Situation

Mrs. Smita is a 42 years old aboriginal female who lives with her family in Brisbane. She has been diagnosed with type II diabetes three years before, after accomplishment of a gall-bladder stone surgery. Due to having work-pressure, she did not get opportunity to follow clinical guidance that led to adverse clinical outcomes. Currently, the patient is experiencing chest pain, breathing shortness, respiratory distress, physical discomfort and excessive sweating. When the patient was presented to the emergency department, she was found confused and worried. In this study, assessment report and recommendation considering the ongoing physical situation of the patient will be discussed.

In this study current case situation of Mrs. Smita is going to be discussed. Mrs. Smita is a 42 years-old female individual who was presented to emergency department of a tertiary care hospital with breathing shortness, pleuritic chest pain, poor oxygen saturation level and myalgia. On concurrent physical assessment and examinations, her body temperature was 38, heart rate was 82 bpm, respiratory rate 25 bpm and blood pressure of the patient at time of admission was 110/56. Due to her low blood pressure level, the patient at the time of her admission needed metaraminol infusion for maintaining blood pressure of the patient. Mrs. Smita was very perplexed and confused and her family members were also found very worried at that time, thinking the further clinical consequences of the patient. Apart from the said physical assessment findings, the patient also complained about some symptoms of excessive sweating, headache and confusion as well. Considering all the physical and clinical signs and symptoms of the patient, further assessment is required in order to diagnose the potential physiological problems to develop plan of action.

The patient belongs from aboriginal background and she prefers using her native language while communicating with medical professionals. She was an active worker in a retail grocery market; however, since after diagnosis of her type II diabetes mellitus and obesity she cannot actively work as before. At her home, she lives with her husband and two sons who are aged 9 years and 7 years respectively. They are also very concerned thinking of their mother’s physical condition; however, could not visit her to the hospital due to having academic pressure. Mrs. Smita has also found very worried about them. The patient was first diagnosed with type II diabetes three years before. Though GP prescribed her metformin with some non-pharmacological interventions to treat type II diabetes, she was not able to follow the guideline appropriately due to having huge work-pressure and hectic schedule. She also maintained a very stressful life and did not get time to manage her meals on time as she was to depend on takeaways. She four years before had a gall-bladder stone surgery that required fifteen days to recover. However, since after the accomplishment of the surgical event, the husband of Smita complained that she started experiencing some physiological troubles (e.g. mobility issue, back pain and fatigue) and it took three to four days to recover automatically. Due to this reason, they did not consult with any physician at that time, but since after one year of completion of her surgical event, she started using confusion, excessive sweating and palpitation. They visited a GP to take advices and at that time she was first diagnosed with type II diabetes and as she was also obsessed, physicians further referred her to a dietician. Despite all the events, Mrs. Smita was not able to follow any of the stated guidelines and recommendations that led to further clinical deterioration. Apart from the stated issues, the patient has a medical history of childhood asthma, hypersensitivity/ allergic response to penicillin group of drug. Her family medical history includes type II diabetes, congestive heart failure, obesity and hypertension. Considering all the stated findings, in the following section of the study, further assessment which is required for the patient will be discussed.  Assessment And Recommendation For Complex Patient Care Of Mrs. Smita Discussion Paper

Background

Being a nurse, I have prioritized some of the issues taking a follow up of the patient’s ongoing condition. The conditions identified are: obesity, type II diabetes, impaired cardiac functioning, impaired electrolyte level and impaired arterial blood gas (ABG) level. In the following section of the study, a systematic flow of further analysis and assessment plans along with rationale will be discussed.

Considering the chest pain and fluctuating pulse rate of the patient some cardiovascular assessments are to be performed focusing on the key issue of congestive heart failure (e.g. as the patient has a family history of CHF). Primarily an ECG needs to be performed. Considering and analysing the ECG findings axis deviation, atrial hypertrophy, myocardial damage and ischemia patterns can be assessed (Gouda et al., 2016). As the pulmonary crackles (e.g. Bibasilar crackles have been detected earlier) along with non-productive pain and breathing shortness, it is assumed that the patient has experienced a congestive heart failure or more specifically left-sided or left-ventricle heart failure (Gouda et al., 2016). ECG needs to be performed in order to confirm the diagnosis of the event. In case of left-sided heart failure, ECG data shows conduction delays, atrial fibrillation, tachycardia and premature ventricular contractions along with persistent ST-T segment alterations or abnormalities and reduced QRS amplitude (Gouda et al., 2016). To collect more evidence on the matter, a chest x-ray of the patient needs to be performed in order to investigate whether there is any presence of enlarged cardiac shadow, alterations in anatomy and structure of blood vessels and abnormal contour (Allen, Guha & Sharma, 2015). In order to differentiate between right ventricular cardiac failure and left-ventricular cardiac failure, cardiac catheterization needs also to be performed as abnormal cardiac pressures and indicative and assist differentiate left versus right-sided cardiac failure as well as insufficiency or valve stenosis. Laboratory assessments needs also to be performed in order to diagnose impaired arterial blood gases (e.g. assumed considering the ongoing respiratory distress, deteriorating oxygen saturation level and physical discomfort) that include arterial blood gasses assessment, pulse-oxymetry assessment and lastly a complete blood country assessment to check whether the haemoglobin level in blood of the patient is appropriate or not as in some cases, poor haemoglobin in blood also raises clinical complications and symptoms like breathing discomfort and poor oxygen saturation level in blood (Inamdar & Inamdar, 2016).

