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What other members of the MDT will be needed in Mayemes care?

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What other members of the MDT will be needed in Mayemes care?

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Multi-disciplinary teams consist of staff from several professional backgrounds who have different areas of expertise.

A consultant psychiatrist or a member of the mental health link team is a priority in Mayemes care. The surgical team will be involved to make further decisions on his mal-union fracture. A member of the children's safeguarding team should be present to address his families situation and involve his mother and brother in his recovery. Plastic surgery team could be involved after his surgery. OT and physiotherapists will become involved immediately after surgery.

Annie WK 2 - group one

How can we engage Mayeme in his care?

Convenient appointment times and engaging with non-traditional forms of media.  Actively invite Mayeme to improve his own care and make his own decisions about his care.  Respect his privacy. Try to strengthen Mayeme relationship with his family for further support in his care. Ensure he has the knowledge about his health and where and when he can access healthcare. Provide a package of care with counselling, diagnostic testing, treatment and information.

Annie wk2

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The nursing concerns would include Mayemes mental health.  You would want to explore why he is harming himself so you can make referrals to the appropriate teams.  The nurse would aim to build up a therapeutic relationship to do this.  The section partner guide within the orthopaedic guidelines states that the nurse should provide holistic care through effective communication.  There has been a malunion of his fracture which has caused functional problems for him so the nurse will need to be aware of the psychological impact this would have on him.  Pain due to the malunion would be another nursing concern and the section comfort enhancer within the orthopaedic states that nurses should be aware of pain that a patient may experience.  The safety of Mayeme is another nursing concern due to his self harm and there is a section within the orthopaedic guidelines regarding the patients level of risk (risk manager).
Sam Group A

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Lacerations - What is the difference between superficial and deep?

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Lacerations - What is the difference between superficial and deep?

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Superficial lacerations are limited to the outer skin layer and can generally be treated at home.

Deep lacerations go through all the layers of the skin and into underlying tissue or bone.

Annie week two - group A

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Malunion and the implications for the patient.

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Malunion and the implications for the patient.

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Malunion occurs when the bone fragments join in an unsatisfactory position usually due to insufficient reduction and premature removal of a cast or other mobiliser.

Delayed complications may come occur after treatment or as a result of treatment.

Surgery is the most common treatment for malunion which come with the risk of surgery.
Malunion may interfere with the mechanics of other joints and lead to osteoarthritis.

Annie - week 2 group A

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Mayeme–wk2  Priorities for nursing care: malunion and self-harm/safeguarding implications.             The radius and ulna have an important role in positioning the hand. The ulna has a stabilising role, while the radius is articulated in a way which allows it to roll over the ulna, moving the hand from supination (external rotation) to pronation (internal rotation). Malunion can cause pain and functional disability, and, may require surgery to restore function. Surgery has the potential for further complications i.e infection and concerns for Mayeme during the post-operative phase; will Mayeme and his family care for the surgical wound as appropriate, will Mayeme return for follow-up appointments and report any complications.  The nurse looking after Mayeme (according to the RCN competency framework) should be able to recognise actual and potential complications of orthopaedic and trauma conditions, injuries and surgery.•	Assesses each child for potential safety risks. This will be dependent on age, mobility and ability to communicate.•	Assesses and observes each child, older adult or vulnerable person for physical and/or behavioural indications of abuse. Act according to local policy if a cause for concern is identified.•	Promptly recognises and reports all complications to medical staff.•	Informs and educates patients and carers about the risks of musculoskeletal conditions and injuries.•	Uses evidence-based preventative measures.•	Prescribes a plan of care based on risk assessment and management.•	Prescribes and delivers care to patients who have complications.•	Refers to other members of the MPT such as tissue viability.Mayeme has a large, deep laceration on his forearm which has punctured a vein. Mayeme requires surgery to heal the wound and will likely require plastic surgery skin grafting to cover the deficit.A laceration is a tearing or splitting of the skin commonly caused by blunt trauma, or an incision in the skin caused by a sharp object, such as a knife or broken glass. A deep laceration may involve injury to deeper structures; tendons, nerves and impaired blood supply. According to the (Nursing Times: Traumatic wounds: nursing assessment and management, 2009) the history and examination of a traumatic wound is vital in deciding the most appropriate treatment regime for the wound and the patient. It will also alert you to the possibility of complications, such as delayed healing or infection. This is difficult in Mayeme’s case; without family input and with his reluctance to share information and providing false information during his previous hospital admission.What is Mayeme’s Tetanus immune status. According to NICE (2017) It is important to remember that immigrants, foreign nationals, patients with a history of vaccine refusal and the over-65 age group may not have received a basic tetanus course. Non-immunised individuals, or those whose immunisation status is not known, should be given a full course of the vaccine.Lyndsey (group B)

