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    Nursing the Patient with Complex Care Needs

    University: Middlesex University London

    • Unit No: 5
    • Level: Post Graduate/University
    • Pages: 11 / Words 2773
    • Paper Type: Essay
    • Course Code: NIP3012
    • Downloads: 282
    Question :

    Sylvester Charles

    Mr Sylvester Charles is an old gentleman who is 58 years old and lives with his wife Susie in a bungalow on the outskirts of a busy costal town. They are parents to one daughter who lives 20 miles away with her family and are very close and she calls her parents every evening and pays a visit to them twice a week. He was a Senior Manager of a well-known insurance company for a period of about 3 months ago but was becoming increasingly stressed due changes in the company that may have resulted in him being made redundant. So, he decided to take early retirement so he could enjoy a better quality of life with his Susie, who works as a nurse at a part-time job at the local district hospital. Sylvester was very much determined to be more physically active in his retirement by paying attention to his garden that was recently neglected by him and was even planning on playing more of golf frequently. Sylvester has a medical history of hypertension, hypercholesterolaemia and diabetes type 2. He even gave up smoking for about 12 months ago.

    One morning, Sylvester was found collapsed in the garden by Susie and was seen mumbling incoherently where he was not able to move the right side of his body and had even vomited. Sylvester had experienced a stroke and was then quickly called by 999 and was even taken to hospital. He was diagnosed with a left sided ischaemic stroke and given rTPA in the ED and admitted to the stroke unit.

    After 6 weeks, Sylvester was at home and making a good recovery from the left sided ischaemic stroke. He is still experiencing some kind of Anomia and Aphasia but had made himself understood. He is self-caring person but is still facing some residual weakness in the right side of his body which makes his mobility challenging at times. Susie has taken a time off from work in order to be at home with him. Soon after few weeks, she notices that he is becoming intermittently confused with a poor attention span, and even does not interact with her as well like he used to interact. He is not bothered and even has no interest in his garden or meeting with friends and family. In addition to it, he is not seen sleeping very well at night which suggests that he spends the daytime dozing in his chair. Susie tries to talk to him in order to find out what is wrong as they were a very close couple, however he tells her “there is nothing wrong”. She further assumes that he may be depressed in addition to his intermittent confusion and she is very concerned about him. Susie thought that things would continue to progress positively when he was discharged and at home and now she is becoming more upset by the current situation.

    Medications:

    Clopidigrel 75mg od

    Atorvastatin 40mg nocte

    Ramipril 5mgs od

    Metformin 500mg bd

    Aspirin 75mg od

    Omeprazole 20mg od

    You are required to review Mr Charles at home by the GP and you are assigned to conduct an assessment by using an appropriate framework and develop a care plan by identifying you prioritised choice of 2 nursing problems

    Care plan template

    Patient Name:

    Date of Birth

    Assessment

    Nursing Diagnosis/Problem (remember ‘PES’

    Goal (SMART)

    Interventions with rational (what actions will be

           

    Evaluation

    The Care Plan:

    • You are required to develop a care plan utilising the template provided for the module, once you have selected your scenario.
    • The care plan will show the use of all the stages of Nursing Process (assess, nursing diagnosis, plan, implement, evaluation).
    • The assessment of the patient will show evidence of a comprehensive assessment by using objective and subjective information from the scenario, with your own understanding in the chosen scenario and by using other assessments e.g. Waterlow score, NEWS2, MUST.
    • Explicit in the assessment section of your care plan if you to decide an appropriate assessment framework for the chosen scenario.
    • The nursing care plan will identify your choice of the 2 most important actual nursing problems in order of priority, goals, interventions and evaluation.
    • The nursing problems are required to be stated in a recognised format e.g. “Acute lower abdominal pain related to difficulty in passing urine”, goals must be SMART, the nursing interventions and evaluation must be in the context with the patient environment for the scenario – primary or secondary care
    • You are required to develop a care plan in landscape format must be submitted as an appendix and should be referred to throughout in the essay discussion.

