Case Management Approach to Nursing - Essay Example

Case Management Plan (Nursing) Introduction: This is a case study of a patient, whose identity will remain undisclosed in this work for ethical and confidentiality reasons. A nickname, Mrs. Chang will be used throughout the work. This writer had an opportunity to assist in her care while she was admitted to the hospital following a trip and fall in the shower few days back, and she was admitted to the hospital due to her age of 82, frailty, baseline neurological disorder with gradually declining cognition and deteriorating mobility, and lack of support at home and community, for further assessment and evaluation. In this work, based on nursing assessment of the case, a nursing case management plan will be enacted and presented in the specified format with an attempt to critically analyzing the care plan based on her needs and at the same time finding evidence from contemporary literature about the justification of the case management plan. Case as an organizer of care delivery and research has been commonly used in practice settings, and this is often person centred. This is one systematic approach to the presently advocated holistic paradigm of nursing care. Before going to present the assessment, analysis, and care plan based on the case management approach, it is important to know why it is important. The idea is to improve the ability of the health care systems to respond efficiently to the demands or needs of the older people like Mrs. Chang. It has greater implications than are apparent. Studies have indicated that most elderly people despite considerable debility prefer to stay at home, while the models of cost-effective care are shortening the lengths of hospital stay. Care in the community has, thus, gained significant importance. Case management approach may be the first step towards successfully achieving this (Brown et al., 2005, 1-32). THE UNIVERSITY OF SOUTH AUSTRALIA SCHOOL OF NURSING AND MIDWIFERY NURS 2024 HEALTH OF OLDER ADULTS CARE MANAGEMENT PLAN CLIENT Name: Mrs. Chang (Alias) NEED/PROBLEM NURSING DIAGNOSIS JUSTIFICATION GOALS JUSTIFICATION NURSING INTERVENTIONS JUSTIFICATION EVALUATIVE OUTCOMES JUSTIFICATION 1. Impaired physical mobility Mrs. Chang is an elderly woman with 82 years of age with late stage parkinsonism. She is thin and frail. On the baseline, she has late stage parkinsonism, although the exact clinical features are not highlighted in this case study. This condition is characterized by gradual slowing of voluntary movement, muscular rigidity, stooped posture, and distinctive rigid gait. Over and above that, she has evidence of rheumatoid arthritis of both hands. As indicated in the history, she tripped and fell in the bathroom; this impairment of mobility may get accentuated with her rheumatic disease. Although not highlighted in the case history, a thorough examination of all her joints is mandatory to indicate the status of age-related osteoporosis and osteoarthritis, which would further aggravate her problem of mobility. During this admission, she was admitted since she sustained a fall at home in the bathroom, and she has been admitted to the hospital for observation and further evaluation. Her current medications have not been mentioned, but she has been on ibuprofen. This indicates her baseline chronic pain, which may further compromise her mobility. The impaired mobility is further accentuated by the fact that at home, she stays with her husband who is older than her by 4 years, who himself may be frail enough to be insufficient to help her out in these activities at home. The patient will express feelings of increased comfort, decreased pain and will be able to perform activities of daily living within the confines of the disease and will maintain joint mobility and range of motion while exhibiting adaptive coping behaviour. Improvement in muscle strength and endurance would be the goal (Burgess-Limerick, 2003, 143-148). An impaired nervous system can manifest in many ways, from subtle weakness to drastic loss of mobility. In her case, the major goal of nursing would be to slow the progression of the disease and improve the mobility and range of motion. With age, there is baseline muscle wasting from the 50-80 years of age, and this is the result of aging process in the neuromuscular system combined with a decreased level of physical activity over and above her rheumatic disease and parkinsonism (Eliopolous, 2005, 1-53). The nursing intervention would include provision of support and reassurance to help to cope with limited mobility. She would be given opportunity to voice her feelings about immobility and nodular joints. While doing the care management plan for her, she and her husband would be included in all phases of care with all their questions answered honestly. Analgesics have been already prescribed, but her response must be monitored depending on her pain pattern. She would be encouraged to perform as much as self-care as his pain and mobility would allow at her own pace. The patient would be recommended to have adequate rest, and she and her husband would be instructed to learn and use energy conservation methods, such as pacing, simplifying work procedures, and protecting joints. With regards to pain medications, they would be instructed to take medications exactly as prescribed, and adverse reactions such as bleeding and gastrointestinal irritation