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Apart from cardiovascular issue, some respiratory assessment needs also to be performed as the patient is currently experiencing symptoms of respiratory distress. In this aspect, an echocardiogram (heart ultrasound) is to be assessed in order to investigate the relation between congestive heart failure and respiratory distress in the patients (Meinel et al., 2020). As non-productive cough is found there, no chance of mucus accumulation and block of airways should be there. However, to confirm the diagnosis of congestive heart failure associated impaired respiration of the patient bronchoscopy needs to be performed in order to analyse airways condition of Mrs. Smita. In some cases, bacterial pneumonia (e.g. caused by Streptococcus pneumonia) results in development and progression of the similar clinical signs and symptoms (Matthay et al., 2019). Therefore, to make the assessment and diagnosis of physiological complication of the patient clear, bronchoscopy is also found effective to indicate whether any viruses or bacteria are present in airways of the patient or not (Scala & Guidelli, 2021).

Assessment

The patient claimed that she was diagnosed with type II diabetes three years before. According to current evidences, it has already been established that chronic condition like type II diabetes has a severe impact on cardiovascular functioning and is a potential risk factor for congestive heart failure (Rosano, Vitale & Seferovic, 2017). Focusing on this key point a fasting blood glucose test and an Hba1c test needs to be performed to assess current blood glucose level and diabetic status of the patient. Clinical management of diabetes along with other chronic complications (e.g. CHF and obesity) often leads some real-life complication due to cross-reaction of pharmacological interventions (O’Cathain et al., 2018). Therefore, in order to ensure gradual improvement and wellbeing of the patient by developing evidence-based intervention and plan of action, the above mentioned assessment needs to be performed.

The patient was also found overweight. Considering this, performing BMI assessment, it was found that the patient was diagnosed with obesity (Luig et al., 2018). The finding was also justified with the findings of other clinical and laboratory assessments (e.g. hip circumference, waster circumference and chest circumference) (Luig et al., 2018). Physical immobility and altered psychological and emotional wellbeing are also some identified areas to develop plan of action. The patient was found to be worried and confused while taken into the ED of the tertiary care hospital. Considering, all the above mentioned findings on prioritized physiological and psychological issues of Mrs. Smita and laboratory and physical assessments, recommendation needs to be developed including both evidence-based pharmacological and non-pharmacological interventions that are considered to bring change in patient’s health condition and ongoing situation.

The major health issues that have been identified in case of Mrs. Smita are obesity, type II diabetes, congestive heart failure and associated respiratory distress (e.g. chest pain, breathing shortness and auscultation) and low blood pressure level. Differential diagnosis will be prioritized in case of appearance of some major alteration in clinical signs and symptoms of the patient. In this section of the study, recommendation will be given based on the identified health conditions and assessment findings.

The recommendation which will be discussed in this section will be from the perspective of a nurse. For example, four major nursing interventions focusing on the CHF of the patient are i) promoting activity tolerance, ii) managing fluid volume, iii) controlling anxiety and iv) reducing powerlessness (Riley, 2015).

i) Promoting activity tolerance: Along with pharmacological interventions and/or medication prescribed by the physician, a total of 30 minutes of regular physical exercise needs to be encouraged where both health-educators, physician and nurse will collaborate in the process of developing a program schedule with an objective to promote pacing as well as prioritization of essential health activities as regular physical activity significantly helps in improving functionality of cardiovascular system (Cattadori et al., 2018).

Further Assessment For Cardiovascular Issue

ii) Managing fluid volume: As alteration in fluid and electrolyte is very common in patients who are suffering from congestive heart failure and other cardiovascular diseases, fluid volume management is considered very essential in this aspect (Pellicori, Kaur & Clark, 2015). In case of Mrs. Smita, fluid status, body weight, electrolytes level and lungs auscultation needs to be thoroughly monitored every day to evaluate effectiveness of evidence-based interventions.

Regulating anxiety: anxiety significantly increases stress response that has a negative impact on cardiovascular health and heart functioning (Celano et al., 2016). In this aspect, patient needs to be ensured with calm and composed environment which will no further increase stress response and anxiety of the patient.

