On 14th July 2011, I attended the Interprofessional Education Conference. The conference started at 12pm and ended at 5pm. Several experienced speakers were invited to give speech and discuss about interprofessional collaboration in clinical setting and the way to work interprofessionally. I took part in the Health Care Team Challenge Competition.
The following is the link of my presentation for the Health Care Team Challenge Competition:
1.0 Introduction
An inter-professional team approach to health care improves the overall quality of care received by patients. Below is the assessment and managed plan for Mr Turner in the rehabilitation ward, 6 weeks following his discharge and long-term. This report is written by an inter-professional team consisting of an occupational therapist (OT), nurse, two pharmacists and a dietitian.
2.0 Body structures and functions
Mental health
Mental health is important for immediate recovery and ongoing issues after rehabilitation due to the large impact an amputation has on lifestyle and family. This includes maximising comfort and addressing any issues regarding body image or psychological stress that have resulted from the amputation1. To accomplish these goals the psychologist, nurse and OT need to assess emotional function, apply a strengths-based approach and trial coping strategies. Post-discharge, Mr Turner can continue receiving support through phone counselling, diabetes support groups and the Mount Magnet Medical Centre.
Pain
Post-operative pain is another key issue. After assessing his current level of pain and impact on activities, interventions include education regarding possible phantom sensation, drug therapy, desensitisation and exercise. Drug therapy ranges from Paracetamol, Panadeine Forte® or Panadeine® to morphine conventional oral liquid depending on the pain assessment2. Key professionals involved in this pain assessment and management include the nurse, OT, physiotherapist, pharmacist and doctor.
Mr Turner is showing signs of poor diabetes management. Testing his glycated haemoglobin levels will help to confirm this. All diabetics need to be treated like they have had their first heart attack, because of high causation, so all parameters that indicate heart failure need to be tested e.g. albumin, c-peptide and pulmonary function test3. A diet assessment and management plan will be written up before discharge. In addition his insulin regime will be checked and cholesterol lowering treatment (eg statin) can be started. Key professionals involved include the pharmacist, doctor, radiologist, nurse and dietitian.
Post-discharge, Mr Turner will require yearly visits to the ophthalmologist (Refer to Mt magnet ophthalmology service), diet and insulin regime support from the Dietitian and Diabetes Educator, monitoring of nervous and muscle tone issues with the physiotherapist, frequent health examinations by the local GP, yearly visits to the podiatrist and medication review by the pharmacist.
During a stressed state, malnutrition is a huge risk factor and increases recovery time3. Energy requirements need to be met to ensure optimal wound healing, immune function and a faster recovery. If nutrition requirements cannot be met orally during this time of increased energy demands, enteral feeding may be needed. Lack of fibre and fluid intake, decreased bowel motion from autonomic neuropathy and medications may cause constipation for which diet and drug therapy would be effective. Fluid and bowel open charts can monitor this. Key practitioners include the dietician, pharmacist, GP, nurse and speech pathologist.
Wound care
Mr Turner will need intensive management of dressings, healing, moisture of the site, and protection from infection4. Precautions to prevent deep vein thrombosis, development of pressure ulcers and flexion contracture of the right knee will be continued. Drug therapy including Prophylaxis antibiotic may help to reduce infection and improve healing. Key professionals involved include the physiotherapist, nurse, OT, pharmacist and doctor.
Fatigue
Fatigue limits activity and participation. Sleep apnoea is a contributing factor to his daytime fatigue. This can be reduced by keeping his bed slightly upright or using a mandibular advancement splint. OT intervention would include education about activity pacing, energy conservation & work simplification techniques. This should be practiced during the hospital stay to maximise transfer of skills to home environment. Referral to the physiotherapist will be made for cardiopulmonary rehabilitation and strengthening.