must be reported as soon as possible given her polypharmacy and warfarin due to atrial fibrillation. Overexertion must be prevented along with minimisation of weight bearing activities. She should stand and work correctly. Given her fall and increased propensity of fall due to her disease conditions, safety devices such as grab bars in the bathroom and elevated toilet seat would help her a lot. She would be taught range of motion exercises with training on gait and posture. Pointing out to improving or at least stabilizing physical functioning, the patient's efforts to adapt must be positively reinforced. Depending on her progress, the patient would be referred to a physical therapist, and help at home care may be necessary to help her cope with her care needs (Brown, 2005, 32-76). Parkinson's disease does not usually affect intellectual ability, but 20% of patients with Parkinson's disease develop dementia, which is perhaps the case with Mrs. Chang, since she appears to forget that she has bumped several times at home leading to bruises. Encouraging her to pursue physical activity and reassuring her is important since there is a chance of developing depression given her social situation and late stage of the disease. Parkinson's disease patient commonly develops depression later in the disease process, and this is characterized by withdrawal, sadness, loss of appetite, and sleep disturbance. Reinforcing coping mechanisms are necessary since they are socially isolated and they have lost their only son. Patients may also demonstrate problems with social isolation, ineffective coping, potential for injury, and sleep pattern disturbance. Falls are the major sources of injury for patient of Mrs. Chang's age group, and they need to be prevented. The accumulation of deficits in her, such as, muscular weakness, decreased balance, or neuromuscular abnormalities would result in mobility impairment and consequent fall and difficulties in performing activities of daily living. Physical training has positive effects on balance, and many older adults lose stability and require assistance to regain balance. Physical training affects muscle strength and endurance and is important in delaying the crossing of the threshold to physical dependence. In her case all, including mobility, gait, balance, and depression and cognition need to be improved (Potter and Perry, 2005, 879-1012). The patient will be able to move with assistance acceptably within 6 weeks, would be able to voice measures to prevent injury within 1 week, and will be doing full course of strengthening exercises within 2 weeks (Eliopolous, 2005, 57-91). The care of the patient with Parkinson's disease has been successful if the patient remains as mobile and independent as possible. The patient should remain safe from injury. Verbalization of understanding of needed lifestyle changes is another indication of success. Patients should be able to state measures to prevent injury if a fall should occur. Gradual return to normal physical activity is expected with the physical exercise regimen (Eliopolous, 2005, 72-86). 2. Self-care deficits due to reduced mobility The incident leading to Mrs. Chang's admission points to her self-care deficits due to her present condition. Although not delineated fully in the history, the nursing diagnostic and assessment procedure must consider the possible presence of bathing or hygiene self-care deficit, dressing or grooming self-care deficit, feeding self-care deficit and resultant imbalanced nutrition, which could be less than body requirement, and impaired physical mobility, leading to risk of injury. Since the levels of disability and functioning differ with the number of chronic diseases and management of chronic diseases depend largely on self-care, self-care is an important parameter to be attended to in care. Her hypertension, Parkinsonism, chronic congestive heart failure, age, and rheumatic disease all contribute to restricted mobility, loss of strength, easy fatigue, restriction of range of motion in the joints, decreased flexibility of the limbs, fear of fall, all contribute to self-care deficits. It becomes really hard for her to get around and do what she used to. Moreover, low self efficacy and sense of loss of control would also worsen the picture further. Self-care is a major component of management of her problems. Moreover, some major determinants for not attaining a high level of self care are age, severe motor impairment due to parkinsonism, perceptual deficit, weak or poor family involvement along with no social involvement in her care, and all of these might have made her psychological adjustment difficult (Brown et al., 2005, 43-83) The patient's self-care needs must be met. The patient will perform bathing and hygiene activities to the fullest extent possible, and the patient will verbalize feelings regarding self-esteem. Although no information has been provided in this case study about the bowel elimination pattern of Mrs. Chang, she would be constipated, and she will resume a normal bowel elimination pattern. The patient will express positive feelings about herself, and will perform dressing and grooming activities to the fullest extent possible (Hayflick, 2001, 32). Motor function has been acknowledged to be the most important determinant of self-care ability. In addition complex perceptual qualities also predict the level of self-care abilities. Both