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Chronic Care across the Lifespan B

Q 1-In the given case study there are multiple risk factors associated with the patient’s condition. The main risk factors are the present clinical comorbidities with which the patient is suffering from, such as diabetes, hypertension and increased weight. These conditions are adding to the cardiovascular burden to the patient. The increased body weight of the patient is also adding to the risk to his health (Rico, 2016). Patient has had an episodic event of hyperglycaemia and it was two years ago. Since then the patient has not taken any proper follow-up with a specialist consultation. The patient is also having trouble with medication adherence. Despite having multiple comorbidities, the patient is not religiously taking any medication. The patient is also having very less interaction as measured socially. He has restricted his visiting circle and can also be seen reflecting upon depressive symptoms. Patient is having a genetic history of diabetes on both paternal and maternal side. He is still not that educated about his condition. Not knowing about the repercussions of his health is an added risk factor to the patient’s current health status. Patient is also having a poor dietary control in terms of food intake. The high carbohydrates and sugary intake in diet can also add to the underlying cardiovascular and diabetes risk factors.

Q 2- The main nursing intervention needed in the given case scenario, is carrying out detailed assessment for the patient. The most important thing that the patient can be encouraged to do, is to monitor his blood glucose level on a regular basis. The patient is having a chronic history of diabetes and is not keeping up with the management of the same, that well. Monitoring the blood glucose levels will be helpful for the patient in keeping a close watch on the fluctuation in the levels and thus, the same can be treated with effective treatment interventions within stipulated time frame. The patient is also in a dire need of medication reconciliation. He has been managed for his diabetes with a set dosage of metformin for very long now. The blood glucose levels monitored will help in tapering or adding on to the present dosage of medication for treatment purposes. Educating the patient is also a crucial intervention that should be implemented in the give case scenario. As the patient is unaware of hid condition in details, he needs to be duly informed about the side effects the condition can bear upon his current health status. Patient education will also be helpful in providing the patient with mental peace, as knowing his condition better will be helpful to him to manage his condition in a more profound manner. Weight reduction is also vital, given the chronic history of the diseases the patient is having and the poor dietary control he is having (Van, 2017).Patient also needs to be enrolled in smoking cessation plan, as the habit of smoking can add to the prevailing cardiovascular risk to his health status.

Q 3- Encouraging the patient for self-management can be an effective way for managing his diabetes and other chronic illness. As the nursing professionals cannot be present in close vicinity to the patient all the time, it is crucial that the patient and his family should be included in the process of health management for the patient (Brenk, 2017). A log book for record keeping can be maintained by the patient and the same can be cross-referred by the healthcare professional on follow-up visits. Patient can also be taught about various diet options that can be best suited for his health. As the patient is not that diligent with taking his medications, he can be prescribed with an electronic medication dispenser. The dispenser will help the patient in taking his medication on time (Iyengar, 2016). The routine of medication intake can also be regulated in sync with the time of meals, such as dinner, lunch and so on, to ensure that the patient dose not skips on any medication. The patient is currently also suffering from depressive symptoms. He can be enrolled in support groups for people dealing with multiple chronic conditions. This will be helpful in instating positivity in the patient and will help him manage his condition in a more schematic manner.

Q 4- The main SMART goal in the case study will be monitoring the blood glucose level of the patient. The patient can be provided with equipment that can be helpful in measuring the blood glucose level with ease. This will also be helpful in keeping a close monitoring on any fluctuation on the levels. The target values for blood glucose levels can be set by the physician and the patient can be encouraged to attain that target. The main barrier in the case study is patient not being educated that well. By doing so, a better cooperation from the patient is liable to be there, which will evidently be helpful in smooth facilitation of the health services to the patient (Tinetti, 2016). Patient should also be well informed about his condition throughout the process. This will be helpful for motivating the patient and keeping him grounded. The weekly basis monitoring of vitals will be helpful in noting the fluctuation in the readings. This is crucial from the point of view of early identification and management of the condition. It is also vital in respect with providing holistic care approach to the patient and will also help in keeping a close vigil on his overall health status.

Q 5-Goal setting is very crucial from the point of view of managing the care for the patient. This helps in educating the patient about not only his condition, but also helps to keep him notified at all times about the repercussions of his condition. Goal-setting process also helps in reducing the myths and disbeliefs of an individual (Clarke, 2017). This will help the patient in attaining set targets and will also be helpful in keeping him focused throughout the facilitation of treatment interventions to him. This approach will help the physician as well in identifying the short comings and those can be rectified to provide the patient with lifestyle modifications required to manage the chronic illness. This will also be helpful in attaining the desired healthcare outcomes within stipulated timeframe and will thus, be helpful in gaining improved healthcare outcomes from the patient. This will be reflected evidently in his improved quality of life as well.

References for Chronic Care across the Lifespan B

Brenk-Franz, K., Strauß, B., Tiesler, F., Fleischhauer, C., Schneider, N., & Gensichen, J. (2017). Patient-provider relationship as mediator between adult attachment and self-management in primary care patients with multiple chronic conditions. Journal of Psychosomatic Research, 97, 131-135.

Clarke, J. L., Bourn, S., Skoufalos, A., Beck, E. H., & Castillo, D. J. (2017). An innovative approach to health care delivery for patients with chronic conditions. Population Health Management, 20(1), 23-30.

Iyengar, R. N., LeFrancois, A. L., Henderson, R. R., & Rabbitt, R. M. (2016). Medication nonadherence among Medicare beneficiaries with comorbid chronic conditions: influence of pharmacy dispensing channel. Journal of Managed Care &Specialty Pharmacy, 22(5), 550-560.

Rico, F., Liu, Y., Martinez, D. A., Huang, S., Zayas-Castro, J. L., & Fabri, P. J. (2016). Preventable readmission risk factors for patients with chronic conditions. The Journal for Healthcare Quality (JHQ), 38(3), 127-142.

Tinetti, M. E., Esterson, J., Ferris, R., Posner, P., & Blaum, C. S. (2016). Patient priority–directed decision making and care for older adults with multiple chronic conditions. Clinics in Geriatric Medicine, 32(2), 261-275.

Van Zyl, M. A., & Harris, L. M. (2019). Provider Responses to Patients with Chronic Conditions who Follow a Plant-Based Diet. Families in Society, 100(1), 106-115.

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