PATIENT CARE MANAGEMENT
Instructions: The completed case report will need to be submitted via the Health of Older Adults (NURS 2024) course site Assessment 3: case report link by the assessment due date.
In order to plan and provide optimal patient-centered nursing care, Registered Nurses need to be able to interpret clinical information and draw upon their knowledge of pathophysiology and evidence-based clinical practice. Therefore, the purpose of this assessment is to support the development of the skills needed to evaluate evidence and to develop reflection and clinical reasoning skills.
Based upon the Horizons Hospital & Health Service (HHHS) NURS 2024 Health of Older Adults client Mary Young, construct a case report. The case report will draw upon your knowledge of pathophysiology and relevant academic literature to support an evidence-based plan of care.Headings and a description of the content for each section of the report have been provided. These serve as a guide for how you will present your case report; however, it is important that all sections of the report are conceptually connected. For example, your knowledge of pathophysiology and your understanding of this particular client should underpin the nursing problems that you identify which should, in turn, drive the nursing management that is relevant for this clinical situation.
The case report should include the following:
Introduction (150 words)
Introduce the client and provide a brief overview of their case. Provide an outline of the purpose and structure of the report. You might like to think about the overview of the case study like a verbal clinical handover: what is the key information from the HHHS patient information, progress summary and medication chart that would be relevant for the plan of care for this client? Primary admission diagnosis (200 words)
Identify the primary diagnosis for the client (i.e. the reason the client was admitted to the HHHS). Provide a brief description of the pathophysiology for the primary diagnosis.
As part of this discussion, it is important to relate the pathophysiology to client’s risk factors and relevant previous medical history.
Nursing problems (200 words)
Use your knowledge of pathophysiology and the subjective and objective data provided in the HHHS progress summary notes to identify five (5) nursing problems that may arise as a result of the client’s primary diagnosis. These problems may be actual or potential nursing problems. Provide a brief description for why these problems may arise for this client.From these, select two (2) nursing problems as the focus for the remainder of the case report. Provide a rationale for your selection.
Nursing Management (600 words)
The nursing management should focus on the nursing assessment, nursing interventions and the role of the Registered Nurse (RN) related to medication management for this client and will address the two (2) selected nursing problems.
Nursing Problem 1: Nursing assessment, nursing intervention, medication management.
Discuss one (1) method of nursing assessment that would need to be performed related to the ongoing nursing management of this nursing problem. Provide a rationale for this type of assessment and briefly describe how this assessment would be conducted in this case.
Discuss one (1) nursing intervention that you would need to implement related to the ongoing nursing management of this nursing problem. Provide a rationale for the intervention. Discuss the role of the RN in the medication management related to the ongoing nursing management of this nursing problem.
Nursing Problem 2: Nursing assessment, nursing intervention,medication management.
Discuss one (1) method of nursing assessment that would need to be performed related to this nursing problem. Provide a rationale for this type of assessment and briefly describe how this assessment would be conducted in this case. Discuss one (1) nursing intervention that you would need to implement related to the ongoing nursing management of this nursing problem. Provide a rationale for the intervention. Discuss the role of the RN in the medication management related to the ongoing nursing management of this nursing problem.
Discharge planning (250 words)
Identify five (5) issues/challenges that you may need to address for this client prior to discharge home. Discuss how you would facilitate discharge planning for this client, with consideration to two (2) of these concerns?
Conclusion (100 words)
PATIENT CARE MANAGEMENT.
There is increased advocacy for patient-centered care in the health care setting considering the realized benefits of such approaches to patient care especially in terms of patient outcomes. The sharing of information in the health care setting coupled with evidence–based practice forms the backbone of patient-centered care. This paper will review the case of Mrs. Mary Young, a female patient diagnosed with Ischemic stroke upon presentation at the emergency department. The patient presents with drowsiness, right-sided weakness, and a slurred speech, but remains responsive. She is accompanied by her daughter who is highly concerned about her mother’s situation, especially her future care. This paper aims to draw upon the best nursing practices that would facilitate the effectiveness of the management of Mrs. Young, including the employment of both patient-centered care and evidence-based practice in drawing on existing evidence to provide the patient with the best of care and allowing the patient to actively participate in their care process.
