The main scope of this assignment is to demonstrate a detailed discussion about the patient, who is presented in the Viva Voce. The paper will mainly investigate all the pathophysiological and pharmacological changes in relation to the patient healthcare. Following this discussion, the paper will assess the need of the patients and will provide a detailed recommendation for drafting person-centred care plan for the patient. At the end, the paper will reflect on the feedback on the professional experience as provided by the facilitator.
In relation to the basic introduction of the patient, it can be said that for confidentiality reasons this paper will not reveal the original name of the patient and other personal details. Written consent was taken from the patient to go through tje case notes for the assignment before Viva voce and was thoroughly viewed by the facilitator. This paper will go with the name Mrs. X in order to discuss about the case of a 94 year old female who lives alone in SA housing with support from family members and friends and minimal services from the commonwealth Home Support Program (CHSP). She was admitted at Milpara Residential Living-ACH group due to mobility related problems on July 2018. Prior to this, she was under care of her GP for 20 to 30 years however, during the course of time, she gradually become confused and unsafe on her mobility so she was transferred to the aged care facility. She has recently lost her grand-daughter due to breast cancer and is depression and her lack of proper vision also increases her sense of depression and increase in the tendency of accidental falls. At residential care, she was promoted to use 4WW (walker wheel) round the clock. She also has regular/ unmodified fluid consistency and needs verbal encouragement for increase in the intake of fluids. She is also anxious and gets easily confused about her diet and mostly prefers sandwich.
According to her daughter, she has frequent loss of memory and has sleep anpea, diabetes along with low potassium level of the body. Her past medical history also included hypertension, hyperlipidaemia, atrial fibrillation and vitamin B12 deficiency and Glaucoma. Her current medications include Alprazolam, Amlodipine, Pantroprazole, Karvezide, Eliuis and Atorvastin along with Duro-K Slow release tablets. The future discussion about the pathophysiology and pharmacological changes leading to her admission is discussed below.
The primary concern is increased in the tendency of the accidental fall. The main underlying factor behind increase in her tendency to accidental fall is her age. According to Ambrose, Paul and Hausdorff (2013), people who are above 65 years of age have increased tendency of accidental fall due to slippage of loss of body balance. Mrs. X is 94 years also and according to the narration highlighted in the case study, Mrs. X has unsteady gait and has difficulty in rising from the seated position and recurrent falls at homes. Ambrose, Paul and Hausdorff (2013) highlighted that major risk factors, which are identified behind the increased tendency of fall among the older adults include gait, polypharmacy and previous history of accidental fall. Other risk factors include advancing age, visual impairments, vfemale gender, cognitive decline in attention and executive dysfunction. After age of 40 years there occurs menopause in women, this further hampers the bone health and increases the tendency of developing osteoporosis. Menopause or perimenopause decreases the secretion of estrogen and this cause loss in the bone mass and bone fragility (Manolagas, O’brien and Almeida 2013). Mrs. X also has dementia and this demented condition is another reason behind her increased in the tendency of fall. According to Jansen et al. (2015), dementia is a symptom of a variety of specific structural brain disease, which leads to the degeneration of the neural impulses along with impairment in the neurotransmitter. This imbalance in the neurotransmitter leads to difficulty in the hand eye co-ordination leading to the increase in the tendency of accidental fall. Mrs. X also had previous case history f Glaucoma, which might also increase her vision loss with age (Bourne et al. 2013). Jansen et al. (2015) further highlighted that dementia hampers the cholinergic neurons and gradual destruction of the pyramidal cells in the cerebral cortex, which creates difficulty in moving joints increases the fall tendency among older adults. Mrs. X past medical history also indicated that she has Vitamin B deficiency. Dai and Koh (2015) argued that nutrient deficiency mainly accelerates the bone loss thereby leading to osteoporosis that increases the propensity of fall. Mainly calcium and vitamin D are regarded as the pillars of maintaining bone health however, the several reviews have highlighted that Vitamin B also plays a major role in regulating bone health. Vitamin B has a direct relation with the biomarkers, which decreases bone mineral density and increases in the risk of osteoporosis (Bailey et al. 2015).
Her current problems also include diabetes and hyperlipidaemia and hypertension. It is due to her hypertension of high blood pressure, her current medication include amlopinine. Amlopinine is an angioselective calcium channel blocker which inhibits the influx of the calcium ions into the vascular smooth muscles and thereby helping to inhibit the contraction of the health muscles and the vascular smooth muscles which in turn reduces the blood pressure (Joshi and Bansal 2013). Another medication that is given to Mrs. X in order to reduce blood pressure is Karvezide. From the present condition of Mrs. X indicates that she has the tendency of developing cardiac complication as she has high blood concentration of lipid, high blood pressure and high blood sugar level. According to Marso et al. (2016), high blood glucose level damages the blood vessels and nerves that control heart functioning which increases the tendency of heart attack. Moreover, people like Mrs. X are more vulnerable in developing cardiac complication because, she has high blood pressure, she has past history of smoking and drinking and high blood lipid level along with lack of physical activity. Thus in order to treat her blood cholesterol level or hyperlipidemia, Mrs. X current medication list contains Atorvastatin. Atorvastatin is a selective yet competitive inhibitor of 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA reductase). HMG-CoA is a rate-limiting enzyme that converts 3-hydroxy-3methylglutaryl-coenzyme A to mevalonate, a precursor of sterols, including cholesterol. So inhibiting HMG-CoA decreases the level of cholesterol in the body (Waters et al. 2013).
