CNA803 Advanced Clinical Nursing Practice Assessment Answer

Introduction

Adult patients often benefit from orthopaedic surgery, which treats musculoskeletal ailments and accidents. Surgical procedures frequently include inherent dangers and difficulties despite the fact that they can reduce pain, restore mobility, and generally improve quality of life (Rhon and Tucker 2022). Healthcare experts are focusing on "prehabilitation," a proactive strategy, to improve surgical results and postoperative recovery.Prehabilitation, also known as preoperative rehabilitation or preoperative conditioning, entails focused preoperative therapies to get patients psychologically and physically ready for the operation. Prehabilitation is a paradigm change in orthopaedic care that acknowledges that preoperative factors might affect patient outcomes in addition to surgical technique and after care (Durrand et al. 2016). Its main objective is to improve patients' physical health, functional ability, psychological well-being, and general health status. This can result in a quicker recovery from surgery, fewer complications, and better long-term results. Prehabilitation has the potential to improve patients' functional capacity and physical fitness prior to surgery, which is one of its key benefits. Patients can enhance their physical strength, endurance, range of motion, and cardiovascular health by performing focused workouts, strength training, and cardiovascular conditioning. Anxiety, worry, and stress are common side effects after surgery, and these emotions can impede healing and raise the possibility of complications afterward. Prehabilitation programmes frequently involve training, therapy, and psychological aid to assist patients in overcoming these emotional difficulties (Molenaar et al. 2019). This literature review will focus on methods, inclusion and exclusion criteria along with discussion which will include different themes.

Background

Orthopaedic surgery has developed significantly over the years, moving from simple operations to sophisticated surgical treatments that treat a variety of musculoskeletal injuries and illnesses. Despite the fact that reducing pain, restoring function, and boosting postoperative recovery have always been the main objectives of orthopaedic surgery, this focus has shifted more and more in recent years (El-Tallawy et al. 2021). Preoperative planning has received less attention in orthopaedic care historically than the surgical procedure itself. Studies have however shown that a number of preoperative variables, including patient physical health, functional ability, and psychological health, can have a considerable impact on surgery outcomes. As a result of this insight, the idea of prehabilitation emerged to be a proactive strategy designed to enhance patients' general health and maximise the advantages of the surgical procedure as a means of preparing patients for surgery (Henry et al. 2020).

Prehabilitation was first investigated in the context of cardiac and pulmonary rehabilitation, but its concepts were gradually applied to orthopaedic surgery, realising the potential advantages of preoperative conditioning for musculoskeletal patients. The term "prehabilitation" first acquired popularity in the latter half of the 20th century and has since come to be recognised as a crucial element of all-encompassing orthopaedic therapy (Weston et al. 2016). Prehabilitation has drawn a lot of attention recently as a viable method to enhance patient outcomes and surgical outcomes.Finding the best prehabilitation therapies, assessing their effects on various surgical populations, and examining their mechanisms of action have been the main goals of research studies and clinical trials (Gurlit and Gogol 2019). Orthopaedic surgeons, anesthesiologists, physical therapists, psychologists, dietitians, and other healthcare professionals frequently collaborate in prehabilitation programmes using a multidisciplinary approach. These partnerships provide a thorough evaluation of patients' physical and mental health, enabling the creation of customised preoperative programmes that cater to specific requirements and objectives (Briguglio et al. 2022).

Prehabilitation use has increased as a result of improvements in our knowledge of the physiological and psychological impacts of surgery and the growing emphasis of patient-centred treatment (Northgraves et al. 2020). The efficiency of prehabilitation therapies for different orthopaedic surgical procedures, such as joint replacement, spine surgery, and fracture repair, is a topic of growing academic and scholarly interest. The purpose of these studies is to assess how prehabilitation affects patient satisfaction, functional results, surgical complications, and hospital length of stay (Shakya and Poudel 2022). It is crucial to critically evaluate the available data, identify knowledge gaps, and create standardised procedures to direct the implementation of prehabilitation programmes in clinical practice given the increased interest in prehabilitation and its potential advantages (van der Velde et al. 2023).

