Person Centred Care for Orthopaedic Patient with Psychological Problems

This article discusses the case of Evelyn Goldstone, an orthopaedic patient with psychological problems, and the importance of providing person centred care. It covers the framework of person-centred care, assessment, nursing problems, legal and ethical issues, and discharge plan.

Person Centred Care
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Introduction:
Case of Evelyn Goldstone is chosen for the care plan. Interest in providing care to the
complex cases and expertise in the similar cases made to choose case of Evelyn Goldstone.
This case is about the orthopaedic old female patient who is also having psychological
problems like short term memory loss and confusion. For Evelyn Goldstone, it is necessary to
provide person centred care because involvement of family members is necessary in her care.
Usually, patient need to be incorporated in the person-centred care; however, due to age
factor it would be difficult to involve Evelyn Goldstone in her care (Moore et al., 2017).
Jane, Evelyn Goldstone’s daughter need to be at the centre of her care and she need to work
alongside healthcare professionals in the decision making for care of Evelyn Goldstone.
Involvement of Jane is important in the care of Evelyn because along with providing medical
care to her psychological and emotional intervention need to be provided to her.
Psychological and emotional intervention is necessary because she is not cooperating for
treatment and reluctant to take food also (Ross et al., 2015).
From the collected objective data like left hip fracture, osteoarthritis and osteoporosis and
subjective data like pain; it is evident that acute pain is the most significant problem for
Evelyn. As a result of pain, she is also having problem of mobility. Left hip fracture, pain and
orthopaedic condition might increase chances of fall in her. Hence, risk of fall is another
problem for Evelyn. Hence, pain, mobility and risk of fall are the three problems for Evelyn.
Since, she is having very severe pain, care plan for pain would be written in this assignment.
Confidentiality about name and health condition of Evelyn would be maintained. Maintaining
confidentiality of patients is important because dignity and self-respect of the patient would
be maintained (McHale and Tingle, 2007).
Discussion:
Person-centred care : Framework of person-centred care (PCC) comprises of structure,
process and outcome. Structure is related to components of health-care system, deliverables
to the patient, health-care resources and organisational characteristics. In the hospital, it is
necessary to build person centred culture to provide PCC to Evelyn. Health education, health-
promotion and prevention plan need to be established for Evelyn and opportunity need to be
given to Jane for these establishments. Hospital need to support staff members for
implementation of PCC. For the promotion of PCC, it is necessary to provide health
information to family members. Hence, health information technology needs to be
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established in the hospital. It is necessary to provide supportive and accommodating
environment for PCC implementation. Applicability of PPC in case of Evelyn, need to be
evaluated. Hence, hospital need to adopt established structure to measure and monitor PCC.
PCC process includes communication between healthcare professionals and Jane.
Communication in PCC include cultivating communication, respectful and compassionate
care, engagement of patients in their own care and integration medical care with
psychological and social intervention (Kennedy, 2016; Stickley, 2011).
Outcome exhibit benefits of PCC implementation and interaction among patient family
members and healthcare providers. There should be relationship and alignment among
structure, process and outcome of PCC. Different aspects like medical, social, cultural,
psychological and emotional are being considered in PPC; hence, it is considered as
multidimensional concept. As a result, it is useful in providing holistic care to Evelyn because
she also needs intervention for medical, emotional and psychological aspects. It indicates
complexity of concept of PCC. Hence, it is necessary to use established framework for
assessment of patient in PCC (Ross et al., 2015).
PCC promotes self-determination for Evelyn and Jane. It also establishes mutual respect and
understanding among nurses and Evelyn and Jane. It is also helpful in providing power to
Jane and giving responsibility to her. It would be helpful in improving her self-esteem and
her involvement in her mother’s care. It is also helpful in establishing common therapeutic
goals in concordance with the Evelyn. It would provide more comfort to both Evelyn and
Jane (Moore et al., 2017). Nurse need to establish interpersonal relationships with patient and
family members to implement PPC. John Heron's six-category intervention analysis is useful
in understanding interpersonal relationships and providing effective clinical services to the
patients. These six categories are classified into authoritative and facilitative. Authoritative
type of nurse should provide information, challenge the other person, play a dominant role
and should take responsibility on behalf of client. Authoritative categories include
prescriptive, informative and confronting. In facilitative model, nurse should draw ideas, find
solutions, and build self-confidence. Facilitative categories include cathartic, catalytic and
supportive. This model is also useful as supervision model and improving clinical
competency of nurse in implementing PPC (Heron, 2001).
