Chronic Care Across the Lifespan B

Q 1- In the given case study, there are multiple risk factors associated with the patient. most of the underlying risk factors are pertaining to her given chronic conditions such as diabetes, hypertension and so on. The patient is having a hard time managing his clinical conditions. Along with her complications the patient is also having high body weight. This is a major risk factor in its own, giving rise to manifestation of other underlying complications. Patient also had an episode of hyperglycemia, which was very recent. The normal routine of the patient also includes not adhering to the medication routine on daily basis. This is a risk factor as the patient is on medication and the same is liable to manage his condition. The high body weight is also an underlying factor for the development of cardiovascular risk in the patient. Despite having multiple comorbidities, the patient has not had any regular follow-ups with a registered physician. Despite the medical history the patient is also having a personal history of smoking as well as drinking. Both habits also add to the risk factor to the overall health status of the patient. The poor dietary control along with the high blood sugar levels can be life threatening for the patient (Sato, 2017). One of the main risk factors is the patient not having complete education about the repercussions of his present health status.

Q 2- The main intervention needed in the given case scenario is a detailed evaluation and assessment of the patient. The patient is not only having current positive status of chronic illness, but the same runs in his family as well. Both his mother and father have had diabetes. This adds to the underlying risk factors with added gravity. There is also a dire need of noting the blood sugar levels on daily basis. The patient is also in a need of medication reconciliation as he has been managing his diabetes with the same dose of metformin. This is required for managing his blood glucose levels. The increasing weight along with poor dietary habits is another issue that needs to be looked after at. The nurses can help the patient by providing him with a diet plan, in accordance with his interests and liking. This is important to reduce the glucose and fat intake and increase the fibrous intake, in order to promote a healthy diet culture.

Reduction in weight will also be helpful in reducing the underlying cardiovascular risk factors of the patient (Duprez, 2017). The patient also needs smoking cessation as it will also help in reducing the cardiovascular risk factors. The depressive mental state of the patient can be helped with the counselling and group therapy to reduce the social isolation from the patient’s daily routine.

Q 3- The concept of self-care management can be very helpful in managing the condition of the patient. The nurse professional assigned in the care of the patient, can work along with the patient in managing the care in a holistic approach (Dwarswaard, 2016). Patient cooperation is very necessary to get better and improved healthcare outcomes from the patient. The main self-management can be done by teaching the patient to note his blood glucose levels on daily basis. The same can be noted down, which can be cross verified for fluctuations in order to get early intervention and prevention of the same. The use of electronic dispensers can be used for medication provision to the patient. By regularizing the medication intake, the patient’s condition can be managed (Lafata, 2016). Weight management is also important and the patient can be provided with a weighing scale in order to have a feedback on his own progress in terms of weight management. The patient can also be taught about his condition, which can be included of teaching the patient about his conditions and complications associated with the same. This better understanding of his condition will help the patient in managing his condition in a more methodical manner.

Q 4- The main SAMRT goal in the case study will be regularly noting for the blood glucose levels. Measuring the blood glucose levels with due diligence will be helpful in keeping a close vigil on any abnormal readings and helping in early management of the condition. The targets for a particular blood glucose level can be set for the patient to attain. The family of the patient can be helpful, as they can be taught how to manage the same and note the readings on their own (Chrvala, 2016). Family can also be helpful in providing a constant support to the patient, throughout the transition of care and can help the patient in staying focused in managing his condition with measures available in place. Setting the goals and targets for the patient can help him in being in touch with his reality and will thus, be able to handle the care in a more realistic manner, knowing the detailed repercussions of not doing the same (Coppola, 2016). Regular counselling and monitoring will also be helpful in keeping a close vigil on the patient’s progress and will help the physician in knowing any early signs of deterioration. Regular examination will ensure for timely intervention of the patient.

Q 5- Goal-setting is a methodical approach that can be very helpful in the given scenario. This will help the patient and their family in getting in touch with the truth about the patient’s underlying chronic condition (Kangovi, 2017). By working in close coordination with the patient, the concerns and myths regarding their condition can also be managed and resolved effectively. Goal-setting will also help the patient in being in constant focus and continue to manage his condition in a regularized manner. The continuation of following prescribed interventions can be very helpful in improving the overall quality as well as health status of the patient. Constant engagement of the patient with his healthcare professional will also help them in staying focused throughout the process of management of the condition (Rising, 2016). It is very crucial in managing the multiple comorbidities the patient is suffering from. The sustainability of the intervention is also crucial from the point of view of constant engagement of the patient and his family and thus, keeping them focused and grounded to achieve the set healthcare targets. Desired outcomes can be fetched, with timely and orderly implementation of the treatment interventions.

References for Chronic Care Across the Lifespan

Chrvala, C. A., Sherr, D., & Lipman, R. D. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Education and Counseling, 99(6), 926-943.

Coppola, A., Sasso, L., Bagnasco, A., Giustina, A., & Gazzaruso, C. (2016). The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine, 53(1), 18-27.

Duprez, V., Vandecasteele, T., Verhaeghe, S., Beeckman, D., & Van Hecke, A. (2017). The effectiveness of interventions to enhance self‐management support competencies in the nursing profession: a systematic review. Journal of Advanced Nursing, 73(8), 1807-1824.

Dwarswaard, J., Bakker, E. J., van Staa, A., & Boeije, H. R. (2016). Self‐management support from the perspective of patients with a chronic condition: a thematic synthesis of qualitative studies. Health Expectations, 19(2), 194-208.

Kangovi, S., Mitra, N., Smith, R. A., Kulkarni, R., Turr, L., Huo, H., ... & Long, J. A. (2017). Decision-making and goal-setting in chronic disease management: baseline findings of a randomized controlled trial. Patient Education and Counseling, 100(3), 449-455.

Lafata, J. E., Karter, A. J., O’Connor, P. J., Morris, H., Schmittdiel, J. A., Ratliff, S., ... & Butler, M. G. (2016). Medication adherence does not explain black-white differences in cardiometabolic risk factor control among insured patients with diabetes. Journal of General Internal Medicine, 31(2), 188-195.

Rising, K. L., Hudgins, A., Reigle, M., Hollander, J. E., & Carr, B. G. (2016). “I'm just a patient”: fear and uncertainty as drivers of emergency department use in patients with chronic disease. Annals of Emergency Medicine, 68(5), 536-543.

Sato, J., Kanazawa, A., Makita, S., Hatae, C., Komiya, K., Shimizu, T., & Goto, H. (2017). A randomized controlled trial of 130 g/day low-carbohydrate diet in type 2 diabetes with poor glycemic control. Clinical Nutrition, 36(4), 992-1000.

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