Introduction: (200 words)182
Mr George Orwell (Mr. George) is a 68 years old male who lives in rural South Australia. He has been transferred to the Farquharson Memorial Hospital (FMH) in Adelaide South Australia for investigation of chest pain. His wife Heather passed away 12 months ago due to breast cancer. Mr George have medical history of type 2 diabetes mellitus, hypercholesterolaemia, hypertension, obesity, coronary artery bypass 5 years ago, anterior myocardial infarction 6 years ago and current smoker 15 cigarettes a day. Mr George medication history is aspirin (300mg daily), candesartan (4mg daily), metoprolol (50mg bd), atorvastatin (80mg daily), spironolactone (50mg daily) and GTN spray as needed.
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The Purpose of the case study is to provide an evidence-based nursing care for Mr George applying an inter-professional model of care. This case study will include introduction, primary diagnosis of the Mr George, two nursing problem based on the primary diagnosis. Throughout the two nursing problems, nursing management will be discussed which includes nursing assessment, nursing interventions, and medication management. On based of all the investigation discharge will be plan for Mr George.
Primary diagnosis ( 300 words) 303
Mr George was admitted in to FMH due to chest pain. Looking at his medical history of Type 2 diabetes mellitus, hypercholesterolaemia, hypertension, coronary artery bypass 5 years ago, anterior myocardial infarction 6 years ago it is indication of coronary artery disease (CAD).
Coronary artery disease (CAD)
Coronary artery disease occurs because of narrowing or blockage of the coronary arteries, usually caused due to atherosclerosis (https://my.clevelandclinic.org/health/diseases/16898-coronary-artery-disease). Atherosclerosis is the build-up of cholesterol, fat and calcium plaque inside an artery, which makes arteries hard with time and narrow causing insufficient blood flow to myocardium. Myocardium infarction appears when coronary artery supplies inadequate blood to the area of myocardium (Lemone 2017). During this disease, mostly some patients are present with few risk factors as Mr George have such as chest pain, hypertension, type 2 diabetes, overweight or obesity, smoking and hypercholesterolaemia. According to (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640469/) 80% of people have CAD are overweight or obese. Smoking can also damage and tighten blood vessels and increase cholesterol levels and blood pressure. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640469/) shows a connection between CAD and hypertension, hypertension is also a major risk in the development of CAD. Patients with high blood pressure are more risks to develop CAD, as uncontrolled blood pressure can result in make artery hard and thick and narrow the channels where blood can flow (https://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/symptoms-causes/syc-20350613). CAD starts with many presenting clinical manifestations. Angina or chest pain is one of the manifestations of that person experience with CAD, which is also experienced by Mr George. Mr George presented with chest pain and previous history of having high blood pressure and breathless on exertion. When plaque build-up, it narrows the coronary arteries, which can decrease blood flow to the heart, this may can cause of chest pain, shortness of breath. Angina or chest pain is a symptom can occur during exertion and severe emotional stress, during this period myocardial requires more oxygen than it supply. These manifestation and symptoms occurred to Mr George because of his previous medical history of having coronary artery bypass 5 years ago and anterior myocardial infarction 6 years ago.
Nursing Problems (300 words) 439
There are many nursing problems related to Mr George, but two main problems are hypertension and fluid overload.
Problem 1: hypoglycaemia
For Mr George hypoglycaemia is a main problem as he has type 2 diabetes mellitus. Mr George is has been fasting overnight for his coronary angiogram in the morning. There are numerous risk factors of hyperglycaemia as in poor vision, fatigue, confusion, paraesthesia and skin infection (Lemone 2017 page 574). Mr George is sweaty, nauseated, anxious, which are signs of hypoglycaemic attack. He is a current smoker and diabetic and fasting overnight which can increase risk of having hyperglycaemia. Very low glucose in the blood can interfere the body function mainly in brain, because sugar is the brain’s main source (https://emedicine.medscape.com/article/122122-overview). Hypoglycaemia is characterized by reduction of plasma glucose concentration to level that may induce symptoms and signs altered sympathetic nervous system stimulation. This condition can arise from abnormalities in the mechanisms involved in glucose homeostasis. The common cause of hypoglycaemia in patients with diabetes is injecting a shot of insulin and skipping a meal or overdosing insulin (https://emedicine.medscape.com/article/122122-overview).
