Patient’s Current Health Condition

Discuss about the Pharmacological Treatment of Insomnia.

The assignment is the outcome of the long term care placement. The assignment is the assessment of the Mrs X an 88 year old patient currently residing in the long term care placement due to left sided cerebrovascular accident which caused right sided hemiplegia. The elderly patient will be evaluated using the “Gordon’s Functional Health pattern framework” (Gordon, 2016). The rationale for choosing this framework is the facility to conduct comprehensive nursing assessment of the patient (Gordon, 2016). The patient data will be collected for focused assessment using two evidence based tools.  The first one is the Hendrich II fall risk model as the hospitalized patient is at risk of fall (Campanini et al., 2018). The second tool is the Braden pressure ulcer risk assessment, to determine the risk of pressure ulcer (Carreau et al., 2015). The aim of the assessment is to prepare the care plan including interventions relevant to the clinical condition of the patient.  The care plan also includes nursing care strategies based on existing literature. The compliance of the care plan to the registered nurses competencies especially Domain 1 (1.2 and 1.5) as mentioned by the Nursing Council of New Zealand (2016) is discussed.

The patient under care is the 88 year old lady admitted to hospital with right sided hemiplegia caused by the cerebrovascular accident. She has the medical history of hypertension that increases the risk of heart failure. She lives after her husband’s death with her children and grandchildren. She has concerning issues with oedema lower extremities of her body such as her right feet. She complains of limited dependence after hemiplegia and pain on rights side due to strike. She has also concerns related to the deprived sleep, bladder and bowel continence. The patient is however active, conscious and responds during interaction. 

The following has been identified with Mrs X on completing the Gordon’s Functional Health patterns framework assessment and compiled as below

The patient demonstrated frustration due to limited dependence caused by hemiplegia. She described her need for help with activities of daily living. She highlighted her medication intake for sleep, bowel and blood pressure. Mrs admitted of her history of smoking and have quit after stroke in 2016.

 The patient demonstrates low pain tolerance as it is adding to her tress. She demonstrates interest in gaining back her independence.  The patient can well verbalise her concerns

Identified Health Issues

Her current vital signs were noted as follows

• Respirations- 22 breaths
• Temperature: 36.8 degrees Celsius
• Blood Pressure- 140/90 maintained with Amlodipine (as it lowers high blood pressure) (Fares et al., 2016)
• Oxygen Saturation- 98%
• Heart Rate- 81 beats per minute
• Weight – 92 kgs, Height: 175 cms- indicating BMI of 30.04, which means, the patient is having obesity (Mandviwala, Khalid, & Deswal, 2016).
• Nutrition-Metabolic pattern

The patient takes rich diet and eats meals three times daily. She fails to adhere to the dietary recommendations. She is recommended to have the puree diet. However, she consumed the normal food taking care of the quantity and consistency of the food.  She is mindful of chewing food on left side of mouth.  Mrs X feed herself and uses lower and upper dentures and does not complain of difficulty in eating mashed food.

 The usual food intake of patient is as follows

1. Breakfast- Porridge with milk, with sugar toast, and one fruit. She takes high calorie food evident from morning tea with hot chocolate, Biscuits, crackers or pikelets with jam and cream
2. Lunch- Takes vegetables and chicken soup alternately, toast with spaghetti and sausages and a fruit
3. Dinner- Toast with scramble eggs, and Steamed fish in sauce.

The patient has high intake of fluid as recommended by professional and is evident from the water bottle beside her and pitcher of water and a cup within her reach.

The patient needs to reduce weight as she is obese and is risk factor for heart failure (Mandviwala, Khalid & Deswal, 2016).  

The skin condition that is pale colour and warm body indicates of low fever.  The pressure assessment was conducted for patient using the Braden’s scale and the score of 18 indicates high risk of ulcer (Carreau et al., 2015). The same is also evident from her inflamed and red around groin, vulva and inner thighs.  However, she prefers Kawakawa Maori remedy than any other remedy.

On further assessment nails/teeth/mucous membranes were all found to be intact and healthy. 

