Care pathways aim to assist care delivery, by providing guidance, milestones and expected outcomes over a set time period (Herring, 1999). Throughout this assignment, the care pathway for women undergoing a full abdominal hysterectomy will be discussed. To do this the term hysterectomy will be defined, and some common conditions resulting in the procedure will be identified. As will recent trends relating to hysterectomies in the United Kingdom.
Care pathways will then be discussed, in relation to the nurses’ role at each stage. The short comings and advantages of using such frameworks will also be identified. In doing this legal and ethical considerations, along with the principals of holistic care in a surgical environment, to meet the needs patients from a diverse society will be addressed. Within this the focus will turn to post operative pain, and the tools used in its assessment. Some common tools used in the assessment of pain will be identified, compared and critically analysed.
Hysterectomy refers to the surgical removal of the uterus; this may or may not involve the removal of the ovaries, fallopian tubes and cervix depending on the nature of the patients condition (Castledine & Close, 2006). This is a major operation and is usually carried out as an elective procedure. The procedure may be carried out abdominally, using a horizontal incision on the lower abdomen, or vaginally, where the uterus is reached by making an incision around the top of the cervix (Santoso & Coleman, 2001). Less common are laparoscopic hysterectomies, which involve smaller abdominal incisions and the uses of a small telescopes, this approach is often referred to as keyhole surgery (Walsgrove, 2001). The type of hysterectomy a patient receives is often determined by the condition.
There are a number of conditions that may result in a patient requiring a hysterectomy including, gynaecological cancers, fibroids which are benign tumours, endometriosis an inflammatory condition, painful and heavy bleeding, uterine prolapse caused by weakening of the muscle and ligaments, allowing the uterus to move into the vaginal canal and pelvic inflammatory disease a long lasting chronic infection (Tortora & Derrickson, 2006). Surgery is normally only carried out as a final resort, after other treatments options have been explored. However, in the case of malignancy a hysterectomy may be a critical aspect of treatment (Walsgrove, 2001).
Dysfunctional or heavy uterine bleeding is the most frequent indicator for a hysterectomy, accounting for forty-six percent of hysterectomies (Donaldson, 2006). 31898, women were admitted to hospital in 2005/6 for an abdominal hysterectomy, using 184907 bed days. 182 of these took place at a local hospital (Hospital Episode Statistics 2007). Ninety percent of all hysterectomies that were performed nationally where performed for benign conditions (Edozien, 2005). The Chief Medical Officers Report highlighted hysterectomies as an extremely common procedure, with one in five women having a hysterectomy by the age of sixty (Donaldson, 2006).
Care pathways are most suited to routine elected procedures such as hysterectomies, as common responses to interventions may be accounted for (Guezo, 2003). Care pathways are designed to insure that there is a clear auditable trail, evidence based practice, an improvement in risk assessment, less time in spent in hospital for patients and improved financial planning (Hinchliff Etal, 2003). This is achieved by providing all members of the multi disciplinary team with a framework on which care can be based (Herring, 1999).
However, it has been argued that care pathways are not compatible with patient centred care, and that the use of care pathways reduces the nurses critical thinking and clinical judgment, because it may be felt that the pathway has to be followed exactly (Hood & Leddy, 2003). The care pathway of a patient that is to undergo a full abdominal hysterectomy begins with the General Practitioners referral to the Consultant. The nurse involvement with such a patient would begin in the pre operative assessment clinic.
The pre operative assessment clinic facilitates, a multi disciplinary approach to care, allowing the coordination of skills and knowledge to provide a comprehensive assessment of patients needs (Manley & Belman, 2002). With the aim of identifying the patients’ suitability for surgery, minimise the risk to patients, provide information, allowing valid consent to be obtained and reduce patient anxiety. The nurses’ role in a pre assessment clinic would involve, carrying out a holistic assessment of the patients physical, social and psychological fitness for surgery (Walsgrove, 2006). A full set of base line observations would be recorded, to measure all future observations against.
Patient education would take place with the nurse providing information about, what to expect before, during and after the procedure. Within this health promotion issues will be addressed, such as the benefits of stopping smoking before surgery (Pudner, 2005). During the physical assessment the nurse will take the patients medical history and record any medications both prescribed and over the counter including herbal remedies, that the patient takes on a regular basis. As these may have contra indications for surgery, for example, a patient that takes aspirin on a regular basis may be advised to stop prior to surgery due to its antiplatelet properties (Davey & Ince, 2000).
The types of investigations that are carried out in the pre assessment of a patient may vary, depending on the type of surgery that is to be carried out. Common investigations include blood tests, it is important to note that Afro-Caribbean and Mediterranean women may also require electrophoresis, to rule out sickle cell disease and ï¿½ thalassaemia. Electrocardiograms will be required for women over sixty, to identify any underlying cardiac problems (Pudner, 2005), urinalysis, scans and lung function tests, all of which are carried out to confirm the patients fitness for surgeries (Jolley, 2007).
In the case of a hysterectomy, the nurse would need to be aware of the social and cultural implications. A hysterectomy may mean different things to women from different cultures for example; the woman’s role in Muslim communities is often directly linked to her fertility and can be destroyed by a hysterectomy. Some West Indians view menstruation itself as a cleansing act. In such cultures a hysterectomy may result in the women being viewed as inadequate (Walsgrove, 2001).
Uncovering fears and misconceptions by giving clear advice and information is a vital part of the nurses’ role (Hughes, 2002). It would be during the pre assessment that the nurse would make appropriate plans and provision for the patients discharge, taking into account the patients’ social circumstances and making referral to other members of the multi disciplinary team if necessary, to ensure that the patient was supported following discharge (Spry, 2005).