Self-care includes activities of daily living (ADLs). A baseline assessment for performance in ADLs can be conducted. OT intervention includes education and retraining in modified techniques, and prescription of assistive devices so as to maximise independence. Liaison between OT and nursing should be implemented to maximise skill development and practice. Referral will be made to HACC services available at Mt Magnet Health Centre for 1 hour daily self-care assistance for Mr Turner post-discharge.
Amputations affects mobility and therefore impacts participation in life activities1. The doctor, physiotherapist, prosthetist and OT will discuss possible mobility options together with Mr Turner and his wife with consideration of his health status and desired lifestyle. The short-term priority will be on wheelchair mobility and ADLs with the use of a manual wheelchair. OT intervention includes wheelchair fitting with residual limb support and pressure cushion. Referral to the physiotherapist and prosthetist will be made for strengthening, standing and ambulation. In the longer term, return to driving can be made with the help of an OT driving specialist.
To transfer to and from the wheelchair, a joint assessment and intervention from OT and physiotherapy is appropriate. These transfers will be practiced with graded difficulty. Education will be given to Mr Turner and his wife about technique and safety precautions.
Mr Turner faces risk of falls and further injury due to the amputation, orthostatic hypotension and retinopathy. The OT will educate Mr Turner and his wife about identifying hazards in the home and safety precautions to prevent falls, while the nurse will educate about precautions to prevent further injury which could lead to future amputations. Post-discharge, a referral to the OT at Mt Magnet will be made to conduct functional home safety assessment and home modifications.
Assessment includes discussion with Mr Turner and wife about the level of importance and need for assistance in these activities. He will practice the appropriate and relevant activities with modified techniques as required, with input from the OT.
Referral will be made to the OT at Mt Magnet to assess and recommend appropriate farming tasks for Mr Turner, recommendation to employ more farming assistants.
OT can also assess and provide appropriate interventions (environmental modifications for access, modified techniques and assistive devices) to enable Mr Turner to return to valued leisure activities such as wood-turning and bowling.
4.0 Contextual Factors: Environmental and personal factors
Relationship with wife
Mr Turner’s main carer is his wife, who would face significant stress with undertaking this new role. Counselling and education will be provided to her about caring and coping strategies. Information about carer support groups and respite services available at Mt Magnet will be provided. Key professionals include the OT, nurse, and social worker. In addition, the psychologist might counsel the couple about potential issues related to intimacy and sexual relations.
A referral will be made to the social worker for eligibility of disability support, carer payment and allowances, and financial assistance schemes.
Mr Turner’s smoking habit would delay wound healing, worsen the issue of fatigue and exacerbate diabetes symptoms. Counselling and education about smoking cessation, prescription of nicotine replacement patches if necessary will be done during the rehabilitation phase with the pharmacist and nurse5.
This is a major issue that impacts upon time and finances for Mr Turner and his wife, as Mr Turner is presently required for appointments in Geraldton. Referral will be made to the Mt Magnet Health Service for medical, nursing and allied health services post-discharge, transportation services for specialised medical treatment required at Geraldton, and delivery of medications6.
Health care professionals are governed by a code of ethics that cover the four main areas of autonomy, non-maleficence, beneficence and justice4. In the case of Mr Turner we have taken into account these criteria to ensure best practice. Autonomy - We respect Mr Turner's right to informed choice, even if they do not concur with professionals view. Non-maleficence versus beneficence - our interventions are carefully considered to avoid harm or stress. We were wary of not imposing any unnecessary intervention or testing procedures to ensure the management plan focuses on healing and does not cause harm. Justice - We have taken into account Mr Turner's financial and social situation to ensure he receives eligible benefits and can remain in his own home.
Inter-professional care is imperative for any client. In this report it is clear that Nurses and doctors have responsibilities throughout all areas of the clients’ care and they are the leading health professions for his assessment and management. Dietitians, physiotherapists, pharmacists and OTs contribute to client care with support from the social worker, podiatrist, prosthetist and ophthalmologist. Many health professionals not mentioned are also influential in Mr Turner’s care, e.g. speech pathologist and dentist. An inter-professional approach towards Mr Tuner’s care, rehabilitation and management will ensure best quality care possible.
