Healing Wounds Case Study

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 ?

Wound Care

Corbett (2012) introduced in her research article opportunities and issues dealing with wound care that is very specific to this problem. The research was premised on the idea that as the field of wound care advances and grows in today's increasingly dangerous society, it is necessary to identify and define useful and practical competencies that can be used to solve these types of problems and issues. She wrote "Accumulating evidence suggests that certified wound care nurses demonstrate superior substantive knowledge compared to noncertified nurses. Wound certified nurse's more accurately stage pressure ulcers and assess lower extremity vascular status than non-certified nurses. With mounting focus on patient safety and outcome performance, job opportunities for certified wound nurses are increasing in hospitals, skilled nursing facilities, home care, and outpatient wound centers."

This article eventually concluded that the science of wound care is becoming more complex and requires more attention in the field of nursing and developing nurse practitioners. The standard roles of nursing have been adjusted to the point where issues such as the one dealing with MS and his problems must be met with and dealt with in a professional manner that reflects this new paradigm related to wound care and the general environment of the medical industry as it relates to these problems.

The evolution of wound care and how it should be approached has changed significantly over the past decades. The ability for teams to cooperate and find the best solutions has modified the myopic and tired approaches of old. Ennis (2012) explained in his research that the new breakthroughs and discoveries of wound care have forced those in the profession to find better ways of dealing with this issue. He argued "In all other fields of medicine there is a formal process in place for physicians to train, certify, and credential. Medicine is constantly evolving and there have been several new fields of specialty care created over the past two decades that can serve as examples for the wound care field to follow. Without academic-based, clinical residency/fellowship training in wound healing ultimately leading to formal certification, the field will be unable to achieve an appropriate status in the medical establishment. Achieving this goal will impact product innovation, payment, and the sustainability of the field."

This research suggests that new procedures and treatments are most likely to be interwoven as the medical profession continues to advance, grow and evolve. This article encourages nurses and other medical professions to examine the advantages of collaboration and teamwork as the best means to address situations much like the case of MS. The data included in this article directly supports the idea that consultation becomes a very helpful tool in the nurses repertoire that can be applied for the patients overall healing condition and will certainly help in alleviating the operational problems that reorganizing efforts often present.

Mejza (2009) examined the Wound Ostomy and Continence Nurses Society to gather important information about this topic in here research article. The intent of her research was to find ways to mitigate the anticipated role of these types of nurses in the future. To help in making this argument, the author examined the role of specialty nurse vs. The roles of a nurse involved in advanced nursing practice. As a result, the author called for more merging of skills and competencies and placed the nurse at a focal point or classification that can be helpful in assigning roles within clinical situations. The author argued "Even though WOC nursing's evolution toward advanced practice nursing and AACN's decision about DNP by 2015 may appear to be a quantum leap in education for the WOC specialty practice nurse, it is not. WOC specialty nursing practice already encompasses many core competencies of advanced practice nursing. In addition, doctoral practice would provide a better match of a degree with the hours required to attain it, bringing parity with other health professions such as physical therapy who have already moved to a similar educational structure. Doctoral preparation will further strengthen the WOC nurse's independence to practice and ultimately improve patient outcomes. Nursing schools throughout the United States are moving to make DNP education a reality; now is the time to design your preferable future and to support a preferable future for all WOC nurses and their patients."

The cost of not treating these types of wounds can exist beyond simply the patient' suffering and ill health. In order to receive the attention this problems sometimes does not get, it is expedient to place the problems in economic terms. Bennett et al. (2004) examined the financial costs of pressure ulcers in the UK and how it related to hospital costs in their research article. Their article aimed to find the costs of treating pressure ulcers in the UK. The approach used a methodology where "protocols of care were developed which reflect good clinical practice in the treatment of pressure ulcers of different grades (defined by the European Pressure Ulcer Advisory Panel classification, Table 1). These protocols define the typical daily resources required to provide the recommended treatment. Costs were assigned to resources using representative UK NHS unit costs at 2000 prices.

Table 1. Pressure ulcer classification. Classification agreed by the European Pressure Ulcer Advisory Panel (EPUAP) (www.epuap.com)

Grade 1: Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.

Grade 2: Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superWcial and presents clinically as an abrasion or blister.

Grade 3: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.

Grade 4:Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.

This research is valuable because it offers a model for others to base their own experiences off of in a truly scientific manner. The results of this examination presented in this research article eventually concluded four key points:

1. Pressure ulcers are a debilitating problem and can cause serious barriers to healing if they are not treated with respect and due diligence.

2. The total cost of treating these pressure ulcers in the UK was nearly 2 billion pounds or 4% of their total health budget for the nation. These costs were considered mostly preventable as well.

3. The trends will see a continued increase in costs of treating these wounds as aging population problems exacerbate the issues at hand.

4. Prevention is the best way to alleviate this problem.

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.