Nursing Case Management Plan - Assignment Example

Case Management Plan (Nursing) Word Count 2952 Introduction: This is a case study of Mrs. Chang, an 82-year-old woman which is a nick used for this case study. In this work, for ethical and confidentiality reasons her identity will remain undisclosed. This writer assisted in her care at the time of her admission to the hospital when she tripped and fell in the shower at home few days back. She was admitted to the hospital for assessment and evaluation of her progressive neurological disorder that led to her declining cognition and gradually deteriorating mobility and overall frailty. Moreover, as indicated in the history, her husband, Mr. Change being an 86-year-old man she has considerable lack of support at home. Most of their friends have deceased, and they have little to no support in the community. She has been admitted to the hospital for further assessment and evaluation of her condition. In this assignment, a nursing case management plan will be designed based on nursing assessment and will be presented in the specified format. This will help in care delivery prioritized based on her needs. While presenting this there will be concurrent critical analysis of the care plan in order to justify it based on evidence from contemporary literature (White and Davidhizar, 2006, 46-47). In the nursing practice area, this is viewed as an organizer of care delivery, and in order to meet the standards and need of evidence-based practice, research is frequently used, and this assignment ensures that the care delivered to her is person centred. (Herleman, 2008, 235-244). CLIENT Name: Mrs. Chang (Alias) NEED/PROBLEM NURSING DIAGNOSIS JUSTIFICATION GOALS JUSTIFICATION NURSING INTERVENTIONS JUSTIFICATION EVALUATIVE OUTCOMES JUSTIFICATION 1. Impaired and compromised physical mobility Mrs. Chang is an 82-year-old elderly, thin and frail woman with late stage parkinsonism with deficiency of information in this case study about the details of that condition. Generally, this condition presents as gradual slowing of voluntary movement, muscular rigidity, stooped posture, and distinctive rigid gait. She has also evidence of rheumatoid arthritis of both hands leading to severely restricted mobility. Moreover, age-related osteoporosis and osteoarthritis may accentuate her mobility problems further. Increase in frequency of fall is very common. Her current medications have not been mentioned, but she has been on ibuprofen. This indicates that she is on chronic pain, which can further compromise her mobility (Nolan and Tolson, 2000, 39-42). The goal of nursing management based on this need will be to improvement her mobility. At the end of care, the patient will be more comfortable with decreased pain, so she will be able to perform her activities of daily living as the limits of the disease condition permits, and this will be manifested by maintenance of joint mobility and range of motion while exhibiting adaptive coping behaviour. Ultimately the goal of care would be improvement of her muscle strength and endurance above her current levels (Rubenstein, Powers, and MacLean, 2001, 686-693). An impaired nervous system leading to a progressive disease can lead to subtle weakness and even drastic loss of mobility. Therefore goals of nursing management would be to slow the progression of the disease and improve the mobility and range of motion to the best possible levels. (Eliopolous, 2005, 1-53). Intervention from the nursing management aspect should include provision of support and reassurance to help her cope with limited mobility. She would be encouraged to express her feelings about immobility and nodular joints. It is imperative that she and her husband would be included in all phases of care and in the care management plan. There will be all attempts to answer all of their questions honestly. There is a chronic analgesic prescription, but that must tailored to her needs. Self-care at her own pace will be encouraged. The patient will need to have adequate rest, and she and her husband would be educated on energy conservation methods. In relation to pain medications, strict adherence to prescriptions will be advised with awareness of adverse reactions. This is more important given her polypharmacy and warfarin. She must avoid overexertion with minimisation of weight bearing activities with exact posture. During her care, she would be trained on range of motion exercises with gait training and posture training to stabilize her status of physical functioning. The patient would be referred to a physical therapist, and home care needs will be assessed. (Brown et al., 2005, 14-24). Parkinson's disease is associated with dementia, for which she forgot that she had bumped several times causing her bruises. There is a possibility of developing depression in her social situation and her Parkinson's disease. She has a probability to demonstrate problems with social isolation, ineffective coping, potential