The Medical Diagnosis Pharmacology and Pathophysiology - Case Study Example

Introduction

This paper examines issues around an 82-year-old female patient who is admitted to the nursing home on December 1st, 2017. For this study to be conducted, approval was given by both the nursing homes’ caretaker and the resident. This woman is married to a very supportive husband who helps her out in several personal tasks and other social support such as showering, moral support, shopping and toileting. This woman was referred to the nursing home from Lyell McEwin Hospital where she was first admitted for emergency following her fall where she sustain a fracture on the humerus of her right neck, acute Kidney injury (AKI) and lower back pain. Her fracture was managed successfully by use of Collar and Cuff and her AKI was also attended to successfully. In order to resolve her leg weakness and her lower back pain, the doctors subjected her to CT-scan and X-ray, which showed no nerve impingement multilevel narrowing. She is also currently undergoing medical diagnosis that includes Asthma, T2DM and Atrial fibrillation. Caution was taken since she has allergy to Dienestrol and Augmentin. Discharge planning was done as per the referral ofGawler Health Service on 30/08/2017, particularly for a comprehensive age care assessment by our age care assessment team (ACAT).

The husband, on the other hand, raised concern about her deteriorating functional ability and her poor memory that pose a lot of challenges to her in copying with the home’s day-to-day activities. This is worsened by the fact that she has problems with word finding, recall coupled by her short-term memory. The cognitive tests indicated that her MMSE was 20/30 and her recall was 1/3.The dementia screen consisted of normal range folate, iron studies, thyroid hormone and b12. In addition, her past medical history indicated a history of Hypertension, obesity, back and chronic pain as well as depression. This diagnosis helps to reveal risks associated with her condition such as falling and memory lapses, which usually make her forget her walker as well as other risks such as stroke, organ damage, heart failure, retinopathy, anemia and glaucoma.

This paper explores the issues related to the medical diagnosis’ pharmacology and pathophysiology in one day when the patient receives a detailed care as well as the symptoms and signs that are observed in the resident and the reason for their manifestation in the course of the illness. The paper will also provide a critical analysis regarding the investigation from the collected data in order to establish the correlation between pharmacology and the pathophysiology with a focus on both theory and context.The paper concludes by giving recommendations that highlight the rationale and issues guiding the resident’s most urgent discharge, which are predicated on the provided feedbacks from the Viva Voce.

Pathophysiology and Pharmacology

Physical Examination and the Health Assessment were conducted as guided by the basics of nursing care in order to assess the health status of the resident. Therefore, privacy, caring and confidentiality were observed throughout the assessment process and the examination of the patient (Calleja, Harvey & Estes, 2015 p. 136).In order to make clinical judgements from the collected data, there was a careful utilization of skills such as percussion, interviewing, inspection, auscultation, palpation and documentation (Calleja, Harvey & Estes 2015, P.142).Nonetheless, the health assessment of the resident revealed that there was no abnormalities observed except those related to her medical diagnosis. Additionally, the resident was subjected to regular and PRN medication as dictated by her conditionThe medication that are selected to be discussed in this paper include Apidra, Spiriva and Warfarin which is closely linked to her medical diagnosis and the results of the assessment findings.This paper will also further explore such illness and conditions such as T2DM, Asthma and Atrial Fibrillation.

Type 2 Diabetes Mellitus (T2DM)

The development of this disease is exacerbated by the impaired pancreatic beta cells’ secretion as well as the insulin resistance, which are the main pathophysiological characteristics of type 2 diabetes. This is aggravated by the cellular resistance to insulin during the development of type 2 DM. Moreover, the resistance is further worsened by inactivity, obesity and other medical contributors such as HDL cholesterol of > 0.9 mmol/L,a triglyceride level of >2.8 mmol/L, Hypertension (>130/85 in adults), increasing age and other medications. According to McCance and Huether (2009), obesity decreases the ability of insulin to affect glucose metabolism as well as the glucose’s uptake by the liver, adipose tissues and skeletal muscles. This leads to Hyperglycaemia, which causes glucosuria, polycosuria and dehydration due to decrease in intracellular volume and increased urinary output, which causes a feeling of tiredness, lethargy, blurred vision frequent infections or slow-healing wounds.

