Pathophysiology, Evidence-Based Care, Health Assessment, Risk Management

Introduction

The case studies of patients provide invaluable record of different clinical practices executes to care for their health by healthcare professional and nurses. It acts as guidance to develop effective management of similar patients in a successful manner and the records help in framing key clinical studies. Thus, in this assignment, the case study of Nellie is to be discussed. The way the therapeutic relationship is built with her is to be explained. Thereafter, the pathophysiology of the disease of Nellie and evidence-based care for the individual is to be mentioned. The health assessment and strategy used for Nellie is to be explained and risk assessment, as well as management in care, is to be discussed. The legal and ethical issues faced in delivering care to the patients is to be explained.

Case Scenario

According to NMC Code of Practise, the personal details and identity of patients should not to be shared and required to remain confidential so that they can be avoided from any harm or abuse (NMC, 2018). Thus, the pseudonym Nellie is to be used to indicate the patient. Nellie is a 72 years old widower for 18 years and is currently living with her brother and grandson. She suffers from angina and recently showed increased episode of chest pain, confusion and loss of memory due to which he has admitted to the hospital. She reported to avoid following of medication for angina and hypertension. She also has glaucoma and rheumatoid arthritis. She is retired and used to work at the local butcher shop that are now closed. Apart from state pension, Nellie relies on small pension of her late husband and is reliant on using public transport. The increased progression of complication has led her to face difficulty in travelling to supermarket which has led him to buy food in more expensive local store.

The physical examination of Nellie mentioned her heart rate is 80 beats/min, blood pressure is 132/78 mm Hg and respiration rate of 24 breaths/min. However, during stress test, the heart rate was detected to be 110 beats/min and blood pressure is 140/78 mm Hg. The electrocardiogram (ECG) mentioned sinus rhythm of the heart beat as 82 beats/min and a PR interval equal to 160 ms. The QR duration was 110 ms, QT was 360 ms with presence of enlargement of left atrial sign, a flat ST segment in leads II, III and VF. The EGC developed at peak exercise level indicated horizontal segmented depression of 2mm in V6 and 2mm in V5. The test confirmed presence of myocardial ischemia and Nellie was admitted for executing coronary cineangiography. Moreover, the ECG showed increase of the segmented depression during recovery that become descendants in the same leads as in II, III and aVF leads. The other vital of Nellie included 142,000/mm3, total cholesterol of 245 mg/dL, creatinine 0.72 mg/dL, LDL-cholesterol 145 mg/dL and triglycerides 100 mg/dL.

Therapeutic relationship in person-centred care

The key purpose of developing a therapeutic relationship between nurses and patients is to assist each other in the treatment to change the life and well-being of the patients with the involvement of their intimate thoughts, emotions, beliefs and decisions regarding care (Wright, 2021). One of the theories to be followed for developing therapeutic relationship with Nellie by the nurses is Peplau phases of interpersonal relationships. The Peplau phases of interpersonal relationship focuses to mention the key interpersonal process which occurs between nurse and patient to support the formation of therapeutic relationship (Hagerty et al., 2017). The four stages of Peplau phases of interpersonal relationship are orientation, identification, exploitation and resolution phase (Forchuk, 2021). In the orientation phase, the nurses mainly involve engaging the patient in their treatment by offering them information and explanation regarding the therapy to be provided and answering their question regarding it (Ikafa & Holmes, 2020). The factors that influence the orientation phase are values, culture, past experiences, pre-convinced ideas and others (Laranjeira, 2021). It is evident as nurses when belong from other culture leads the patients to feel they would be unable to provide care by maintaining their cultural customs. This causes patients develop disbelief regarding the nurse’s efficiency to care and hinder effective development of therapeutic relationship orientation (Moreno-Poyato et al., 2018). Thus, to orient in framing effective therapeutic relationship with Nellie, the nurses are to determine her cultural context and develop care as well as provide information of treatment in such a way, so her culture is respected. This would make Nellie feel valued and show compliance in framing therapeutic relationship with the nurse.

