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Nursing Care Plan For Patients With Chronic Illness

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Question:

Discuss with Nursing Care Plan and Implement method for Patients with Chronic Illness.

 

Answer:

Introduction

Luigi has developed an ulcer on his right leg. It has become infected as oral antibiotics aren’t affecting him, as a result developing cellulitis. Cellulitis is a condition in which bacteria (Streptococcus and Staphylococcus, gram positive bacteria) enters the ruptured skin and causes infection which can be life threatening, if not treated. He is unable to walk unaided. Luigi is also not having a proper diet which is affecting his renal function, therefore, admitted to the hospital and is under medication but at the same time he is upset to be away from his family. Luigi needs special nursing care and may also require interdisciplinary team assistance, since he has multiple issues to deal with. Nurses have a huge role in care management as they don’t only look after the medication part but also support the patients and their families emotionally.

Guiding principles of nursing care for chronic conditions

The principles are developed, to guide the health-care provider community, to establish quality intervention plans for the patient, by also encouraging their families to participate in the care program. A spirited relationship should be there between the patient, families and the healthcare providers. Their privacy and confidentiality should be respected, scope of which only a patient can decide. Talking or communicating to the patient is an integral part of the nursing care. Arguments should be avoided, and patients and their family’s right to choose must be respected. There are responsibilities mutually divided among the patient, families and the providers making it effective. It is to understand by the providers that the patients and their families may have certain circumstances where they may not engage to a certain extent. In such cases advocacy of the patient who can’t participate at all should be inevitable (Robert Wood Johnson Foundation, 2012). In chronic conditions, like in case of Luigi, health education plays a significant role as it spreads awareness among the patient and families regarding the disease. If his family is educated well about the treatment plan for the cellulitis and the diabetic diet, by the nurses and the healthcare providers, positive results may be seen very soon. Patients like Luigi, suffering from chronic illness are already doing self management which should be acknowledged and providers should understand that their needs may vary from other individual as per language or culture (Government of Australia, 2011). Patients should be assured of care continuity and intensive follow-up.

 

Nurse’s role in management of patient with chronic conditions

Nurses play an important role for the patients like Luigi who is suffering from chronic condition like diabetes and at the same time needs assistance with cellulitis he just developed. It is essential to understand first that a nurse undergoes a life-long learning process. A nurse should have core therapeutic and medical technology knowledge which effects the decisions taken by the same and hence it gives empowerment to others. Patient advocacy, safety and end of life care are some of the key roles played by a nurse (Batalden & Davidoff, 2007). They are dynamic and use interdisciplinary approach for better outcomes. Nurse uses their leadership qualities and ethical codes to give special care to the patients. Luigi’s diabetes require lots of self care as well as professional guidance, because nurses are better listeners, communicators and spend more time with the patients, they can discuss about self management in his case. Sometimes worse diabetic conditions can lead to foot ulcers. A diabetic specialist nurse can help Luigi and his wife understand the management of this disease, e.g., the diabetic diet has to be followed, since his wife does all the cooking. Also managing and monitoring weight, renal function, blood pressure and cholesterol control should be done. The nurse should be prompt and encourage families and the patient, giving them medical health education which can be performed over the phone too hence called Tele-health (Muili, 2015). Routine checkups and giving insulin therapeutic management is part of nurse’s role as Luigi is commenced on sliding scale insulin titrated to his BGL’s. The nurse should work on skills on timely basis and must be able to design a constructive and cost-effective treatment plan to intensify the patient’s convenience. Nurses should use their leadership qualities to provide sympathetic and holistic care to the patients and their families. The assigned nurses for chronic patients have additional responsibilities as compared to general nurses e.g., critical thinking, decision making, quality management and problem solving qualities. Nurses are expected to have knowledge about the legal issues as well. They should have strong networks so as to get in touch with other interdisciplinary team if required in Luigi’s case since he is suffering from multiple issues.

