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·       What is a peri-prosthetic fracture, and what are the risks and complications of this type of fracture?

A Peri-prosthetic fracture is a broken bone that occurs around an implant of a total hip replacement. This is a serious fracture which in Rebecca’s case occurs in the femur, and often needs to be treated with further surgery. These fractures are rare but Rebecca may be more prone to them due to her osteoporosis, poor quality and strength of the bone surrounding the implant. This condition and its additional risks should be considered when planning Rebecca’s care.

Additional risks for this fracture include falls, muscle weakness or poor balance. A loosened femoral stem is also an additional major risk resulting in this type of fracture and may occur over time due to everyday activity.

This fracture can be very painful and this should be effectively managed with analgesia to ensure Rebecca is comfortable. It is also important to ensure the sciatic nerve through the hip and blood flow to the lower leg are not compromised by the fracture.

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Group F - Week 4: What type of treatment regimens are available for osteoporosis?  What other interventions are recommended?

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Group F - Week 4: What type of treatment regimens are available for osteoporosis?  What other interventions are recommended?

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Group F Week 4 : Why is Rebecca having so many complications from her surgeries? What has the impact of her lifestyle in her first few decades of life been on her bone health, and how is this impacting her now?

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Group F Week 4 : Why is Rebecca having so many complications from her surgeries? What has the impact of her lifestyle in her first few decades of life been on her bone health, and how is this impacting her now?

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Due to Rebecca’s past history of fractures as well as Rebecca’s intense to moderate physical activity, from childhood to adulthood, and restricted dietary intake, she is more likely to retain these fractures due to low bone mineral density. Furthermore, now Rebecca is going through menopause it is going to reduce the amount of calcium Rebecca will need to absorb for musculoskeletal development increasing the likelihood of fractures to occur. According to Jester et al (2011), Bone, joint, and muscle health are an important aspect of the well-being of all individuals across the lifespan. Without an effective musculoskeletal system, general health suffer and disability may ensue. This is causing Rebecca to have such complications after surgery as even though Rebecca is receiving surgery to help support fractures, it does not support the fact that Rebecca has low BMD which causes her bones to be more fragile increase the risk for the fracture to reoccur.

The appreciation that infancy and childhood are important periods of life for bone development has led to a need for suitable methods for monitoring bone health. (National osteoporosis society, 2004). Rebecca’s childhood and adolescence brought about great intensity for physical activity and restricted diet which impacted on her musculoskeletal health. According to Weichselbaum & Buttriss (2011), There is also substantial evidence that poor diet and poor physical activity patterns in childhood can lead to problems that manifest later in life, particularly in relation to osteoporosis. Due to Rebecca’s intense physical activity, which weaver al states that children with higher levels of physical activity are more likely to have fractures, Rebecca’s increase risk of fractures has occurred since doing gymnastics since she was 3 years of age and her frequency of exercise which she has kept up with till now. Furthermore, Rebecca’s restricted diet when she was younger and her beliefs in vegetarianism has impacted the amount of calcium she has received in her previous life stages which has reduced the amount of BMD (bone mineral density) she has in her bones further increasing her risk of receiving fractures. Therefore, because of the lack calcium caused by Rebecca’s restricted diet, and intense physical activity as well as the amount of fractures that Rebecca has had, it has inhibited her musculoskeletal development which is now impacting her lifestyle by not being able to get involved with her work, feeling reluctant to go out of the house alone as well as struggling to accept the idea of taking regular medication.

References

Jester, R., Santy, Julie, & Rogers, Jean, RGN. (2011). Oxford handbook of orthopaedic and trauma nursing (Oxford handbooks in nursing). Oxford: Oxford University Press

National Osteoporosis society. (2004). A practical guide to bone densitometry in children. Retrieved from https://nos.org.uk/media/2068/bone-densitometry-in-children-pdf.pdf

Weaver, C., Gordon, M., Janz, K., Kalkwarf, F., Lappe, H., Lewis, J., . . . Zemel, B. (2016). The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: A systematic review and implementation recommendations. Osteoporosis International, 27(4), 1281-1386.

Weichselbaum, E., & Buttriss, J. (2011). Nutrition, health and schoolchildren. Nutrition Bulletin,36(3), 295-355.

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Group F - Week 3: What is the difference between osteopenia and osteoporosis, and what are the potential treatment options?

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Group F - Week 3: What is the difference between osteopenia and osteoporosis, and what are the potential treatment options?

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Group F - week 3 - What other services of the multi-disciplinary team or services might be needed to provide holistic care?What guideline and policies exist to support you? 

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Group F - week 3 - What other services of the multi-disciplinary team or services might be needed to provide holistic care?What guideline and policies exist to support you? 

