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A patient is a 58-year-old man named Mr. Ian Dury and he lives in rural South Australia. He had a past medical history of many serious health issues like obesity, hypertension, hypercholesterolemia, type 2 diabetes mellitus, coronary artery bypass 5 years ago, and anterior myocardial infarction 6 years ago. He is a smoker and has been medicated with following medications like hydrochlorothiazide, atorvastatin, atenolol, losartan, and aspirin. He also often forgets about when to take his medications and he has pitting oedema in both legs with an associated diminished pedal pulse. Dury's fluid balance chart indicates that his previous 24-hour urine output has dropped from 1200ml to 450ml. He gets breathless on exertion and has used is GTN spray on average about 4 times a day. Moreover, he has not discussed his health complications with his son. This essay will discuss the primary diagnosis of the patient with an understanding of the pathophysiology of the disease. As the patient is an old man so nursing assessments, interventions, and management will be discussed in the following sections of this essay, as per an elderly diseased man with literature support. The later part of this essay will also discuss his discharge plan as well.
He has been admitted to the hospital for investigation of chest pain for which it is planned that he will undergo a coronary angiogram with an iodinated radiocontrast medium. This shows that the patient has coronary heart disease and according to Wang et al. (2016), the pathophysiology of this disease is –the various factors like smoking, stress, hypertension, age, and diabetes mellitus causes arterial wall injury issues that result in the desquamation of the endothelial lining. This causes increased permeability or adhesion of molecules due to which the lipids assimilate in the area. This results in continuous aggregation of molecules in the area and thrombus formation occurs, leading to chest pain. During admission, Dury showed pitting oedema in both legs and his previous 24-hour urine output has dropped from 1200ml to 450ml and a rise in creatinine with a fall in glomerular filtration rate (GFR) and Mr. Dury is diagnosed with worsening chronic kidney damage (CKD). According to Manski-Nankervis et al. (2018), the pathophysiology of this condition is - high blood pressure leads to hypertension and risk factors like smoking and diabetes cases injuries to blood vessels in the kidney and body, as a result, CKD occurs resulting in low GFR. This is because the urine output is reduced. As the kidney is damaged creatinine levels increase and wastes are accumulated inside the body leading to oedema.
The first nursing problem, in this case, is decreased urine output. According to Venuthurupalli et al. (2017), if a patient with type 2 DM is left untreated then it can cause a serious complication like heart issues or kidney problems at a serious level. It is found that CKD causes reduced urine output with increased blood pressure. The increased sugar levels in diabetes and cholesterol damage the kidney due to which the kidney cannot function properly. In this case, the patient is found to have a reduced glomerular filtration rate and reduced urine output at the time of admission (Woo et al. 2016). Another problem is the increased blood pressure and according to Jayasinghe et al. (2019), high blood pressure shows that the patient is suffering from circulatory issues. Due to coronary heart disease and obesity, the patient’s blood vessels are blocked or narrow that restricts the flow of blood, this results in the forced flow of blood that causes high blood pressure. Moreover, this extra pressure also damages the arteries.
The nursing assessments, interventions, and management for decreased urine output are as follows:
The nursing assessment for decreased urine output is a comparison of urine output with fluid intake. The void patterns are assessments provide characteristics of bladder function like renal function, fluid balance, and effectiveness (Han et al. 2019). The nursing intervention for reduced urine output is asking the patient to avoid caffeine and encourage him to take adequate fluid intake. The sufficient level of hydration improves the urine output and also prevents infection development in case of kidney damage issues (Jones et al. 2019). The nursing management in this case is the use of oxybutynin or propantheline. Such drugs reduce the spasticity of the bladder and its associated symptoms like nocturia, urgency, frequency, and incontinence (Shubair et al. 2018). If there is low urine output then the kidney loses the ability to remove the wastes and maintain the fluid-electrolyte balance inside the body. So, the registered nurse should provide effective assessments and interventions to ensure that the patient’s fluid-electrolyte balance is restored.
According to Joshy et al. (2016), in Australia Goldfields Kidney Disease Nursing Management Program (GKDNMP) has been implemented in regional and remote areas in which the nursing staff and hospital provide medical services to the elderly patient who is facing kidney disease. The role of a registered nurse is also important in such cases as the administration of medication dosage should be on time and there should be no skipping if medicine and interventions, therefore, the role of a registered nurse is of great importance. According to Zeng et al. (2018), in the case of patients with chronic kidney damage, the multi-disciplinary team should ensure that they help effectively to optimize the care services. They should encourage effective communication with other associated health professionals to ensure that comprehensive care is provided to the patient. The registered nurse should take feedback from the patient about his condition and should also encourage the family members to take part in decision-making (McNamara et al. 2017). As in this case, the patient has not shared the information about his health status with his son, so it should be ensured that such elderly patients are also encouraged to communicate for effective and complete care.
