Introduction
This paper presents a case study analysis of an acutely ill patient. The patient of focus in the case is a 31 year old male with an acute meniscus tear on the right leg, which sustained during football training session. For the purpose of protecting the privacy and confidentiality of the patient, as provided by the NMC code of conduct (2015), I will refer to him as Mr. R. The patient is married with two children. His family is worried about his pain and inflamed knee joint. Mr. R plays football professionally and is concerned that the injury would affect his career. The meniscus tear occurred due to a sudden twist of the affected leg during the training. Mr. R is overly anxious and wants to know whether he will be able to participate in active football matches following his acute injury. The analysis of the selected case study is based on the argument that delivery of evidence-based care for a meniscal tear will allow Mr. R to return to active sports as soon as possible. The case study analysis includes the pathophysiology of the acute illness, patient history, clinical assessment, related treatments, care plan and interventions, evaluation, recommendations and the role of an assistant practitioner in the care process.
Pathophysiology
Traumatic tears of the meniscus are commonly associated with twisting sports, such as soccer, football, rugby and basketball. It is notable that tennis players, runners and skiers are also at a significant risk of tearing their meniscus (Feucht et al., 2015). Degenerative conditions that cause wear at the knee joint, such as arthritis also heighten the risk of meniscal tears. Acute knee injuries are also associated with aging. Therefore, meniscal tears may occur during normal activities among the elderly (Tekin et al., 2015). Professions that involve lifting and flexion of knee, such as manual labor and construction also increase the risk of a meniscal tear. Brady and Weiss (2015) add that knee instability and previous injury to ligaments at the knee joint contribute to tears of menisci. Notably, high friction sporting turfs in sporting activities, such as soccer and football often contribute to meniscal tears among gamers. Improper landings, falls or slips that usually occur due to bad weather or poor sporting ground also predispose players to the risk of meniscal tears (Brophy, Sandell & Rai, 2017).
The lateral and medial menisci of the knee distribute force and absorb shock between the tibia and the femur. However, when the distribution of force at the knee is compromised due degenerative wear or traumatic injury, joint structure and cartilage receive excessive force, which result in tears of the menisci (Sung-Do et al., 2016). Forkel et al. (2015) indicate that rotational forces acting against a flexed knee are the main causes of meniscal tear. For example, external rotation of the femur when the foot is planted causes a valgus force, which acts on a flexed knee, resulting in a meniscal tear. Internal rotation of the femur when the foot is planted causes a varus force to act on a flexed knee, which also contributes to meniscal tear (Feucht et al., 2015). When the meniscus is torn, the inside of the knee becomes rough, which causes symptoms such as locking, catching, pain and buckling. Tekin et al. (2015) demonstrate that the rough surfaces that characterize a knee with meniscal tear increase the risk of arthritis, especially after return to sports. The periphery of the meniscus has limited penetration of the vascular system or blood supply. Therefore, inadequate vascularization makes it hard for the meniscus and surrounding areas to heal after a meniscal tear (Brady and Weiss, 2015).
History
The medical history of Mr. R indicated that he was diagnosed with stage 2 osteoarthritis six months prior to his meniscal tear. Ohsawa et al. (2016) explain that stage 2 osteoarthritis is regarded as a mild stage of this condition. Radiological tests indicate growth of bone spur in the knee. However, joint cartilage is still health in stage 2 osteoarthritis. Spacing between adjacent bones is usually normal in stage 2 osteoarthritis. This means that bones are not scraping or rubbing against one another (Ungur et al., 2014). In addition, synovial fluid is still sufficient and joint motion is normal in stage 2 of the condition. However, it is during stage 2 osteoarthritis that symptoms of the condition begin to appear. Patients start to experience stiffness and pain after running or long walks as the osteoarthritis progresses to stage 3 (Ohsawa et al., 2016). After the diagnosis of stage 2 osteoarthritis, Mr. R’s doctor recommended non-pharmacological therapies, such as improving the quality of life, low-impact exercises and practicing a healthy diet. Mr. R. was also given anti-inflammatory painkillers or NSAIDs for mild pain relief. The patient was advised against excessive exertion. However, he continued playing professional football. Therefore, his osteoarthritis and exertion during football increased his risk of a meniscal tear.
Patient Assessment
Assessment of Mr. R indicated that his vital signs were as follows: blood pressure 60/90 mm Hg, heart rate 67 beats/min, temperature 37.8 °C and respiratory rate 18 breaths per minute. Therefore, all his vitals were within normal ranges. Mr. Rs vitals specifically demonstrate that his injury neither affect major organs nor caused an infection.
Related Treatments
The initial treatment of Mr. R’s acute injury involved RICE steps or Rest, Ice, Compression and Elevation. The goal of the initial treatment was to relief his pain and to ease inflammation at the knee due to the torn meniscus. The patient was given the anti-inflammatory medication ibuprofen to help relieve his inflammation and pain. After the patient’s pain calmed, an orthopedic surgeon assessed the extent of his meniscal tear and indicated surgical repair. Mr. R underwent partial meniscectomy to repair the torn meniscus. This surgical procedure was indicated for the patient because torn pieces of his meniscus floated to the space in his knee joint, which led to the locking of his knee. Therefore, partial meniscectomy was conducted to remove the torn portion of the meniscus and to make it smooth.
