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Autor: anton 08 April 2011
Words: 3148 | Pages: 13
In this essay I will discuss theoretical principals of rehabilitation of a particular patient I cared for while on clinical placement. It will focus on the role of the multidisciplinary team involved in this rehabilitation process post acute myocardial infarction and the education and support given to the patient and her family during the discharge planning process. Also I will be including statistics and evidence of pathophysiology. The National Service Framework for Older People (Department of Health, 2001) sets out eight standards including standard three about intermediate care services that promote independence and provide effective rehabilitation services. Active rehabilitation is seen to reduce the risks of hospital readmission, increase the likelihood of discharge from hospital, and prevent older people being placed in long-term residential care.
The aim of this essay is to analyse the rehabilitation process and understand the principles of rehabilitation for nursing practice. This will be achieved based on the reason for the patient's admission. Discussion on the patient's rehabilitation needs, the rehabilitation members who were involved in relation to the phase of cardiac rehabilitation that was used. The goal of the rehabilitation is to help the patient achieve optimal function again. The common goals for the rehab include: improved independence in the performance of basic activities of daily living such as grooming, dressing, hygiene and feeding, laundry and housekeeping tasks, meal planning, grocery shopping and community mobility. Also to provide the patient with education to help prevent another stroke. To abide by the Nursing and Midwifery council (NMC) code of Professional Conduct (2002) on confidentiality the patient will be referred to as Amanda. Amanda was a 56 years old lady, who lived with her husband. She had four children. She smoked 20-30 cigarettes a day for the 25 years and drinks alcohol occasionally. Her past medical histories were diabetes, chest pain and systemic hypertension.
Coronary heart disease (CHD) is the major cause of death in the UK and the survivors of acute myocardial infarction are at high risk of mortality. It is responsible for more than 110,000 deaths in England in 1998 including41,000 under the age of 75 Department of Health (2000). It can be seen from Amanda lifestyle that there was a possibility of her developing coronary heart disease. The term coronary heart disease refers to the symptoms of coronary occlusion caused by atherosclerosis" NT (1994,pg. 5). There are several factors considered to contribute to CHD. Cigarette smoking, obesity, person's sex, diabetes mellitus, exertional chest pain and age for women over the age of 55 were among the factors considered to contribute to CHD which might lead to acute myocardial infarction. Coronary heart disease alone is the most common cause of death in the UK, accounting for 1 in 4 deaths in men and 1 in 5 deaths in women (British Heart Foundation 1998).
Amanda was admitted from Cardiac Care Unit (CCU) to medical ward following a suspected myocardial infarction. Myocardial infarction is a "pathological term used to describe the death of a portion of heart muscle" Jones and West (1995,pg7). This in order words occurs when a coronary artery blocks completely resulting to death of the dependent muscle. The infarction can involve any part of the heart, but it commonly affects the left ventricle NT (1994,pg.7). On admission during assessment, Amanda was in pain, discomfort, anxious and restless. Amanda was on pain relief during the acute phase which was intravenous (iv) diamorphine. Her skin was also pale and clammy. This according to Hand (2001,pg.49) is as a result of peripheral vasoconstriction as the body diverts the blood supply towards the vital organs, the brain and the heart. Several blood tests and electrocardiograph (ECG) were carried out. Other signs of distress and her history of chest pain, systemic hypertension were used to prove the provisional diagnosis of myocardial infarction that was made earlier.
Cardiac Rehabilitation programme is offered to patients post myocardial infarction. Rehabilitation is defined by the Royal College of Nursing RCN, (2000,pg.3) as re-enablement which means "helping people adapt to changes in their life circumstances." Cardiac rehabilitation is defined by Jowcett and Thompson 1996 cited in Noy (1998,pg.1033) as "the process by which patients with coronary heart disease are enabled to achieve their optimal physical, emotional, social and economic status". Furthermore, it is also defined by the World Health Organisation WHO, (1993) cited in the National Service Framework for coronary heart disease DOH, (2000,pg.3) as the "sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible physical, mental and social conditions, so that they (people) may, by their own efforts preserve or resume when lost, as normal a place as possible in the community". Rehabilitation is a complex activity that requires contributions from many members of the healthcare team. Rehabilitation is a planned, goal-directed activity that requires assessment and re-assessment using standardised measures to monitor progress. It must include patients and their families and friends.
Cardiac rehabilitation programme is structured to be either hospital based, community based or home based. It was recommended by WHO, (1993) that cardiac rehabilitation should start at the time of coronary heart disease, or as soon as possible following admission with acute event from phase one. The cardiac rehabilitation programme consist of four phases Coats et al (1995,pg.153-156). Phase one (in-patient stay) starts from when a patient is in coronary care unit or in a medical ward until the patient is discharged from the hospital. Its contents are reassurance, involving partner and friends, providing information and education. It also includes risk factor assessment, mobilization and discharge planning.