for injury, and sleep pattern disturbance (Bephage, 2005, 205-210). Falls are the significant reasons of injury for Mrs. Chang. Her problems of muscular weakness, decreased balance, or neuromuscular abnormalities may combine to result in mobility impairment leading to ADL deficits and fall. Literature suggests physical training has positive effects on balance, and institution of physical training is necessary which is known to improve muscle strength and endurance. (Potter and Perry, 2005, 879-892). Mrs. Chang will demonstrate ability of movement with assistance within an acceptable level within 6 weeks, would be able to express measures to prevent injury within 1 week, and will be able to do a full course of strengthening exercises within 2 weeks (Eliopolous, 2005, 56-90). The patients with Parkinson's disease demonstrate greatest result with maintenance of maximal mobility and independence to remain safe from injury. The patient would be able to verbalize understanding of the need to use lifestyle changes including measures to prevent fall with gradual return to normal physical activity with the physical exercise regimen (Eliopolous, 2005, 82-86). 2. Reduced mobility leading to deficits in self-care Mrs. Chang has self-care deficits at the present state of her affairs. History does not mention anything about this. This may lead to impaired physical mobility, leading to risk of further injury. The levels of functioning and disability vary with the number of chronic diseases. Self-care is an important parameter in care. Loss of strength from all the listed chronic diseases, easy fatigue, restriction of range of motion in the joints, decreased flexibility of the limbs, fear of fall, all result in self-care deficits. Therefore promotion of self-care is a major component of the nursing management of her problems. (Brown et al., 2005, 41-86) The patient will perform bathing and hygiene activities to the fullest extent possible by self. The patient will be able to verbalize feelings of self-esteem. This case study lacks information about the bowel elimination pattern. Following care, she will resume a normal bowel pattern. The patient will have positive feelings about herself. She will perform dressing and grooming activities to the fullest extent possible by herself. (Hayflick, 2001, 32). Self-care abilities are determined by motor function. Recent studies indicate that complex perceptual qualities also predict the ability of self-care. In Parkinsonism, higher levels of perceptions are known to be impaired, with dementia aggravating it further. Cognitive abilities are necessary to sense forms and other visuospatial components, and these are affected in her case. Nutritional deficit would reduce her strength and increase her frailty, leading to easy fatigue in self-care activities (Bachrach-Lindstrom et al., 2007, 2007-2014). Failing to do would reduce confidence and positive feelings about her abilities to herself. (Lindeman et al., 2002, 10-14). Nursing intervention would include encouraging the patient to participate in the ADLs as much as possible in order to maintain independence and self-esteem. Assistive devices should be provided when necessary. Adequate rest must be provided. An occupational therapist must be involved to develop a program of daily exercises. The patient will be protected from injury by all means. Household safety measures will be explained and demonstrated. (Singh et al., 2001, 497-504). Goal of healthcare for older, particularly multiply and chronically ill persons should be to optimize function and comfort. These problems often impact older adult's ability to live independently. An older adult's ability to independently complete activities of daily living (ADLs) is a benchmark for health. (Pearson, FitzGerald & Nay, 2003, 41-48). The patient will be able to eat and eliminate alone in 7 days. The patient will be able to bathe and groom herself in 2 weeks. The patient will have improved mobility in the close environment in 3 weeks. Acute admission always causes deterioration of the self-care activities. Regain of physical strength and self-esteem is time-consuming affair. With the improvement in nutrition, practice and encouragement in the ward, hopefully these time landmarks will be met. Goals may need to be revised following discussion with the patient, and new goals would be decided (Pearson, FitzGerald & Nay, 2003, 41-48). 