Case Scenario and Patient Profile
Question:
Discuss about the Focus on Intervention nursing pharmacology.
Healthcare professionals are required provide high quality and safe healthcare services through proper approach to decision making. The provision to ensure continuity of care is reliant on critical thinking and judgment making ability. Clinical reasoning has been denoted to be a complex cognitive process that focuses on thinking strategies to ensure better patient outcomes. The Levett-Jones clinical reasoning cycle is an effective tool using which nurses can solve problems and make informed decisions while caring for the patients. The different components of the cycle are consider analysis of patient condition, collection of cues, processing of the information, identification of patient problem or situation, planning and implementation of interventions, evaluation of outcomes and reflection on the process. The present paper applies the clinical reasoning cycle to a case scenario of Peter Mitchell for prioritizing care needs and understanding the best suited interventions for the student.
The patient in the present case is Peter Mitchell, a 52 year old male who is suffering from morbid obesity and type 2 diabetes. he is overweight at 145 kg and his height is 170 cms. The patient had been admitted to the medical ward due to poorly controlled diabetes, sleep apnea and obesity ventilation syndrome. He had suffered symptoms of increased hunger, shakiness, diaphoresis, high BGL levels and difficulty breathing whilst sleeping. The patient has been discharged home with referral to the community care unit for follow up and ongoing support for management of clinical comorbidities and obesity.
Peter Mitchell has a past medical history of obesity, type 2 diabetes, hypertension, depression, sleep apnoea and gastro oesophageal reflex disease. Peter is a smoker and smokes approximately 20 cigarettes per day. While he was previously admitted to a care unit, a dietician had recommended a diet for weight reduction and the GP had educated him about the importance of weight loss. A physiotherapist had also suggested light exercises to promote weight loss. Peter had however showed non-adherence to such weight loss guidelines.
Peter is an unemployed male who had lost his job three years ago. He had gained considerable weight after he lost his job and started taking insulin. He suffers from frequent fatigue and his uncomfortable about his body image. He is socially isolated and rarely goes out. Further, he is challenged to carry out his daily activities of living. Though he is motivated at present to lose weight and quit smoking, he needs support and help in this regard. His current medications include insulin 30 BD, metformin 500 mg, lisinopril 100mg, nexium 20 mg metoprolol 50 mg, and pregabalin 50 mg. At the time of his discharge, his vital signs were BP 180/92mmHg, RR 23 Bpm, HR 102 Bpm and Sp02 95% on RA.
The chronic condition that Peter is suffering from is type 2 diabetes which is a metabolic disorder marked by prolonged increase in blood glucose level due to body’s failure to produce sufficient insulin (Mohamed, 2014). The prominent risk factors for diabetes include obesity and sedentary lifestyle. In the present case, peter is obese at 145 kg and he has also been having a sedentary lifestyle with minimal physical activities. According to Legler et al., (2015) the relationship between obesity and diabetes is of much interdependence. The passage from obesity to diabetes is marked by the defect of insulin secretion ability, and it has been proved that obese patients have defective insulin secretion, worsening diabetic condition. The underlying condition pertains to the increase in overall fatness, preferentially visceral and ectopic fat depots, leading to insulin secretion defects (Rao et al., 2017). Defect in fat oxidation capacity is the cause of emerge economy and impaired weight loss. Increased weight gain has also been linked with hypertension and in the present case peter has high blood pressure at 180/92 mmHg. The normal blood pressure reading of a healthy person is 120/80 mmHg (Galie et al., 2015).
Chronic condition and Medications
On further assessment it has been found that peter is an avid smoker. As opined by Ganesan et al., (2017) smokers have more chances of developing type 2 diabetes when compared with non-smokers. Further, people who smoke regularly face more difficulties in controlling hyperglycemia as compared to non-smokers. Peter is also at risk of developing health complications due to smoking coupled with diabetes such as heart disease, kidney disease and retinopathy.
The medications recommended to peter have the aim of controlling hyperglycemia and related conditions. Metformin is the first line medication for treating type 2 diabetes. Lisinopril is an ACE inhibitor that is administered for treatment of high blood pressure. Nexium is used for treating stomach and esophagus problems, and the same is recommended since peter suffers gastro oesophageal reflex disease. Metoprolol is also a drug for treatment of hypertension, and pregabalintreats pain caused by nerve damage due to diabetes (Karch & Karch, 2016).
With respect to peter’s social life, it is to be mentioned that Peter suffers from low self-esteem and his uncomfortable about his body image. He is a divorcee and lives alone, leading to extreme social isolation. This is aggravated by his reluctance to socialize due to embarrassment linked with his body image. Low self-esteem due to obesity has been linked with depression in literature (Butcher et al., 2018). Social isolation is a key contributory factor for depression in addition to low confidence level.
The two care priorities for peter are addressing depression due to social isolation and disturbed body image, and promoting weight loss and smoking cessation. Peter has been suffering from feelings of powerlessness and social isolation due to his disturbed body image. There is also evidence of lack of follow-through with diet plan outlined by dietician. Reduction of depression would lead to better self- image. Further, promotion of weight loss and smoking cessation are required for proper management of diabetes. Peter is reported to be motivated to lose weight and quit smoking; however, he needs support for the same.
