Clinical Scenario
Mr Ian Dury is a 58 year old male living in rural South Australia. His wife Elizabeth passed away 18 months ago from a prolonged battle with cervical cancer.
Mr Dury has been transferred to the Sisters of Mercy Memorial Hospital (SMMH) Adelaide South Australia for investigation of chest pain and it is planned that he will undergo a coronary angiogram with iodinated radiocontrast medium. Mr Dury has been diagnosed with a long history of Ischemic Heart Disease otherwise known as Coronary Heart Disease (CHD)
Past Medical History
Medications
Mr Dury states that he sometimes has difficulty remembering when to take his medication. He commented that he does not like taking his fluid tablets before he goes out because it makes him go to the toilet too often.
Upon admission Mr Dury is alert and orientated but appears slightly anxious. During is admission assessment his vital signs seem unremarkable however, he has noted pitting oedema in both legs with an associated diminished pedal pulse. He states that he gets breathless on exertion and has used is GTN spray on average about 4 times a day. He states that he has not spoken to his son about his admission to hospital. Mr Dury has been scheduled for a coronary angiogram the following morning.
Nursing notes
48 hours following the coronary angiogram that was undertaken to diagnose coronary artery disease Mr Dury’s fluid balance chart indicates that his previous 24 hour urine output has dropped from 1200ml to 450ml. Urgent blood tests for kidney function demonstrate a rise in creatinine and a fall in eGFR and Mr Dury is diagnosed with worsening CKD induced by the contrast used for the coronary angiogram.
Upon commencement of your shift Mr Dury’s vital signs are the following: Pulse 100bpm, BP 170/90, RR 18, SaO2 94% on room air and temperature 36.5.
His fluid balance chart has had a positive balance of over a litre in the past 24 hours.
It is noted that Mr Dury has a haematoma on his right wrist from the previous angiogram.
General information:
This assignment must be supported by at least 20 credible references presented in Harvard Style. These references should include course readings and the wider nursing academic literature.
Introduction: (200 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 case study 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 hospital). Provide a brief description of the pathophysiology of the disease and demonstrate how the presenting manifestations support the client’s primary diagnosis.Identify the complication experienced during admission. Provide a brief description of the pathophysiology of this complication in relation to the clients pre-existing medical conditions.
Nursing Problems (200 Words)
Using your knowledge of pathophysiology and the clinical manifestations of the client; identify two (2) nursing problems that arise as a result of the client’s complication developed during the admission. These problems may be actual or potential nursing problems. Provide a brief description for why these problems arise for this client. Support this discussion using current literature.
Nursing Management (800 Words)
The nursing management must focus on the inpatient 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) identified nursing problems. Support this discussion using the current literature.
(This section of the report focuses on assessments and interventions that the Registered Nurse conducts. So avoid reverting to simple referrals to other members of the health team. What does the nurse physically do to provide optimal person-centred care as part of the nursing management plan? You should also prioritize your care. What is the most pressing concern for the client at this stage?)
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 (400 Words)
The discharge plan must focus on the multidisciplinary management for this client and can refer to the nursing problems addressed throughout the paper.
Discuss the aim for discharge planning and the importance of using a multidisciplinary approach. Discuss the role of the Registered Nurse to facilitate the multidisciplinary discharge plan for this client. Identify the members of the multidisciplinary health care team and the role that they would play. You can include your identified nursing problems discussed in the paper.
(You may also like to discuss what socio-economic factors may impact your discharge planning.)
Conclusion (200 Words)
Summarize the major findings of this case report.
Please note the word limit in each section is provided as a guide to help you structure this assignment..
General information:
This assignment must be supported by at least 20 credible references presented in Harvard Style. These references should include course readings and the wider nursing academic literature.
Case Report
Introduction
Mr Dury is a 58-year-old man transferred to the Sisters of Mercy Memorial Hospital (SMMH) to be investigated on chest pains. Despite the chest pains, Mr Dury has been diagnosed with a long history of Coronary Heart Disease. He also has a past medical history of different diseases like hypertension, type two diabetes, obesity; he is a current smoker and smokes 25 cigarettes daily to mention a few. Dury is under medication, but unfortunately, he sometimes forgets to take them. He opts not to take his fluid tablets as they make him go to the toilet quite often. During his admission to the hospital, it is visible that Mr Dury has oedema in both of his legs. He also mentions that on exertion, he gets breathless and has used his GTN spray on average about four times a day. He is scheduled for an angiogram the following morning, and 48 hours later, there is a decrease in his urine output from 1200 to 450ml in the past 24 hours. Blood test for kidney function in Mr Dury indicates a fall in eGFR and an increase in creatinine. Therefore, he is diagnosed with worsening CKD that came from the contrast that was used in the angiogram. The report is divided and outlined in five main parts, and every part has an essential role that relates to the care of an adult person undergoing cardiovascular event.