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From the case study there has been a number of specialists involved in Rebecca’s case. From Rebecca’s recent trauma, there are a number of people that should be involved from the multidisciplinary team.  A physiotherapist is the main choice involved in Rebecca’s care. Due to having a cemented total hip replacement, Rebecca will be referred to the physiotherapists who will help recover and mobilise Rebecca post-surgery, within the community and hospital setting. According to Scottish intercollegiate Guidelines network (SIGN) (2009), early mobilisation may prevent complications such as pressure damage and deep vein thrombosis. Early mobilisation in combination with pre and post-operative physiotherapy may be of value in reducing pulmonary complications. Physiotherapists should work with Rebecca whilst in the hospital and furthermore in the community setting to make sure that Rebecca is mobilising effectively and improving with her mobility after the hip replacement.

Another referral which may be beneficial to Rebecca is Mental health service within the community to make sure that Rebecca’s wellbeing is not affected. Due to her previous history with injury in connection with mental health it may be appropriate to do the referral to make sure that this recent traumatic injury will not affect her mental health and that she is recovering well outside the hospital setting.

An occupational therapist may also be involved to provide holistic care pre and post-operatively to the patient. The occupational therapists can help towards the mobilisation of the patient and empowering them by given them information about the surgery pre-operatively as well as providing support and equipment post-operatively if the patient requires to do so.

A counsellor may also be involved in the multi-disciplinary team If Rebecca still has anxiety towards her diet and still attends sessions where the counsellor can identify any concerns to MDT about Rebecca’s feelings before and after the surgery. Also, the dietician maybe involved if there are still concerns with Rebecca’s diet.

Community nurse is also involved in the multi-disciplinary team and will be refereed once Rebecca is in the community after surgery to monitor Rebecca’s wellbeing whilst at home and recovering from her surgery. SIGN (2009) states that supported discharge schemes with liaison nurse follow up can monitor patient progress at home and help to alleviate fears in which the patient may have after their surgery. The use of a community nurse will help support not only Rebecca but her husband after the surgery by supporting them but also listening to their concerns and empowering them in the recovery process.

The RCN (2013) provides a framework for orthopaedic and trauma practitioners in clinical practice. It recognises that trauma and orthopaedic practitioners require specific specialist knowledge and skills at different levels of practice and what is needed from health professionals involved when looking after a patient with a traumatic injury. In particularly, I would look at the partner and guide domain and comfort enhancer during this stage of Rebecca’s care. To make sure that she is provided with information about her injury and supported with guidance in what is going to happen with her injury and any concerns which may arise but also to make sure that before and after the surgery that her pain and comfort in monitored and managed and her mobility is not impaired after the surgery.

Similarly, as a nurse, it is our responsibility to follow the NMC code to maintain the professional standard of practice and behaviour when working with vulnerable individuals, it is our responsibility to maintain training and knowledge to keep up to date with new information and promote professionalism and safety in our environment so that individuals have high quality care and are supported and cared for in our practice.

Mental health services

references

-       Scottish Intercollegiate Guidelines Network. (2009). Management of hip fracture un older people. Retrieved from http://www.sign.ac.uk/assets/sign111.pdf.

-       Royal College of Nursing. (2013). A competence framework for orthopaedic trauma and practitioners. Retrieved from https://www.rcn.org.uk/professional-development/publications/pub-004316

-       Nursing Midwifery Council (2015) The Code. Retrieved from https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf.

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What is the difference between osteopenia and osteoporosis, and what are the potential treatment options?

Osteopenia - Bone mineral density is lower than normal, t-score between -1.0 and -2.5

Osteoporosis - Bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium or vitamin D. T-Score below -2.5

Treatment options -
1. Balanced diet that involves enough calcium and vitamin D (helps with bone growth) e.g dairy products
2. Exposure to the sun
3. Supplements
4. Weight-bearing exercises
5. Lifestyle changes e.g smoking, drinking alcohol and carbonated drinks
6. Medications
Sophi

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·       What is a fractured neck of femur, and what are the associated risks and complications of this fracture type?

A fractured neck of femur is a serious injury and particularly prevalent in older people. Over 90% o hip fracture patients are older than 65 and have pre-existing comorbidities. It is a fracture at the top of the femur bone just below the ball and socket joint. There are two types of fracture which may occur.

Intracapsular Fracture is when the femur breaks at the junction with the neck of the femur within the hip bone, this often results with a half hip replacement or total hip replacement.

Extracapsular fracture is when the break occurs further down the femur outside the hip joint and is fixed using metal work.

https://www.plymouthhospitals.nhs.uk/what-is-a-fracture-neck-of-femur

Associated risks and complications of this fracture are often not medical problems following a hip repair with around 20% of patients affected by post-operative complications. These include: cognitive and neurological alterations, cardiopulmonary affections, venous thromboembolism, gastrointestinal affections, urinary tract complications, perioperative anaemia, electrolyte and metabolic disorders and pressure scares being the most prevalent of problems. These may however be particularly prevalent due to the age group of those in need of the surgery, as older people have a weakened bodily function and immune system and are therefore more prone to secondary infection and complications.

Carpintero, P. et al. (2014). Complications of hip fractures; A review. World Journal of Orthopaedics. 5(4). 402-411. Doi: https://dx.doi.org/10.5312%2Fwjo.v5.i4.402

heather

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group G- What is a fractured neck of femur, and what are the associated risks and complications of this fracture type?