The patient complains of the bladder incontinence and requirement of the pads all the time. She stated having constipation and need of laxative that is laxsol for easy emptying of bowels (Every-Palmer, et al., 2017).

She described her bowel motion to occur once in a day in afternoon between 2:30-4:00 and describes her stool as solid, medium and deep brown in colour. She has concerning issues with oedema lower extremities of her body. She wakes at night to urinate.

The patient initially independent and after hemiplegia her dependence has increased. She can mobilise with wheel chair but needs help with activities of daily living. on fall risk assessment using the Hendrich II falls risk model, a score of 8 was found putting her at high risk of fall. In the get up and go test there was inability to rise without assistance (Campanini et al., 2018).

Mrs complained of lack of stable sleep pattern, and high pain. She needs splint at night to prevent foot drop and pain medication.

There are not many significant issues with speech, voice, or memory as she can remember names. She requires glasses for reading and hearing is intact for her age

Gordon’s Functional Health Pattern Framework Assessment

The patient is family oriented and identifies herself as a mother, teacher, wife, grandmother, friend, social worker, teacher, and a JP.  She prefers to comb her hair herself indicating high self care and groom. She also demonstrates independence using unaffected hand as much possible. She cannot walk and takes help for hygiene and transfers.

She loves to be in company of her family and loves to enjoy weekends and holidays with friends. She herself advocates as her son has EPA.

The patient is widow but stated to be happily married for 60 years. She had no regrets with her marriage and enjoys being with her two sons , five grandchildren and her professional life.

She is able to cop because of family strength. Other stress coping strategies includes reading and playing bingo

The patient admires education and states her practicing religion as Anglican. Mrs X believes in respecting elders and treating them with respect and dignity.

 The two concerning issues as per the above assessment are the risk of fall due to hemiplegia, and pressure ulcer. For the first issue the Hendrich II fall risk model assessment was completed.  This model gives information of the risk factor associated with the patients with a certain score (Campanini et al., 2018). As per the data collected the patient did score   for altered elimination, and for taking antiepileptic that is Gabapentin and for taking Temazepam a benzodiazepines. Gabapentin is useful to treat seizure and shingles (Lu et al., 2017). Temazepam is used to treat trouble causing unstable sleep (Schweitzer & Feren, 2017).). Based on the get-up-and-go-test, it was found that the patient scored for unable to rise without assistance during test.  This test highlights the patient’s ability to independently sit or lay in bed.  Therefore, the total score sums up to 8 putting her at high risk of fall (Campanini et al., 2018).  The patient is a high risk patient as she is completely dependent on staff for transfers. Therefore, the nursing implication in this case is to develop fall prevention strategies as a part of the care plan. In this situation, the nursing goal is to decrease the fall risk factor and related injuries. Therefore the nursing interventions are targeted for improving mobility issues and promote beneficence (Manda-Taylor, Mndolo & Baker, 2017).  To ensure safety the patient may have her belongings close by her side and alarm system to notify her attempt to wake up (Health Quality and Safety Commission New Zealand, 2017). The same will be discussed in subsequent sections in details.

Risk Factors for Fall and Pressure Ulcer

The next issue to be highlighted was pressure ulcer and it was confirmed by completing the Braden pressure ulcer risk assessment model. It helps assess the patient’s mobility, degree of physical activity which is risk factors for pressure ulcer (Trepanier & Hilsenbeck, 2014). Her score in details is as follows –

1. Sensory perception of pressure related discomfort- 3 indicating slightly limited response to verbal commands with slight hearing loss. Lack of feeling of pain may be one or two extremities
2. Degree of skin exposure to moisture- 3 indicating Mrs X skin is occasionally moist may when changing the linen or wiping face with towel
3. Degree of physical activity- 2 indicating chair fast that is restricted to electronic wheel chair as the patient cannot bear her own weight
4. Mobility that is ability to change body positions- 2 indicated very limited mobility. It highlights the difficulty making significant changes independently.
5. Usual food and nutrition pattern-3 indicating intake of complete meal while meeting nutritional requirements
6. Friction and shear- 1 indicating problem where moderate assistance is required

The score sums up to 14 indicating high risk of pressure ulcer (Carreau et al., 2015).  Te score implies nurses to take actions for preventing the pressure ulcer such as measures to maintain skin integrity maintain fluid balance chart or encourage patient report pain (Cooper, 2013). It will be discussed in details in subsequent sections.

