Title: Select one aspect of care which you have undertaken in children’s nursing practice in relation to the discharge process and critically analyse and discuss the key components of that care in relation to your experience, discharge planning and the specific research/literature you have reviewed.
The aspect of care to be discussed is pain management for a 4 year old boy after facial surgery, on a Nurse Controlled Analgesic morphine pump, being discharged from the recovery room to the ward
The need for discharge planning in optimising patient care has been identified in many recent studies and papers (viz. Mills M M et al. 2006). The basic rationale in all arguments for discharge planning is so that mechanisms to facilitate discharge can be put in place both before interdepartmental discharges and transfers, as well as before the eventual discharge, throughout the period of hospitalisation, so that they do not overwhelm healthcare professionals, the patient or parents at the end of the stay in the facility, department or the hospital.
A useful general tool for planning discharge is enunciated by Bruccoliere with identification of tasks and deadlines for transition tasks set shortly after admission and ideally incorporated into daily multidisciplinary ward rounds. This is specifically targeted at total hospital discharge, but has features aimed at departmental discharges or transfers. (Bruccoliere T 2000). This type of approach has been advocated by Halm who has expanded the tool to include a formal review by the responsible nurse (or team leader) for all paediatric patients whose discharge is anticipated within one week, to ensure that the discharge plan includes a projected day of discharge, a check on home equipment and medication, home health needs, home feeding plan, screening needs (e.g. car seat trial; hearing, developmental, or feeding assessment for the very young child), identification of a primary care doctor, and necessary follow-up plans in either primary care or the hospital outpatients. (Halm M A et al. 2003). Such measures may be appropriate for the patient in question at the end of their hospital stay. In this particular case however, one is considering a specific instance of interdepartmental transfer and the discharge planning mechanisms are therefore more specific.
This particular examination of departmental discharge will be focussed primarily on pain relief. The key concepts of discharge planning where pain relief is a major feature (in specific consideration of these circumstances) are
Assessment of pain
Control of pain pharmacological and nonpharmacological
Safe storage and use of opiates
Individual pain control plans developed with the child and parent (longer term consideration)
Appropriate hand over mechanisms for relevant healthcare professionals.
(After Pagnamenta R et al. 2008)
Outline of the child and family and context (include family involvement in preparation for discharge focusing on the particular aspect of nursing care (pain management).
In line with elements of confidentiality outlined in NMC, this essay will refer to the patient concerned as Boy F. (NMC 2004)
Boy F. had a delayed extensive facial reconstruction following facial trauma and had been in the recovery room for four hours while his blood pressure and other vital signs stabilised. Pain relief was identified as a major priority in his case.
The family comprised of both parents and an older sister who had been present at the hospital throughout the operation and were known to be waiting on the ward for his return.
It is known that the family are very questioning and highly involved with the patient’s care and that they would be full of questions relating to the morphine pump when Boy F returns to the ward.
The policy of empowerment and education of the patient’s family has been fully embraced in this particular circumstance, (Howe J et al. 2003) and must therefore form a part of the overall discharge plan.
Critical analysis of the evidence that supports this aspect of nursing care. Critically analyse and discuss the key components of the care provided in relation to your experience, the discharge process and the research literature reviewed. Break the discharge process into the 4 parts of the Nursing Process: assessment, planning, implementation and evaluation.
Assessment (To include; Government recommendations on starting discharge planning on admission and having a discharge coordinator)
There are two major elements to the assessment of this case. Planning and pain control. In terms of total hospital discharge, the Government has issued guidance in the form of “Discharge from hospital : pathway, process and practice (PPP 2003) which, although primarily aimed at hospital discharge, has sections of guidance on organisation of departmental discharges. This was formalised in the context of the NHS Plan (Department of Health 2000), which called for the establishment of a nominated discharge coordinator for each case.
In any case of pain control, one of the most important elements of successful control is initial pain assessment. (Treadwell M J et al. 2002). This has the advantage of targeted and appropriate pain relief, but also allows for the retrospective assessment of pain levels to ensure that current dosage of medication is likely to be adequate. (Morton N J 2007)
With problems inherent in effective communication with the younger child, a number of different rating scales have been developed and validated and these include the Postoperative pain score (PPS) for infants up to about 12 months, (Barrier G et al. 1999), the CHEOPS pain scale for children between 1 and 3 yrs old, (Taddio S E et al. 1994, the Faces scale for children back pain 3 and 6 yrs. (Champion G et al. 1998). Children older than this can often use a VAS (visual analogue scale) with reproducible accuracy. (Champion G et al. 1998).