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group G- What is a fractured neck of femur, and what are the associated risks and complications of this fracture type?

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A fractured neck of femur are crack or breaks in the top of the femur close to the hip joint. Fractured neck of femur are usually caused by a fall and most common in older people who may have reduced vision or mobility problems. Symptoms of a fractured neck of femur include; pain, being unable to weight bare, bruising and swelling. Fractured neck of femur have many complications, some medical and some in the surgical treatment itself.  Some complications include; cognitive alterations (delirium), pressure ulcers, urinary tract infections, venous thromboembolism, perioperative anaemia (complications of a hip fracture 2018).

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What other referrals do you think might be required for Rebecca, and how would you engage her with services?

Rebeca could be referred to Rheumatologists. They are doctors who investigate, diagnose, manage and rehabilitate patients with disorders of the musculoskeletal system such as the locomotor apparatus, bone and soft connective tissues. As these doctors are specialised in this particular area they will have more in depth knowledge about Rebecca’s situation and can prove the best treatment and recovery.

I would also refer Rebecca to mental health or just someone to talk to, so she doesn’t feel alone. She may have a self esteem due to all the injuries she has sustained from her gymnast career.

However, we can make these recommendations to Rebecca but if Rebecca chooses not to attend (DNA) then the services will be no use to her. As a result, its important to find out why she hasn’t been attending. Rebecca must be the core of her patient centred care, its no use making appointments for her if she isn’t attending. A trust bond must be established so that Rebecca can open up about her rehabilitation and how she is feeling so that we can help her every which way we can.

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What are fragility fractures, and why would this type of fracture be a concern in someone of Rebecca’s age?

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or low energy) trauma. (Kanis JA et al. 2001) For example, falling from standing height or less.

This type of fracture would be a concern as it indicates that there her bone density is at a low level and she is at risk of developing osteoporosis.
Women are more affected by men, more than 1 in 3 women will have one or more osteoporotic fractures in their lifetime - in comparison to men where only 1 in 5 will. There are also other indications to why she may of suffered with this fracture. Such as, low body mass, and ethnicity -Caucasian men and women are at a higher risk.
As Rebecca is at a young age and is seen to be fit and active, this fracture would raise concerns as it highlights that there may be an underlying problem with her bone density. This could of been caused by her restricted diet as she is not getting enough calcium and Vitamin B which are essential for bone growth. As the nurse caring after Rebecca I would try to educate her about bone density and the implications people's lifestyles can have. I would offer her support and further treatment from specialists such as dieticians.

Kanis JA, Oden A, Johnell O et al. (2001) The burden of osteoporotic fractures: a method for setting intervension thresholds. Osteoporosis International 12: 417 - 27.

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Group F - Week 2: What other referrals do you think might be required for Rebecca, and how would you engage her with services?

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Group F - Week 2: What other referrals do you think might be required for Rebecca, and how would you engage her with services?

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Group F -- week 2 - What are your nursing concerns for Rebecca?  Consider the RCN Competencies – what skills and knowledge do you require here, and how would you apply them/

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Group F -- week 2 - What are your nursing concerns for Rebecca?  Consider the RCN Competencies – what skills and knowledge do you require here, and how would you apply them/

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Concerns around healing of bone/repeated break (Fragility Fracture)/ DNA to dietician and ?reasoning and lack of engagement with addressing health and dietary needs.

I feel the most applicable domain to the nursing concerns around Rebecca is the Partner/Guide Domain. This section discusses the nursing role in relation to support and guidance; Patient information and education; Health promotion and Rehabilitation. I feel these are all aspects which may influence the next steps for Rebecca and address the concerns raised.

According to the RCN Competencies, the nurse at level 5 should be informing the patient of their bone health and the effects of healthy eating and healthy living. This should be done by discussing at the level of understanding for Rebecca, perhaps discussing her understanding of her diet initially provides further insight into her reason for opinion, and allow the nurse to hear her level of understanding and match this. This may engage Rebecca further and allow the nurse to use health promotion and education interventions more effectively, and empower Rebecca to engage with the Dietician. It is important Rebecca understands the meaning of low density bones, how this occurs and the initial interventions to reduce – such as eating more calcium and vitamin D to provide the bone with more vitamins for strength.  While recognising Rebecca’s wishes to be vegan and respect this, offering alternative which fit with this diet preference.

It is also important that should Rebecca continue to refuse this advice the nurse offers appropriate alternatives to promote healing of the fracture and further repetition in the future – this could be in the form of lifestyle advice, such as less weight training involving the wrist, or perhaps in rehabilitation and physio involvement to strengthen the area as much as possible.

