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Nursing Care Plan : Chronic Illnesses

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Nursing Care Plan : Chronic Illnesses

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Nursing Care Plan : Chronic Illnesses

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Discuss about the Nursing Care Plan for Chronic Illnesses.

Chronic illness has been a major issue of concern in the society. It has been a major cause of death in different parts of the world. However, it should be acknowledged that chronic illnesses can be handled if adequate healthcare services are provided using appropriate intervention strategies. This paper presents and in-depth and critical analysis of Luigi’s care plan. Luigi is a 77-year old male patient who has been diagnosed with Type II Diabetes and Chronic Renal Failure. This is complex multimorbidity that requires a lot of attention to address. The paper looks at the recommended interventions, guiding principles and the roles of Registered Nurse in the patient’s treatment.
Guiding Principles
Chronic illnesses require attentive care of the healthcare providers. Whenever given an opportunity to serve a chronically-ill patient, a healthcare provider should dedicate time to offering high quality services. In fact, more attention should be given to patients with multimorbidity. This is what Luigi, who suffers from a combination of Type II Diabetes and chronic renal failure. For Luigi to properly manage his condition, he requires to be adequately assisted by a primary healthcare provider (Kirkman et al., 2012).  This is the surest way through which the patient can learn to appreciate his condition, and acquire recommended coping and management skills. However, when discharging his duties, a primary healthcare provider needs to operate under the guidance of well-outlined principles.
The first principle to apply is collaborative management. Here, the nurse should acknowledge that the multimorbidity condition of the patient requires a collaborative approach. Meaning, the nurse should not operate in isolation, but be ready to work with other professionals. The fact that Luigi suffers from a renal kidney failure and Type II Diabetes implies that he should be handled by different experts. It should therefore be incumbent upon the nurse to consult physicians, social workers, counselors, pharmacists, and other specialists (Vogeli, Shields, Lee, Gibson, Marder, Weiss & Blumenthal, 2011). When necessary, the nurse should refer the case to these experts since they are knowledgeable on different areas. Before making any important decision, the nurse should seek the opinion of these experts because they have diverse knowledge that if put together, can help in providing high quality services to the patient.
The other principle to apply when handling the patient is self-management. Despite getting an opportunity to serve Luigi, the nurse should not assume to be the sole decision maker. Instead, the nurse should be ready to cooperate with the patient and seek his opinion whenever necessary. This simply means that the nurse should deliver a patient-centered care that advocates for the involvement of the patient in the making of major decisions regarding his health. The principle of self-care can be achieved if the nurse takes the initiative to empower the patient (Schneider, O’Donnell & Dean, 2009). A patient like Luigi who suffers from a multimorbidity condition does not only need to be treated, but be given opportunity to acquire management and coping skills. It can empower the patient to be an active participant in the management of his condition. It can be much better if the patient extends the empowerment activities to the patient’s families and carers who are involved in his treatment.
Last, but not least, the nurse should apply the principle of individualized care. As a professional, the nurse should always be versed with the information that the diverse nature of the society calls for flexibility in healthcare delivery. The uniqueness of each patient means that each situation is to be handled differently. Although it might be necessary to deliver group-based care, Luigi’s case can yield more results if individualized (Kirkman et al., 2012). If properly done, the nurse can get enough time to understand the uniqueness in his conditions, analyze his history and identify the most appropriate intervention to provide.  It is no doubt that the individualization of cases is a better alternative for the patients with multimorbidity conditions.
Roles of the Registered Nurse in the Acute Medical Ward in the Management of the Patient and His Family
Chronic illness does not necessarily means that a patient cannot live. Since it is not a death sentence, all cases of chronic illness should be properly handled by a trained healthcare provider. The critical conditions of Luigi necessitate that he should continue to be admitted in the healthcare facility. Here, there are RNs and other specialists who can offer the necessary care. This is a clear proof that a RN is an exceptional professional who plays a very significant role in the treatment of chronic illnesses.
