The History About The Multidisciplinary Team

Published Date: 02 Nov 2017

Introduction

This Case study aims to explain in detail the framework used to care for patients in hospital. The multidisciplinary team is involved in decision making to Assess the patient, to put in place the best Plan related to that patient, to Implement day to day care and Evaluate to determine the usefulness and the limitation of the Care Plan. The patient chosen for this case study came to the hospital by helicopter as she had suffered life-threatening injuries as a result of a road traffic accident (RTA). To maintain privacy and confidentially as the NMC (2012) code states, the patient will be called Mrs White.

Mrs White a 50 year old married woman presented with major trauma injuries, she had history of panic attacks, fatty liver and suspected gallstones. She was on citalopram medication for the panic attacks. Initial physical examination showed multiple fractures of the pelvis, damaged spleen and severe upper leg injuries. The initial contact with this patient was made after three weeks of her admission to the ward, where together with a staff nurse assistance was given with her personal care.

Mrs White had undergone a serious of complicated operations. One of them called Laparotomy performed to examine the abdominal organs to aid the diagnosis due to her serious initial condition. During the Laparotomy she had a splenectomy, as the spleen had been damaged by the impact with the car, she had a colostomy bag put in place due to a lack of mobility as she broken her pelvis and an external fixation had been put in place to keep her bones in right position. This was a very complex case, therefore some of the conditions will be discussed and explained and some just referred to. The Care Plan was put in place to organise the patients care, her needs and observations taken of her daily life function. Please see Appendix 1 for further information on Nutrition.

Care plan

Caring for a complex injured patient is not an easy task. The Care Plan developed for Mrs White outlined the specific goals that she needed to achieve, which people needed to be involved to help her to achieve these goals, and identified how frequently her care had to be re-assessed. The medical and the nursing teams together built a specific care plan for Mrs White needs. The plan involved medics, physiotherapists along with nutritional and skin specialists. Her assessment continued throughout her treatment.

Assessment

Assessment is one of the four stepped processes used by the medical team to identify the patient’s needs. It is an instrumental part of the nursing process, it implies the need for evaluation of an individual’s status to be ongoing, rather than a one-off procedure. (Roper et al.1983). As she was conscious and awake, some questions asked by the medical team were answered, this combined with specific assessment tools which, will be discussed, made for easier identification of the patient’s needs.

Firstly a general assessment of Mrs White revealed that she needed to be fully assisted to maintain her personal hygiene, she needed help with her mobility and her nutrition needed to be monitored as a result of her weight loss.

The patients mobility was very limited due to her multiple injuries and the external frame put on her pelvis to keep it in place. She had to lie in bed almost still, not able to move the lower part of her body but she could move her arms.

As previously mentioned assessment tools were used, an example of the tools used to monitor Mrs Whites clinical condition for ulcer sores was the Waterlow Risk Assessment, Waterlow (1985) and skin Bundle, St. Vincent’s Medical Centre (2004). These allowed medical and non medical staff to monitor and record any changes of the patient’s skin condition. Both risk assessments are in used by the NHS to monitor and prevent pressure ulcers. Waterlow (1985) stated that Waterlow Risk Assessment like all risk assessment is based on scoring system and it is considered a simplistic tool so for this reason a professional judgement must be utilised to determine a risk status of the patient. Please see Appendix 2 for an example of the Waterlow Assessment. In this case the patient scored more than 15 points consequentially the risk of pressure sores was very high. She was turned every two/three hours, night and day to help her with the circulation and mobility. The medical team referred Mrs White to the multidisciplinary team of physiotherapists to start her mobility exercises. An additional tool used to monitor the patient’s physiological functions was the Modified Early Warning Score (MEWS), ACT Health (2007). The purpose of the Mews was to detect and act upon early signs of deterioration; as well as improving communications between nursing staff and junior doctors. It’s use flags-up which patient needs immediate attention, and improved the documentation of patient observation.

Using the risk assessments, the health care team kept under control the four physiological readings, Blood pressure, Heart rate, Respiratory rate and the Temperature of the patient. For example if the blood pressure value and the heart rates were too high and the respiratory rates were also rising, the trigger score on the chart would be over 4 or greater, once this is reached it will activate a protocol to be followed, ACT Health (2007).

Mrs White reached a few times the high score, consequently the frequency of the observation put in place was changed from four hourly to two hourly checks, until all the values returned to normal. Due to her lack of mobility the patient hadn’t had a good appetite therefore she needed to be encouraged and prompted with food to avoid more weight loss. Furthermore, screening had been carried out to control the patient’s nutrition. Additional measurements to be taken were added to her daily plan such us fluid balance to monitor the input and the output, as well as the food chart to supervise how many calories were consumed. The health care team used a tool called Malnutrition Universal Screening Tool (MUST). MUST has been designed to help identify adults who are underweight and at risk of malnutrition, as well as those who are obese. (RCN 2003).

