Nursing is an emerging sector, which is related with the well being of population. The skills, knowledge, and experience in nursing field are the prime aspects that help in managing the overall care procedures for the patients. Care management is important for an individual patient to improve their condition and well being (Barrett et al. 2012). To analyse the importance, here I stated about my personal care experience with a hypertension patient. Hypertension is the situation that elevates the blood pressure and can extend to damage multiple organs (Alexander 2017). My hypertension patient is suffering from chest pain, severe dizziness, breathing trouble, and lethargy. Hypertension is one of the most common and acute disease, which needs immense clinical care settings including emergency departments, acute care medical clinics, and urgent care centres. Hypertension is often identified from associated symptoms such as end-organ injuries, which cannot be managed without immediate treatment and medications (McNaughton et al. 2013). Schmieder (2010) depicted, “end organ damage in hypertension can be detected early, reflects accurately the hypertensive patient’s overall cardiovascular risk, and should be prevented and treated with antihypertensive treatment” (p.866).
Rosendaal et al. (2016) noted that hypertension care, acute care, follow-up care, intervention, and reference for treatment along with others need financial assistance in those countries, wherein free healthcare provision is lacking. Doctors’ visits and prescription medication are some of the prime concerns during the treatment of hypertension, which is relatively cost-effective for a health insurance holder (High Blood Pressure Treatment Cost 2017). The roles of nurses in hypertension treatment and management include several aspects such as diagnostics and medication management. This also includes detection, referral, follow up, coordination of care, patient education, counselling, performance measurement, and quality improvement along with population health management (Himmelfarb et al. 2016). McCormac & Krause (2012) asserted that the patient-centred care facilities, as well as, the multidisciplinary care team can be effective for hypertension care management. The awareness regarding the hypertension and effective screening both are important for the treatment and disease management procedure (Himmelfarb et al. 2016). Considering these contexts, the study focuses on providing an in-depth care for my patient from his admission to the treatment process twice in a month. Therefore, I will choose Roper, Logan and Tierney’s (RLT) model for effective care setting for the patient with hypertension.
Analysis of Underpinning Care Planning
Holistic nursing care practice must need significant activities including maintenance of safe environment, effective communication between care givers and patients. Additionally, it also require proper breathing, appropriate diet along with drinking, elimination of negative implications, patient hygiene including washing & dressing, controlling the body temperature, mobilising, working, and effective sleeping of individual patient. The situations can either be included or excluded as per the preferences of patients’ health related physical and psychological conditions. According to the RLT model, there are certain factors such as psychological, biological, environmental, socio-cultural, and politico-economic that can affect the condition of the patients (Medeiros et al. 2013).
According to the RLT model, the associated factors, which are highlighted in previous section, can influence the activities of individual’s health, circumstance, and living conditions. These factors help in determining the individual patient’s relative independence in the context of activities on a daily basis. The biological factor of individual activity refers towards the impact of individual health, injury, and illness. It is also highlighted the scope of the patients’ physiological implications. On the other hand, psychological factors include emotions, cognitions, spiritual beliefs, and the capability of understanding. It is the process through which an individual can understand, believe, hope, feel, and reflect (Roper-Logan-Tierney Model of Living 2016).
Besides, socio-cultural factors have the significant impact on culture, as well as, the society of an individual patient. Culture and socio-cultural beliefs distinctively affects the values and interdependence of the individuals. Furthermore, the culture and socio-cultural beliefs of individual nurses are significantly affecting the perception of care practice. Additionally, it also affects the patient outcomes. Hence, it can be stated that culture and socio-cultural beliefs influences the nursing environment as well. The environmental factor of RLT model can represent the theory as a ‘green’ version. From the environmental aspects, this model can be stated as ‘green’ model, as it has a significant impact on daily living of the individuals. The model considers positive ‘green’ environmental impact on the patients’ standard living in an effective way. Politico-economic factor is related with government, politics, and economies that also have a critical affect the living pattern of individuals. These activities can be significantly utilise within the nursing practice without any kind of hesitation, but most often the nurses are uncomfortable in delivering the care provisions as per the patient’s preferences and activities of their daily living. This situation can occur due to the rigidness of individual’s practice or lack of awareness regarding multicultural nursing aspects. It has been evident that the RLT model also represented the similar aspect regarding the significant impact over the patients. The conjunction of these stated factors with the daily life of the patients can also be affects the treatment criteria (Roper-Logan-Tierney Model of Living 2016).