Primary Admission Diagnosis
Complaints of chest pains from Mr. Dury necessitated him to be sent to the sisters of Mercy Memorial Hospital for an angiogram. Upon reaching the hospital, he further mentioned experiencing breathlessness on exertion, which required him to use his GTN spray four times a day. After the coronary angiogram, Mr. Dury was diagnosed with a long history of coronary heart disease. The coronary heart condition is associated with piled-up cholesterol on the artery walls, which are a hindrance to nutrients and oxygen to reach the heart (Ali, 2012). The chest pains Mr. Dury complained of are a result of minimal oxygen supply to the heart due to narrowed arteries due to piled up plaques.
When he was tested for kidney functions, he rose in creatinine and was diagnosed with Chronic Kidney Disease. After the diagnosis with CKD, his vital signs were different. For instance, his pulse was higher than the normal 40bpm, as it was 100bpm. Chronic kidney disease damages a person’s kidney as it decreases their ability to do their everyday jobs (Jean, Souberbielle & Chazot, 2017). CKD may be a result of other disorders like high blood pressure and diabetes. From the case scenario, it is evident that Mr. Dury suffered from type 2 diabetes and hypertension, the two main CKD causes. Therefore, these two diseases may have been the causes of his current problem CKD.
Nursing Problems
One of the most significant nursing problems expected in Mr. Dury’s case is his risk of infection. The risk of infection may come from the patient going through various invasive procedures, and since the patient has a chronic disease, the procedures have higher risk factors for infections (Dalrymple & Go, 2008). Despite the patient having CKD, he has pitting edema on both of his legs. Dury has a fall in GFR, and there is a possibility of water retention in his body that is causing edema. It is the kidneys that remove excess water and salt from the human body. Therefore, if the kidneys are not properly working, one experiences edema.
The second nursing problem is the patient may experience pain from the angiogram. In addition to this, if the patient’s kidneys fail to stabilize, he may experience pain as well from the dialysis process. The angiogram process is not painful, but one is often sedated during the process. However, after the process, one may develop pain. For instance, the artery that is catheterized may experience injury hence causing pain to the patient. Bruises attained during the angiogram process may also take a long time before they fully heal (McCrindle et al., 2017). Before the healing process, the bruises may feel sore and prevent one from taking part in their everyday activities.
Nursing Management
Risk of pain
Chronic kidney disease, often referred to as chronic kidney failure, is the gradual loss of a person’s function. Kidneys have an essential function in the human body as they filter excess fluids and waste from human blood (Jaddi, Alvankarian & Abdullah, 2017). After the wastes are filtered, they are removed from our bodies through urine. In case the disease gets to the advanced levels, wastes and high levels of fluid may build up in a person’s body.
In the given case, Dury has a risk for pain from the angiogram done to him. The nursing assessment required in this problem would be to look for different symptoms in the patient. For instance, since the patient lies for two or more hours during the angiogram process, a nurse may assess for back pains in the patient (Hoglun. Stenestrand, Todt & Johansson, 2011). The nurse may also assess the chosen artery where the catheter is inserted during the procedure. She might have to look and observe the wound on how much it is improving after the procedure. Lastly, since there is a wound on the body from the catheterization, the nurse should assess the patient’s headache and fever.
The nursing intervention approach required for the pain problem’s risk is ensuring that the patient lies flat for hours after an angiogram. In doing so, it will be possible for any serious bleeding to be prevented, and the affected artery may also properly heal during this procedure (Finh et al., 2014). In addition to this, it would also be advisable for the patient to have bed rest after the procedure. Lastly, it would be advisable for the nurse to encourage Dury to make some lifestyle changes. For instance, encouraging Dury to quit smoking and start working out is a nursing intervention well-required.