On admission, the patient would be introduced to the nursing staff and orientated to the ward. The nurse would discuss the procedure with the patient in a sensitive manner, describing to the patient what to expect during her stay, to elevate any anxieties (Pudner, 2005). In preparing the patient for theatre the nurse would, carry out a full set of observations including weight, height and body mass index, measure and fit the patient with anti embolism stockings, to reduce the risk of deep vein thrombosis, (DVT) and ask the patient to change into a theatre gown (Dougherty & Lister, 2004). The pre operation checklist would also be completed; this may vary from trust to trust.
However, typically included are things such as, ensuring that the patient is wearing the correct name band, to allow easy identification, the recording of any allergies and making sure that the patient has fasted for the appropriate length of time, six hours for food and two to four hours for fluids; to reduce the risk of aspiration pneumonia. The patient would also be asked to remove all jewellery, apart from a wedding ring which can be taped; this is to prevent diathermy burns from current concentration. Remove make up and nail varnish; to allow skin and nail beds to be observed for circulation and pass urine before the administration of any pre medication, to prevent damage to the bladder, post operative discomfort and allow complete bed rest after the pre medication has been administered (Pudner, 2005).
The pre operation checklist and any other documentation including, the consent form must be completed before the administration of pre medication, as after the patient may be drowsy and information gained unreliable (Dougherty & Lister, 2004). Although valid written consent for surgical procedures is obtained by the medical staff, it is the nurses’ duty to ensure that the written consent has been obtained prior to carrying out pre operative procedures (Alexander Etal, 2000). It is also imperative that all members of the multi disciplinary team obtain consent before carrying out any interventions (Dimond, 2005).
The nurse would accompany the patient to the theatre reception. The patients’ identity and intended procedure would be confirmed on arrival. When transferring patient care to the perioperative team the patient’s safety is of up most importance, and it is vital that all relevant documentation remains with the patient. It is at this point that a nurse from the perioperative team will ensure that the pre operative check list has been completed (Scott Etal, 1999). The nurse would then explain to the patient what was going to happen, and try to elevate any anxieties (Kenworthy Etal, 2002). The perioperative nurse would remain with the patient whilst the anaesthetic was administered, to provide physiological support and reassurance (Radford Etal, 2004).
During the intra operative phase of the patients’ pathway, the role of the nurse is mainly concerned with patient safety. There are two main nursing roles within the operating theatre. One is the circulating nurse, who is responsible for marinating accurate records, positioning the patient and providing equipment needed (Alexander Etal, 2000). The other is the scrub nurse, who is responsible for monitoring the sterile field and accounting for all swabs, sutures and instruments (McGarvey, 2000). However the nurse also has a responsibility to act as the patients advocate, during this extremely vulnerable time. (Boyle, 2005)
When the operation is complete the patient is taken to the post anaesthetic recovery unit (PACU), where the nurse would assume responsibility for the patient until satisfactory levels of consciousness are regained. Before the patient can be admitted in to PACU, the nurse must be informed of the procedure that has been carried out, patients’ anxiety levels pre operatively, fluids and medication given intra operatively, drain’s and catheters that may be in situ and any untoward occurrences during surgery (Hatfield & Tronson, 2001). The nurse will then assist the patients’ recovery, by ensuring that the patients’ airway remains free from obstruction, that all observations remain within normal parameters’ and that the oxygen is administered safely.
It is common for patients to report pain after surgery and it is essential that pain is managed effectively both from an ethical point and to avoid post operative complications (Etal, 2002). Poorly managed pain may result in postoperative complications such as, hypertension, DVT and tachycardia (Hughes, 2004). Despite this nurses have faced criticism for poor pain assessment and management, with patient pain being under estimated. Suggestions have been made that this is due to a lack of knowledge and personal attitudes of what pain should be interfering with care (Etal, 2002).
Before pain can be appropriately managed it must first be assessed. As pain is subjective it assessment is not always easy and there are many factors that may affect an individual’s perception and expression of pain such as culture, past experiences, gender, age and emotional state (Turk & Melzack, 2001). There are many definitions of pain but the one that is perhaps most apt for nurses is, “pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1979, p11).
There are many pain assessment tools available to aid nurses in the assessment of pain; such tools also allow for pain and interventions taken to manage pain to be documented (Schofield, 2007). Pain assessment tool can be categorised in to unidimensional and multidimensional. Unidimensional tools include the Verbal rating score (VRS), which works by patients describing their pain using a pre set list that reflects pain intensity.
The VRS is quick and easy to use but, has been criticised for offering too few descriptors for patient to choose from (Shorten, 2006). Furthermore a comprehensive command of the English language is required, meaning that it may be unsuitable for patients that do not have English as their first language (Hatfield & Tronson, 2001). An alternative to this is the Visual Analogy scale (VAS), when using the VAS patients’ are asked to indicate where their pain would fall on a 10cm line with zero being “no pain” (Manly & Bellman, 2002). The VAS dose offer significantly more choice to patients and allows slight changes in pain intensity to be monitored (Davey & Ince, 2000).
However, this method of pain assessment may be difficult for some patients to comprehend, it is also inappropriate for patients with visual or perceptual motor problems (Wall & Melzack, 1999). Similar to the VAS is the Numerical rating scale (NRS), one of the simplest and most widely used tools available. The patient is asked to place a numerical value between one and ten on their pain this can either be done verbally of visually (Shorten, 2006). The VRS, VAS and NRS all provide a quick and efficient measure of pain intensity and are commonly used in both clinical and research settings. However, unidimentional tools do not account for the many facets of pain, it has been suggested that such tools are inadequate and do not provide a comprehensive measure of pain (Turk & Melzack, 2001).