Collaboration with interdisciplinary team for nursing care

For Luigi, in his diabetic condition a plan with goals of better treatment is developed by interdisciplinary team in collaboration with patient and their families, nurses and physicians, which should be well coordinated for chronic diseases to be treated successfully. Such kind of team may include nurse care managers, medical specialist, psychiatrists, physicians and health workers (Barbara, Paul & Elizabeth 2014). Luigi nurse may collaborate with them to review his case history and provide guidelines for treatment of diabetes, depression, cellulitis and his deteriorating renal function. A good nutritionist can also be lined up in this case to attend his wife for the proper diabetic diet plan to be followed as she does all the cooking. His son should be counseled by making him aware of the problems they may face and the family care to be given to his father. The interdisciplinary can held meetings on the regular basis for achievable treatment goals clarification, record patient’s progress, intensify the treatment plan if he is not responding to the medical care provided and finally a follow-up which may be required when the patient returns home. Also his family should be taught about the goodness of such team as the healthcare delivery has always been successful. Some strategies which a well coordinated team follows is: Planning treatment: This is probably the most important approach, intensity of which, determines the success. A well written, formal treatment plan helps to simplify the complexities. Patient’s priorities and preferences, if taken care of, can satisfy the patient. Population established care: It is assured that the effective treatment reaches out to the ageing population and every patient who need them. Clinical management: Evidence based information about the patient is provided to analyze the current situation, risk factors and accordingly adequate treatment is given (Edward, 2000). Self management: If patient is already involved in self management then it can do wonders to the confidence of the patient and his family. Most of the doctors or physicians don’t have training or time to counsel the patient to encourage them for self management or behavioral change. Here come the trained nurses handy as they can help to support patients in this matter. Effective consultation: A patient who is chronically ill may be a little difficult to consult as he needs multiple help. Hence a well coordinated team may help in an effective consultation, helping patients to be well informed and more aware. Continue follow up: It is a crucial step to figure out any adverse effect or nonresponsive demonstration towards treatment. A follow up can be done by the nurses over the phone or by meeting them personally. Luigi nurse may closely monitor his chronic condition and, keeping in mind his emotions and preferences, should well communicate with the care team to help him. The nurse should use the leadership skills wherever required (Thomas et al, 2005). Only a nurse can make family members understand their responsibilities during the treatment and after they return home. This should be well communicated to both wife and the son, as family provides the emotional support needed the most at this time. Once Luigi returns home, he should do self management and follow a strict diabetic diet plan. Apart from nutritional factor, he should take proper medications for his foot ulcer and kidney problems. In some cases where extensive care is required after returning home, community healthcare services may help in providing an adaptive environment e.g., wheelchairs, monitoring equipments, special beds etc. A nurse can also help family members and patient to guide about the same, which should be cost effective also.

 

Nursing interventions for the chronic patient

The condition which Luigi is facing requires early nursing intervention as the situation, if not controlled, can be life threatening. He is not only suffering from diabetes but has also developed a foot ulcer. This foot ulcer is in a really bad shape and is worsening day by day because of diabetes. His kidney isn’t functioning properly because of poor diet.

Nursing intervention for leg ulcer or cellulitis:

The foot or lower leg ulcer is the most common condition in the patients with diabetes. One of the reasons is that even a slight change in blood glucose level can affect the nerves and hence lesser sensation is felt on the leg’s skin or feet. Also arteries going to the feet may narrow down, as a result blood circulation there remains poor and even a minor wound takes a long time to heal and develops into an ulcer. The registered nurse should use communication skills and educate about the basics of foot care. Studies have shown that educating patients about foot care has decreased foot ulcers (Aalaa et al, 2012). In Luigi’s case, the nurse should be empathetic towards him and should be prompt in treating the ulcer he has developed. Oral antibiotics are given in cellulitis but even that isn’t working for him because of which he is hospitalized. Suitable dressing should be done depending on the wound, whether wet or dry, which again shows the knowledge and concern of the nurse.

