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

 

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.

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.  

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.

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.

 

-       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?

-       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 

-       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.

-        

-       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

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

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

 

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

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

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.

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. 

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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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

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.

 

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. 

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.

 

 

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

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.

 

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

 

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

 

 

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.