3. Falls risk. The patient has an increased risk of falling that may cause physical harm. Her age of 82 and this admission with a history of fall increases her risks. Moreover, while caring and bathing, it was noticed that there were multiple bruises that indicated multiple injuries while at home. Her arthritis has aggravated the situation more. She has decreased lower extremity strength that has impaired her mobility. Due to her parkinsonism, she may have urgency and incontinence of bladder. This has not been mentioned in the history. Moreover, she has difficulty with gait and coordination. She has diminished mental status from dementia associated with parkinsonism. Her medications include antihypertensive agents. Although not highlighted, her home environment may be cluttered due to the fact that the person who takes care for her more aged than her. A review of circumstances of fall with her lead to the finding that anti-slip measures were not taken, that could have led to this trip and fall. The patient will remain free from injury and falls, and the risks of falls would be reduced. Older women experience more hospitalizations for fall-related hip fracture. Both normal and pathological aging changes, as well as unsafe environments, contribute to the high rate of falls among older adults. Pathological aging changes include neuromuscular and cognitive disorders and osteoporosis as relevant to her case (van Leeuwen et al., 2001, 8-13) She would be encouraged to request assistance with ambulation. The bed should be in the low position with side rails raised as appropriate. While in the hospital, an alarm system will be used to alert the staff that the patient is getting up, so staff can assist the patient to get up and ambulate. Walkers or other assistive devices will be provided to provide support and prevent falls. The occupational therapist can assist in identifying appropriate adaptive devices. Special walking techniques must be learned to offset the shuffling gait and the tendency to lean forward. (Done & Thomas, 2001, 816-821) (Pearson, FitzGerald & Nay, 2003, 41-48). The patient is at considerable risk for injury from falls. If the leg weakness is more, the physiotherapist can employ strengthening exercises. Cognitive problems lead to poor planning, judgment, monitoring safety, poor ability to follow instructions, and difficulty learning. (Done & Thomas, 2001, 816-821). The patient will be able to able to voice understanding of fall reduction measures in 1 week. The patient would be able to demonstrate an appropriate gait in 2 weeks. The patient will demonstrate strength and self-care activities in 3 weeks (Isola et al., 2008, 2480-2489). Patient and family education plan should include a clear explanation of the disease, assisting the patient to remain functionally independent as long as possible. Frequent rest periods aid in preventing frustration and fatigue. The environmental hazards must be evaluated in the home. (Done & Thomas, 2001, 816-821). 4. Polypharmacy The patient is on multiple medications. Factors that need to be considered include the changes in pharmacokinetics and pharmacodynamics of drugs in an aged individual. Use of warfarin needs continuous and regular monitoring and supervision. Moreover, there are issues with adverse effects. She is using naturaopathic medicines, which may interact with the therapeutic agents, and most probably she is taking these medications on her own without prescription. The decrease in renal function associated with ageing also contribute to alteration in the pharmacokinetic pattern, hence diminished clearance of the drug, and therefore, she needs dose adjustment (Schmidt, 2004, 169-175). To establish a complaint medication regimen without problems of adverse effects or polypharmacy, where the patient can be educated on proper ways of medication regimen. Allowing access to medical care is important for her to maintain the appropriate therapeutic regimen. The discharge planning must accommodate education regarding drug therapy (Ioannides-Demos & Christophidis, 1993, 411-415). To educate patient and family about drugs, drug interactions, and the effects of polypharmacy. The medical officer will be contacted who can interfere and stop naturopathic medications. To facilitate dispensing, a dispenser will be used and demonstrated. INR would be done periodically, and safety needs to be established with adjustment of warfarin dose. Elderly persons are at risk because of the higher number of prescription and OTC medications they consume. Access to medical supervision is important to effect compliance. Her cognitive decline may lead to failure to identify drug and dosage and prevent compliance. INR is necessary to prevent bleeding complications. The patient will be able to demonstrate and voice understanding of her medication regimen within 1 week. Once INR is cleared, the warfarin may continue in its older dose. The patient and family will demonstrate understanding of the need to see a physician while on warfarin therapy. The patient will stop naturopathic medications. The holistic aspect of health through nonpharmacologic measure would be reviewed and demonstrated to the patient. Nurses should check their patients' knowledge of the dosage schedule of their drugs to enhance compliance. Dosage schedules should be simplified. Nurses should consider the use of non-drug treatments to improve the health of those in their care, which may include diet, exercise, relaxation methods, and so on. (Hatcher, 2001, 36-43). 