A registered nurse is tasked with assisting the physician in administering treatment (Bauer & Bodenheimer, 2017). Apart from administering medication, their role is to monitor the patients for recoveries and any developments that may require reporting to the physician. In the case of Dury, a registered nurse will have the roles of monitoring his respirations, apical heart rate, and blood pressure. Further, the registered nurse could ensure that Dury engaged in physical activities that could not induce pain. For the risk of pain, a registered may also ensure that they encourage bed rest and straightness in the patient for six hours (Corbridge & Steventon, 2019). Since the patient lies in bed for a long time during and after the procedure, it causes fatigue. Therefore, an RN should ensure that they check the patient’s pressure to see that it is normal.
Risk of Infection
It is expected for patients of chronic kidney disease to undergo different changes in their lives. Pitting edema is often a result of liver, kidney, or heart problems. Pitting edema occurs when a person’s body is full of fluid. Dury has a lot of underlying conditions like CKD, CHD, hypertension, and diabetes. His kidneys have a higher likelihood of having been the cause of pitting edema in him because within 24 hours, and there was a reduction of his urine output. Hence it was evident that his kidneys were not properly functioning. Pitting edema can be treated via vascular surgery. After the surgery, a patient may get an infection from the wound.
The nursing assessment for Dury would constantly be checking his urine output. The urine output analysis is used to measure how much urine a person’s body produces a given amount of time (Powles et al., 2013). The process is helpful in the diagnosis of kidney problems and how the kidney functions. Secondly, just like any liquid, our body fluid has weight. Therefore, the nurse can take the patient’s weight every day, especially in the morning. During this process, the patient should wear the same amount of clothes every day for accuracy. The weight measurement is an excellent indicator of how much fluid one has in the body if the results are compared day in and out. Since he has pitting edema, Dury’s nursing interventions are instructing the caregiver or family in this case, Durys’ son, on the appropriate fluid restrictions (Holmes et al., 2013). The second nursing intervention is to assist the patient with repositioning after every two hours in immobility. The last nursing intervention is to monitor the patient’s fluid intake and to take prescribed diuretics. Diuretic medications are drugs used for the treatment of edema (Smith, 2014). These drugs help ensure that the excess fluids are excreted out of the body through urination.
It is the registered nurse’s job to follow up on the patients and ensure that all the medication was taken when it is required and that no doses are skipped. The registered nurse is further supposed to observe the changes or developments observed (Bartunek et al., 2006). For example, the RN should establish whether the prescribed drugs are working positively or if the patient may need further medication. Considering there can be more than one option of medication for a given condition, the RN should be able to establish which medication was working with the patient, and which one required substitution (Jaarsma et al., 2009). In the case of Dury, a registered nurse would be required to ensure that he did not forget to take his dose. It is also noted that Mr. Dury himself admitted to not liking some medications, so he skipped them occasionally. It would be the job of a registered nurse to ensure that nothing like that happens.
Discharge planning
Discharge planning is an approach to process and care continuity. It includes goal setting, implementation, planning, assessment, identification, evaluation, and coordination. The goal of discharge planning is to support health care continuity to a patient. It is so because discharge planning is the vital link between the treatments the patient receives at the hospital and the community’s care after discharge (Shepperd et al., 2013). A proper discharge planning is essential because it can reduce the patient’s readmission chances, and it also assists inpatient recovery. It is also essential to educate the patient and his family on the various ways of cleaning the wound where the catheter was inserted. For example, informing them about the importance of maintaining hygiene like washing hands before wound cleaning prevents infections on the wound (Alper et al., 2017). The patient and his family should receive the necessary knowledge on symptoms of complications like an infection on the wound and stroke. This aspect is necessary because it prepares them for emergencies that may occur from Dury’s illnesses. When planning discharge, the nurse may advise the patient and his family on the importance of admission to an acute care setting for ultrafiltration.
A multidisciplinary approach is a calculated approach to health care. In this approach, treatment options and planning are processes that involve healthcare and medical professionals in working together with not only the patient but also his family (Clarke & Forster, 2015). This approach is essential because it includes different medical professionals who are experts in different areas hence attaining optimal effect on the patient. Secondly, this approach is also essential as it ensures that evidence-based care is delivered to the patient. Lastly, this method is essential as it improves health outcomes and enhances client satisfaction. In multidisciplinary discharge planning, Registered Nurses ensure a connection between in and out-patient care (Mudge et al., 2016). For example, they ensure that the patient and their family clearly understand the dos and don’ts after discharge to encourage healing and prevent injuries.