In the case of Boy F, the faces scale was used. The child is asked to indicate which, of a series of nine faces, best reflects the pain that they are feeling at the time. This tool is validated to produce a good repeatability and inter-rater compliance. This mechanism allowed for an assessment of the degree of pain perceived by the patient and appropriate adjustment of the Nurse Controlled morphine pump to minimise the pain experience for the patient.
Planning (To include; justification of why planning is appropriate to discharge process – with evidence)
Post operative pain relief is likely to be a feature of Boy F’s case for at least the next few days. It is planned to keep the morphine pump in place for at least the next two days. It cannot be assumed that the nurse taking over the care will be completely familiar with the device, and therefore part of the planning process must be to make provision for the recovery room nurse to both demonstrate and satisfy herself that the receiving nurse fully understands the use of the device prior to the handover. (Yura H et al. 1998)
Other aspects to be considered in the planning stage, are to ensure that the appropriate paper chain is competed relating to the controlled drugs. It is important also to establish that the receiving ward has the appropriate drugs (in the appropriate form) in stock and readily available after transfer.
Other aspects of pain relief must be considered and would include the psychological aspects of pain relief. These are particularly important in the young child. (Suresh S et al. 2002). In the context of this particular situation one must consider empowerment and education of the patient even at this comparatively young age. To explain to Boy F what is happening, to give him the knowledge that he is surrounded by sympathetic people who will help him and to allow him to have confidence the he is surrounded by faces that he knows in otherwise strange and hostile situations, are all measures that will help to minimise the overall pain experience associated with the operation. (Carr A J et al. 2001). For this reason it would be helpful if the handover (discharge procedure) could be to a nurse from the ward who was already known to Boy F. if this was not possible, then the new nurse should allow sufficient time prior to handover to allow a period of familiarisation with Boy F. (Walker L S et al. 2002) Clearly there must be an element of planning to allow for this to happen.
In the light of the potential of questioning by the family, appropriate measures should be anticipated, planned for and then instigated so that the ward nurse who effects the transfer would be fully aware of all aspects of the pain relief strategy. This would help to instil confidence into the family during an obviously stressful time.
Implementing (what happened, how you implemented the chosen aspect of care e.g. notified the pain team – back up with evidence)
Implementation of the discharge plan was facilitated by requesting the receiving nurse to attend the recovery room allowing 30 mins. to be briefed on the use of the morphine pump. Prior to handover, the Faces (pain assessment tool) assessment was repeated to ensure that the patient was sufficiently comfortable.
Written details of the analgesic regime were both explained and handed over prior to discharge. The Pain team in the hospital was notified of the discharge and requested to assess the patient on the ward.
The receiving nurse was also able to utilise the time to allow Boy F to get to know and trust her. This proved to be particularly important later when the dressings had to be changed and Boy F was only happy if this nurse could do it for him.
Evaluating (Reflective, evaluate the whole process, support with evidence)
A reflective evaluation would suggest that this experience could be construed by taxonomies such as the experimental learning proposed by Steinaker and Bell, as providing a situation where a student could reflect and learn from considering not only the actual situation that arose, but also by investigating the background literature which forms the evidence base of the clinical situation. (Steinaker and Bell 1979). In essence, they suggested that an adult learns best by the provision of circumstances that are new experiences which could be evaluated and then used as a basis for further learning.
I felt that this particular discharge form the recovery suite had been handled particularly well. Prior assessment and planning had allowed a smooth handover which proved to be beneficial for the patient as well as for the family, and was therefore professionally satisfying.
Demonstrate knowledge and understanding of key aspects of discharge process in relation to child, family and aspect of nursing care
The anaesthetist had made a good decision to allow nurse controlled morphine pump. Other anaesthetists could have simply prescribed stat doses of analgesia which may not have controlled the overall pain experience for Boy F in a satisfactory fashion.
It is clearly important to consider all aspects of the discharge in terms of one’s own responsibility to the patient, and to facilitate a smooth transfer of responsibility to another healthcare professional.
The key aspects of the discharge process have been set out above, and include anticipation of potential problems, risk assessment of these problems, formulation of measures to combat potential problems and their successful implementation. (Fawcett J 2005)
Evidence of integrated theory and practice
The concept of the multidisciplinary treatment team is important in this type of situation. The receiving nurse should be regarded as the nominated member of the ward team who takes responsibility of transferring information from the recovery ward to the ward team. The presence of a pain management team must not be overlooked.
