Multiple health need is a theoretical account to have an comprehensive view on multiple interwebbing needs of a client which pairs health and social issues. There cannot be a common frame work for the complex needs for all, but it is individual specific and need separate response from care givers. (Rankin & Regan)
A 37 year old client named Mr Shaiju came to the emergency department with alleged history of road traffic accident (RTA) in which a lorry ran over the tibia of the left leg. On admission Mr Shaiju had immense pain over the left leg and was having tachycardia and hypotension. The skin over the left tibia was degloved and the client looked apprehensive .On radiological examination Mr Shaiju was diagnosed with a compound fracture of tibia and fibula. The orthopedician advice for a Below knee Amputation since there was popliteal artery injury along with nerve injury and bone fracture, which when associated together in patient is a higher risk to end up into amputation (K. Rerkasem 2006), even though the patient had history of Type II diabetes Mellitus by considering the finding of Guo Jiong Jiong et al (2009) that immediate operation is possible in a patient with fracture. The client was moved with traction splints to Surgical Intensive Care Unit (SICU) after taking routine investigations like blood routines (HIV , HbSAg screening, Liver Function Test, CBC ESR and Urine Routine, Random Blood test, Urea , Creatinine) and ECG . In SICU Mr Shaiju was prepared for surgery.
Amputation is the method of surgical removal of a limb or a portion of limb which no longer be beneficial for the person, instead it produce immense pain and cause threats to the life of individual because of injury or infection.
Below Knee Amputation is the process of surgical removal of lower portion of leg beneath from knee joint (Riley Lee Richard 2005).This can arise to many interlinking needs for the patient like economical social, psychological demands which are not directly linked with condition but play a crucial role in the recovery of the patient
In order to mention the multiple health needs of the patient with below knee amputation, practitioner use the above mentioned case of Mr. Shaiju who was a victim of RTA because he was drunken and driven cycle into a lorry and broken the tibia and fibula of right leg along with injury to both nerve and artery resulted in below knee amputation. This client is a perfect example of a case of multiple health need of patient undergone amputation since he is having all needs
To protect confidentiality all the persons are mentioned with pseudo names in accordance with Nursing & Midwifery Guideline in 2008
The subject of this case study Mr Shaiju is a 37 year old who has been admitted in authors unit with severe injury to right lower limb because of RTA.On physical examination his height was 168 cm weight was 68kg and Body Mass Index (BMI) was .He was hypotensive with Blood Pressure and Tachycardic .On auscultation he was having crackles and he was having an episode of cough since one week. He was having a surgical mark on the left iliac region of abdomen. He was having a muscular build and the rest of all system was functioning normally. He was assessed for fracture, abdominal or head injury by observation, neurological examination and also an abdominal ultra sonography and results of all those were negative.
System wise Examination
1. General Appearance: Muscular body built. He was apprehensive and cooperative to author despite of severe pain he was having.
2. Skin: Good skin turgor,but skin is dry and pale over palm and lower extremity
a) Skull is normal, round appearance with no sign of injury or bruise mark.
b) Hair is thick and some are white in colour
c) No visible facial abnormalities
a) Pupils are equally round and reactive to light and accommodation
b) Eyebrows are equal
c) No evidence of periorbital oedema
d) Cornea is smooth
e) White sclera
a) No foul smelling discharge present
b) Normal position of pinna
c) Recoil of pinna is present when it is folded
6. Nose: No abnormal discharge present
7. Throat & Mouth:
No obvious swelling and sore present, Normal Deglutition and gagging reflex present.
a) No visible enlargement of thyroid gland and jugular vein distension
9. Chest: Normal appearance, no gynecomastia present
10. Cardiovascular: No cardiac murmurs, normal rhythm of pulse
11. Respiratory: Crackles on the both lungs with frequent coughing
12. Gastrointestinal: No organomegaly present and normal bowel sounds present.
13. Extremities: No abnormality found other than crush injury over right lower limb
14) Urogenital System: Normal urine output present, no haematuria or pyuria present
15) Neurological System: Normal reflexes present
Past Medical History
The past medical history was not good when the operation while considering the possible complication associated with it. Shaiju had severe medical histories like Type II Diabetic Mellitus (DM), hypertension and also chronic alcoholism He was diagnosed of having diabetics in 2006 and was on regular oral hypoglycaemic. In the year 2007 he was diagnosed of a victim of chronic renal failure as hypertension is a main predisposing factor for the disease ( ).He was on regular haemodialysis as this is the best treatment option available for chronic alcoholism ( ) beside with the supportive medication.
Past Surgical History
He had undergone appendicectomy one year before and the operative and post operative history was uneventful. He had developed a heterogeneous mass in the hilum of liver and on later examination it was found to be a cyst and Endoscopic retrograde collangiopancreatography (ERCP) was performed .On ERCP gallstones and stone on hepatic duct was found out and removed and a drain was put to remove pus collection from the cyst.
He is having a nuclear family with wife and three children and he is the only bread winner of the family. His parents were died because of old age and cause of death according to him was because of Cardiac Arrest. His uncle and mother was having DM and hypertension. He had four siblings in which three of them died because of cancer and another one recently died because of RTA, so he was very stressed since he also encountered with an accident.