As part of the holistic approach to Rebecca, the nurse should discuss the effects this fracture and future bone weakness may have on her wider lifestyle and daily living. This may highlight to Rebecca the gravity of the concerns and allow her to make an informed decision on attendance to the Dietician, and compliance and engagement with the advised plan of care. This should involve a Psychological impact assessment, as nurses at Level 5 are expected to complete – and may highlight a deeper explanation for Rebecca’s relationship with food and diet and allow this to be addressed by the appropriate teams.

This could have been addressed with Rebecca before the DNA with the dietician to build a better trust and rapport between the nursing professional and the patient and should be discussed with Rebecca on attendance of the Fracture Clinic for and explanation and further support to be given.

heather

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What is the ACL, and what does it do in the body?

The anterior cruciate ligament (ACL) is one of the ligaments inside the knee joint. It runs diagonally connecting the front (anterior) of the tibia to the back (posterior) of the femur. This ligament helps to stabilise the knee joint by controlling backward and forward movements of the knee. It stops the tibia bone from moving forwards in front of the femur.

What does the repair and rehabilitation of this injury entail?

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What guidelines and policies are there to support you? (Week 1)Group F 

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What guidelines and policies are there to support you? (Week 1)Group F 

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Group F - What are fragility fractures? why would this type of fracture be a concern in someone of Rebeccas’ age?

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Group F - What are fragility fractures? why would this type of fracture be a concern in someone of Rebeccas’ age?

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According to nice guidelines (2016) a fragility fracture is a fracture caused by a fall from standing height or less.

Fragility factures result from mechanical forces that would not ordinarily result in fracture, known as low level trauma The World Health organization states (WHO) Fragility fractures are osteoperotic factures which are caused by low bone density and can lead to osteoporosis.

As Rebecca’s is at a young age and has an active lifestyle this fracture would raise concerns and highlights reduced bone density as NICE (2017) states that reduced bone density is a major risk factor for fragility fractures. Furthermore, Fragility fracture is the clinically apparent and relevant outcome in osteoporosis (NICE,2017). This may be due to her restricted diet from such a young age which she is keen to maintain, which may restrict the amount of calcium and vitamin B she would need to maintain bone density. A healthy diet providing adequate calcium at all stages of life, coupled with an active lifestyle, will help to ensure strong bones. Furthermore, according to Schenker (2002) This is particularly important during childhood, adolescence, and early adulthood when bones are developing. Around 90-95% of peak bone mass is attained by the end of the second decade. Adolescence is a particularly critical period, with approximately 40% of peak bone mass in girls being laid down during this time.

Therefore, as a nurse looking after Rebecca, it is our responsibility to support people to make lifestyle changes to improve their bone strength including advice on nutrition as it has a potential role in the prevention of bone diseases, particularly osteoporosis (Bonjour et al, 2009).

References:

National Institute for Health and Care Excellence (2012). Osteoporosis: assessing the risk of fragility fracture. (CG146)

National osteoporosis society (2017) retrieved from https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/12/falls-fragility-fractures-pathway-v18.pdf

National institute of Clinical Excellence(nice)(2016)  Osteoporosis. Clinical guideline for prevention and treatment. Executive summary. National Osteoporosis Guideline Group (NOGG)

National Institute of Clinical Excellence (2017). Osteoporosis. Assessing the risk of fragility fracture

Bonjour, J., Guéguen, L., Palacios, C., Shearer, M., & Weaver, C. (2009). Minerals and vitamins in bone health: The potential value of dietary enhancement. British Journal of Nutrition, 101(11), 1581-1596.

Schenker, Sarah. (2002). Diet and bone health: In the sixth article in our series on nutrition, Sarah Schenker explains the importance of calcium and vitamin D. (Education). Student BMJ, 57.

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Group C: What is ACL, what does it do in the body and what does the repair and rehabilitation of this injury entailed?

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Group C: What is ACL, what does it do in the body and what does the repair and rehabilitation of this injury entailed?

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ANTERIOR CRUCIATE LIGAMENT (ACL).

Anterior cruciate ligament (ACL) is one of the pair of ligaments that help to stabilise the knee joint. It connects the thighbone (femur) to the shinbone (tibia). This ligament is commonly torn during sports that involve sudden stops and changes in direction such as gymnastic like in the case of Rebecca, as well as in tennis, basketball, soccer and volleyball.

The ACL is responsible to restrain excessive forward motion of the knee as well as the inward twisting or rotation of the knee.

ACL repair involves a surgical tissue graft replacement of the ACL to restore it function, the torn ligament is removed from the knee before the graft is inserted. ACL reconstruction is highly successful operation with good rehabilitation. about 90 to 95% of individuals who undergo this surgery can expect to return to full sports participation within six months, hence there is hope for Rebecca to get back fully to her dream.

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Group D: What guidelines and policies are available to support you?

Different NHS Trust have developed guidelines to help in the management of ACL. The guidelines developed by The Royal National Orthopaedic Hospital(NHS) provide information on the rehabilitation of patients undergoing ACL repair. These includes:

·Indication for surgery:

The main indication of ACL reconstruction surgery is symptomatic instability following ACL injury.

