Complex Challenges in Nursing Care

Table of Contents


The idea of Chronic and complex needs of the patients.

Why does Mrs. Mary require complex care?.

Three healthcare specifications that need attention.

Need for prioritizing these healthcare specifications.

Accounts for requirements.

Role of registered nurse.

Potential barriers.

Issue related to medication.



Introduction to Mrs. Mary Tonkin Case Study

The essay is based on the case study of Mrs. Mary Tonkin. She is a 79-year-old widow, who is living alone in a big house all by herself. She is based out of a suburb in Marion metropolitan South Australia. Her husband passed after ten years before after falling from a ladder and due to complications of hip fracture. She is having three sons. One of her sons Sam lived nearby and takes care of her on a routine basis. Sam's wife wants Mary to be moved to a residential care facility, however, Mary is not in the favor of the same. In the past three years, her clinical health has deteriorated quite negatively and has impacted largely on her activities of daily living as well as her independent status of living. Apart from facing fatigue and shortness of breath, she has also not been able to do gardening and cleaning in her house. Lately, Mary has been struggling with issues of forgetfulness. She is also having left side hemiparesis, due to a recent event of a stroke. She requires a walking stick to manage her ambulation. She has a past medical history of trans ischemic attack in 2016, a history of right sided cerebrovascular accident in 2018, cholecystectomy in 2000, diverticulosis, hypertension, and atrial fibrillation. She is also recently been diagnosed with diabetes type-2 with HbA1C reading of 11.8, noted two months back. She also underwent internal fixation for collie’s fracture in the year 2018. Apart from these conditions, she is having allergies to penicillin and sulphonamides. Mrs. Mary was recently admitted to the hospital setting after having a rapid episodic event of atrial fibrillation. She experienced dizziness and shortness of breath, accompanied by severe fatigue. She for admitted to the emergency care setting for the management of the same.

This essay will help in reflecting upon the concept of chronic and complex care needs and linking the same to the case study of Mrs. Mary. The evaluation will also help in highlighting the role of a multidisciplinary team, in managing the care of the patient. The details will also include the medication administration for the patient and the potential barriers in providing the same to the patient. These multiple aspects will be connected to the case study of Mrs. Mary, to assess the positive and negative impact of the same on the patient, post-implementation.

The Idea of Chronic and Complex Needs of The Patients

The condition of Mrs. Mary can be reflected as having multiple complications. Apart from having physical impairments, the patient is also suffering from cognitive as well as behavioral impairments related to her health status. Complex care is the process of providing defined care to the patient, with respect to their individual healthcare requirements (Burgos, 2020). This is mainly considered to help with health promotion and attaining improved healthcare outcomes from the patients. The complex care plan for the patient is also devised to make sure that the chances of abnormal incidences are reduced considerably and there is a reduced incidence of hospital re-admission for the patient. The care plan is also to be crafted, by keeping a close consideration for the overall healthcare requirements for the patient and to enable care in a holistic manner. the care provision is to be rendered to the patient with respect to the financial status of the patient. This is crucial to enable the provision of specialist care required to manage the chronic illness of the patient. Chronic and complex care plan looks at the patient, through the aspect of interrelating the clinical conditions of the patient. This type of care helps in catering to the progressively adverse clinical signs and symptoms of the patients (Harvey, 2019). This model of care is also required in multiple chronic clinical conditions such as hypertension, diabetes, heart diseases, kidney diseases, and many other ailments as well. With the help of a detailed assessment of the patient, his specific and emergent healthcare needs and requirements can be evaluated. This can thus, be a useful method to render care to the patient, in accordance with the same. Thus, the process can also be fruitful in providing improved and positive healthcare outcomes in patients, post-implementation. As chronic care provision to the patient, is mainly based on providing care for prolonged ailments, it can be beneficial in multiple aspects to improve the overall quality of life for the patient. It can help in marginalizing the harm to the patient, through patient-centered care and long-term care approach method (Gordon, 2020). The system also allows the care plan to be revised from time and on, so as to address the recent requirements of the patient. With the help of multiple healthcare professionals involved in the process, the patient’s needs can be met with full competence and as per the required standards of complex needs provision to the patient.

