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Collaborative Nursing Practice Collaborative Care In order to improve the quality of patient care and ensure that the goals of care are being achieved, many settings are using the collaborative care delivery model. The collaborative “approach involves teams of health professionals working together to provide more coordinated and comprehensive care to clients,” (Kearney 2008). An interprofessional team can consist of nurses, physicians, care technologists nutritionists, counselors, physical therapists, educators, care givers and the patient.
These members work together for the common purpose of enhancing the wellness of a particular patient. Case Study Subject The subject patient is a 53 year old obese female presenting with a stage IV pressure ulcer on the sacrum. The ulcer exhibits severe tunneling and purulent foul smelling drainage. History includes left total knee replacement approximately four weeks ago, hypertension, gout, chronic kidney disease, depression, obesity, and coagulopathy secondary to post-operative warfarin therapy. Patient stated she was unable to participate regularly in post-operative physical therapy due to a painful flare-up of gout.
She also states she has not eaten in two days due to nausea and diarrhea from antibiotics. The Nursing Process and Collaborative Care Based on nursing assessment the salient nursing diagnoses for this patient are: 1. “Impaired tissue integrity related to mechanical destruction of tissue secondary to pressure” (Carpenito, 2009, p. 326) as evidenced by deep sacral wound. 2. “Impaired physical mobility related to restrictions” (Carpenito, 2009, p. 326) secondary to pain. 3. “High risk for infection related to exposure of ulcer base to fecal/urinary drainage” (Carpenito, 2009, p. 26). According to NANDA (1990), “a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. ” The focus of care for the nursing diagnosis is activities that a nurse can identify and perform independently of other providers. Collaborative problems encompass a scope beyond the nurse practice to include other practitioners.
According to (Carpenito, 2009, p. 4-5), “collaborative problems are certain physiologic complications that nurses monitor to detect onset or changes of status. Nurses manage collaborative problems using physician-prescribed and nursing- prescribed interventions to minimize the complications. ” In this case study the collaborative problem is the potential complication of sepsis. The nurse is responsible for monitoring the signs and symptoms of sepsis and to “collaboratively intervene to stabilize the client” (Carpenito, 2009, p. 5).
The following signs and symptoms are monitored; vital signs, urine output, blood cultures, white blood cell count, and mental orientation. The nurse also carries out and coordinates physician-prescribed interventions such as; tissue and blood cultures, intravenous antibiotics, wound care, pressure relief systems, debridement, and surgical interventions. Managing the nursing diagnoses and collaborative problem for this patient, involved the following personnel; professional nurses, advanced practice wound care nurses, physical therapists, a nutritionist, and many physician specialists (hospitalist, renal, plastic surgery, and psychiatry.
Even thought this patient is obese, a weighted feeding tube was placed to increase protein intake, and the protein dosages were recommended and monitored by a dietician. Electrolytes were monitored for kidney issues, and complex wound care was provided. The primary nurse monitored the wound every two hours to ensure the wound vacuum system was in place and working properly and drainage was noted. Debridement of the wound and dressing and vacuum changes were performed by an advanced practice wound nurse. Physical therapy worked with the patient twice daily to improve strength, as she was only able to stand briefly at the bedside.
Discharge planning was initiated for either short term placement in a skilled nursing facility or home with the assistance of home health personnel. Counseling or psychiatry should have been included in this patient’s care since she has a history of depression, was taking medication for the condition, and would often cry during the day. The transition of care upon leaving the acute care setting needs to be coordinated to ensure that the needs of the patient will continue to be met after discharge. This transition stage benefits from the involvement of a case manager, who is usually a registered nurse.
According to Firman (1991), “patients are less likely to feel that they are victims of the complex health care system if their care is being coordinated consistently by one person. ” The case manager assists in arranging any type of care the patient will need including transition to a skilled nursing facility, home health needs, mental health needs, and referrals to such agencies as Council on Aging (patient is older than 50), Lake County Outpatient Mental Health Services, Community Dietician, and Respite Care.
In this case, the patient was transferred to short a short term skilled nursing facility for additional wound treatment and physical therapy. There was no attention given to her ongoing needs for counseling or support for her depression. Using Collaborative Care The most common uses for collaborative care are patients with chronic diseases and patients with complex problems in need of care across a continuum of health care settings. Chronic diseases that benefit from the use of the collaborative model of care include type II diabetes mellitus, iseases of the cardiovascular system such as hypertension and heart failure, and renal disease, such as failure or chronic insufficiency. In addition, addictions such as those to illegal substances or alcohol, and mental health issues are ideal for the application of the team approach to care. Evidence clearly shows that the collaborative approach significantly increases the quality of care and patient satisfaction with his or her care.
According to Kearney (2008), “team care is complex because the members must recognize each other’s competencies, determine the division of responsibilities for patient care and adhere to essential communication and documentation protocols. ” Successful collaborative teams exhibit respect and focus for the common patient goals, have clear role assignments, respect and understand each member’s competencies, use effective and frequent communication and are able to resolve conflicts in a timely manner without major disruptions in the flow of care to the patient.
Barriers to successful collaborative team care include any type of breakdown within the team. The most common issues that impact negatively on successful collaboration include disrespect for other members, role boundary conflicts, ineffective communication and power struggles between professions. Conclusion As society ages the number of people with chronic diseases and complex illnesses will continue to increase. The acute care setting is only one stop along the continuum of care for the treatment of these conditions. Collaborative care is an essential part of providing quality care both in and out of acute care settings.
The best collaborative teams have a leader who is usually a nurse, and they remain focused on the common goal of meeting the needs of the patient. In addition frequent communication and documentation are necessary to avoid duplication or fractionalization of care. References Eley, D. , Del Mar, C. , Patterson, E. , Synnott, R. , Baker, P. , & Hegney, D.. (2008). A nurse led model of chronic disease care: An interim report. Australian Family Physician, 37(12), 1030-2. Retrieved August 21, 2009, from ProQuest Health and Medical Complete. (Document ID: 1617588311).
Carpenito-Moyet, Lynda Juall (2009). Nursing care plans & documentation : Nursing diagnoses and collaborative problems (5th ed. ). Philadelphia: Wolters Kluwer Health / Lippincott Williams & Wilkins. Firman, Julie. (1991). Case Management: Quality Care Today. Hospital Materiel Management Quarterly, 12(3), 22. Retrieved August 21, 2009, from ProQuest Health and Medical Complete. (Document ID: 488623). Flynn, A. , & Mangione, T.. (2008, January). Five Steps to a Winning Project Team. Healthcare Executive, 23(1), 54-55. Retrieved August 22, 2009, from ProQuest Health and Medical Complete. Document ID: 1409863201). Kearney, A.. (2008, March). Facilitating interprofessional education and practice. The Canadian Nurse, 104(3), 22-6. Retrieved August 21, 2009, from ProQuest Health and Medical Complete. (Document ID: 1459601381). NANDA Nursing Diagnoses. Philadelphia: North American Nursing Diagnosis Association, 1990. The Collaborative Partnership Approach to Care: A Delicate Balance (rev. reprint). (2006, February). The Canadian Nurse, 102(2), 8. Retrieved August 21, 2009, from ProQuest Health and Medical Complete. (Document ID: 992838421).