The goal of the surgical intervention was to prevent knee joint degeneration. Therefore, patient care involved pre and post surgical care. He was prepared for his partial meniscectomy during pre-operative care. The care process in the pre-operative stage included stabilizing his knee and educating him. This allowed him to be prepared both physically and psychologically for the partial meniscectomy. After the surgical treatment, Mr. R went through rehabilitative therapy, which involved selected exercises, walking and periods of rest. The rehabilitation was aimed at making the patient’s knee strength to return to normal. It is during rehabilitative care that the patient started to prepare for resuming normal activities.
Patient Care Plan
Assessment
Assessment of a knee injury requires patient care skills, such as focused exam and history taking. It also requires professionalism, which allows for compassionate care and respect for the patient. Assessment is the prerequisite to differential diagnosis. Therefore, practitioners should apply effective communication and interpersonal skills during the patient assessment process. Medical knowledge on anatomy of the lower limb and mechanisms of injury to the knee is another important requirement in assessment of knee injury. A focused medical history was carried out to determine the nature of Mr. R’s pain, including how it occurred, the location of the pain and injury associated events, such as locking and instability of the knee. Steps applied in the assessment of the patient include inspection, palpitation, testing range of motion, strength testing and McMurray test for tears to the meniscus.
Planning
Treatment interventions and short term and long term goals of treatment to acute orthopedic injuries should be carried out by practitioners. In the case of Mr. R, a plan was developed for assessment, education, short and long-term goals, functional outcomes, treatments and equipment and discharge. Specific functional and knee stretching exercises were listed as part of short term treatment goals. A plan for returning the patient’s knee to full strength in the long term was also developed. Clinical knowledge on acute knee injury and treatment options is required for effective planning of care for a patient with a meniscal tear. Planning for patient care is an important aspect of professional practice in orthopedics. This is because the patient care plan acts as a reference point for the implementation of appropriate, evidence-based and patient-centered care interventions to promote positive health outcomes (Feucht et al., 2015).
Implementation
Both non-surgical and surgical treatments were implemented in the management of Mr. R’s meniscal tear. The specific treatment interventions implemented for the patient are described in the related treatments section above. Knowledge and skills related to surgical repair of menisci, such as ACL reconstruction were a requirement for the care of Mr. R. During the rehabilitation stage, knowledge and skills on physical therapy are required for effective care of a patient with acute knee injury. Note taking skills were also vital in making progress notes during the care and rehabilitative treatment of Mr. R. Progress notes indicated how the patient responded to the treatment and achievement of short and long-term treatment goals.
Evaluation of Care
Patient care outcomes should be evaluated to ensure that the care plan goals are achieved. Mr. R’s symptoms were evaluated to determine the effectiveness of treatment interventions in reducing his pain, inflammation and the mobility and strength of his knee. It was determined that the patient’s treatment goals were achieved. However, the long term outcomes of the underlying stage 2 osteoarthritis were not yet determined at the end of the care process. Notably, the risk of acute injuries to Mr. R’s joints in future was not eliminated since his osteoarthritis would progress to stage 3.
Interventions
The pharmacological interventions reduced Mr. R’s pain and inflammation. Barratt (2010) explains that ibuprofen acts by inhibiting cyclooxygenase, an enzyme that mediates the production of prostaglandins. Since prostaglandins is a mediator of sensations, such as inflammation, pain and fever, inhibition of its production causes relief of these symptoms. Partial meniscectomy contributed to relief of swelling and pain at the patient’s knee and allowed him to start the process of healing. Rai et al. (2016) demonstrate that partial meniscectomy is recommended if torn pieces of meniscus cause swelling, pain and inflammation.
Evaluation
Mr. R’s condition got much better after the implementation of surgical and pharmacological interventions. The angles of knee joint flexion and extension increased gradually as the patient was healing. In addition, the patient was able to do moderate functional and stretching exercises 1 week after the treatment interventions were initiated. This indicated that his knee joint was returning to full strength and function. The patient also reported that his pain had gone and he was working participating in his rehabilitative physical therapy sessions.
Recommendations
Mr. R should work collaboratively with his physical therapist to help him return to his normal activities as quickly as possible. Working with the physical therapist will enable the patient to learn not to favor the healing leg during walking and improve the strength and functioning of his knee. Since Mr. R’s profession is physically demanding, he will need to take time to heal. Returning to active football before his knee has fully healed would cause more problems, especially since he is also under medication for stage 2 osteoarthritis (Roll, Darragh, Campo & King, 2012). Therefore, his rehabilitative treatment should be extensive and aimed at restoring the flexibility, endurance, coordination and strength of the knee. Mr. R should also work closely with his surgeon so that he can be able to determine when it is appropriate or safe to resume his sporting activities.
