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Case Study Requirement:-
Assessment Task One: Case Study One Multiple factors influence the care of patients with chronic conditions. As a Primary Heath Care nurse, it is important that care given is prioritised based on both clinical and patient needs. Prioritisation of the patient needs for care is integral to daily nursing practice. This requires integrating and collaborating different aspects of patient needs in order to maximise care activities and the effectiveness of nursing interventions. This case study is designed to demonstrate the integration of various principles of managing care of patients with chronic conditions. Students will be expected to identify and discuss two PRIORITIES OF CARE and apply the clinical reasoning cycle to these as a means of justification. Please refer to the subject outline and marking rubric when answering this question. NRSG366 Assessment Task One: Case Study One Case scenario Peter Mitchell is a 52 year old male with morbid obesity and type 2 diabetes who was admitted to the medical ward with poorly controlled diabetes, obesity ventilation syndrome and sleep apnoea. Peter was referred by his GP after he presented with symptoms of shakiness, diaphoresis, increased hunger, high BGL levels and difficulty breathing whilst sleeping. Peter has been a smoker for approximately 30 years and smokes approximately 20 cigarettes per day. On his previous admission, Peter was seen by a dietician and commenced on low energy, high protein diet (LEHP) to assist with weight reduction. His GP had previously discussed weight loss with Peter however he had never wanted to do anything about it as it seemed ‘too hard’. Peter was also reviewed by the physiotherapist and was commenced on light exercises which he was to continue at home on discharge. Peter has been discharged home, with referral to community care unit for ongoing support and follow up, after four weeks in the medical ward to manage his weight and clinical comorbidities. Past medical history ? Obesity (weight 145kgs with a BMI of 50.2m2). ? Type 2 diabetes (Diagnosed 9 years ago) ? Hypertension ? Depression (Diagnosed three months ago by GP). ? Sleep apnoea ? Gastro oesophageal disease reflux disease Social History Peter is an unemployed male who receives government benefits. Peter lost his job three years ago as a fork lift driver at the Moranbah coal mine in far North Queensland. Peter states that he has always been a ’biggish guy’ with his ‘normal weight’ sitting at around 105kg but since starting insulin and losing his job he has gained a significant amount of weight. NRSG366 Assessment Task One: Case Study One Consequently, because of his weight issues Peter has difficulty finding work due to fatigue and feeling generally ‘uncomfortable’ about his size. Peter is a divorcee who lives alone, his two sons live in the same state but live in different cities and rarely visit him. He is socially isolated because he is embarrassed by his size and he rarely goes out. Peter is also finding it increasingly difficult to perform activities of daily living (ADLs). Peter realises that he is in the prime of his middle age life and is motivated to lose weight and quit smoking but isn’t sure where to start. Current Medication ? Insulin Novomix 30 B D (34units mane & 28units nocte) ? Metformin 500mg BD ? Lisinopril 10mg daily ? Nexium 20mg daily ? Metoprolol 50mg BD ? Pregabalin (Lyrica) 50mg nocte Last observations on discharge ? Weight 145kgs ? Height 170cms ? BP 180/92mmHg ? RR 23 Bpm ? HR 102 Bpm ? Sp02 95% on RA
The purpose of this essay is for students to present a comprehensive discussion and justification identifying two (2) care priorities within a clinical scenario using the Levett-Jones’ Clinical Reasoning Cycle. Students are required to provide critical analysis and justification of the care priorities using appropriate academic references.