Reducing powerlessness: The patient needs to be encouraged to verbalize their response and participate in shared decision making process which will help further in making decision for the patient.

Apart from that, proper administration of supplemental oxygen maintaining flow rate and intensity in order to ensure gradual improvement and overall wellbeing of the patient needs also to be performed where improvement in oxygen saturation level can be monitored by observing oxygen saturation level displayed in pulse oxymeter.

Involvement of a dietician needs to be arranged for the patient that will help in developing an appropriate diet plan for the patient (Ojo, 2019). According to current evidence diet significantly helps in improving chronic disease condition of patients by managing endocrine function, cellular and physiological homeostasis and metabolic processes (Ojo, 2019). Therefore, in order to maintain blood pressure and cardiac function, a DASH diet needs to be promoted by the dietician.

On the early days of admission to emergency department, the nurse needs also to ensure safe medication administration, proper IV channel establishment, maintain hygiene protocol in order to reduce risk of development and progression of hospital-acquired infection and lastly, ensure physiological and emotional wellbeing of the patient. All the nursing interventions are to be performed in a systematic and scheduled manner involving the patient and her family members (e.g. husband) into the therapeutic process where shared decision making will help in obtaining best possible clinical outputs.

Next, while taking care for progression of diabetes, the nurse needs to promote regular physical activities and dietary interventions as instructed in peer-reviewed articles and journals (Awang Ahmad et al., 2020). Regular physical activities and dietary interventions assist making improvement in type II diabetes response by increasing sensitive of target cells to insulin, increasing rate of glucose metabolism and secretion of pancreatic enzymes that play essential role in metabolism of glucose under standard physiological condition (Awang Ahmad et al., 2020). Timely medication administration must be followed staying adhered to the safety and quality standard service of Australia. Subcutaneous insulin administration via muscular route needs to be performed if required; however, it requires approval from physician. Lastly, the nurse is responsible for performing regular assessments on blood glucose level of the patient and providing education for self-management of diabetes as no specific cure option of the disease has yet been discovered.

Respiratory Assessment

For managing obesity, the patient is to be provided with adequate disease specific education and dietary information that will help further in reducing body weight and decreasing the potential complications or risks associated with progression of obesity (e.g. further deterioration in heart function, development and progression of hypertension and hyperglycaemia (Walsh, Grech & Hill, 2019). Hydration maintenance needs to be ensured by the nurse in this aspect in order to ensure proper blood volume and appropriate level of electrolytes in blood of the patient. As the patient has diagnosed with type II diabetes, no further recommendation for bariatric surgery needs to be provided where a three months of follow-up on the effectiveness of physical exercise on weight management of the patient is to be monitored.

To decrease prevalence of anxiety and confusion, yoga and meditation needs to be performed along with guided imagery interventions, as according to current evidences, all the said interventions have positive response on anxiety management in healthcare facilities (Celano et al., 2018). However, to follow all the stated interventions and execute the plan of action in an appropriate manner, the nurse needs to properly communicate with other team members of MDT in order to ensure that no clinical miscommunication is going to result in patient’s clinical deterioration. Proper decision making, utilization of appropriate tools and technologies, verbal and non-verbal communication with the patient as well as her husband is considered to bring positive changes in the event.

The procedure needs to be accomplished with developing appropriate discharge plan for the patient including all essential particulars (e.g. dietary interventions, physical exercise, regular medication chart, insulin administration if required and community activities and relaxation).

Conclusion

Considering all the above mentioned facts and findings, it can be stated that managing complex patient situation in healthcare facility is not an easy task and it requires good hold on nursing skills, education and perspective on complex disease management. Considering all the assessment findings and medical diagnosis report, it has been found that the patient is suffering from congestive heart failure, type II diabetes and obesity. All the essential interventions are mentioned in this study which will be able to bring some positive changes in physiological condition of the patient.

Reference

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Impaired Electrolyte Level And ABG Level

Awang Ahmad, N. A., Sallehuddin, M., Teo, Y. C., & Abdul Rahman, H. (2020). Self-Care Management of Patients with diabetes: nurses’ perspectives. Journal of diabetes and metabolic disorders, 19(2), 1537–1542. https://doi.org/10.1007/s40200-020-00688-w

Cattadori, G., Segurini, C., Picozzi, A., Padeletti, L., & Anzà, C. (2018). Exercise and heart failure: an update. ESC heart failure, 5(2), 222–232. https://doi.org/10.1002/ehf2.12225

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Walsh, K., Grech, C., & Hill, K. (2019). Health advice and education given to overweight patients by primary care doctors and nurses: A scoping literature review. Assessment And Recommendation For Complex Patient Care Of Mrs. Smita Discussion Paper