Case Study: Managing Chronic Illness and Patient Care

This report presents a case study on managing chronic illness, focusing on a patient with COPD and the role of the inter-professional team in patient care and discharge planning. The report emphasizes the importance of a collaborative approach, including the nurse, patient, and caregiver. The nurse's responsibilities include providing patient education, implementing interventions like pulmonary rehabilitation and guided self-management, and ensuring patient-centered care aligned with QSEN competencies. The report also highlights the use of evidence-based practices, such as providing written instructions and follow-up care. The goal is to improve patient outcomes and support the caregiver in providing effective home-based care. The report references relevant literature to support its findings, and is written from the perspective of a student on Desklib.

Running head: MANAGING CHRONIC ILLNESS NEEDS
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Managing Chronic Illness Needs
Name
Institutional Affiliation

MANAGING CHRONIC ILLNESS NEEDS 2
Case Scenario
The role of the inter-professional team is to proactively organize the process of
discharge and patient care after hospitalization (Mennuni et al., 2017). The team should
work in collaboration with the caregiver to develop a care plan. The nurse can address the
wife's concern by equipping her with adequate and easy-to-understand information
regarding the clinical condition of the patient and the support necessary to plan and care for
the patient. The nurse can initiate various management interventions such as pulmonary
rehabilitation, guided self-management, and patient education (Fletcher & Dahl, 2013).
The nurse practices align with the QSEN competencies. Patient-centered care is
achieved by ensuring that care is based on the value and needs of the patients. Therefore,
involving the patient and wife in decision-making is essential while respecting their choices
during discharge. Additionally, communication is an effective strategy for enhancing patient
care.
Teamwork is achieved by engaging the inter-professional team in addressing the
patient’s condition. Evidence-based practice is achieved by using current evidence in
educating the wife and that patient on self-management and home-based care and preparing
the written guidelines on how to care for a COPD patient after discharge. Verbal
communication should be complemented by a written list of instructions, brochures and
books to guide the caregiver on management to the patient’s condition (Mennuni et al.,
2017). The nurse can achieve quality improvement by making a follow-up on the progress of
the patent after discharge and supporting the wife to provide appropriate care in various
situations. Safety is ensured by ensuring that all interventions are safely conducted through
transparency in communication and effective reporting.

MANAGING CHRONIC ILLNESS NEEDS 3
References
Fletcher, M. J., & Dahl, B. H. (2013). Expanding nurse practice in COPD: is it key to
providing high quality, effective and safe patient care?. Primary Care Respiratory
Journal, 22(2), 230. doi: 10.4104/pcrj.2013.00044
Mennuni, M., Gulizia, M. M., Alunni, G., Francesco Amico, A., Maria Bovenzi, F.,
Caporale, R., … Zuin, G. (2017). ANMCO Position Paper: hospital discharge
planning: recommendations and standards. European heart journal supplements :
journal of the European Society of Cardiology, 19(Suppl D), D244–D255.
doi:10.1093/eurheartj/sux011