For the entire period that Luigi will be in the acute ward, he will continue relying on the RN for the delivery of interventions. In other words, the RN will be charged with the responsibility of providing evidence-based care to the patient. Apart from assessing the patient, the RN is responsible for setting up a treatment plan for the patient. It is the RN, who coordinates the treatment process of the patient, organizes for medications, depression screening, and evaluates the patient’s compliance with the recommended medications (Hsu, Coleman, Ross, Johnson, Fishman, Larson & Reid, 2012). All these are necessary activities that should be done to a chronically-ill patient. It is not possible for Luigi to manage his conditions without necessarily being guided by the RN. For this reason, the RN should always be available to closely monitor the patient and help him to deal with multimorbidity no matter how challenging it might be. The monitoring process should continue even when the patient is discharged from the hospital because the RN needs to follow-up the patient to ascertain his progress.
The RN is also responsible for empowering the patient, his family and carers. The complex nature of the patient’s conditions implies that he cannot perfectly manage it without a proper guidance of the RN. The delivery of patient-centered care requires that the patient should be adequately empowered at all times. The RN should not tire from educating the patient and his family on important issues such as management, compliance and coping. These are sensitive issues that require adequate training by a specialist (Ludman & Von Korff, 2012). Type II Diabetes is a chronic condition ha causes physiological, emotional and psychological changes in the life of the patient. Hence, while serving Luigi at the acute ward, the RN should create enough time to educate him. Similar services should be offered to the patient’s family who are also concerned about his health.
Multidisciplinary Collaboration
To effectively deliver high quality care to Luigi, the nurse should adopt a multidisciplinary approach. Here, the RN should not assume to be a know-it-all. Instead, the RN should always be ready to work with other professionals, who are, in one way or the other, involved in the delivery of services to chronically-ill patients like Luigi. These include the physicians, psychiatrists, social workers, and pharmacists. Whereas the RN is responsible for delivering primary care to the patient, the pharmacist should be consulted to help in providing a proper guidance on the use of medication and all the other matters related with prescription and compliance (Katon, et al., 2010). On the other hand, the physicians should be consulted when the RN feels that expertise advice and guidelines are required to help in handling the patient’s multimobidity conditions.
The most basic form of collaboration in the healthcare facility should be established amongst the RNs themselves.  Acute care is not a simple task to be handled by only one nurse. Whenever discharging his duties, a RN should work alongside other nurses to help in monitoring the patient and delivering services needed at any given time. When nurses come together and work as a team, they can help one another in serving the patient. At the same time, collaboration can be fruitful in making well-thought, justifiable and rational decisions (Von Korff, Katon, Lin, Ciechanowski, Peterson, Ludman & Rutter, 2011). When nurses collaborate, they can work as a team and this can benefit them in many ways. Apart from helping them to create a conducive environment, team work enables the nurses to engage in joint decision-making, a brilliant idea that can enable them to deliver exceptional services to the patient.  
The establishment of a cordial working relationship with such specialists can play an integral role in handling the patient. No RN can single-handedly manage Type II Diabetes and Chronic Renal Failure without relying on well-trained experienced specialists for consultation or referral in case of complexity. Although the RN should constantly monitor the patient, there are certain procedures that the nurse cannot handle (Morgan, Coates, Dunbar, Reddy, Schlicht & Fuller, 2013). Should that be the case, the nurse should not hesitate to seek for the intervention of the specialist. For example, when the patient develops serious complications on his renal conditions, a specialist renal failure expert should be immediately called for to attend to him. The same should be done in case of emergency and serious issues arise on the patient’s diabetic condition.
Similar closeness should be established with the psychiatrists, counselors and social workers because Type II Diabetes often result into psychological distresses that can overwhelm the patient if no psychological intervention is provided. It is therefore obvious that the input of these professionals should be incorporated when educating the patient and his family members. These are skilled counselors who can study the patient’s mental conditions and give appropriate guidelines on how to manage the situation and lead a stress-free no matter how difficult it might be (Mastal, 2010). When properly educated, the patient can acquire accurate information on the causes, symptoms, intervention strategies, and medication. Despite the fact that RN should be educative, better results can be obtained if the nurse adopts collaborative approach.