Solution
Introduction
One of the most critical aspects of nursing is approaching patient care in a holistic and comprehensive manner, which does not only focus on the physical ailments the patient is suffering but also considers the mental health status of the patient and to understand all the inherent issues which might be perturbing the patient and is responsible for his present status (Harries & Harries, 2001), (Hunter & Arthur, 2016). Clinical reasoning in nursing hence, is of immense significance as, for an individual to be an effective care giver it is crucial that effective clinical analysis and reasoning skills are present which directly lead to positive patient outcomes, and those with poor reasoning skills fails to detect the underlying problems resulting in the failure to rescue (Banning, 2008). As per Levett & Jones in 2009, clinical reasoning process is associated with – collecting information, processing such information, coming to an understanding, plan and implement the interventions, evaluate the outcomes and learn from the process (Levett-Jones et al., 2010). This gains even more importance in the background, where adverse patient outcomes are gradually escalating, and as per a study by NSW Public Health System, failure to effectively diagnose, failure to institute adequate treatment and inappropriate management of complications become the top three reasons for adverse patient outcomes (Capon & Rissel, 2010).
The case situation deals with Peter Mitchell, a 52 year old divorcee, who survives on government benefits after losing his job, and suffers from morbid obesity, poorly controlled diabetes and other ailments. After careful analysis, it was identified that there is two core areas in which care should be prioritized – primarily, focus must be presented on improving his mental health and secondly, care must be focused on helping him to lose weight.
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Analysis
As aforementioned, the nursing care should be focused on two areas – improving his mental health, and secondly, helping him to reduce his extra weight.
Peter has been diagnosed with Depression, three months ago by his GP, and also suffers from hypertension, T2D; sleep apnoea and gastro oesophageal reflux disease. A number of his issues, stem from the fact that he is overweight. His morbid obesity, can be linked to hypertension, incurrence of Type II Diabetes, sleep apnoea etc and also can be linked to having a depressed mental health (Grandner & Malhotra, 2017), (Mezuk, Eaton, Albrecht, & Golden, 2008). In addition to this, he is recently facing difficulties to perform his daily activities – ADLs, which comprise of routine activities which individuals do without needing any external help – eating, bathing, toileting, walking, dressing and continence. Hence, much of his issues stem from the obesity. Peter understands that his weight is a problem, but he does not know from where to start, and lacks motivation in his life. Hence, the nursing care we advocate for is to be based on two folds – Mental Care & Weight Reduction Help.
The process of Clinical Reasoning has been followed to reach upon these two care strategies. Primarily, all the information and cues have been identified, then processing and evaluation of such information led to these two care strategies, interventions were planned which will be mentioned as follows. Evaluation of the outcome is expected to follow the right path and lastly, a critical reflection on the learning will be presented.
Mental Health Care
Peter is a divorce, who lives alone and is unemployed. His two sons are grown up, and live separately and rarely visit. He lost his job three years back, and since then there has been a rapid accumulation of extra weight. He always was on the “larger” body type, but due to his present 145 kgs weight, he feels embarrassed to socially mix with his community, and hence rarely goes out. He was diagnosed with depression three months back. Though he understands the importance of losing weight, he does not know where to start. From his circumstances, it is not unnatural to feel depressed, isolated, embarrassed, disregarded, undervalued, frustrated, inadequate and overall hopeless etc. His apparent lack of will and motivation to lose weight also stems from his depressed mental state (Thakur & Blazer, 2008). Hence, as a nurse, it is my primary aim to provide him effective care in helping and improving his mental status.
The goals of this Priority of Mental Health care would be – to develop a relationship with Peter based on trust and empathy; promote his sense of positive self image and regard; promote the effective problem solving and coping skills in a manner in which Peter feels empowered; promote positive behaviour namely, having medications on time and, adopting healthy diet and conduct basic exercise; undertaking strategies to stop his smoking and other substance abuse; promote Peter’s engagement with their social support network, and make him communicate with others undergoing similar issues so that Peter finds a common ground for empathy and does not feel alone; ensure that effective collaboration with the other service providers are achieved through development of working relationships as well as communication and lastly, provide support and promote several self care activities for Peter (Delaney & Barrere, 2012).
The treatment for improving his mental health should depend on the following aspects – counselling and involvement of psychological therapies if required; medication and if absolutely required, then administration of electroconvulsive therapy (Mitchell & Kakkadasam, 2011).