Why Does Mrs. Mary Require Complex Care?

As reflected in the given case study, Mrs. Mary has been suffering from multiple impairments for quite some time now. Her overall health status and level of independent activity have also been compromised for a longer duration now, leaving her with restricted abilities. The case study, therefore, requires an introduction of a chronic and complex care plan to be administered to the patient (Hopman, 2016). Apart from having her own medical issues, she is also having a past medical history of multiple conditions. Her mother and father, both had complex conditions from which they died as well. Currently patient has high blood glucose levels, which can be a considerable risk factor given her history of stroke. She is also being managed for atrial fibrillation recently, of which she is also having a past medical history. These comorbidities can add to the overall health burden of the patient, if not given proper attention. Therefore, there is a dire need for chronic and complex care plans in the given case scenario (Scherer, 2016). The patient is also having signs of forgetfulness. She might be developing some underlying mental health-related issues. As her mother had Alzheimer's it is very much possible that Mrs. Mary might be developing the condition too, given the close association of the condition to genetics (Burke, 2016). She is also having left side hemiparesis and is unable to manage her chores on her own. She is in dire need of assistance from a healthcare professional to help her with her physical as well as mental limitations. The patient being quite older in age, is also living alone in her home. However, her son pays her a frequent visit, she still has to manage most of her time on an independent basis (Le, 2017). She lacks the support and vicinity to any other human being, who can provide her assistance, in times of any health-related crisis. So cumulatively, her condition of forgetfulness, physical limitations, diabetes mellitus, and her recent episodic event of atrial fibrillation, demands the introduction of a chronic and complex care plan for the patient, to cater to her specific healthcare needs.

Three Healthcare Specifications that Need Attention

The three main conditions and symptoms that require care for the patient on an emergent basis are her forgetfulness, her recent event of atrial fibrillation, and her hemiparesis due to stroke.

Managing her forgetfulness can be considered under evaluating the mental health pattern in the patient. given her mother's medical history of Alzheimer's, it is most likely that the patient is also developing this condition. She can be observed to have mild symptoms of the mental health-related issue and it can add to the emotional distress of the patient. the care plan should be based on diagnosing the details of her condition and thereafter, promoting activities that can help in providing psychological support and care to the patient. It can also be based on evaluating her on the reasons for memory loss and its pattern so that the same can be enhanced in the patient.

Diabetes is another risk factor for the overall health of the patient and interfering with the present clinical conditions as well. Studies have shown a direct link between diabetes and the advancement of stroke in patients. As the patient has a prior history of atrial fibrillation and cerebrovascular accident, the increased blood sugar level can increase the chances of another episodic event of stroke observed in the patient (Aune, 2018). Given her age and uncontrolled levels of blood sugar, the patient is also exposed to multiple diabetes related complications. The increased blood glucose levels can cause multiple functions impairments and can manifest clinical conditions such as diabetic retinopathy, diabetic neuropathy, diabetic nephropathy, and many other chronic ailments (Park, 2019).

Her condition of hemiparesis can hinder the physical competence of the patient. The patient requires an assistive device to manage her ambulation. This is posing a restriction to her activity of daily living, to be carried out in full capacity (Hussain, 2017). The patient can be emotionally challenged due to her physical limitations as well. Given her history of stroke and her increased blood glucose levels, the patient is also prone to develop another incidence. She also lacks the desired support system to provide her care in case of any mishappening.

Therefore, the three major concerns for the patient in the given case study, which might require the provision of chronic and complex care plan can be as follow:

  1. Her memory loss and forgetfulness.
  2. Her increased blood sugar levels due to manifestation of diabetes mellitus-2
  3. Her condition of hemiparesis, which requires external support to manage the condition.