The nursing interventions for reducing the fall risk in patient are keeping the necessary items in the easy reach, such as telephone, urinal, water, as keeping gem too far may cause hazard and fall.  The patient will be provided with alarm system to prevent patient going out of bed without any assistance. It is the top priority amongst patients with a high fall risk scores (Morse, Merry & Bloswick, 2016). The patient’s bed will placed in lowest position for easy transfer to wheel chair. The patient’s room will be ensured with adequate lightening to increase visibility at night time wake up (Trepanier & Hilsenbeck, 2014).  The patient will be advocated to use hearing aid as it promotes health as well reduce hazard by increasing the auditory orientation to the environment. It will reduce the impact of falls; and minimize risk of falls or injuries. The patient will be assisted with physiotherapy. The physiotherapist may be consulted to develop detailed plan for strengthening and conditions. It will help develop flexibility and endurance (Karinkanta et al., 2010). These evidence based interventions promote a safe, stress-free environment for the patient, knowing her personal items are within reach when required (Health Quality and Safety Commission New Zealand, 2017, p. 3).  

 The package of care for Mrs X to reduce the risk of pressure ulcer includes medium package (Raju et al., 2015). The nursing care strategies for this condition involves daily monitoring of the full skin integrity and documentation of the same for tracking the changes as impairment becomes prominent with thinning of epidermis (Cooper, 2013). The patient may be repositioned on bed frequently to prevent ulcer and sores.  The patient will be educated to do frequent small shifts of the body weight. Further, it will be ensured that the patient’s bed linen is clean dry and wrinkle free, as moisture increases skin maceration. The patient will be provided with her preferred Kawakawa Maori remedy for redness of skin to protect skin for excoriation. It is the traditional healing method of New Zealand. This remedy is known for antiviral and anti-inflammatory properties (Aichele, 2016).  Since the client has elimination problem there will be appropriate adherence to the food chart and fluid balance recommendations. The input and output will be monitored to prevent infection.  The incontinence pads will be frequently checked and the same will be instructed to Mrs X. It is because urine turns into ammonia and is erosive to skin (Thompson, 2017).  As the patient has slight intolerance to pain she will be instructed to report pain over bony prominences as it is the area of high risk for tissue ischemia. Also prophylactic pain medication may be an issue (Black et al., 2010).

Nursing Interventions for Fall Prevention

Overall the assessment conducted and the care plan was designed in the manner that it complied with the competencies for registered nurses, Nursing Council of New Zealand (2016).  During nursing care, it will be ensured that the patient is respected (means whakaaute in tikanga practice) as she older adult and believes in treating elders with respect and dignity. This practice is in alignment with cultural safety principle as per treaty of Waitangi. The Domain 1, competency 1.2 was met by protecting the patient’s dignity and respect during hygiene practices and assisting for mobility. Further, the patient was given her preferred Kawakawa Maori remedy for redness of skin. It will help patient determine as being culturally safe.  It indicates meeting the competency 1.5 of Domain 1 in the Competencies for registered nurses, Nursing Council of New Zealand (2016). Therefore, the nursing care demonstrated the professional responsibility of respecting the patent’s identity, personal beliefs, goals and values.

References

Aichele, P. E. (2016). Medicinal Use of Native Plant Life in New Zealand: Analyzing Rongoa Maori and Western Science Interactions.

Black, J. M., Cuddigan, J. E., Walko, M. A., Didier, L. A., Lander, M. J., & Kelpe, M. R. (2010). Medical device related pressure ulcers in hospitalized patients. International wound journal, 7(5), 358-365.

Campanini, I., Mastrangelo, S., Bargellini, A., Bassoli, A., Bosi, G., Lombardi, F., … & Merlo, A. (2018). Feasibility and predictive performance of the Hendrich Fall Risk Model II in a rehabilitation department: a prospective study. BMC health services research, 18(1), 18.