Mrs. X also takes Alprazolam. Alprazolam belongs to the class of benzodiazepine anxiolytic. It is a minor tranquilizer and is used as a medication against anxiety (Stein 2015). She is also given Mirtazapine as an anti-depressant as she is depressed since sudden death of her granddaughter out of breast cancer. This anti-depressant medication has dual action. It is regarded as noradrenergic and specific serotonergic antidepressant (NaSSA) which acts via antagonizing the adrenergic alpha2-autoreceptors and alpha2-heteroreceptors and thus controlling the depression (Walker 2013).
Mrs. X was initially admitted to Queen Elizabeth hospital following her accidental fall in the weed of her garden on January 2018. She became unconscious and did not recall her fall. As she was not reliable with her mobility, she was admitted to ACH-Milpara residential living. Her vital signs denoted on first day of admission include high blood pressure 165/85 mmHg. According to Cornelissen and Smart (2013), hypertension is classified when the systolic pressure is above 140 mmHg and the diastolic pressure is above 90mm Hg. This from the observation it can be said that Mrs. X has high systolic pressure. Going through her case notes it can also be highlighted that her pulse rate: 88, respiratory rate: 22. According to Berman et. al. (2015, pp. 577-99), the normal respiratory rate is between 14 to 18 breaths per minute thus it is evident from the observations that she has higher respiratory rate at the time of admission. Her body temperature was normal 36.5 degree Centrigrade and 96% of oxygen saturation along with an ECG report of 500 beats per minute. Her poor ECG reports established the linkage of her past medical history of atrial fibrillation during the year 2010. At ECG 500 beats minute, the atrial walls do not produce organized contractions instead they quiver leading to atrial fibrillation (Martini, Nath and Bartholomew, 2014, p.767; Porth 2011, p. 474). According to Ruff et al. (2014), atrial fibrillation requires anti-coagulation therapy and constant monitoring. It is due to this reason that Mrs. X medicine list contains Eliquis Tablets, which is an active apixaban. It helps to prevent blood clot via blocking Factor Xa (an important component of blood clotting). Her potassium level in the blood was initially higher than the normal but was back to normal after some time. However, her blood cholesterol level was found at the border recording 240 mg/Dl.
Her physical assessment revealed that she was having fragile skin and thus the patient care plan includes wound chart assessments. According to Kirkorian et al. (2014) proper wound assessment helps in evaluation of the wound care options for the older adults who have fragile skin. Additional nursing care plan that has been included in case of Mrs. X will be regular monitoring of the blood glucose level for the effective management of diabetes (American Diabetes Association, 2015). Regular monitoring of the blood pressure level was also recommended in order to proper regulation of the atrial fibrillation and other associated cardio-vascular complications (O’brien et al. 2013). The physical assessment also revealed that she has elongated toenails. Elongated toenails can cause harm to her fragile skin creating further provision of wound. However, due to diabetic condition, the healing of wound might take time and thus proper podiatry assessment and care is mandatory (Powers et al. 2016). Podiatry management will help Mrs. X to take proper care of her wound as she was unable to do the same due to lack of proper eye-sight and gait related problems.
Thus the observation revealed that major risk factor for Mrs. X is apart from her increase in the tendency of fall is proper monitoring and treatment for cardio-vascular complications like atrial fibrillation, proper management of the blood glucose level in order to control diabetes and effective podiatry management to maintain basic hygienic regulations. Moreover, her fragile skin also demands immediate concern.