Considering the significant traits of RLT model, it is highlighted that the concept of the model is important for nursing practices and care framework due to its consistent style of care provisions. The RLT model can develop a distinctive and most effective care pattern for the nursing practitioners. Furthermore, the concept of model also helps in generating potential impacts on their deliverable treatment procedures. The rationale of the care model, therefore, assists in understanding a better logic of individual care process. Additionally, the model is less complicated as compared to other nursing concepts or models. It is self-explanatory as well, which ultimately assists in the overall nursing process towards significant outcomes. On the other hand, it has been observed that RLT model is developed on the basis of basic cognitive behaviours of individual patients, from which nurses should be able to understand the effective care pattern and implement it. Apparently, the model is simple, however, without in-depth knowledge and nursing practice, it is difficult for individual practitioner to incorporate this concept of model within his/her effective practice (Roper-Logan-Tierney Model of Living 2016).
Patient Presentation and Condition
My patient, named Mr. S (name is changed for confidentiality) is a 45 years old man suffering from the problem of hypertension. In the emergency unit of our health care organisation, he came with complain of chronic chest pain. Contextually, it is also observed that he has dizziness, lethargy, and have trouble while breathing such as shortness and shallow. Additionally, on the basis of clinical analysis, it is evaluated that he also developed problems relate to his eye sight and memory. Professionally, he was a teacher and dedicated towards his students and the educational system. For his recently developed health problems including hypertension, he took some medicines such as Diuretic and Beta blocker, which helped in controlling his blood pressure level. However, it has been observed by his family that he is an un-mindful person and most of the time, he forgets to take medicines. It can be stated that his severity of hypertension has emerged, which has further led the patients to gain weight, chest pain, vision problem, blurry memory, and difficulties in breathing as well. Due to his present critical condition, he booked an appointment for check-up twice a month. Currently the patient suffers from chest pain and other co-morbid symptoms, for which he needs further clinical assessment. The patient does not have any kind of surgical history. However, he has family history of hypertension. For better understanding the criticality of the patient, the following general aspects on hypertension are described thoroughly:
Onset: The onset symptoms of hypertension are essential factors for evading the future complications in case of an individual patient. According to the clinical practitioners, there is a specific time span, where individuals can be exposed to hypertension. If the appropriate treatment procedures can be taken, individuals can secure their well being avoid the problem related to hypertension. Based on the perceptions of clinicians, an individual is exposed to develop hypertension after the age of 18 years. Contextually, people ranging between 18 to 39 years age are often found to be highly prevalent to develop the symptoms of hypertension. At this age, individuals should check their blood pressure on a periodic basis to evade the critical consequences (Busko 2017).
Aetiology: There are two types of aetiology of hypertension, which includes primary hypertension and secondary hypertension. Primary hypertension is most often observed among the adults and is found to start gradually from many years. On the other hand, secondary hypertension is significantly developed for several reasons including obstructive sleep apnea, kidney problems, adrenal gland tumours, thyroid problems, congenital defects in blood vessels (by birth), medications such as birth control pills, certain prescription drugs, and over-the-counter pain relievers. In addition, it also includes the use of illegal drugs and dependency on alcohol among others (Mayo Foundation for Medical Education and Research 2017).
Burden: According to the global reports, it is observed that at the age of 45, high blood pressure is common among the men. If the patient has family history of blood pressure, there is a significant chance of developing this disease easily. Overweight, less physical activity, tobacco dependency, maximum salt, less potassium, vitamin D consumption, excessive stress, alcohol dependency, and chronic medical condition can be identified as the burden for hypertension (Mayo Foundation for Medical Education and Research 2017a).
Pathophysiology: It is complex, as well as, multi-factorial disease because it targets multiple organs and gradually creates hindrance on their activities. Genetics is one of the prime factors that can influence hypertension with respect to the individual’s medical history. Additionally, improper diet intake, obesity, excess salt consumption can increase the activities of neurohormonal system, which can ultimately result in hypertension (Hamrahian 2017)
Potential Complications: Due to high blood pressure, there are certain chances of severe other co-morbid scenarios including heart attack, heart failure, Aneurysm, weak & narrow blood vessels of kidneys, thick, and narrow blood vessels of eyes. Additionally, it also involves metabolic syndrome and problems in memory or understanding (Kennard & O’Shaughnessy 2016; Mayo Foundation for Medical Education and Research 2017b).
