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Introduction - Nursing Case Study: Care and Discharge Planning for Mr. Brian May with Multiple Comorbidities

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In the present case, the name of the patient is Mr Brian May, and his age is 62 years; who have suffered from various physical and mental issues. As a registered nurse, Mr May needs to provide appropriate care support which follows the Australian nursing standards. He has suffered from several issues as he already has type 2 Diabetes, Hypertension, Obesity, hypercholesterolemia and depression.

In the analysis of the present situation that is identified, due to health issues, a car accident has occurred where a fracture is identified in his left fibula. In addition, he has tested positive for Covid-19, where more safety is needed to develop a care plan for him. Besides this, He has suffered from chest pain as his breath rate is 24 per minute, and he complained about chest tightness.

Therefore the development of nursing interventions for those with that situation, and he smoked for a long time, and 25 cigarettes are smoked by him per day, which increased complications for developed support for Covid-19. Therefore the present report has developed on the issues faced by Mr May and the development of intervention plans for him.

In the present report, issues are identified, and management for those is developed by following nursing standards that help plan discharge.

Primary admission

In the given case that is identified, Mr May was admitted to the hospital due to a car accident where he crashed his car by losing control of a car. As some injuries are identified, he has been admitted to a hospital where other health issues are identified, such as type 2 diabetes mellitus. The identified injuries are listed below;

  • Fracture left fibula
  • Blunt chest injuries
  • Left pneumothorax
  • Left-sided laceration on the forehead

Pathophysiology and clinical manifestations of injuries:

In the analysis of the identified injuries, the most critical issue is a fracture in the left fibula. In the assessment of the fracture that is identified, plaster is applied by the registered orthopaedic and pain relief is suggested. Therefore due to the presence of excessive pressure in the bone, the fracture is chapped, and the situation is much more severe where more rest is needed (Ncbi.nlm.nih.gov, 2022). After removal of the plaster, an x-ray is needed, which helps to confirm the situation.

Laceration on the forehead where bleeding is spotted should have a five-minute pressure application, and a clipping is done in the wound with an application of antiseptic to avoid bacterial contaminations. In addition, Blunt's chest injuries are identified as he is faced with tenderness and pain in the chest, and an x-ray is done where a minimal injury is identified (Ranhoff et al. 2019, p. 210). Besides this, Oxygen therapy is given, which needs to be continued, and testing of the Covid is done as the registered nurse needs to follow the recommendations suggested by the specialists and needs to help him get some rest as he had a restless time. According to the view of Mitchell et al. (2020, p.1075), analysis of the severity of the injuries helped to develop intervention plans for those patients. Based on "Standard 1", all the steps of critical thinking are followed in the present report.

Identification of a nursing problem

In the above section, clinical manifestations of the injuries of Mr May are identified, and care plans for him are also identified where some issues are identified based on the nursing standards. The identified main two issues of nursing care and interventions are identified in the below section;

  • Type 2 diabetes and obesity
  • Presence of Left pneumothorax and Covid-19 positive report of Mr May.

In the above section, those two factors are identified, which are increased risk factors for the development of the nursing care process for Mr May. In the management of a patient, dietary support is needed as he has a fracture in the left fibula; it is much more complicated to overcome the issues with obesity. As per the view of Chamberlain, Pollock and Fulbrook (2018, p. 295), it is much more complicated to develop care and quick recovery for a patient who has suffered from type 2 diabetes and obesity as pressure on the leg is increased due to being overweight as BMI is 30. In addition, much time is needed in the recovery process, as in type 2 diabetes, a longer time is needed in the healing of a wound (Lv et al. 2019, p. 48).

Another issue or problem which is identified is covid-19 positive besides pneumothorax which increased complications in the care and management plan of the registered nurses. Based on the given case study, he smoked for a long time, and 25 cigarettes were smoked by him per day, which is identified as another cause of the development of pneumothorax. There are other risk factors identified due to the presence of both situations in Mr May, “development of acidosis” as a poor prognosis has happened (Mitchell et al. 2020, p. 1072). Therefore these complicated factors are increased risk factors for the development of a nursing care plan for Mr May.

Nursing management

In the above section, two main issues have been identified that need to be implemented with nursing care support and needed support has been developed based on the RN standards of Australia.

