the patient is fully convinced of the procedure and the pros and cons of the procedure at hand (Potter, Perry, Stockert, and Hall, 2017)

In some cases, there may arise a tension between the respect for autonomy of the patient and paternalistic healthcare practices (Mehta, 2015).  Institutions that employ paternalism practice usually tend to ignore and override the preferences of the patient in order to enhance the benefit of the welfare of the patient.  The negative risks involved in Molly’s surgery are outnumbered and outweighed by the positive implications.  My duty as a nurse will therefore be, to ensure that Molly takes the surgery.  Emphasis is done more on the advantages (Lewis, Dirksen, Heitkemper, and Bucher, 2014)

Importance of Adequate Explanations in the Consent Process

As a nurse, appropriately taking part in the consent process may be vital for Molly’s sound decision making. As the nurse incharge,I should ensure that the surgeons involved are present to do adequate explanation and familiarization to ensure that Molly is comfortable with the surgical procedure .  A good, healthy and professional nurse- to- patient relationship is developed between Molly and I so as to address her anxiety and impact her comprehension hence influence her disclosure of information needed for the surgical procedure.

Consents should never be viewed as chiefly legal procedure since the perception may lead to overshadowing of provision of the autonomy of the patient, which is the ethical goal of consents.  It should not be viewed as a static process but rather a continuous process. The form may be a representation of a legalized documentation but the bigger picture entails ethical obligation to respect the patient’s rights and decision(LeMone, Burke, Bauldoff, and Gubrud, 2015).   It also prevents the misdirected attention given to the consent form signing.

By the end of the process of obtaining an informed consent, Molly must be at a position to make a sound and reliable decision. This is after processing meaningful information and being able to communicate a meaningful response.  Capacity determination is different from consent determination, which is more of a legal procedure (Doenges et al., 2014). If a situation that Molly is not able to make a sound decision arises, due to she becoming extremely disoriented or delusional, a surrogate, who assumes authority becomes the reliable decision maker.  If by chance she does not have a designated surrogate, a proxy may come in handy in such a situation (Craven, 2015)

However, these designated health care surrogates and proxies are obliged into making judgments that can be substituted. Therefore, should she have made a preference before she becomes incapacitated, the surrogate or the proxy, when making the decision,  will use this.  Refusal of a recommended treatment is her right.  She should be aware that a consent is not only freely given but also withdrawn at will. A new course of action should be taken ,should the procedure be conducted without her consent. This may be performed through a court action.  Her decision should therefore be much respected.

As a nurse, I would first take her through the educative process to ensure that she is aware of what all the process entails. I should be at a position to tell whether the patient understands the whole point and be ready to respond to any upcoming question or concern.  It will be a collaborative exercise between Molly, the physician and I. Before she signs the form, the physician involved must have taken the consent. Employment of teach back method can be very instrumental; asking her to repeat what she has understood from what is taught. However,the teaching cannot take place prior to that of the physician (Martin and Kaplan , 2016).

Employ a form of judgment that is professional, for the determination of boundaries appropriate for therapeutic relationship with her.  This should be maintained within professional boundaries to offset any unethical issue.  Moreover, it is very important that these are only conducted at her free will.  A surrogate of her choice will be chosen upon any appraisal that may render her incapacitated (Ignatavicius and Workman, 2017).

Consent made by the patient is more of an ethical than a legal concept.  Clients must not only understand, but also agree with the potential consequences that may come up during their care.  The physician must take whatever the amount of time necessary to ensure that the information is taken, understood and a sound response is given with regard to it (Craven, 2015).  No physician should guarantee outcomes in any given operation since the patients are different and they all depend of the individual patient conditions. Nonetheless, an appropriate advice should be given.  This principle of informed consent is endorsed widely by American College of Surgeons; an organization that has more than 54,000 members that renders it the largest surgical organization in the world (Erickson and Blazer- Riley, 2012)

The patient stands a chance to know the kind of risks involved in the surgical procedure and their severity should any complications arise. However, the credibility of this procedure has been put through various accusations.  These include; cultural biasness of the procedure, it is taken to be more of ritualistic and legalistic than ethical (LeMone et al.,  2015). Some people also argue out that its enforcement is very uneven. Even though the patient has legal right to sue the physician in situations where the consent is not adhered to, there are emergency cases that may arise and may not necessarily need consent (Horner 2015).

