Pressure ulcer management and treatment in a pediatric patient with cerebral palsy

MS Case Study Nurse Practice

When patients enter hospitals it is oftentimes they become more ill and sicker due to inappropriate care and professional ignorance. This is due mainly to the amount of hubris involved within the medical profession and a tendency to ignore empirical evidence as practiced to success. This approach underlines the most important aspects of healing and the medical profession itself.

The argument for continued improvement in the treatment of patients is best exemplified in the case of MS. His ill health has led to more problems and the approach by the nurse practitioner and her staff is critical to the ultimate survival of this young child who innocently trusted the advice of both his parents or caretakers that the medical staff would be able to treat him with the care and respect that every patient deserves when being encountered during a medical treatment or hospital stay. This is essential what nurses do and how they must approach their work, in a professional and dignified manner that admits mistakes when they happen and look to the present to find solutions so they do not occur in the future.

The purpose of this essay is to discuss and highlight the proper and relevant strategies in the case of MS. MS' situation is the following: " MS is 15-year-old adolescent with cerebral and developmental disorder. He had ICU care because of viral pneumonia. He currently was transferred from the hospital to the facility. Because of his disease, he cannot eat by mouth thus he is provided the feeding by Gastro-tube. Also, he cannot move by himself. When arriving at the facility, the nurse noted stage II pressure ulcer on his sacral area. The nurse consulted to a family nurse practitioner who has Wound, Ostomy, and Continence Certification and is a member of wound care team in the facility to ask for management and treatment guidance because the nurse has only taken care of one patient with stage I pressure ulcer.

The family nurse practitioner who was consulted to manage MS's ulcer searched the literature and information about the ulcer. She made order to treat the ulcer and made the strategy to manage the ulcer. She also consulted to the nutritionist in the facility to manage and improve his nutritive conditions. Moreover, she made the strategy to manage and prevent pressure ulcer for patients with same condition in the facility."

The field of wound care is becoming more and more important as new pathways of healing are being discovered through this type of examination of the problems. While competencies may be somewhat unrefined and scattered, it is essential that given the current structure of the nurse practitioner profession, learning and self education, through experiment and theory development are necessary components to adds such validity in such areas as wound treatment.

This essay will review pertinent literature on the subject to highlight the academic perspective on the matter and view possible new directions in which this type of research is headed towards. The essay will then explore relevant strategies to deal with the unique situation and propose actions and plans that reflect a strategy that is consistent with sound and valid ideas reflected in the literature. The essay will then investigate theoretical bases upon which to implement the strategy. An implementation plan will also be included in this document as well as an assessment model to help provide a feedback loop and provide a means of improving and restructuring the model if deemed necessary.

Literature Review

It is important and necessary to examine the research that has been done on the issues reflected in this case. Such areas of research include, wound treatment, patient care, nursing ethics, team management, informatics, viral pneumonia and gastro feeding methods. The following research questions can be useful in aiding the review and applying it to the complex situation at hand:

How can wound treatment research be helpful in treating MS?

What are the risks involved with this approach ?

What are the benefits of a research based approach to clinical issues ?

What are the ethical issues involved with this case ?

How can theories be used to demonstrate the value of this approach ?

What theories are important and relevant to the case of MS ?

Relevant Strategies

Regardless of any specific strategy that can be applied to this problem at hand, it is necessary and important to look at the qualities of the problem which will allow a better examination and choosing of the correct strategy to implement for this case study. The problems discussed in this case need to be addressed at the root or cause. By finding and ultimately applying a strategic outlook that is consistent with this approach will allow the solutions to flow in a more accepting atmosphere that resonates with well educated and professional personnel that understand the bigger picture due to nursing practices that reflect a consultative tone to their operation.

It is also important to realize that a strategy is a guiding light of an organization or a group, and that tasks and purposes inherent within the overall strategy must be carried out and understood throughout the organization or the group that is working on this problem. Strategies are only useful when they are applied and when all other tasks and objectives that relate to this problem are aligned with the strategic values presented in this guidance from leadership and other sources of authority.

Objectives

The goals or end state of this problem must be first considered before applying any strategic input on the matter. Objectives must be clear, concise and somehow provide an overreaching view of the situation. Details are not important when developing objectives, and the big picture should be considered as important in this process. The objectives for this problem are listed as follows:

Heal the patient and return him to a healthy state of independent well being.