Methods

Search Strategy

In order to review available literature an online search was conducted. Research databases searched included cumulative index to nursing and allied health literature (CINAHL) Complete, MEDLINE Complete, Google Scholar and PubMed through the University of Tasmania library mega search of library databases. The key search terms applied included ‘compression stockings, ‘DVT, ‘Post operative’ and ‘older patients’. Prehabilitation, preoperative rehabilitation, orthopaedic surgery, surgical outcomes, DVT, medication management are a few search terms that may be relevant to this subject. In addition, corresponding Medical Subject Headings (MeSH) and Booleans searches were conducted using ‘AND’ and ‘OR’, alongside key search terms to allow for alternative terms and/or spelling. Advanced search settings were implemented to include articles with a publication date range from 2016 – present due to the continuous release of newly manufactured dressings and evolving research. Furthermore, articles were only considered for selection if presented in English, from peer-reviewed journals, in full-text, involved an adult population and contained adequate discussion relevant to the stated Population Intervention Control Outcome (PICO) question. See appendix #1.

Inclusion and Exclusion Criteria

The goal of the study on the positive and negative effect of prehabilitation for adult orthopaedic surgical patients is to present a thorough and current examination of the advantages and disadvantages of this strategy. The peer-reviewed studies released within the last five years have been considere in order to assure the study's objectivity and validity. Only English-language articles that were published in peer-reviewed journals were chosen in order to ensure consistency and accessibility. The researchers want to capture the most recent developments and findings in the field of prehabilitation for patients undergoing orthopaedic surgery, hence they have focused on recent peer-reviewed publications. This strategy aids in ensuring that the study's conclusions are supported by the most recent data and industry standards.

Additionally improving the study's credibility is the elimination of articles that were not peer-reviewed. Prior to a study's publication, it is critically important to have it peer reviewed by experts in the field who evaluate its quality, methodology, and validity. The study seeks to reach a wider audience of researchers, practitioners, and policymakers globally by concentrating on articles written and published in English. The study's findings are more useful and pertinent to the international scientific community because English is a language that is frequently used in scientific communication and that many reputable journals use to publish articles in.

Quality Appraisal

Based on the Joanna Briggs Institute Levels of Evidence for Effectiveness the quality of the paper by Nguyen et al. 2022 is appropriate. The study conducted was RCT which is one of the strongest forms of proof for effectiveness in clinical research. The study design includes a detailed explanation of the randomization processes, allocation concealment techniques, and blinding methods. Prior to total knee replacement (TKR) for knee osteoarthritis, the participants were most likely randomly assigned to the prehabilitation group or the standard care group. The paper has a sufficient sample size to identify important effects.The paper discusses both primary and secondary outcome measurements pertaining to postoperative healing, patient satisfaction, and functional results. These outcome metrics ought to be clearly stated and pertinent to the study's question.To ensure the validity of the conclusions, the publication has detailed the statistical techniques used for data analysis, such as intention-to-treat analysis and treatment of missing data. The result and interpretation includes effect sizes, confidence and intervals.

Results

Literature selected included a systematic review, randomised control trials (RCTs) comparative studies, retrospective comparative studies and . A total of 22 articles were selected for use within this literature review providing insight at multiple evidence layers, both from primary and secondary sources at levels I-IV. Two studies incorporated a literature review within the discussion, while others were from lower levels of the Evidence Hierarchy.

Discussion

Theme 1: Improved Physical Fitness and Functional Capacity

Prior to having orthopaedic surgery, prehabilitation therapies have repeatedly shown to improve patients' physical health and functional capacity. Following prehabilitation programmes, numerous studies have shown a considerable increase in muscle strength, endurance, range of motion, and cardiovascular fitness. These advancements help to enhance surgical outcomes because more physically fit patients are more likely to withstand the physiological strains of surgery and recover more quickly. Additionally, improved functional capacity enables patients to reclaim their independence and resume daily activities earlier, thus increasing their quality of life postoperatively (Punnoose et al. 2023).