Planning

Planning, is the second phase of the nursing process and extends from the assessment and in conjunction with the patient where possible, family members or carers, decide how the individuals needs, wants and desires in relation to health are to be met. (RCN 2004).

At this stage the multidisciplinary team was involved to coordinate the patients needs, the physiotherapist team, nutritional nurse and skin care nurse.

After the initial assessment had been carried out it was established that Mrs White needed complete assistance to maintain her personal hygiene, physiotherapy for her mobility and the nutritional nurse to assist with her weight loss, an ongoing plan was designed to meet all these goals.

The first element of the plan was to encourage Mrs White to have a good breakfast before the morning personal care. The explanation was given to the patient regarding her nutritional care plan, to make sure that she understood the importance of her high calories and high proteins nutrition therapy, to re-gain her weight loss Lundman (2011), as well as to recuperate enough energy to carry out the physiotherapy plan every day. To do so the medical staff used a tool called MUST, which helped to spot the signs of malnutrition and dehydration. The nutritional team helped to assess and discover what kind of food Mrs White liked to eat and drink; along with other nutritional supplements such as Ensure drink.

The nursing staff discussed with Mrs White how she wanted her care delivered, in the manner that she felt comfortable; consent were given and the dignity of the patient always maintained.(NMC 2012). This information was entered into the plan.

The second element of the plan involved the physiotherapy. The physiotherapist team were always scheduled for late morning and for early afternoon with simple exercises. The beginnings were very mild and easy steps to help to re-gain muscle power in her legs, increased slowly every day up to a point when she could perch on the side of the bed.

The third element of the plan involved the skin specialist nurse. The plan detailed that the nurse specialist would assess the patients skin state once per week. As a result of this the patient’s skin was maintained with no resultant deterioration.

Implementation

Implementation is the third phase of the nursing process. This involved providing information about available services to educate patients and their families to perform specific care activities to overcome their conditions, also Geron & Chassler (1994), state that implementation has to be timely and cost-effective with the goal of maximising the patient autonomy and choice while using the least intensive, intrusive and most cost effective intervention. For example, in Mrs White’s case, the weight loss and lack of movement were important parts of her condition; subsequently the medical team referred Mrs White to the nutritional team, the physiotherapist and tissue viability nurse. These three conditions, lack of mobility, weight loss and skin viability were related to each other; this means lack of appetite, made the patient less energetic and feeling lethargic, the skin did not receive the nutrients required to be healthy and the mobility reduced, as a result of, made exercises difficult to be performed as not sufficient calories to burn.

The nutrition team came to visit Mrs White to assess and study her condition, to find why she was losing weight and how they could assist her on her nourishment.

First of all, they started to identify why she hadn’t had a good appetite, they checked her swallowing reflex, evaluated what kind of diet she was receiving and if she liked the food served. They organised a meeting with Mrs White and her family to see what kind of plan of action they could put together to help her to gain weight. They provided information food leaflets with pictures to stimulate her desire for food. Looking at images of high calories and well presented food is very important as help to stimulate the brain’s appetite control center and results in an increased desire for food, according to a study conducted by The National Institutes of Health, National Center on Minority Health and Health Disparities (2010).

Nutrition

The nutrition team put in place a diet regime to be followed rigorously every day to help the patient to gain the energy and the strength necessary for the body to start to function normally again. Nutrition is the supply of material-food required by organisms and cells to stay alive. (Nordqvist 2009). In hospitals, diet may refer to the food requests for the patients, including nutritional solution administered via an IV (intravenous) or IG (intragastric tube). The nutrition therapist designed a balanced diet which the human body needs; this consisted of different nutriments. These major five elements that patient needed, were found in plant and animal organisms that humans eat (Parsons 2008). During a meeting with Mrs White’s family they were instructed in what kind of food they could bring to the hospital to help to achieve the patients nutritional goals. What Mrs White needed was to introduce into her diet, some of the five important food elements, such us Carbohydrates which the main function is to supply energy for the body, particularly the brain and the nervous system. An enzyme named amylase helps break down carbohydrates into glucose (blood sugar), which is used for energy by the body (Saunders 2010). They are divided in two main groups simple or complex that are depending on the chemical structure of the food, and how rapidly the sugar is processed and absorbed. Simple carbohydrates have one or two sugars and complex have three or more sugars. Carbohydrates together with proteins and nucleic acids are the building blocks of life. Also Mrs White needed to eat proteins to help her body functions. Proteins are required to built and repair tissues, they are source of energy and transport nutrients to the body. Without them the basic life functions cannot be carried out, for example respiration requires muscle contractions and that requires proteins. (Lloyd 2011). Proteins have important function in the human body, they help to grow and repair. The food suggested for Mrs White was meat, fish, pulses, eggs and dairy. Minerals are also important in every day diet as the human body needs them to maintain several functions, like formation of blood and the control of the physic-chemical process. The most important is Calcium as it is required for the formation of the bones and teeth. Also it is essential to prevent blood clotting and control the function of the nerves and the muscles (Kutsky 1991). In addition to calcium, sodium is required for the conduction of nervous impulse and it helps in balancing the water and acid-base in the body, as well as the osmotic controller together with potassium that share the same functions. Introduced into Mrs Whites diet were Lipids (fats), that are used by the human body as organ protection and energy supplements together with the Vitamins which have to be balanced in the life cycle. The body needs groups of vitamins (NHS 2012).The most important are: A, B, C, and D. The patient needed the inclusion of some of the most important vitamins such as C to keep the skin healthy and help to heal cuts, and D to fix the calcium in the bones, and teeth. Fluids were introduced to the patient upon her arrival on the ward, as her dehydration and temperature deteriorated due to her injuries; those needed to be addressed quickly to re-establish her water-electrolyte imbalance. Consequently IV route was used together with oral supplements to solve this problem.

