NSG2NCI | Nursing | A Case Study of Patient with Chronic Illness

Answer:

Introduction

This is a case study on patient Liz who is Forty-nine years old, weighs 87 kgs, is 165 cm high. She was diagnosed with chronic bronchitis five years ago. Since then she has been trying to cut down her cigarette smoking. At the moment she smokes 3 sticks daily. In addition to this, she occasionally drinks. She exercises by walking their dog for fifteen minutes around the neighborhood. Her cholesterol is high and she has ongoing hypertension and she is on anti-hypertensive medication. Patient Liz has recently relocated so as to avoid domestic violence from her partner. She lives with her son who is 22 years old and is a cook. To support him she started driving an uber. She was admitted three days ago after she suddenly got dizzy and right-sided weakness for over 6 hours. While in the emergency department she underwent a CT scan, blood tests and ECG that showed that she had an atrial fibrillation and transient ischemic attack. Due to this, she was refrained from driving the uber until her next visit to the neurologist for the next two weeks. This saddens her and makes her regret ever going to the emergency room. This essay focuses on answering the following questions; firstly, the chronic illness that Liz is at risk of developing. Secondly, an identification of the health services that are available in Australia that would aid Liz in managing the risk of developing the chronic illness identified above. Thirdly, this is a reflection on the services that Liz received. Lastly, a conclusion summarizing the essay.

1. Right ventricular failure translating to heart failure.

Patient Liz is disposed to Right Ventricular Dysfunction/heart failure. The relationship between the right ventricular failure and the chronic pulmonary diseases was described by Laennec 200 years ago as “all the diseases that cause severe and a long continuous period of dyspnea, they cause hypertrophia or the heart dilation due to the constant efforts of the heart to perform, so as to take blood into the lungs against the opposing resistance which results from the dyspnea. This is common in chronic lung diseases as there are structural changes of the lung parenchyma and an abnormality in the functioning of the gas exchange that causes pulmonary hypertension with the hypertrophy and remodeling of the right ventricle (Kolb & Hassoun 2012). In addition to this, the chronic hypoxemic and the disruption of the pulmonary vascular beds causes an increase in the ventricular afterload. This is generally defined by the marked hypertrophy with a preserved cardiac output and myocardial contractility. The right ventricular failure is a rare disease except during chronic lung disease. Research finding on patients with chronic lung diseases indicates that 26% of the American deaths are as a result of pulmonary hypertension. It was also reported that 30-70% of the chronic obstructive pulmonary diseases get pulmonary hypertension which further causes the right ventricular failure (Kolb & Hassoun 2012; Brown et al., 2016).

Similarly, the mortality (more than 50%) cases of chronic obstructive pulmonary disease (COPD) the most common cause is a cardiac failure and not a respiratory failure. COPD is the most common cause of mortality and morbidity of the adults that are heavy and medium smokers. As mentioned above COPD, impacts the functioning of the right ventricle. In COPD the decreased/limitation of the airflow causes an increase in the pulmonary resistance which causes an increased afterload on the right ventricle. The increased resistance causes hypoxic vasoconstriction, pulmonary vascular remodeling. This structural changes in the pulmonary vascular results from the inflammation induced by tobacco smoke and this are amplified by the chronic hypoxemia. This later causes pulmonary hypertension which complicates COPD (Chhabra & Gupta 2010). The right ventricle responds to this by undergoing dilatation and hypertrophy. This structural adaptation causes an increased end diastole pressure, a reduced right ventricle ejection fraction, reduced recoil/elasticity and less negative intrathoracic pressure. The later causes the two ventricles to compress on each other reducing the dilatation in the RV which in turn causes a reduction in the preload which causes a decreased cardiac output which translates to heart failure. In addition to this, smoking predisposes the patient to cardiovascular disease for example atherosclerosis. Smoking increases the oxidative stress and the systematic inflammation that causes inactivation of the anti-proteinase, mucus hypersecretion, damages of the airspace, an influx of the neutrophils, and an expression of the proinflammatory markers (Chhabra & Gupta 2010; Moe, 2016).

2. Services provided in Australia that are beneficial to patient Liz.

Liz has COPD and this predisposes her to heart failure. To reduce this, she needs to quit smoking. Tobacco smoking is a challenge in Australia, as it is ranked among the largest population killers, the cause of illnesses, disabilities and financial strains to the society.  Statistics have shown that over 3 million people in Australia aged above 14 smoke while 600000 persons are occasional smokers. The smokers have been noted to regret having started smoking and they wish to quit smoking. Many smokers have tried to quit have been reported to relapse before successfully quitting although for others they are unable due to the chronic tobacco dependency (Miller & Wood 2012; Rahman, Hann, Wilson, Mnatzaganian & Worrall-Carter 2015). This is the same case to patient Liz, she has been trying to cut down cigarette smoking and now she is down to three sticks daily.

Smoking cessation services

The country has come up with different smoking cessation programme/services, this would benefit patient Liz. These services include pharmacological, clinical and behavioral cessation interventions. For the behavioral intervention, the country has made it possible for self- help as they provide materials with quitting strategies, this include; leaflets, booklets, and internet programs. Secondly, they have come up with clinical interventions/services both minimal and intensive. They include; aversion therapy, group behavior therapies, proactive telephone counseling and individual behavioral counseling. For the pharmacological intervention, they have nicotine replacement therapies and anti-depressants. This will be useful to patient Liz so as to ensure that she quits smoking without relapsing (Miller & Wood 2012; Vuong, Hermiz, Razee, Richmond & Zwar 2016).

Keeping fit services.

