Holistic Care Needs- A Case Study Report

Introduction

The concept of holistic care can be defined in various contexts; however, to gain a

comprehensive understanding of the term, Jasemi et al. (2017) proposed viewing Holistic care as

the provision of care to patients which is based on a mutual understanding of their physical,

emotional, psychological and spiritual dimensions. They also state that there needs to be an

emphasis in the partnership between healthcare professionals and the patient which will

eventually lead to recovery. Craik (2020), shows that in ancient Greek medicine, many

hippocratic authors had a view of the human organism as complete somatic and mental unity,

inferring that treatment of an individual is not purely medical. Nightingale further expounded on

this concept by understanding the inseparability of a person’s health and the environment, as

shown in Thornton, (2019)

Operative procedures cannot be simply viewed as approaches to fixing what is wrong with a

person or treating different ailments as cases to be solved. According to Wong et al. (2022), there

needs to be an understanding of the whole person; with physical, cultural and social context as

well as differences in safety and wellbeing taken into consideration. Building relationships with

the patients by taking time to actively listen, express care and empathy while also incorporating

personalised care for the patient. Involving family members, respecting their values, etc(Hsu et

al., 2019). As an operative department practitioner, it is my responsibility to adopt a holistic

approach during the perioperative period, providing safe and effective care to patients, working

towards preventing physical, emotional, and psychological complications of surgery, and helping
patients and their caregivers, including family, to return to a sense of normalcy as soon as

possible.

In this paper, we will identify the holistic care needs of the case study patient while reviewing

the assessment of the care required, the planning of the care, its implementation, and the

evaluation of the process as a whole. We will pay attention to each of these steps in the

pre-operative, intraoperative, and post-operative stages. We will also assess how care planning

and communication contributed to improved safety for the patient and an overall better

experience in the perioperative setting. All the while including personalised contributions to

these goals as an operating department practitioner.

Patient Brief

The patient was a 58-year-old female with a nine year history of type 2 diabetes mellitus as well

as a previous stage one hypertension diagnosis. Her current treatment included the use of

metformin and dietary monitoring. With discontinued hypertensive treatment as her current

blood pressure readings were within normal ranges. She has been undergoing chemotherapy for

the past two years for bladder cancer. Recently, she decided to undergo a transurethral resection

of the bladder tumour (TURBT) procedure to remove the superficial aspect of the cancer as there

was no evidence of the cancer invading the muscular layer.

Presentation

On arrival at the hospital for the TURBT procedure, she was frail with a BMI of 16.9 and

complaints of hematuria, dysuria and pollakiuria. This procedure was to serve as a form of

treatment for the cancer. With removal of the superficial aspect in view. There was no evidence

as of the point of her arrival to the invasion of the cancer into the muscular layer.
Upon entering into discussions with the patient, she voiced her anxiety about the procedure as

she believed it brought a factor of uncertainty into her future. Her husband had died as of 5 years

ago in a car accident and she lived with her one daughter at that moment. She informed us of her

fear of leaving her daughter behind if the procedure did not work out for her. While there is no

current prognosis of death in the future as a result of the cancer, she believes that the cancer may

continue to progress and eventually become terminal for her. Which is in line with her diagnosis

of clinical anxiety which I noted when I saw her medical records. I was also mindful of the

prescription of alprazolam for her clinical anxiety.

Assessment and Implementation of Holistic Care Needs

The first step included the creation of a care plan catered towards the perioperative process. As

perioperative care deals with several professionals across different disciplines and variable

timeframes, Elsevier (date unknown) infers that it is necessary that a proper care plan is

introduced so as to plug in whatever gaps may result from negligence or other factors. This

prevents treatment inconsistencies, redundancies and even clinical errors. It also provides a

proper template for the strategies to be employed in order to resolve the needs identified as part

of the assessment in line with Ajibade (2021). As a result, a proper care plan was implemented

with this patient so as to serve as a guide for the different medical professionals involved in her

Healthcare. I personally contributed to the outline of her care plan as well as championing the

effort for the collection of her informed consent. I ensured I explained all the aspects of the

surgical procedure. This is of importance because Raveesh, Nayak and Kumbar (2016), express

the view that a well-publicised malpractice suit can ruin a healthcare practitioner's career and

practice. And they infer that the best way to handle any medico-legal issues is to prevent them
from happening in the first place. As such, she was duly informed about all the risks and

complications that could reasonably occur during the procedure before she gave her consent.

