In the case study, Ben is a 28 years old man and had an accident 3 years ago which resulted in an L4-L5 spinal fusion and associated medical restrictions resulting from chronic lower back pain. He also receives medical assistance for his post-traumatic stress disorder (PTSD) and back injury and visits the clinic monthly for psychological consultation for PTSD. For the last 3-4 months, Ben’s lower back pain has been increasingly affecting his ability to operate at work and also his ability to get adequate sleep at night thereby making him reply highly on pain medication. He is also prescribed with ibuprofen, panadeine forte, and if required oxycodone. Ben has been receiving psychological treatment focused on cognitive behavioral therapy for several years and over the last 6 months, has been feeling increasingly depressed. His psychiatrist suggested medication for his depression.
A patient is medically complex it means he is under chronic pain or cognitive issues (Hanscom et al., 2015). In this case, Ben is suffering from chronic lower back pain because of his back injury and also shows cognitive issues like his depression and stress affects the brain normal functioning and generated cognitive issues. According to Tottenham et al. (2016), the target region of stress hormones is the prefrontal cortex, this region controls major functions like decision making and working memory. It was found that depression and stress cause cognitive impairment by suppression of prefrontal cortex functions. He is also taking two medicines for treating and reducing his pain and undergoing psychological sessions as well. As he is living with his parents as a result he cannot regularize his gyms, exercise, and psychological sessions, all these make them a medically complex patient. According to Fernando et al. (2017), the role of psychiatrists is very important for improved mental and physical health of the medically complex patients. A psychiatrist can reduce the level of stress and depression in such patients making their medically complex state to a better normal state. For chronic pain, anti-inflammatory drugs are recommended and Ben is recommended with two of them showing that he is in a complex medical state. Ben has a medical history of PTSD that is also associated with stress or depression that Ben is already suffering from and it is found that all these chronic conditions together impact the health level of Ben making him a multimorbidity patient.
According to Azaïs et al. (2016), the caring of a multimorbidity patients face many barriers or challenges like multiple clinicians and settings, conflicting results, ever-changing health graph of the patient, need for multiple decisions, and various conflicting health care management plan. The multimorbidity patients have to take sessions from different health care professionals each prescribing specific plans with conflicting clinical priorities and these professionals if not communicate well with each other this ultimately results in inefficient health care plans for the patient. The patient might also feel unsupported and under-whelmed. In this case, Ben has a medical history of post-traumatic stress disorder (PTSD), chronic lower back pain, increased depression, and stress. Ben visits the clinic monthly for psychological consultation for PTSD regularly and started sessions for depression treatment sessions also. This generates a conflicting management health care plan. Moreover, Ben also found that exercise is very useful in managing his symptoms of depression and PTSD but his lower back pain might restrict him to only particular exercises to be performed so that he did not harm his lower back lumbers. It is found that ibuprofen has a side effect of depression. Ben is already a depression suffering multimorbidity patient if the drug showed this side effect on Ben then his condition will deteriorate. Similarly, panadeine also shows similar side effects that might affect the patient’s health.
Before the accident, Ben had a very active role as an infantry soldier and felt frustrated by the restricted duties due to his injuries. His frustration can negatively impact his health as he is also a patient of stress and depression. Moreover, he does not like speaking about his injuries and health issues, this ends up generating a barrier in nursing management. According to Foo et al. (2020), if there is no effective communication with the patient then he might not discuss openly and confidently about his health problems. The patient might not tell about his signs, symptoms, feelings, or feedback, all these points help the health care providers to develop a strong nursing management plan for the patient. Ben’s father is also less interested in knowing about the benefits of psychological therapy whereas his mother is having reserved nature as she does not make him feel bad by talking about his pain and suffering.
In such a case, if the patient does not get involved in decision-making activities or share the loneliness feelings of the patient then the patient might feel hopeless as well and not feel interested in his treatment sessions thus establishing a barrier for nursing management (Foo et al., 2020). Family involvement in a patient caring plan can create a positive impact on the patient’s mind and help in nursing management as well. Another factor that impacts nursing management is a lifestyle. Ben has started living with his family as a result he is now not able to regularly visit his psychiatrists and gym to maintain his good health. Moreover, more alcoholism might end him up with less money with which he might not be able to undertake his medication, health sessions, and other nursing expenses in the future resulting in non-continuity of care.
