CHRONIC AND COMPLEX CONDITITIONS: Chronic & Complex – Cast Study PART B

Introduction

Chronic Renal Failure and Diabetes

The problem of chronic and complex health conditions has rapidly increased to become a serious medical and public health challenge. Because people with chronic conditions experience suboptimal health outcomes, as well as incur increasing healthcare expense, improved medical attention is essential to enhance healthcare quality (Smith, 2012). In fact, providing quality care to people with chronic illness is a big challenge to health providers given the complex clinical care management required. The aim of this research study is to explore nursing care involving Mr. Luigi who is suffering from worsening renal functioning, poorly controlled diabetes mellitus and leg ulcer. The paper will examine the guiding principles as regards to the role of registered nurse (RN), nurse planning, nursing interventions and interdisciplinary team collaboration for Luigi who is being stabilized for his diabetes, wound dressing and mobility support.

Guiding Principles of Chronic Conditions

Healthcare has become more complex owing to expanding co-morbidities, aging population, and increase in available options for health interventions. Management of complex and chronic diseases like diabetes and renal failure constitutes a prime burden of health care globally. In order to enhance patient outcomes, guiding principles of chronic conditions have gained relevance and prominence in recent times. These principles include advocacy, self-care, and patient empower.

Self-management refers to the ability of the individual to manage the disease process, the changes that take place in daily living and the emotional corollaries of living with the condition. The self-management framework acknowledges that individuals must deal with both the disease and its consequences, and the effect it imposes on own life. It recognizes the core role of the patient/family in disease prevention, health promotion and effective disease management.

The guiding principles behind self-management are patient-led, nurse-facilitated processes, otherwise called patient-centered care. This requires that care planning for each patient to be personalized so that their individual needs, choices, and prevalence are met (Trehearne, 2014). In regard to Luigi’s case, the nurse should involve the patient /family in decision making by way of tapping on the patient’s social, cultural, spiritual and physical concerns.  Involving Luigi in decision making will not only promote cooperation but also improve adherence to treatment regimens for better outcomes. In patient-centered care, the nurse informs Luigi of his expected roles, the available interventions and expected outcomes.

Another important principle that implies to Luigi’s case is self-care. In self-management, the purpose of self-care is to improve the capacity of the patient to take control of is own life. In the case study of Luigi, the patient should be helped to improve his self-management and problem solving skills and take responsibility of his own life. Luigi seems to have poor self-management skills as characterized by poorly managed blood glucose levels and overweight due to poor diet. Evidence suggests that care plans integrating self-management skills can improve health outcomes (Chang & Johnson). Self-manage is not only a process where patients are educated and trained on certain skills, but it is also an outcome when persons with chronic conditions attain the knowledge and skills to manage the emotional and medical facets of their condition. On their part, the health providers work collaboratively with the individual offering self-management support in order to achieve the common goals.

Patient empowerment is a patient-centered, collaborative approach which helps patients develop the capacity to take control of their lives. Empowerment is not confined to certain health behaviors, interventions or strategy; it is also a vision for helping individuals to make decisions concerning their health (Tol, 2015). In other words, empowerment focuses on maximizing the capacity of Luigi take control over and make decisions about his own health. Empowerment will improve Luigi’s confidence and problem solving skills to manage his condition and to accept reality.  The primary goal of healthcare providers is to increase the capacity of Luigi to make informed decisions, as well as choose meaningful, achievable goals (Collins, & Rochfort, 2016). Empowering patients is a demonstration of respect for the patient’s ability to participate in their care.

Advocacy involves defending or protecting the patient’s interests and these interests must reflect patient-defined aspirations and needs. Luigi requires prompt assistance and easy access to address his pressing situations and the role of the nurse is to ensure has the necessary tools, resources and skills to manage his condition. As patient advocate, the nurse communicates with patients, their families and other health professionals to obtain comprehensive information for use in implementing care plan. They prepare appointments and perform tests and serve as gatekeepers. The advocate employs external resources by coordinating care, making referrals. In relation to preventive care, the nurse can work with Luigi to prevent complications associated with diabetes and leg ulcer.

Role of Registered Nurses in Collaborative Teams

The RN play important roles in care management of chronic conditions, such as coordinating care, assessing the patient’s knowledge level of the disease process, making referral, and advocate for patient needs (Lin et al, 2012). These roles are applicable to Luigi’s case.

The registered will nurse coordinate multidisciplinary team in the management of Luigi’s chronic condition. Leading the interdisciplinary team in managing Luigi’s condition, the RN shares information with the team, identifies opportunities and resources for improving the care.  The nurse also ensures that Luigi has access to appropriate intervention or service within a reasonable timeframe (Chang & Johnson, 2014). The coordinating nurse brings together a rich experience, skills, and knowledge in the intervention planning to manage the concerns stemming from the patient and family. To provide patient-centered care, the registered nurse serves successfully within inter-professional and nursing teams, promoting open communication, shared decision making and mutual respect (Laughlin, & Beisel, 2010).

