Holistic patient-centred care formulated by ‘T’-shaped transdisciplinary nurse and ‘U’ that is referred to as ‘You’, the geriatric surgical patient
The team recognised that achieving exemplary surgical and functional outcome for elderly patients involves not only rehabilitation during early post-operative days but a period of prehabilitation is crucial to optimise their nutritional, functional and physiological state before major surgery. The transdisciplinary nurse works collaboratively with allied health members to visit elderly surgical patients who satisfy criteria for home-based optimisation regime during prehabilitation and rehabilitation phases. She would take on the role as physiotherapist and assist the patients with strengthening exercises to enhance their functional recovery to baseline following major surgery. This nurse also plays the role as dietitian and reviews the oral intake and nutritional status with plans established together with the team’s dietitian. The role as pharmacist is also undertaken by the same nurse during home visits to ensure that the physiological health of the elderly surgical patients is effectively optimised through medication compliance.
Tables 3.1 and 3.2 further illustrate the perioperative role of the nurse in transdisciplinary nursing.
Preoperative role of the nurse in transdisciplinary nursing
Preoperative transdisciplinary nursing
Preoperative assessment to stratify the risks of patient and direct who in the team can optimise for his/her operation
Goals jointly set with patient and communicated to all team members
Pre- and post-operative optimisation plan will be made with considerations above. This is done through effective communication and collaboration with all members of the Geriatric Surgery Service. Means of communication with the patient and family will be established in the planning phase with considerations for cognitive and intellectual status of individual patients as well as limitations from physiological changes related to the ageing process
Educational package will be provided after the surgeon’s consultation for psychological preparation. Personalised prehabilitation plans established with patient and team members during the planning phase as well as measures to prevent post-operative delirium will be reinforced during the education process to allow better patient engagement during the perioperative period
Post-operative role of the nurse in transdisciplinary nursing
Post-operative transdisciplinary nursing
Constant post-operative reviews with focus on the following:
Communication and supervision of junior nurses to manage nursing care and goals that are in line with goals established with the transdisciplinary geriatric surgery members
Clinical assessment of patient between team reviews to detect early signs of perioperative complications
Constant updates on progress and management plans to patient, family and team members. This is to allow mutual understanding for better management of expectations during the course of recovery
Role release and role support among team members to allow for rehabilitative activities to take place from first post-operative day
Reinforcement of preoperative education to improve compliance
Post-discharge follow-up to ensure the well-being of patient is maintained
3.4.1 Case Study
Mdm. Tan S. N. is an 84-year-old lady with a background history of hypertension and hyperlipidaemia. She is widowed with two children and stays with her son who works as lecturer in the university. Family is extremely supportive. She is independent in managing her own activities of daily living and is community ambulant without aid. Mdm. Tan was diagnosed with cancer of the colon. Both patient and family were extensively spoken to by the surgeon together with the nurse specialist on her disease process as well as exploration of treatment goals and options. Benefits and risks of various treatment options were discussed bearing in mind the risk stratification for the patient.
Although her risk profiles were unremarkable, Mdm. Tan was adamant towards refusal for surgical resection of her diseased colon. Ample time was invested to establish the rapport and trust between the nurse and patient before further counselling and reiteration of surgeon’s advice could take place. Mdm. Tan eventually understood that the likelihood of having her independence robbed by the disease process would soon become a reality if surgery was not performed. The rapport established had allowed Mdm. Tan to confide her fears and worries to the trusted nurse which were predominantly loss of independence and being a burden to her family. Educational slides with video testimonies of patients with similar conditions who have had surgeries done were shown to reassure her of the high possibility of a good surgical outcome with collaboration of the transdisciplinary Geriatric Surgery Team. She eventually agreed to undergo surgery after much consideration and support received. Jointly set goals were communicated to all members of the transdisciplinary team to establish a care plan that focused on achieving the goals.
During her early post-operative days, quality nursing care was rendered to compliment the established goals which include closer monitoring and reporting of any deranged parameters, protocol-driven prevention of post-operative delirium, timely administration of oral analgesics for pain free rehabilitation, elimination of disturbances to sleep and proper communication of treatment plans to Mdm. Tan and her family. With support from the family and healthcare team, Mdm. Tan’s active engagement during the perioperative period had allowed her to recover uneventfully from her major surgery. She had returned to her premorbid functional status on the day of discharge which was within a week post-operatively. A few days after her discharge from the hospital, Mdm. Tan noticed there was purulent discharge oozing from her surgical site. She could then receive treatment for the superficial wound infection from a transdisciplinary team member without having to go through the hassle of long waiting hours at the emergency department.
She was extremely appreciative of the effort from the transdisciplinary team for spending much time and patience that changed her mind towards surgery and the holistic care she received throughout her hospitalisation from all members of the healthcare team. She continued to do well functionally and resumed her usual daily activities without many difficulties. Mdm. Tan participates in annual gathering organised by the Geriatric Surgery Service of Alexandra Health (Singapore) for their elderly patients who underwent their surgical journey with them.