these parameters are affected in her condition. Higher levels of perception is impaired in Parkinsonism and dementia and these need cognitive abilities for forms and other visuospatial components, and these are effected in her case due to advanced disease. Nutritional deficits would reduce strength and would aggravate her frailty and would lead to easy fatigue when attempting some self-care activities. Failure to do so would reduce confidence and positive feelings about her abilities to herself. Added to this, her cognitive decline would lead to failure of assessing the environment and may lead to trauma, injury, or fall while doing such activities. This is the case with her since the multiple bruises over her torso, which she is unaware of, are indicative of trauma and injury, and this incident of fall in the shower is the greatest embodiment of the rationale to promote her self-care activities (Lindeman et al., 2002, 10-14). Nursing intervention would include encouraging the patient to participate in the ADLs as much as possible. This would help the patient maintain independence and self-esteem. It is important to provide emotional support to the patient and to listen to her concerns. To promote independence, the patient should be encouraged to participate in care decisions and to perform as much of her own care as possible. The independence should be encouraged by helping the patient recognize the ADLs that she can perform alone. Assistive devices should be provided as appropriate. For example, to help the patient turn himself in bed, rope was ties to the foot of the bed and extended it to the patient so that she can grasp it and pull herself to a sitting position. To help her with severe tremors and achieve partial control of her body, she can be made to sit on a chair and use its arms to steady herself. It is to be remembered that fatigue may cause the patient to depend on others, so adequate rest must be provided. The patient is to be helped to overcome problems related to eating and elimination. An occupational therapist must be involved to develop a program of daily exercises to increase muscle strength, decrease muscle rigidity, prevent contractures, and improve coordination. The program should include stretching exercises, swimming, use of a stationary bicycle, and postural exercises. Frequent warm baths and massage should be given to help relax muscles and relieve muscle cramps. The patient will be protected from injury by using the bed's side rails and assisting the patient as necessary when she walks and eats. Provision of clothing without buttons and with fasteners can be made and advised. Her diseases, their progressive stages, and treatments need to be discussed, and proper positioning must be demonstrated. Household safety measures will be explained and demonstrated such as installing or using side rails in halls, toilets, showers, and stairs and removing throw rugs from frequently traveled floors to prevent patient injury (Singh et al., 2001, 497-504). It has been acknowledged that the primary goal of healthcare for older, particularly multiply and chronically ill persons should be to optimize function and comfort rather than to solely treat individual diseases. As a result of these medical illnesses, older adults experience a variety of problems with activities of daily living (ADLs), which include bathing, dressing, eating, toileting, continence, and transferring. These problems often impact older adult's ability to live independently, because their functional decline may prevent them from bathing on a regular basis, preparing food for themselves, or paying their bills on time, which all affect the individual's quality of life. An older adult's ability to independently complete activities of daily living (ADLs) is a benchmark for health. Assessment of functional limitations in older adults is very important for detecting disease and dysfunction, selecting appropriate interventions, and evaluating the results of these interventions. With the older adult, the ultimate goal is to maintain optimal function and be as independent as possible. The geriatric interdisciplinary team works towards promotion and maintenance of functional independence with the goal of assisting the older adult to live independently as long as possible and preventing hospitalization and institutionalizations (Pearson, FitzGerald & Nay, 2003, 41-48). The patient will be able to eat and eliminate alone in 7 days. The patient will be able to bathe and groom herself in 2 weeks. The patient will have improved mobility in the close environment in 3 weeks. Acute admission always causes deterioration of the self-care activities. With ongoing help in the ward and involvement of the occupational therapy in the care, it would take time for her to get habituated to the activities mentioned. Moreover, regain of physical strength and self-esteem is time-consuming affair. With the improvement in nutrition, practice and encouragement in the ward, hopefully these time landmarks will be met. Even though this timeline is a prolonged one, given her other co-morbid conditions, all affecting mobility and strength, she would need to be given more rest and time. If the goals are unmet in the stated timeline goals will be revised following discussion with the patient, and new goals would be decided (Pearson, FitzGerald & Nay, 2003, 41-48). 