A Case Study of a Patient with Complex Health Needs

This assignment reviews a case study of a patient with complex health needs. The care that was provided will be analyzed and evaluated. The objective is to highlight how complex health needs pose challenges for healthcare professionals. The pathological processes will be briefly explored to show how the patient’s care needs have occurred. The care that has been provided in the care study will be evaluated with supporting evidence, including legislation, policy, and guidelines. The patient’s health has been approached holistically and has been viewed as an individual (Brooker,2007) to ensure this, behavioral, cultural, and social aspects of care will all be evaluated to determine how these factors have impacted the patient’s care.

To protect the patient’s confidentiality and adhere to the guidelines of the Nursing and Midwifery Council (NMC, 2015), I am going to rename the patient Tom. The patient was an inmate at the prison in which my placement took place; he attended the nursing clinic three times weekly for a number of reasons. His main medical issue was a reoccurring venous leg ulcer on his left leg, for which he received a number of different treatments, eventually discovering compression treatment was in the best interests of the patient’s health. The patient had many issues with different aspects of his health, which made his nursing care very complex. The leg ulcer originated because the patient was a previous intravenous drug user. Literature indicates that leg ulcers are more common in the older generation (Finlayson et al, 2008); however, Tom was only 34. This introduced many social and physiological issues, such as body image, and Tom found it a very embarrassing problem as his ulcer would often have an odor. Therefore, Tom faced many emotional challenges. The environment in which the care was provided introduced many complications as it raised many issues with the social aspect of care. Also, pain management was difficult to control as the prison had many limitations to prevent any further risks to the patient’s health. Tom also had many mental health issues, which made his compliance with treatment very challenging. Research suggests that patients with mental health problems generally have more issues with physical health (Latoo et al, 2013). Alongside the listed health issues, they struggled with an unhealthy diet and poor nutrition and consequently were under nursing care for weekly monitoring., this posed further complications with the healing of the infected leg ulcer and the patient’s self-esteem. This patient struggled with many complex challenges both with nursing interventions and mental health.

Complexity is defined as ‘consisting of many different and connecting parts’ (Oxford Dictionary, 2010). When applying complexity to the healthcare setting, complexity raises many challenges for healthcare professionals and can have an effect on the patient’s care.  Rankin and Regon (2004) explain complexity to compromise of both breadth and depth of care, referring to the complications and vastness of the healthcare providing. Complexity theory is important within the nursing profession as it provides a framework that is said to be far more holistic and realistic (anonymous author, 2012).

There are many different definitions of what leg ulcers are, Nelson, Cullum, and Jones (2006) suggest that an ulcer is the loss of skin on the leg or foot, which usually takes longer than six weeks to heal. In the case study Tom is suffering from a venous leg ulcer due to previous intravenous drug use. Venous leg ulcers occur from venous valve incompetency and calf muscle insufficiency; therefore, this leads to venous stasis and hypertension. The final result of this pathological process is that the microcirculatory changes and causes localized ischemia (SIGN, 2010). This process can be continuous and the ulcer can reoccur and change in shape.

The first nursing intervention that will be discussed is the role the nurse plays in healing the leg ulcer. The use of compression bandages/therapy is a highly thought-out way of healing leg ulcers (Fassuaidis, 2005). However, the care is made more complex as the patient is very non-compliant.

Compression treatment is used to heal venous leg ulcers, and the framework (NICE, 2015) is in place to ensure that the patient has the correct health needs to receive the treatment. Compression works if the valves in the large veins become damaged, blood will then oscillate up and down the segments. The reduced backward flow will decrease the venous pressure. The use of compression bandaging introduces pressure to the lower limbs, compression of the veins with incompetent valves produces and increases blood flow towards the heart and reduction of venous reflux (Dealey,2015).

Referring back to the case study, Tom was receiving compression treatment for his venous leg ulcer. The correct procedures had been undertaken to ensure that this was the most beneficial and hopeful treatment for healing. However, the patient was very non-compliant and would not adhere to the guidance given by the nurses. Compliance is proposed as a very complicated matter, mainly based on the patient’s attitude and ownership of the problem (Faddusidis, 2005) therefore it is important that the patient is involved in their care and encouraged to self-care where possible (Rungapadiachy, 2008).  Literature states there are many reasons why a patient can be non-compliant for example, the environment, lack of knowledge, mental health, or poor pain management (Edwards,2003) Compression and noncompliance is a very complex argument which is not addressed can have a detrimental effect on the patient’s health and wellbeing. Knight (2008) supports this as it is suggested that poor management of venous ulcers can cause them to enlarge and become deeper therefore reducing the chances of healing successfully. Conversely, there are numerous different ways in which healing could be affected.