The nursing assessments, interventions, and management for high blood pressure are as follows:
The nursing assessment for high blood pressure is frequent monitoring and recording of the blood pressure of the patient. The monitoring of blood pressure frequently gives information about the patient’s progress or deterioration status and treatment outcomes (Theofanidis and Gibbon 2016). High blood pressure is associated with hypertension, stroke, kidney disease, and other health complications (Theofanidis and Gibbon et al. 2016). The nursing intervention is monitoring the blood pressure of the patent after the medication administration or after the treatment. In the case of high blood pressure treatment, the response of the patient is dependent on either the synergistic effects of the drugs or the individual effect of the drugs (Kuipers et al. 2016). Nursing management is the use of calcium channel antagonists for the patient. These are used to treat high blood pressure by preventing the entry of calcium and thereby lowering the blood pressure by preventing the stronger contraction of heart and arteries (Kuipers et al. 2016). In Australia, the registered nurses are supposed to follow the standards of the nursing and midwifery board of Australia to provide multidisciplinary services to the patient to deliver complete and quality care.
According to Thoma et al. (2018), the elderly patient often forgets about their medication intake so the registered nurse should ensure the right time of medication. The elderly should be provided with an inter-professional approach for care in case of serious health problems like kidney disorders or diabetes. The registered nurse should timely perform the assessment and monitoring of the patient with an evaluation of his vitals like blood pressure, heart rate, and others and another health status to track his progress reports. If the patient is elderly then the registered nurse and other associated health professionals should allow extra time for the patient for effective face-to-face interaction (Cui et al. 2019). Moreover, it should be ensured that the patient is provided with patient-centered care and he is treated with dignity and respect. The physicians, physiotherapists, and nutritionists should collaborate to ensure that the caring plan of the patient has no conflicting elements and treatments are effective (Sanchez et al. 2016).
The plan should be made soon after the patient is admitted to the hospital so that he gets lone-term and complete care (Coyle et al. 2017). According to Giles et al. (2020), a multidisciplinary discharge care plan improves hospital–general practitioner integration, satisfaction, involvement, and quality of life. The teams of multidisciplinary included health professionals like a registered nurse, nutritionists, physicians, physiotherapists, and many others. The patient is discharged for the hospital as soon as his progress reposts and his recovery rate increase and he shows the signs similar to that of a nearly normal person. The discharge plan for this patient involves nutritionists to plan his diet in the following manner: limited processed foods like Sauces, pickled foods and meats, less salt, more protein, and more phosphorous in the diet (Sanchez et al. 2017). These will help him in controlled blood pressure and normal urine output levels with normal kidney functioning.
At home, the patient should weight himself regularly to track his progress report and visit his physician as pert the appointments set by the doctor. He should not smoke or drink and perform daily exercises, should intake more fluids and blood pressure medications. The patient should never miss his drugs that reduce the spasticity of the bladder and its associated symptoms like nocturia, urgency, frequency, and incontinence. The patient should be provided with medications of blood thinners like pradeaxa, eliquis, and Arixtra, to help prevent blood clots (McNeil et al. 2019). The discharge plan should also include the instructions that the patient is supposed to keep himself hydrated and never miss or skip his medications. Moreover, he should also daily assess his vitals like blood pressure, heart rate, and others. He should immediately report to his physician of any unexpected sign or symptom occurs. The registered nurse should encourage the family members to take part in nursing care and understand the disease and management plan of the patient so that the elderly patient gets long-term continued care (Birks et al. 2018).
The patient had medical complications like diabetes, hypercholesterolemia, hypertension, and a few others. The patient has decreased urine output and high blood pressure. The patient’s glomerular filtration rate is also low and had oedema issues as well. However, effective nursing assessment, interventions, and management can help to a great extent to improve the health of the patient. The registered nurse should educate the patient and his family members about the patient’s disease and health problems and ensure that there is proper feedback from the patient. The effective involvement of the patient’s family members along with the patent in the monitoring of vitals and maintaining a lifestyle as per the discharge plan so that patient receives care in the long-term. An implementation of an inter-professional approach in making the discharge plan and treatment plans of the patient help in providing complete care to the patient. Like, the physiotherapist and physician visits should be conducted for the patient so that the health professionals can assess the patient regularly on his stages after his discharge. The role of the registered nurse and multidisciplinary team in making an effective discharge plan can ensure that the patient gets continued care even after the discharge from the hospital. If the patients are old aged then the health providers should give more time for such patients to make them understand their treatment and take proper feedback from them as well.
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