It is therefore undisputable that interdisciplinary collaboration is a viable tool in the treatment of acute illness. Nursing is a broad area that involves a lot of specialists who have diverse training backgrounds. The complex situations encountered by the RNs leave them with no option rather than embracing a collaborative approach with others (Institute of Medicine, 2011). Consultation and referrals are better tools that can help in improving the quality of healthcare especially when dealing with chronic cases like Luigi’s. RNs have interdisciplinary collaboration opportunities that should be explored whenever handling any patient. After all, the RNs should never advance their own interests, but always seek to deliver benevolent services for the benefit of the patient. This is exactly what Luigi wants. 
Nursing Interventions
Luigi has been diagnosed with a multimorbidity condition. Suffering from a Type II Diabetes and Chronic Renal Failure leaves no doubt that the patient as a chronic and complex condition. He therefore requires uninterrupted support from the RN, physicians, pharmacist, and family members. Each of these has a significant role to play in his life. The nurse will be of great contribution because of the primary healthcare services delivered to him (Bodenheimer & Berry-Millett, 2009). Nonetheless, to serve him well, the nurse requires adopt a wide range of interventions. A proper choice of intervention of an intervention can be appropriate because it an enable the nurse to help the patient to manage and cope up with his complex condition.
Individualized Stepped Care Intervention
One of the most important interventions to adopt is the individualized stepped care.  Under this intervention, a nurse is supposed to give attention to the patient. Each patient should be regarded as a unique individual who has a peculiar set of background, needs, weaknesses, strengths, and hopes. Under individualized stepped care, a nurse is supposed to be keen on personally observing the patient before making important decisions regarding the kind of treatment to provide. So, when attending to Luigi, the nurse should apply this intervention because it can benefit the patient a great deal (Bodenheimer & Berry-Millett, 2009). The treatment should not be based on diagnosis alone.
The nurse should be guided by the observations made on the patient’s compliance to medications, and response to treatment. If appropriately applied, the individualized stepped intervention can help in delivering quality services to the patient. It is an efficient and cost-effective intervention that can aid in making informed decisions regarding the health of the patient (Laughlin & Beisel, 2010). Multimorbidity is a sensitive and complex condition that requires a lot of keenness. All the procedures performed on Luigi should be supported by observations. Luigi’s condition is quite demanding, but can still be managed if this kind of intervention is applied. This can help in handling the patient’s Type II Diabetes and Chronic Renal Failure deteriorating conditions.
Psychological Intervention
Psychological intervention is a strategy in which the healthcare provider seeks to address the psychological needs of the patient. In most cases, chronic illnesses result into psychological changes in the patients. These, if not handled well, can negatively impact on the patient. Therefore, anytime a RN is given an opportunity to care for a chronically-ill patient, the nurse requires creating enough time to offer psychological support. As a patient, Luigi requires psychological assistance from the nurse (Lin, Korff, Ciechanowski, Peterson, Ludman, Rutter & Katon, 2012). His diabetic condition causes lots of psychological and emotional distresses to him. The nurse should therefore dedicate his energy to educate the patient on how to manage the psychological changes experienced so far.
Additional training should be given on how to adjust to the diagnoses and treatments given by the healthcare provider. If all the psychological needs are addressed, Luigi can get to learn and appreciate why he should cope up well and manage his conditions without unnecessarily succumbing to the distresses it causes. Behavior change is a key factor in the management of chronic conditions. However, no patient can readily accept to change behavior as required. Many patients with multimorbidity do not comply with the medications given (Tomcavage, Littlewood, Salek & Sciandra, 2012). The complex conditions of such patients often make them to develop unexpected psychological behaviors that might delay their chances of recovering. In this regard, a committed nurse must offer standardized psychological support to the patient. The contributions of psychological intervention should not be disputed because it is an evidence-based intervention. It has been acknowledged for immensely contributing to the satisfaction of the patients’ psychological and emotional needs.