    The Essay:

    1. Briefly evaluate the nursing care you have decide to implement for your chosen case study.
    2. It must include a clear introduction stating the aims of case study essay, what will be discussed and how it will conclude, which must be followed through in the work.
    3. Develop the planning of the care underpinning this discussion with relevant literature and clinical guidelines.
    4. Brief analysis of decision making in patient care will include the use of appropriate assessment tools. Examples such as NEWS2, Wound assessment, Waterlow score, VIP score, vital signs and fluid balance in order combine important subjective and objective data to produce an accurate picture of the patient’s complex care needs. This must be integrated throughout the essay.
    5. Briefly state the cause of the two identified nursing problems and the factors that influence the care planned for the patient.
    6. It must be underpinned with a rationale appropriate for Level 6 study for the nursing care/interventions; show application of relevant pathophysiology and include application of relevant pharmacological/non-pharmacological interventions.
    7. Briefly state the relevant and up-to-date supporting literature/evidence/clinical guidelines to show knowledge and understanding from the taught module content and application to practice.
    8. Determine the roles of any MDT members where relevant that would be involved.
    9. The concluding part of the essay will analyse the nursing care to show an appreciation of the need to evaluate nursing care. It will need to debate achievement/non-achievement of the nursing goals and the evidence to support this.
    10. Safe care is a must be shown throughout the whole discussion.
    Answer :

    INTRODUCTION

    A care plan has been defined as the care needs and certain types of services which are provided to needy people in order to meet their needs. The support and care planning are considered as series of facilitated interaction in which both the nurse as well as the patient actively participates and explore ways through which the health issues can be managed either non pharmacological or pharmacological ways (Gausvik and et.al., 2015). A specific care plan assist in providing direction for clients care depending upon their diagnostic list and needs. The report is based on case study of Mr. Sylvester Charles who has a history of hypertension, hypercholestrolaemia and diabetes 2 and recently being diagnosed by left sided ischaemic stroke. The report is based on formulation of care plan of Mr. Charles by carrying out assessment using Activity of Daily Life framework.

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    MAIN BODY

    Charles has a history of hypertension, hypercholestrolaemia and diabetes 2, one morning he fainted which was due to left sided ischaemic stroke. Due to such condition, he was experiencing anomia and aphasia which made him less expressive. Susie noticed that he has become periodically confused with poor attention and insomniac condition. Some medications like Clopidigrel, Atorvastatin, Ramipril, Metformin, Aspirin and Omeprazole have been used by subject to cope up with above issues. All such practices making him more weak and confused, because of such situation an effective care plan has to be made for assessing the issues more deeply and organising the plan which has to be taken for improving the condition of subject. Care plan will be made for left sided ischaemic stroke and type 2 diabetes which will focus on nursing diagnosis, goals, intervention, rationales as well as evaluation plan. The formulated care plan for Mr. Charles are designed below.

    Patient Name: Sylvester Charles Date of Birth: February, 1962
    Assessment Nursing Diagnosis/Problem (remember ‘PES’) Goal ( SMART) Interventions with rational ( what actions will be required to address the identified problem)

    1) Left sided ischaemic stroke For assessment of such problem some major test needs to be run for evaluating what type of stroke has been strike in patient by nurses and doctors. Some test are:

    Physical exam – The doctor will examine the body by carefully listening to the heart beat and checking the blood pressure. Some neurological examination will also be conducted in order to monitor how does the stroke has affected nervous system (Song and et.al., 2015).

    Blood test – Various blood test may be run for checking how quickly the blood of patient gets clots. Such test also help in determining the blood glucose level as well as the possibility of infection. Computerized

    Tomography scan (CT) – Such type of scan utilises an array of X rays for building an image of brain. A CT scan show actual picture of bleeding in brain or reflects the condition of tumour or ischaemic stroke. A dye may be injected in patient bloodstream to view blood vessels of brain or neck.

    Magnetic Resonance Imaging (MRI) – It is one of the most powerful technique which requires powerful radio waves and magnets which aids in creating elaborated view of brain. MRI can effectively detect damaged brain tissues which may be caused by ischaemic stroke or haemorrhages.

    Carotid ultrasound – Sound waves are used in this test to create defined image of carotid arteries which are present in neck. Such test highlights the are which are being deposited by fats and may block blood flow.

    Echocardiogram – In this also sound waves are used to make an image of heart, the image helps in identifying source of clot which may be a reason of causing stroke.

    2) Type 2 diabetes For assessment of type 2 diabetes several test are being conducted for diagnosing by doctors as well as nurses. Some test are:

    Blood sugar test – These test are expressed in milligrams or milimoles. The test is not relied on eating pattern rather it is a random blood sugar test which simply indicates the level when being tested.

