NMIH105 Primary Health Care Nursing | Health Promotion
Case Study
He has now returned home and his discharge summary recommends that he is to meet with his GP for follow up.
Mr Pitman’s GP works in a large superclinic in the Illawarra which offers multidisciplinary care and access to GPs, nurses and allied health professionals, including exercise physiologists, clinical psychologists and a dietician.
Mr Pitman’s GP reviews his hypertension and pain medications and suggests that he meets with Mark Stamford, the registered general practice nurse (GPN) for a health assessment and review of his wound.
Mark has known Mr Pitman for several years and is familiar with his history of hypertension and osteoporosis. The GPN also knows that since the death of his wife, Mr Pitman has lived alone with his dog “Ruby” and enjoys going to his local RSL to catch up with mates. Mr Pitman has a son who lives interstate and a daughter who lives locally.
The GPN arranges a convenient time for Mr Pitman to come in for a health assessment. Mark knows that the assessment for people aged 75 years and older is a detailed and prolonged assessment, and explains this to Mr Pitman (Medicare Benefits Schedule (MBS) Item 707).
On assessment the GPN records the following:
HR: 68
BP: 145/78
Respirations: 14
On inspection, Mr Pitman is ambulating well with support of a walking frame and his wound is clean and dry with a small amount of exudate on the distal fringe. Pain originating at the wound site is manageable with his current medications. On a scale of 1 to 10, with 10 being severe pain, Mr Pitman rates his pain level at a 2-3 when ambulating. As the GPN progresses through the health assessment he explores how Mr Pitman is coping with his activities of daily living. Mr Pitman states that his daughter brings him an evening meal each day and sandwiches for the following lunch.
As part of the 707 health assessment, the GPN conducts cognitive screening on Mr Pitman through a Standardised Mini-Mental State Examination (SMMSE). The GPN records that while Mr Pitman is coping independently as best he can at home there is moderate cognitive decline. To prevent any further decline to Mr Pitman’s physical and psychological health, the GPN arranges referrals/home services so that he doesn’t end up in hospital again.
Structure your assignment so that it meets the following requirements:
GPN health assessment
Activities of Daily Living
Nursing Care Recommendations and Rational
Also explore the services available through the multidisciplinary team at his own superclinic and those available to him in his community. Provide rationales for your recommendations and support these with evidence from academic literature and Government websites.
Answer:
GPN health
General practice nurses play a crucial role in health promotion, and health maintenance and prevent disease or any other illness by providing care to the patient along with information about the disease, education to the community (McInnes, Peters, Bonney & Halcomb, 2015). General practice nursing is an expanding the area of clinical practices which generally focuses on health promotion in an aged population with chronic illness. Therefore, in general practice, a health assessment was introduced for patient aged 75 or older than 75 for assessing physical health, psychological and social function (McKenna, Halcomb, Lane, Zwar & Russell, 2015). These health assessments also consider whether the prevention or health care provided to the patient or not. A healthcare practitioner may select any of 701, 703 or 707 health assessments of Medicare health benefits to treat the patient depending on the degree of severity of the illness (Hamirudin, Ghosh, Charlton, Bonney & Walton, 2015). The aim of this health assessment is to help the practitioner to identify any risk factors exhibited by patient aged 75 or more than 75 in a structured way which may require further attention. In this case study, Mr Harry Pitman, an 83 years old veteran who was admitted to the hospital for total hip replacement. His GPN stated that he had the history of hypertension and osteoporosis and arranged a convenient time for his health assessment. The component of these health assessments includes the measurement of blood pressure, pulse rate and rhythm, assessment of medication, assessment of psychological function, cognition and mood. It also includes that practitioner should provide the information about the recommendation and interventions at the direction of medical practitioner (Reed, Masters,& Roeger, 2015). Special care should be provided to the older patient according to the assessment guideline. Medicare health benefits for this assessment are item 707 which are prolonged assessmentand the cost of this assessment is $263.55 (Hamirudin, Ghosh, Charlton, Bonney & Walton, 2015). According to the case study, he had constipation and sometimes incontinent at night after hip replacement which indicates the increased risk of pelvic organ prolapsed (Cauley et al., 2016). Since he had a history of osteoporosis, his left neck of the femur was easily fractured. Other risk factors associated with the fractured neck are a defective vision, physical inactivity, low body mass index. He was walking with the support of a walking frame but a small amount of exudates observed in distal fringe which might give rise to the infection. Moreover, due to readymade meals and lack of nutritional food may slow down the process of wound healing. As part of 707 health assessment, GPN conducted cognitive screen for MR. harry pitman through a standardized mini-mental state examination that set a questioner to assess to screen cognitive behavior. This screening test suggested that he had moderate cognitive decline. It includes the mild amount of dementia or memory impairment that interferes with the daily activity of the patient. Sometimes, it also considered as the early stages of Alzheimer (Silberschmidt et al., 2017). The reason for this decline can be loneliness since he lived alone with his dog, his wife died, and son lives away from the family. Moreover, in many cases hospital admission to the hospital also affect the behavior of the patient.