Phase two (immediate post-discharge) involves post discharge fellow-up which can be through telephone or home visits whereby deterioration or non compliance with treatment will be identified. Further assessments and inverstigation are also made and more education.Phase three (intermediate outpatient) constitutes of prescribed individual exercise which is based on clinical status, risk stratification, and assessment of previous physical activity and future needs. It also includes supervised exercise session, home based programmes and vocation assessment.
Finally phase four (long term maintenance) it involves maintaining exercise and other lifestyle changes. Monitoring for risk factor change and secondary prevention. Monitoring of adherence to therapy and vocational support. Phase one of the four phases was used during Amanda's rehabilitation programme. It is designed to restore and promote a positive outlook to recovery and to ensure that the journey of returning to near normal life is as easy as possible. Her prognosis was good but as a result of her condition, she was depressed and anxious. She was reassured by her nurse and was informed all the time about the progress she was making. Therapeutic value for the patient concerned is essential throughout the four stages of rehabilitation process. Cardiac rehabilitation should be carried out using a holistic framework ensuring individualised care with the goal of empowering patients to use their knowledge and social networks. It should also be stimulating, relaxed and have a positive atmosphere. A comprehensive rehabilitation programme should benefit the patient physically, mentally and spiritually RCN (2000,pg 4).
For effective holistic approach to take place in rehabilitation process it should involve the skills of rehabilitation professionals. Members of the rehabilitation team bring together different perspective and skills in a well organize way to provide for the needs of the individual. Cardiac rehabilitation programme is a multidimensional, multidisplinary intervention . Though it may differ in content, it still shares the same goal. Davis and O'Cornnor (1999 pg. 53) highlighted that rehab is a multiple subject and this makes it unconvincing that all the areas of the treatment needed by the patients could covered by only one discipline. The members of the rehabilitation team are nurses, medical team (Doctors), dietician, physiotherapist, occupational therapist, social worker, pharmacist, cardiologist psychiatrist and health visitor. Those involved in Jane's case are nurses, medical team (Doctors, dietician, physiotherapist, occupational therapist, social worker, discharge coordinator, dietitian, pharmacist, Speech therapist and health visitor.
Nurses play an important role whatever and however the structure is ranging from psychological intervention/support, physical intervention, education and information giving as well as in lifestyle change. They help in easing the transition from hospital phase which is the patient phase to the early post discharge phase and other phases of cardiac rehabilitation. In addition, they coordinate the cardiac rehabilitation programmes as well as members of the rehabilitation team and the manage the nursing team, Waters and Luker (1999) cited in RCN (2000, Pg. 5)
Nurses are central to effective communication between all the members of the team. They are also in a position to make contact with patients and be able to reinforce the activities initiated by other team members with 24 hours a day period. In cardiac rehabilitation process nurse's role is underpinned by person centered care plans which starts with assessment of each patient incorporating their goals for future. Assessment is an ongoing and systematic process which enables nurses to collect and analyze information about each individual patient. A holistic assessment of their needs is important because assessment is the initial of the four stages of nursing process.
In Amanda's case the focus was to enhance herself esteem and confidence and to enable her to take control over the situation. Assessment was based on function ability taking into account the disease process and prognosis. However, much emphasis was made on the assessment of the effect of the myocardial infarction on her activities of daily living. Amand's husband accompanied her when she came to the ward. They were orientated and made comfortable by one of the staff nurses. Information on her social, family and past medical history were collected using interviewing and observation skills. Her medical notes were also reviewed to gain better understanding of her condition. She and her family were involved in making decisions about her care.
Using effective communication and listening skills I wrote a care plan and consent gained. She was able to discuss with the help of her husband her lifestyle. This was to identify risk factors for heart disease. She was given information on how to reduce them to prevent further attacks. The information was in form of verbal discussion and leaflets directed to both patients and families. Amanda was also assisted with her activities of daily living during the acute phase such as hygiene needs, elimination needs, eating and drinking etc.
The medical team which includes Doctors and General practitioner (GP) are an essential part of the rehabilitation team. They are the first contact the patient has before meeting any other team members. Their role is to assess on regular basis patients' heath status, examine and investigate. They also explain diagnosis and prognosis to patients and relatives. In addition, GP reinforces the initial messages brought up in hospital for example risk factor changes Davis and O'Connor (1999). Similar care was given to Amanda, explanation of the process of rehab. And the reason for ongoing interventions were given. They carried out several tests for diagnosis and to determine the progress. They also worked with other members especially nurses when and as necessary to promote recovery.
Physiotherapists are also part of the team who work in both primary and secondary care.
They focus on the use of physical approaches in the preventive and treatment of disease and disability. They deal with problems associated with cardiovascular, respiratory, neuromuscular and musculoskeletal system. They also teach other members and families on how best to assist patient Squires (1996,pg. 201) In relation to Amanda's, they assessed her and start her on exercise as a daily routine in the ward. This helped to improve cardiovascular efficiency and fitness. The exercise helped to relieve pain and aid the healing of the part of the muscle that was damaged because during exercise more oxygen is supplied to the area.
