• Internal Code :
  • Subject Code : NUR231
  • University : Charles Darwin University
  • Subject Name : Nursing

Case Study: Jolene

The case study is about Jolene a 35-year-old woman she lives in Dalby with her husband and she help her husband on the farm for part 2 years. 18 month ago she meets with an accident that leads to a compound fracture involving tibia and fibula with blunt force head trauma. About 3 months after the surgery Jolene returned to the emergency department complaining extreme chest pain and dyspnoea and on diagnosis reveal that pulmonary embolus with DVT. She was prescribed with anticoagulant medicine and about 12 months ago she found to be disoriented and immediately administered to the emergency department then only she encountered tonic-clonic seizures lasting 3 minutes. On diagnosis, traumatic epilepsy was found due to motorbike accident. Now on visiting the GP, she said she thinks she is pregnant and GP also revealed that Jolene is in the first trimester of confinement.

One of the complications that are associated with Jolene is the pulmonary embolism that occurs due to the blood clot. The blood clot causes the blockage of the artery in the lungs that lead to decrease in blood flow in the lungs. The initiation of the pulmonary embolism occurs when the embolus breaks from a blood clot and reaches the blood vessel in the pulmonary artery tree causing the blockage. Pulmonary embolism increases the risk of chronic thromboembolic vascular disease and chronic thromboembolic pulmonary hypertension.

When the emboli reach to the pulmonary artery it creates a blockage that can breakdown or lodges the artery that leads to haemodynamic compromise, collapse and dyspnoea. There are chances individual encountering pulmonary embolisms also face deep vein thrombosis as the risk factor for both of the disorders overlaps. The pulmonary embolism leads to increased right ventricle load because of increase of oxygen demand that causes loss of function of right ventricle and progression of dilation which leads to arrhythmia and hypotensive shock (Huisman et al., 2018).

The deep vein thrombosis occurs due to the blood clot formation in the vein that is located in deep inside of your body. When the lower limbs of the body encounter the blood clot leads to a decrease in the supply of the blood in the legs. There are many complications associated with deep vein thrombosis and one of them is pulmonary embolism. Three reasons can lead to the formation of the thrombosis like venous stasis, vascular injury and hypercoagulation. Many symptoms can lead indicate the presence of the DVT which include legs or arm swelling, pain in walking; enlarged vein and skin look blue. The decrease blood flow, increase clot formation and injury to the blood vessel that directly increases the risk for the formation of the clot. It is considered to be one of the reasons for morbidity and mortality worldwide causing 60,000 deaths annually (Stone et al., 2017). Jolene was also diagnosed with DVT with pulmonary embolism as she complains about the chest pain and dyspnoea.

Epilepsy is the neurological disorders that lead to seizures that lead to increase patient complication and one of the reasons to encounter the epilepsy is a traumatic brain injury. Many reasons are associated with epilepsy like brain injury, stroke, brain tumour and birth defect. There two two type seizures generalised that include seizures affect both of the hemispheres and focal only affect one of the hemispheres. During the epilepsy resistance of the excitatory neuron decrease that leads to changes in the ion channels that lead to the development of the seizures. The up-regulation of the circuit that is involved in the excitation cause epileptogenesis that causes failure of the blood-brain barrier that leads to the development of the seizures (Lucke-Wold et al., 2015).

Anticoagulant medicine includes certain medicines that are involved to reduce the chances of blood clot formation that can increase complication. The anticoagulant drugs are involved to disrupt the blood clot formation and they can be divided into the category according to their mode of function. The first class include an anti-platelet drug that is involved to decrease the platelet aggregation that directly helps to inhibit the thrombus formation. There are only three types of anti-platelet drug that are utilized which include oral cyclooxygenase inhibitors, GP IIb/III receptor inhibitor and oral P2Y12 receptor inhibitor. The second category includes an anticoagulant agent that prevents the clotting process by disturbing the different clotting factor involved in the cascade. Many anticoagulant agents are in clinical practice like heparin, synthetic pentose, vitamin K inhibitors, direct thrombin inhibitors and direct coagulation factor Xa inhibitors (Fan et al., 2018).

One of the anticoagulant agents that are utilized to inhibit the clot formation includes Vitamin K antagonists that directly work by blocking the vitamin K-epoxide reductase that prevents the formation of the vitamin K-dependent clotting factor in the active form. The Vitamin K antagonistic have two functions first is the pro-thrombotic effect that block the protein C and S followed by the antithrombotic effect which inhibits the different coagulation factor II, VII, IX and X. On the other heparin is also one of the drugs that can be used to inhibit the clot formation by binding with the receptor that causes a conformational change to factor Xa that lead to increase the activity of the antithrombin III (Harter et al., 2015).