The study conducted by Briguglio and Wainwright. 2022 explains why nutritional and physical prehabilitation are necessary. Malnutrition and physical deconditioning can affect surgical outcomes, thus addressing them before surgery may be beneficial. They emphasise individualised prehabilitation programmes that include patients' nutritional demands and physical ability. Briguglio and Wainwright. 2022 propose including nutritional and physical prehabilitation into elective orthopaedic surgery. Prehabilitation therapies include nutritional assessment and intervention, exercise programmes, and patient education.The authors offer solutions and discuss prehabilitation's potential to reduce surgical complications, improve functional results, and boost patient satisfaction.

Hip or knee arthroplasty is a frequent operation for older people with joint degeneration or arthritis to increase mobility and decrease discomfort. Prehabilitation may reduce postoperative complications, hospital stays, and patient satisfaction. 10 systematic reviews were included and the authors also stress the need of individualised prehabilitation programmes to meet older individuals' health and functional needs.The article discusses how prehabilitation for older persons may improve surgical outcomes and patient satisfaction (Almeida et al. 2022).

Theme 2: Reduction in Postoperative Complications

Prehabilitation therapies may reduce the incidence of surgical site infections, deep vein thrombosis, and pulmonary problems by improving patients' health and physical condition prior to surgery. Prehabilitation programmes that educate participants on self-care, nutrition, and quitting smoking can also help patients heal from wounds more quickly, avoid unnecessary hospital readmissions, and have better surgical outcomes overall. However, more investigation is required to pinpoint the precise mechanisms by which prehabilitation lessens postoperative problems and to pinpoint the best interventional approaches for various patient demographics (Chmelo et al. 2021).

McIsaac et al. 2022 intend to review the evidence and evaluate prehabilitation therapies across surgical specialties. The author synthesises the findings from chosen systematic reviews on postoperative complications, hospital stay, functional outcomes, and patient satisfaction. They also examine exercise, dietary support, and psychological prehabilitation therapies from systematic studies. The umbrella review evaluates prehabilitation in adult surgery patients. The authors evaluate the systematic reviews' quality and evidence for various outcomes. They also identify literature gaps and limitations, emphasising the necessity for high-quality studies to prove prehabilitation therapies work in specific surgical populations.

Theme 3: Prehabilitation Before Surgery

The study conducted by West et al. 2021 focusing on the development of prehabilitation as a proactive strategy to improve surgical outcomes. They emphasise the value of risk stratification and patient selection in determining who will most benefit from prehabilitation therapy. The article stresses the importance of individualised prehabilitation plans designed to meet patients' unique needs while taking into account aspects including age, comorbidities, and the type of surgical operation.The authors also look at the data demonstrating the advantages of prehabilitation, such as gains in physical fitness, functional capacity, and psychological well being.

Another study conducted by Widmer et al, 2022, demonstrating the value of total hip angioplasty (THA) as a routinely carried out surgical surgery to reduce pain and enhance functionality in patients with hip joint problems. Two-third of the patients were 65 years old. This systematic review included only 14 articles out of 400. They place emphasis on the advantages of prehabilitation in enhancing patients' physical and mental health prior to THA, which may improve postoperative results. The authors' systematic review includes research that looked into prehabilitation therapies in THA patients. The review includes either educational treatments, preoperative exercise programmes, or both. In order to determine the efficacy of prehabilitation therapies, the authors evaluate a variety of outcomes, including pain, function, range of motion, quality of life, and comorbidities.

Theme 4: Enhanced Psychological Well-being and Patient Satisfaction

Interventions during prehabilitation have a positive effect on patients' psychological health and overall satisfaction with the surgical process. Prehabilitation plans that include psychological assistance, counselling, and education can lessen these emotional loads, boost patient self-assurance, and encourage a positive outlook. Prehabilitation participants frequently report less preoperative anxiety, more readiness, and higher levels of satisfaction with the surgical procedure (Levett and Grimmett 2019). The ability of patients to deal with the difficulties of surgery and to recuperate and recover more quickly depend greatly on their psychological health.