Investigation

As a care plan, there are several diagnostic tests that may be utilized to monitor diabetes management which include the Glycated (c) (HbAlc or Alc) < 7%, the fasting plasma glucose (FPG) with a normal range of 3.9-6.1, serum cholesterol (HDL<4.0), urine glucose and ketone levels, triglyceride levels, urine test conducted for protein’s presence as albumin, serum electrolytes as well as regular self-blood glucose level check which comprise of BGL 2hours post meal of 6-10 mmol/L and facting BGL of between 6-8 mmol/L. The diagnosis of the resident’s T2DM revealed some observation of abnormalities with the resident having some frequent episodes of urination that contributes to Hyperglcaemia, which also causes serum hyperosmilarity, a feeling of tiredness and lethargy. The assessment that was done on the resident indicated that the resident was 158cm in height, 75kg in weight and a body mass index (BMI) of 30kg/m2, which falls in the obesity range. She also has a fasting BGL of 7.3 and 2 hourly post meals periods at 1130, 1630 and 1930 with 16.1, 18.5 and 15.2 respectively. The lab results showed that her cholesterol level was above 4 while her HBA1c was approximately 8%. In addition, she was suffering from hypertension and therefore, apical and radial pulses were found to be 73 beats/minute with a regular pulse rhythm but the blood pressure was found to be 126/74 mmHg. From the heart beat assessment, there were no abnormalities observed due to the fact that the treatment was controlled. However, the resident suffered from lower leg oedema and AKI, which is resulting from uncontrolled high blood pressure. The blood glucose levels also affected the blood vessels of the kidney (Diabetes Australia).

Pharmacological Management of T2DM

• Apidra 10units once daily at 1200

A clear appearance characterizes therapid onset-fast-acting insulin, but when it comes to working, it only takes 5-10 minutes to take effect. However, the effect’s peak manifests itself within a time frame of 1-3 hours and lasts for around 5 hours. Through stimulation of peripheral glucose, the insulin can lower the level of glucose in the blood. But there are adverse reactions that are usually related to Apidra such as allergic reactions, injection site reactions, hypoglycemia, pruritus, rash and lipodystrophy. The insulin should be used in instances where there is hypoglycemia and also with a person having Apidra hypersensitivity. The role of a nurse who handles a patient with such conditions is to monitor BGL before administering the insulin and in cases where the BGL is less than 3 mmol/L, the nurse should withheld its administration. Moreover, the nurse should also monitor the resident’s fluid intake so as to mitigate its effects on renal and hypokalemia functions.

Pathophysiology of Atrial fibrillation

The diagnosis conducted on the resident showed that she had Atrial fibrillation. But because the treatment of the resident was controlled, no abnormalities were observed. According to January et al., (2014, p. 120), Atrial fibrillation is characterized by arrhythmia or abnormal heart rhythm that is marked by irregular heartbeat. It has been noted that the main cause include the disruption of the electric messages that control the heart’s steady rhythm or heartbeat (Porth, 2010, pp. 383-384). In addition, the symptoms, though often elusive, has been observed to include a fluttering heartbeat or palpitations, fainting, chest pains, irregular heartbeat and dizziness (Curtis, 2013, p. 1663). As a result, the treatment has to be crucial although the symptoms of AF are not clearly manifested. January et al., (2014, p. 135) further argues that if AF is not treated early, it may lead to several complications such as stroke and heart attack. There are also other factors that cause AF which include chronic illness that irritate the heart, hypertension and coronary heart diseases (Lemone et al., 2014, p 1650).

Investigation

In order to diagnose AF, several tests can be conducted such as laboratory investigation, physical examination and diagnostic tests. The procedures, which are very critical in AF diagnosis, include heart monitoring, Electrocardiogram (ECG), blood test, chest X-ray, and echocardiogram. In implementing the physical examination, the level of practice is essential (Nursing and midwifery Board of Australia, 2012). In the assessment that was conducted, the radial and apical pulse of the resident was found to be 7 e beats/minute, with a regular heartbeat and blood pressure of 126/74 mmHg. The capillary refill took place every 2 seconds. Forms the heart assessment, no abnormalities were observed due to the controlled treatment of the resident.

Pharmacological Management of Atrial Fibrillation

• Warfarin 3mg once daily at 1700

The oldest oral anticoagulant includes warfrin, which is a vitamin K antagonist. This is taken by patients in order to prevent thrombosis and also for AF. The function is to suppress coagulation through reducing the production of four clotting factors as VII, IX, X factors and prothrombin. The productions of vitamin K-dependent factors are reduced by 30-50% in therapeutic doses. The risks associated with Warfrin include severe liver or kidney disease as well as uncontrolled hypertension, nausea and bleeding. Consequently, the role of the nurse include assessing the laboratory results and looking at the medical history so as to find evidence of abnormal bleeding. The warfrin’s protein binding and metabolism are affected by multiple drugs. It is therefore important that the resident’s INR result is monitored before administering the medication so that INR is raised to an appropriate value which is between 2.5 -3.5. for most patients.

Pathophysiology of Asthma

Asthma is one of the airways’ inflammatory disorders, which have symptoms such as breathlessness, wheezing, coughing, chest tightness and anxiety. The inflammation causes the increase of sensitivity of the airways to multiple stimuli. This inflammation of the airways is recurrent in patients with Asthma brought about by a number of changes such as airway edema, bronchoconstriction, airway hyperresponsiveness and airway remodeling. In instances of asthmatic patients getting inflammation, the inflamed tracts react by producing excess mucus, narrowing of the airways and which leads to difficulty in breathing.