    Fasting blood sugar test – The blood sample is drawn out after overnight fasting. Less than 100 mg/dL indicates normal level of sugar. A reading above 100 to 125 mg/dL is pre diabetic while higher than this reading during fasting period is said to be diabetic.

    Glycated haemoglobin test – By the help of this test, the average sugar level of past 2 to 3 months can be indicated. The test give a constant idea about the level of sugar determining whether a person is pre diabetic or fully diabetic.

    The nursing diagnosis related to ischaemic stroke are less family coping, poor attention, confusion, anomia and aphasia. The nursing diagnosing problem in diabetes are weakness, irregular sleep pattern, does not interact with any family member, risk of infection or injury and mobility problem. Patient will improve level of motor and cognitive function within 2 months. Patient will show stable signs and no deterioration of health within 2.5 months . Patients blood glucose level less then 180 mg/dL within 1 months. The fasting glucose level will be less than 140 mg/dL within 2 months. Stroke
    • The nurses keep sure that the head of patient are little elevated as well as slightly in neutral position. The benefit of such intervention helps in lowering the arterial pressure by regulating the venous drainage and at the same time improving the perfusion level (Matney and et.al., 2016).
    • Various factors are assessed for lowering the cerebral perfusion as well as evaluating the intracranial pressure. Such type of assessment will further aids in determining and at the same time affects the choice of intervention. Degradation in neurological signs for regulating after the initial consultation may reflect the lowered capacity of transferring the patients to critical unit of medical care for evaluating ICP. Progressive treatment is very essential in case of such patient who are deteriorating their health after stroke.
    • Assessing as well as closely monitoring the neurological status frequently assist in understanding the level of consciousness and enhanced ICP. The location of exact damage can also be determined by comparing the baseline as well as the recent neurological state (Sheppard and et.al., 2015). Transient ischaemic attacks are also determined by such intervention which ultimately help in warning about stroke.
    • Maintaining environment which promote bed rest and relaxing surrounding. Clustered nursing intervention can be employed in between the care activities which help in enhancing intracranial pressure.
    • Nurses provide Clopidigrel with aspirin to patient for lowering the chest pain. It also assist in keeping the blood vessels wide which further prevent in formation of blood clots. Clopidigrel effectively block the creation n of harmful clots which can further help in managing risk.
    • Errors which can be easily heard in conversation with patients should be carefully noted according to which feedbacks must be given. Such practice assist the patients in understanding that they are not interacting properly or clearly, due to this they try to maintaining a good verbal chat by clarifying meaning (McManus and et.al., 2015).
    • Altering the position in every one or two hour minimise the chance of tissue injury. The affected side by stroke has poor circulation as well as less sensation. Such procedure can thus act as a therapeutic intervention.
    • Nurses try to keep the patient in prone position for limited period of time, this help in regulating the hip extension and physical movement.
    • Various props like footboards are utilised for supporting the head and making sure that blood circulation is not hampered by any sharp object (Doenges, 2019). Using arm sling in such cases also help in lowering shoulder pain and problem.
    • Proper exercise should be engaged in daily routine by moving the hand and arm at different level for preventing the oedema. Hard hand rolls should be placed between palm and fingers for making high stimulation and it also aids in keeping the thumb in functional position. Such practice also help in coping up with the issue of sleeping problem.
    • Vitals should be kept as same pace which aids in stabilising the blood pressure and eventually reduces the chance of getting injury. Pad chair seat and water filled cushions may be utilised for preventing skin breakdown.
    • Ramipril is administered by nurses for maintaining the blood pressure at normal pace. Aspirin is provided to eliminate all kind of pain and to comfort the subject which consequence in sound sleep (Agyeman-Yeboa, Korsah and Okrah, 2017).
    • Electrolyte balances and proper fluids must be kept in check which assist in removal of confusion and make the patient attentive. The nurse in such case should take help of whole family to make Mr. Charles feel comfortable in home environment for family coping and confusion.
    Diabetes type 2
    • Signs of hyperglycaemia can be assessed which results in evaluating whether there is a adequate amount of blood insulin is present when compared to glucose. High glucose may imbalances the osmotic level which may disturbs the level of hunger, thirst and urination. For such reasons the blood glucose level should be monitored before and after eating meal in order to keep a balance in ration of insulin and glucose.
    • Proper as well as balanced diet must be provided to the patient for eliminating the issue of weakness. Such issue makes a patient less effective in moving (Westra and et.al., 2015).
    • Metformin is given to subject with managed exercising programmes and proper diet. It has been used for controlling high sugar level in blood. Type 2 diabetic patients, that is Mr. Charles has given such medication which altogether aids in preventing blindness, nerve issues, sugar level and many more.
    • The signs of infection, fever, sputum and urine must be check time to time for preventing the spread of infection or injury. The nosocomial infection may also create problems which can be managed by maintaining proper health hygiene and promoting the value of hand hygiene.
    • Asepsis condition must be maintained while administering the medicines and applying insulin injections, such practice assist in regulating sterile condition so that no infection can be initiated.
    • Less mobility and poor attention made the subject to rely on assistance of nurse or any family member. Due to such circumstances, perineal or catheter care are provided so that the patient does not have to move from one location to bathroom. Such practice should be completed in most sterile way, thus nurses must clean devices carefully to eliminate the risk of urinary tract infection.
    • Peripheral circulation may got impaired due to bed rest which can be managed by providing gentle massage in areas to make the skin dry free and allow the blood circulation to go through spontaneously. Massaging at night may also help in reducing the disturbed sleep cycle and further helps the client to sleep at night (Stade and Dykes, 2015).
    • Eating habits must be discussed and nurses should encourage in relying on balanced diet so that all health needs and requirements are fulfilled timely and patient do not feel weakness at any point.
    • The exact feelings of clients should be listened thoroughly. This practice aids in recognising the actual problems which are facing by client. All family members should express their thought and experiences with one another so that they can interact with each other on daily basis and patients can become clear about the motives.
    • Light exercises is important not only to keep the blood glucose level to optimal rate but also to make light movements in order to make the clients make some physical moves.
    • Pulse rate, glucose level, respiration rate, blood pressure must be evaluated on time for checking the fatigue condition. Uninterpreted sleep must be ensured by giving them sleeping pills or involving them in some activities which can make them physically and mentally exaggerated. All practice assist in preventing fatigue.
    • By involving the subject in motor activities like walks and indulging them into playing broad games or drawings. Such roles are observed to prevent the issue of depression. The tension gets relieved and mood of such patients gets lighten and they are seen to manage the anxiety as well as stressed level optimally.
    Evaluation – From the above care plan it can be evaluated that patient earlier showed resistance in receiving interventions and medications. After two or three days, the client was quite adjusted and then all assessment followed by interventions are rendered to Mr. Charles at various time period. The blood glucose level was almost met at the given time but the problem of depression and confusion took a long time. Susie was happy to see that her partner was now talking to her better than earlier. The sleeping pattern was hard to manage, because the condition was worse. After proper exercising and medications the situation got into hand and lots of improvements were observed.