Need for Prioritizing These Healthcare Specifications

Given the past medical history and family history of the patient, she needs to be evaluated in a comprehensive manner for her current abnormal signs and symptoms. The patient should be scanned with proper diagnostic techniques in place to determine a set clinical diagnosis for the patient. Thus, helping in providing a suitable care plan for the healthcare specifications of the patient. The patient is also able to recognize her pattern of absenteeism and forgetfulness. This can reflect as the patient having primary symptoms and the condition has not progressed that far. Therefore, early detection can be helpful in providing early care management for the patient (Palmer, 2018). This will also be fruitful in determining the best possible approach and treatment modality for the patient, to enable her with comprehensive care and management for abnormal clinical signs and symptoms.

The second main concern of increased blood glucose levels is another condition of the patient which requires attention. Not only the patient is suffering from diabetes type-2, she is also having uncontrolled blood glucose levels. The average blood glucose readings for the past 3 months are also considered on the higher limit. Given the age and multiple comorbidities the patient is suffering from, diabetes can pose a serious risk to the overall well-being of the patient. There is a dire need to not only manage the increased blood sugar levels with appropriate medication but to also closely monitor the readings on a regular basis (Chen, 2018). The patient is provided with the medication of metformin to manage the same. She is also having a history of cardiac ailment and hypertension. Elevated blood sugar levels can be troublesome news for the person suffering from the same, as diabetes is considered as a potential risk factor for both of these conditions. The needs are thus to be assessed on an emergent basis and proper action should be taken as per the required standards of the chronic care plan provides for the patient. The patient is already taking metformin and still the blood sugar levels are elevated, the plan should also include medication review for the patient. The introduction of insulin can be helpful in lowering the advancing blood glucose levels of the patient. Her third need is to manage the residual impact of hemiparesis in patients (Mooradian, 2018). This is limiting her physical activities and is also restricting her from having an independent state of living. Physical limitations can also be an underlying risk factor for the development of emotional and psychological distress in patients. As our patient lives all by herself and suffers from multiple chronic conditions, she requires personal attention to manage her condition in a schematic manner. With proper medication management and treatment support, the patient can be helped with reducing her limitations and eliminating potential barriers in promoting her overall health status and improving her quality of life.

Accounts for Requirements

The emotional and psychological needs of the patient can be met with the help of a gerontologist. These healthcare professionals have a sound knowledge about the various aspects of the aging process and the multiple health-related issues arising from the same (Kocman, 2019). They can also help in carrying out a comprehensive assessment for the patient and thus, evaluating the key areas of concerns. Gerontologist can help in catering to the mental, physical, psychological as well as emotional needs of the patient. Thus, enabling care in a composite manner. They can also work along with multiple healthcare professionals, as an integral part of the multidisciplinary team, to render a specific care plan for the patient (Moscova, 2020). Management of diabetes can be carried out by medication and monitoring of the patient on a regular basis. The role of the nurse can be helpful in carrying out these duties and ensuring regular follow-ups regarding the same. Medication management can also be beneficial for managing her other conditions and thus, lowering the attributed risk factor, closely related to these conditions. The role of a nurse can be helpful in the process of medication acknowledgment and reconciliation, for managing her conditions in a schematic manner (Ma, 2020). The condition of hemiparesis can also be managed with the help of a multidisciplinary approach. It can be carried out with the help of involving multiple healthcare professionals as a composite part of the care plan and management for the patient. Thus, enabling care in a collective and holistic manner to the patient, providing resolves to all of her potential limitations.

Role of A Registered Nurse

The nurse can be the main leader of the multidisciplinary team for the patient. The nurse can meet with the patient to know her emotional, physical, mental, and behavioral needs. This will help in planning for a care plan for the patient in a more schematic manner. Nurses can also work with physicians, to ensure specialist reviews for multiple chronic illnesses the patient is suffering from. Mental health care nurses can work with the psychologists to make sure a detailed assessment of the current mental health related issues and concerns in carried out effectively. Thus, the healthcare plan will be crafted in accordance with the same. A physical therapist can help in promoting an independent physical status for the patient (Falvey, 2016). They can also help in providing assistance for hemiparesis of the patient and thus, motivating her to manage her activities of daily living on her own. Nutritionists and dieticians can also help in defining a balanced diet for the patient, to help her with the management of her chronic condition. Proper nutrition will also help in promoting a healthy state of living and thus, promoting harm minimization for the patient (Winter, 2017). The nurse can play a vital role in being constantly engaged in robust communication with other healthcare professionals, to modulate the care plan as per the required healthcare assessment and provision of care for the patient (Wang, 2018). Thus, leading to improved physical and mental healthcare outcomes and improved quality of life in the patient.