Investigation

There should be a keen, focus and timely assessment of a person suffering from asthma. The current symptoms of asthma include dysponoea and chest tightness. To relieve asthma problems, identification of factors that exacerbate asthma should be identified as well as the frequency of attack, current medications and allergies that are known. During the physical examination, factor such as color, level of distress, respiratory rate, breath sounds in the entire lung fields, excursion and apical pulse should be noted. Diagnostic tests include forced expiratory volume, arterial blood gases and peak expiratory flow rate. In addition, when conducting primary assessment in a patient having acute asthma, noting the oxygen saturation level is critical as guiding by the following parameters for instance when the spo2 is >94% it’s mild/moderate, between 90%-94% is severe but when it is less than 90% is life threatening.

Pharmacological Management of Asthma

• 1puff of Spiriva daily

Spiriva (Tiotropium) has been anticholinergic agent for a long time. It shows prevention of muscarinic receptors of the smooth muscle in the bronchial airways which leads to bronchodilation. The effect of drug can last for up to 24 hours. Narrow-angle glaucoma, neck obstruction, urinary bladder obstruction, decreased renal function and dry mouth are some of the most common serious side effects. Nursing the elderly ought to be taken as a caution when using this medication. The duty of a nurse when treating a resident depends on checking anticholinergic effects such as urinary retention &tachycardia, keeping drug as well as informing the physician in case of an occurrence of angioedema.

Recommendations

Depending on the resident’s conditions, current and ongoing needs of resident should be considered in management of nursing. Her cardiovascular status normally related to structural cardiac dysfunction, preexisting comorbidities and advancing age that needs close monitoring. According to Porth &Matfin (2009) some of the most reoccurring complications for instance stroke and heart failure leads to high rate of mortality and morbidity.

According to Lemon et al (2014) and P. (1557), it is evident that strict observance of treatment plans as well as patient outcomes is improved by nursing intervention made through transition of care coordination and education of patients. Prevention and management of atrial fibrillation involves dealing with risk factors, which are adjustable through changes of lifestyle that are likely to involve exercise or management of weight (January et al 2014, P. 230). Management of hypertension involves dietary approaches such as reducing total and saturated fat intake, maintaining adequate calcium and potassium intakes as well as reducing intake of sodium. No added salt (little to moderate restriction of salt) decreases blood pressure as well as potentiating effects of antihypertensive drugs for many people with hypertension. Diabetes management needs a strict balance between the expenditure of energy, the dose, timing of insulin or oral antidiabetic agents and the intake of nutrients. Carbohydrate should be included in all diabetic snacks and meals. A healthy meal plan has food that is rich in dietary fibre. A healthy meal consist of small amounts of sugar for instance, a teaspoon of honey or jam spread over multigrain toast or 1-2 teaspoons of sugar added to porridge. Apart from nutrition daily Control blood glucose levels, exercise and control weight needs to be seriously put into account on a daily routine. Additionally, a regular visit to the optometrist to check her eyes is also important.

Concerning diagnosis of asthma, the most essential discharge issues is related to education of resident in order to prevent the attack of asthma such as learning ways of monitoring her illness conditions using some devices like Peak expiratory flow rate (PEFR) used on daily basis, using medication on time, trying to reduce stress, taking enough rest, being mindful during doing daily routine’s such as ADL’s, having a simple exercise and preventing environmental triggers.

Reflection

A good feeling due to my enthusiasm, efforts as well as insinuation to concentrate on issues and trying to improve my skills and knowledge for a life-long training as a nursing student as well as improving to give a high quality care while in my placement and future was as a result of a very good response about my contribution in group discussion and Viva Voce. My presentation and all provided details even more than expected ones impressed my facilitator and commented that I have done a very good sjob that is good for me as a student. In her response, there are parts which I have applied and developed in this paper on the area of recommendation as well as a little in investigation part.

The most important part of effective learning is feedback. It gives students an opportunity to understand the subject being studied and guide them clearly on how to enhance their learning. A requirement of registration gives specifications on how a registered nurse should show competence in giving nursing care. The competencies are grouped into domains such as: care provision and coordination, collaborative and therapeutic practice, critical thinking and analysis as well as professional practice. According to Nursing and Midwifery Board of Australia (2012), it is important for a student of nursing to learn the ways of giving nursing, which is evidence-based for cultural groups, communities, families and patients of all ages.

During my resident assessment and placement, I decided to acknowledge the rights that others have, maintain practice within the ethical and professional framework, assume the responsibility of harm prevention and to observe my duty of care. Additionally in line with Nursing and Midwifery Board of Australia (2012), I combined organizational policies and guidelines with professional standards, sought clarification and questioned ambiguous decisions and orders, kept the confidentiality and privacy in giving care, participated in clinical audits and activities of care review.