The recommendation for Mrs. X mainly included proper exercise and balanced diet. Rigorous physical exercise might not be an option for Mrs. X taking her age and health into consideration but regular physical activity at a mild to moderate level will help to reduce the chances of unwanted fall (Giné-Garriga et al. 2014). Special tai chai exercise can further help to increase her muscle agility and reducing the tendency of fall as reported by the study conducted by Tousignant et al. (2013) in frail older adults. A physiotherapist will also help to promote the muscle agility of Mrs. X (Ambrose, Paul and Hausdorff 2013). The interiors of the room must be spacious, with less use of furniture and slip resistant floor in order to reduce the fall rates further (Ambrose, Paul and Hausdorff 2013). Maintenance of proper diet will help to regulate her blood glucose level and thereby helping to control diabetes. This proper management of diet (loss salt and no sugar) can be undertaken under the effective monitoring of a professional dietician. The dietician will help to frame a cyclic diet, which will be rich in nutrients and thereby helping to break to monotony (American Diabetes Association 2015). In order reduce the chances of fall further use of 4ww is mandatory. Since she also suffers from vision loss, 4ww will promote independent movement along with reduction in the fall rates and injuries (Ambrose, Paul and Hausdorff 2013). In order to cope up with her elongated toenails, use of right shoes in top-toe shape and regular cutting of nails by direct carers will be helpful along with the use of emollient cream. Proper mental health counseling will help her to recover from depression and anxiety. Moreover, it will be the duty of the nurse to indulge in effective communication with Mrs. X. This will help to occupy her mind and stay away from depressive thoughts (DiCenso, Guyatt and Ciliska 2014, pp: 102-105).
The reflection provided by my PEP facilitator was very encouraging and had a positive attitude. My PEP helped me to get a clear idea regarding what to do. My facilitators praised me for my skills of effective engagement to learn new things and thereby building up therapeutic relationship. My PEP also highlighted that I need to work on my communication skills in order to overcome my introvert nature. My facilitator also instructor me to use proper evidence based approach while devising care plan for the patient and this goes in accordance with the finding of DiCenso, Guyatt and Ciliska (2014, pp: 37-40).
This placement was a great experience and it will help to refine my professional career further as a registered nurse. Proper knowledge about by professional responsibilities will help in my practice. The self-reflection and self-evaluation also helped me work on my drawbacks. According to Asselin and Fain (2013) self-reflection is a better way to work critically of the drawbacks. A nurse is required to practice in a reflective mode, and Nursing and Midwifery Board of Australia (2016) further propose this concept.
References
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American Diabetes Association, 2015. Standards of medical care in diabetes—2015 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 33(2), p.97.
Asselin, M.E. and Fain, J.A., 2013. Effect of reflective practice education on self-reflection, insight, and reflective thinking among experienced nurses: A pilot study. Journal for nurses in professional development, 29(3), pp.111-119.
Bailey, R.L., Looker, A.C., Lu, Z., Fan, R., Eicher-Miller, H.A., Fakhouri, T.H., Gahche, J.J., Weaver, C.M. and Mills, J.L., 2015. B-vitamin status and bone mineral density and risk of lumbar osteoporosis in older females in the United States–3. The American journal of clinical nutrition, 102(3), pp.687-694.
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Jansen, W.J., Ossenkoppele, R., Knol, D.L., Tijms, B.M., Scheltens, P., Verhey, F.R., Visser, P.J., Aalten, P., Aarsland, D., Alcolea, D. and Alexander, M., 2015. Prevalence of cerebral amyloid pathology in persons without dementia: a meta-analysis. Jama, 313(19), pp.1924-1938.
Joshi, S. and Bansal, S., 2013. A rare case report of amlodipine-induced gingival enlargement and review of its pathogenesis. Case reports in dentistry, 2013.
Kirkorian, A.Y., Weitz, N.A., Tlougan, B. and Morel, K.D., 2014. Evaluation of wound care options in patients with recessive dystrophic epidermolysis bullosa: a costly necessity. Pediatric dermatology, 31(1), pp.33-37.
Manolagas, S.C., O’brien, C.A. and Almeida, M., 2013. The role of estrogen and androgen receptors in bone health and disease. Nature Reviews Endocrinology, 9(12), p.699.
Marso, S.P., Bain, S.C., Consoli, A., Eliaschewitz, F.G., Jódar, E., Leiter, L.A., Lingvay, I., Rosenstock, J., Seufert, J., Warren, M.L. and Woo, V., 2016. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. New England Journal of Medicine, 375(19), pp.1834-1844.
Martini, F.H., Nath, J.L. and Bartholomew, E.F., 2015. Fundamentals of Anatomy &Physiolog. UK
Nursing and the Midwifery Board of Australia. 2016. Competency Standards. Access date: 23rd September. Retrieved from: https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx
O’brien, E., Parati, G., Stergiou, G., Asmar, R., Beilin, L., Bilo, G., Clement, D., De La Sierra, A., De Leeuw, P., Dolan, E. and Fagard, R., 2013. European Society of Hypertension position paper on ambulatory blood pressure monitoring. Journal of hypertension, 31(9), pp.1731-1768.
Porth C.M., 2011, ‘Chapter 3 Inflammation, the Inflammatory Response, and Fever’, Essentials of Pathophysiology, 4thedn, Philadephia, USA, p.61.
Powers, J.G., Higham, C., Broussard, K. and Phillips, T.J., 2016. Wound healing and treating wounds: Chronic wound care and management. Journal of the American Academy of Dermatology, 74(4), pp.607-625.
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