Potential Barriers

The two main barriers in the given condition can be considered as ageism and with respect to social context. The patient is a 79-year-old female, who is living alone and suffering from multiple comorbidities. These chronic impairments can hinder the emotional, mental as well as physical well-being of the patient. The patient being an older person, might not cooperate that well with the healthcare professionals, who can help her with her conditions (Gleason, 2016). This might hinder the care delivery process for the patient. Another pre-text can be the social factor. The patient resides in a dwelling which is far out of reach. Having such multiple conditions, the patient should be living proximal to a healthcare setting, so that emergent care can be provided to her, in case of any un-called-for situation. She also lacks physical support of any kind and stays away from her next of kin. However, her son pays her a visit on regular basis, she lacks continuous monitoring and care by a specialized healthcare professional. Given her condition, she is unable to manage her health and its pertaining concerns on her own. There is both physical and emotional risk associated with the inability to manage her condition on her own. Therefore, she requires both physical as well as emotional comfort for managing her activities of daily living and avoiding any mishappenings (Wildenbos, 2019).

Issue Related to Medication

There are two main issues that can be closely related to medication in the patient given in the case study. The primary concern is medication reconciliation and the secondary concern is medication management (Bemben, 2016). The patient is having metformin for managing her condition of diabetes. However, she is still having high blood glucose levels. To control the abnormal blood glucose levels, the current health status of the patient should be assessed and medications should be reviewed for her. This will be beneficial not only for managing her diabetes but also for safeguarding her from other potential risk factors. The secondary concern of medication management can also be considered with respect to medication adherence in the patient (Kvarnström, 2018). Having multiple comorbidities, the patient in the given case study might require strict adherence to medication administration so as to avoid any complications. The role of the nurse can be helpful in managing the same. They can work in close coordination with the medical team and the patient, providing them with regular updates, and managing multiple medications for the patient.

Conclusion on Mrs. Mary Tonkin Case Study

The details of the essay shed light on the healthcare-related needs and specifications of the patient in the given case study. It also identifies the potential barriers and limitations the patient might be having. The paper highlights the role of the nurse as well as the multidisciplinary team approach for enabling care to the patient in a composite manner. The details of the clinical history provided for the patient makes Mrs. Mary a potential candidate to manage with the help of a chronic and complex care plan, to cater to the underlying health care needs of the patient.

References for Mrs. Mary Tonkin Case Study

Aune, D., Feng, T., Schlesinger, S., Janszky, I., Norat, T., & Riboli, E. (2018). Diabetes mellitus, blood glucose, and the risk of atrial fibrillation: A systematic review and meta-analysis of cohort studies. Journal of Diabetes and its Complications32(5), 501-511. DOI

Bemben, N. M. (2016). Deprescribing: an application to medication management in older adults. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy36(7), 774-780. DOI

Burgos, R., Joaquín, C., Blay, C., & Vaqué, C. (2020). Disease-related malnutrition in hospitalized chronic patients with complex needs. Clinical Nutrition39(5), 1447-1453. DOI

Burke, S. L., Maramaldi, P., Cadet, T., & Kukull, W. (2016). Associations between depression, sleep disturbance, and apolipoprotein E in the development of Alzheimer's disease: dementia. International Psychogeriatrics28(9), 1409-1424. DOI

Chen, W. C., Lee, C. C., Chien, M. N., Liu, S. C., Wang, C. H., & Yang, W. S. (2018). Blood glucose management of type 2 diabetes in older people. International Journal of Gerontology12(3), 170-174. DOI

Falvey, J. R., Burke, R. E., Malone, D., Ridgeway, K. J., McManus, B. M., & Stevens-Lapsley, J. E. (2016). Role of physical therapists in reducing hospital readmissions: optimizing outcomes for older adults during care transitions from hospital to community. Physical therapy96(8), 1125-1134. DOI