Reflect on the Nursing Assessment of the Patient
Gibbs Model of Reflection
Description: My patient has been suffering from chronic hypertension and has developed severe chest pain. Contextually, after consulting with patient and his family members, it is identified that he is suffering from obesity caused due to unhealthy food habit, which made his situation more complex. He is admitted in emergency unit of our health care organisation. Furthermore, he has also been facing the problem relating to his eye sight, as it has been affected. These problems have been observed over the period of three months. In the last month, he felt pain in his chest along with breathing problem, dizziness, and lethargy, which made him worried so that he came to the emergency unit.
Feelings: Considering Mr. S’s condition, personally, I feel that it is my priority to assess his appropriate problem areas (such as severe chest pain) including his co-morbid symptoms including breathing problem, dizziness, and lethargy). According to my perception, severe chest pain and its co-morbid symptoms are the prime reasons for his admission. I also understand that these problems are increased due to the lack of proper diet, physical activity, and improper medication. First I need to make him aware about his hypertension condition and his recent consequences such as severe chest pain and breathing problems. I need to make him concern about his weight, diet, physical activity, and medication. Personally, I feel bad because he still has remaining several years to his retirement and the health consequences may have an impact on his professional life. Additionally, I also feel that if he makes necessary changes in his lifestyle, there is a certain chance to live a better life.
Evaluation: Due to his long term unhealthy habits, it is difficult to make him habituated to live a healthy lifestyle, which would include healthy diet, exercise, and healthy habits. Therefore, to make him aware and educated, I can focus on providing clinical education relating to his conditions and consequences along with effective treatment. According to the proper treatment criteria, consumption of mineral enriched foods has to be reduced, as it can increase the hypertension for him. Regular medicinal and exercise schedule is also prepared for his betterment. The procedure is needed for proper cooperation of the patient and his family to meet the satisfactory outcomes.
Analysis: The patient’s long term unhealthy lifestyle, lack of awareness, less cooperativeness, and improper medication schedule are the major factors that that affected the outcome. The support of the family along with medical alignment and health care organisational structure are the factors that helped in treating the patients.
Reframe: The negative situation can be avoided by handling Mr. S’s pessimistic approach. To make him serious and positive towards the treatment schedules and other clinical framework, I need to provide him counselling on the overall treatment procedure, its functionality, effects, consequences, and the negative effects on the patients. During the counselling session, I can also provide him practical evidences of severe hypertension cases and its hazardous consequences along with the numerical statistics of positive events.
Action Plan: From this case, I learnt that the patients cannot always be cooperative. At times they not aware about the consequences, and are often found to be unenthusiastic. In the present case, the patient often forgets to take medicines, which has worsened his condition. However, it is the accountability of nurses and responsible care giver to guide the patients and their families accordingly. After the Mr S’s admission, medical education and communication with his families will be significantly incorporated for improving his condition. Next time, I will focus on care pattern and counselling session with patient and their families at the beginning of the treatment to develop an understanding regarding the patients’ behaviour and work on their awareness regarding the disease.
ADPIE (Assessment, Diagnosis, Planning, Implementation, and Evaluation)
ADPIE process is able to help care professionals to memorise the medical steps of treatment and provide effective care to the individual patients (NurseTheory 2017). In this case, the patient is non-cooperative with the clinical framework. He was diagnosed with hypertension, chest pain, and breathing trouble. According to the diagnosis, further planning of the treatment procedure has been evaluated. It is implemented and evaluated on the basis of patient’s consistency and cooperation of the process. Based on his disease, I further need to consider my treatment and intervention planning for the implementation process. Implementation is an important area for patient’s betterment. I need to plan specific implementation process along with the back-up plan for the ensuring enhancement in the health outcome of the patient. If the patient is not cooperative in implementation process, I need to take supportive intervention planning, wherein I include counselling and family oriented discussion. In the evaluation process, firstly I need to make notes on the therapies, patient’s cooperativeness, feelings, health outcomes and report’s measurements. To discuss these notes, I consider a discussion session with my peers, and patient’s family to understand the progress or need of improvements in specific areas.
Priorities of Care
Evidence-based practice involves relevant and valid concept along with evidences, which are often found to be associated with different domains including nursing knowledge, skills, and attitudes (Ilic 2009). Contextually, it is observed that evidence-based practices are able to enhance the care driven facilities for the patients. Additionally, it also helps in enriching the nursing practice and strengthens the path of further nursing researches at large (Brown 2013). Considering the situation of my patient Mr. S’s hypertension symptoms and its related criticalities, I followed ABCDE approach for segregating my priorities during the assessment of the patient’s condition. As previously mentioned my patient has been suffering from severe chest pain and breathing problem. Therefore, I focused on comforting the patient. Considering the ABCDE approach, my priority concerns are relied on the patient’s airway, breathing, circulation, disability, and exposure to effectively assess, as well as, treat him for betterment (Thim et al. 2012). Being a nurse, my first concern was to provide personal safety of the patients for which I needed to be careful about his airways, blood circulations, and blood pressure. The symptoms of the patient were not contagious, for which I did not use gloves and mask.