Activities of daily living:
Falls are the common and neglected cause of injury in, especially older patients. Injury associated to fall can happen for any individuals. For elders, the most serious consequences are the fracture in any of the bone of anatomy, but in severe cases, the individual can die because of a sudden fall. However, elderly patients have the higher risk of injury due to sudden fall and fracture observed in the hip, femur, pelvis and vertebra (Opsahl, Ebright, Cangany, Scott & Shaner, 2017). Accumulated pieces of evidence suggested that there are three prime reasons why older people more prone to injury due to fall. Chronic health conditions such as severe cardiovascular disease, dementia and low blood pressure that causes the dizziness in individuals and subsequent injury and fracture. Dehydration can cause a sudden fall in the individual since it induces hypotension, confusion and loss of balance. In many scenarios, individuals fall especially older people fall due to poor vision and muscle weakness and other changes in the bone. Mostly in older patients, joints become stiff, and bone becomes thin, weak. Some individuals might lose some sensation in their legs and feet. Therefore, it becomes hard for them to prevent fall and they experience severe injury. Most falls in elder individual observed at daytime and mostly elder individual experience a sudden fall during the use of bathroom (McDonald, Orr & Pope, 2016). Moreover, studies suggested that in few cases older individual experience sudden fall due to inflammation of the regulatory part of the ear. According to Australian Bureau of statistics, out of four one individual older than 65 years experience injury due to fall and ended up in the emergency room of the hospital (McDonald, Orr & Pope, 2016). In severe cases, in every 19 minutes, an older adult dies from a fall injury. Over the years it was estimated that 507,000 falls required medical admission and about 18% of medically treated fall injuries ended up in the emergency room of a hospital with 69% of the treatment carried out outside of the hospital. Medicare costs for treatment of fall injuries were approximately $30 billion in 2015, and it exponentially increases over the years (Carande-Kulis, Stevens, Florence, Beattie & Arias, 2017). The incidences of fracture become predominant in elder individuals since many older individuals are reluctant to report the fall because they fear the restrictions of a few daily activities.
Fractured neck of femur is a severe injury that primarily occurred in the older patient. It takes a long time of approximately six weeks and might make more extended period even after surgery. It is rare incidence that anyone able to walk in a broken bone and even after surgery majority of individuals unable to walk correctly with stable balance in legs. In the case study, Mr. Harry pitman, an 83 years old man was admitted to hospital for total hip replacement due to fall and fracture in left neck of the femur. Since he had a history of osteoporosis, fracture of left neck of femur easily occurred by sudden fall. Poor nutrition and specific medication also contribute to fracture of the femur. The outcome of this fracture has enormous impact on the daily activities of the patient as observed in the case of Mr Pitman. The Roper-Logan-Tierney Model of nursing had taken into account some of the daily activities that require the assistance of health care practitioner for improving quality of life. These activities include maintenance of a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobilization and sleeping (Alligood, 2017).This model also considered the importance of the contribution of a social and psychological factor in enhancing the quality of daily activities inpatient. As observed in the case study, due to the fracture he experienced obstacles in specific daily activities such as the inability of ambulating autonomously. After split, he was walking with the help of a walking frame. He was also impaired to dress independently and feed independently. He had to eat cold readymade meals since he had a hard time managing meals. He had poor personal hygiene and faced problem in finishing toilet tasks. He lived alone with his dog after the death of his wife, and his son lived away from him. Eventually, due to hip replacement after fracture, he was not able to get out of the bed alone to reach the toilet and needed the assistance of another person. He also felt constipated and incontinent at night, so he mostly remained in pyjamas in a weekend unless his daughter who lived locally came and able to help him for efficiently improving his daily activities.