As aforementioned, Molly would be taken to the recovery room after surgery. Once in the recovery room, she will awaken fully from the sedation after a while. She will then be placed on the monitors again. While the knee is still numb, a urinary catheter will be inserted on Molly.  A machine is then attached to her epidural catheter.  This is the PCA (patient-controlled analgesia). This machine has a button that helps the patient control the amount of pain medicine according to the pain experienced.  It is however calibrated to prevent any harm that may come up due to continuous pressing of the control button (Potter et al., 2007)

Being a diabetic patient, her levels of glucose must be monitored.  It should be ensured that glycaemia is controlled.  Fluid and electrolyte balance should also be kept in watch. A quick return to normal carbohydrate intake should be encouraged.  This is to ensure a return to the usual diabetes regimen. Foot and pressure areas are to be frequently examined.  Little pressure is applied on the joint at a given frequency by a physiotherapist (Horner, 2015).

There may be complications such as; blood clot that may be caused by deep vein thrombosis. Rivaroxaban and Apixaban can be used to control the clotting (Mehta, 2015).  Pulmonary embolism may also occur and in  such a case, blood-thinning drugs are used.  The surgical wound may also develop an infection.  Antibiotics are normally the first line of defense in handling it.  Excessive bleeding and wound hematoma are other common complications that may arise.  This may cause death in hemophiliacs. The recovery process must be an active one. Some soft physical exercises should be performed to her and improvement records taken.

Any complication that may require the attention of a physician is immediately reported.  Stiffness of the joint may also occur.  This may be caused by premature termination of rigorous exercise performed by the physiotherapist. Swelling may further worsen the stiffening.  Intensive physiotherapy may be used to correct the condition.  In addition, manipulation of the joint under an anesthetic influence may also be a proper corrective measure for the stiffness (Nyary and Scamell, 2015)

Conclusion

Collaboration between surgeons and nurses in proper execution of an informed consent, may lead to the achievement of patient autonomy.  These professionals can contribute within their legal specialization and scope of practice to minimize litigation risks by meeting fully the legality obligations imposed by informed consent statutes.

Institutions that ,in their medical procedures, employ a patient-centered care procedure, greatly stand a position to succeed. The patient is involved in each step of decision-making and this prompts them to be more free and open up to the physician, an important factor in diagnosis through history assessment.   

References 

Becker, R., & Hirschmann, M. T. (2015). 54 Constrained Condylar Total Knee Replacement. The Unhappy Total Knee Replacement, 6(8), 657-662. doi:10.1007/978-3-319-08099-4_65

Kee, J.L., Hayes, E.R., & McCuistion, L.E. (2014). Pharmacology: A Patient-Centered Nursing Process Approach. (8th ed.). St. Louis: Elsevier/W.B. Saunders.

Nyary, T., &Scamell BE. (2015). Principles of bone and joint injuries and their healing. Surgery(Oxford). 33 (1), p 7-14.

Gastmans, C. (2013). "Dignity-enhancing nursing care: A foundational ethical framework". Nursing Ethics. SAGE Publications. 20 (2): 142–149. doi:10.1177/0969733012473772

Doenges, Marilynn; Moorehouse, Mary; Murr, Alice (2014). Nursing care plans : Guidelines for Individualizing Client Care Across the Life Span (9th ed.). Philadelphia: F.A. Davis Company.

Horner, R. D. (2015). Putting the Patient Back in Patient Care. Medical Care, 53(1), 1. doi:10.1097/mlr.0000000000000266.

Erickson, M., & Blazer-Riley, J. (2012). The Client-Nurse Relationship: A Helping Relationship. In Communications in Nursing (Seventh ed., pp. 16-31). St.Louis, Missouri: Elsevier Mosby.

LeMone, P., Burke, K.M., Bauldoff, G., & Gubrud, P. (2015). Medical-Surgical Nursing: Critical Reasoning in Patient Care (6th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall.

Martin, N. D., & In Kaplan, L. J. (2016). Principles of Adult Surgical Critical Care. KAPLAN.

Craven, H. (Ed.). (2015). Core Curriculum for Medical-Surgical Nursing. (5th ed.). Pitman, NJ: Academy of Medical-Surgical Nurses.

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). St. Louis: Elsevier.

Schipper, O.N., Jiang JJ, Chen L, et al; Effect of Diabetes Mellitus on Perioperative Complications and Hospital Outcomes After Ankle Arthrodesis and Total Ankle Arthroplasty. Foot Ankle Int. 2014 Nov 20. pii: 1071100714555569.

Hinkle, J.L. & Cheever, K.H. (2014). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (13th ed.). Philadelphia: Lippincott Williams & Wilkins.

Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2017). Fundamentals of Nursing (9th ed.). St. Louis: Elsevier/Mosby.

Ignatavicius, D.D. & Workman, M.L. (2016). Medical-Surgical Nursing: Patient-Centered Collaborative Care (8th ed.). St. Louis: Elsevier.

Mehta, A. (2015). Chapter-05 Complications and Revision TKR. A Practical Operative Guide for Total Knee & Hip Replacement, 3(9), 67-106. doi:10.5005/jp/books/12451_6

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