Faddusidis (2005) refers to compression bandaging as having the highest healing rates in comparison to all other treatments when treating venous leg ulcers. This is supported by Finlayson (2010) who agrees by affirming that compression is the primary way to promote healing and prevent recurrence. As this may be the case there are disadvantages to the compression dressings which may cause problems to the plan of care, Edwards (2003) argues that the lack of tolerance to the four-layer compression bandaging is too high and interrupts the planned healing process.

However, literature preaches that compression dressings are more effective for healing venous ulcers than the use of no compression (Fletcher, Cullen, and Sheldon, 1997). In the care study, Tom suffered from a lack of tolerance and poor pain management therefore leading him to be non-compliant consequently having a negative effect on the healing of the wound. Interestingly, studies show that the majority of patients who suffer from leg ulcers associate the pain with the bandaging and not the actual wound itself (Edwards,2003). SIGN (2010) supports this theory as research shows that the main reasoning for noncompliance with treatment is pain, discomfort, and interference with lifestyle. In this situation pain control is much harder to manage, this is due to the environment in which he is in and the further risks that this may pose. This is supported by the Royal College of Nursing (2009) which states when medicine management is adhered to under the guidance of the NMC (2015) it is important that issues of security and risks must be also addressed. Therefore this may need further assessment and legislation may be involved such as the Mental Capacity Act (2004).

Morrison et al (2004) suggest that pain management is an underestimated and common problem when working against the tolerance of compression and when not managed in the correct way can lead to further health issues such as anxiety, depression, and sleep deprivation. However, this should not be an issue as there are nursing tools such as pain scoring. This tool is a way to measure a patient’s pain on a scoring level of 0-10. This is very useful when in a hospital setting as this can be controlled continuously by the healthcare staff. However, in a community setting this would not be the best use of nursing tools. Pain management is very complex and incredibly easy to get wrong, Knight (2008) states the fact that throughout compression treatment appropriate analgesia should be provided, however, there are many risks to evaluate within the care of the specific patient, referring back to mental health and risk of overdose.

There are numerous pieces of literature that state that the technique and application of compression bandaging are not correct and can have a negative effect on the patient as it will cause pain. Research suggests that poor application is associated with pain therefore the patient will remove the treatment and it is assumed that they are non-compliant. This suggests that the standard of care provided is low, however, this is disagreed with by (Edwards, 2003) who states that nurses who perform compression treatment have undergone extensive training in which to do so. There is training under the guidelines of (NMC, 2015) therefore there should not be any incorrect application consequently causing unnecessary pain to patients.

It is suggested that pain does not just have a psychological effect on the patient but also a physiological one, it is stated that pain leads to peripheral vasoconstriction therefore constriction of the new capillaries in the wound could result in a lack of nutrients and oxygen to the cells subsequently preventing healing. This would have a negative effect on the efficiency of the compression treatment (Wissing and Unison, 1990). Research agrees with this theory as it is stated that wound pain has a negative impact on the healing process (Woo et al, 2008). This relates back to Tom as prolonged unrelieved pain results in a lack of compliance with treatment and, therefore coincides with the argument that the underlying problem needs to be treated as a result of the ulcer being healed successfully.

The nursing intervention which is highly important to help give the patient the most holistic and patient-centred care is providing the patient with the correct knowledge and empowerment. This will enable to self-care and understand the detriments, that may be caused to their health when being non-compliant (Watterson, 2003). In this case, giving Tom the correct knowledge and confidence to be able to understand the reasoning behind the compression and help manage the pain. This may help with compliance to the treatment and make the care given less complex. It is brought to light that when providing compression treatment and healing leg ulcers, nurses lack empathy, Charles (1995) suggested that nurses did not listen to the patients and did not give clear explanations about their condition. Subsequently having an effect on their treatment, research explains that a patient requires full knowledge of their treatment before they are able to comply with treatment (Edwards, 2003). Nudds (1987) further supports this as the research shows that the patients who understood their treatment and the pathophysiology of the wound, were more committed to the treatment and wearing compression bandaging. However, referring back to the case study, the patient was fully aware of his treatment, and the nurse and I showed empathy and care towards him, yet he still did not comply with the treatment. The nurse’s role in creating a sense of empowerment at this stage is crucial.

Empowerment is described as the process that involves building individual and collective confidence and raising the self-esteem of the individual through valuing their knowledge and experience and supporting them to be part of the decision-making process (Watterson, 2003). It is highlighted within the literature that in some cases nurses believe that giving the patient a sense of empowerment is achieved by giving the patient the information. This is often done by giving information in leaflet form, and although this can be effective it is dependent upon the patient. However this is disagreed with by Watterson (2003) who proposes that this method of communication will be useless if the patient has not fully reached the point of the empowerment process where they can exchange the information for control, this will be achieved with verbal communication. Sully (2010) supports this view as it is recommended that it is more effective to engage with the patient using communication and involve them in the decision making process.