    Activity of Daily Life framework are terms which have been used in the domain of health care for denoting various self care activities either in patients home or in other environment. There are some activities which are very basic and should be conducted on their own n order to make their life functioning better (Kaakinen and et.al., 2018). Some individuals have seen to avoid such activities because they can not perform such task on their own. In such case they need a professional assistance. ADL are utilised as a way of measuring an individual's functional status, which are highly essential to perform in order to survive. An assessment can be made by evaluating whether the subject is capable enough to carry out their basic functional needs.

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    Personal hygiene is one of such activity which must be maintained that include grooming, bathing or hair care. Continence management is another framework which monitor the ability of individuals mental or physical ability to use bathroom. Dressing and feeding are another variables which evaluate whether they can easily feed or dressed all by themselves or they require hand of some nurse or care providers. Ambulating is another element which confers people to change from one position to another or to walk without any kind of assistance. Such type of framework are made to evaluate the level of help a patient need in order to make their life going. Memory care can be regarded as ADL which are required to keep mental functioning like mobility, attention clearly. Mr. Charles being a patient could not ambulate, take care of memory or take good personal hygiene due to his poor attention, confusion and disturbed sleeping pattern. Proper assistance is required to such subject in respect to make him do all such activities which are essential to keep the processes of life stable.

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    CONCLUSION

    From the above report it can be concluded that, the care plan is defined as the attention needs and definite types of services which are rendered to demanding people in respect to meet their needs. The care and support planning are considered as series of facilitated interaction through which the health problems can be managed either pharmacological or non pharmacological ways. The Personal hygiene, continence management, dressing and feeding, ambulating as well as memory care are some ADL which are utilised in assessment and formulating care plan.

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