The necessity of managing older patients' surgery-related issues. Older people often have unique comorbidities, diminished physical fitness, and a higher risk of surgical complications. Prehabilitation programmes for this population optimise health and function to improve surgical outcomes and prevent adverse effects. In this paper 205 of the patients were 70 and above. The paper discusses multimodal prehabilitation programmes for older surgery patients. These may include exercise, nutrition, psychological support, and education. The authors evaluate the evidence supporting each of these components and their potential benefits in preparing older patients for surgery (Borrell-Vega et al. 2019).

Theme 5: Multimodal Prehabilitation

Almeida et al. 2020 synthesise systematic reviews to examine the effects of prehabilitation in older persons having total joint replacement (TJR). Prehabilitation may reduce postoperative complications, hospital stays, and patient satisfaction. The authors also stress the need of individualised prehabilitation programmes to meet older individuals' health and functional needs. The article discusses how prehabilitation for older persons may improve surgical outcomes and patient satisfaction. The authors go over the many prehabilitation strategies included by the systematic reviews, including assistance for healthy eating, education, and exercise regimens. They emphasise the data confirming these therapies' efficacy in raising older individuals' functional ability, quality of life, and physical fitness as they get ready for TJR.

Theme 6: Limitations and Considerations

Prehabilitation therapies have limitations and other factors that need to be considered despite the excellent outcomes that have been seen. First, the implementation of prehabilitation programmes may face difficulties due to a lack of resources, including financial resources, qualified employees, and suitable facilities. Comprehensive prehabilitation services may not be available to all patients or healthcare systems. Furthermore, the timing and length of prehabilitation interventions need to be carefully evaluated because long waiting times for surgery can have an adverse effect on patients' general health and may not be practical in circumstances of urgent surgery (Tew et al. 2020). Additionally, prehabilitation procedures might not be appropriate or beneficial for many individuals, especially those with serious comorbidities or complicated medical problems.

Recommendations

The successful execution of prehabilitation programmes for adult orthopaedic surgery patients depends heavily on nursing. Working closely with the surgical team to assess patients' physical health, functional ability, and psychological well-being, nurses should actively take part in the process of determining whether patients are qualified for prehabilitation. Nurses can help create individualised prehabilitation plans that take into account each patient's particular needs, comorbidities, and surgical procedure by working with other healthcare experts. Nursing care in prehabilitation must include patient education and support. Nurses can inform patients about the advantages of prehabilitation and the particular interventions involved. In order to measure the success of therapies, nurses should regularly examine patients' physical fitness, functional capacity, and psychological well-being as they proceed through the prehabilitation phase. In order to provide complete care and get the best patient outcomes, orthopaedic surgeons, physical therapists, psychologists, and other healthcare professionals must work together interdisciplinary.

Gaps and Limitation

Prehabilitation has shown encouraging effects in adult orthopaedic surgery patients, however there are still certain gaps in the study literature that need to be filled. There is a dearth of standardised prehabilitation procedures for various orthopaedic surgeries and patient populations, prompting additional research to determine the most efficient mix of therapies. Additionally, there is a lack of long-term follow-up information on the benefits of prehabilitation, necessitating long-term studies to evaluate patient satisfaction, functional results, and postoperative recovery. To comprehend the financial impact of establishing prehabilitation programmes and their potential to lower postoperative problems and hospital stays, it is also important to examine cost-effectiveness. Additionally, research is required to examine the advantages and difficulties of prehabilitation in a variety of patient demographics, including older adults and those with comorbid conditions. Studies comparing various prehabilitation strategies, such as exercise-based programmes, dietary therapies, and psychological support, might direct the creation of evidence-based prehabilitation regimens. To encourage broad acceptance and improve prehabilitation practises, it is also crucial to comprehend the challenges and enablers of prehabilitation implementation in actual clinical settings.

