Nurses Role in Management of Chronic Conditions - Case Study Example

Case Study in Relation to Mrs. SS Introduction Mrs. SS is a 68 year old female patient, who presented with complains of increasing dyspnoea on exertion and was admitted to the medical unit of a hospital in Saudi Arabia. She lately developed a respiratory tract infection, with deteriorating of her dyspnoea over the last three weeks, and associated frequent cough and oedema in legs. Also, she has orthopnoea. Her medical history shows for a severe myocardial infarction at 62 years of age, type II diabetes, hypertension and chronic kidney disease. She is taking medications regularly with non-complaint of medication program. On physical examination, she is suffering of respiratory distress and using of accessory respiratory muscles; she is tachypnoeic (36 breaths per minute). Her oxygen saturation is 88 %( room air) and temperature is 37.1C. She has diaphoretic and her skin is cool. She also has venous leg ulcer on left ankle, and ascites. On cardiovascular examination, she has a heart murmur. She has a blood pressure of 162/106 mmHg, and full bounding pulse at rate of 92 beats per minute. Her urinalysis: protein ++++, pH 6.8, SG 1.020; blood, glucose and ketones- Nil. Her laboratory results depicted high level of Potassium, Urea, Creatinine and HBA1C. Also, it shows low level of HCO3, eGFR and Hb. Chest radiograph indicated left ventricular hypertrophy with fluid in lower lung fields; ECG indicated a normal sinus rhythm. She is recently on renal diabetic diet and oxygen via Hudson facemask, at a flow rate of 6 L/minute, daily weighing and referral to renal team. Signs and/or symptoms Dyspnea, also referred to as shortness of breath can be explained as an uncomfortable breathing awareness (Lansing et al, 2009). Jensen et al, (2009) state that dyspnea takes place whenever breathing work is excessive, like during strenuous exercises or work, as demonstrated in the case study where Mrs SS experiences dyspnea on exertion. Dyspnea is deemed to be the initial manifestation of a disease that is life threatening or it can also have a functional origin. Mrs SS had suffered a myocardial infarction (MI) and according to Valensi et al, (2011) classical myocardial infarction (MI)’s symptoms include shortness of breath and chest pain. This is why she could be experiencing increasing dyspnoea on exertion. Acute dyspnea has various causes and the most frequent dyspnea causes are cardiac and pulmonary diseases, in addition to metabolic acidosis, acute loss of blood, poor physical condition, and anxiety. A respiration rate below 12 or above 25 breaths per minute is considered abnormal and could be an indication of a serious underlying health problem (Odell et al, 2009). Relating this to the case study, Mrs SS’s respiratory rate is 36 breaths per minute and according to Odell et al, (2009) this is considered a clinical deterioration in the patient. In accordance with the case study, dyspnea is brought about due to tachypnea as the patient is tachypnic with 36 b/m. Using accessory muscle in breathing is indicative of respiratory distress. In respiratory tract infections, cough is normally a frequent symptom, as evidenced by Mrs SS’s frequent cough episodes. The patient experienced oedema in legs; Taylor (2011) states that standing and immobility for extended periods are the two frequent causes of having oedema in the legs. The patient’s pulse rate of 92 beats per minute is within the normal range, which is between 60 to 100 beats per minute in adults (Zhang & Zhang, 2009). However, the abnormal sign that helped the identification of the patient’s problem is the presence of a heart murmur. Heart murmur is significant of heart failure as evidenced by cardiomegaly (Zhang & Zhang, 2009). Heart murmurs are considered as abnormal sounds in the process of the heartbeat cycle. By itself, a heart murmur is not a disease but may signify an underlying problem of the heart, in this case the MI that Mrs SS had. In the cases of hypertension in adult, the blood pressure is 140-160/90-100 mmHg or higher due to the cardiac muscle’s inadequate pushing of blood throughout the body (Arguedas, Leiva & Wright, 2013). Mrs SS is considered hypertensive since her BP reads 160/106mmHg, which is above the normal value. Diabetes causes excessive sweating (Dirksen, 2011); this is why Mrs SS presented with diaphoresis as she is diabetic. The presence of a venous leg ulcer on the patient’s left ankle is an indication of a long standing venous hypertension (Arguedas, Leiva & Wright, 2013). Key issues or problems The first key medical issue in the patient is acute cardiovascular failure (hypertensive). This means that hypertension causes heart failure by bringing about left ventricular hypertrophy, heart muscle’s thickening that leads to effective relaxation of muscle between heart beats. This causes difficulty for the heart to get filled with sufficient blood to supply organs of the body, particularly during exercise, resulting in the body to retain fluids and increasing the heart rate. Edema on the ankle can be present as seen in Mrs. SS. On abdominal examination, there may be ascites as a result of chronic heart failure, as seen in the case study. In acute cardiovascular failure, there is reduced cardiac output meaning that the heart is not able to pump sufficient blood that meets the body’s metabolic needs (Sells et al, 2009). This causes altered heart rhythm and rate, paleness and weakness. Another nursing diagnosis is excess fluid volume related to reduced cardiac output and water and sodium