The second team, the physiotherapists came to see the patient and they provided an exercise regime to be followed for 4 weeks and reviewed this every week to check on the results achieved and to verify if the treatments needed to be increased or decreased.

The third team involved was the tissue viability nurses. They put in place a visit twice a week because the patients skin condition was being maintained very well and this was thought to be sufficient. They also monitored the progression of the main plan. Nutrition and exercise play an important part for the patient rehabilitation. They are the keys for the body to re-establish the balance between mind and body. (NHS 2009).

Evaluation

Evaluation is the fourth phase of the nursing process, put in place to monitor the progression of the goals planned in the previous stages and to make changes according to the patients needs. At this stage new problems can be identified and corrected in order to achieve the outcomes. Evaluation process is used in everyday life in order to make simple or complex decisions. Each time a person is required to make some sort of change and before choosing a particular course of action, a review of all available options is taking place. Different options are assessed; advantages and disadvantages associated with each option are considered. (Patton1990).

The multidisciplinary team scheduled a meeting once a week to keep under control the treatment aims designed for the patient. The nutritional therapist was one of the team involved in Mrs White regime, they were checking twice a week to see if the patient had improved her desire to eat and more importantly to maintain her weight.

In this case nutrition and mobility were considered very important in Mrs White recovery.

The patient started to reach the goals of her plan; consequently some of her exercises were increased therefore her appetite increased and weight loss decreased. The multidisciplinary team put in place the care plan and established by continuing evaluation that this was the best course of action for the patient.

This regime continued to be evaluated and monitored for eleven weeks then the patient was discharged from the hospital and sent to a rehabilitation hospital to learn how to walk and eventually return to a normal life.

During Evaluation security and confidentiality of all the documents used by the teams has to be addressed. Documents have to be stored in a secure place where confidentiality can be maintained. Each ward has a secure document trolley divided by bed numbers. The records are accessed by the medical team or only the people involved in the care of that patient. Every action taken regarding the patient, has to be documented, dated and signed

(NMC 2009). The hand writing has to be legible and clear. Abbreviations cannot be used as they can mean different things to different people. Using simple language and uncomplicated medical terminologies makes the records easier for the patients and non medical teams to understand. As the record keeping is an integral part of every intervention, the health care or student needs to be assessed as competent in the complete provision of care which includes record keeping (RCN 2012). In practice, the medical staff are accountable for any actions and omissions in any document, without the evidence it will be difficult to confirm professionalism of actions taken. (NMC 2009).

Conclusion

To conclude, this case study has been complicated but very interesting from a leaning point of view. The multidisciplinary team were involved upon the patient’s admission to the ward. The care plan had been put in place immediately and monitored everyday as well as changed according to the improvement of the patient or modified if Mrs White did not respond positively to the treatments. They designed specifically a care plan for the patient with a diet program to help to increase energy and gain weight, also and exercises regime to re-educate her muscles and maintain healthy skin. The team involved the patient’s family and provided information on available services to help them to understand how to care and overcome the patient’s conditions. The care plan was developed in four phases proved to be very effective for Mrs White as she responded positively to treatments. First step was the assessment process used by the medical team to identify the patient’s needs, the second step was the plan were the multidisciplinary team was involved to coordinate the patient needs, third step was the implementation which had to be timely and cost-effective with the goal of maximising the patient autonomy and choice while using the least intensive, intrusive and most cost effective intervention and the final step the evaluation where new problems could be identified and corrected in order to achieve the outcomes.

The main teams involved, (the nutrition therapist, the viability nurses, the physiotherapists and the medical team) on the ward, worked together to give the best care and treatments available to improve Mrs White condition and made the patient able to be transferred to the rehabilitation hospital to start a new plan to help her to re-gain her lost mobility, caused by the road accident. This continued and co-ordinated course of treatment will help the patient to go back to her normal life, having had the best treatment available from a combined team.