Being a professional practitioner, I need to follow ‘look, listen, and follow’ cycle for understanding the requirement of patients and ask peers for the assistance in such critical condition (Resuscitation Council 2017). In this cycle, I have to look after the patient’s condition and his vital signs, listen to his complications and then I need to follow the nursing practice accordingly. If the patient does not breath normally and unresponsive, I need to follow resuscitation guidelines for comforting and help him in respiration. For understanding the immediate requirement and segregating my priorities, I have to assess vital signs of the patient along with ECG monitor, pulse oximeter, and non-invasive blood pressure to monitor his blood pressure, heart conditions, and pulse rates. Due to his present condition, I need to follow the overall check up pattern regular on his appointments (Resuscitation Council 2017).
To assess and treat the patient accordingly, I consider clinical, therapeutic, and supportive interventions as a part of the priority goals fulfilment in this particular this case. Generally, clinical intervention is depicted about the professional activities, which relied on the medication and clinical recommendations (Eldh et al. 2017). Therapeutic intervention is different from clinical intervention but it is more integrative and involved procedure for the individual patients. Counselling, family therapy, and cognitive behavioural therapy along with others are the instances of therapeutic interventions (NHS.UK 2017). On the other hand, supportive intervention is the procedure through which an individual patient can access emotional support from the care givers along with the families as well. Psychological support in severe and chronic illness helps to recover individual patient towards wellness (Oncology Nursing Society 2016).
As per my priority concerns, airway is one of the prime issues in hypertension. Airway obstruction can be identified as the emergency condition. It is highly risky for the patient suffering from hypertension, especially those patients, who have breathing problem. The obstruction of airway can damage patient’s brain, can also cause severe cardiac arrest, kidney failure, and even lead to the death of the patient. Due to these reasons, I needed to consider my patient’s situation as a medical emergency and provide him with therapy support, as well as, clinical intervention including airways suction, airway opening manoeuvres, and inclusion of an oropharyngeal or nasopharyngeal airway. As per the patient’s requirements, if these procedures did not work appropriately, I would have needed to follow tracheal intubation procedures. At time, the patient may need high concentrated oxygen for comforting his breathing trouble. According to the need of the patient and condition, I need to deliver him a self-inflating bag and specific level of oxygen saturation (Resuscitation Council 2017).
Breathing trouble may develop life threatening conditions and it is vital to treat it with a prompt action. According to Peate & Dutton (2014), being a nurse, I need to count the patient’s respiratory rates and try to understand deterioration rates with fingers on his radial pulse. Assessment of the breath depth and chest expansion is also required to monitor (Peate & Dutton 2014). In accordance with breathing trouble, as a responsible care person, I need to check his chest percuss and chest auscultation. With the proper consumption of the medicines for hypertension, the patient also needs to treat respiratory disorders, which I can be done by providing with oxygen. If the breathing is inappropriate, I also need to improve the ventilation process and call for experts’ help. In the case of medical emergency, I have to control the reasons of ‘shock’, which can be introduced for the hypovolaemia. In the case of hypertension patient, the shock can be due to high blood pressure and hypovolaemia along with rapid heart rates and internal/hidden haemorrhage. For avoiding such type of circumstances, being a care provider, I need to monitor patient’s hands to check the colour, temperature of body, count the pulse rates, and blood pressure. I further have to measure capillary Refill Time (CRT) to understand the ‘peripheral perfusion’. Systematically, other factors including age and circumstances of the patient also need to take into consideration for CRT (Resuscitation Council 2017).