The study by Chan et al. (2018) argued that hindered past experiences in care where the patients are been disrespected leads to create orientation in effective interpersonal relationship in care. This is because the past experiences lead the patients to develop pre-convinced ideas that all the nurses may be disrespected towards them. Thus, understanding the past care experiences of Nelloe is to be determined by the nurses and work accordingly to ensure avoiding implication of any hindered pre-convinced ideas so that they she can be made to comply in care and support developing therapeutic relationships. The second stage is identification phase in which the patients works independently with the nurses to express feelings and belongings in turn decreasing their feeling of hopelessness (Fernandes & Naidu, 2017). According to this phase, to form effective therapeutic relationship with Nellie, the nurses caring is to provide her independence to share her thoughts regarding the care information delivered and treatment to be provided. This is because it would make Nellie feel empowered to take own decision and avoid feeling helpless in care. The decision-making by the patient is important because NMC Code of Practice informs that patients are to be encouraged in deciding their own care and their refusal to any care is to be accepting to support their human rights (NMC, 2018). Thus, Nellie is to be involved in deciding her own care to avoid violation of the NMC Code of Practice.

The third stage is exploitation phase in which the nurses are to allow the patients to fully use the provided services and make specific requests in care to be fulfilled based on their needs of health. The fulfilment of the request and full ability to use care services makes the patients feel an integral part of the care and valued by the nurses which support formation of effective therapeutic relationship (Arabacı & Taş, 2019). Thus, the nurses caring for Nellie are to allow her fully to exploit the care and treatment services so that she feels being an integral part of the services where his decisions are valued, in turn, allowing him to trust the nurses and develop enhanced therapeutic relationship. The resolution phase is the termination of any therapeutic relationship where the patients' needs are already been cared (Cacayan et al., 2021). According to this phase, the nurses caring for Nellie to ensure effective completion of therapeutic relationship are to determine all her needs and demands regarding care is fulfilled as well as she has developed healthier emotional balance in taking further care. This is also important as NMC Code of Practise mentions the nurses have the duty to identify the needs and demands of care of the patients as well as effectively fulfil them to provide care in their best interest (NMC, 2018).

According to NMC Code of Practice, the nurses are to effectively listen to the needs and demands of the patients and respond strategically to their preferences and concern (NMC, 2018). This is because listening leads the nurses to understand the necessities in care for the patients and accordingly delivery services to fulfil them which makes the patient feel valued and develop trust as well as show compliance out of value towards the care (Santana et al., 2018). Thus, the nurse caring for Nellie is required to have effective listening skills so that they can make the patients feel at the centre of care and develop therapeutic relationship. According to Wolf et al., (2017), the nurses to keep the patients remain at the centre of care are required to develop open-ended questions regarding care and avoid interruption during communication. This is because open-ended question regarding care leads the nurses to understand the level of understanding of the care among the patients. It leads the nurses to deliver information about treatment to the patients which they can use to develop critical thinking in deciding the best care for them while being in the centre of the treatment (Nilsson, Edvardsson & Rushton, 2019). Thus, the nurses caring for Nellie to keep him in the centre of care are to develop open-ended communication, information sharing and avoid interruption during communication.

Evidence-based care

In determining the evidence-based care required for Nellie, the health assessment is to be made by following ABCDE assessment framework. This is because the framework helps in initial holistic health examination of the patients to determine the symptoms expressed in their condition along with their seriousness and prioritise about the treatment to be offered to the patients for their good health and well-being (Smith & Bowden, 2017). The ABCDE approach stands for Airway, Breathing, Circulation, Disability and Exposure (resus.org.uk, 2018). The airway assessment indicates to determine any damage or blockage in the airways. This is because untreated obstruction in the airways would lead the patient experience hypoxia which creates risk of damage to the heart, kidney, brain and others (Steele, Greenwood & Desai, 2017). In case of Nellie, no airway blockage or damage was identified as she expressed no symptoms related to such condition. This is evident as airway blockage causes choking or gagging, noisy breathing, struggling to breathe and others (Lonergan et al., 2021).

The breathing assessment is executed for determining respiration efficiency of the patient as hindered management of abnormal breathing may cause life-threatening condition (resus.org.uk, 2018). In case of Nellie, the breathing rate is mentioned to be 24 breaths/min which is normal. This is because the normal breathing rate of an individual ranges from 18-25 breaths/min (Drummond, Fischer & Arvind, 2020). The circulation assessment is executed to determine the efficiency of the heart in executing its function under any health issue (resus.org.uk, 2018). One of the key diagnosis of unstable angina is stress test. This is because stress test helps to show the way heart work and support circulation during physical activity revealing any hindered blood flow not detected in stable condition (Gecaite et al., 2019). At stress, the heart rate of Nellie is 110 beats/ min which is abnormal as in healthy adults, the heart rate ranges from 60-10 beats/min. The blood pressure of Nellie under stress is also not normal as he has 140/78 mm Hg blood pressure whereas the normal blood pressure is 120/90 mm Hg. This indicates that Nellie has high blood pressure which is making her heart work faster and in harder manner which can damage the lining of the arteries (Glushko et al., 2018). The people with unstable angina often shows normal heart rate as the heart rate is increased during the attack, but the blood pressure in the condition often remains high. This is because angina is caused due to narrowing of the arteries out of deposition of plaque in the inner lining (Tocci et al., 2018). The case history of Nellie also mentions she has hypertension and during stable condition she expressed better heart rate and circulation compared to stress indicating presence of angina. In this situation, medication such as propranolol 120 mg and captopril 37.5 mg are to be administered to Nellie.