He is a coli worker and belongs to a socially deprived group of society. He did not have support from any other family member since he is the only earning member and his other relatives are belong to low socio economic strata .The subject was living in a rented house. The roof was tiled and having accessibility to safe water.
He was well nourished and is a non vegetarian. He was taking foods four times a day and had at least 8 glass of water per day.
MANAGEMENT AND TREATMENT
Crush Injury of Lower Extremity
¿½ To bear the weight of the body.
¿½ To enable in locomotion.
The main focus of the orthopedician is to manage the condition by below knee amputation, even though that may be considered as the failure of surgeon to perform amputation since due to the advancement of surgery in micro vascular technique, revascularisation and internal fixation of fracture (Ertl Jan 2005). But in this case the bone was fragmented due to crush injury by RTA.A transtibial procedure was used. Informed consent was taken from the patient and the risk for above knee amputation was explained. The patient was given supine position and tourniquet was applied. An anterior-posterior incision was used. The muscle layer was dissected first and followed by the neurovascular structures. After the soft tissues dissected the osseous tissue is approached using chisel. After the dissection is performed anterior flap is attached to posterior flap. Drains are placed to prevent the formation of hematoma and the extremity is wrapped in sterile dressing and plaster cast is applied with leg in extension. The splint was removed on 7th day, as the normal duration will be between 2-7 days (Ertl Jan 2005). The patient was on broad spectrum antibiotics since he was a high risk candidate for infection due to diabetics mellitus ( ) and NSAIDS.
ALCOHOLISM & ALCOHOL WITHDRAWAL SYNDROMME
Alcoholism is a condition arises because of either psychological or physical strive alcohol is consumed which is manifested by behavioural and responses of other kind and is associate with a temptation to consume alcohol to get its physiological effect or to nullify the effects caused if you not taking alcohol. (World Health Organisation 1992).
Alcohol Withdrawal syndrome is a group of clinical manifestation which arises due to the reduced concentration of alcohol in the blood , which is essential for the normal functioning of that individual since the body developed dependency to alcohol ( Winnington J et al 1998 )
The reduced intake of alcohol because of long post operative period caused decrease of alcohol levels in patients¿½ blood so that body cannot perform the normal function, since his body developed dependency. The withdrawal symptoms were sweating in night, tremors, increase in heart beat and respiration, reduced amount of sleep, agitation and irritability. He was aggressive and also had auditory hallucination.
The patient developed alcohol withdrawal syndrome on the 3rd post operative day, the common complication of alcohol abstinence after a long history of drinking. The patient was referred to psychiatrist and was advised to give Polybion an Intravenous drug of multivitamin and Serenenace tablet in order to make the patient calm.
Diabetic Mellitus (DM) is a metabolic disorder in which there may be absolute or relative absence of insulin hormone or resistance of insulin or a combination of both which deter the proper carbohydrate, fat and protein metabolism.
DM is of two types
1. Non insulin dependent diabetes mellitus or NIDDM or Type II DM
2. Insulin dependent diabetes mellitus
Anatomy & Physiology
Pancreas is an endocrine gland situated behind stomach and it is in the left upper quadrant of abdomen .It is an exocrine as well as endocrine gland. . The two important hormones are Glucagon and Insulin. The former convert glycogen stored in body tissues to glucose for meeting energy requirement and the later do vice versa that is glucose to glycogen. Pancreas is having three pats head neck and tail. It is supplied by pancreaticoduodenal and splenic artery and pancreaticoduodenal vein.
The risk factors for DM can be grouped as non modifiable( age, family history , ethnic origin) and modifiable risk factors (Obesity, hypertension, polycystic ovarian disease , viral infection , drugs , stress and gestational diabetics mellitus ) .Mr Shaiju had family history ,and hypertension . These caused hyperglycaemia. The hyperglycaemia cause increased glucose uptake which penultimately leads to cellular starvation and ultimately in polyphagia since satiety centre is stimulated because of the starvation. The hyperglycaemia causes increased glucose elimination from kidney since it exceed renal threshold. This result in polyuria since more water will be gone out since glucose will attract the water. The hyperglycaemia increase blood osmolarity which in turn result in polydypsia since intracellular dehydration occurs as fluid shifts from intracellular to extra cellular space and also it result in reduced blood flow which causes complication of diabetics like dry itchy skin, nephropathy, neuropathy, retinopathy and confusion. Mr Shaiju was devoid of complications and had polydypsia, polyphagia and polyuria.
Throughout the days the blood sugar level of patient was very much raised due to underlying history of diabetics and stress due to hospitalisation. The patient was advised to start insulin injection subcutaneously from 2nd postoperative day since the oral hypoglycaemic agents was found ineffective, with the advice of doctor specialised in diabetics.
Chronic Renal Failure (CRF)
Anatomy & Physiology
Kidney is a retroperitoneal bean shaped organ situated between T12 and L3 vertebrae and is guarded by 11th and 12th ribs. The basic functional unit of kidney is Nephron. The physiological functions are excretion , controlling the fluids in blood , maintain ionic regulation of pH of the body fluids, it share the function of synthesising vitamin D along with skin, and it maintain red blood cell concentration.