Establishment of goals
The primary goal would be to ensure an enhanced quality of life for Peter. In relation to depression, the goal would be to ensure that Peter verbalizes a more realistic self-image and does not suffer from social isolation. In regards to weight loss and smoking cessation, the goal would be to promote both through proper interventions (Blais, 2015).
The primary intervention for peter in relation to social isolation would be to involve in role-laying new ways of dealing with situations and behaviors. This would make the patient comfortable while he interacts withindividuals in the society. It is imperative to discuss negative self-concepts related to obesity and diabetes as these impede positive social interactions. Individual counseling would be needed for providing encouragement and support (Moorhead et al., 2014). For addressing disturbed self-image, it is crucial that the nurse determines the views of the patient of being obese and the impact of obesity on his life. The rationale is that mental image encompasses the ideal of individuals, and depends from person to person (Butcher et al., 2018). Open communication is needed to be fostered as the same supports the patient’s responsibility of controlling chronic conditions. The patient might be further encouraged to use imaginary for visualizing self at desired weight. Mental rehearsals are useful for dealing with anticipated changes (Black, 2016).
Social life and care priorities
Simultaneous focus is also to be given on motivating the patient to lose weight and quit smoking. The patient is to be encouraged to indicate why there is personal relevancy of quitting smoking. He is also to be educated about the negative consequences of tobacco use, including acute and long-term risks (Moorhead et al., 2014). At the same time, he is to be provided with a diet chart that promotes weight loss. The diet plan would be outlined as per requirement of weight reduction, BMI of the patient, age, and length of time for achieving desired weight (). Exploration and discussion is needed with the patient regarding events and emotions associated with eating. This helps in identifying the differences between emotional need of physiological need of food intake (Blais, 2015). Realistic increment goals are to be set for the patient. Rapid and excessive loss light leads to fatigue and inconvenience, thereby leading to failure in achievement of step goals. Motivation is sustained by meeting “stair-step” goals (Butcher et al., 2014).
The implementation of the aforesaid interventions is likely to promote better quality of life for Peter. Success of the implemented interventions would be evaluated by weight loss, smoking cessation and decreased depression. Peter is expected to demonstrate positive behaviors regarding weight loss and smoking cessation. Change in eating patterns is to be assessed. His inclination towards leading a healthy life with adequately controlled hyperglycemia is to be evaluated further (Butcher et al., 2015).
The present case scenario provided a favorable chance to apply the clinical reasoning cycle for care delivery. Each step of the clinical reasoning cycle is important for proper diagnosis of patient condition, identification of appropriate treatment and management of related complications. Clinical reasoning has laid the foundation for clinical judgment, problem solving, and decision making. Key insights gained from the application of the reasoning cycle to the patient scenario would be applied in future practice to ensure optimal health promotion.
Conclusion
Diabetes is a specialist area in primary care where nurses are to manage patient conditions effectively through implementation of strategies addressing patient needs. Application of the clinical reasoning cycle was useful for facilitating a person-centered and holistic care approach for the patient Peter. Patient outcomes achieved are as per the requirements when intensive care is provided through clinical reasoning abilities of the nurse.
References
Black, B. (2016). Professional Nursing-E-Book: Concepts & Challenges. Elsevier Health Sciences.
Blais, K. (2015). Professional nursing practice: Concepts and perspectives. Pearson.
Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagner, C. (2018). Nursing Interventions classification (NIC)-E-Book. Elsevier Health Sciences.
Galiè, N., Humbert, M., Vachiery, J. L., Gibbs, S., Lang, I., Torbicki, A., … & Ghofrani, A. (2015). 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: the Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). European heart journal, 37(1), 67-119.
Ganesan, S. M., Joshi, V., Fellows, M., Dabdoub, S. M., Nagaraja, H. N., O’Donnell, B., … & Kumar, P. S. (2017). A tale of two risks: smoking, diabetes and the subgingival microbiome. The ISME journal, 11(9), 2075.
Karch, A. M., & Karch. (2016). Focus on nursing pharmacology. Lippincott Williams & Wilkins.
Legler, J., Fletcher, T., Govarts, E., Porta, M., Blumberg, B., Heindel, J. J., & Trasande, L. (2015). Obesity, diabetes, management and associated costs of exposure to endocrine-disrupting chemicals in the European Union. The Journal of Clinical Endocrinology & Metabolism, 100(4), 1278-1288.
Mohamed, S. (2014). Functional foods against metabolic syndrome (obesity, diabetes, hypertension and dyslipidemia) and cardiovasular disease. Trends in Food Science & Technology, 35(2), 114-128.
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2014). Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.
Rao, H., Wu, E., Fu, S., Yang, M., Feng, B., Lin, A., … & Wei, L. (2017). The higher prevalence of truncal obesity and diabetes in American than Chinese patients with chronic hepatitis C might contribute to more rapid progression to advanced liver disease. Alimentary pharmacology & therapeutics, 46(8), 731-740.
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