·Possible complications:

Infection, bleeding, deep vein thrombosis, nerve damage etc

·Surgical techniques

·Expected outcomes

·Pre-operative

·Post- operative

NICE have developed guidelines on preventing weight gain which will be used to support Rebecca. The guidelines encourage dietary habits that reduce the risk of excess energy intake and a dietary pattern that is mainly based on vegetables, fruits, beans and pulses, wholegrains and fish.

NICE guidelines on Post Traumatic Stress Disorder will be used by the nurse to support in their care for Rebecca. Rebecca can be referred to the mental health service if more input is required.

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Group H - what guildlines and policies are there to support you? 

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Group H - what guildlines and policies are there to support you? 

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When a patient has undergone ACL reconstruction surgery there are a number of guidelines and procedures that have been put in place in order to support the patient thought their rehabilitation. NICE guidelines have developed policies for reconstructing damaged intra-articular cruciate knee ligaments this is known as MIB (medtech innovation briefing). This is commissioned by NHS England as part of its five year forward plan to try to accelerate innovation in new treatments and diagnosis. Other policies include rehabilitation guidelines for patients undergoing Anterior Cruciate Ligament Repair (ACL), this is devised by the Royal National Orthopaedic hospital and this gives guidelines on rehabilitation at its various phases such as goals, restrictions and treatments.

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Group H - What are your concerns for Rebecca?  What actions do you think you need to take?

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Group H - What are your concerns for Rebecca?  What actions do you think you need to take?

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Rebecca has limited her food intake and is very wary about what she eats. I think Rebecca and her parents need more education on a healthy balance diet. Rebecca can still eat several times a day in small quantities and maintain her gymnast figure; this education would also be beneficial for her during rehabilitation. Without the right and sufficient nutrients, it may take Rebecca longer to recover. I would recommend Rebecca being referred to a dietitian for support and advice so that she can become less anxious about her self-appearance if she is educated about the foods she can eat to maintain her weight in a healthy matter.

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What is ACL?                                               The Anterior Cruciate Ligament (ACL) is a paired ‘X’ shaped ligament which is one of the four major ligaments of the human knee. The main function of the ACL is stabilisation. An ACL tear is the most common serious injury of the knee, often caused by cutting and or pivoting sports. A fully torn ACL requires surgery and approximately 6-9 months of strenuous rehabilitation (Prodromos, 2017).                      References Prodromos, C. (2017). The Anterior Cruciate Ligament: Reconstruction and Basic Science E-Book. London: Elsevier Health Sciences

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What is ACL?                                               The Anterior Cruciate Ligament (ACL) is a paired ‘X’ shaped ligament which is one of the four major ligaments of the human knee. The main function of the ACL is stabilisation. An ACL tear is the most common serious injury of the knee, often caused by cutting and or pivoting sports. A fully torn ACL requires surgery and approximately 6-9 months of strenuous rehabilitation (Prodromos, 2017).                      References Prodromos, C. (2017). The Anterior Cruciate Ligament: Reconstruction and Basic Science E-Book. London: Elsevier Health Sciences

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Group D

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Group C  - What are you nursing concerns and priorities? Consider the RCN Competencies – what knowledge and skills do you need to meet Rebecca’s holistic needs here?

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Group C  - What are you nursing concerns and priorities? Consider the RCN Competencies – what knowledge and skills do you need to meet Rebecca’s holistic needs here?

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The competency from the RCN’s ‘competence framework for orthopaedic and trauma practitioners’ which I feel is best suited for this week’s scenario, and will help me structure my work is ‘Partner/Guide’ competency. This competency helps guides practitioners on support and guidance, patient information and education, health promotion and rehabilitation. One of my main nursing concerns and priorities for Rebecca would be to appropriately support her and her family emotionally to ensure that they are coping with the consequences of her injury. Also to refer to other services if I felt like her psychological needs were not being met. These concerns are listed as competencies for a competent nurse at level 5, as a band 5 nurse is required to assess psychological impact, provide support and then make appropriate referrals. I would also be concerned about Rebecca’s nutritional diet, as it is strict and follows a vegetarian lifestyle which also cuts out dairy products which are good sources of calcium and vitamin D which are used to help rebuild bone. Her priority would now be to go through rehabilitation and have a supportive diet in place. Therefore, to achieve this I as a competent would have to educate Rebecca and her family on healthy eating and living, and how this can affect bone health. Consequently, in order to help Rebecca, her diet would have to change to aid her recovery. I would make a plan with the support of a Physiotherapist and Dietician, as that would be an appropriate team to work with who may be able to educate myself as well. Then I would give detailed evidence-based verbal and written information on changes. All my priorities are supported by competencies given by the RCN.

In order to meet Rebecca’s holistic needs I would need certain knowledge and skills, such as good interpersonal and communication skills. Rebecca is still a child and has grown up to follow a strict lifestyle and therefore not be as willing to change. I would need to be able to support her appropriately and listen to any concerns she has. I would then help support her and try to accommodate her better, this can be done through the help of the MDT.

