Task    

Students will assess, prioritise and plan the care of the guided case study patient using a clinical reasoning framework in hospital and community setting. Introduction and conclusion not needed.

Case study

Mr. Johnson is a 75-year-old man, was brought to the emergency department (ED) by his daughter with concerns about his increasing levels of pain, intermittent periods of acute confusion and deteriorating overall general health.

Initial Assessment

Mr. Johnson is alert but disorientated to time and place. He appears dishevelled and malnourished, with a strong odour of urine. He was brought in a wheelchair and was guarding his L knee. Daughter stated Mr. Johnson took two (2) Ibuprofen (neurofen) tablets couple of hours ago with minimal effect.

BP - 140/93
HR - 96 bpm and regular Peripheral pulses - Present RR - 18 rpm
Temp - 37.0C (tympanic) Sa02 - 98% RA
BGL – 9 mmol/L Height -170 cm
Weight - 74 kg (weighed 80 kgs six months ago)
ECG - NAD
MMSE – 23/30
L Knee Xray- NAD
Urinalysis - dark concentrated yellow, clear urine, SG 1.010, pH 7, Leukocytes and nitrite- positive.

Medical history

Mr. Johnson has a history of multiple chronic medical conditions, including osteoarthritis, osteoporosis, hypertension, and diabetes. He is on several medications and has regular visits with his primary care physician.

Medications
Ibuprofen Panadol osteo
Alendronate (Fosamax) Norvasc Cholecalciferol Calcium supplements
Metformin Hydrochloride Gliclazide Hydrochlorothiazide Patient history

Mr. Johnson lives independently in his own home and usually cooks his own meals at home. His daughter visits him couple of times each week. Mr. Johnson walks for an hour daily and catches up with his friends at the nearby park once a week. He enjoys spending time with his grandchildren. He never smoked and drinks a bottle of beer after dinner while watching TV. He wears glasses for long distance and bilateral hearing aids.

Recently the daughter noticed Mr. Johnson increasingly neglecting his personal hygiene, nutrition, and household upkeep. Mr. Johnson has been socially isolated. and had multiple falls at home recently.

Admitting diagnosis: Early signs of dementia.

You are the registered nurse looking after Mr. Johnson, and you are required to plan her care guided by a clinical reasoning framework and the provided case study information. Sections you need to respond to include:

1.    Patient assessment (500 words)

•    Provide an initial impression by identifying relevant and significant features from Mr. Johnson’s current ED presentation.

•    Discuss the possible causes for Mr. Johnson’s intermittent cognitive impairment.
 Do you agree or disagree with Mr. Johnson’s diagnosis of an early onset of dementia. Justify your opinion and support your discussion with evidence from the case study.

•    Evaluate the impact a misdiagnosis may have on the care provided for Mr. Johnson.

Mr. Johnson’s intermittent confusion resolved after 3 days. He was assessed by the Aged Care Assessment Team (ACAT) and was eligible for a community care package. Mr.Johnson was discharged home with regular codeine for his chronic pain.

2.    Physiological changes of ageing and identify patient issues (500 words)

•    Discuss how the normal physiological changes of ageing may increase Mr. Johnson’s risk of falls. Identify three (3) evidence-based nursing interventions with rationales that should be implemented for Mr. Johnson to reduce the risk of falls. (Do not include referrals in your answer).
•    Evaluate how Mr. Johnson’s chronic pain would impact on his capacity to complete two of his activities of daily living (ADL’s) ensuring you have justified your choice of ADL’s.

3.    Pharmacological management and nursing considerations (500 words)

•    Discuss why Mr. Johnson, as an older adult, is more vulnerable to adverse drug effects. Ensure you include factors related to the anatomical, physiological and behavioural considerations associated with ageing.
•    Identify with rationale two (2) nursing interventions you would consider when caring for Mr. Johnson who takes multiple medications (polypharmacy).

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Case Study Assessment

Patient Assessment

Upon initial assessment of Mr. Johnson's presentation in the Emergency Department (ED), several pertinent features become immediately apparent. Firstly, he exhibits signs of disorientation in relation to time and place, which is indicative of potential cognitive impairment (Pringle et al., 2021).

Secondly, his physical appearance suggests a level of neglect, reinforced by the malnourished state he presents in, as well as the strong odour of urine, indicating potential incontinence or poor personal hygiene (Cristina et al., 2021).