Nursing theory is clearly an excellent basis for practice, but there is an element of professional and clinical knowledge that is required to translate that theory into practice. Areas such as the establishment of professional empathy between nurse and patient are theoretical concepts (Mason T et al. 2003) but it requires considerable time and effort to translate the theoretical concept into reality. This is particularly true when dealing with younger children. (Hogston, R et al. 2002)
Identifies implications for clinical practice (reflect upon your findings and outline implications for future practice)
The findings from the investigation for this essay revolve around the clear need for assessment and planning of any discharge, whether it is from a department (as in this case) or from the hospital at the end of a course of treatment. This essay has identified various areas such as the knowledge of the receiving nurse relating to a morphine pump and the need to build an empathetic environment for the child to minimise his total pain experience as being crucial elements in the discharge process as well as more formal needs such as the need to leave a clear paper trail for controlled medication.
Summary of essay – no new points here. (provide clear and concise conclusion)
This essay has considered the case of Boy F and his discharge from the recovery room. It has assessed his needs, considered his imminent discharge from the department, considered the potential problems that might be encountered, formulated a plan of action to address these problems and presented some of the evidence base behind the theoretical issues,
Barrier G Attia J, Mayer M N, Amiel-Tison C Shnider S M : (1999) Measurement of a post operative pain scale and narcotic administration in infants using a new clinical scoring system : Intensive Care Med. 1999; 15 : S 37 – S 39
Bruccoliere T. (2000) How to make patient teaching stick. RN. 2000;63 : 34 – 38
Carr A J, Higginson I J. (2001) Are quality of life measures patient centred? BMJ Vol 18 Issue 42 2001
Champion G Goodenough B, von Bayer C, Thomas W : (1998) Measurement of pain by self report, in Finley G, McGrath P, (eds) Measurement of pain in infants and children. Seattle, WA IASP Press 1998; 123 – 160
Department of Health (2004). The NHS Plan. A plan for investment. A plan for reform. Cm 4818. HMSO : London 2004
Fawcett J (2005) Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories, 2nd Edition. Boston: Davis & Co 2005 ISBN : 0 – 8036 – 1194 – 3
Halm M A, Gagner S, Goering M, Sabo J, Smith M, Zaccagnini M : (2003) Interdisciplinary rounds. Clin Nurse Spec. 2003; 17 : 133 – 142
Hogston, R. Simpson, P. M. (2002) Foundations in nursing practice 2nd Edition, London: Palgrave & Macmillian. 2002
Howe and Anderson (2003) Involving patients in medical education. BMJ, Aug 2003 ; 327 : 326 – 328.
Mason T and Whitehead E (2003) Thinking Nursing. Open University. Maidenhead. 2003
Mills M M, Sims D C, Jacob J. (2006) Implementation and Case-Study Results of Potentially Better Practices to Improve the Discharge Process in the Neonatal Intensive Care Unit. Paediatrics Vol. 118 Supplement November 2006, pp. S 124 – S 133
Morton N J (2007) Management of postoperative pain in children : Archives of Disease in Childhood – Education and Practice 2007 ; 92 : ep14 – ep19;
NMC (2004) Nurse Midwifery Council: Code of professional conduct: Standards for conduct, performance and Ethics (2004) London : Chatto & Windus 2004
Pagnamenta R, Benger J R. (2008) Factors influencing parent satisfaction in a children’s emergency department: prospective questionnaire-based study. Emergency Medicine Journal 2008; 25 : 417 – 419 ;
PPP (2003) Discharge from hospital: pathway, process and practice : HMSO : London 2003
Steinaker, N. and Bell, R. (1979) ‘The experiential taxonomy: a new approach to teaching and learning’, Academic Press: London. 1979
Suresh S, Barcelona S L, Young N M, Seligman I, Heffner C L, Cote C J (2002) Postoperative Pain Relief in Children Undergoing Tympanomastoid Surgery: Is a Regional Block Better than Opioids? Anesth Analg 2002; 94 : 859 – 862
Taddio S E, Nulman I, Goldbach M, Ipp M: (1994) Use of Lidocaine / Prilocaine cream for vaccination pain in infants : J Paediatr 1994; 124 : 273 – 280
Treadwell M J,. Frank L S, Vichinsky E. (2002) Using quality improvement strategies to enhance pediatric pain assessment. International Journal for Quality in Health Care 14 : 39 – 47 (2002)
Walker L S, Lewis Claar R, Garber J (2002) Social Consequences of Children’s Pain: When Do They Encourage Symptom Maintenance? Journal of Pediatric Psychology, Vol. 27, No. 8, 2002, pp. 689 – 698
Yura H, Walsh M. (1998) The nursing process. Assessing, planning, implementing, evaluating. 5th edition. Norwalk, CT: Appleton & Lange, 1998.
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