According to O’Connor et al. (2018), the barriers of effective pain management include fear of opioids, physician time constraints, inadequate pain assessments, and few more. Other barriers are like lack of motivation, fear of activity, stressors, and lack of support from family or friends. Ben is left by his friends and family is also not involved in his nursing plan, his stress, depression, and frustration collectively generated a lack of motivation for Ben such that he might not feel a caring and supportive environment. Lack of such an environment for a patient makes him less interested to get well soon thus acting as a barrier in nursing care as the patient might not get self-involved and interested in his own health decisions.
The term multimorbidity means that there is a presence of multiple conditions in a patient that are highly chronic, this has a significant impact on the health of the patient, resulting in an increased decline in organ functioning and ultimately death. The interpretation of the views and symptoms by the multimorbid patient about their depression frequently conflict with the sense of identity, this generates barriers for the acceptance of diagnosis and treatment (Wallace et al., 2015). The treatment and diagnosis are important for every patient especially when the patients are from the multimorbidity category because their diagnosis can give insights about their health issues and associated health issues that might arise linked to their present illness. Moreover, their treatment can help in the collective treatment of many related or linked health problems. The treatment and diagnosis plans are strongly affected by the beliefs about symptom causation and treatment. According to Ricci-Cabello et al. (2015), lack of time usually results in hindering the patient care plans for patients with multimorbidity. Similarly in this case study, Ben also cannot manage to regularize his gyms and psychiatric sessions as he is staying with his parents. To deal with the increased stress and depression Ben started gym and exercises but as he is a chronic lower back pain patient he cannot continue with the same because this might harm his back.
If Ben attends the sessions for stress by his psychiatrist then this also helps him to treat his depression thereby enabling him to treat two of his serious health conditions by a single treatment plan. This shows that multimorbidity impacts on the treatment of multimorbidity patients. While making the decisions for the patient with multimorbidity the clinical complexity associated with the healthcare system and the clinical decision-making is affected because the treatments sessions or surgeries or health care plans are needed to be synchronized so that the patient receives effective care by managing a proper nursing management care plan (Ricci-Cabello et al., 2015). Moreover, it is found that a patient with one serious health issue is usually associated with other health issues like increased stress and depression might be related to or associated with hypertension as well. This can be diagnosed while diagnosing for stress and depression ensuring that whether the patient is suffering from associated health issues or not so that an effective plan is made for him.
Azaïs, B., Bowis, J., & Wismar, M. (2016). Facing the challenge of multimorbidity. Journal of Comorbidity, 6(1), 1–3. https://doi.org/10.15256/joc.2016.6.71
Fernando, A., Attoe, C., Jaye, P., Cross, S., Pathan, J., & Wessely, S. (2017). Improving interprofessional approaches to physical and psychiatric comorbidities through simulation. Clinical Simulation in Nursing, 13(4), 186-193. https://doi.org/10.1016/j.ecns.2016.12.004
Foo, K. M., Sundram, M., & Legido-Quigley, H. (2020). Facilitators and barriers of managing patients with multiple chronic conditions in the community: A qualitative study. BMC Public Health, 20(1), 273. https://doi.org/10.1186/s12889-020-8375-8
Hanscom, D. A., Brox, J. I., & Bunnage, R. (2015). Defining the role of cognitive behavioral therapy in treating chronic low back pain: An overview. Global Spine Journal, 5(6), 496-504. https://doi.org/10.1055%2Fs-0035-1567836
O’Connor, Siobhan & Deaton, Christi & Nolan, Fiona & Johnston, Bridget. (2018). Nursing in an age of multimorbidity. BMC Nursing. DOI:10.1186/s12912-018-0321-z.
Ricci-Cabello, I., Violán, C., Foguet-Boreu, Q., Mounce, L. T. A., & Valderas, J. M. (2015). Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice: A scoping review. European Journal of General Practice, 21(3), 192–202. DOI:10.3109/13814788.2015.1046046
Tottenham, N., & Galván, A. (2016). Stress and the adolescent brain: Amygdala-prefrontal cortex circuitry and ventral striatum as developmental targets. Neuroscience & Biobehavioral Reviews, 70, 217-227. https://doi.org/10.1016/j.neubiorev.2016.07.030
Wallace, E., Salisbury, C., Guthrie, B., Lewis, C., Fahey, T., & Smith, S. M. (2015). Managing patients with multimorbidity in primary care. BMJ. DOI: https://doi.org/10.1136/bmj.h176
Yang, L., Zhao, Y., Wang, Y., Liu, L., Zhang, X., Li, B., & Cui, R. (2015). The effects of psychological stress on depression. Current Neuropharmacology, 13(4), 494–504. https://doi.org/10.2174/1570159x1304150831150507
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