Assessment: For effective assessment, nurse and patient collectively need to identify needs
and concern of patient. Patient assessment need to be patient focused. Patient assessment is
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useful in obtaining information which is required for planning intervention, achieving goals
and facilitating evaluation of the care plan. McCormack and McCance’s framework is useful
for the patient assessment. Patient assessment should be respectful and individualised,
permitting negotiation, and allowing patient and family members to participate in the
decision making. Steps involved in patient assessment are observation, data collection and
clinical judgement (Wolstenholme, et al., 2017; Thim et al., 2012).
Assessment of Evelyn need to be performed for both subjective and objective data. Objective
data comprises of observable and measurable data. It also includes data related to lab and
diagnostic tests. Objective data include BP- 121/73, Pulse- 96, Saturation Level 98%,
Temperature- 37.6 and VAS pain score 10/10 on movement. Objective assessment data also
include concurrent health conditions like gastric reflux, osteoarthritis, osteoporosis,
Alzheimer’s Disease and short-term memory loss. X-ray examination revealed fracture in her
left neck of femur. Subjective assessment data include pain, moaning and disorientation.
Roper, Logan and Tierney assessment tool need to be used for assessing daily activities of
living. In case of Evelyn, Roper, Logan and Tierney assessment tool would be useful in
assessing mobilisation, communication, breathing, eating and drinking. McCormack and
McCance framework is useful making PCC more tangible for implementation in the actual
practice (McCormack et al., 2017; McCormack, B. and McCance, 2016).
This framework uses empirical data for the assessment of patient. Hence, it is considered as
valid method for the assessment of patient. This framework is useful in establishing caring
relationship among service provider and recipient. Caring relationship is necessary in case of
Evelyn because medical, psychological and emotional intervention need to be provided to her
and her family members. Nurse need to acknowledge emotions and compassion of Evelyn
and her daughter to establish mutuality in her care. According to this framework, it is
necessary for the nurse use values like trust, involvement and humour in her care. Trusting
relationship among the nurse and; Evelyn and Jane is important aspect because patients need
to believe in the care provided by the nurses. Moreover, trusting relationship facilitate PCC
(McCormack et al., 2017; McCormack, B. and McCance, 2016).
Nursing Problems: Based on the collected subjective and objective assessment data; it is
evident that Evelyn is having specific nursing problems. These problems include acute pain,
mobilising, risk of falls, confusion and eating and drinking. It is essential to identify problems
in the patient to provide care to the patient.
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Goal: To maintain Evelyn comfort and pain to a level that is manageable for her.
Intervention: Comprehensive assessment needs to be performed to assess location, onset,
duration, frequency and severity of pain. Bolton pain assessment tool need to be used for
assessment of pain score in Evelyn. Nurse need to foresee pain relief and acknowledge pain
report of Evelyn. Foreseeing pain relief can be useful in providing early intervention and
reducing dose requirement for pain relief. Acknowledging immediate pain reporting is useful
in reducing anxiety due to pain. Minimizing anxiety is necessary because anxiety can
exaggerate pain sensation. It is necessary because it is useful in providing effective pain
management to Evelyn. Nurse should observe for non-verbal signs of pain like moaning,
guarding and facial grimace for Evelyn. In few instances, patient might not verbalise pain.
These behaviours would be helpful managing pain in Evelyn. Evelyn’s vital signs need to be
assessed because vital signs get affected due to pain. It is evident that tachycardia,
hypertension, and increased respiration occur due to pain in patients like Evelyn. However,
nurse need to be careful while assessing these vital signs in Evelyn for pain assessment
because due to her older age also, there is possibility alterations in these vital signs (Foss et
al., 2009; Thim et al., 2012).