If the patient experiences a cardiovascular collapse, he needs to undergo for the fluid replacement to improve the cellular perfusion of the patient. On a similar note, Good & Kirkwood (2017) stated, “successful reversal of cardiovascular collapse must focus on the cause and on improving cellular perfusion” (p. 574). Additionally, he may also need restoration of tissue perfusion and haemorrhage control to restrict the damage to the multiple organs, as well as, to attain haemodynamic stability (Rossaint et al. 2010). Simultaneously, I also need to consider the symptoms of the patients accurately to make sure that they do not lead towards cardiac failure. As mentioned in the initial symptoms, my patient has chest pain so he immediately needs general treatment of Acute Coronary Syndromes (ACS) and regular Electrocardiography (ECG). General treatment of ACS includes clinical, therapeutic, and supportive intervention for recovering the patient. The treatment includes following steps:
- Care provider nurse should deliver Aspirin (300 mg) for oral intake soon after identification of chest pain
- Nitroglycerine tablet or spray can be used as the second step
- If the patient suffers from the breathing trouble, he need to take concentrated oxygen, which I can prescribe him
- To avoid the chances of respiratory depression and sedation, the patient should be given intravenous Morphine (Resuscitation Council 2017)
My next prioritise procedure is aligned with disability context. My patient’s symptoms can be identified as the initial signs of multiple organ failure and disability. To avoid the negative implication, clinical, and supportive intervention has to be incorporated in this case. With the help of supportive intervention and being a responsible care giver, I must check patient’s drug chart for identifying the reversible drugs, which caused depressed consciousness. The repeat blood glucose measurement needs to be monitored for addressing the effects of the treatment. Being a responsible nurse for Mr. S, I have to be careful about the patient’s consciousness and airway protection for maintaining the breathing system. According to Grzeskowiak (2015), I must be aware about the associated hazards of my patient’s symptoms. The final priority concern from my side is allied with exposure. According to this phase, I need to understand the patient’s medical history for which it is essential to contact the family members of the patient. It can be a part of supportive intervention of patient-centred care procedure due to the effective implications (Omole et al. 2011). From the medical history of the respective patient, I can develop clinical notes and charts for patient’s medication, diet, exercise, and other necessary amenities. These aspects are to be significantly discussed with the patient’s family members, for delivering a better and integrated care (Resuscitation Council 2017).
Considering the situation of the patient, I need to include both clinical, as well as, therapeutic intervention for this phase, which can help in increasing the involvement of patient and his family. In this specific phase, I can review the schedule of the patient and his previous medical reports and then discuss it with his family regarding the further possible steps related to clinical intervention. This discussion will help to improve the condition of the patient with the assistance of appropriate medication, family orientation, and nursing support. According to American College of Emergency Physicians (2016), being a responsible professional nurse, I can estimate and understand the relation between health outcomes and medical interventions. My findings, treatment procedures, outcomes, assessment, and change actions can be discussed with my peers as well, as it can ultimately help me to deliver a better health care to the patient.
Recommendations for Future Practice
Based on my personal understanding, I can state that the necessity of counselling, psychological support, and clinical educational support to the patients and their families are able to develop a comprehensive health care framework. This can be used for addressing emergency consequences of hypertension and other symptoms. Additionally, the community visit for the nurses is recommended for developing a better concept of their practices. Moreover, multicultural effectiveness among the nursing group is also necessary for their transparent communication skills, which I also practically understand from this case scenario. Contextually, developing mobile charities for the remote areas and the patients are capable to get better treatment framework from them.
Based on the overall discussion, it is highlighted that the reflective study is stated about a case scenario, where the patient developed co-morbid symptoms of hypertension due to his non-cooperative behaviours towards the treatment procedures. Being a nurse, I will focus on developing comprehensive understanding regarding patient’s behaviour, preferences, outcomes, and nursing actions. The key problems of his situation are allied with unhealthy foods, less physical activity, maximum salty food, and non-maintenance of the medicinal schedules. His family was very supportive to the clinical framework, which helped the individual nurse to develop a counselling session to make him aware regarding his conditions. The clinical, therapeutic and supportive interventions are effectively utilised in his case and these interventions are provided individual care givers a better example for their future career in nursing.
RLT theory helps to gain knowledge regarding simple cognitive traits in nursing practice, while being a healthcare professional, it is learnt that it is difficult to hire less experienced nursing staff. During the discussion development on this case scenario, it is emphasised that the requirement of confidentiality of individual patients for maintaining the care protocols. The case scenario is aided in developing the understanding regarding the care protocols including onset, aetiology, burden, and pathophysiology. Hence, it has significantly enhanced individuals’ understanding regarding the emergency treatments of chest pain and breathing trouble, which can be co-morbid symptoms of hypertensions. Simultaneously, being a care professional, it is further learned about the treatment procedures along with the priority concerns, medication, therapeutic, and supportive interventions. It is able to develop a potential recommendation for the future pathways in nursing career.
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