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Mayeme–wk2  Priorities for nursing care: malunion and self-harm/safeguarding implications.             The radius and ulna have an important role in positioning the hand. The ulna has a stabilising role, while the radius is articulated in a way which allows it to roll over the ulna, moving the hand from supination (external rotation) to pronation (internal rotation). Malunion can cause pain and functional disability, and, may require surgery to restore function. Surgery has the potential for further complications i.e infection and concerns for Mayeme during the post-operative phase; will Mayeme and his family care for the surgical wound as appropriate, will Mayeme return for follow-up appointments and report any complications.  The nurse looking after Mayeme (according to the RCN competency framework) should be able to recognise actual and potential complications of orthopaedic and trauma conditions, injuries and surgery.•	Assesses each child for potential safety risks. This will be dependent on age, mobility and ability to communicate.•	Assesses and observes each child, older adult or vulnerable person for physical and/or behavioural indications of abuse. Act according to local policy if a cause for concern is identified.•	Promptly recognises and reports all complications to medical staff.•	Informs and educates patients and carers about the risks of musculoskeletal conditions and injuries.•	Uses evidence-based preventative measures.•	Prescribes a plan of care based on risk assessment and management.•	Prescribes and delivers care to patients who have complications.•	Refers to other members of the MPT such as tissue viability.Mayeme has a large, deep laceration on his forearm which has punctured a vein. Mayeme requires surgery to heal the wound and will likely require plastic surgery skin grafting to cover the deficit.A laceration is a tearing or splitting of the skin commonly caused by blunt trauma, or an incision in the skin caused by a sharp object, such as a knife or broken glass. A deep laceration may involve injury to deeper structures; tendons, nerves and impaired blood supply. According to the (Nursing Times: Traumatic wounds: nursing assessment and management, 2009) the history and examination of a traumatic wound is vital in deciding the most appropriate treatment regime for the wound and the patient. It will also alert you to the possibility of complications, such as delayed healing or infection. This is difficult in Mayeme’s case; without family input and with his reluctance to share information and providing false information during his previous hospital admission.What is Mayeme’s Tetanus immune status. According to NICE (2017) It is important to remember that immigrants, foreign nationals, patients with a history of vaccine refusal and the over-65 age group may not have received a basic tetanus course. Non-immunised individuals, or those whose immunisation status is not known, should be given a full course of the vaccine.Lyndsey (group B)

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Is the injury a result of self-harm or abuse?There are several issues for nurses to be aware of when considering a self-harm minimisation approach, including:•	Have a patient’s needs in relation to self-injury been discussed by the whole team?•	Has the patient’s capacity to make an informed decision about his or her self-injurious behaviour been assessed?•	Is the patient aware of the risks of severe injury?•	Is the patient aware of the importance of good wound care, and able to identify when an injury may require medical assessment?Managing self-harm can pose many different risks; prevention can be a source of extreme distress, eventually resulting in a more violent, less controlled, act of self-injury, behaviour that can potentially increase the risk of serious and/or long-term harm, and even accidental death.The NMC recommends a comprehensive assessment of the patient, including capacity to make informed decisions, liaising with other professionals involved in the patient’s care, researching case notes and engaging in discussions with the patient. The needs of the patient in relation to self-injury should be identified and a safe self-injury care plan negotiated and agreed between the patient and nursing, medical and management teams. The development of this plan promotes consistent practice, as well as encouraging shared responsibility for care, clear boundary setting and empowerment of the patient.Oxford handbook of orthopaedic and trauma nursing - Rebecca Jester, Julie Santy, Jean Rogers 2011Self-injury and harm minimisation on acute wards - Chris Holley, Rachel Horton, Lisa Cartmail, Eleanor Bradley 23/05/2012 Lyndsey (group B)

