• Internal Code :
  • Subject Code : NUR341
  • University : Charles Darwin University
  • Subject Name : Nursing

Case Study: Alexander Kumar

Contents

Aged care services and interdisciplinary care

Age-related changes and Patient assessments

Medication management

Reflection

References

Aged Care Services and Interdisciplinary Care

a) Aged care centres also are known as elderly care as it renders holistic care to the older population as per their unique needs. It consists of both home services and residential aged care services. Three aged care options are existing for elder people to support them to remain self-dependent includes home services (a person will stay at their home and access services and/or care at home only), aged care (access all the services like a meal, nursing services and accommodation), and retirement village (services are accessible for a cost). In the present case, Alex is suffering from hypertension and myocardial infection, whereas his wife Sarah has dementia. Alex is fulltime caregiver for his wife, but in the present scenario, he is suffering from leg ulcer.

Therefore, both need external support and interdisciplinary care. Initially, both can be shifted to aged care as Alex will recover then the couple can get home services. Aged care will offer personal care assistance like personal hygiene, bathing, dressing and continence management to both of them (Westbury et al, 2018). Further, the couple also needs allied health and nursing services. Sarah is not atoll manage herself without her husband, therefore, she especially needs meal and nutrition support. Further, it is vital to make dementia patient engage in physical activity and/or favourite activities. In the present case, Alex and Sarah must be motivated to indulge in exploring nature and reading a favourite book.

After the improvement in the Alex condition, both can be shifted to home for further care. Their home care must include personal care, meal preparation; domestic assistance, continence management; nursing services, mobility assistance and transport facility. Personal care is needed, as Sarah is not able to take a bath and dress up alone. Further, the couple needs help in movement as both have under fall risk. Moreover, both need continuous nursing service due to their age-related health issues (Cera et al., 2014).

Age-Related Changes and Patient Assessments

a) In the present case scenario, Alex has been admitted to hospital with a chief complaint of ulcer appeared over 3 months back. Moreover, his past medical history reveals that he is suffering from myocardial infarction, hypertension, arthritis and GORD. Myocardial infarction is also called a heart attack, condition arrives when there is partial or fully stoppage of blood supply to the heart. Risks associated with this condition are smoking, increased blood pressure, diabetes, poor diet, extreme alcohol intake, among others. As per the condition of the Alex, cardiovascular (Heart) examination must be done in- order to evaluate the risk of cardiogenic stroke (Thygesen et al., 2018).

Further, Hypertension is interconnected to myocardial infarction. High blood pressure has effects on various body parts including urinary system, nervous system and eyes etcetera. Hypertension cause damage to blood vessels those supplies to the kidney and can lead to kidney failure. Therefore, in the present case, Kidney evaluation is a must. Further, high blood pressure can lead to choroidopathy or eye-bleeding, therefore, eye evaluation can be done in Alex's case. Following habit history of the patient, it is vital to look for liver and respiratory damage too. The patient is a chronic smoker and admitted that he consumes daily alcohol. Alcohol along with the history of hypertension can act conglomerate to hurt the liver.

Drinkers have more risk to develop liver failure, cirrhosis, jaundice and cancer. Lungs can severely be affected by cigarette smoking. In the current case, Alex has non-filtered cigarette rolled by him only. Smoking irritates and inflames the lung. Moreover, it can damage the lung tissue and can cause lung cancer, emphysema and pneumonia. Bone assessment should take into consideration as Alex is suffering from arthritis. Arthritis affects the bone joints and their surrounding tissues. Further, can lead to wear away from the bones' cushion ends.

b) Five assessments that are vital in the current cases are stress and pain assessment, fall risk assessment, test for edema, blood test and radiographic assessment. Stress is an integral portion of our lives, further can have negative as well as beneficial effects. In the current case, Alex sleeps only for 5-6 hours at night with broken sleep pattern. Moreover, he needs to wake up in the night to assist his wife Sarah with toileting. Further, his wife has dementia, so Alex needs to take care of her fulltime. Alex at the age of 85 is taking care of his wife with interrupted sleep episodes therefore; he could be into stress. Therefore, stress evaluation is a must in this case. It is vital to recognize stress degree followed by rendering care to make it well.