The propranolol acts to completely obstruct the functioning of the β1 and β2 adrenergic receptors leading the heart to work slowly and with less hardship which causes lowering of the raised blood pressure. They also act to widen the arteries and veins for enhancing blood flow to the heart (Babiak-Choroszczak et al., 2018). In contrast, the captopril acts in blocking the angiotensin I to angiotensin II conversion which prevents breakdown of the vasodilatory prostaglandin leading to inhibit vasocontractions which promotes enhanced vasodilation of the arteries to lower blood pressure (Rajaram, 2021). Therefore, both the medications are to be used in immediately controlling the heart rate and blood pressure to normal from elevated level in managing hypertension for Nellie. The NICE guidelines mention that if the patient experiences chest pain, electrocardiogram (ECG) is to be performed for detecting the efficiency of the heart in supporting circulation (NICE, 2018). Since Nellie was admitted to the hospital with unstable angina, the EEG is important to detect if she has the probability of heart attack or myocardial ischemia.

The ECG report of Nellie mentions an increased depression of the ST segment in stress and it was found to be further depressed during the recovery stage indicating presence of myocardial ischemia (Favarato & Gutierrez, 2016). Thus, medication enoxaparin 60 mg is to be provided to Nellie. This is because enoxaparin acts to bind with the antithrombin circulating the blood which irreversibly inactivates the Xa which is the clotting factor in the blood. It leads patients with myocardial ischemia to avoid formation of blood clots and increased complication (Favarato & Gutierrez, 2016). The disability assessment is important to be made to examine the hindered condition of the body that may have led to development of the current health complication (resus.org.uk, 2018). In case of Nellie, the disability assessment indicated that he has full consciousness regarding his health. It is evident as he scored 15 on the Glasgow Coma Scale score which is equal to indicating the person is fully conscious (Jakob et al., 2021). However, Nellie due to rheumatoid arthritis has trouble in making movement. The NICE guidelines mention that Nonsteroidal anti-inflammatory drugs (NSAIDs) are to be provided to rheumatoid arthritis patients in helping them cope with the pain and retain movement (NICE, 2018). Thus, NSAIDs are to be prescribed to Nellie to help her cope with rheumatoid arthritis pain that has led her incapable in making enhanced movement.

In people with unstable angina, the chest pain may sometimes make them lose consciousness and thus the aspect was assessed (Puelacher et al., 2019). The LDL level in case of Nellie is 145 mg/dL whereas the total cholesterol level is 245 mg/dL. The normal level of total cholesterol in healthy individuals is below 200 mg/dL whereas the normal LDL level is to be below 100 mg/dL (Favarato & Gutierrez, 2016). The total cholesterol and LDL level of Nellie is higher than normal and required to be controlled as it acts as risk for worsening of myocardial and angina due to increased formation of plaque in the arties (Nichols et al., 2019). Thus, medication simvastatin 40 mg is to be administered and prescribed to Nellie. This is because simvastatin acts to lower the production of cholesterol in the body to avoid further build-up of plaque which lines the arteries inner walls to narrow them and increased hindered blood flow to the heart resulting in development of myocardial ischemia (Bach et al., 2019). The exposure assessment of Nellie indicated that she has no external bruises or cuts on the body that could report of any health concern.

Health assessment strategy and tools

The health assessment in patients is to be made in continuous manner before, during and after the implementation of care services and treatment. This is because it helps to determine the extent to which the health of the individuals is improved and assist in early detection of health challenges to be experienced (Malik, 2019). The health assessment of Nellie is to be performed by using NEWS2 and SBAR assessment tool. The purpose of National Early Warning Score 2 (NEWS2) is to determine early warning score of vital health condition of the patients and supports effective monitoring of health in hospitalised patients to detect any sudden health changes to be managed at the earliest (rcplondon.ac.uk, 2017). Thus, the use of NEWS2 is important in health assessment of Nellie as it would help in monitoring her health condition.