The impairment of daily activities had a massive impact on an individual’s life. Specifically, the fracture events hindered the standard functions of the individual to lead a quality life. Impairment of daily activities affects the psychological stability of an individual along with the mental framework of the individuals. Therefore, a significant number of people experiences emotional distress and severe depression. The evidence accumulated in research field reported that emotional distress is directly proportional to the severity of pain. Therefore, exponential increases in emotional distress also increase the severity of illness. In the case study, the overall hindrance in normal activities significantly affected his emotional well being along with physical well being. Besides, his GPN also conducted n cognitive screening which suggested the moderate cognitive decline. This kind of cognitive decline is not severe but noticeable and measurable. In such events the memory and other thinking and decision making skills become impaired (Gardener et al., 2015). This can be observed due to specific side effects of administrated medications, unstable metabolism due to inadequate nutrition consumption or common illness. Social and environmental factors also contribute in the event of cognitive declined and patients might express the anger, anxiety (Elliott, Annear, Bell, Palmer &Robinson, 2015). He lived alone with his dog after the death of his wife, and his son lived away from him. As observed in the case of Mr Pitman, the moderate cognitive decline might give rise to the early stage of Alzheimer (Gardener et al., 2015). Therefore, His GPN arranged referral home services to prevent such psychological instability and enhance the quality of daily life.
Nursing care recommendations:
Fracture of the femur is a common phenomenon in an elderly patient that has severe outcome and require immediate assistance of medical expertise. However, the patient faces the obstacles in many daily activities and quality of life decreases. Hospital discharges in such cases strictly dependent on the recovery processes. Nurse practitioner ensures the proper recovery in such cases. To heal patients appropriately, it should be recommended for the nurse to arrange a walker or crutches for stable leg movements (Johansen et al., 2017). Rearrangement of the further for manoeuvre with a walker is also part of a nurse’s job. As a health care practitioner, it should be recommended to the nurse to feed food containing calcium to strengthen bone (Prestmo et al., 2015). It is also suggested that nurses should remove any mats or rug that increases the probability of fall. Nurses should arrange firm and higher chair than average for comfortable sitting position and safety measures. For wound management, it should be recommended to the nurses to keep the area clean and dry. A dressing should be applied in the place and it should be changed by nurses routinely. It should be recommended to ensure the bathing time of the patient and proper bathing position. Nurses should raise the toilet seat in the bathroom to ease the difficulty of the patient in the bathroom. It should be recommended to use assistive to use a shower chair in severe cases and place grabbing tool for avoiding further bending or bending too far (Prestmo et al., 2015). It should be recommended to place frequently used item nearly for the patient in order to avoid further movement. In order to manage the swelling, it should be advised to apply ice and elevate the legs slowly. Wearing compression stockings may help to reduce severe pain after surgery. For medication, narcotics, non-narcotic painkillers, oral or injectable blood thinner and stole softer should administrate to ease the pain of the patient (Berry, Rothbaum, Kiel, Lee & Mitchell, 2018). Supplements of vitamin should be given to strengthen the immunity of the patient and strengthen the bone. It should be recommended to monitor the body mass of the patient and incorporate vegetable in the food diet. Nurses should encourage the patients to involve themselves in mild exercises such as the slow lifting of legs, swimming and slight movement of hips and bicycling to enhances the lifestyle. In Australia, the department of veteran affairs provides the care a veteran requires during the recovery from any illness and restores the healthy lifestyle (My Aged Care, 2018). Veterans home care offer the available veteran domestic assistance, personal care, safety-related home and garden maintenance. The community nurse program also conducted for eligible veterans for receiving clinical care and personal care such as medication management, wound care, hygiene survives by staying in their home rather than the hospital.
References
Access aged care information and services | My Aged Care. (2018). Retrieved from https://www.myagedcare.gov.au/eligibility-diverse-needs/veterans-0
Alligood, M. R. (2017). Nursing Theorists and Their Work-E-Book. Elsevier Health Sciences.