Sophi

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What guidelines and policies are there to support you?

Many NHS trusts have constructed guidelines for the care of a patient who has injured the ACL. These guidelines outline the aims for the surgeons to enable mobility, reduce pain and provide stability that has been affected since the injury. (Hull and East Yorkshire Hospitals NHS Trust, 2018) An ACL reconstruction rehabilitation protocol was developed to aid patients and physiotherapists in the essential exercises that will maximise recovery.

Regarding Rebecca’s mental health a referral to CAMHS will be made to provide support after the injury where she may suffer from PTSD to her frustration about her routine and eating. An assessment will initial be made and recommendations will be given to ensure that her mental health is supported. Throughout the NHS there are guidelines and policies that will be followed depending on the aspect of support that will be given. MDTs will each have their own policies which will be adapted to Rebecca’s needs and meetings will be held to ensure that information doesn’t contradict what other service provisions are provided for Rebecca.

Claire

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Group G: What are your nursing concerns and priorities? Consider the RCN Competencies and the skills needed to complete holistic care for Rebecca.

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Group G: What are your nursing concerns and priorities? Consider the RCN Competencies and the skills needed to complete holistic care for Rebecca.

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This injury will impact on Rebecca in many ways; for the purpose of this week’s work I would like to focus on the ways in which the nurse could positively help Rebecca by educating her and her family on her diet and how this can speed her recovery. To do this I would use the RCN Framework (2017) Domain 1: Partner/guide competences; using this domain will allow the nurse to be able to support Rebecca and also advise her family as the process will be long and Rebecca may struggle mentally with the rehabilitation programme. Nutrition will be important to Rebecca during the early stages of her rehabilitation and foods high in vitamins will increase the repair of the ligaments injured; as Rebecca is a vegetarian she may need to be counselled about her diet as foods high in protein such as eggs, chicken and fish are recommended. The nurse could prioritise this when communicating with the parents as they may be able to speak to Rebecca about changing her diet while she recovers for the best opportunity to pursue her future career. Parents having knowledge of what can help recovery will enable them to encourage Rebecca and will mean that health promotion has also been taught to the family. During this difficult time the nurse may also have to explore the psychological impact the injury may have on Rebecca and how this can be improved; Rebecca could work with staff to plan her rehabilitation following professional’s advice which will enable her to be in control of her care and may positively impact her mental health; this could be centred around her diet, mobility and her over all rehabilitation such as a timetable of events. The nurse looking after Rebecca would need to work alongside Rebecca and her family to ensure that the correct care was given to Rebecca that enabled her rehabilitation to be successful as quick as possible using education and health promotion about the injury and what can be done to speed up recovery. Using a holistic approach to Rebecca’s care the nurse will be able to gain key aspects of what is important to Rebecca and how the MDT can improve the care she is given and give her responsibility.

Emily

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What is the ACL, and what does it do in the body?

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What is the ACL, and what does it do in the body?

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The anterior cruciate ligament (ACL) is one of the four main ligaments of the knee. This ligament runs diagonally in the middle of the knee and prevents the tibia from being able to slide out in front of the femur. It keeps the knee stable and provides rotational stability to the knee. There are many ways in which the ACL can be injured and studies have shown that female athletes often have a higher incidence of ACL injury within certain sports.

What does the repair and rehabilitation of this injury entail?
Treatment for an ACL injury will vary depending on the individuals needs. However, many injuries will require surgery as a torn ACL will not heal without surgical intervention. A torn ACL  would have to be sutured back together and reconstruction using a tissue graft using an arthroscope. Rehabilitation following surgery is vital and often a physical therapy program may be used to strengthen the knee and regain the motion.
Rehabilitation may take from 6 - 9 months to be able to return to full activity. The patient may also be kept in a protective knee brace to protect the reconstructed ACL graft from stress or further injury.
Mary

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Rebecca (14)

Nursing Concerns and Priorities relating to RCN framework Domain 1, partner/Guide:

Due to the big change in Rebecca’s life due to the injury, Rebecca may be feeling depressed or be experiencing some sort of mental health issues. The nurse would be competent in assessing the psychological impact on Rebecca and also her family (Royal College of Nursing, 2012). The nurse can help Rebecca’s mental health by encouraging and supporting her in her rehabilitation and recovery to encourage her that she will get better and the quicker she gets better, the quicker she can get back training. The nurse must also ensure they are competent in health promotion to promote musculoskeletal health whilst educating on bone health and the healthy diet and lifestyle that accompanies the healing of bones (RCN, 2012). If competent, the nurse should ensure Rebecca is getting the right nutrients whilst considering her vegetarianism and her diet regime set by the British Gymnast Team. Maybe this diet plan would need to be changed. Rebecca might also be reluctant to eat due to wanting to maintain her figure but the nurse must educate Rebecca that a healthy diet makes a healthy recovery. The nurse must also educate a healthy recovery by encouraging Rebecca and her family that she must not go back training too early as she needs to heal.