Alex is suffering from myocardial infarction therefore; he is under a vulnerable patient group and has a high risk of fall. Fall assessment must be done to evaluate the fall risk in Alex's case. The Morse Fall Scale is the simple and rapid technique of evaluating the patients' possibility of falling. The registered nurse must evaluate the fall risks followed by deciding the control measures (Sun, R., & Sosnoff, 2018, Sardo et al, 2016). Findings must be recorded 6in order to implement them. In myocardial infarction patients, elevated hydrostatic pressure can cause edema.

Clinical assessment must be performed for edema evaluation. Followed by, proper blood test including blood glucose evaluation. The patient is admitted with chief complaint f non-healing wound from the last three months. Non-healing wounds are the main characteristic feature of diabetes mellitus. Assessment must be performing to rule out diabetes mellitus. Radiographic assessment can be proving effective in rule out the effect of arthritis on joints. Alex is suffering from arthritis therefore radiographic evaluation must be done (Levy, N., Sturgess, J., & Mills, 2018).

Medication Management

a) Pharmacokinetics can be defined as the body reaction towards the drug in the form of absorption, distribution, bioavailability and excretion. With the growing age, all of the above-stated processes is changed; further, some of the changes are clinically relevant. In most of the cases, the excretion mechanism of the body got slow, require to decrease the drug dose. In old age, the surface area of small bowel decrease, gastric emptying slow down and gastric pH shoots up that leads to changes in absorption of the drug. For example, enteric-coated medicines (aspirin, erythromycin) get easily release in the gastric pH in old age and can lead to adverse effects. With growing age, whole-body water declines and fat increases.

Increased body fat leads to increase volume distribution for lipophilic drugs and increase the elimination half-lives. In the older person, Cytochrome P-450 enzyme leads to reduce hepatic metabolism. Therefore, decreased clearance by 30 to 40 per cent. As per the theory, the maintenance dose should be reduced by 30 to 40 %, however, drug metabolism rate varies from patient to patient, therefore, dose adjustment must be individualized. Phase I reactions are likely to prolong in old patients, therefore, drugs that are metabolized through phase-1 their clearance rate is low. However, phase II reaction is not hampered by age. After 40 years of age, the first-pass metabolism decreases by 1 per cent per year.

Therefore, elder patients have higher drug circulation values as compared to the young patient. For example, propranolol, nifedipine and nitrates have high toxic effects due to high circulation rate. One of the significant changes with aging is a reduction in drug's renal elimination. Renal function is vital therefore, a maintenance dose of medicine must be adjusted when the patient is dehydrated or become ill (van den Anker et al., 2018).

b) The adverse drug reactions (ADR) are commonly concomitant with older age. ADR is classified into Type A and Type B. Type- A reactions are dose associated while Type –B are non-dose dependent and unpredictable. Type-A reactions are predictable. Further, it can be avoidable as associated with accentuation pharmacological effects of the medicines. Half of the cases of ADR are preventable; most of the cases are attributable to the anticoagulant, antidiabetic, diuretics and NSAIDs drugs. In the present case, the patient is on aspirin and other drugs also therefore, there is a lot of risk of ADR development. ADR is difficult to identify in an elderly patient, as they exist with common symptoms including fatigue, falls, constipation, and/or cognitive decline (Aulton, M. E., & Taylor Eds, 2017).

Falls can be associated with other health conditions like visual impairment, osteoarthritis or myopathy. Further, many drugs as sedatives, antiarrhythmic and antihypertensive autonomously increase the fall risk. The age of the patient is one of the factors responsible for adverse drug events. Age-associated biological changes affect pharmacokinetics includes absorption, metabolism, distribution and excretion of the drug.

Moreover, with increasing age, person’s body composition altered (less water and more fat), reduced body size, reduced kidney and liver function causes multiple medicines to gather in the person's body at a higher level for a long period as compared to the young people. Polypharmacy is one of the important factors that can contribute to an increased rate of ADRs in old patients. Alex is also on multiple drug therapy for hypertension, myocardial infarction, GORD and arthritis. Polypharmacy can lead to synergistic toxicity that is greater than the toxicity risk sum up of all the drugs alone (Lavan, & Gallagher, 2016).

c) In accordance to the medical history of Alex, he is on many medications including Aspirin 100 mg every morning, perindopril 2mg every morning, Glyceryl trinitrate spray 400 mcg, Omeprazole 20mg, Panadol Osteo 2 tablets twice a day and Ibuprofen 400mg when needed. In the present case, Alex is suffering from myocardial infarction. Therefore, he is on Aspirin 100 mg to reduce the chance of stroke and heart attack. Further, it is beneficial in arthritis and relief pain. Associated complications with aspirin are allergic reaction, hives, rashes, peeling skin, bleeding sign (blood in cough, blood during micturition, tarry stool, bruises), kidney issues like problematic micturition, liver issues like loss of appetite, stomach upset, yellow skin, dark urine, hearing loss, dizziness and seizures. Perindopril 2 mg is used for hypertension.