References
2. Pharmaceutical Society of Australia, Australasian College of General Practitioners, Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists. Australian Medicines Handbook 2010. South Australia: Australian Medicines Handbook Pty. Limited; 2010.
3. Mahan LK, Escott-Stump S. Krause's Food and Nutrition Therapy. 12 ed. St Louis, MI: Elsevier Saunders; 2009.
4. Crisp J, Taylor C. Fundamentals of Nursing. Sydney: Mosby Elsevier; 2005.
5. Pharmaceutical Society of Australia. Smoking Self Care Card. 2011 [cited 2011 July 7].
6. Mount Magnet Medical Centre. Mount Magnet Medical Centre Brochure. 2011 [cited 2011 July 7].
Mr Turner is a 67-year-old male who resides with his wife on a ten thousand acre property in the shire of Mt Magnet. He and his father-in-law built their present two-storey home with the first floor fully wheelchair accessible to accommodate his mother-in-law, who used a wheelchair prior to her death two years ago. Mr Turner and his wife live on the ground floor and use the top floor of the home for visitors when their 3 children and 7 grandchildren visit.
Two years ago Mr Turner quit his 1 pack of cigarettes per day smoking habit of 30 years but he has resumed smoking a “few” cigarettes per day in the past three months. He denies chest pain or shortness of breath but he does have a persistent cough. His wife states that he snores at night and is often restless. He sleeps best propped up with two pillows. He describes his feet as “pretty numb.” He has not reported any falls but recognizes a fall could be a problem.
Prior to his kidney transplant, Mr Turner was an active farmer and his wife volunteered part time at the local Meals on Wheels. Since the transplant, Mr Turner can no longer manage the farm and his wife has had to take on many of the farm chores with the help of casual farm labourers. She finds it difficult to assist him during the day and to transport him to and from his frequent medical appointments which at times require a long drive to Geraldton.
Hospital Treatment
Ten days ago Mr Turner was admitted to the Geraldton Hospital for a non-healing foot ulcer. He had driven 800 miles to attend his sister's funeral. When he returned home, his right foot was badly swollen and erythematous. A large blister was evident over the metatarsal plantar aspect of the foot. Upon arrival at the hospital, his temperature was 39.4° and the ulcer was draining green purulent material. He was immediately admitted to the hospital for evaluation and treatment.
Upon admission he was started on antibiotics. In the operating room the infected area of the plantar space of the right foot was incised and drained. Purulent material was collected and submitted for culture.
Culture results: Staph. aureus, Strep. intermedius and Strep. constellatus.
Antibiotic treatment was changed to IV only.
Mr Turner and his wife were presented with two treatment options:
1. Aggressive debridement, infection control and surgical revascularization
2.Amputation of the right leg.
During his hospitalization, he received acute care services from OT and physio. Initially, he required a maximum assist of 2 persons for transfers postoperatively. But within 3 days he was able to transfer to wheelchair with minimal assistance. He was independent in sink activities such as oral care and hair care and washing his upper body. He fed himself independently. He was able to dress his upper body independently but required moderate assistance to dress his lower body due to fatigue from exertion and trunk instability.
He required maximum assistance with all other lower body care, e.g. bathing, toileting, and changing the wound dressing. The operation site remained clean and dry and slightly edematous, with the skin pink and cool to the touch. He reported feeling tired following very little exertion such as sitting up on the edge of the bed.
You are the interprofessional team tasked with Mr Turner’s rehabilitation and his return to the community including risk management and ongoing support.
Describe your priorities within the rehabilitation unit and then for the first 6 weeks post discharge, justify who would be the lead professions during Mr Turner’s journey and how they would be supported by the remainder of your team. Also consider which other health professionals outside of your team you might want to involve.