Counselling will prove to be beneficial for Peter, as it will help out in identifying his deep seated conflicts and personal problems and also will help Peter in understanding the reasons for depression. It can include several intervention strategies like – cognitive behaviour therapy (CBT) and psycho-dynamic therapies or interpersonal therapies (Fowler & Peters, 2014). The psychosocial therapies thus mentioned include, information, education and support for Peter which will help in understanding, manage his level of stress and effective bring about compliance with the medication.
As it is a time taken process, it is too early to comment on what is expected as the final outcome, but it is hoped that stability and improvement of his mental health will be achieved.
Care in Weight Reduction
Obesity is a very complex disorder which is associated with a number of health ailments and increases significantly risks of diseases especially, diabetes, high blood pressure and heart disease (Astrup & Finer, 2000; Everard & Cani, 2013; Hauner, 2010). Peter already is suffering from Diabetes and hypertension, and has a present BMI of 50.2m2. Peter understands his condition but lacks motivation to start, and this lack of information and strong will, is making him more susceptible to other risks and diseases.
Ideally, Peter’s nursing care to manage weight should be focused on four agenda – imbalanced nutrition management, management of disturbed body image, management of social isolation and lastly, provision of efficient knowledge (Zizza, Herring, Stevens, & Popkin, 2002).
Diet planning and reviewing the actual diet intake, and making Peter understand how his actions will impact his health is a critical starting point. Nursing interventions like, carrying out and reviewing daily food diaries, exploring and discussing the emotions and the events associated with eating, formulation of a specific eating plan with the patient and making the patient understand its importance, identification of realistic achievements goals etc are strategies which can be taken pertaining to effective calorie management (Brown & Psarou, 2008).
As it is mentioned in the case that Peter is socially isolated, and also feels “embarrassed” due to his size, management plan to improve his own self image should also form a critical part of this obesity care. Open communication should be promoted, and responsibilities for both the nurse and the patient must be outlined. Peter can be encouraged to use imagery to view himself in his ideal weight and also help can be provided in helping him practice new behaviour. Peter’s apparent social isolation can be managed by – encouraging him to express feelings and his own perceptions to his problems, list all the behaviours which cause Peter discomfort, involve role playing to help Peter manage such discomforting behaviour, discuss the negative self concepts which might be hampering social interactions, encourage Peter to use positive self talk and help Peter interact and communicate in several support groups which have similar individuals going through identical issues (Hahler, 2002).
Appetite suppressants can be administered for Peter to help him cope better to the stress which occur due to behavioural as well as lifestyle changes at the start of weight reduction programs (Zizza et al., 2002). Vitamins and minerals supplements must be provided and an effective and customized weight reduction plan should be advised to Peter. As he is presently morbidly obese, time will be required to achieve a significant improvement, but the fact of his owning the treatment strategies advocated to them is a positive outcome.
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A number of Peter’s problems stem from non-compliance of medications. Therefore, the medications to handle, diabetes, hypertension, gastro-oesophageal disease etc, if taken regularly along with the right diet, will take care of the physical ailments he is presently suffering from. Along with this, medications if required to improve his mental health, appetite suppressants if any should be administered, keeping in mind the already prescribed medications for his physical problems. A key aspect of Peter’s treatment, is the counselling and helping him getting involved in support and social groups which will make him interact with other individuals who too are going through similar, if not identical situations. This will help him cope with the problems and apparent “embarrassment” which he feels when he tries to leave home.
As nurses to help provide care for Peter, it is required that we primarily, create and sustain a friendship with him, whereby he can share his problems, his fear, his frustrations, his depression and what as per to him are his greatest issues in life. Then we can help him understand how treatment, in the manner we are advocating will help him counter all the problems he is presently facing, and will solve the physical ailments which are plaguing him presently. Communication shall act as one of the strongest pillars of the nursing care plan designed for Peter, and the other pillar will be Technical Expertise, which will help us device the most efficient and effective treatment care plans for him.