Non-pharmacological interventions like relaxation exercise, breathing exercise and music
therapy need to be provided to Evelyn. Non-pharmacological treatments would be helpful in
augmenting release of endorphins which would be helpful in improving therapeutic effect of
medications for pain relief. Optimal pain relief medication needs to be administered because
different types of pain require different pain relief medications. Analgesic regime needs to be
reviewed because patient-controlled analgesia pump is not favourable for her due to
Alzheimer’s disease and short-term memory loss. Pain medication record need to be
maintained which is useful in determining effectiveness of medication which is useful in
alteration of the dose (Foss et al., 2009). Anti-inflammatory medication should not be given
to her due to gastric reflux. Pain score need to be assessed pre and post analgesia. Pain score
need to be evaluated every 24 hours. Nurse need to reduce or eliminate factors which are
responsible for precipitation or potentiation of pain. These factors include fear, fatigue and
monotony. Elimination of pain precipitating factors are necessary because pain is the
subjective parameter which varies from person to person and external factors influence it.
Interventions for the pain management need to be planned according PCC framework.
Structure, process and outcome aspects of the PCC framework are useful in planning
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interventions for pain relief. Structure of PCC framework states that pain interventions need
to be planned at the organisational level. Structure deals with making availability of resources
for pain intervention. Process of PCC framework states that pain interventions need to be
planned at the patient and healthcare provider level. Process is related to action to be carried
out to provide intervention. Outcome of PCC aspect states that pain intervention need to be
planned at patient, healthcare provider and organisational level. Outcome is related to
usefulness of the intervention (NICE Guidelines, 2012).
Roper, Logan and Tierney model would be used for assessing mobility necessary for
performing daily activities. It would be useful in providing necessary intervention. Nurse
should ensure positioning in proper alignment and reposition every two hours. Hence, Evelyn
will not experience complex feeling due to immobility. Nurse should teach use of adaptive
accessory for mobility. Mobility accessories would be useful in improving mobility. Nurse
nee to identify factors facilitating safety in Evelyn and modify environment accordingly. It
would be helpful in understanding whether intervention need to be provided for improving
safe mobility. If environment is not familiar, there is possibility of fall of Evelyn. Patients
like Evelyn who are disoriented or confused are at higher risk of fall. Nurse should ensure to
put side trials up and put items necessary for Evelyn in her reach. If items are out of reach of
Evelyn, she needs to stretch her body to get these items. Hence, there is possibility of losing
balance and fall (Kenny et al., 2017; Greenwood and Oldmeadow, 2009).
Legal and ethical issues: According to Nursing and Midwifery Council Code of Conduct for
the confidentiality nurse need to respect patient’s right to privacy and confidentiality.
Information related to care of patient’s need to be shared appropriately. Patients should be
informed about how information about their care would be shared and who will provide care.
Information related to health of patient need to shared only with the permission of patients
and when safety patients override need for confidentiality (NMC, 2015). Pain management is
fundamental human right and healthcare providers are obliged to provide management to
patient like Evelyn. Many international guidelines stated that pain management is primary
ethical duty of healthcare provider. Hence, it is mandatory for the healthcare providers to be
aware of multiple pain related ethics. One of the most important pain related ethics is
patient’s appraisal in the decision making of their own pain relief. It is in alignment with the
case of Evelyn because in her case, PCC need to be implemented. Patient and family
members involvement in the decision making is of significant importance in case in PCC. In
case of Evelyn, Jane should be encouraged to take part in decision making. Opioid crises are
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a significant ethical issue in case pain management. Hence, healthcare providers need to
consider risks associated with the opioid administration because risk minimisation is the basic
human right (NICE Guidelines, 2016).
Discharge plan: Pain need to be assessed during discharge for Evelyn. Sufficient time need to
be given for preparing discharge plan for older person like Evelyn. Jane need to be involved
in preparing her discharge plan. All the healthcare professionals involved in her care need to
be informed about her discharge plan. Discharge plan for Evelyn should include her
functional goals following her discharge and list of prescribed medications. List of prescribed
medicine should also include dose, frequency and anticipated duration of medication
consumption. For opioid medicines administered during hospitalisation, prescription plan and
stopping strategy need to be mentioned in the discharge plan for Evelyn (Galvin et al., 2017).