The nurse is also involved in patient assessment in order to establish goals and create care plans. The nurse assesses Luigi’s personal experience and knowledge of the disease process for the purposes of planning. Registered nurses are the first health professionals to assess the health status of the patient. They intervene when clients experiences adverse events. The assessment by nurses in charge of multidisciplinary program has been found to bear significant clinical influence on clients with long term conditions (Chang & Johnson, 2014).

Another role of the nurse is to provide the educational element of the intervention. They provide patient education, as well as support the patient in self-management to attain treatment goals (Schoenly & Knox, 2013).  This involves educating Luigi how to deal with the practical and emotional aspects of the chronic condition.

The RN also can provide social support to the patient/family as far as self-management is concerned. Luigi and his patient need emotional and psychological support to accept their reality of their condition to self-manage their lives.

As an advocate, the nurse is responsible for defending the patient against rights violation, exploitation, and unethical practices. The nurse can intervene on Luigi’s behalf, and advocate for his many other needs.

Interdisciplinary Collaboration

Healthcare has become more complex owing to expanding co-morbidities, aging population, and increase in available options for health interventions. Management of complex and chronic diseases like diabetes and renal failure constitutes a prime burden of health care globally. Therefore, the care management of these conditions requires multidisciplinary approach. In Luigi’s care management, the nurse will lead interdisciplinary team consisting of diabetes education, nephrologist, dietician, pharmacist, endocrinologist, psychologist, social worker, and rehabilitation professional.

The nurse will collaborate with the nephrologist to regularly assess and screen Luigi for complications and design care plan to reduce such complications (Johns, et al., 2015). Because diabetes is an endocrine condition, the collaboration of the nurse and the endocrinologist is vital to assess the functioning of endocrine system. The role of the endocrinologist is to assess the functioning and integrity of endocrine organs, liver and kidney (Johns, et al., 2015).

Complex conditions like renal failure and diabetes can increase the risk of depression. This is where the psychologist comes in to offer counseling on how to deal with emotional and psychological turmoil associated with this Luigi’s condition. Furthermore, nutrition will play an essential part in stabilizing Luigi’s blood sugar. The dietician is needed to advise Luigi on appropriate diet to manage his condition.

The pharmacist is required to advice Luigi on dosage and adherence, and education the patient on the side effects and other adverse events of drugs (Johns, et al., 2015). The social worker will assist Luigi to get required resources and link Luigi to important community resources like social groups.  Other professionals to be included in this interdisciplinary team include podiatrists, rehabilitation professionals, and dermatologists (Johns, et al., 2015).

Nursing Assessment

Mr. Luigi has lived for 15 years with poorly controlled diabetes mellitus. His blood glucose levels have increased and he is overweight. He leads sedentary lifestyle and pays less attention to his diet. After experiencing blurred vision and swelling on the ankle, Luigi visited a hospital and was diagnosed with chronic renal failure. He is unable to walk without support aide. He is also suffering from pressure ulcers.

Based on the case study of Mr. Luigi, the following diagnoses can be identified: knowledge deficit about the condition and its consequences, impaired physical mobility, excessive fluid volume associated with renal failure’s to remove excessive body fluid, and disruption of family processes.  The goal for patients with chronic renal failure is to reduce further complications, as well as provide supportive care.

Nursing Diagnoses: Stabilization of Blood sugar Level

The nurse will give priority to Luigi’s poorly controlled blood sugar level. Stabilizing his blood sugar level is essential in lowering risks like hypertension, edema, weight gain and renal failure. Regulation of blood sugar will also facilitate quick wound healing (Sá, Cavalcante, Stival, & Lima, 2011).   Among the interventions that the nurse will weigh in include administering intravenous insulin. The purpose of this anti-diabetic drug is increase gluconeogenesis and glycolysis in order to effectively manage blood glucose. The nurse will also administer oral hypoglycemic drug to stimulate the pancreas to secrete insulin.

The nurse will also consider nutritional intervention. The nurse will identify nutritional diets that can stabilize Luigi’s blood glucose.  Diets rich in lower sugar are known to stabilize blood glucose.

Nursing Diagnosis: Wound Care

Poor wound healing observed in people with chronic renal failure like Luigi is due to poorly controlled diabetes mellitus, aging or neuropathy (Bluestein & Javaheri, 2008). Pressure ulcers can also result from poor nutrition. Luigi has all the three conditions present. Without proper care, Luigi’s wound could lead to serious complications like bacterial infection and necrotic tissue growth. The goal of wound dressing is to control infection and relieve pain.

The nurse will intervene by carrying out daily cleaning and dressing in order to minimize bacterial load and help preserve a moist wound environment for the purpose of facilitating healing (Bluestein, & Javaheri, 2008). Dressing is important as it reduces caregiver time, offers consistent moisture and cause less discomfort.