5. Deficiency in coping, communication, social support and family care The patient is being cared for at home by her husband, who is now 86. As the patients age, so do the significant others who are providing care, where the caregiver is no longer able to meet the increasing needs of the patient. There is no social support since the friends have deceased and lost her son. The patient has problem coping and communicating (Ward, 2002, 33-35). Family members will seek support resources and develop adequate coping behaviors. The patient will maintain family and peer relationships. The patient will develop alternative means of communication. The family must be educated in the management of her condition. The education plan should include a clear explanation of the disease and the needs. The patient and family must be taught about the importance of reporting side effects to the physician. (Forster, 2003, 283-184). The patient and family will be taught about coping and communication. Household safety measures will be explained. (Eliopolous, 2005, 82-88). Patients are assisted and encouraged to set achievable goals. There should be a planned program of activity throughout the day. Family and social support groups can play a major role in this (Done & Thomas, 2001, 816-821). On discharge, family will be actively participating in patient's care and family's knowledge about the drugs and disease and safety measures will be demonstrable at the time of discharge. Family support in coping, communication, mobility, assistance, safety measures, and pharmacotherapy would be very important in this case, and consideration of a social support group would be necessary given the age of her husband (Done & Thomas, 2001, 816-821). Issues arising from the plan: The patient has the diagnoses of parkinsonism, congestive heart failure, rheumatic disease, and atrial fibrillation. Case management through needs assessment is a whole system approach considering Mrs. Chang's and her husband's responses to her baseline illnesses of Parkinson's Disease (PD), hypertension (HT), atrial fibrillation (AF), and rheumatoid arthritis (RA) to both hands. Other issues are her declining cognition, difficulty in mobility due to PD, lack of social support due to death of friends and only son, and these are bound to create some self-care deficits. For her, a fall in the toilet is very natural, and her husband, would not be able to respond to this accident leading to a panic. All these conditions are prone to cause deterioration of her health-related quality of life. Along with that, multiple medications is another issue. She has been on Levadopa (1.5 grams tds), Digoxin (62.5 mcg daily), Warfarin (4mg daily), Enalapril (5mg bd), and Ibuprofen (400mg tds) along with naturopathic medications. This constitutes a case of polypharmacy where supervision is necessary to ensure complaince and availability of medications. Moreover, drugs like warfarin needs frequent checkups of INR, which may not have been possible for her to undergo due to age, frailty, and mobility reasons. There is no supervision available for her at home. This is evident from her lack of monitoring of the INR and appearance of bluish spots in the torso, which may be petechiae for its size, indicating the necessity of adjustment of warfarin dose and coagulation check. The naturopathic medicines may have some drug-drug interactions, which again needs to be supervised (Haughton, 2000, 34-38). Conclusion: This is a broad analysis of her overall condition, and as a case, she needs to be managed appropriately with efficient and cost-effective care delivery, and to this end, the practice model must accommodate a case management and the elements of Mrs. Chang's and her family's support system. The main goals in her case management would include improvement in her mobility, reducing her fall risks, improvement in her symptoms and self-care deficits, reducing her polypharmacy and ascertaining appropriate medication regimen with necessary followup with a physician, helping her to cope and communicate, and helping her family to help her improve (Slater and McCormack, 2005, 601-608). A social support group is preferable along with establishment of safety measures at home, with key being the patient's and her family's education and active participation. A home visit to assess home safety issues is also incorporated in this case management approach. Reference List Bachrach-Lindstrom, M,, Jensen, S., Lundin, R., and Christensson, L., (2007). Attitudes of nursing staff working with older people towards nutritional nursing care. J Clin Nurs; 16(11): 2007-14. Bephage, G., (2005). Promoting quality sleep in older people: the nursing care role. Br J Nurs; 14(4): 205-10. 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Expanding Our Understanding', The Journal of Dementia Care, Sept/Oct: 33-5. White, I. and Davidhizar, R., (2006). Learning to care for older adults in an associate degree nursing program: a discovery process. Caring; 25(5): 40-2, 44, 46-7. Read More