Health promotion is key to the role of any nurse working within the criminal justice system (Perry, 2010). There are numerous amounts of supporting literature and policy which promotes health and self-care for example Your Health, your way (DOH,2006).  These are useful tools in which health care professionals can refer to ensure that the patient is involved in all aspect of their care and promotes self-care and education to patients. This is important especially in wound care, as knowledge can help the healing process. However, it is apparent within the case study of Tom , the environment in which the patient is in make it more complex, this is supported by Perry (2010) states that most offenders do not have direct access to this information, therefore are reliant upon other sources, such as communication from the healthcare professionals . This links with the discussion of the importance of communication and health promotion as (Snyder, 2006)  stated that communication is the foundation of all interaction, and building relationship consequently have positive impact upon the compliance of patients within healthcare.

The cultural, and social aspect of care are very important when looking at the patient in a holistic manner to provide patient centred care (Arnold, 2011). It is suggested that chronic leg wounds effect the quality of life for patients, effecting things like there body images and relationships with people close to them. Evidence suggests that that the low self-esteem and confidence can have a negative effect on the patients mental health (Condon,2006). Arguing that it has a knock on effect for the compliance of treatment .Although these sociological and physiological complexities may have a negative impact upon the care of this patient this is balanced with the use and support from the multidisciplinary teams and support groups which are available with the nurse’s guidance. NMC (2015) states that it is part of a nurse’s role to inform multidisciplinary teams to provide the best possible care for the patient.

To conclude the evidence evaluated shows that in most cases the best treatment for venous leg ulcers is compression, however when a patient is non tolerant or non-compliant to the care that has been provided it can have a negative impact upon the patients’ health. Literature also shows that pain can complicate the patients care when not controlled properly. However the communication and education that is provided by the healthcare staff can improve the care and help the patient understand the importance of the treatment (Synder, 2006). Research expresses that in broader terms if patients are going to continue to comply with such an aggressive dressing, healthcare professionals need to gain a better understanding of the patient’s perceptions. This will help the healthcare team empathise with the patient, therefore be able to give the correct support and advice. Hopefully this way the patient will begin to comply with the treatment (Edwards,2003).

The second aspect which complicated the care in the case study of Tom, was poor nutrition and how this effected many aspects of Tom’s health, including the healing of his wound. Todorvic(2002) states that nutrition has a very critical role in the healing of wounds. It is said that poor nutritional status can cause inadequate and delay of wound healing. Literature suggest that inadequate support from healthcare teams can have a dramatic effect on a patient’s nutritional state (Todorvic, 2002).  The nurse’s role within this care should be to identify and monitor patients who may be at a nutritional risk, research proposes that this should be done in the primary assessment and should be a continuous ongoing process NICE (2012).However it is argued that the nutritional assessment of a patient is often not done to appropriate standard in health and community settings, therefore having a negative impact upon the patient’s general health and delaying the process of successful wound healing.

It is noted that vulnerable patient groups such as Tom are at a higher risk of malnutrition and that offenders often have underlying health and social factors which are more likely to be at risk of poor nutrition (Leach, 2014). This literature supports the argument that underlying problems/ condition must be addressed to be able to further the healing of the leg wound Raising the point that the patient should be assessed holistically taking into consideration the social, economic and physiological aspects of the patient (Lunnon,2013). Yet this is not the case for all patients.

Malnutrition is described as ‘a state of nutrition in which deficiency or excess and imbalance of energy, protein and other nutrients causing measurable adverse effect on tissue and body fat (Leach, 2014).This can have a negative effect on the healing rate of wound and is a huge risk to patients, The world health organisation (WHO, 2012) support this by stating that poor nutrition is one of the greatest threats to public health. Policies, frameworks and guidelines are introduced into healthcare to try to prevent this from occurring, RCN (2013) believe that a full bodied malnutrition plan/ tool in prison will reduce the risk to patients. NICE guidelines agree as they suggest that patients in institutionalised care settings should all be screened to reduce the risk of deterioration.