Conclusion

Prehabilitation, the process of preparing patients for orthopaedic surgery physically and emotionally, has demonstrated to be helpful in enhancing surgical results and post-operative rehabilitation. Prehabilitation may help patients encounter fewer surgical problems, recover more quickly, and have better long-term results. Prehabilitation assists patients in maximising their physical well-being and capacity prior to surgery. This could entail specific exercises and activities that enhance cardiovascular health, strength, and flexibility. Patients who are more physically active may be better able to withstand the strains of surgery and recovery, thereby lowering the chance of problems. Prehabilitation has a similar impact on the mind. Surgery patients frequently experience preoperative anxiety and tension; by addressing these worries beforehand, a more optimistic view might result. Patients may become more involved and motivated in their post-operative rehabilitation and contribute to better outcomes when they feel more secure and mentally prepared for surgery. Prehabilitation is difficult to put into clinical practise, though. Comprehensive prehabilitation programmes may be challenging to start and manage in healthcare settings with limited resources. In these circumstances, it is vital to strike a balance between the advantages of prehabilitation and the distribution of resources. Another crucial component of prehabilitation is personalization. Because every patient's condition is different, the prehabilitation programme should be too. In order to develop individualised prehabilitation programmes that maximise benefits and minimise potential hazards, healthcare professionals must thoroughly analyse and monitor individuals. Controlling patient expectations is one potential downside. Patients may have optimistic expectations regarding the results of surgery as a result of prehabilitation's beneficial effects. Clear communication between patients and healthcare professionals is crucial to reducing this. In order to assist patients have realistic expectations, it is helpful to describe the surgical procedure and the anticipated results.

References

Almeida, G. J., Khoja, S. S., and Zelle, B. A., 2020. Effect of prehabilitation in older adults undergoing total joint replacement: an overview of systematic reviews. Current Geriatrics Reports, 9, pp.280-287. https://doi.org/10.1007/s13670-020-00342-6

Borrell-Vega, J., Gutierrez, A. G. E., and Humeidan, M. L., 2019. Multimodal prehabilitation programs for older surgical patients. Anesthesiology Clinics, 37(3), pp.437-452. https://doi.org/10.1016/j.anclin.2019.04.004

Briguglio, M., and Wainwright, T. W., 2022. Nutritional and physical prehabilitation in elective orthopedic surgery: rationale and proposal for implementation. Therapeutics and Clinical Risk Management, pp. 21-30. 10.2147/TCRM.S341953

Chmelo, J., Chmelová, I., and Phillips, A. W., 2021. Prehabilitation, improving postoperative outcomes. Rozhledy v chirurgii: mesicnik Ceskoslovenske chirurgicke spolecnosti, 100(9), pp.421-428. https://doi.org/10.33699/pis.2021.100.9.421-428

Durrand, J., Hackett, R., Yates, D., and Danjoux, G., 2016. Prehabilitation. Perioperative Medicine–Current Controversies, pp. 15-47. 10.7861/clinmed.2019-0257

El-Tallawy, S. N., Nalamasu, R., Salem, G. I., LeQuang, J. A. K., Pergolizzi, J. V., and Christo, P. J. 2021. Management of musculoskeletal pain: an update with emphasis on chronic musculoskeletal pain. Pain and therapy, 10, pp.181-209. https://doi.org/10.1007%2Fs40122-021-00235-2

Gurlit, S., and Gogol, M., 2019., Prehabilitation is better than cure. Current Opinion in Anesthesiology, 32(1), pp. 108-115. https://doi.org/10.1097/aco.0000000000000678

Henry, L. E., Aneizi, A., Nadarajah, V., Sajak, P. M., Stevens, K. N., Zhan, M., and Henn III, R. F., 2020. Preoperative expectations and early postoperative met expectations of extremity orthopaedic surgery. Journal of Clinical Orthopaedics and Trauma, 11, pp. S829-S836. https://doi.org/10.1016%2Fj.jcot.2020.06.027