Prevention and management strategies need to be mentioned for probable side effects of
medications. All the contact details need to be given for the person to whom Jane need to be
contacted if pain relief is not adequate post-discharge. Contact information about follow-up
appointments, referrals for outpatient and community-based rehabilitation need to be given to
Jane. With the consent of Jane, discharge plan needs to be given to the residential aged care
facility. It is necessary to send Evelyn to residential aged care facility because it is a suitable
place to take care of her. Jane alone could not take care of Evelyn alone; hence, in aged care
facility service providers would take care of her. Moreover, social isolation can exaggerate
pain in Evelyn. Hence, in aged care facility Evelyn can socialize with other older people and
it would minimize pain sensation in her (Couturier et al., 2016).
Personal values: It is necessary to maintain personal values of the patient and family
members while planning care for the patient like Evelyn. It is also in alignment with the
person-centred care. Nurses and healthcare professionals need to give respect Evelyn and
Jane by understanding their feelings and by encouraging them to contribute in decision
making of Evelyn’s care. In case of Evelyn, autonomy is not possible because due to her age
and health condition, it is difficult to expect independence in her. Life-experience of patient is
useful tool for providing intervention to the patient. However, in case of Evelyn, life-
experience cannot be considered because her age and psychological condition like confusion
and dementia would not give accurate outcome. In this case, Jane’s help need to be taken to
understand life-experience of Evelyn because she cannot provide life experience due to her
dementia. Understanding relationship of care provider and carer with patient is important
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aspect in providing nursing intervention for pain management. In case of Evelyn, nurse need
to establish both personal and therapeutic relationship with Evelyn. It is evident that change
in the environment of care for patient with pain is useful in reducing dose and duration of
pain medication. Quiet environment is useful in minimizing pain perception (Addario et al.,
2018).
Evaluation: Evaluation of pain intervention in Evelyn should not be only focused on medical
treatment but also it should focus on biochemical, physiologic, functional, and quality of life
measures. In evaluation, pain relief need to be assessed which is useful in reducing duration
of hospital admission and hospital readmissions. Pain relief in Evelyn need to be evaluated by
reviewing pain score and analgesia regime. Pain score would be reviewed every 4 hours and
analgesia regime would be evaluated every 24 hours. Mean pain score need to be evaluated
after 24 hours. Evaluation also need to be performed for stabilization of the biochemical
parameters and vital signs. All the subjective and objective parameters need to be stabilized
to assess pain relief (Addario et al., 2018).
Conclusion:
In this assignment, case study of Evelyn was described. Evelyn is a 92 years lady admitted to
orthopaedic ward with fractured left neck of femur. Person centred care was implemented for
Evelyn. Mccormack and Mccane framework was used for implementing person centred care.
Established frame work was used for the assessment of Evelyn. Both the subjective and
objective parameters were assessed during her assessment. After the completion of
assessment, she was diagnosed with left hip fracture. Relevant to her diagnosis, three
problems were identified for Evelyn. Pain was considered as the major problem and motility
and fall risk were considered as the other problems for her. After the identification of
problems, goal was set for her. For Evelyn goal was, ‘To maintain Evelyn comfort and pain
to a level that is manageable for her’. To meet the goal set for her, interventions necessary to
reduce the pain were implemented. Interventions provided for Evelyn were with reference to
the person-centred care framework. Nurse and other healthcare professionals made sure that
legal and ethical implications were considered while providing interventions to her. Personal
values of Evelyn and Jane were considered while providing intervention to Evelyn. Person-
centred care discharge plan was prepared for her and referral was made for the outside
treatment and care. Different strategies were implemented to the evaluation of the care plan
for Evelyn. Evaluation was directed to assess whether goals were met for Evelyn.
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This assignment benefited by providing more insight into the person-centred care of old
patient. This assignment gave experience of following step-wise and systematic approach for
providing person-centred care to the old patient. It also helped to understand impotence of
personal, legal and ethical issues while providing care to the patient. This assignment would
definitely help in future to implement this approach in the actual practice. It would give more
confidence to use person-centred approach in the old patient.
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pp. 52-59.
Couturier, B., Carrat, F. and Hejblum, G. (2016) A systematic review on the effect of the
organisation of hospital discharge on patient health outcomes. BMJ Open. 6(12):e012287.
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Foss, N.B., Kristensen, M.T., Palm, H., and Kehlet, H. (2009) Postoperative pain after hip
fracture is procedure specific. British Journal of Anaesthesia, 102(1), pp. 111-6.