The positive contribution of NEWS2 in care is that it helps in creating enhanced clinical outcomes for the patients as it predicts the warning score of each health vital of the patients (Phillips, 2021). It also helps in fulfilling the “Preserve safety” aspects of NMC Code of Practise which mention observing and assessing signs of normal or worsening health in person who is receiving care in the hospital so that timely support can be provided to avoid any problems or safety issues (NMC, 2018). Thus, the use of the NEWS2 score is relevant for Nellie as it would help in assessing the effectiveness of the clinical outcome of the treatment provided regarding her hypertension, rheumatoid arthritis pain and myocardial ischemia along with additional support required for her better well-being to ensure safety of health. Another positive outcome of NEWS2 score use is that it helps in detecting and prioritising patients at risk to be delivered effect care (Phillips, 2021). In case of Nellie, NEWS2 score was 3 points that indicate she has low-to medium health risk regarding unstable angina and myocardial ischemia.

The low sensitivity of the NEWS2 score tool acts as a limitation towards its use in managing health condition of the patient. This is because lower sensitivity indicates increased false positive of risk to be identified in patients (Phillips, 2021). Thus, the health risk level identified in case of Nellie through NEWS2 score may not always be true. The other limitation of using NEWS2 framework is that it hindered effective clinical judgement and may create bias in care delivery (Rigoni et al., 2021). This is because high-risk patients may be provided more extensive care and support by nurses while neglecting low-risk patients as they have low risk of health deterioration. Thus, use of NEWS2 score may led to create partiality in care delivery to patients like Nellie. In contrast, the SBAR tool helps in improving the effectiveness of communication between the patients and nurses. The purpose of the tool is to create structured communication for allowing information regarding care to be transferred accurately between professionals and patients. It helps to reduce the need of information repetition and error development among healthcare staffs (Shahid & Thomas, 2018).

The SBAR tool stands for situation, background, assessment and recommendation (NHS, 2021). The purpose of using the tool for Nellie is to allow her health information to be shared without need of repetition between nurses and health professionals so that she can be offered continuous quality care. This is because during care, the nurses change shifts and lack of communication between nurses leads to create duplication of care for the patient. Moreover, during change in shifts of the nurses increased time is required to share patient information which may led to loss of mentioning vital patient information in some cases (Bonds, 2018). However, the presence of SBAR would limit the error for Nellie as her health assessment and background along with health situation remain thoroughly mentioned in records to be reviewed by the nurses based on their shifts without missing of any data. Thus, the positive aspect of SBAR use is that it ensures credible nursing handover of patients (Müller et al., 2018). It also helps in meeting the “Practise effectively” aspect of NMC Code of Practise that informs clear and accurate records of the patients are to be present in all condition (NMC, 2018).

The limitation of using SBAR tool is that it requires training for the nursing and healthcare staff to effective use it in making successful communication and delegation of care through it (Bonds, 2018). Thus, the nurses caring for Nellie in case are not are trained in SBAR would be unable to use it. The other limitation of SBAR use is that it needs change in work culture for adopting and sustaining the communication formats mentioned in them by healthcare professionals and providers (Kim & Kim, 2018). Thus, in case the nurses caring for Nellie are reluctant to support the culture change required for effective implementation of SBAR, the tool could not be used which would compromise the patient experience and quality of care.

Risk Assessment and Management

The risk assessment and management in healthcare includes examining and identifying the probable risk or problems to be face in delivering care to the patients along with the way they can be managed to limit their effective for enhanced health outcome of the patients (Kaya et al., 2019). The five-key principle of risk management in healthcare are avoiding risk, identifying risk, analysing risk, evaluating risk and treating risk to be resolved (rcpsych.ac.uk, 2018). The avoiding risk principle mentions that appropriate strategies are to be identified for use to avoid any problem to be eliminated from the health scenario of the patient (Ramesh et al., 2018). In case of Nellie, the presence of myocardial ischemia creates risk for heart attack in future for the patient. Thus, effective measures are to be taken such as continuous health monitoring and regular intake of prescribed medication is to be supported for Nellie. Moreover, presence of glaucoma and rheumatoid arthritis creates risk for Nellie to experience blindness and probability to fall as well as get physical hurt which are to be avoided to ensure her better health.