Primary Admission Diagnosis
Young is diagnosed with Ischemic stroke upon admission at the emergency department. Ischemic stroke is a type of stroke defined by the sudden interruption in the circulation of blood to a particular part of the brain, leading to a similar loss in terms of neurologic function. On the other hand, acute ischemic stroke results from embolic or thrombotic cerebral artery occlusion. Unlike hemorrhagic stroke, acute Ischemic stroke is more common. It is important to note that stroke is a highly dangerous condition that may lead to adverse consequences including permanent paralysis or even death. Patients with Ischemic stroke may present with various symptoms including monoparesis or hemiparesis, binocular or monocular visual loss, hemisensory deficits, Diplopia, Ataxia, Dysarthria, and reduced level of consciousness, among others (Sohrabji, 2016, p. 170). Mrs. Young presented with dysarthria as her speech was slurred, and hemiparesis, whereby she experienced one-sided weaknesses. It is important to note that such symptoms can occur singly and hence it is important to ensure that the sighting of any of them is taken seriously. Nevertheless, in most cases, these symptoms occur in combinations, as it is the case for Young. Being elderly, young is more predisposed to stroke as a result of age related factors. According to Sohrabji (2016, p. 165), aging results in reduced functionality of the critical support cells within the central nervous system, which in turn leads to malfunctioning of the circulatory network to the brain, an aspect that may result to ischemic stroke in cases where there is impaired supply of blood to the brain.
There are various nursing problems that may arise from Young’s Ischemic condition, all of which require the intervention of the nurse in order to facilitate the recovery of the patient. One such condition is the ineffective cerebral tissue perfusion, which is related to the blood flow interruption (AANN, 2004, p. 20). This problem is evidenced by the: tampered level of consciousness for the patient; restlessness and changes in the sensory or motor responses; emotional, intellectual, language, and sensory deficits; and the alterations in the vital signs. Another nurse problem common among such patients is the impaired physical mobility of the patient. Such impairment may be related to cognitive or perceptual impairment, and neuromuscular involvement in view of other condition such as paresthesia and flaccid paralysis. Impaired verbal communication is also a problem that nurses contend with when dealing with patients diagnosed with Ischemic stroke (AANN, 2004, p. 22). It is important to note that due to impaired communication, it is difficult for the nurse to establish an interactive relationship with the patient and to understand the needs of the patient, hence making it difficult to facilitate patient-centered care. In addition, nurses are faced with the problem of disturbed sensory perception which may result from psychological stress or alter sensory reception, integration, and transmission. Lastly, nurses face the problem of patient’s risk for impaired swallowing, which is related to perceptual or neuromuscular impairment (AANN, 2004, p. 27).
Nursing Problem 1: Impaired physical mobility
As earlier mentioned, one of the major problems that nurses face during their management of patients diagnosed with Ischemic pressure includes impaired physical mobility as a result of hemiparesis, spasticity, loss of coordination and balance, and brain injury (Sohrabji, 2016, p. 174). If not addressed, the problem of lost mobility may result in devastating consequences, one of which may be permanent paralysis.
The best way to assess Young’s motor function is to as her to try to walk and to observe her. Nevertheless, this may not be possible, especially in the case where the patient is comatose, which is the case in Young’s situation. In this case, Young’s motor function may be assessed via examining her response to the central pain. To do this, the nurse should squeeze her shoulder muscles. If the patient withdraws to central pain, then they are better in terms of their mobility.