Nursing intervention for diabetic diet:

To follow a healthy nutritional plan is crucial for Luigi, because it is not only making his diabetic condition worse, but also deteriorating his renal function. His wife does all the cooking so it is essential to understand the importance of a good diabetic diet and a nurse can guide her for the same. The body weight should be weighed regularly and accordingly decide on the food and eating patterns (Nanda Nursing Interventions, 2011). Obesity and overweight is one of the main reasons of diabetes, hence weight control is necessary. Liquid diet if required should also be considered. It is also salient to make sure that the patient is able to digest the food plan designed and there is no abdominal pain. Apart from the dietician collaboration, blood sugar examination and insulin treatment should be done on the timely basis. In acute cases, protein intake reduction (0.7-0.9 g per day according to body weight) improves the renal function. Further complications of diabetes may be controlled by lowering blood pressure and consuming less protein in diet. The nurse should coordinate with a nutritionist and serve Luigi food rich in vegetables, fruits, high fiber and whole grains. Low fat nuts and dairy products may be added to the diet plan. Less sodium intake (lesser than 1900 mg per day) may lower the risk of cardiovascular problems (American diabetes association, 2007). Carbohydrate should not be completely removed from the diet plan and a monitored amount should be added to the diet. The nurse should take care of these recommendations and provide the same to Luigi while in hospital. His wife should be given proper written diet plan, to follow strictly, when he gets back home to regain a healthy lifestyle and avoid further complications.

 

Nursing interventions for worsening renal function:

Diabetes is the main reason for kidney dysfunction and this state is named as Diabetic Nephropathy (Melinda, 2014). Blood pressure and sugar level control can slow down kidney failure. Proper medication should be prescribed otherwise renal function will continue to deteriorate and may lead to dialysis and even kidney transplantation in acute cases. The nurse firstly should educate Luigi and his family about the preventive care which they should take to avoid kidney failure, since in his case it is into early stage. It is a well known fact that prevention is better than cure, hence certain factors should be controlled e.g., blood glucose level, blood pressure, dyslipidemia (Jorge et al, 2005). Also an intensive diet plan and no smoking regime should be followed. Luigi’s nurse should monitor the urine sample test on timely basis to determine if the kidneys are responding to the treatment. His family should be taught softly about the course of action in case the situation goes out of hand. If Luigi is into smoking, he should be encouraged not to do so. At the same time diet intervention becomes salient, to make sure the protein intake is low and adequate amount of carbohydrates, high fiber, fruits and vegetables are added to the diet plan. In addition to this, nurse should counsel them about the ways of sugar and blood pressure control. They should be told about the adverse affects of been obese or over weight.

Nursing interventions on medication:

Luigi is admitted to the hospital for treating ulcer and diabetes. He has developed severe bacterial infection on his leg for which he is given antibiotics. IV Ceftriaxone is given to stop bacterial growth (Amy, 2014). The nurse should inform him about the medication he is going to receive and also the dosage which is given depending on the medical condition. The fluid intake generally should be high during the course of this medication, however, this should be followed as directed by the physician, and nurse should take care of this factor. Along with the antibiotics, nurse should also consider cleanliness and appropriate dressing to be done depending on the type of wound. The patient is also commenced on sliding scale insulin titrated to his BGL’s (blood glucose level) to stabilize his diabetes. In sliding scale therapy, the insulin dose depends on the level of blood sugar before meal (Steve, 2016). Nurse can check the blood sugar with the help of glucometer and accordingly insulin is provided. If the blood sugar is high, insulin dosage also would be more. The nurse should also consider personal factors into consideration. E.g., insulin dosage depends highly on the kind of diet taken. If the carbohydrate in meal is higher, more insulin would be needed. Another point is that the weight of the patient and the amount of insulin depends on each other. Nurse should also keep in mind to check whether Luigi is sensitive or allergic to insulin or not. Keeping all this in mind insulin should be given to the patient appropriately.

Nursing intervention for chronic illness and family support: Luigi is mostly upset because he is away from home and his family. A nurse, who is considered to be a great listener and has great communication skills, should listen to his emotions, preferences and empathetically respond to them. It should be a priority to provide a family-centered care. The nurse should be able to manage any complexities to advocate high quality health care. They should educate Luigi’s family to adhere to their medication compliance to prevent relapse once he gets back home. Taking medicines on time, following diet plan should be adhered to, which his family can help with. Medication, education and nursing skills, if combined effectively can help patients to understand and manage their chronic diseases. Patients like Luigi who have this long term illness need lots of patience and care. Only a nurse can balance out a professional and friendly relationship with such patients (World Health Organization, 2004). His family should be educated by the nurse about the importance of a great ‘family time’ which makes a huge difference to the healing process. Celebrating an occasion together, having a laugh with the family, means a lot in such cases.