Gleason, K. T., Tanner, E. K., Boyd, C. M., Saczynski, J. S., & Szanton, S. L. (2016). Factors associated with patient activation in an older adult population with functional difficulties. Patient Education and Counseling99(8), 1421-1426. DOI

Gordon, K., Gray, C. S., Dainty, K. N., DeLacy, J., Ware, P., & Seto, E. (2020). Exploring an Innovative Care Model and Telemonitoring for the Management of Patients with Complex Chronic Needs: Qualitative Description Study. JMIR Nursing3(1), 156-191. DOI

Harvey, C., Palmer, J., Hegney, D., Willis, E., Baldwin, A., Rees, C., ... & Marshall, R. (2019). The evaluation of nurse navigators in chronic and complex care. Journal of Advanced Nursing75(8), 1792-1804.

Hopman, P., Heins, M. J., Korevaar, J. C., Rijken, M., & Schellevis, F. G. (2016). Health care utilization of patients with multiple chronic diseases in the Netherlands: differences and underlying factors. European Journal of Internal Medicine35, 44-50. DOI

Hussain, I., Spagnoletti, G., Salvietti, G., & Prattichizzo, D. (2017). Toward wearable supernumerary robotic fingers to compensate for missing grasping abilities in the hemiparetic upper limb. The International Journal of Robotics Research36(13-14), 1414-1436. DOI

Kocman, D., Regen, E., Phelps, K., Martin, G., Parker, S., Gilbert, T., & Conroy, S. (2019). Can comprehensive geriatric assessment be delivered without the need for geriatricians? A formative evaluation in two perioperative surgical settings. Age and Ageing48(5), 644-649. DOI

Kvarnström, K., Airaksinen, M., & Liira, H. (2018). Barriers and facilitators to medication adherence: a qualitative study with general practitioners. BMJ Open8(1), 153-232. DOI

Le Berre, M., Maimon, G., Sourial, N., Gueriton, M., & Vedel, I. (2017). Impact of transitional care services for chronically ill older patients: a systematic evidence review. Journal of the American Geriatrics Society65(7), 1597-1608. DOI

Ma, C., & Zhou, W. (2020). Predictors of rehospitalization for community‐dwelling older adults with chronic heart failure: A structural equation model. Journal of Advanced Nursing76(6), 1334-1344.

Mooradian, A. D. (2018). Evidence-based management of diabetes in older adults. Drugs & Aging35(12), 1065-1078. DOI

Moscova, L., Leblanc, F., Little, J., Le Breton, J., Vallot, S., Fabre, J., ... & Ferrat, E. (2020). Changes over time in attitudes towards the management of older patients with heart failure by general practitioners: a qualitative study. Family Practice37(1), 110-117. DOI

Palmer, K., & Onder, G. (2018). Comprehensive geriatric assessment: Benefits and limitations. European Journal of Internal Medicine54, 8-9. DOI

Park, S., Kang, H. J., Jeon, J. H., Kim, M. J., & Lee, I. K. (2019). Recent advances in the pathogenesis of microvascular complications in diabetes. Archives of Pharmacal Research42(3), 252-262. DOI

Scherer, M., Hansen, H., Gensichen, J., Mergenthaler, K., Riedel-Heller, S., Weyer, S., ... & Wiese, B. (2016). Association between multimorbidity patterns and chronic pain in elderly primary care patients: a cross-sectional observational study. BMC Family Practice17(1), 1-8. DOI

Wang, Y., Wan, Q., Guo, J., Jin, X., Zhou, W., Feng, X., & Shang, S. (2018). The influence of effective communication perceived respect and willingness to collaborate on nurses' perceptions of nurse-physician collaboration in China. Applied Nursing Research41, 73-79. DOI

Wildenbos, G. A., Jaspers, M. W., Schijven, M. P., & Dusseljee-Peute, L. W. (2019). Mobile health for older adult patients: Using an aging barriers framework to classify usability problems. International Journal of Medical Informatics124, 68-77. DOI

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