The Vitamin K antagonists have the bioavailability of about 99% and the half-life associated with the drug include 32-42 hour. The onset action of the drug is considered to be of about 36-72 hour. The route of elimination for the drug is hepatically metabolized and it has many advantages like having the antidote, not expensive, high bioavailability. Some of the disadvantage associated with the drug includes great variability of individual dose, dietary restriction and slow onset (Mekaj et al., 2015). The pharmacokinetics associated with heparin administration includes 30% bioavailability and half-life of about 1-2 hours but it mainly depends upon the dose.

The oral route of administration is not preferred due to null absorption and medicine is metabolized in the liver followed by excretion in the urine. Some of the advantage associated with heparin administration it is more predictable as an anticoagulant, better bioavailability and dose-independent excretion with a longer half-life. The certain disadvantage of medicine includes expensive, lead to clumping of leucocyte and poor drug interaction (Oduah et al., 2016).

The first line of the treatment for pulmonary embolism and DVT include anticoagulant medication therapy. The health care associates are expected to assess the risk for the patient before the administration of the anticoagulant as it can increase the risk for bleeding or thrombosis. The follow up should be accurately maintained to continuously monitor the patient to red cue the chances of complication (Gee, 2018). The first-line treatment for epilepsy includes administration of the antiepileptic drugs that help to reduce the rate of the seizures. These drugs are divided into the three-generation and the first generation include phenytoin, phenobarbital.

The second line of treatment ZNS and third lien of medication include Iacosamide. It decreases the frequency of the severity of the seizures that help to reduce complication. It has good oral absorption and bioavailability that increase its requirement for treatment. The drug is metabolized in the liver and excreted in the unchanged in the kidney that helps in easy clearance. Some advantage associated with the drug include multiple routes of admiration, no dose adjustment require and no drug interaction. On the other hand, disadvantage associate with the drug includes dizziness, ataxia and dose-depend program (Hanaya & Arita, 2016).

Nurses are expected to provide the person-centred care to improve the care process that leads to a better health outcome of the patient. Person-centred care improves patient participation in the care that improves the accuracy of the care concerning patient health status (Nursing and Midwifery Board, 2017).

The person-centred interventions that can be used to reduce the chances of the complication associated with the anticoagulant drug include patient-focused support intervention. The intervention aims to reduce the chances of complications that are associated with anticoagulant drug administration by utilizing the different aspect to address patient. The first aspect that is included in the intervention includes INR monitoring of the patient that directly help to reduce the risk associated with medicine like hemorrhagic or thromboembolic complication. The INR monitoring is performed by the patient by utilizing the point of care test via a portable device to perform a test that is monitored by the health care professional to maintain the medication dose.

Decision method is another method that utilized patient perception and their opinion regarding the benefit/harm of the medication. It helps to identify the patient preference regarding the treatment option that can be utilized to tailor the care. Educational intervention is also one of the methods that can be utilized to improve the information regarding the use of anticoagulants drug. Pharmacist counselling is also preferred to improve the patient understanding regarding medicine and its accurate use that can reduce the chances of complication. Visual aid is the last aspect that is considered in the intervention which aims to improve understanding by reducing the communication and language barrier (Yiu & Bajorek, 2019).

The interventions that can be utilized to reduce the complication associated with DVT include the utilization of the graduated compression stockings or pressure stocking. The pressure stocking intervention can help the patient to improve the blood flow by pushing the fluid upwards and it is also considered to reduce the swelling and pain associated with the DVT. Nurses are expected to educate the patient about the importance of pressure stocking and its accurate use (Hanison & Corbett, 2016). Percutaneous transcatheter intervention that is utilized to reduce the complication associated with pulmonary embolism. The catheter-based therapy aims to reduce pulmonary artery pressure and increase the systemic perfusion that helps reduce complication. There are three categories of the percutaneous intervention which include aspiration thrombectomy, thrombus fragmentation and rheolytic thrombectomy that should be preferred according to patient preferences (Setty, 2017).

The interventions that can be applied to reduce the complication associated with antiepileptic medicine include multifaceted intervention that includes a different aspect. The first aspect of the educational intervention that helps the patient to understand the medication and possible safety measure those are required during administration to reduce complication. The educational intervention includes information regarding treatment procedure, medication information, dosing and adherence to medical dose. The second aspect includes behavioural intervention that includes filling simple worksheet regarding routine so that medication routine can be maintained accordingly. The behavioural intervention also includes face-to-face motivational intervention to enhance the self-management technique to maintain the accurate medicine dose (Al-Aqeel, 2017).

The non-pharmacological interventions that can be helped to reduce the complication associated with epilepsy include lifestyle change intervention. The first aspect of the intervention includes dietary intervention as the individual encountered epilepsy should follow the special dietary routine. The dietary routine of the individual should include the ketogenic diet should be preferred that include decrease high fat, low-protein, low carbohydrate diet. The ketogenic diets are directly associated to improve nutrition intake that helps to reduce the rate of seizures faced by the patient.