3. Risk of falls. The patient has an increased susceptibility of falling that may cause physical harm. Her age of 82 and this admission with a history of fall increases her risks. Moreover, while caring and bathing, it was noticed that there are multiple bruises that indicate multiple injuries while at home. Her arthritis has aggravated the situation more. Her frailty leads to the possibility that she has decreased lower extremity strength that has impaired her mobility. Although not mentioned in the history, due to her parkinsonism, she may have urgency and incontinence of bladder. Moreover, she has difficulty with gait and coordination. She has diminished mental status from dementia associated with parkinsonism. On the top of that her medications include antihypertensive agent. Although not highlighted, her home environment may be cluttered due to the fact that the person who takes care for her more aged than her. A review of circumstances of fall with her lead to the finding that anti-slip measures were not taken, that could have led to this trip and fall. The patient will remain free from injury and falls, and the risks of falls would be reduced. Many falls are benign and result in no injury to the older adult. However, when an older adult falls, the consequences may be devastating. They are likely to develop a fracture, which begins them on a spiral of iatrogenesis, which may end in death. Older women experience more hospitalizations for fall-related hip fracture. Both normal and pathological aging changes, as well as unsafe environments, contribute to the high rate of falls among older adults and place them at higher risk for falls. Normal changes of aging surround sensory alterations, such as visual and hearing decline, as well as changes in urinary function. Pathological changes include neuromuscular and cognitive disorders and osteoporosis as relevant to her case (van Leeuwen et al., 2001, 8-13) As long as Mrs. Chang is in the hospital, all the lights should be within her reach all the times. The patient should be reminded to request assistance with ambulation. The bed should be in the low position with side rails raised as appropriate. While in the hospital, an alarm system will be used to alert the staff that the patient is getting up, so staff can assist the patient to get up and ambulate. The restraints are not used. The environment should be free from clutter, throw rugs, or other items that may cause the patient to trip. Walkers or other assistive devices will be provided to provide support and prevent falls. Her leg weakness must be assessed. Cognitive problems will be looked for more closely. The patient will be explained household safety measures, such as installing or using side rails in halls and stairs and removing throw rugs from frequently traveled floors to prevent patient injury. An electric warming tray keeps food hot and permits the patient to rest during the prolonged time that it takes to eat. Special utensils also assist at mealtime. A plate that is stabilized, a nonspill cup, and eating utensils with built-up handles are useful self-help devices. The occupational therapist can assist in identifying appropriate adaptive devices. Special walking techniques must be learned to offset the shuffling gait and the tendency to lean forward. The patient is taught to concentrate on walking erect, to watch the horizon, and to use a wide-based gait (Done & Thomas, 2001, 816-821) (Pearson, FitzGerald & Nay, 2003, 41-48). The patient is at risk for injury from falls related to problems with mobility. Maintaining the bed in a low position reduces the risk of injury or fall when getting out of bed. Side rails may increase the risk of injury, and must be used carefully. Restraints can increase the risk of injury. If the leg weakness is more, the physiotherapist can employ strengthening exercises. Cognitive problems lead to poor planning, judgment, monitoring safety, poor ability to follow instructions, and difficulty learning. Balance may be adversely affected because of the rigidity of the arms since arm swinging is necessary in normal walking (Done & Thomas, 2001, 816-821). The patient will be able to able to voice understanding of fall reduction measures in 1 week. The patient would be able to demonstrate an appropriate gait in 2 weeks. The patient will demonstrate strength and self-care activities in 3 weeks. Patient and family education is important in the management of her care. The education plan should include a clear explanation of the disease, assisting the patient to remain functionally independent as long as possible. Every effort is made to explain the nature of the disease and its management to offset disabling anxieties and fears. A conscious effort must be made to swing the arms, raise the feet while walking, and to use a heel-toe placement of the feet with long strides. The patient is advised to practice walking to marching music or to the sound of a ticking metronome because this provides sensory reinforcement. Doing breathing exercises while walking helps to move the rib cage and to aerate parts of the lungs. Frequent rest periods aid in preventing frustration and fatigue. Evaluation of client's use/misuse or failure to use assistive aids is necessary when indicated. Client may have assistive device but is at high risk for falls while adjusting to altered body state and use of unfamiliar device. The environmental hazards must be evaluated in the home. Determining needs/deficits provides opportunities for intervention and instruction concerning clearing of hazards, intensifying client supervision, and obtaining safety equipment if they are not already in place (Done & Thomas, 2001, 816-821). 