Use effective and efficient managing of resources.

Minimize pain and suffering as much as possible.

Maximize profits through economic and wise decision making.

Provide a sense of professionalism and duty to the problem at hand.

Approaches to Wound Care

The fundamental components of wound care must be included in any relevant strategy applied to this case study and the eventual healing of MS. Wound care consists of several approaches that, when balanced and tempered in the right fashion can provide a means of fully addressing the problems at hand. Each area of emphasis when done by itself does do much in healing wounds, but when used in concert and with the right synchronization, this effort can be used to minimize the wounds and provide the organization with a cost effective means of doing so while acting and performing in a professional manner.

Nutritional health is one area of emphasis that can be used in strategically minimizing the problems associated with wounds and pressure ulcers. Arnold & Barbul (2006) urged that nutrition is of the utmost importance in any useful approach in treating wounds. They argued "wound healing and nutrition have an intimate relationship that has been recognized by physicians for hundreds of years. Malnutrition or nutrient deficiencies can have a severe impact on the outcome of traumatic and surgical wounds. Wound failure, as reflected by wound infections and/or delayed healing, significantly contributes to the financial burden imposed on health care systems worldwide. Nutrition profoundly influences the process of wound healing, such that depletion exerts an inhibitory effect and nutritional supplementation has a positive effect. Within this paradigm, the physician should be able to recognize patients who may be expected to have wound-healing difficulties and offer early intervention to avoid wound failure."

Wound debridement is also an other technique or tactic that can be strategically implemented to help heal the wound. The dead tissue that needs removing can prevent MS from having a quick recovery of his problem. The need for nurses to continually check and recheck opportunities to complete this debridement technique is essential to helping the patient reach a return to normal life and a fully recovered status. This approach includes maintaining a clean bed and bedding area.

The posture, location and environmental circumstances of situation should dictate how a patient develops these types of wounds or ulcers. An effective strategy to combat this is to ensure that patient is moved and positioned as such to prevent any unnecessary wounding. The need for the human body to move and express itself can turn on the body if it is not positioned in the right posture.

Large Scale Strategies

In the large scale, is necessary to investigate the appropriate macro strategies in order to fully grasp the totality of the situation at hand. While MS's cases is the most important aspect of the current analysis, it can be understood at a deeper and more profound level when understood in the greater context of nursing and the medical profession. When these ideals are understood in such a model, a new appreciation is gathered for the role of both strategy and the need for its useful practice within the nursing environment.

Education is a large scale strategic initiative that can be understood at all levels of nursing. The more knowledge that a nurse can attain, the more it can be used. There is an issue of over-education however, and the quality of data and knowledge gained must be tempered with sheer quantitative tendencies. When nurses can adapt to environments with fundamental learning skills that address how one learns is the best approach to education. This "learning to learn" process is essential in developing success from any strategic attempts to improve a situation. This balance is something that all leaders can apply when the ideal circumstances arrive.

Evidence gained through practice provides pure science as a means to strategic involvement with the nurse practitioner. In other words, nothing beats experience in terms of learning and finding out true healing methods that actually work. The role of experience is key to developing good nurses and therefore good patient outcomes. The nursing profession is often criticized for its harsh treatment of its newcomers and how the profession essentially "eats their young. " This trial by fire is essential for nurses to be broken in to the high demands, physically, emotionally and spiritually, that nursing reflects on a day-to-day basis This approach must be tempered with care and love as this is also essential in the experience gained through practice and increased awareness.

Bullying is a big problem in the nursing world and eliminating this problem would go a long way in solving many deep seated problems in and outside the clinical environment. The nature of medicine requires a well balanced and human approach that reflects the ethical contents of the Hippocratic Oath. Rocker (2008) explained how the bullying culture is not a beneficial strategy and needs to be understood as a harmful practice that needs cultural adjustment within the nursing ranks. He wrote "bullying among nurses is now recognized as a major occupational health problem in United Kingdom (UK), Europe, Australia, and throughout North America. Cooper and Swanson reported that 5% of healthcare workers in Finland have experienced bullying. In a survey of National Health Trust community workers in the UK, 38% of staff reported having experienced bullying and were likely to leave their job as a result, whereas 42% had witnessed the bullying of others. Chiders (2004) noted in "The Nurses in Hostile Work Environment's 2003 Report" that bullying is very prevalent in hospitals and workplaces across the United States (U.S.) to the extent that 70% of victims leave their job, 33% of these victims leave for health reasons and 37% because of manipulated performance appraisals. After much study Cooper and Swanson concluded that workplace bullying is a significant, under-reported, and under-recognized occupational safety and health problem."