In line with the patient’s history, signs of preoperative anxiety were noted. Oteri (2020) writes in

the Neurosurgical Review journal that Preoperative anxiety is a common reaction which up to

80% of patients who are scheduled for surgical procedures exhibit and this is characterised by

physical and psychological changes which may affect their perioperative period. A

cross-sectional study on preoperative anxiety in adults by Eberhart et al., (2020) indicates that

the female gender has the strongest impact on APAIS anxiety subscales. The gender of which our

patient is. Part of the relevance of the anxiety is that patients with a high level of preoperative

anxiety will require higher doses of anaesthetic agents and analgesic drugs as noted by Mulugeta

et al. (2018). In line with this, I ensured I adopted some non-pharmacological approaches to her

anxiety. Such as the provision of soothing music, aromatherapy as well as the preoperative

preparation videos in line with Wang et al. (2022). In order to properly manage anxiety,

physician-patient communication was one of the approaches necessary to solicit trust and as a

result mitigate a measure of anxiety (Ramamohan et al., 2018). Different members of the

perioperative team found ways to support the patient in their own right. I also ensured the plans

put in place for the presence of a female support worker in the anaesthetic room throughout the

procedure of anaesthesia were followed. This support worker offered to hold her hands while the

patient was being put to sleep. She also offered calming words and engaged in soothing

discourse with the patient in an attempt to minimise her anxiety. After the procedure, when she

was extubated I personally escorted her to the recovery room. When she regained consciousness,

I asked her how she was feeling before informing her that the surgery was all done and
everything went well. On hearing this, she was very relieved. I shared some positive thoughts

with her which she sincerely appreciated.

Plans were put in place to handle the diabetic and hypertensive conditions of the patient. In line

with standard procedure as shown in Gopal et al. (2020), there was a clinical lead in charge of

her diabetic management. I liaised with the clinical lead and we provided her with information

and education concerning her diabetic management during admission, during recovery as well as

as after discharge. I informed the patient that she would be expected to continue with

self-management as soon as possible. Some of the factors that I took into consideration as

regarding her care preoperatively were the starvation time before anaesthesia, blood glucose

monitoring, positioning of the patient at a surgery time earlier in the day, as well as the use of a

proper medication administration chart. While in the theatre, proper management of blood

glucose levels as well as electrolytes were taken into consideration. All this in line with standard

procedure cited above. The WHO safety checklist was used by the operating team in line with

research by Ambulkar et al., (2018), while including the previously agreed care plan for the

patient. Postoperatively, avoidance of iatrogenic error in line with diabetic management was

applied in addition to the monitoring of glucose levels, electrolytes and fluid balance. I also

inspected her feet and pressure areas. A date and time for discharge was also set as soon as

conclusions were made in regards to clinical criteria fulfilled by the patient before discharge,

which I relayed to the patient. Proper optimisation of cardiovascular and renal functions during

the operation amongst other guidelines was observed (Dhatariya et al., 2016).

In consideration of the patient's hypertensive history, appropriate precautions and a standardised

approach were adopted. This was of particular significance given that elevated blood pressure

can have detrimental effects on the operative process. In accordance with nationally stipulated
guidelines for hypertension management, we implemented the appropriate measures before,

during, and after the operation. The current guidelines permit the surgical process to proceed for

patients with Stage 1 and Stage 2 hypertension (BrJCardiol, 2017), the category under which our

patient's medical history fell. However, on the day before and immediately prior to the surgery, I

measured the blood pressure of the patient. The patient's highest blood pressure readings were

recorded at 135/85mmHg. As these readings, as well as those from the past 12 months, did not

exceed 160/100mmHg, the patient was cleared by her general practitioner for surgery. Her blood

pressure also indicated that she could be managed by secondary care and the preoperative

assessment clinic to which I submitted her records. For the surgical procedure, we planned to

administer general anaesthesia to the patient, as there were no contraindications, and spinal

anaesthesia may have resulted in postdural puncture backache for the patient after surgery

according to Lee, Yoon and Heo (2020). I aided the anaesthesia team by preparing all the

necessary specialist equipment.

Without proper padding as stated by Garrubba & Joseph (2016), there was a risk of developing

pressure sores not only during the admission but also on the operating table. To mitigate this, I

prepare gel pads for use on the surgical table to prevent pressure sores around the wrists. I also

prepared gamgee pads to use around her legs to prevent pressure sores from developing.

Moreover, I put in the request forms for higher-specification mattresses for the patient during her

stay in the ward before and after the procedure (McInnes et al., 2015). Dietary planning was

recommended by the physician to which I made research and prepared a plan for review in line

with Asif (2014), and the notes were sent to the GP to be implemented to ensure that the patient

returned to a normal body mass index.