The risks to be faced patient in care are to be identified so that it nature and level are determined as well as people involved in creating the risk can be understood (rcpsych.ac.uk, 2018). In this aspect, the key risk identified for Nellie is her probability to experience heart attack due to mismanagement in taking medication out of forgetfulness or avoidance. This is because previously she has already showed missed taking medication for hypertension and unstable angina after related symptoms are resolved. The risk analysis is done to examine the likelihood of occurrence of the identified risk (Randell et al., 2021). In case of Nellie, she moves around in public transport which creates increased probability of her to experience fall and get physically hurt as she already reported hindrance in movement due to rheumatoid arthritis. It is evident as she has been buying things from expensive convenience store and avoided going to supermarket due to hindrance in movement out of arthritis pain. Moreover, the likelihood of risk of not taking medication prescribed regularly is high as she has previously done such actions. In risk management, the risk is to be evaluated to determine the way risk could be eliminated or reduced (rcpsych.ac.uk, 2018). This is because it would promote enhanced health of the patient (rcpsych.ac.uk, 2018). In case of Nellie, his habit of taking medication regularly could be improved by providing him detailed information about the adversities of suddenly stopping the medication after the removal of symptoms regarding heart complication and the reason behind the medication to be taken regularly even after the symptoms are managed. This is because it would make him understand the importance of taking medication and health hindrances to be faced for not following the actions. Moreover, her brother and grandson are to be educated by nurses regarding the way they are to ensure Nellie follow proper medication needed for her improved health. The treatment of risk is to be executed by determining who is responsible for the action to create risk and when along with way it can be monitored (Randell et al., 2021). In case of Nellie, she is responsible in creating risk and weekly visit to her home is to be executed and interaction with family members are to be made by care workers to ensure she is following the prescribed medication.

Legal and Ethical issues in delivering care

The Health and Social Care Act 2012 mentions that clinical commissioning groups are to be present in the locality to provide equal care to all irrespective of any discrimination (legislation.gov.uk, 2012). In case of Nellie, according to the Act, the clinical commissioning group are to be involved in supporting his ability to access effective quality care irrespective of discrimination. The NMC Code of Conduct mentions that nurses are to act within their expertise and provides care in the best interest of the patient (NMC, 2018). In case of Nellie, it is seen that the health analysis and prescribing of the dosage of medication is done by the physician taking care of the individual whereas nurses ensured delivery of quality care by using treatment that is best for improving his current health condition. Thus, the nurses following the protocol mentioned in the NMC policy. The NMC Code of Practise also mentioned that no forceful care is to be provided to patients and informed consent are to be accessed from them (NMC, 2018). In case of Nellie, the nurses are to access informed consent from her regarding each aspect of care and never force any treatment indicating the policy mentioned by the NMC is effectively followed.

Beauchamp and Childress mention four key ethical principles to be followed in care that are autonomy, non-maleficence, beneficence and justice (Macklin, 2019). The autonomy of the patient is to be respected in care so that they can feel valued out of their decision regarding care been followed (Eberl, 2020). However, avoiding autonomy of patients makes them feel forced to accept care and disrespected due to which they avoid compliance in accepting care (Sena, 2017). In case of Nellie, autonomy is followed as she was allowed to take the independent decision regarding her care. Non-maleficence is referred to the obligation of the nurses to avoid harm to the patients (Bradley, 2017). However, failure to maintain non-maleficence leads patients experience harm and abuse along with deteriorated quality care (Macklin, 2019). In case of Nellie, non-maleficence is effectively followed as no harmful action was inflicted towards her. The beneficence ensures beneficial healthcare actions are taken for the patient to ensure their good health (Manda-Taylor, Mndolo & Baker, 2017). In case of Nellie, NICE guidelines and evidence-based practice are followed to deliver beneficial healthcare. The justice ethics indicate that equal care is to be provided to all patients (Macklin, 2019). In case of Nellie, she is confirmed to equally cared along with other patients while in the hospital.

Conclusion

The above discussion informs that Nellie is 72-year old individual with unstable angina for which he is admitted in the emergency and further health evaluation confirmed she is suffering from myocardial ischemia. The Peplau phases of interpersonal relationship is followed in developing therapeutic communication with him. The ABCDE assessment is used to examine her key health issues and accordingly medication as well as additional treatment are determined to resolve the identified condition. The SBAR and NEWS2 are used for making health assessment of Nellie that mentioned enhanced health management of her. A risk assessment is executed resolve identified risk in her care and legal as well as ethical issues are evaluated for Nellie which indicates she is legally and ethically been cared in effective manner.

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