The most comprehensive and representative of the positive qualities discussed above, is a strategy of consultation. Consultation presents a shared vision of success that incorporates the powers and energies of those who are willing to do so in their own special way. Communication and honesty are necessary components of this approach or strategy and consultation should be performed in a relaxed and comfortable manner as to promote learning and displace the personal ego issues that always seem to arrive when such disagreements arise. The true healer knows when to let go and become at peace with being wrong and allowing others to take the lead. Consultation models allow nurses to follow useful pathway to finding the balance that is necessary to solving such problems. This strategic approach is preferable in many ways in the Case of MS and will applied as such to address the situation.

Theoretical Base

The complex issues that involve national politics and economics has made practicing modern medicine very difficult in many aspects. Despite the seemingly overwhelmingly amount of conflict of interest incidents that occur on a regular basis, patients do often receive good and healing treatment that is actually cost effective. This does not happen much, however to increase the instances of success, the theoretical basis on which to draw from is extremely important in ultimately applying the approved strategy that is needed in this situation.

Watson (2006) presented her Caring Theory as a means to guide both administrative and clinical practices. The human aspects of nursing are thoroughly addressed as sufficient motivation for practical behaviors that reflect caring and healing. "The evolving caring-healing practice environment is increasingly dependent on relationships, partnerships, negotiation, coordination, new forms of communication patterns, and authentic connections.1 The new emphasis is on a change of consciousness, a focused intentionality toward caring-healing relationships and modalities, and a shift toward a spiritualizing of health vs. A limited medical view alone. Thus, new standards, principles, guidelines, and models of excellence are required for advancing and sustaining professional relationship-centered caring practices, " (p.45).

Watson's theory is being applied in more ways and more aspects today as the theory is beginning to become a popular means to address many of the ethical issues that have arrived due to the confluence of politics and medicine in recent years. The model is based on the following ideals:"

The whole caring-healing consciousness can be expressed and portrayed within a single caring moment.

Human caring and healing processes -- or non-caring consciousness -- of the practitioner is communicated to the one being cared for.

Caring consciousness transcends time, space, and physicality -- that is, caring goes beyond the given moment, and situation, and informs the future experiences of practitioner and patient

Caring-healing consciousness is dominant over physical illness and has the potential to help the patient access the healer within, or potentiates inner healing processes

One's (caring) intentionality and consciousness energetically affects the "whole field, "for example, thoughts that are positive, such as love, caring, joy, compassion, affection, and forgiveness, have a higher frequency of energy. Likewise, thoughts that create emotions such as anger, hatred, jealousy, and fear have low-frequency energy and therefore lower the frequency of the system"

Watson's theory portrays nursing as more than simply just a science but also as a human event that transcends business and economics. Despite this fact, caring serves the economic purpose better than a non-caring posture and that such an approach can be applied in a systematic and applied manner. Nurse leadership must reflect the basics of this theory in order for the model to truly take hold and have a strong impact on those in the environment. This theory places extra demands on the emotions and possibly the spiritual demands of the nurse leader or nurse practitioner.

Caring is not always easy to do, even though it should be. Caring requires empathy and professionalism that goes beyond the nurse's personal issues and places the emphasis of healing back on the patient where it belongs. "The human caring relationship is transpersonal. In that it connotes a special kind of relationship: a connection with the other person, a high regard for the whole person and their Being-in-the-world. In the transpersonal human caring relationship, the nurse enters into the experience of another person, and another can enter into the nurses experiences. It is an ideal of inter-subjectivity in which both persons are involved. It is an art in which the nurse forms a union with the other, connecting with the spirit-filled person, behind the patient, that transcends the physical. This connection honors the upmost concern for human dignity and preservation of humanity. (Watson,2007).

This theory of caring will serve as the basis for the strategy used to help MS and his current situation. The need to resort to basics and simple fundamental nursing ideals will best be reflected in this case when all actions or inactions are based within the theoretical framework that is presented by Watson and her ideas on caring and its place within the nursing profession. Using caring as a theoretical basis provides some problems as the subjective nature of care can be troublesome to communicate in many instances. Once again, the role of the leader must be able to step in and become helpful in delegating authority and managing what truly needs to be done and how the theory can best be applied in this clinical situation.