CRF is a disease condition in which kidney cannot maintain body¿½s normal internal environment since there occurs gradual progressive deterioration in the number of functioning renal tissues.
There are predisposing factors (Age above 55 & Family history of DM and Hypertension) and precipitating factors (Life style like smoking and alcoholism, certain diseases like hypertension and DM, recurrent infections). Mr Shaiju had the family history of DM and hypertension and also had both diseases and he was a chronic alcoholic. These factors caused thickening of small vessels and deposition of collagen in them resulting in decrease blood flow. This causes glomerulosclerosis and thereby reducing glomerular filtration rate (GFR).This result in gradual progression through 5 stages according to the Kidney Disease Outcome Initiative Classification.
Stage I: GFR will be normal (>90ml/min/1.73meter square)
Stage II: GFR will be mildly reduced (60-89ml/min/1.73meter square)
Stage III: GFR is moderately reduced (30-59 ml/min/meter square)
Stage IV: There occurs severe reduction in GFR(15-29ml/min/meter square)
Stage V : There occurs failure of kidney (<15ml/min/meter square)
Mr Shaiju was on 4th stage of CRF and had pruritis, anorexia, and decreased libido.
The patient was having a history of chronic renal failure and hypertension so he was given antihypertensive (ACE inhibitors), loop diuretic, vitamin and mineral supplements and especially Vitamin D supplement. There was a high concern for the worsening of the disease because of the high course of antibiotics science kidney is the organ meant for excretion of waste products of drug metabolism ( ) . He was on protein restricted diet.
The author as a nurse practitioner looked the patient holistically like physical, psychosocial and economic dynamics rather than particular disease.
Alcoholism is associated with many medical problems which is harmful for the normal functioning of the body. It also is the causative factor of RTA as in the case of him ( in United Kingdom one in seven RTA is due to alcoholism) and problems with co-ordination ( Ritson Bruce 2000).There will be a great expectation of the patient for health care professionals to ask about the drinking habits of the patients (Kaariainen et al 2001).The hospital is the best site for prevention since the admitted patient in the hospitals demonstrate high willingness to change (Emmon et al 1992).The nurse practitioner used this opportunity to identify yhe dangerous alcohol consumption habit of the patient and given counselling as stated by Lock et al on 2002.
The nurse practitioner identified the risk of developing contractors a major concern after the amputation (Christian Adrian 2006) and also the physical movement act as the stimuli in mechanical form for the skeleton in maintain normal homeostasis of bones (Lundon Katie 2000).The immobilization cause sudden loss of bone mass (Krolner et al 1983). So the patient was given range of motion exercises along with physiotherapists. The residual limb was covered with elastic bandage so that the residual limb attains proper shape and is devoid of swelling (Christian Adrian 2006). Mr Shaiju had muscle pain skin pain and bone pain and he was given health education regarding that the former two will diminish quickly and the later will last longer as quoted by Erhl Jan in 2005. The patient was given special care for phantom limb sensation and given massage from mild to severe pattern and also towel used , both for desensitization so that the nerve reflex is reduced (Riley Lee Richard 2005).The patient was given health education that residual limb should be kept covered and elevated in order to enhance blood supply and wound healing.
From physical examination nurse practitioner identified the crackles in the lungs and cough. The patient was given chest physiotherapy and steam inhalation so that the present condition was relieved.
The stress of operation results in an increased circulatory adrenaline, adrenocorticotrophic hormone, cortisol and growth hormone which result in deficiency of insulin in body and also develop resistance to insulin (Heller 2002). The nurse practitioner identifies the tough job to find out hypoglycaemia in a sedated patient after surgery since the diabetic patient. The patient¿½s blood glucose was checked half hourly to relieve the risk of hypoglycaemia and its complication.
The nurse practitioner identified the risk of decline in physique and functional capability in haemodialysis patient (Johansen L Kirsten 2003). Adequate attention was given for this aspect and patient was approached with that mind set and was referred to dietician for preventing malnutrition.
The nurse practitioner given information regarding the temporary problem with verbal, visual and spatial learning, which would be regained within few weeks if the chronic alcoholics abstains from alcohol (Ellenberg Leah 1980).The point about the alcohol hinders the performance of suitable form of behaviour and self interpretation regarding events happened in past (Hull G Jay 1981) was informed to patient. The patient was also informed regarding the loss of functioning in which alcoholics deter better processing of information and physical activity and also the increases chance of aggression after consumption of alcohol (Hull g Jay1986).
The term diabetes mellitus denote a severe issue to health care because of the increasing cost and the hindering nature of disease on the individuals affected to live a better quality of life. The complications of DM can be prevented by proper primary care which reduce two third of the cost. Physical activity and weight regulation promote reduction in the expenditure for mortality and morbidity (G John 2009).
The nurse practitioner coordinated the rehabilitation team which consist of dietician, social workers, occupational therapist by proper referrals, informing the proper condition and improvement of patient and helping them in the rehabilitation process.
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