The nursing intervention within the case study of Tom was to complete his assessment and identify the outcomes. This is often done with tools such as MUST (Lunnon,2013) these tools are effective ways to identify any issues and what actions need to be put in place to rectify these. Research states that is important not just to look at the numerical facts and make a plan based on numbers but to dig into the social aspects into what could be causing the persons habits .Suggesting that the tools and frameworks which are set in place for nurses are only useful and successful when used correctly. However this is challenged by Posthauer(2012) who states that each trust should have a policy in place which defines the frequency of screen, resulting in patients not deteriorating. An advantage of the MUST screening tool is that it has been trialled and developed by healthcare professionals, therefore has been adapted for easiness of use and improved upon in areas. However literature states that it is often that the assessments are completed but not always acted upon .This could have a negative effect on the patient’s future care. Literature also states that another disadvantage to the nutritional screening tools in accordance with the wound healing is that they need to be evaluated in sync with each other and is important that they are documented correctly (NMC,2015)and monitored frequently, this may include weekly weights of patients. Correct documentation in adherence with the guidelines of the NMC (2015) is hugely important when recording patient’s assessment, this is because if done incorrectly useful tools such as MUST nutritional screening tool become invalid and can have a damaging impact upon the patient’s care/health.

The purpose of a nutritional screening tool to identify if the patient or individual are at risk or it is used when a patient is already undernourished Potshauer (2012) .These tools are said to be very successful, conversely literature argues that the issues of validity and reliability must be considered (Carr,2008) furthermore Moffett et al (2007) stresses however important the tools are highlighted to be, this should not over take clinical and professional judgement. This is referring to that if a nutritional risk has or has not been highlighted it is very much important that the nurse must look at the patient holistically, breaking down the social, psychological, physiological aspects. However sign (2010) disagrees with this statement and suggests that there is no good quality evidence that shows effectiveness of nutrition inventions for the treatment of leg ulcers.

Referring back to the case study of Tom, it was the social, physiological and environmental factors which was making his care more complex, the environment in which the care setting was taking place limited Tom to exercise as and when wanted, which literature states can have a negative effect on a person psychologically and also physically, therefor having a negative effect on his diet.

As previously states the environment also limited Tom to his diet, as there is not the freedom to cook and buy food as he pleases, however guidelines state that there is a national framework on the level and quality of food intake for the offenders (Ministry of Justice,2012).Although as previously discussed the patient was a very non compliment patient, The MUST tool was advantageous as it was able to give guidelines on the steps needed to be taken to ensure that the patients’ health was a not been compromised, nevertheless  literature states that the most vital role for nurses with nutrition and wound healing is education for the patient( Lunnon,2014).The nurse’s role is to provide patient centred and evidence based care . Health promotion to patients is critical, to involve the patient in their own care.  Weekes (2004) supports this view by suggesting that the correct appropriate nutritional advice can bring positive change resulting in a happier, healthier patient. It is argued that this is not always the nurses that should be the correct people to provide this information, the multi-disciplinary team such as dietician, doctors, mental health workers all play a vital role (Nagi, 2012).

The care study was a patient with many different interlinking problems, which made his care complex. All the issues revolved around one main aspect of nursing care which is communication. Research shows that good communication in nursing and involving the patient in their care will have positive outcomes (Baughan, 2013) resulting in a higher quality of care. Consequently poor communication and lack of empathy can negatively affect the patient’s experience of care.

The many complexities in healthcare are crucial to a patients treatment, it is emphasised throughout the importance of nursing interventions. Tools which nurses use are a very well structured and safe way of assessing a patient’s nutrition. However, these tools are no use if the healthcare team are not completing and acting upon the information gathered.

To conclude this assignment, evidence is brought to light and evaluated to show that there are many complexities with patient’s health both physically and mentally that create a number of challenges to overcome when caring for the patient. Legislation, guidelines and frameworks are put in place and are available to make these challenges easier to overcome with guidance. To reflect up on the case study of Tom, as the environment was a very unusual environment to be working within their where a number of Prison official guidance which had to be considered when caring for the patient. This made the care provided even more complex. However it does not change the nursing basics such as being an advocate for your patient and always being mindful of the 6 c’s. It is Important to follow the code of conduct (NMC, 2015) and apply these within practice. Research has shown that venous leg ulcers and the compliance of treatment is an ongoing battle, this may be the case however it is important to treat each patient as an individual and look at all their needs however complex they may be. Within the assignment it highlights the importance of the involvement from multi-disciplinary teams and how they can address all the needs of the patient in a more qualified manor therefore this should enable the patient to receive the best quality of care and give support to the other members of the healthcare team. After evaluating the patients care, it shows that there are many reasons why patients can be non-compliant with their treatment. It is not necessary that the patient is ‘head strong’ and unwilling, but a possibility that they lack the knowledge and confidence. It is up to the healthcare professionals to determine what it is that the patient requires to ensure that they are receiving the best quality care possible (Edwards, 2003).

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