Intervention for Type 2 diabetes and obesity

In the case of Mr May, the presence of Type 2 diabetes is identified where “testing and monitoring, medication adherence, diet and weight management” is needed in the nursing intervention. Therefore, regular monitoring of the blood sugar level is needed where the viability of insulin is needed to be checked. “Less than 140 mg/dL (7.8 mmol/L)” is identified as the normal blood sugar level; therefore, assessment of those levels needs to be checked regularly (Ranhoff et al. 2019, p. 220). As he is identified as an obese person as his BMI is 30; therefore, management of his weight is needed to get quick recovery from the fracture. In the management of weight, some dietary modifications are needed for Mr May, such as;

"Food to be included"

  • Whole grains (oats, brown rice)
  • Moderate protein foods
  • High-HDL foods (olive oil, sesame oil)
  • Fibre enriched Fruits

“Food to be avoided”

  • High-lipid and Low-LDL meat and foods (pork, beef, lamb, butter, cheese)
  • High-sugar foods and sweeteners.
  • Cigarette and alcohol

“Medication support”

Those are identified as the dietary intervention for Mr May where appropriate rest is needed, and in the assessment that is identified, restlessness is found for Mr May. Based on nursing standards 1 and 5 that found the development of a care plan needs to be included in the safety plan for a patient (Goel et al. 2019, p. 240). In the analysis of the given case, that is found he has taken some medication support which included; "Atenolol, Atorvastatin and Metformin", and those are taken for Diabetes. On the other hand, some side effects are identified from those medications, such as; “shortness of breath, tightness in the chest, Loss of appetite and Headaches” (Guzinski et al. 2019, p. 40). Therefore in the nursing management process, Metformin is needed to be replaced as those are increased complications in Covid patients. The issues which are developed in the consumption of this medicine are found in the diagnosis of Mr May. Therefore, “Prandin” is suggested, which is repaglinide and has much lower side effects than Metformin which is suggested for Mr May.

Besides that dietary support and medication support, regular monitoring is needed to identify the effectiveness of those interventions. On the other hand, in the given case, he is not able to exercise and suffers from restlessness, and he has an addiction to smoking. Besides this, mental support and communication strategies of the nursing intervention is need to be applied as he has suffered from depression, too (Chamberlain, Pollock and Fulbrook, 2018, p. 299). With the application of effective communication strategies based on “Peplau's Interpersonal Relations Theory” in the therapeutic treatment process, interpersonal relation development is needed. According to the view of Haddeland et al. (2018), communication is a complex factor based on “attitudes, practices and beliefs 'that need to be maintained by the RN during support to Mr May. In the application of the present theory, 4 phases need to be followed “pre-interaction; orientation; working; and termination” which helps in the development of the “nurse-client relationship”.

Therefore, the critical analysis application of this theory is the development of a nursing care support plan for Mr May in the present case.

Intervention for Left pneumothorax and Covid-19

In the present case of Mr May, he has already had a complication in the left lung for the presence of pneumothorax which is more complicated with the presence of Covid-19. Therefore for the present situation, some effective nursing intervention is needed, which includes “diagnosis, analysis, medication and dietary support, monitoring” processes which are based on the nursing standards for RN (Burgess et al. 2020, p.7). In the present case, “supplemental oxygen therapy” is already suggested for him, and those are given to him. According to the view of Lauck et al. (2019, p.456), “observation, needle aspiration and chest tube insertion” are identified as intervention support of the nursing therapy where oxygen therapy increases resolution rate. Therefore monitoring of the Oxygen therapy is needed, which is suggested via nasal specs as complications are found in such cases. Observation of the inhibited drainage and need to ensure the tube and daring unit must be secure.

Besides this, in controlling the situation, the RN may use water-seal chambers to monitor the fluid level and analysis of the bubbling. In the analysis of the recommendations, “Underwater seal drain (UWSD)” is suggested, which helps in the control of the situation as it helps to monitor complications of the situation (Spence et al. 2019, p.460). Based on the clinical guideline for the use of the underwater seal drain (UWSD), some actions need to be followed;

  • Need to keep Darin at chest level,
  • Development of facilitating damage in chest level
  • Tubing excluded obstruction,
  • A secure connection between chest tubes and drainage.