The members of the multidisciplinary team for the patient will include the following; first, Dury will need a nephrologist. A nephrologist is a doctor with advanced training in the treatment of kidney disease. These doctors provide the necessary care and guidance on how to handle medication problems. Secondly, he will need a nurse. It is the nurse’s responsibility to manage the care given to a patient. Nurses comfort and take care of the patient in every stage, from preparation to recovery (Halpern et al., 2014). The nurse will work with the nephrologist to see to it that Dury gets full recovery. Lastly, he will need a patient care technician. These are technicians who work under the nurse and nephrologist and are involved in their kidney care and dialysis.
Conclusion
Dury had a lot of problems that facilitated his coronary artery disease condition. He had the worst lifestyle, and that is evident from his smoking habits and his previous diagnoses. For a 58-year-old, his diagnoses were too much, and unfortunately, they were a result of his lifestyle. In addition to this factor, Dury was careless and cared less about his health. For instance, he chose to ignore his syrup medications with an excuse that they made him visit the toilet more often. However, it is essential to note and recognize the essential roles nurses play in their patients’ lives. For instance, in the hospital, the registered nurses ensure that patients take their medications and are well taken care of. From a multidisciplinary approach perspective, the registered nurse ensures the patient and his family are aware of what medications the patient is on and how they should be taken. The role of nurses goes beyond hospitals. There are various interventions that nurses can take part in to ensure patient satisfaction. Therefore, it is only fair to state that there can never be proper care in hospitals without nurses.
References
Ali, N. (2012). The Obesity Reality: A Comprehensive Approach to a Growing Problem. New York. Rowman & Littlefield Publishers. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360432/
Alper, E., O’Malley, T.A., Greenwald, J., Aronson, M.D. and Park, L., 2017. Hospital discharge and readmission. UpToDate. Waltham, MA: UpToDate.
Bartunek, J.M., Rousseau, D.M., Rudolph, J.W. and DePalma, J.A., 2006. On the receiving end: Sensemaking, emotion, and assessments of an organizational change initiated by others. The Journal of applied behavioral science, 42(2), pp.182-206.
Bauer, L. and Bodenheimer, T., 2017. Expanded roles of registered nurses in primary care delivery of the future. Nursing Outlook, 65(5), pp.624-632.
Clarke, D.J. and Forster, A., 2015. Improving post-stroke recovery: the role of the multidisciplinary health care team. Journal of multidisciplinary healthcare, 8, p.433.
Corbridge, R. and Steventon, N., 2019. Oxford handbook of ENT and head and neck surgery. Oxford University Press.
Dalrymple, L.S. and Go, A.S., 2008. Epidemiology of acute infections among patients with chronic kidney disease. Clinical Journal of the American Society of Nephrology, 3(5), pp.1487-1493.
Fihn, S.D., Blankenship, J.C., Alexander, K.P., Bittl, J.A., Byrne, J.G., Fletcher, B.J., Fonarow, G.C., Lange, R.A., Levine, G.N., Maddox, T.M. and Naidu, S.S., 2014. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation, 130(19), pp.1749-1767.
Halpern, S.D., Becker, D., Curtis, J.R., Fowler, R., Hyzy, R., Kaplan, L.J., Rawat, N., Sessler, C.N., Wunsch, H. and Kahn, J.M., 2014. An official American thoracic Society/American association of Critical-Care Nurses/American College of chest Physicians/Society of critical care medicine policy statement: the choosing Wisely® top 5 list in critical care medicine. American journal of respiratory and critical care medicine, 190(7), pp.818-826.
Höglund, J., Stenestrand, U., Tödt, T. and Johansson, I., 2011. The effect of early mobilisation for patient undergoing coronary angiography; a pilot study with focus on vascular complications and back pain. European Journal of Cardiovascular Nursing, 10(2), pp.130-136.
Holmes, R.F., Davidson, M.W., Thompson, B.J. and Kelechi, T.J., 2013. Skin tears: care and management of the older adult at home. Home Healthcare Now, 31(2), pp.90-101. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7949896/
Jaarsma, T., Beattie, J.M., Ryder, M., Rutten, F.H., McDonagh, T., Mohacsi, P., Murray, S.A., Grodzicki, T., Bergh, I., Metra, M. and Ekman, I., 2009. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. European journal of heart failure, 11(5), pp.433-443.
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Mudge, A., Radnedge, K., Kasper, K., Mullins, R., Adsett, J., Rofail, S., Lloyd, S. and Barras, M., 2016. Effects of a pilot multidisciplinary clinic for frequent attending elderly patients on deprescribing. Australian Health Review, 40(1), pp.86-91.
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