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Is the injury a result of self-harm or abuse?There are several issues for nurses to be aware of when considering a self-harm minimisation approach, including:•	Have a patient’s needs in relation to self-injury been discussed by the whole team?•	Has the patient’s capacity to make an informed decision about his or her self-injurious behaviour been assessed?•	Is the patient aware of the risks of severe injury?•	Is the patient aware of the importance of good wound care, and able to identify when an injury may require medical assessment?Managing self-harm can pose many different risks; prevention can be a source of extreme distress, eventually resulting in a more violent, less controlled, act of self-injury, behaviour that can potentially increase the risk of serious and/or long-term harm, and even accidental death.The NMC recommends a comprehensive assessment of the patient, including capacity to make informed decisions, liaising with other professionals involved in the patient’s care, researching case notes and engaging in discussions with the patient. The needs of the patient in relation to self-injury should be identified and a safe self-injury care plan negotiated and agreed between the patient and nursing, medical and management teams. The development of this plan promotes consistent practice, as well as encouraging shared responsibility for care, clear boundary setting and empowerment of the patient.Oxford handbook of orthopaedic and trauma nursing - Rebecca Jester, Julie Santy, Jean Rogers 2011Self-injury and harm minimisation on acute wards - Chris Holley, Rachel Horton, Lisa Cartmail, Eleanor Bradley 23/05/2012 Lyndsey (group B)

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·       What nursing actions could you take, or would you have taken, in A&E, to engage Mayeme in his care episode?

Perhaps most concerning is the circumstances around the accident. I would be asking Him about the accident, did he deliberately move in front of the car?

Id ask him open questions about his feelings at the time of the accident and afterwards, to get a general idea of his mental health.

Id also be thinking about his parents/guardian, and bringing them into the care episode to support him. Id ask for some contact details and go from there. If unable to, id contact his school and explain the situation to them (presuming school uniform). If Mayeme is unhappy with involving his family, id seek another appropriate adult, such as his social worker or his form tutor.

My overall goal is to build a therapeutic relationship with him, to establish trust and make him feel safe in my care.

If he feels safe, then he is more likely to return to the fracture clinic. If I can build some trust, then perhaps he will admit his real name. Id try to establish what his fear of revealing his true self is, it may be that in his home country, medical care is expensive, and he may have been trying to avoid a large bill, not realising that care is free at the point of use in the UK.

Id be an advocate for Mayeme, this may be his first experience in and UK hospital, he may be scared. Id explain at each step of his treatment what was happening and why. Id stress the importance of following up in clinic with his injury.

As English is not his first language, I would use an interpreter if possible, to help him better understand the significance and impact of his injury.

·       What policies and guidelines are in place to help support you?

The NMC code

Royal College of Emergency Medicine, Best Practice Guideline, Emergency Department Care.

Royal College of Paediatrics and Child Health, Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings

Damien. Group B

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What are your nursing concerns for Mayeme?  Mayeme’s avoidance to contact his support worker

·         does Mayeme have a good support network?

·         Mayeme’s mental health

·         Psychological consequences of the injury/care episode

·         Why did Mayeme give a false name?

·         Is the bone healing correctly/complications?

·         Is the wound being cared for correctly/follow-up advice being followed? Prevention of cast sores

·         Cast removal

·         Mayeme was given the bicycle to provide easy transport, how is Mayeme coping without this and is he attending school?

Consider the RCN Competencies – what knowledge and skills might be required in Mayeme’s case, and how might you apply them?

·         Using communication skills/tools to ensure Mayeme’s understanding

·         Appropriate language

·         Building a therapeutic relationship based on trust/safeguarding

·         Holistic care

·         Understanding of consent for minors

·         Using pain assessment tools to gauge severity of pain and appropriate analgesia
Lyndsey (group B)

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·         What are your nursing concerns for Mayeme?  Consider the RCN Competencies – what knowledge and skills might be required in Mayeme’s case, and how might you apply them?

There are several nursing concerns for Mayeme.  The competence framework for orthopaedic practitioners states that professionals must understand the child’s cognitive abilities and able to communicate in an appropriate manner.  English is not Mayemes first language so he made need an interpreter.  The framework also states that the health professional needs to ensure that the child’s parents/guardians are there to be involved in the care of their child as they will be involved in the caring of the child at home.