Conclusion
The case study was about Peter, who is presently undergoing a number of issues due to his morbid obesity and declining mental health status. Two priorities of care were identified – mental health and weight reduction, which when tackled is expected to solve Peter’s present ongoing problems and will promote his overall wellbeing of physical and mental help. In the wake of this paper, it was mentioned, how it is the aim of nursing to provide holistic care, and taking care of Peter’s physical and mental health in the interventions mentioned as above, will provide him the most efficient care possible.
Reference List
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Astrup, A., & Finer, N. (2000). Redefining type 2 diabetes: “Diabesity” or “obesity dependent diabetes mellitus”? Obesity Reviews. https://doi.org/10.1046/j.1467-789x.2000.00013.x
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Banning, M. (2008). Clinical reasoning and its application to nursing: Concepts and research studies. Nurse Education in Practice, 8(3), 177–183. https://doi.org/10.1016/j.nepr.2007.06.004
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Brown, I., & Psarou, A. (2008). Literature review of nursing practice in managing obesity in primary care: Developments in the UK. Journal of Clinical Nursing. https://doi.org/10.1111/j.1365-2702.2006.01862.x
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Capon, A. G., & Rissel, C. E. (2010). Nsw public health bulletin. NSW Public Health Bulletin, 21(June). https://doi.org/10.1071/NB07104
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Delaney, C., & Barrere, C. (2012). Advanced practice nursing students’ knowledge, self-efficacy, and attitudes related to depression in older adults: Teaching holistic depression care. Holistic Nursing Practice, 26(4), 210–220. https://doi.org/10.1097/HNP.0b013e31825852aa
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Everard, A., & Cani, P. D. (2013). Diabetes, obesity and gut microbiota. Best Practice & Research Clinical Gastroenterology, 27(1), 73–83. https://doi.org/10.1016/j.bpg.2013.03.007
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Fowler, S. B., & Peters, M. D. J. (2014). Behavioral therapies versus other psychological therapies for depression. Clinical Nurse Specialist, 28(4), 209–210. https://doi.org/10.1097/NUR.0000000000000054
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Grandner, M. A., & Malhotra, A. (2017). Connecting insomnia, sleep apnoea and depression. Respirology, 22(7), 1249–1250. https://doi.org/10.1111/resp.13090
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Hahler, B. (2002). Morbid obesity: a nursing care challenge. Dermatology Nursing, 14(4), 242-249-256.
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Harries, P. A., & Harries, C. (2001). Studying clinical reasoning, part 2: Applying social judgement theory. British Journal of Occupational Therapy, 64(6), 285–292. https://doi.org/10.1177/030802260106400604
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Hauner, H. (2010). Obesity and Diabetes. Textbook of Diabetes, 131–142. https://doi.org/10.1007/978-3-319-13126-9
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Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement: Clinical educators’ perceptions. Nurse Education in Practice, 18, 73–79. https://doi.org/10.1016/j.nepr.2016.03.002
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Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y. S., Noble, D., Norton, C. A., … Hickey, N. (2010). The “five rights” of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically “at risk” patients. Nurse Education Today, 30(6), 515–520. https://doi.org/10.1016/j.nedt.2009.10.020
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Mezuk, B., Eaton, W. W., Albrecht, S., & Golden, S. H. (2008). Depression and type 2 diabetes over the lifespan: A meta-analysis. Diabetes Care, 31(12), 2383–2390. https://doi.org/10.2337/dc08-0985
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Mitchell, A. J., & Kakkadasam, V. (2011). Ability of nurses to identify depression in primary care, secondary care and nursing homes-A meta-analysis of routine clinical accuracy. International Journal of Nursing Studies, 48(3), 359–368. https://doi.org/10.1016/j.ijnurstu.2010.05.012
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Thakur, M., & Blazer, D. G. (2008). Depression in Long-Term Care. Journal of the American Medical Directors Association. https://doi.org/10.1016/j.jamda.2007.09.007
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Zizza, C. A., Herring, A., Stevens, J., & Popkin, B. M. (2002). Obesity affects nursing-care facility admission among whites but not blacks. Obesity Research, 10(8), 816–823. https://doi.org/10.1038/oby.2002.110
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