Problem 2: Fluid overload
Fluid overload is a condition where there is too much fluid in blood, which excess fluid salt and water, which spreads in the whole body and results in weight gain (https://www.chf-solutions.com/fluid-overload/). In fluid overload the symptoms that patient show are swelling, weight gain and shortness of breath. As during the admission assessment Mr George’s noted to have pitting oedema in both legs with an associated diminished pedal pulse. Due to this he is most likely to represent to clinical manifestation of fluid overload. His fluid balance chart indicates positive balance of above one litre in last 24 hours, which is indicating risk of fluid overload. Fluid overload also occurs due to retain salt, increased total body’s sodium content, which then increase total fluid content in the body (https://www-uptodate-com.access.library.unisa.edu.au/contents/clinical-manifestations-and-evaluation-of-edema-in-adults?search=fluid%20overload&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1) . Fluid overload can be caused by several chronic disease process such as heart failure, renal failure and kidney disorder that produce too much protein in urine but for Mr George case it can be due to excessive sodium. Clinical manifestation of fluid overload is increased blood pressure caused by excess fluid in blood stream, moist crackle in lungs, shortness of breath, mental confusion and headache(https://www.healthline.com/health/hypervolemia#signs-and-symptoms). These manifestations can affect Mr George he stated of having headache, shortness of breath on exertion pedal pulse. Mr George has cardiac condition and is prescribed spironolactone 50 mg daily, but he stated he said he don’t like to take a fluid tablets before he go sleep as it is making him urinate frequently. He also has difficulty remembering taking medication, which is leading problem to cause of fluid overload.
Nursing Management (500 words) (250 each prob) 743
Problem 1: hypoglycaemia
Registered nurse (RN) plays an important role in patients care. For Mr George blood glucose level (BGL) assessment is since his history of type 2 diabetes to maintain his sugar level in normal readings. BGL should be done to keep the blood sugar levels within the specified range (https://www.diabetesaustralia.com.au/blood-glucose-monitoring). BGL assessment should be conducted to control the sugar level to assess the effectiveness of the interventions that has been done to maintain BGL in normal range (Tollefson & Hillman, 2016). According to (https://www.diabetesaustralia.com.au/blood-glucose-monitoring) patient who have type 2 diabetes and don’t use the insulin or forget to check BGL regularly can avoid the further risk of developing diabetes-related complications.
To minimize the further complication of diabetes for Mr George there are various intervention that RN should use per nursing standard 6 provide safe and appropriate are to the patient (NMBA 2016). Mr George needs a frequent monitoring on his BGL as he is fasting overnight and to keep the medical team updated. For his BGL assessment RN should arrange glucometer, reagent strips matching to glucometer, Alcohol swab, cotton balls, sharp container, gloves and lancet to puncture skin to capillary depth. To assess his BGL Mr George consent is important reduce his anxiety and to gain a therapeutic relationship. Before pricking the finger wiping the fingers with alcohol swab is very important because if there is any food or juice particles left on finger can affect the result of BGL readings. To test blood sugar level RN needs to prick Mr George prick the side of fingertip with lancet and add a small drop of blood on to testing strip and place that strip to the blood glucose meter, which will then a show number. After conducting BGL assessment it is RN role to accurately document the readings in BGL chart in time manner and report the medical team if there are any concerns.
As a nurse to administer the medication to safely nurse should use eight rights. To provide a safe medication nurse should check if the doctor has prescribed correct medication and dose. Check the side effects of the medication because some medication can have reaction such as rash, vomiting and swallowing. In regard to Mr George Hypoglycaemia RN needs follow FMH policies and procedure for his treatment as each health care place have a different to treat. In urgent situation RN should inform the doctor about his BGL range to prescribe fast acting glucose orally.