Mayeme has not been to hospital before and may find the environment intimidating or he may be nervous.  The nursing experience should aim to be a positive one for the child so the nurse will aim to communicate with Mayeme effectively.  The nurse should have good communication skills as these are essential in building a therapeutic relationship.  The nurse needs to be aware of safeguarding issues which may present themselves when taking to the patient and in this case it states that he pulled out in front of a car so did he see the car and did he do it on purpose.  The nurse would ideally have some safeguarding training or be aware of who to talk to if they had any concerns.

The competence framework for orthopaedic practitioners has a section on Comfort enhancer.  The pain and anxiety experienced by Mayeme needs to be assessed using an appropriate pain assessment tool and analgesia given if needs and again with him being a child and English not being his first language this is a concern.  You would want to be able to talk to Mayeme and build up some trust.  You would also want to anticipate pain that he may have when he goes home and give him advice on how to deal with it using analgesia or other techniques.

A cast was placed on Mayemes arm and so consent needs to be gained to do this along with pain relief when the cast is applied. You would want to give Maymeme and his parents/carers advice about looking after the cast including what he can and can’t do and how the cast will affect his activities of daily living.  The patient and family need to be educated in what may go wrong with the cast and what symptoms to be aware of including sensation in fingers and developing pressure ulcers developing under the cast.

Information about caring the cast should be given to Mayeme and family verbally and the health professional should ensure that they understand.  The information should also be supplied written down and a contact number given.  In this case we don’t know what Mayeme understand about the cast and does he understand what he has been told.

Sam Group A

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Follow up is essential to -Advise on physical progress Full assessment including X-rays (to see how the fracture is healing) Muscle weakness/grip strength  Medication for pain Referral for physio/OT/aids Avoid readmission or attendance at the hospital to re-set/operate Check psychological recovery including environmental and social.       

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Follow up is essential to -Advise on physical progress Full assessment including X-rays (to see how the fracture is healing) Muscle weakness/grip strength  Medication for pain Referral for physio/OT/aids Avoid readmission or attendance at the hospital to re-set/operate Check psychological recovery including environmental and social.       

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Annie - Group A

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Cast aftercare requiring follow up

Cracking, softening or breakdown of the cast.

Circulatory and nerve impairment .

Arterial compression – checking for white, blue, purple or black extermeties.

Venous pressure – check limb for redness, pain and sometimes swelling.

Nerve compression – pins, needles, numbness and limitation of movement.

Pressure/cast sores.

Stiffness of joints.

Skin reactions.

Annie Group A

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when reading the frame work introduction these guidelines do not actually apply in an A&E department as there will be other frameworks in place. Same for critical care
Kris Wright Group A

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things that stood out to me in this weeks scenario were safeguarding issues. why were his parents or care givers not contacted to collect him from the department. other things that could have helped in locating him were the name of his school he attended as if heading to school he would be in a uniform. If the nursing staff couldnt get a contact number from him for his guardians they should have contacted the school. This could also be a way of finding him, contacting the school and describing him to staff there as im sure there wont be many students with broken arms or off school due to a RTA. This to me comes under the RCN domain of risk assessment, why was he allowed to leave without a parent? why wasnt his details checked in the system? did the triage nurse observe the uniform he was in?

Kris wright group A

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Late Physiological Complications of fractures of the radius and ulna which require follow up -

Swelling from the injury

Stiffness of elbow and wrist

Joint instability –difficulty in moving the joint as he did before.

Infection – if had metalwork/surgery

Mal-union – a fracture that does not health properly and may be twisted or deformed.

Non-union – the bone does not heal at all.

Soft tissue irritation

Compartment syndrome – swelling within the cast can cause increased pressure within the limb compressing the nerves and blood vessels within the arm.

annie

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Biomechanical studies have shown the accuracy of reduction significantly affects pronation and supination which are associated with post-operative satisfaction. To maintain a good range of pronation and supination, it is vital that apposition, length, axial and rotational alignment are aligned. Stammers, J & Barry, M. (2014). Orthopaedic Trauma the Stanmore and Royal London Guide. London: CRC Press, Taylor & Francis Group. PP155-163. 

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Biomechanical studies have shown the accuracy of reduction significantly affects pronation and supination which are associated with post-operative satisfaction. To maintain a good range of pronation and supination, it is vital that apposition, length, axial and rotational alignment are aligned. Stammers, J & Barry, M. (2014). Orthopaedic Trauma the Stanmore and Royal London Guide. London: CRC Press, Taylor & Francis Group. PP155-163. 

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Annie