If the patient is showing reduced mobility, nursing intervention is important in preventing deformities and improving the mobility of the patient. One of the interventions that could be upheld in such a case involves establishing nan exercise regime that will allow the nurse to expose the patient to a full range motion at least four or five times every day in order to regain motor control, maintain joint mobility, prevent constructures in the extremities that are paralyzed, to prevent neuromuscular system deterioration, and to enhance the circulation of blood (Sohrabji, 2016, p. 166). Motion exercises to be increased in cases where there is development of tightness in certain parts of the body.
Medication and management
The physical mobility of the patient is a problem that is mainly solved through physically engaging activities that are intended at promoting the movement of the joints and the areas that have seen reduced mobility.
Nursing problem 2: Risk for Impaired Swallowing
To assess the presence of impaired swallowing, it is important to review the patient’s ability to swallow and the pathology. During this assessment, the it is important to assess the patient’s tongue involvement, the clarity of the patient’s speech, episodes of coughing, capacity to protect the airway, and presence of breath sounds that are adventitious (AANN, 2004, p. 33). Such measures should be weighed periodically I order to note changes. It is important to note that these factors are highly important when implementing nutritional interventions.
One of the immediate interventions towards reducing the risk of impaired swallowing involves always having suction equipment at the bedside especially during the initial stages of attempting to feed the patient. This is important in ensuring that there is timely intervention in case the patient chokes as this will reduce the untoward effect of aspiration. The nurse should also promote effective swallowing by ensuring that there is enough time, preferably a minimum of 30 minutes, between the taking of medicines or engaging in activities, and eating, as this would limit fatigue while enhancing optimal muscle function. The nurse should also place the patient in an upright positon during feeding as this allows for the use of gravity to enhance swallowing. Considering the fact that Mary Young is unconscious, tube feeding may be recommended if she cannot take any of the foods orally. In addition, IV fluids may be administered to prevent the patient from developing dehydration. It is also important to ensure that the multidisciplinary healthcare delivery team is well coordinated towards ensuring that Mrs. Young’s needs are identified and met. The inclusion of an occupational and speech therapist and a dietician in the healthcare delivery team is important in ensuring that the risk of aspiration in silence is reduced.
Before discharging Mary, it is important to consider and address issues of concern to the transition process from the hospital setting where she is constantly monitored and managed, to a home setting where she may have to take care of herself, or be cared for an untrained caretaker, such as her daughter. The first issue of concern that the nurse may consider addressing prior to discharge is the is of knowledge deficit. The patient and her family may lack proper information concerning the patient’s condition, an aspect that may hamper their effective management of her condition at home. Another issue that ought to be handled is the issue of self-care deficit. This may result from cognitive or perceptual impairment and may lead the impaired ability of the patient to carry out activities of daily living (ADLs). Proper training of the patient to be self-dependent may be effective in promoting a reduction in self-care deficit. The problem of ineffective coping is also of great importance to the nurses especially when preparing patients diagnosed with stroke for discharge. It is important for the nurse to encourage the patient that they can recover from the situation in order to facilitate the patient’s acceptance of their self.
It is clear that the management of Mary is a
holistic process that requires the nurse’s understanding of the patent’s condition
and application of predetermined approaches through evidence-based practice to facilitate
the healing process. Being a highly critical patient, Mary requires close examination
by a nurse and hence effective addressing of her needs. Being unconscious,
Young cannot be able to communicate her needs to the nurse, hence it is
important for the nurse to develop other measures that will allow him or her to
understand Young and to aid her towards recovery. Prior to discharge, it is
important for the nurse to prepare Mary for the transition to the home setting
by ensuring that she is self-confident and self-aware, hence accepting of their
situation and the measures that have to be embraced towards recovery.
AANN, 2004. Guide to the Care of the Patient with Ischemic Stroke: AANN Reference Series for Clinical Practice. Glenview, IL: American Association of Neuroscience Nurses.
Sohrabji, F., 2016. The Impact of Aging on Ischemic Stroke. In: Advances in Geroscience. New York: Springer International Publishing, pp. 161-196.