retention. Myocardial infarction is the second medical issue in the case study. Generally, blood pressure of the patient is initially raised due to peripheral arterial vasoconstriction generating from an adrenergic reaction to ventricular dysfunction and pain. The rate of respiration can be raised in response to anxiety or pulmonary congestion. Patients that have myocardial infarction can have the malaise, chest discomfort, and fatigue (Ignatavicus & Workman, 2010). Others include wheezing, generation of frothy sputum, and coughing as seen in the case study can occur. Acute bronchitis or acute lower respiratory tract infection refers to the productive cough onset in a patient that has no history of COPD and no pneumonia evidence (Lawn et al, 2011). This infection is normally brought about by viruses, but can be caused by bacteria as well. Signs of lower respiratory tract infection presented by the patient include coughing, tachypnea, and pleural effusion. Another major medical issue presented by Mrs SS is chronic kidney disease (CKD), which is also referred to as chronic kidney failure that explains kidney function’s gradual loss. When CKD reaches its advanced phase, dangerous levels of electrolytes, wastes and fluids can build up in the body. Some of the signs and symptoms include swelling of ankles and feet, chest pain, shortness of breath, and hypertension (Ignatavicus & Workman, 2010). Analysis result shows inadequate kidneys function such as increase in urea, creatinine. The patient’s urinalysis results indicate protein ++++, which is also referred to as proteinuria. Even though there may be presence of protein in urine as a result of physiological reasons like stress, strenuous exertion, constant urinary protein indicates the presence of a disorder that involves the kidney like in patients that have chronic kidney disease (CKD) such as Mrs. SS. As a factor proteinuria determines the decrease rate in the rate of glomerular filtration. Another symptom of CKD is water retention (Iseki, 2009), which is evident in Mrs. SS as she experienced oedema in legs over the past 3 weeks. Checking lab results to establish whether there is improvement is imperative in knowing the status of the patient. Another medical issue in the case study is diabetes types 2. The risk of diabetes type 2 increases as one gets older, particularly after 45 years of age. That is probably since people seem to exercise less, gain weight and lose muscle mass as they age. Despite of when one last ate, any reading of 200 mg/dL or higher in random blood sugar level indicates diabetes, particularly when accompanied with any diabetes signs and symptoms. In diabetes type 2, not sufficient insulin is generated to sustain a normal level of blood glucose (insulin deficiency), or the body is not able to effectively use the produced insulin (Betihavas et al, 2011). This is referred to as insulin resistance. Some of the symptoms related to diabetes include excessive sweating and leg ulcer (Fairman et al, 2011), both of which are seen in the case study. Currently, there is rising demand for RNs that have enhanced skills that can handle complex and diverse patients in various practice settings (Moore & McQuestion, 2012). APN is an umbrella term that classifies RNs with advanced skills and knowledge practising at greater level compared to the conventional RN (Dennis et al, 2009). They include nurse anaesthetist, case manager, clinical nurse specialist, and nurse practitioner (NP). The role of NP is differentiated through their comprehensive practice within fields of complex clinical assessment, diagnostics, prescribing, and referral (Anderson, 2012). Care Recommendations After identifying problems presented by Mrs. SS, it is imperative to state that nurses have a central role in promotion of optimal outcomes of the patient. Nurses with extra skills, scope of practice or training may facilitate improvement of management of chronic diseases in patients (Houweling et al, 2011). In the case of the case study, the nurse will be able to note that Mrs SS’s respiratory rate is above the normal range and this signifies an underlying condition (Parkes, 2011). Monitoring respiratory pattern addresses the ventilatory pattern of the patient (Preston & Flynn, 2010). A lot of acute pulmonary worsening is preceded by breathing pattern’s change. Respiratory failure can also be seen with respiratory rate’s change (Flynn, 2010). The nursing intervention for tachypnea and dyspnea is to initiate oxygen therapy to Mrs SS in order to maintain adequate oxygen supply to vital organs and the brain. Another intervention is to position the patient to optimize respiration, like elevating the head of bed at 45 degrees and repositioning at least after two hours (Ignatavicus & Workman, 2010). A position that is upright allows for maximal lung expansion and air exchange (Duffield et al, 2009). One of the interventions in reduced cardiac supply is monitoring blood pressure as well as pulse. The rationale behind this is that patients, who have renal failure, are normally hypertensive that is due to excess fluid and rennin-angiotensin mechanism’s initiation (Ignatavicus & Workman, 2010). The nursing intervention for excessive fluid volume is monitoring and recording vital signs so as to acquire baseline data (Ignatavicus & Workman, 2010). For coughing, the nurse should help the patient to breathe deeply and perform coughing that is controlled (McHugh et al, 2009). The patient should inhale deeply, hold her breath a little longer, then cough 2 to 3 times with an open mouth at the same time as tightening