Problem 2: Fluid overload
For Mr George, he is risk of fluid overload so RN should start using Fluid Balance Chart (FBC) to observe the fluid intake and output. Fluid balance means the amount of water lost from the body must equal the amount of water taken in such as output via respiration, urination must equal to input via eating and drinking. For further assessment RN should examine skin, oral cavity, peripheral extremities, cardiovascular and reparatory systems as well as vital sign to keep it updated.
The intervention for fluid overload is individualised to the patient needed and situation. In the case Mr George requires an education about the intervention. RN should explain and instruct about monitoring his weight everyday with the same amount of clothes or same amount of cover removed when weighed on scale to avoid any error. RN should monitor FBC for Mr George to know the amount going in his body and what comes out. FBC chart is very essential part of the patient with fluid overload. RN can sum of each day fluid balance over the time. To keep Mr George from fluid overload RN can give him less fluid.
According to NMBA standard… RN should administer the medication safely. As Mr George have difficulty remembering the medication RN should arrange a meeting with his son which he haven’t contacted after coming to the FMH. RN should involve his son in his medication care and explain the importance, expected side effects of the medication. As Mr George does not take Spironolactone medication before he goes sleep because it makes him urinate frequently, instead of that RN should discuss with the doctor if he can have that medication on other time of the day.
Discharge Planning (500 words)
Discharge planning is the important for the patient who needs more support with their recovery after leaving hospital. RN’s are responsible for helping with discharge planning process (LeMone 2017, page 1629 – 1630). There more chance with Mr George’s hypoglycaemia and fluid overload to be get worst at home after he discharge from hospital because he has difficulty remembering the medication and he is current smoker. After evaluating his situation discussion need to be done with him and his son about the care that will be needed. For Mr George hypoglycaemia RN should encourage him to take the insulin on time and structured self- monitoring BGL check at certain times of the day.
Multidisciplinary team is a group of health care team, such as (psychiatrists, social worker, community health nurse, OT etc). To plan Mr George condition would need diabetes specialist to guide and to educate him. Physiotherapist and dietitian should also be involved in his care due to his pitted edema on his legs which is due to fluid overload.
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Physiotherapist are responsible for patient education and edema control. They help the patient with appropriate activity and position changes to prevent fluid accumulation in dependent area. They diagnosis, assess and will treat the patient with the physical problem. As a physiotherapist, will encourage Mr George to exercise which will re-establish the normal circulatory flow through muscle contractions (https://www.physio-pedia.com/Fluid_Excess/Intoxication). Exercise would help Mr George with his two problems Hypoglycaemia and fluid overload to prevent to have CAD.
Dietitian plays a crucial role in the recovery of the patient with fluid overload and Hypoglycaemia. By refereeing Mr George to dietitian would help a lot in way he eats and drink to recover from fluid overload. They will make a recommendation on his diet plan according to the medication. With the risk of fluid overload, they will make a chart according to how much fluid should Mr George should consume every day. They can also teach how to self-monitor fluid input and output on FBC.
Diabetes specialist (DS) plays an important role in the early detection of diabetes and is able to intervene and manage the condition early on. They have high knowledge of diabetes and insulins therefore they can decide when treatment can be commenced. They can teach the patient how to check BGL. Education includes understating of medication explaining the effect and side effects.
Psychologist also part of the multidisciplinary team and can help Mr George in his recovery. As Mr George’s wife passed away 12 months ago, he may require an emotional help. Psychologists can help to improve his healthy behaviour, preventing disease and improve the quality of life.
Conclusion (200 words)
In the conclusion, the purpose of the case study was to provide an evidence-based nursing care for Mr George applying an inter-professional model of care. taking majors, identified two nursing problems, hypoglycaemia and fluid overload. It is RN role to plan discharge. To avoid the future problems multidisciplinary team can help to Mr George, which included physiotherapist, dietitian, diabetes specialist and psychologist. It is RN’s role in medication management to educate Mr George to take right medication on right time with right dose. According to standard 7 a nurse expects a better and healthy life of her patient (NMBA). It is their role to keep Mr George to have CAD.
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