It helps in maintaining blood pressure and helps in the prevention of heart attack. The serious side effects associated with perindopril are severe dizziness, vision changes, stomach pain, jaundice, cramping, depression, confusion, allergic reaction, and breathe shortness. GTN spray is for angina relief (chest pain) by widens the heart’s blood vessels. GTN sprays can cause headache due to widening effects on the brain's blood vessel followed by fainting and dizziness due to fall in blood pressure. Omeprazole is effective in GORD. Common side effects include abdominal pain, vomiting, dizziness, and headache. Panadol Osteo and ibuprofen is for muscle pain. These pain-killers can cause constipation, vomiting and nausea. It can be concluded that Alex can have any of the above-stated side effects (Aulton, M. E., & Taylor Eds, 2017).

Reflection

Alex is 85 years old who suffers from left leg ulcer and lives with his wife. His wife Sarah is a dementia patient and he is her full-time caretaker. When geriatric patients were admitted, I always tried to gather their medical history from their family. As older patients have little interest in showing their needs. In the present case, I was not able to gather any information from the patient’s wife as she is suffering from dementia. This made me afraid. By Green, 2016 assertive skills are important while rendering holistic care to the patient. Further, it is vital to interact thoroughly with an old person. However, communication with the old patient is a little difficult. In this case, I succeed to make Alex recognize my nursing role.

Initially, it was difficult to create the communication environment with Alex as I hold the acceptance that geriatric patients have deficits in their memory. I believe that as a registered nurse, it is my responsibility to render person-centred care to my patients. In the current case, I had gone through the medicine chart thoroughly to avoid medication error, as it is very common in an old patient. In this practice, I have learnt that the emotional and psychological needs of geriatric patients should be given utmost importance. Moreover, I have learnt the adverse drug reaction concept through the evaluation of this case.

References

Aulton, M. E., & Taylor, K. M. (Eds.). (2017). Aulton's Pharmaceutics E-Book: The Design and Manufacture of Medicines. Elsevier Health Sciences.

Cera, M. L., Abreu, D. C. C. D., Tamanini, R. D. A. V., Arnaut, A. C., Mandrá, P. P., & Santana, C. D. S. (2014). Interdisciplinary Therapy for patients with dementia. Dementia & neuropsychologia, 8(3), 285-290.

Green, J. (2016). Enhancing assertiveness in district nurse specialist practice. British journal of community nursing, 21(8), 400-403.

Lavan, A. H., & Gallagher, P. (2016). Predicting risk of adverse drug reactions in older adults. Therapeutic advances in drug safety, 7(1), 11-22.

Levy, N., Sturgess, J., & Mills, P. (2018). “Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: why?. British journal of anaesthesia, 120(3), 435-438.

Sardo, P. M. G., Simões, C. S. O., Alvarelhão, J. J. M., & Simões, J. F. F. L. (2016). Fall risk assessment: retrospective analysis of Morse Fall Scale scores in Portuguese hospitalized adult patients. Applied Nursing Research, 31, 34-40.

Sun, R., & Sosnoff, J. J. (2018). Novel sensing technology in fall risk assessment in older adults: a systematic review. BMC geriatrics, 18(1), 14.

Thygesen, K., Alpert, J. S., Jaffe, A. S., Chaitman, B. R., Bax, J. J., Morrow, D. A., & White, H. D. (2018). Fourth universal definition of myocardial infarction (2018). Journal of the American College of Cardiology, 72(18), 2231-2264.

van den Anker, J., Reed, M. D., Allegaert, K., & Kearns, G. L. (2018). Developmental changes in pharmacokinetics and pharmacodynamics. The Journal of Clinical Pharmacology, 58, S10-S25.

Westbury, J. L., Gee, P., Ling, T., Brown, D. T., Franks, K. H., Bindoff, I., ... & Peterson, G. M. (2018). RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities. Medical Journal of Australia, 208(9), 398-403.

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