“Dietary intervention”

In the present case that is identified, Mr May has complications of pneumothorax, and he tested positive for covid-19; therefore, some dietary modification is needed. “Increased zinc and Vitamin C intake” is suggested by Mr May as it helps in the lower symptoms of Covid, which have an impact on the respiratory system (Fernández-Quintela et al. 2020, p. 2589). According to WHO, a Covid patient with pneumothorax needs to consume fruits and need to lower the level of sugar intake (Euro.who.int, 2022). Besides this, weight management is needed in the development of the care plan for the present situation Mr May.

“Medication support”

In the diagnosis and development of “An arterial blood gas (ABG)”, in the analysis of the identified assignment, that is found his body is light acidic as normal rage is “7.35-7.40”, where 7.30 is identified. Besides this, PaO2 is lower than the normal range, and PaCO2 is higher; therefore, “acidosis” is identified (Medlineplus.gov, 2022). Therefore “oxygen therapy” is suggested, which is already developed, and the application of Interpersonal Relations Theory is needed.

Discharge planning

Based on the interdisciplinary management approach, a discharge plan includes “identification, assessment, goal setting, planning, implementation, coordination, and evaluation”. Therefore the aim of the discharge planning is to engage the family members and patients during the transformation from hospital to their home after preventable readmission. As per the view of Patel et al. (2019, p. 85), “improve patient outcomes, healthcare processes and levels of satisfaction” are some effective results of the use of an interdisciplinary approach to the patient discharge process. On the other hand, developing a care plan in a holistic manner and avoiding complications in the assessment process by application of an interdisciplinary approach is important. Therefore an effective interdisciplinary approach is used by the registered nurse, which helps to develop the team and action which are needed in discharge.

Role of the RN in discharge plan:

  • Development of planning for in-patient and out-patient care,
  • Analysis of injury and level of healing
  • Arrangement of patient referrals included home care, primary care and therapeutic care,
  • Teaching of self-modification
  • Development of team and teamwork,

Members of the multidisciplinary health care team and their roles:

  • Psychiatrists or Counsellors who give mental support to Mr May and help encourage him for self-modification and care.
  • A clinical nurse or RN who analyses his injuries and their healing level and his fitness for the discharge process.
  • The pharmacist checked the suggested medication for Mr May and taught him about its importance.
  • Occupational therapists or registered orthopaedics checked his fracture and level of healing (Lauck et al. 2020, p. 456).
  • Dietitian has developed a suggested diet plan for Mr May, which will help him to increase his health and overcome complications.

Therefore with the development of teamwork, the registered nurse has developed a discharge plan, and the suggested plan is listed below section;

  • In the first stage, the venue of the discharge process is identified, and in the present case, Mr May goes to his home, which is present in a rural area. Besides this, medication support which is identified in the treatment process and support of the family members is needed (Patel et al. 2019, p. 85). On the other hand, as he lived alone, an enrolled nurse needed to give support to him in his home and take primary care, including appropriate medication support.
  • In the next stage, an X-ray of the fibula and other tests such as “arterial blood gas (ABG), ECG and x-ray of lungs” need to be taken before discharge. In addition, the specialist and registered nurses need to check those issues and ensure he is ready to be discharge (Meo et al. 2018).
  • The needed care which is needed for future implication need to be identified, which are suggested by a multidisciplinary health care team. Diet plans that need to be followed after returning home are identified by dieticians as low-fat, moderate protein, low-carbohydrate and high fibre foods (Kang et al. 2020, p.1701). Therefore the development of medication support is suggested by the pharmacist. Support for the “glucose monitoring items and a wheelchair” needs to be arranged by the family, which is done for Mr May.

Conclusion

Therefore in the above analysis, supportive nursing intervention is developed for Mr May, which is included in the discharge plan. It is concluded that due to the presence of obesity, T2DM, pneumothorax and covid-19, the situation becomes more complicated for Mr May. In addition, the medication support which is taken by Mr May, Metformin, increased complications in pneumothorax and chest injuries. Therefore it is concluded the alternative Prandin is suggested to Mr May, and a mild acidosis is identified in the report by Mr May. It is concluded the application of oxygen therapy gives support to him, and dietary intervention is also suggested for him. A discharge plan is developed with the identification of the roles of multidisciplinary healthcare team members, which helps to increase success in the care of Mr May. Therefore it is concluded that registered nurses get success with their team in the development of care and discharge plans for Mr May.

Reference

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