Carreau, L., Niezgoda, H., Trainor, A., Parent, M., & Woodbury, M. G. (2015). Pilot study compares scores of the Resident Assessment Instrument Minimum Data Set Version 2.0 (MDS 2.0) Pressure ulcer risk scale with the Braden Pressure Ulcer Risk Assessment for patients in complex continuing care. Advances in skin & wound care, 28(1), 28-33.

Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care unit. Critical care nurse, 33(6), 57-66.

Every-Palmer, S., Ellis, P. M., Nowitz, M., Stanley, J., Grant, E., Huthwaite, M., & Dunn, H. (2017). The porirua protocol in the treatment of clozapine-induced gastrointestinal hypomotility and constipation: a pre-and post-treatment study. CNS drugs, 31(1), 75-85.

Fares, H., DiNicolantonio, J. J., O’Keefe, J. H., & Lavie, C. J. (2016). Amlodipine in hypertension: a first-line agent with efficacy for improving blood pressure and patient outcomes. Open heart, 3(2), e000473.

Gordon, M. (2016). Manual of nursing diagnosis.. (13^th ed.).  Burlington,MA: Jones and Bartlett

Health Quality and Safety Commission New Zealand. (2017). Topic 5: Safe environment and safe care are essential to prevent falls. Retrieved from https://www.hqsc.govt.nz/assets/Falls/10-Topics/2017_Topic_5_-_Safe_environment_and_safe_care_are_essential_to_prevent_falls.pdf

Karinkanta, S., Piirtola, M., Sievänen, H., Uusi-Rasi, K., & Kannus, P. (2010). Physical therapy approaches to reduce fall and fracture risk among older adults. Nature Reviews Endocrinology, 6(7), 396.

Lu, X. C. M., Cao, Y., Mountney, A., Liao, Z., Shear, D. A., & Tortella, F. C. (2017). Combination therapy of levetiracetam and gabapentin against nonconvulsive seizures induced by penetrating traumatic brain injury. Journal of Trauma and Acute Care Surgery, 83(1), S25-S34.

Manda-Taylor, L., Mndolo, S., & Baker, T. (2017). Critical care in Malawi: The ethics of beneficence and justice. Malawi Medical Journal, 29(3), 268-271. Retrieved from: https://www.ajol.info/index.php/mmj/article/viewFile/163204/152692

Mandviwala, T., Khalid, U., & Deswal, A. (2016). Obesity and cardiovascular disease: a risk factor or a risk marker?. Current atherosclerosis reports, 18(5), 21.

Morse, J., Merry, A., & Bloswick, D. (2016). Research Approaches to the Prevention and Protection of Patient Falls. Fall Prevention and Protection: Principles, Guidelines, and Practices, 341. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=SBcNDgAAQBAJ&oi=fnd&pg=PA341&dq=Keeping+the+patient%E2%80%99s+call+bell+in+reach+and+installing+a+sensory+mat+&ots=YYaeQlWTT7&sig=OjbZqwoXlgiN_VSBepVfQstn-5c#v=onepage&q&f=false

Nursing Council of New Zealand. (2016). Competencies for registered nurses. Wellington,NZ: Nursing Council of New Zealand 

Raju, D., Su, X., Patrician, P. A., Loan, L. A., & McCarthy, M. S. (2015). Exploring factors associated with pressure ulcers: A data mining approach. International journal of nursing studies, 52(1), 102-111.

Schweitzer, P. K., & Feren, S. D. (2017). Pharmacological treatment of insomnia. In Clinical handbook of insomnia (pp. 97-132). Springer, Cham.

Thompson, L. (2017). Management of Urinary Frequency, Urgency and Nocturia in a Healthy, Elderly Woman: A Case Report. Retrieved from:
https://ir.uiowa.edu/pt_casereports/32

Trepanier, S., & Hilsenbeck, J. (2014). A hospital system approach at decreasing falls with injuries and cost. Nursing economics, 32(3), 135. Retrieved from: https://search.proquest.com/openview/d6e1ab69adb152e7bf5d700db3f49b79/1?pq-origsite=gscholar&cbl=30765