The second part of the intervention includes psychological intervention that includes relaxation therapy, cognitive therapy, behavioural therapy and educational intervention. The third aspect includes yoga intervention that helps to improve the physical and mental wellbeing of the patient by improving flexibility, stretch and breathing capacity. The acupuncture intervention is also considered to reduce complication associated with epilepsy as it helps to stimulate specific body points (Jackson et al., 2015).

It is evident from the case study that Jolene has encountered pulmonary embolism and DVT after the accident that increases her complication. The Jolene also faced seizures due to epilepsy after that she was prescribed with the medication. The patient was prescribed with an anticoagulant to reduce thrombosis as it delays the clot formation but it also has some side effect like bleeding and person-centred intervention is utilized to reduce the complication associated with the medication. Pressure stocking and percutaneous transcatheter intervention can be used to reduce complication associated with thrombosis. The antiepileptic drug helped to reduce epilepsy but can lead to the side effect that can be reduced by multifaceted intervention and lifestyle intervention can be used to reduce complication associated with seizures.

References

Al-Aqeel, S., Gershuni, O., Al-Sabhan, J., & Hiligsmann, M. (2017). Strategies for improving adherence to antiepileptic drug treatment in people with epilepsy. The Cochrane database of systematic reviews, vol. 2, no. 2, pp. 1-46. https://doi.org/10.1002/14651858.CD008312.pub3

Fan, P., Gao, Y., Zheng, M., Xu, T., Schoenhagen, P., & Jin, Z. (2018). Recent progress and market analysis of anticoagulant drugs. Journal of thoracic disease, vol. 10, no. 3, pp. 2011–2025. https://doi.org/10.21037/jtd.2018.03.95

Gee , E. (2018). Principles and nursing management of anticoagulation. Nursing Standard, vol. 32, no. 23, pp. 50–63. doi:10.7748/ns.2018.e11060

Hanaya, R., & Arita, K. (2016). The New Antiepileptic Drugs: Their Neuropharmacology and Clinical Indications. Neurologia medico-chirurgica, vol. 56, no. 5, pp. 205–220. https://doi.org/10.2176/nmc.ra.2015-0344

Hanison, E., & Corbett, K. (2016). Non-pharmacological interventions for the prevention of venous thromboembolism: a literature review. Nursing Standard, vol. 31, no.8, pp. 48–57. doi:10.7748/ns.2016.e10473

Harter, K., Levine, M., & Henderson, S. O. (2015). Anticoagulation drug therapy: a review. The western journal of emergency medicine, vol. 16, no. 1, pp. 11–17. https://doi.org/10.5811/westjem.2014.12.22933

Huisman, M. V., Barco, S., Cannegieter, S. C., Le Gal, G., Konstantinides, S. V., Reitsma, P. H., … Klok, F. A. (2018). Pulmonary embolism. Nature Reviews Disease Primers, vol. 4, no. 18028, pp. 1-18. doi:10.1038/nrdp.2018.28

Jackson, C. F., Makin, S. M., Marson, A. G., & Kerr, M. (2015). Non-pharmacological interventions for people with epilepsy and intellectual disabilities. Cochrane Database of Systematic Reviews, pp. 1-29. doi:10.1002/14651858.cd005502.pub3

Lucke-Wold, B. P., Nguyen, L., Turner, R. C., Logsdon, A. F., Chen, Y.-W., Smith, K. E., … Richter, E. (2015). Traumatic brain injury and epilepsy: Underlying mechanisms leading to seizure. Seizure, vol. 33, pp. 13–23. doi:10.1016/j.seizure.2015.10.002

Mekaj, Y. H., Mekaj, A. Y., Duci, S. B., & Miftari, E. I. (2015). New oral anticoagulants: their advantages and disadvantages compared with vitamin K antagonists in the prevention and treatment of patients with thromboembolic events. Therapeutics and clinical risk management, vol. 11, pp. 967–977. https://doi.org/10.2147/TCRM.S84210

Nursing and Midwifery Board. (2017). Professional Standards. Available at: https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Oduah, E. I., Linhardt, R. J., & Sharfstein, S. T. (2016). Heparin: Past, Present, and Future. Pharmaceuticals (Basel, Switzerland), vol. 9, no. 38, pp. 1-12. https://doi.org/10.3390/ph9030038

Setty, N. (2017). Non-Pharmacological Management of Pulmonary Thromboembolism. International Journal of Pulmonary & Respiratory Sciences, vol. 2, no. 2, pp. 001-004. 10.19080/IJOPRS.2017.02.555582.

Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: pathogenesis, diagnosis, and medical management. Cardiovascular diagnosis and therapy, vol. 7, no. Suppl 3, pp. 276–284. https://doi.org/10.21037/cdt.2017.09.01

Yiu, A., & Bajorek, B. (2019). Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review. Therapeutic advances in drug safety, vol. 10, pp. 1-27. 2042098619847423. https://doi.org/10.1177/2042098619847423

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