The nurse may also perform skin care and nutritional assessment determines if they are connected to ulcer pressures. If that is the case, the nurse will consider skin moisturizers and dietitian consultation as preventive measures. The patient will be encouraged and educated to consume adequate diet using his favorite foods, snacks and receive mealtime assistance (Bluestein, & Javaheri, 2008). Supplements and high calorie foods are recommended to prevent further malnutrition.

Management of wounds require multidisciplinary care (team-based collaborative approach) comprising of dietitians, primary care doctors, wound-care and home nurses, podiatrists, rehabilitation professionals, dermatologists, and psychologists. Pressure ulcer care management involves reducing skin pressure, managing colonization and bacterial load, and wound cleansing (Bluestein, & Javaheri, 2008).

Assessment: Impaired Physical Mobility

Luigi suffers impaired physical mobility typified by changes in walking due to loss of integrity of bone structures and slow movement. He is unable to walk with the support. This may have been caused by sedentary lifestyle, poor diet, and aging of course. The planning outcome is to improve physical mobility and coordinated movement.

Intervention: Improving Physical Mobility

The nurse should asses Luigi’s physical mobility in order to determine the extent of the physical impairment and provide assistance in self-care, advice with respect to the traction care, caloric energy control, and fall prevention. The patient will be encouraged to create cramps for facilitating the ambulation.

The patient will be assessed for pain (location, frequency and intensity) and circulation.  The patient will be provided with assistive devices and aides to prevent fall, balance the walking.  The patient will be taught and encouraged to practice physical activities. Exercise therapy can improve mobility and functional status.

Nursing Assessment: Deficient knowledge

Luigi has knowledge deficit about the condition and self-care typified by lack of attention to control blood glucose levels, poor diet and lack of general knowledge about the condition. The planning outcome is to increase knowledge about the health problem and associated treatment.

The Nurse will assess Luigi’s understanding of the cause of chronic kidney failure, what this means, its consequences and related treatment. Luigi may have no prior experience with the cause, consequences, and treatment of renal failure. The nurse will clearly explain the renal function, corollaries of kidney failure using appropriate means of communications that the patient understands best. The nurse will also provide written and oral information about dietary and fluid restrictions, reportable problems, medications, treatment options, community resources to access, symptoms and signs. Psycho-education entails a package of educational elections and information associated with a disease process, together with its treatment, focused on improving patient awareness, understanding and disease management.

Support for the Family

The management chronic condition of Luigi may interrupt family processes and support is necessary in this respect (Pillitteri, & Pillitteri, 2010). The support services required of the nurse include home visiting, connecting, connecting Luigi and his family to existing community resources and services.  The goal is to improve support system, psychosocial adaptation and cope with life changes. Patients such as Luigi require social and psychological support to enhance their social and emotional functioning.

Psychological support entails providing psycho-education to Luigi and his family to adapt to the reality of their lives.  The patient and his family will receive counseling and education on renal function and its consequences so that they can make informed decisions and take responsibility to manage their condition. The healthcare provider will increase the capacity of the patient/family to make decision. Involve the family in decision making and discussions, and help the family understand the need for hospitalization.

Family members will be given the opportunity to express their fears, anxiety and frustrations. The family will be allowed to make regular visits and time to spend with their loved one.

Family members will be encouraged to participant in the patient’s health team. This will facilitate involvement of the family in multidisciplinary planning (Gulanick & Myers, 2011).

 

Reference

Bluestein, D., & Javaheri, A. (2008). Pressure Ulcers: Prevention, Evaluation, and Management. American Family Physician, 78(10):1186-1194.

Chang, E., & Johnson, A. (2014). Chronic illness & disability: Principles for nursing practice. Sydney : Churchill Livingstone/Elsevier

Collins, C.,& Rochfort, A. (2016).Promoting Self-Management and Patient Empowerment in Primary Care. In Oreste O. Capelli Primary Care in Practice – Integration is Needed (12-56). InTech Distrubuters

Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and outcomes. St. Louis, Mo: Elsevier Mosby.

Johns, T. S., et al. (2015). Interdisciplinary care clinics in chronic kidney disease. BMC Nephrology, 16:161-169.

Laughlin, C.B., & Beisel, M. (2010). Evolution of the chronic care role of the registered nurse in primary care. Nursing Economic, 28(6), 409–414.

Pillitteri, A., & Pillitteri, A. (2010). Maternal & child health nursing: Care of the childbearing & childrearing family. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Sá, D., Cavalcante, A. M., Stival, M. M., & Lima, L. R. (2011) [Nursing clinical trial in patients on hemodialysis]. Rev Enferm UFPE, 5(2):165-73.

Schoenly, L., & Knox, C. M. (2013). Essentials of correctional nursing. New York, NY: Springer.

Smith, S.M. (2012). Managing patients with multi-morbidity: Systematic review of interventions in primary care and community settings. British Medical Journal, 345, e5205.

Tol, A. et al. (2015).An empowering approach to promote the quality of life and self-management among type 2 diabetic patients. Journal of Education Health and Promotion, 4:13-17

Trehearne, B. (2014). Role of the Nurse in Chronic Illness Management. Nursing Economics, 32(4), 178-184

 

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