Role of Assistant Practitioner
As an assistant practitioner, I play important roles meant to address the needs of my patients from the point of admission through discharge to making follow-ups. I am responsible for ensuring that a comprehensive medical history is obtained (Pawlak, 2013). In playing this role, I ensure that adequate and relevant information is obtained from the patient to aid the determination of the nature of his condition and its severity. In the case of Mr. R, I participated in getting background information pertaining to his acute injury. I played the role of determining the how, where, when and what happened to his knee. Through my observation of the RN, I learned how to get a comprehensive description of the pain from the patient. I also learned on how to inquire about the kind of medications the patient was taking at the time to help in determining underlying conditions and possible pharmacological contraindications (Selby, 2010). The RN specially asked the patient if he has any allergies to ensure that he was given the right medications.
An assistant practitioner also plays the role of documenting patient history and all care interventions. I recorded all pertinent background information given by the patient to aid in the diagnosis of his acute injury (Bassett, Korsh, Swan & Korsch, 2017). For example, I inquired and recorded the patient’s account of severity and type of his pain. I also determined that the patient’s pain was aggravated by movement of the knee. As an assistant practitioner, I was also responsible for collecting and recording physical findings pertaining to the patient’s acute illness (Tekin et al., 2016). I observed the inspection of the patient’s knee by the RN, which was aimed at assessing the nature of his pain, disability and injury due to his acute injury. I specifically observed the patient’s posture and gait, swelling and skin condition and made relevant notes to aid the diagnosis of his meniscal tear.
I understand that an assistant practitioner is responsible for providing professional opinion on the kind of acute illness or injury affecting patients (Minyoung et al., 2016). Therefore, I learned by both objective and subjective exams by the RN and considered the anatomical location, description and severity of the injury to conclude that Mr. R had a meniscal tear. Assistant practitioners are also responsible for developing a comprehensive plan for the care of patients (Schmidt-Rohlfing et al., 2011). On the basis of this understanding, I learned from the RN how to plan for the treatment interventions that Mr. R would receive prior to his partial meniscectomy. I worked with the RN to ensure that the patient had crutches to aid his movement. I also learned from the RN how to develop a patient assessment and education plan. I gained insight on considerations to put in mind in educating the patient, such as severity of the illness and concerns related to recovery. Assistant practitioners are also responsible for developing both short and long-term goals of care (Minyoung et al., 2016). I contributed my knowledge in orthopedics in the development of the goals the treatment of Mr. R would achieve in the short term and long term. This included goals for increasing the mobility and strength of his knee and promoting positive outcomes out of rehabilitative interventions.
Assistant practitioners are obliged to monitor the progress of patients and their response to treatments (DeJong et al., 2016). This understanding allowed me to monitor Mr. R’s response to both pharmacological and surgical interventions. I noted that his pain had decreased and that he was positive about the prescribed rehabilitative care. I also understand that assistant practitioners must monitor the compliance of patients to medications or treatment interventions (Schmidt-Rohlfing et al., 2011). Therefore, I encouraged the patient to comply with prescribed treatments so that he would speed up the healing process. I also addressed the concerns of the patient pertaining to the side effects of his medications. DeJong et al. (2016) explain that assistant practitioners promote compliance to treatment interventions by supporting patients through education and counseling. I played the role of educating and counseling the patient on the importance of adhering to his physical therapy and rehabilitative care. For instance, I encouraged the patient to work closely with his physical therapist, nurse and surgeon to ensure that the long term goals of his treatment are effectively achieved. Minyoung et al. (2016) demonstrate that holistic and evidence-based care in orthopedics involves the implementation of a comprehensive care plan that entails patient education, pharmacological education, relevant medical procedures and rehabilitation. I am convinced that Mr. R received holistic and evidence-based care.
Conclusion
The discussion of the care of Mr. P demonstrates that evidence-based care for a meniscal tear facilitates healing and allows patients to resume normal activities as soon as possible. From the case study it is notable that the assessment of patients for acute injury to the knee requires practitioners to have focused exam and history taking, interpersonal and communication skills. Medical knowledge on anatomy of the lower limb and mechanisms of injury to the knee is another important requirement in assessment of knee injury. The planning of care is important as it allows for the determination of treatment as well as short term and long term goals of care. For a meniscal tear, functional and knee stretching exercises are part of short term treatment goals. Long term goals include returning the patient’s knee to full strength. The implementation of care is an important stage in the treatment of meniscal tear as it allows for the delivery of appropriate therapeutic interventions, such as pharmacological treatments and surgical procedures.
The case study analysis indicates that the implementation of treatment interventions allows patients with meniscal tear to start healing through a rehabilitative program. During the rehabilitation stage, knowledge and skills on physical therapy are required for effective care of a patient with acute knee injury. The care process must also be evaluated to ensure that the goals of care are achieved. From the case study, it is notable that Mr. R’s symptoms were evaluated to determine the effectiveness of treatment interventions in reducing his pain, inflammation and the mobility and strength of his knee. Assistant practitioners play important roles throughout the process of patient care. in the case of meniscal tear, assistant practitioners are responsible for taking comprehensive medical history from the patient, observing and inspecting the injury for severity, documenting the care process, educating the patient and participating actively in the implementation of care interventions.
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