4. Polypharmacy The patient is on multiple medications. Several factors influence medication use and the problems experienced by ageing people in relation to the use of medication. These include the changes in pharmacokinetics and pharmacodynamics of drugs in an aged individual. Due to multiple chronic conditions, she is on multiple drugs, many of which may have issues with appropriate compliance. Use of warfarin needs continuous and regular monitoring and supervision. Moreover, there are issues with adverse effects. She is using naturaopathic medicines, many of which may interact with the therapeutic agents, and most probably she is taking these medications on her own without prescription. The physical changes including alteration in weight and contour, changes in lean body mass, water, bone, and fat. The decrease in renal function associated with ageing also contribute to alteration in the pharmacokinetic pattern, hence diminished clearance of the drug, and therefore dose adjustment ( Schmidt, 2004, 169-175). To establish a complaint medication regimen without problems of adverse effects or polypharmacy, where the patient can be educated on proper ways of medication regimen. This leads to altered health maintenance due to insufficient education. Allowing access to medical care is important for her to maintain the appropriate therapeutic regimen. She is supposed to be in the hospital setting for a limited period of time, hence the discharge planning must accommodate education regarding drug therapy (Ioannides-Demos & Christophidis, 1993, 411-415). To educate patient and family about drugs, drug interactions, and the effects of polypharmacy. For enhancing the point to avoid polypharmacy, the medical officer will be contacted who can interfere and stop naturopathic medications. To facilitate dispensing, a dispenser will be used and demonstrated. INR would be done, and safety needs to be established with adjustment of warfarin dose. Elderly persons are at risk because of the higher number of prescription and OTC medications they consume (polypharmacy) and because of visual and cognitive impairments, which can cause them to forget what medications have been consumed and in what amounts they were taken. The greater the number of drugs used, the greater the risks of interaction, side effects, and adverse drug reactions. Many drugs, when given together, will interact. These interactions can increase or decrease the activity of either or both drugs. Sometimes access to medical supervision is important to effect compliance. Her rheumatic disease of the hands may create problem in opening the bottle. Her cognitive decline may lead to failure to identify drug and dosage and prevent compliance. INR is necessary to prevent bleeding complications. The patient is able to demonstrate and voice understanding of her medication regimen within 1 week. Once INR is cleared, the warfarin may continue in its older dose. The patient and family will demonstrate understanding of the need to see a physician while on INR therapy. The patient will stop naturopathic medications. The effects of non-drug measures to take care of the holistic aspect of health would be reviewed and demonstrated to the patient. Nurses should check their patients' knowledge of the dosage schedule of their drugs to enhance compliance. Dosage schedules should be simplified if possible-for example, doctors and pharmacists can be asked to use medications that can be administered on a once-daily basis. If a person experiences side-effects or adverse reactions, nurses should ensure that the cause is identified to differentiate symptoms of a new condition from the side-effects of medication. Nurses should ask their patients about any non-prescription medication that they might be taking in addition to prescribed medication, and should check to see if there is any risk of interaction with any prescribed drugs. Nurses should consider the use of non-drug treatments to improve the health of those in their care. Diet, exercise, relaxation methods, and so on should all form part of an holistic plan of care that takes account of non-drug alternatives (Hatcher, 2001, 36-43). 5. Deficiency in coping, communication, social support and family care The patient is being cared for at home by her husband, who is now 86. As the patient ages, so do the significant others who are providing care. The point may be reached at which the caregiver is no longer able to meet the increasing needs of the patient. There is no social support since the friends have deceased. The patient has problem coping and communicating (Ward, 2002, 33-35). Family members will seek support resources and develop adequate coping behaviors. The patient will maintain family and peer relationships. The patient will develop alternative means of communication. Family members will discuss the impact of the patient's condition on the family unit. The family must be educated in the management of her condition. Teaching needs will depend on the severity of her condition. The patient's and family's need for information is ongoing as adaptations become necessary. The education plan should include a clear explanation of the disease, assisting the