Berry, S. D., Rothbaum, R. R., Kiel, D. P., Lee, Y., & Mitchell, S. L. (2018). Association of clinical outcomes with surgical repair of hip fracture vs nonsurgical management in nursing home residents with advanced dementia. JAMA internal medicine, 178(6), 774-780.doi:10.1001/jamainternmed.2018.074
Carande-Kulis, V., Stevens, J. A., Florence, C. S., Beattie, B. L., & Arias, I. (2015). A cost–benefit analysis of three older adult fall prevention interventions. Journal of safety research, 52, 65-70. Retrieved from: https://ro.uow.edu.au/cgi/viewcontent.cgi?article=3812&context=smhpapers
Cauley, J. A., Cawthon, P. M., Peters, K. E., Cummings, S. R., Ensrud, K. E., Bauer, D. C., ... & Kado, D. M. (2016). Risk factors for hip fracture in older men: the osteoporotic fractures in men study (MrOS). Journal of Bone and Mineral Research, 31(10), 1810-1819.doi:10.1002/jbmr.2836
Elliott, K. E. J., Annear, M. J., Bell, E. J., Palmer, A. J., & Robinson, A. L. (2015). Residents with mild cognitive decline and family members report health students ‘enhance capacity of care’and bring ‘a new breath of life’in two aged care facilities in T asmania. Health Expectations, 18(6), 1927-1940. doi: 10.1111/hex.12236
Gardener, S. L., Rainey-Smith, S. R., Barnes, M. B., Sohrabi, H. R., Weinborn, M., Lim, Y. Y., ... & Szoeke, C. (2015). Dietary patterns and cognitive decline in an Australian study of ageing. Molecular psychiatry, 20(7), 860. doi:10.1038/mp.2014.79
Hamirudin, A. H., Ghosh, A., Charlton, K., Bonney, A., & Walton, K. (2015). Trends in uptake of the 75+ health assessment in Australia: a decade of evaluation. Australian Journal of Primary Health, 21(4), 423-428. Retrieved from: https://ro.uow.edu.au/cgi/viewcontent.cgi?article=3149&context=smhpapers
https://books.google.co.in/books?hl=en&lr=&id=l7stDwAAQBAJ&oi=fnd&pg=PP1&dq=RoperLoganTierney+Model+&ots=yVsJWSRRac&sig=3aqrplGbk9eerPXGhaGn_C7x1VY#v=onepage&q=Roper-Logan-Tierney%20Model&f=false
Johansen, A., Boulton, C., Hertz, K., Ellis, M., Burgon, V., Rai, S., & Wakeman, R. (2017). The National Hip Fracture Database (NHFD)–Using a national clinical audit to raise standards of nursing care. Retrieved from: https://www.orthopaedictraumanursing.com/article/S1878-1241(17)30002-3/pdf
McDonald, D., Orr, R. M., & Pope, R. (2016). A comparison of work health and safety incidents and injuries in part-time and full-time Australian Army personnel. Journal of athletic training, 51(11), 880-886. doi: 10.4085/1062-6050-51.10.12
McInnes, S., Peters, K., Bonney, A., & Halcomb, E. (2015). An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. Journal of advanced nursing, 71(9), 1973-1985.
McKenna, L., Halcomb, E., Lane, R., Zwar, N., & Russell, G. (2015). An investigation of barriers and enablers to advanced nursing roles in Australian general practice. Collegian, 22(2), 183-189. Retrieved from: https://doi.org/10.1016/j.colegn.2015.02.003
Opsahl, A. G., Ebright, P., Cangany, M., Scott, D., & Shaner, T. (2017). Outcomes of adding patient and family engagement education to fall prevention bundled interventions. Journal of nursing care quality, 32(3), 252-258. Doi:10.1097/NCQ.0000000000000232
Prestmo, A., Hagen, G., Sletvold, O., Helbostad, J. L., Thingstad, P., Taraldsen, K., ... & Johnsen, L. G. (2015). Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. The Lancet, 385(9978), 1623-1633. Retrived from : https://dx.doi.org/10.1016/S0140-6736(14)62409-0
Reed, R. L., Masters, S., & Roeger, L. S. (2016). The Australian Defence force post-discharge GP health assessment. Australian family physician, 45(3), 94. Retrieved from : https://www.ranveteranswelfare.asn.au/news.
Silberschmidt, S., Kumar, A., Raji, M. M., Markides, K., Ottenbacher, K. J., & Al Snih, S. (2017). Life?Space mobility and cognitive decline among mexican americans aged 75 years and older. Journal of the American Geriatrics Society, 65(7), 1514-1520. doi: 10.1111/jgs.14829
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