A comprehensive debriefing was conducted with the patient to inform her of all possible

outcomes and effects of the surgery, including those associated with the pre-, intra-, and

post-operative periods. This process began several weeks prior to the procedure, with important

points being reiterated at various times. I was tasked with answering any questions as well as

provision of information within my capacity. While the patient's surgeon and her GP doctor also

engaged in extensive conversations with her, keeping her informed and involved throughout. Her

daughter was also fully informed with the patient's consent and educated regarding the procedure

and all its ramifications with regular updates, while envisaging an improvement in satisfaction

and reduction of anxiety following the publication of Howe et al (2021). As well as information

useful for her full recovery after discharge from the hospital. This included all medications to be

used, the dietary plan to get her to normal BMI as well as information on follow-up

appointments. The daughter was also present for some of the previous meetings with the GP.

Upon my inquiry, I discovered the patient was a practising christian anglican. My research did

not find any stipulations in her faith which frowned upon any surgical procedures. While I

informed her she could be offered religious counselling, she declined the presence of any man of

the faith before the procedure. I raised this point as some members of certain religions or sects

have special requirements regarding surgery and perioperative practices (Trzciński et al., 2015).

Some also prefer to have prayers or rituals performed before their operation proceeds. In her case

she carried out her own personal, quiet prayers. I encouraged her to leave the situation in God’s

hands inferring that he would make the procedure a success and she seemed relieved after the

interaction.

In regards to her prescription, I cross checked for the absence of any possible negative

interactions with some of the drugs used for anaesthesia: notably Metformin, alprazolam and
chemotherapy drugs. None were indicated to have negative interactions with drugs used for

general anaesthesia. According to her case files and questioning of the patient; I could not find

any history of allergic reactions to any drugs, food, etc.

Small & Laycock (2020) report that nearly 20% of patients experience severe pain in the first 24

hours after surgery. As a result, plans were put in play to monitor and handle pain throughout the

process. Perioperatively, I asked the patient from time to time her degree of pain most especially

after the procedure was completed. After the procedure she was a bit disoriented upon waking up

but not long after she regained full consciousness. I spoke with her as to her pain levels and she

responded coherently, with enough information. Some of the pain management approaches listed

in the above article were implemented by myself and other members of the team. She went on to

speak to the surgeon who went ahead to administer a suitable prescription to deal with the level

of pain she was experiencing after the procedure and was informed that the surgeon would send

details of the follow up plan post surgery.

Evaluation of the process

In line with the essence of holistic care, there is a discussion called Holistic needs assessment.

This covers the physical, psychological, spiritual and social needs of the patient (Hull University

Teaching Hospitals NHS Trust, 2016). Some weeks after the procedure I conducted this

discussion with the patient and made enquiries to ensure that the needs of the patient were met in

every aspect. She was very happy with the procedure as a whole, especially with some of the

lengths we went to mitigate her anxiety.

As regarding different aspects of her needs, I personally ensure I followed preset guidelines and

employed extra effort in different aspects to provide a satisfactory healthcare experience.

Review of how care planning and communication enhanced safety as well as

resulted in a better experience.

Sentinel events in medicine are often caused by communication breakdowns and inadequate

planning, resulting in increased patient morbidity and mortality (Garrett, 2016). Effective

communication is essential for ensuring patient safety in any healthcare program. In

perioperative settings, clear, standardised, complete, and timely communication enabled all

members of the healthcare team to effectively manage their responsibilities and individual roles,

despite their different disciplines. By embracing a culture of safety through planning and

effective communication with patients, we improved both patient experience and caregiving

processes. I also had clarity as to my roles and responsibilities to fulfil.

Recent studies have shown that the presence of clinician-patient communication and provision of

information to patients significantly increase perioperative patient satisfaction (Trinh, Fortier and

Kain, 2019). In our caregiving process, I and other members of the team adopted these

modifiable factors resulting in a holistic perioperative process that led to great patient

satisfaction.

Multicomponent intervention is necessary to achieve the ultimate goal of quality perioperative

care, integrating primary, secondary, and social care for patients from the point of conception of

the surgical idea to full recovery. These interventions include shared decision-making, risk

assessment, preoperative and post-operative care, psychological and physiological status,

lifestyle modifications, syndromes, and rehabilitation (Centre for Perioperative Care, 2021).

Proper planning and communication with the patient and their family, as well as between
members of the hospital team involved in the procedure, are necessary to achieve these

outcomes.

In conclusion, the adoption of proper planning and effective communication has been shown to

enhance safety, improve patient experience, and result in better caregiving processes in

perioperative settings. It is essential to embrace a culture of safety through planning and effective

communication to achieve the ultimate goal of quality perioperative care personally as an ODP

or as a member of the larger collective team.

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