 

Conclusion:

A nurse plays a crucial role in supporting patients with chronic illness. They should be well trained in care management, which means to follow guiding principles for nursing plan, better communication skills, and behavioral change (Linda et al, 2007). Also booster training regime should be provided to enhance their qualities and improve patient’s quality of life. They should have leadership qualities and problem solving aptitude. Luigi’s case requires self management and lots of care by the family. The registered nurse must be qualified enough to analyze the situation as to when collaborate with the interdisciplinary team. To follow the guiding principles of nursing is utmost important in patients with chronic conditions. Nursing interventions like taking care of the medications, diet plan etc should be well implemented. His wife and son should be well educated about the present scenario, and the complications which may arise in future. They should be encouraged to spend quality time together as family support is very important when patient is undergoing a treatment. Many issues like personal hygiene, nutritional food intake, and self management should be politely taught to the family and Luigi.

 

References

Robert Wood Johnson Foundation 2012, Nursing experts release guiding principles for patient engagement, viewed 15th july 2016,< https://www.rwjf.org/en/library/articles-and-news/2012/07/nursing-experts-release-guiding-principles-for-patient-engagemen.html>

Government of Australia. (2011). WA Chronic Conditions Self management Strategic framework 2011-2015. Department of health, Western Australia.

Batalden, P., Davidoff, F. (2007). What is Quality Improvement and How Can It Transform Healthcare. Quality and Safety in Health Care, (16), 2-3.

Muili, L. (2015). The importance of diabetes specialist nurse. University of West London, UK.

Barbara, T., Paul, F., Elizabeth, H. (2014). Role of the Nurse in Chronic Illness Management. Nursing Economics, 32(4), 178-184.
 
Linda. et al. (2007). US Nurses Perceptions of Their Role in Diabetes Care. The diabetes educator, 33(1), 152-162.
 
Thomas. et al. (2005). Nurses as leaders in chronic care. British Medical Journal, 330(7492), 612-613.
Edward, H. (2000). The role of patient care teams in chronic disease management. British Medical Journal, 320(7234), 569-572.

Aalaa. et al. (2012). Nurses role in diabetic foot prevention and care; a review. Journal of Diabetes and Metabolic Disorders, 11, 15.

Nanda nursing interventions 2011, Nursing interventions for diabetes, viewed 15th july 2016,< https://nanda-nursinginterventions.blogspot.in/2011/05/nursing -intervention-for-diabetes.html>
American diabetes association. (2007). Nutrition Recommendations and Interventions for Diabetes. British Medical Journal, 30(1), 48-65.

New York State 2015, What Problems are Caused by Diabetes?, viewed 15th july 2016,< https://www.health.ny.gov/diseases/conditions/diabetes/problems_caused_by_diabetes.htm>
Melinda, R 2014, Diabetes Health Center, viewed 15th july 2016,< https://www.webmd.com/diabetes/guide/diabetes-kidney-disease>

Jorge. et al. (2005). Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Diabetes Care, 28(1), 164-176.

Amy, N 2014, IV Antibiotics Could Help Treat Skin Infections, viewed 15th july 2016,<https://www.webmd.com/news/20140604/easy-to-use-iv-antibiotics-could-help-treat-serious-skin-infections>

WebMD 2015, Ceftriaxone Intravenous, viewed 15th july 2016,< https://www.webmd.com/drugs/2/drug-8750/ceftriaxone-intravenous/details>

Steve, K 2016, Sliding Scale Insulin Therapy, viewed 15th july 2016,< https://www.healthline.com/health/diabetes/sliding-scale-insulin-therapy#Overview1>

Nursing Link 2016, Top 10 Qualities of a Great Nurse, viewed 15th july 2016,< https://nursinglink.monster.com/benefits/articles/5019-top-10-qualities-of-a-great-nurse?page=3>

World Health Organization 2004, General Principles of Good Chronic Care, viewed 15th july, 2016,< https://www.who.int/hiv/pub/imai/generalprinciples082004.pdf>

 Stetler. et al. 2009, Institutionalizing Evidence-Based Practice: An Organizational Case Study Using a Model of Strategic Change, viewed 15th july 2016,< https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-4-78>

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