Galvin, E.C., Wills, T. and Coffey, A. (2017) Readiness for hospital discharge: A concept
analysis. Journal of Advanced Nursing. 73(11), pp. 2547-2557.
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NICE Guidelines. (2011) Patient experience in adult NHS services: improving the experience
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Appendix: Care plan for Evelyn
Assessment Diagnosis Plan (Goal) Intervention Rationale Evaluation
Evelyn, 92 yr
old.
Objective
Data
Left Hip
Fracture
92 years old
Past Medical
History-
Osteoarthriti
s,
Osteoporosis
, Alzheimers
and Gastric
reflux.
Subjective
Data
Pain
Moaning
Disoriented
Clinical
Assessment
BP- 121/73
Pulse- 96
Saturation
Level 98%
Temperature
- 37.6
VAS pain
score 10/10
on
Left Hip
Fracture.
c/o
BP- 121/73
Pulse- 96
Saturation
Level 98%
Temperature
- 37.6
VAS pain
score 10/10
on
movement
Evelyn will
report pain
controlled
at levels of
< 5 on a
scale of 0 to
10 within
the next 24
hours.
Perform
comprehensive
assessment for
location, onset,
duration,
frequency and
severity of pain
scale for
interval of 0 to
4 hours.
Monitor
Evelyn vital
signs like
tachycardia,
blood pressure
and high
respiratory rate
at every 2
hours.
To ensure
Evelyn
receives
appropriate
treatment, it
is necessary
to perform
accurate
assessment
(Clarke,
2014; NICE
Guidelines,
2011;
Gregory
and
Richardson,
2014).
Pain
stimulates
sympathetic
system
which is
responsible
for
tachycardia,
hypertensio
n and
increased
hypertensio
n (NICE
Evelyn
verbally
expressed
there is
reduction in
the pain
sensation.
Non-verbal
signs also
indicates,
pain is
absent in
Evelyn.
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movement
Observe and
monitor Evelyn
for specific
non-verbal
signs like
moaning,
guarding and
facial grimace.
Administer
prescribed pain
relief
medication to
Evelyn.
Observe
Evelyn’s
response to
pain relief
medication
after every 15
minutes and
record the
observation.
Guidelines,
2011; Foss
et al.,
2009).
Pain
produces
behavioural
responses in
patients like
Evelyn
(Clarke,
2014; Foss
et al.,
2009).
Analgesics
are helpful
in relieving
pain (NICE
Guidelines,
2011; Foss
et al.,
2009).
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Provide non-
pharmacologic
al treatment
like relaxation
exercise,
breathing
exercise and
music therapy.
VAS pain
score 10/10
on
movement
Pain and
immobility.
Evelyn will
not develop
complicatio
n due to
pain.
Evelyn will
learn to use
accessory
instruments
in 4-5 days.
Position in
proper
alignment and
reposition
every two
hours.
Teach
application of
adaptive
accessory.
Evelyn will
not face
complex
feeling due
to
immobility.
Mobility
accessories
are useful
in
improving
mobility
(Kenny et
al., 2017;
Greenwood
and
Oldmeadow
, 2009).
Normal
mobility
started.
No
complication
due to
immobility.
Roper,
Logan and
Tierney
model of
assessment.
Evelyn
developed
complicatio
n of
immobility
To improve
immobility
in 2 days.
Identify factors
for safety and
modify
environment
To
understand
whether
intervention
need to be
After 7-8
hours of
implementin
g
interventions
14

and risk of
fall.
accordingly.
Put side trials
up and put
items necessary
for Evelyn in
her reach.
provided. If
environmen
t is not
familiar,
there is
possibility
of fall of
Evelyn
(Kenny et
al., 2017;
Greenwood
and
Oldmeadow
, 2009).
Patients like
Evelyn who
are
disoriented
or confused
are at
higher risk
of fall
(Greenwoo
d and
Oldmeadow
, 2009;
Kenny et
al., 2017).
If items are
out of reach
of Evelyn,
she needs to
stretch her
for reducing
fall, Evelyn
was free of
fall.
15

body to get
these items.
Hence,
there is
possibility
of losing
balance and
fall (Kenny
et al., 2017;
Greenwood
and
Oldmeadow
, 2009)
16