Furthermore, his guarding of the left knee suggests pain or discomfort in that region, although the X-ray results show no apparent discrepancies. His vitals, including blood pressure, heart rate, and respiratory rate, are within normal ranges for his age, but it's worth noting his elevated blood glucose levels, which may be related to his history of diabetes (Haque et al., 2019).

The sporadic cognitive impairment that Mr. Johnson is experiencing might be caused by several sources. His medical history, which includes diabetes, hypertension, osteoporosis, and osteoarthritis, along with the usage of several drugs, may interact or have adverse effects that might result in bouts of acute confusion (Keine et al., 2019).

Given that he was in pain when he was brought in, it is possible that his suffering is aggravating his cognitive problems. Furthermore, the presence of leukocytes and nitrites in the urine findings suggests a potential urinary tract infection (UTI) (Chernaya et al., 2021).

His sporadic cognitive impairment may be explained by the sudden disorientation or delirium that UTIs in older persons are known to induce (Kennelly et al., 2019).

Even when the admitting diagnosis points to early dementia symptoms, it is important to take the whole clinical picture into account. The MMSE score of 23/30 for Mr. Johnson does show some cognitive loss, but it is not a definitive diagnosis of dementia.

Furthermore, given the resolution of his confusion after three days and the urinalysis results, it's plausible that his acute confusion could have been precipitated by the UTI rather than an onset of dementia (Hogg et al., 2022).

Thus, while it is not within the purview of this assessment to definitively disagree with the diagnosis of early dementia, it would be prudent to consider the UTI as a significant contributor to his presentation and perhaps seek further neurological evaluation before confirming a dementia diagnosis.

Misdiagnosis, especially in older adults, can have profound implications. In Mr. Johnson’s case, if he were incorrectly diagnosed with early dementia, the care provided might focus heavily on managing cognitive decline, potentially overlooking other treatable causes of his confusion, such as a UTI (Zeng et al., 2020). This can cause Mr.

Johnson and his family to experience extended periods of needless suffering, which could lead to hasty judgements regarding his living situation or level of competence. In addition, he could receive more drugs or treatments that are not required, which could conflict with his current drugs or make his other diseases worse.

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Physiological Changes of Ageing And Identification of Patient Issues

Numerous physiological changes that come with ageing may impair a person's capacity for balance, which raises the risk of falls (Sherrington et al., 2020). In Mr. Johnson's instance, his present health and medical concerns make the impact of these alterations more worse.

First of all, an individual's gait and balance can be seriously compromised by musculoskeletal changes brought on by ageing, such as reduced muscle mass, strength, and flexibility (Safiri et al., 2021). Because Mr. Johnson has a history of osteoarthritis and osteoporosis, these illnesses may worsen his joint and bone integrity, increasing his risk of falling.

Second, according to Wittich and Simcock (2019), sensory abnormalities, especially in vision and hearing, are typical in the elderly. Mr. Johnson may have some degree of vision and auditory impairment as evidenced by the fact that he utilises bilateral hearing aids and needs glasses for distance.

These sensory deficits can obstruct his ability to navigate his environment safely, making obstacles or hazards less detectable. Lastly, the ageing process can lead to reduced proprioception, which is the body's ability to sense its position in space (Ferlinc et al., 2019).

With diminished proprioceptive abilities, Mr. Johnson could find it challenging to maintain stability, especially on uneven surfaces or when transitioning from sitting to standing.

Evidence-based Nursing Interventions to Reduce the Risk of Falls:

Individualised Exercise Programme: An evidence-based intervention to mitigate the risk of falls in the elderly is the implementation of a tailored exercise programme focusing on strength, balance, and flexibility training (Casas-Herro et al., 2019). Engaging Mr. Johnson in such a programme can counteract the musculoskeletal deterioration associated with ageing, enhancing his gait, and improving his balance, thus reducing his susceptibility to falls.

Home Safety Assessment and Modifications: Conducting a thorough home safety assessment to identify potential fall hazards can be instrumental. Following the assessment, necessary modifications, such as securing loose rugs, installing grab bars in the bathroom, and ensuring adequate lighting, should be made (Phu et al., 2019). By optimising Mr. Johnson's living environment, the risk of trips or slips due to environmental factors can be significantly reduced.

