Comprehensive Assessment and Nursing Interventions for Community-Based Palliative Care: A Case Study of Ravi Maharaj

Running head: COMPLEX CARE
Name of the Student:
Name of the University:
Author note:

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Introduction:
The purpose of the essay is to perform comprehensive assessment related to the nursing process and critically analyze the
nursing interventions which would be used for the patient under accurate surveillance of community-based palliative care team.
Considering the case study of Ravi Maharaj, the critical nursing problems will be addressed with the integration of care plan
emphasized on the anxiety management and generalized pain management. A nursing care plan has been designed as a part of the
nursing process which prioritizing two nursing priorities for the wellbeing of the patient. This essay will critically appraise the
assessment framework and give a concise idea of the pathophysiology of Ravi and consider other assessment tools that would be
suitable for Ravi. Considering the nursing problem identified, specific, measurable, achievable, realistic and timely (SMART) goal
would be designed for physical and mental wellbeing and it would include the multidisciplinary team to meet the complex care need
of the patient. Besides, pharmacological and non-pharmacological interventions appropriate for the patient would be critically
evaluated with the help of relevant guidelines. After evaluation, potential intervention would be implemented with the assistance of
evidence-based practice. The critical analysis would be focused on a 59 years man, Ravi Maharaj.

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Discussion:
To design a holistic care plan, initial step is assessment of the patient for determining the health condition and ensuring that the
patient would receive responsive patient centric care. The mountain of evidence highlighted a variety of the frameworks which is
applicable for the patient depending on the chronicity of the health conditions. Considering the case study, The ABCDE approach is
not appropriate for the patient since resuscitation council suggested that ABCDE is a systematic approach of assessment, identification
and treatment of terminal or life threatening diseases in the clinical urgencies rather than applied for chronic illnesses observed for
Ravi (Holub et al. 2017). Hence, Roper Logan and Tierney proposed activity of daily living is more suitable for management of the
health condition of Ravi with the collaboration of the nurses because this will approach provide nurses with an opportunity to design
accurate care plan (Kennedy-Malone Martin-Plank and Duffy 2018). The activities of daily life approach would undertake the
independence Ravi for faster recovery at home. As observed from the statement of Ravi that he refused to admit in ICU of hospital,
for managing the symptoms of terminal stage of alcohol-induced liver disease, an effective care plan would be required. Hence,
considering the health condition of Ravi, APIE (Assessment, Planning, Intervention, and Evaluation) approach would be applied for
critically analyzing the health needs of Ravi for an effective care plan (Williams and Hopper 2015). NICE (national institute for
health and care excellence) guidelines can be applied which would further help in the assessment and prevention of the health
conditions (Perkins et al. 2015).
In the current context, the nursing problems are anxiety because of the guilt that he was not able to visit temple and he will die
at home and pain in the left upper abdomen because of the alcohol disease and. Since he was feeling guilty because he was Hindu and

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was not able to visit temple, anxiety management is another nursing problem. Therefore, to provide support and care to the patient,
reduction of the anxiety is required, which is first nursing priority.
Moreover, it was observed that before draining fluid from the abdomen resulted in the pain and to avoid the pain he was
sleeping in the chair since he was incompetent to lay down. As observed in this case study, he had gone through repeated drainage of
water because of fluid accumulation to manage the pain. Therefore, pain management is identified as second the nursing priorities.
Kimbell et al. (2018), stated that the core principle of palliative care is to manage the symptoms of the chronic disease for minimizing
the suffering of the patients.
Pathophysiology:
As observed in this case study, Mr. Ravi is suffering from the terminal liver disease and severity of the disease is prevalent
throughout the globe, especially in men rather than women. As highlighted by Low et al. (2018), majority of the premature of deaths
associated with the alcoholic liver disease in people aged in between 50 to 88 years (Kotha and Berry 2018).In the context of
pathophysiology, there is a range of the disorders are associated with liver disease such as hepatitis, cirrhosis, fibrosis, jaundice. As
discussed before, the main problem that has been identified for nursing priority is the pain in upper abdomen due to alcohol liver
disease and associated ascites which indicated excessive fluid retention (Flores, Ho and Asrani 2018).
As discussed by Watson and Mortimore (2018), ascites is identified as one of the major complications of liver disease and
associated pain. Ascites is defined as an accumulation of the protein containing fluid in the abdomen. Rush et al. (2019), suggested

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that the majority of the patient develop ascites within 10 years of diagnosis of liver disease, therefore, it might happen that Ravi was
suffering from the ascites that further suggested the lack of early detection. Livingston et al. (2017), highlighted that it is associated
with hypertension and due to the pressure running through the liver which further led to functional impairment because of scaring with
alcohol. Therefore, he was also administrated with Amlodipine which is a drug associated with the reduction of hypertension.
Moreover, to reduce or prevent the complication of the liver, lactulose was given to him. Lombardi et al. (2017), suggested that this
drug is orally administrated to reduce the complications in the liver and proved to improve mental status of patient. Since he was also
suffering from anxiety related to the guilt and worry that he will die at home, this drug will improve the mental status of him
(Monsieurs et al. 2015). The damage of liver-associated manifested as the swelling and accumulation of protein-containing fluid,
inflammation, and pain. Therefore, he was also administrated with oromorph which is a short acting morphine given in palliative care
to reduce severe pain that he was experiencing due to the liver disease.Walling et al. (2017), suggested that because of the disease,
hepatic cells failed to drain the toxic protein and by-products from the body resulted in the accumulation of it in the lower abdomen.
One of the byproducts that cannot be released due to the dysfunctional liver is bilirubin which started depositing under the skin giving
jaundice like appearances which further give rise to itchy skin (Potosek et al. 2014).
Considering the etiology, the most common one is alcohol consumption since he used to consume 50 units of alcohol per week
until 8 months ago he was diagnosed with liver disease. Besides, since he had a history of type II diabetes mellitus which is
associated with hyperglycemia and hyperinsulinemia, it resulted in the hyperglycemia-induced oxidative stress causes the scaring of

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the liver (Holub et al. 2017). Considering the situation of Ravi, from the objective data it was observed that he requires immediate
surgical attention.
Critical appraisal of the assessment framework:
Roper Logan and Tierney proposed activities of daily living approach focuses on the healthy living of individuals by
stimulating various method of self-care. Larson (2015), further supported this approach since it provides the basic framework to the
nurses to care for the patient with physical disabilities and unable to perform daily activities. The framework considers 12 crucial
activities to ensure the healthy living and wellbeing of the patient.
In the current context, the main activities which are concern of Ravi include management of anxiety associated with impending
death because he was worried he will die at home and he was also feeling guilty for inability to visit temple , mobility issue because of
the fluid accumulation, eating and drinking. In the current context, assessment parameters are cultural and spiritual beliefs of patient
friends and family members. Since he was a Hindu and unable to visit temple because of physical conditions, he was struggling to
come for diagnosis which led to anxiety. Moreover, he felt guilty because of his habit of drinking which is forbidden in religion that
also led to the anxiety. Therefore, anxiety assessment along with management is required for the patient . Considering the mobility
issue, although he can move from beds to chair but require support for the walk for preventing accidental fall. Eating and drinking is
another concern since he is required to maintain a proper diet for management for T2DM which include the restriction in alcohol