She is obese and has a high level of bad cholesterol which further predisposes her to heart failure through atheroma formation. One of the health promotion strategies in Australia is strengthening the primary health care. This is achieved through health programs/services to the community, provision of clinical care that is competent, a good access to both the secondary and the tertiary care and the advocacy for the community to address the health risks factors and the social determinants. In our case, the predisposition to heart diseases/failure in our patient can be reduced through modification of the risk factors (Reeve et al., 2015; Shams, Ajorlou, & Yang, 2015). This includes; cutting down her weight to normalize her basal metabolic index because as per now she is obese. Secondly, by cutting her cholesterol levels. The Australian nation has made this possible as it offers self-help, through booklets, media, leaflets on how to cut weight through healthy diets, healthy lifestyles, and exercise. Secondly, it has provided nutritional guidance for specific age groups and genders so as to ensure healthy living. Thirdly, it offers clinical interventions whereby the population gets educated on heart failure, the predisposing factors and gets medical checkups (Reeve et al., 2015). This will be beneficial to patient Liz.

3. Reflection on the services beneficial to Liz and the challenges they contain.

Patient Liz is at risk of getting right ventricular dysfunction/heart failure due to chronic bronchitis which resulted from the excessive smoking. She is also obese and her cholesterol levels are high. To reduce this risk factors, the following services offered by the Australian nation would be beneficial; the smoking cessation programs and the weight reduction and cholesterol reduction services. As mentioned above these services includes self-help which is obtained through self-patient education obtained from written media, print media and the electronic media (Triandafilidis, Ussher, Perz, & Huppatz, 2018; Ponikowski, 2016).

The barriers/challenges that face the smoking cessation programs and cholesterol reduction and weight cutting programs in Australia include; firstly; the public-private mix in the health care funding (Macri, 2016). This has made health care services to be less equitable as the 50% of the medical cost is from the patients’ pockets. This would hinder Liz health care as she needs regular cholesterol checks ups which she has to pay for. This might discourage her from seeking this services.  Secondly, the health inequality and the concerns with the equity. The health care system in Australia is inequitable as it seems to favor the employed, those in urban areas and the high-income earners (Macri, 2016). Liz is unemployed and a low-income earner. This might disadvantage her and hinder her from accessing health care. Thirdly, the issues facing the medical research sector. There are discrepancies on which intervention program is most effective in smoking cessation (Triandafilidis, Ussher, Perz, & Huppatz, 2018; Krahnke, 2016).  Lastly, the demographic changes as the preventive initiatives do not effectively reach out for those most at risk and the services for chronically ill concentrates on the acute care. This would limit her access to these services.

References

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Chhabra, S. K., & Gupta, M. (2010). Coexistent chronic obstructive pulmonary disease-heart failure: mechanisms, diagnostic and therapeutic dilemmas. Indian J Chest Dis Allied Sci, 52(4), 225-238. Retrieved 20, August 2018 from https://www.researchgate.net/profile/Victor_Lasebikan/publication/49818707_Outpatient_pulmonary_rehabilitation_in_severe_chronic_obstructive_pulmonary_disease/links/0912f5059bcb8aee94000000.pdf#page=39

Kolb, T. M., Hassoun, P. M. (2012). Right ventricular dysfunction in chronic lung disease. Cardiology clinics, 30(2), 243-256. DOI: https://doi.org/10.1016/j.ccl.2012.03.005

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Macri, J. (2016). Australia’s Health System: Some Issues and Challenges. J Health Med Econ, 2:2. Retrieved 20, August 2018 from https://health-medical-economics.imedpub.com/australias-health-system-some-issuesand-challenges.php?aid=8344

Miller, M., & Wood, L. (2012). Smoking cessation interventions: a review of evidence and implications for best practice in healthcare settings. In Smoking cessation interventions: Review of evidence and implications for best practice in healthcare settings. Commonwealth of Australia.

Moe, G. (2016). Heart failure with multiple comorbidities. Current opinion in cardiology, 31(2), 209-216. DOI: https://doi.org/10.1097/HCO.0000000000000257

Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., ... & Jessup, M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 18(8), 891-975. DOI:10.1093/eurheartj/ehw128

Rahman, M. A., Hann, N., Wilson, A., Mnatzaganian, G., & Worrall-Carter, L. (2015). E-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis. PloS one, 10(3), e0122544. Doi: https://doi.org/10.1371/journal.pone.0122544

Reeve, C., Humphreys, J., Wakerman, J., Carter, M., Carroll, V., & Reeve, D. (2015). Strengthening primary health care: achieving health gains in a remote region of Australia. The Medical Journal of Australia, 202(9), 483-487. doi: 10.5694/mja14.00894

Shams, I., Ajorlou, S., & Yang, K. (2015). A predictive analytics approach to reducing 30-day avoidable readmissions among patients with heart failure, acute myocardial infarction, pneumonia, or COPD. Health care management science, 18(1), 19-34. doi: https://doi.org/10.1007/s10729-014-9278-y

Triandafilidis, Z., Ussher, J. M., Perz, J., & Huppatz, K. (2018). Young Australian women’s accounts of smoking and quitting: a qualitative study using visual methods. BMC Women’s Health, 18, 5. https://doi.org/10.1186/s12905-017-0500-1

Vuong, K., Hermiz, O., Razee, H., Richmond, R., & Zwar, N. (2016). The experiences of smoking cessation among patients with chronic obstructive pulmonary disease in Australian general practice: a qualitative descriptive study. Family practice, 33(6), 715-720. doi: https://doi.org/10.1093/fampra/cmw083