the upper muscles of the abdomen. Taylor (2011) states that this technique can facilitate increase of sputum clearance and reduce cough spasms. Nursing interventions for diaphoresis include changing the patient’s linen and bathing or sponging her face as required (Ignatavicus & Workman, 2010). The medical team should be contacted if the patient continues to have excessive sweating. Mrs SS has venous leg ulcer as well as edema therefore one of the nursing interventions is to do a limb elevation. Immobility, edema and limb dependency are all the contributors of venous hypertension. Elevation of the limb reduces edema and enhances microcirculation’s flow (Ignatavicus & Workman, 2010). Patients with chronic medical conditions require complex needs to care hence a collaborative management is essential (McHugh et al, 2009). Ignatavicus & Workman, (2010) argue that nurses ought to first learn how to recognize the way situations come up via analytical reasoning, prior to responding spontaneously by just understanding what to do. Cowen & Moorhead, (2011) state that nursing actions need to be led by rationales that are evidence based, which can establish abnormal and normal physiological ranges and offer a framework that suitable clinical judgment can be done. This enables the nurse to determine the level of urgency and when the doctor should be called in case of a clinical deterioration in a patient’s condition (Clark et al, 2011). Nursing interventions, specifically surveillance, have actually been identified as having a role in both complications’ early detection and medical errors’ correction (Henneman et al., 2012). Another intervention for Mrs SS is administering the prescribed medications because this is considered a pharmacological intervention. One of the medications given is Frusemide 80 mg BD, which is a diuretic used to treat fluid retention, also referred to as edema, and hypertension (Dirksen, 2011). Peridopril 8 mg is another indicated medication, an ACE inhibitor that is long-acting, and is used in the treatment of hypertension and heart failure. Lercanidipine 10mg is also administered daily for management of hypertension. Atorvastatin 10mg is administered daily to lower levels of cholesterol as well as minimize the risk of heart attack (Rosa et al, 2014). Calcium carbonate 600mg TDS is administered to manage symptoms brought about by indigestion, evidenced by Mrs SS’s bloated abdomen. Calcitriol 0.5μg is given daily since it is used in patients that have kidney disease that are not able to make adequate type of vitamin D. Since Mrs SS is diabetic, it is imperative to give her Lispro 25% 12 units BD to manage her situation. Other interventions include daily weight watch as this will establish whether the patient is maintaining a healthy weight or not. Diet, which is a lifestyle intervention, is among the most significant treatments in the management of kidney and diabetes disease (Noordman et al, 2012). As a result, checking the patient’s renal diabetic diet is essential. Mrs. SS identified with myocardial infarction requires analgesia with an opioid medication such as morphine sulphate 5-10mg and anti-emetic such metoclopramide 10 mg. These will help ease the pain as well as control any anticipated vomiting. Since the patient has chronic conditions, education on health promotion will be of benefit to Mrs SS since it entails some lifestyle changes like exercise and nutrition, which are both relevant to the conditions that Mrs SS has. de Bruin et al, (2012) contend that enhanced collaboration will also benefit the patient as it improves outcomes of the patient. Collaborative chronic illness management entails goal setting and devising a plan of care with patients, support for self-management, and dynamic follow up that monitors effectiveness and adjust care as required (Bohlen et al, 2012). This is why the Mrs SS is referred to the renal team, which consists of a nephrologist & CKD nurse practitioner. Educating the patient about medication compliance with regards to medication program is beneficial because the patient will be able to have a sense of self-management and take charge of her condition’s management. Conclusion This paper has presented a case study of a patient with chronic conditions. The nurses’ role in management of chronic conditions has also been discussed. Successful self-management of chronic conditions demands adherence to behaviors of healthy lifestyle, although a lot of health promotion interventions that are healthcare –based have led to small and unsustainable transformations in behavior of patient. Patients that have chronic conditions may be overwhelmed already by burdensome illnesses and therapies, and not able to respond adequately to the extra work needed of behavior modifications. Behaviors of healthy lifestyle in patients with chronic illnesses can improve the outcomes, result in clinically significant results, and decrease burden and costs on the system of health care. As discussed above, there are evident advantages to patients in nursing development to involve higher levels of skills and knowledge, and delivering these is accomplished in the patients’ interests. Reference Lansing, R. W., Gracely, R. H. & Banzett, R. B. (2009).The multiple dimensions of dyspnea: review and hypotheses. Respir Physiol Neurobiol, 167, 53. Jensen, D., Webb, K. A., Davies, G. A. & O'Donnell, D. E. (2009).Mechanisms of activity-related breathlessness in healthy human pregnancy. Eur J Appl Physiol, 106, 253. Valensi, P., Lorgis, L. & Cottin, Y. (2011). 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