Collaborative Team Intervention
The RN who has been mandated to serve Luigi has a large number of roles to perform. By getting a chance to offer primary care to the patient, the nurse is in charge of assessing the patient’s condition, diagnosis, disease management, education, follow-up, and managing the inpatient-outpatient transition. These are numerous activities that might not be efficiently performed by the nurse alone. In other words, the nurse should readily accept to work in collaboration with other specialists (Smith, Soubhi, Fortin, Hudon & O’Dowd, 2012). In a hospital setting, there are many professionals who are knowledgeable on different areas. Therefore, when handling a patient with multimorbidity conditions, the nurse should not perform all the activities alone.
When the nurse wants to help Luigi to manage his diabetic condition, the nurse should discharge all his duties as expected. At the same time, the nurse needs to cooperate with other nurses and specialist diabetic physicians. These are experts who can help the nurse to deliver quality and satisfactory services to the patient. The same thing should be done when handling Luigi’s renal complications. Regardless of the efforts put by the nurse, advice should be sought from renal failure specialists (Gabbe, Landon, Warren-Boulton & Fradkin, 2012). Better still; the nurse should seek for the intervention of the psychiatrist whose contributions can play a major role in addressing the patient’s psychological needs. From this discussion, it is evident that a collaborative approach can be a viable intervention. It is based on past evidence that commends it because it emphasizes the need of bringing together different experts to collectively deal with the complex multimorbidity.
Chronic illness makes life difficult for many patients. The situation worsens when one is diagnosed with multimorbidity-a condition which troubles Luigi, who has been diagnosed with Type II Diabetes and Chronic Renal Failure. Luigi can regain his health if a well-organized treatment plan is adopted for him. If the RN perfectly discharges his roles and applies the individual stepped care, psychological and collaborative interventions, Luigi can be empowered to manage his conditions and lead a healthier life. These are evidence-based interventions whose proper use can be fruitful in addressing Luigi’s complex multimorbidity. Type II Diabetes and Chronic Renal Failure can still be managed even if they are serious conditions that have been causing many deaths. What the patient requires is a right prescription, treatment, and thorough education on a proper management of the condition.
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Gabbe SG, Landon MB, Warren-Boulton E, & Fradkin J. (2012). Promoting health after gestational diabetes: a National Diabetes Education Program call to action. Obstet Gynecol.119(1):171–6.
Hsu, C., Coleman, K., Ross, T.R., Johnson, E., Fishman, P.A., Larson, E.B., & Reid, R.J. (2012). Spreading a patient-centered medical home redesign: A case study. Journal of Ambulatory Care Management, 35(2), 99-108.
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Katon, W.J., et al. (2010). Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine, 363(27), 2611-2620.
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Lin, E.H., Von Korff, M., Ciechanowski, P., Peterson, D., Ludman, E.J., Rutter, C.M., & Katon, W.J. (2012). Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: A randomized controlled trial. Annals of Family Medicine, 10(1), 6-14.
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Mastal, M. F. (2010). Ambulatory care nursing: Growth as a professional specialty. Nursing Economic$, 28(4), 267-269, 275.
Morgan, M.A., Coates, M.J., Dunbar, J.A., Reddy, P., Schlicht, K., & Fuller, J. (2013). The TrueBlue model of collaborative care using practice nurses as case managers for depression alongside diabetes or heart disease: A randomized trial. BMJ Open, 3(1).67-73.
Schneider, K.M., O’Donnell, B.E., & Dean, D. (2009). Prevalence of multiple chronic conditions in the United States’ Medicare population. Health and Quality of Life Outcomes, 7, 82.
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Von Korff, M., Katon, W.J., Lin, E.H., Ciechanowski, P., Peterson, D., Ludman, & Rutter, C.M. (2011). Functional outcomes of multi-condition collaborative care and successful ageing: Results of randomized trial. BMJ, 343, d6612.

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