Implement The Strategy

Implementing this strategy must be performed in two distinct but concurrent stages that focus firstly on the short-term treatment of MS, but also in the long-range sustainability of this unit's ability to treat and heal wounds as in the special case of MS. The First stage will create direct interventions that the nurses can perform on MS and further their treatment along. The second state of implementation deals with solving this problem long-term and instituting a simultaneous line of both education and clinical practice to contribute to the long-term success of this effort.

Stage 1

Initial consultation must be done with the patient. This is a must. Communication problems will exist as the weakened condition of the patient has created this difficulty. It is important for nurses to remember the essential message of Watson's theory in that the event of caring is trans-personal and sacrificial in nature. The nurse must put aside her own ego and her own preconceived notions about her ideal situation, and attempt to empathize with the patient to best understand his needs in this situation.

Empathy is a key component in this equation and is at the heart of all good nursing practices. This is where the consultation begins and will ultimately return again as well, as the process is ever lasting as long as the patient is in the care of that patient. It is human nature to cut corners and seek easier methods of achieving success. This ideal should be embraced in employing Watson's caring theory, as there is much ease to the model and processes discussed here. The notion of simplicity is often frowned upon in the medical and nursing communities, due to the intellectual aspects of the profession. Intellect must be balance with the human aspects of this profession as well. This simple approach helps to eliminate the often times distracting ideas that come in the way of good intentions and well delivered caring methods.

Stage 1 involves the family nurse practitioner who must take a leadership stance on this issue and show the rest of those involved, including the doctors, other nurses, family, and most importantly the patient, that she is prepared to empathize with the patient in an attempt to fix the problems associated with MS's current condition. This act serves as both a demonstration of sacrifice and serves as the beginning of stage two which based on the necessity and value of continual education regarding this issue.

Stage 2

Education serves as the objective for stage two of implementing Watson's theory of caring through the act of consultation, a valuable tool in a nurse's tool bag. Stage two is about learning and education and focusing the culminating effects of that process on a decision or a series of decisions that may be represented in a new policy or clinical practice. This is applying the research and educational approach to a clinical setting and allows for the free and frequent communication between essential parties.

Social skills are not taught explicitly in education institutions dealing with the medical profession. The need for medical professionals, and especially those in leadership positions need to be well versed in public relations, communication skills and basic manners. Being polite is often a challenge in today's world, but when necessary caring and empathy should be demonstrated at all times to foster an environment of learning.

Successful consultation depends on people being available and aware of their role in the situation. Many times the over specialization of the medical profession works against itself as common cures can be shared with some simple cross talk among varying offices, disciplines and even practices. This cooperative stance is the true hallmark of a useful and productive consultation effort that can prevent recurring problems from resurfacing and providing new opportunities for growth among the nurse profession. Keeping in mind that no single person is all knowing and has the solution to every problem can assist in this stage as there becomes a trend to over rely on a source of knowledge or data for reasons not based on fact but opinion. Discretion is important in weighing what can be used from a consultations and what cannot be used in this practice. This takes experience and practice and nurses must be prepared early in their careers to face such challenges.

A non-linear and non-hierarchical approach must be taken when implementing the aforementioned strategy. Good intentions and empathy can spread like a harmful virus. The intent and purpose of the actions that nurses inspire are very important in the healing process and provide the necessary substance for creating a healing environment in many cases. The long-range impact of this approach can help other cases like MS's who are experiencing unnecessary wounds and ulcers due to mis-care. This case, while painful and stark, can provide very useful and long lasting learning points that can help evolve and transform nursing as a profession into a stronger unit in the future.

Evaluation

The need to find a method for honest and frank medical evaluation or assessment is essential to helping solve the problems of MS and bring about the necessary transformation of the problematic environment. Evaluation requires a look inward and to see how problems can be solved from the inside out. This approach is not popular in many aspect, but represents a practical and honest means of achieving the aforementioned objectives and aligning with Watson's theory of care.