Occupational therapists give treatment that involve carefully planned programmes of activities. They are selected to meet individual needs and lead to rehabilitation and discharge Turner, (1992) cited in Squires (1996, pg. 222). Occupational therapist made a home visit to Amanda's house to assess whether and how she would be able to manage things like household tasks on her own because her husband worked full time. Dietician was also involved in Amanda's rehabilitation because hyperlipidaemia is one of the risk factors that tend to make a person more likely to develop CHD. So the dietician taught and gave her information on how to control fat consumption which is important factor in preventive nutrition, she was also assisted on how to modify dietary fat intake
Discharge coordinator's role was to coordinate discharge panning and liaise with community involving patient, GP and the primary care team. This took place when the medical team satisfied with her progress. Discharge coordinator ensured that all the necessary things like social support, short term care packages and referrals were done and other things she might need will be in place when she goes home.The role of social worker in Amana's rehabilitation was to lias with the hospital team, and organise things like financial support from the department of social security. Social worker also ensure that other aspects of her social life are taken care of as she will be out from work for sometime depending on her progress with rehabilitation.
Amanda was referred to health visitor whose role was to make early contact once she has been discharge form hospital. Health visitor will assess and set up individualise rehabilitation programme for her as well as ensuring continuity of care. The pharmacist is responsible for supply of medicine in the ward and when the patient is discharged when it has been prescribed by Doctor's. It is called TTA that is Tablets to Take Away. Rehabilitation needs are viewed within the family context because it is essential to recognize that family members are also affected and are experiencing difficulties in adapting to the situation. As Nolan and Nolan(1998,pg221) wrote that programme of rehabilitation should involve not only the person affected but also the wider family and they require an outlet for their own fears concerns.
Family's influence is clearly significant as they present a more continuous figure in the patient's life. This is because they are there before the beginning of the illness and given the right circumstances they will carry on to be there long after any carer. Therefore family should be part of the rehabilitation team and work in association with patient nurses Smith (1999,pg. 79) Normington (2000, pg. 436) also said that involving families can be a powerful tool of practical and emotional support for the patient.
Amanda made a very good progress on her recovery and discharge plan was started. Her discharge plan actually started from the time of admission like all in patient. During her stay in the ward, a case management was formed. "The essence of case management is a framework for efficient and effective rehabilitation and discharge planning" Smith (1999, pg. 2020) . For a successful discharge the framework should have clear, concise document which is user friendly at clinical level.
Discharge planning is the process whereby patient's needs are identified and plans are made to ensure continuity of heath care from one environment to another Jackson, (1994) cited in Dougherty and Lister (2004,pg.170). It is required for a continuity of care between hospital and home. Effective and safe discharge planning process take into account a patient's physical, psychological, social and economic needs. It also promotes high level of independence for patient and their families by encouraging adequate self-care activity.
Amanda was discharged a week after her admission and was given out patient appointment to see her consultant. Health promotion education on several things was given, they are medication, lifestyle factors which included dietary intake and smoking cessation. She was also encouraged to plan for risk situation in which she might be tempted to smoke. Advice about returning to daily life and work and how to contact support groups were given.
Amanda had helped and support from family and friends which made it easier for her to cope with her condition. The role of informal carers also play important part of rehabilitation. Informal carers are people who provide unpaid care for family members, friends, neighbours or others who are sick, disabled or elderly. The majority of these carers were female around a quarter of both male and female carers were aged 45 to 54 with around a fifth of carers falling in each of the adjacent age groups. Women were slightly more likely than men to be caring for 50 hours or more while men were slightly more likely than women to be caring for less than 20 hours. Voluntary services play a key role in supporting patients and carers at home (Daly 1999)
Coping mechanisms vary in adults while some might have developed a personal approach of coping with stressful situations others have not . The issue of psychological need was not dealt with in Jane's case Amsterdam et al (1994) cited in Nolan and Nolan (1998, pg.203) said that patient's fear of death is higher than the actual risk of death and that this can lead to a negative perception of future prospect. Psychological intervention post infarction should start as soon as possible. Ideally not possible, it should be recognised. It is an important area of care which nurses should be trained adequately. Moreover, in order to achieve the lifestyle changes it should be trained adequately. Moreover, in order to achieve the lifestyle changes it she become a routine part of care Lewin, (1995) cited in Nolan and Nolan 1998,pg.222).
To conclude, cardiac rehabilitation reduces mortality and morbidity and improves quality of life. It also has physical and psychological benefits for patients. Individualised programme continues to be the best approach to cardiac rehabilitation. For rehabilitation to be effective there should be collaboration and liaison between rehabilitation service, aftercare arrangement and better use of primary care. Patient education is also necessary because it enhance compliance to medical advice. Cardiac rehabilitation should begin early on hospital admission and more emphasis should be placed on the impact of coronary disease on the family and on the patient's emotional reactions. It is essential that nurses continue to develop their knowledge, skills, awareness, competence and confidence in providing care to patients and their families if we are to meet the challenges of care delivery in a responsive and humane way.
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