Levett, D. Z. H., and Grimmett, C., 2019. Psychological factors, prehabilitation and surgical outcomes: evidence and future directions. Anaesthesia, 74, pp.36-42. https://doi.org/10.1111/anae.14507

McIsaac, D. I., Gill, M., Boland, L., Hutton, B., Branje, K., Shaw, J., and Wijeysundera, D., 2022. Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews. British Journal Of Anaesthesia, 128(2), pp. 244-257. https://doi.org/10.1016/j.bja.2021.11.014

Molenaar, C. J., Papen-Botterhuis, N. E., Herrle, F., and Slooter, G. D., 2019. Prehabilitation, making patients fit for surgery–a new frontier in perioperative care. Innovative Surgical Sciences, 4(4), pp. 132-138. https://doi.org/10.1515%2Fiss-2019-0017

Nguyen, C., Boutron, I., Roren, A., Anract, P., Beaudreuil, J., Biau, D., and Rannou, F., 2022. Effect of prehabilitation before total knee replacement for knee osteoarthritis on functional outcomes: a randomized clinical trial. JAMA network open, 5(3), pp. e221462-e221462. 10.1001/jamanetworkopen.2022.1462

Northgraves, M. J., Arunachalam, L., Madden, L. A., Marshall, P., Hartley, J. E., MacFie, J., and Vince, R. V., 2020. Feasibility of a novel exercise prehabilitation programme in patients scheduled for elective colorectal surgery: a feasibility randomised controlled trial. Supportive Care in Cancer, 28, pp. 3197-3206. https://doi.org/10.1007%2Fs00520-019-05098-0

Punnoose, A., Claydon-Mueller, L. S., Weiss, O., Zhang, J., Rushton, A., and Khanduja, V., 2023. Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis. JAMA Network Open, 6(4), e238050-e238050. https://doi.org/10.1001%2Fjamanetworkopen.2023.8050

Rhon, D. I., and Tucker, C. J., 2022. Nonoperative care including rehabilitation should be considered and clearly defined prior to elective orthopaedic surgery to maximize optimal outcomes. Arthroscopy, Sports Medicine, and Rehabilitation, 4(1), pp. e231-e236. https://doi.org/10.1016%2Fj.asmr.2021.09.038

Shakya, P., and Poudel, S., 2022. Prehabilitation in Patients before Major Surgery: A Review Article. JNMA: Journal of the Nepal Medical Association, 60(254), p. 909. https://doi.org/10.31729%2Fjnma.7545

Tew, G. A., Bedford, R., Carr, E., Durrand, J. W., Gray, J., Hackett, R., and Danjoux, G., 2020. Community-based prehabilitation before elective major surgery: the PREP-WELL quality improvement project. BMJ Open Quality, 9(1), p. e000898. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206908/#:~:text=%C2%A010.1136/bmjoq%2D2019%2D000898

van der Velde, M., van der Leeden, M., Geleijn, E., Veenhof, C., and Valkenet, K., 2023. What moves patients to participate in prehabilitation before major surgery? A mixed methods systematic review. International Journal of Behavioral Nutrition and Physical Activity, 20(1), pp.1-10. https://doi.org/10.1186%2Fs12966-023-01474-6

West, M. A., Jack, S., and Grocott, M. P. 2021., Prehabilitation before surgery: Is it for all patients?. Best Practice and Research Clinical Anaesthesiology, 35(4), pp.507-516. https://doi.org/10.1016/j.bpa.2021.01.001

Weston, M., Weston, K. L., Prentis, J. M., and Snowden, C. P. 2016. High-intensity interval training (HIT) for effective and time-efficient pre-surgical exercise interventions. Perioperative Medicine, 5, pp. 1-9. https://doi.org/10.1186%2Fs13741-015-0026-8

Widmer, P., Oesch, P., and Bachmann, S., 2022. Effect of prehabilitation in form of exercise and/or education in patients undergoing total hip arthroplasty on postoperative outcomes—A systematic review. Medicina, 58(6), p 742.https://doi.org/10.3390/medicina58060742

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