patient to remain functionally independent as long as possible. Every effort is made to explain the nature of the disease and its management to offset disabling anxieties and fears. The patient and family must be taught about the effects and side effects of medications and about the importance of reporting side effects to the physician. Support can be given by encouraging the patient and pointing out that activities are being maintained through active participation. A combination of physiotherapy, psychotherapy, medication therapy, and support group participation may help reduce the depression that often occurs (Forster, 2003, 283-184). The patient and family will be taught about coping and communication. Teaching will be provided about the disease, its progressive stages, and treatments. The actions of prescribed medications and possible adverse effects will be explained. Household safety measures will be explained such as installing or using side rails in halls and stairs and removing throw rugs from frequently traveled floors to prevent patient injury (Eliopolous, 2005, 82-88). Patients often feel embarrassed, apathetic, inadequate, bored, and lonely. These feelings may be due, in part, to physical slowness and the great effort that even small tasks require. Patients are assisted and encouraged to set achievable goals. Patients must be active participants in their therapeutic program, including social and recreational events. There should be a planned program of activity throughout the day to prevent too much daytime sleeping as well as disinterest and apathy. Family and social support groups can play a major role in this (Done & Thomas, 2001, 816-821). On discharge family will be actively participating in patient's care and family's knowledge about the drugs and disease and safety measures will be demonstrable. Family support in coping, communication, mobility, assistance, safety measures, and pharmacotherapy would be very important in this case, and consideration of a social support group would be necessary given the age of her husband (Done & Thomas, 2001, 816-821). Issues Arising from the plan: The patient has parkinsonism, congestive heart failure, rheumatic disease, and atrial fibrillation. Rightfully, case management is a whole system approach since it would consider Mrs. Chang's and her husband's responses to her baseline illnesses of Parkinson's Disease (PD), hypertension (HT), atrial fibrillation (AF), and rheumatoid arthritis (RA) to both hands. Other issues associated or which have presently developed are her declining cognition, difficulty in mobility due to PD, lack of social support due to death of friends and only son, and these are bound to create some self care deficits. Taking the example of this present incident, given her situation and age, a fall in the toilet is very natural, and her husband, being aged further, would be barely able to respond to this accident, and a psychological panic is expected. All these conditions are prone to cause deterioration of her health-related quality of life that needs attention. Along with that other issues may creep up, such as, multiple medications. She has been on Levadopa (1.5 grams tds), Digoxin (62.5 mcg daily), Warfarin (4mg daily), Enalapril (5mg bd), and Ibuprofen (400mg tds) along with naturopathic medications. This constitutes a case of polypharmacy where supervision is absolutely necessary to ensure complaince and availability of medications. Moreover, drugs like warfarin needs frequent checkups of coagulation profile, which may not have been possible for her to undergo due to age, frailty, and mobility reasons. There is no supervision available for her at home. This is evident from her lack of monitoring of the INR and appearance of bluish spots in the torso, which may be petechiae for its size, indicating the necessity of adjustment of warfarin dose and coagulation check. The naturopathic medicines may have some drug-drug interactions, which again needs to be supervised (Haughton, 2000, 34-38). Conclusion: This is a broad analysis of her overall condition as a whole, and as a case, she needs to be managed appropriately with efficient and cost-effective care delivery, and to this end, the practice model must accommodate a nursing-oriented case management skill base and the elements of Mrs. Chang's and her family's support system. The main aims in her case management would include improvement in her mobility, reducing her fall risks, improvement in her symptoms and self-care deficits, reducing her polypharmacy and ascertaining appropriate medication regimen, helping her to cope and communicate, and helping her family to help her improve. A social support group is preferable along with establishment of safety measures at home, with key being the patient's and her family's education and active participation. To this end, this case management approach is perfectly suitable. Reference List Brown, D., Edwards, H., Lewis, SM., Heitkemper, MM., Dirksen, SR., (2005). 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Home Healthcare Nurse, 22(3):169-175. van Leeuwen, M., Bennett, L., West, S., Wiles, V. & Grasso, J. 2001, 'Patient Falls from Bed and the Role of Bedrails in the Acute Care Setting', Australian Journal of Advanced Nursing, Dec. 19(2): 8-13. Ward, R. 2002, 'Dementia, Communication, and Care: 1. Expanding Our Understanding', The Journal of Dementia Care, Sept/Oct: 33-5. Read More