Regular Review of Medications: A periodic review of Mr. Johnson's medications is crucial, given that some drugs or drug interactions can cause dizziness, hypotension, or other side effects that can increase fall risk (Moreland et al., 2020). By ensuring that Mr. Johnson's medications are optimally managed, potential drug-induced risks leading to falls can be minimised.

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Impact of Chronic Pain on Activities of Daily Living (ADLs):

Chronic pain, as experienced by Mr. Johnson, can profoundly impact an individual's capacity to perform ADLs. Two such activities that would likely be affected in Mr. Johnson's case are:

1.Mobility (Walking and Transferring): Chronic pain, especially in weight-bearing joints like the knee, can make movements such as standing, walking, or transitioning from sitting to standing extremely challenging (Schwan et al., 2019).

Given that Mr. Johnson already guards his left knee, it's plausible that his pain significantly impedes his mobility. This could explain his recent falls and might also be a reason for his diminished engagement in previously enjoyed activities, such as walking in the park.

2.Self-care (Personal Hygiene): Chronic pain can also affect an individual's ability to engage in self-care activities like bathing, dressing, or grooming (Faronbi et al., 2019). In Mr. Johnson's case, his presentation to the ED – appearing dishevelled with a strong odour of urine – suggests that his personal hygiene has been compromised. The pain might make it difficult for him to bend, reach, or stand for extended periods, thus hindering his ability to adequately care for himself.

Pharmacological Management And Nursing Considerations

The physiological processes of ageing introduce a range of alterations in the body’s anatomy and function, predisposing older adults like Mr. Johnson to a heightened susceptibility to adverse drug effects. Several factors underscore this vulnerability:

1.    Anatomical and Physiological Considerations:

•    Altered Pharmacokinetics: Ageing is associated with decreased liver size and blood flow, leading to reduced hepatic metabolism of drugs (Falcone et al., 2020). Concurrently, a decline in renal function, evident in the reduced glomerular filtration rate, affects drug excretion, causing drugs to remain in the system for more extended periods, raising the risk of accumulation and potential toxicity.

•    Decreased Body Water and Increased Body Fat: Older adults often have a reduced volume of body water and an increased proportion of body fat. This change can affect the distribution of water-soluble and fat-soluble drugs, respectively. For instance, a water-soluble drug might reach a higher concentration in an elderly person, while a fat-soluble drug might have an extended duration of action due to its storage in fat tissues (Ponti et al., 2020).

•    Reduced Gastric Acid Production: Diminished gastric acid secretion can affect the absorption of certain medications, altering their intended effects (Corcoran et al., 2019).

2.    Behavioural Considerations:

Cognitive impairments, like the intermittent confusion displayed by Mr. Johnson, can lead to medication non-adherence, either through forgetfulness or misunderstanding of dosing instructions (Mendes et al., 2019). This non-adherence can result in therapeutic failure, overdose, or increased side effects, especially when combined with other medications.
Given Mr. Johnson’s polypharmacy, the complexities of managing multiple medications are evident. Interactions between different drugs, coupled with the physiological changes of ageing, can precipitate adverse effects or diminish the efficacy of one or more of the drugs.

Nursing Interventions for Polypharmacy Management:

1.    Medication Reconciliation:

•    Rationale: Ensuring the accuracy and consistency of Mr. Johnson's medication list is of paramount importance. Regularly reconciling his medications can prevent potential drug interactions, duplications, or omissions.

This process involves verifying the current medication list, clarifying any discrepancies, and documenting any changes (Martyn-St James et al., 2021). Given Mr. Johnson’s cognitive impairments, involving his daughter in this process can provide a more comprehensive picture and ensure all medications, including any over-the-counter drugs or supplements, are accounted for.

2.    Patient Education and Medication Management Aids:

•    Rationale: Educating Mr. Johnson and his primary caregiver about each medication's purpose, dosing, potential side effects, and interactions is crucial. This knowledge can empower them to identify any unexpected reactions or changes in Mr. Johnson’s condition that might be attributed to his medications.

Furthermore, using medication management aids, such as pill organisers or medication administration charts, can facilitate adherence and reduce the risk of errors. Given Mr. Johnson's cognitive challenges, visual or auditory reminders might also be beneficial in ensuring timely medication administration.

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References

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