Donabedian (2006) wrote about evaluating medical care and the importance it has when a clinical setting and situations like the one discussed in this essay. He wrote "Many advantages are gained by using outcome as the criterion of quality in medical care. The validity of outcome as a dimension of quality is seldom questioned. Nor does any doubt exist as to the stability and validity of the values of recovery, restoration and survival in most situations and in most cultures, though perhaps not in all. Moreover, outcomes tend to be fairly concrete and, as such, seemingly amenable to more precise measurement, " (p.693).

The idea in achieving a successful assessment is attaining usable and practical knowledge and data that can be applied in future efforts. This requires a constant and systematic effort of after action reviews and reexaminations of past performance. This is a hallmark quality of any profession and in order to keep the nursing profession in high esteem those practicing this profession must hold themselves up to a higher standard that requires such self-reflection. This ability to look inward and to fix one's own approach to caring and healing can bring great clarity when dealing with the assessment portion of this transformation. This cycle of transformation was described by Campbell et al. (2007) as they discussed the importance of context and design in evaluating interventions such as the one discussed in this case study. They wrote "The process of development ends with one of three scenarios. Firstly, it may become clear that the intervention is unlikely to be cost effective in the current environment and does not warrant the cost of a large randomized trial. Secondly, the evidence supporting the intervention may become so strong that there is no doubt that it will be beneficial -- in which case it should be implemented. Finally, although doubt may remain about the effects of the intervention, it is sufficiently promising to warrant the costs of a definitive evaluation. In that case, the researcher who understands the underlying problem, has developed a credible intervention, and considered the key points in evaluation will be in a strong position to conduct a worthwhile, rigorous, and achievable definitive trial."

Assessing a consultation requires the assessor to take in several sources of information and put them together to form a clear picture of what has happened or taken place. Feedback from many sources including supervisors and doctors, peers, friends, administrators and others, can all be included in the assessment. The source of the information should be taken in consideration of who presented it, but facts cannot be argued and only opinions are subjective. Finding the objective truth in the subjective words and communications of other scan be difficult if nurses in leadership positions are not prepared to assess their own performance in an honest and truthful manner.

The veil of perfection within the medical community must be addressed within assessments of consultations. Honest feedback must be accepted without protest and with attitudes that do not reflect the feelings of the staff, but rather the healing of the patient is kept as the highest priority. The difficulty in this entire process lies within the problems associated with successfully assessing a ward or nurse organization. To overcome these problems of assessments those involved must be open to change growth and the ability to recover from mistakes. Admitting when a mistake is made early in the problem will often prevent major problems in the long run. When assessing problems, immediate and direct attention that is deemed necessary should be implemented as soon as possible to assist in keeping assessment practices viable and worthwhile. When improvements are ignored, the facade of such assessments soon become evident and then eventually ignored and discounted for other methods most likely not aligned with the aforementioned strategy.

The importance of assessment in this case is realized when the proper perspective is placed upon the situation. Cowan et al. (2005) addressed this problem in their research when the discussed the issue of competence as being problematic in being openly discussed and addressed within the nursing profession. They wrote "Doubts have been raised as to whether competency standards are appropriate to nursing practice, as they may have the potential to be reductionist, positivist and focusing on outcome orientated technical procedures. There are concerns over the artistic and humanistic aspects of nursing such as empathy and attentive listening becoming de-emphasized, because it is easier to value and measure scientific and technical aspects that can be repeatedly demonstrated. There are also concerns that the drive for competence may lead to nurses being merely trained to meet minimum competency levels. "

Conclusions

The case of MS can be approached from a number of different methods, however it appears that with the impact and influence of Watson's theory of Caring on the consultations of the nursing staff involved with the patient is helpful in leading a transformation towards a solution to this and other problems like this. The issue of wound care is one that is purely and simply preventable. The need for an internal change can help direct the necessary behaviors to reduce such inappropriate and uninterested behavior within the nursing profession.

Leaders must be ready to take criticism and hatred when changes arrive and they are tasked to make those changes into practiced policies and behaviors. By keeping a patient-centered philosophy based on Watson's caring ideals, the personal and ego-based problems that are associated with consultations and communication exchanges can be kept to a minimum and the best, most healing environments can be created for patients such as MS.

MS's acute wounds can be treated with simple clinical steps that every nurse is aware of and has been trained on. The true problems associated with the issues surrounding MS, are one of empathy and care. Being a nurse requires adopting a professional attitude and subscribing to a higher ideal. The ability to make money and profits must be tempered with healing patients who are in need of the training that a nurse possesses.