Soph

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Group F - What are you nursing concerns and priorities? Consider the RCN Competencies – what knowledge and skills do you need to meet Rebecca’s holistic needs here?

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Group F - What are you nursing concerns and priorities? Consider the RCN Competencies – what knowledge and skills do you need to meet Rebecca’s holistic needs here?

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From the case study and the information we have received I believe are priorities at this moment in time involve supporting a rehabilitating Rebecca’s injuries and promoting knowledge of nutrition to help support and improve her diet in relation her career and her own physical needs.

Furthermore, looking at the RCN framework, I decided to focus more upon the partner/guide domain as i believe at this moment in time this is the domain which focuses on the support the nurse would give to Rebecca and how to help her in early stages of recovery.

Support and guidance

-       Partnership between the patient and healthcare professional and the role of guiding the patient through their journey. Also working with the family and MPT to ensure seamless holistic care

-       Supports and encourages the patient when mobilizing according to the rehabilitation plan, with a focus on maintaining musculoskeletal integrity and mobility

-       Mental Health - devastation, depression due to change in regime, intensity of career. Start querying eating disorder?

Patient information and education

-       Provides basic information to the patient and carers about their musculoskeletal condition/ injury. This is in relation to Rebecca’s mobility allowing Rebecca and her parents to know about the injury and making sure she stays well rested during the healing process.

-       Nutrition- letting her understand nutritional information for her own restricted diet and healing process

Health promotion

-       Uses simple health promotion strategies to promote musculoskeletal health within the immediate community by giving Rebecca and parents information and support about basic nutrition, following Rebecca’s beliefs of vegetarianism, but also emphasizing the importance of dairy products, meat products in relation to musculoskeletal health and providing other high calcium and protein products adequately meeting Rebecca’s nutritional needs.

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Rehabilitation

-       Assesses the psychological impact of orthopedic and trauma conditions and injuries on individuals and their families and provides appropriate psychological support -  Rebecca’s devastation of being unable to commit to gymnastics following injury. Referral to CAHMS and support of mental health towards Rebecca’s and parents and what mental health interventions put in place.

-       Develops and executes remobilization and rehabilitation plans according to patient need within an MPT

-       Makes timely and appropriate referrals to other professionals where the patients physical, social and psychological needs indicate necessary

According to this domain the knowledge and skills do a nurse would need to meet Rebecca’s holistic needs would include possessing effective communication skills, Utilising excellent customer care skills and possessing sufficient understanding of musculoskeletal condition, surgery and injuries to safely care for Rebecca

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Group D- week one  What are your concerns for Rebecca? What actions do you think you need to take?

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Group D- week one  What are your concerns for Rebecca? What actions do you think you need to take?

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As a nurse my main concern would be that Rebecca is very aware and conscious about her weight. Rebecca is very mindful that she may gain weight during her rehabilitation period as she is unable to maintain her normal training routine, and I would be concerned that this could lead to an unhealthy relationship with food and early stages of an eating disorder. Rebecca is a vegetarian and although this is a good life style choice to follow I would like to explore why Rebecca decided to take up this kind of dietary requirement, and see if it was for the right reasons and not just to cut out certain foods. I also would be concerned that as she is already extremely aware of her diet and weight, that during her rehabilitation period, she would start to cut down her food intake and/or skip meals, because she is unable to do her normal training routine, I would feel concerned she would do this to avoid putting on any weight and/or to avoid the need to loose weight when she is able to go back to her intensive training routine.

I think Rebecca would benefit from some education into healthy eating and how to maintain a well-balanced diet during her rehabilitation and for afterwards when she is able to go back to her training. A referral  to a dietician would be a good option as this would give Rebecca some education into her diet and how to maintain a healthy balanced diet, the dietician would be able to help Rebecca with any concerns she has with eating certain foods and how to maintain her weight in a good healthy way. I think Rebecca would also benefit from a eating plan, this way she can plan her meals with her family,  shop for her meals  and prep her meals in advance, this would give Rebecca control over her diet and make her feel less anxious about what she is eating. I would also like to have her family involved, so they too can have education on what is good for Rebecca to be eating during and after her rehabilitation, it also gives Rebecca the support at home as well. Involving her family would also give them the educations of early signs of eating disorders and anxiousness towards food and what to do if Rebecca’s they do become aware of them.

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Group D - What are your nursing concerns and priorities? 

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Group D - What are your nursing concerns and priorities? 

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As a nurse, my concerns about Rebecca would be her diet, as she is anxious about gaining weight, she may not eat a lot whilst being in hospital, this needs to be recognized by staff or the nurse so that the nurse can provide Rebecca and her family verbal and written information to educate them about how important it is for Rebecca to continue to eat and have a good diet. The nurse needs to assess psychological impact of the trauma on Rebecca and her family to then provide appropriate psychological support. This could help Rebecca with her mental struggles about her diet and body image. To be able to do this the nurse needs to refer and communicate Rebecca’s needs to other health professionals.

The priority would be to ensure Rebecca is getting the nutrients she needs in her diet in order to help her recovery and then carry on with this diet whilst in rehabilitation.

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Group G - What are your concerns for Rebecca? What actions do you think you need to take?

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Group G - What are your concerns for Rebecca? What actions do you think you need to take?

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My concerns for Rebecca are that she is having the wrong outlook on her diet and appearance. She thinks that less is more and that by limiting her diet will improve her performance in gymnastics when in fact it will make it worse. This demonstrates a lack of education and so I feel that Rebecca would benefit from some information regarding diets and how each food group helps maintain a good body strength and weight.

Furthermore, it is a concern that she appears to be so worried about her weight and not being able to train during her rehabilitation period. This could be an indicator of an eating disorder and Rebecca struggling with her self-image and need to compete in sport in an obsessive manner. Rebecca might benefit from some help from a psychiatrist who could talk to her about why she feels like this, and ways to tackle her thoughts in order to improve her psychological strength.

The biggest concern for Rebecca is whether her anxieties will affect her rehabilitation period. If she refuses to eat a balanced diet and is insistent on continuing to lose weight, this will pro long her rehab and could effectively worsen her condition and cause further problems for her physical and mental health. It is important for professionals and Rebecca’s friends and family to provide her with the correct dietary education and encourage her to participate in improving her health in order to reach her end goal of being able to take part in gymnastics again. This is giving Rebecca a motivation to get better whilst also improving her understanding on her diet and why each food group is important in her recovery and in her training.

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Group G-  what is the ACL? What does it do in the body? What does the repair and the rehabilitation of this injury entail?

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Group G-  what is the ACL? What does it do in the body? What does the repair and the rehabilitation of this injury entail?

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The ACL is the anterior cruciate ligament and is one of the key ligaments that helps to stabilise the knee joint. The ACL connects the femur to your tibia. The ACL helps to keep the knee stable when rotating and prevents anterior movement of the tibia and femur as well as hyperextension of the knee.
When the ACL is damaged it usually requires surgical repair and rehabilitation. Our role as nurses is to educate the patients during their rehabilitation and their recovery on the importance of performing the excercises given to them by the physiotherapists after there surgical intervention.  This inclues excercises to bend, straighten and move the leg. Recovey from injuring your ACL is approximatly 1 year.
Sport injury rehab helps atheletes effectively treat pain and return to normal function. Specific stengthening and flexibility excercises will be implemented. Progressive excercises are included in sports rehabilitation programmes to ensure the injury site returns to a functional state.

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Group F - What are your concerns for Rebecca?  What actions do you think you need to take?  

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Group F - What are your concerns for Rebecca?  What actions do you think you need to take?  

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Nutrition – Vegetarian and low dairy for gymnastic aesthetic.

To discuss nutrition and daily diet with Rebecca, perhaps reviewing diet plan given by British Gymnastic Team. Dietician referral and ensuring Rebecca understands need for food for energy and different food groups eg complex carbohydrates necessary for exercise and slow release. Support of vegetarianism and highlighting ability to eat healthy and do this, how to receive other forms of protein and minerals usually gained from meat.

Investigate Bloating, relation to allergy? Lactose intolerance? Other means of receiving calcium if to continue and importance of this in relation to body eg. Bone strength.

Discuss importance in altering diet to meet rehabilitation needs eg increasing calcium and dairy (not in uniform so bloating not to worry about).

6 months of rehab. Rebecca’s devastation, depression during rehab and ?ED, change in daily structure.

Discuss with Rebecca her opinion and outlook on rehab. Ensure promotion and explanation of why it’s necessary and impact of compliance on speed of recovery (and return to gymnastics). According to Erikson (1959) 14 years will be developing for more independence and sense of self, professionals to respect and meet this with inclusion of Rebecca in Rehab decisions and plan of care.

To create daily plan during hospital admission to provide structure which she is missing from training. This can be discussed and created with Rebecca to improve compliance and should include sessions eg OT/ Dietician/Physio/School and should include breaks.

To monitor mental health and psychological adjustments to injury. Focus on other aspects of life and maintain social aspect of gymnastics. Contact to peers or other gymnasts who have suffered injury may help reduce anxiety and be assured and encouraged to comply with medical advice and plan of care.

Positive enforcement and encouragement from nursing staff/doctors/physios that plan of care and recovery is running as expected may further increase compliance and encouragement to continue with rehab fully.

Referral to CAMHS ?post dietician input regarding possible eating disorder. To monitor and assess psychological impact of injury and facilitate support and ?counselling for this to develop effective coping strategies. Nursing staff to support interventions put in place and respect adjustments which may need to be made to meet Rebecca’s mental health needs.

Community referral, regular follow ups and support once discharged. CAMHS input may be more necessary at this point to manage psychological impact of change of structure, incorporate parents and peers in distraction and promoting alternative aspects of lifestyle.

E. Erikson (1959) Erik Erikson’s Stages of Psychosocial Development. Retrieved from https://www.simplypsychology.org/Erik-Erikson.html.