Case Study Analysis: Managing Deterioration in Clinical Practice

This report presents a comprehensive analysis of a case study involving an 85-year-old woman, Olga Novak, experiencing a deterioration in her clinical condition. The report begins with an introduction and a table of contents, followed by an exploration of clinical decision-making (CDM) processes relevant to the case, including initial assessment, problem identification, and rationale for nursing actions. The pathophysiology of Olga's conditions, including osteoarthritis, mild cognitive impairment, and atrial fibrillation, is then discussed, providing a detailed understanding of the underlying mechanisms. The report further outlines appropriate clinical interventions, such as medication management, physiotherapy, and lifestyle modifications, to address the patient's various health issues. A concept map visually represents the interconnections of Olga's conditions and treatments. The report concludes with a summary of the key findings and recommendations for effective patient management.

Managing Deterioration
Students will apply their
clinical reasoning skills and
critically examine a case study
where a person experiences a
deteriorat

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................3
CLINICAL DECISION MAKING (CDM).....................................................................................3
PATHOPHYSIOLOGY..................................................................................................................5
CLINICAL INTERVENTION........................................................................................................5
CONCEPT MAP.............................................................................................................................7
CONCLUSION................................................................................................................................7
REFERENCES................................................................................................................................9

INTRODUCTION
Deterioration occurs mostly in the medical surgical units because the nurses do not pay
much attention to the condition of the patient but involves in making direct contact with them.
This must be analysed that when the person is becoming critically ill and then instant response
must be taken (Kozlowski and et.al., 2017). This report will shed light on the case study of 85
year old woman Olga Novak and the way in which her health was deteriorating. The clinical
decision making will also be discussed involving her problem identification and the clinical
review. The pathophysiology and the clinical interventions will also be described in detail. This
will be evidenced by making a concept map for the case.
CLINICAL DECISION MAKING (CDM)
CDM is basically a problem solving process in which the information of the patient is
gathered and analysed and decisions are taken accordingly in order to improve the outcomes as
well as improves the quality of care given to the patients. There are various steps in the CDM
which starts with diagnosis followed by assessing the severity and ends with management. This
also helps in assessing the risks of the adverse outcome due to the inappropriate management and
also of the harmful effects due to the therapeutic interventions (Yang, Steinfeld and Zimmerman,
2019). The history of the patient is also needed along with the physical examinations. This
sometimes becomes difficult because one disease can lead to many different signs and
symptoms.
In the present case, Olga Novak was a woman who was 85 years old was living alone and also
taking the aged care package of level 1. This can be analysed that when she was of 40 years, she
suffered from osteoarthritis which is basically a common form of arthritis (Chow and Chin,
2020). Due to this, the joints of knees, hands, spine and hips of the lady were damaged. Though
she was given the medication of Panadol 625 mg but this disease is degenerative which worsens
with the increasing age. The pain due to stiffness in the joints is common in this. Due to this, the
depression and sleep disturbances can also take place. There was no one with her to assist her
with all the needs which is why she was helpless. Her son and daughter also come only once in a
week and fulfils her financial needs. She was a widow, which is why there was no one to support
her mentally as well as physically. This is why; she was not stable mentally because no one was
there with her to share her problems.
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Along with the osteoarthritis, she was also suffering from Mild Cognitive Impairment for 6
months which worsens with time and age. This could also lead to depression and anxiety leading
to the worsening of mental condition (Goodman-Casanova and et.al., 2020). The women may
forget many things due to this and even her medications also.
Along with all these mentioned diseases, she was also diagnosed with the atrial fibrillation due to
which her heart rhythm became fast and irregular approx 175 beats in a minute. Due to all these
diseases and problems, the woman was suffering a lot and one day she had to activate her
medical alert system. She could not walk and move independently which is why she was found
sitting in the armchair and was looking pale. Her BP and SpO2 range was normal but she was
feeling pain in her right hip without even falling. This could be due to the osteoarthritis which
was faced when she was 40 years old. She also complained of feeling nauseous and dizzy which
is why she pushed the buzzer. This can be diagnosed that the effects of the mild cognitive
impairments were again seen in her. She could not found anyone around here which worsened
her situation. Before 6 weeks, she faced atrial fibrillation and she now complained of the
symptoms she was facing due to the same (Lippi, Sanchis-Gomar and Cervellin, 2021).
This can be analysed from the situation of Olga Novak that her all the past medical disorders
were regenerating as all the symptoms were seen when she was alone. This creates a need for an
effective care plan along with the effective medications. Firstly, there is a need of a carer who
can be with her for the whole day and night and can monitor all her problems she faces during
the whole day. Because this may happen that she forgets many things which remain unnoticed by
the doctors. So, the carer can assist her with all the basic needs and can also evaluate her routine
activities and he issues she face while doing the same. The carer can support her in making her
doing some sort of exercises and can take her out for shopping which can make her mentally
stable. The woman also needs to lose her weight and must be involved in proper exercises.
Movement therapies must be done including the gentle exercises and the stretches. The
medications like glucosamine and chondroitin, omega-3 fatty acids, avocado-soybean
unsaponifiables etc. (Vina and Kwoh, 2018).
The mild impairments can be improved by the physical activities, brain-training games, reducing
the chronic stress, social connections, getting enough sleep etc. The woman was not connected
socially with anyone as she was not able to go out to meet her friends. The woman was not able
to sleep properly because of the pain due to arthritis (Sanford, 2017). This worsened her
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condition. There are no particular medications for the same but the Alzeimer’s drugs can be
taken such as donepezil , galantamine etc.
In order to improve the rapid heart rhythm, there is a need to prevent the blood clots and control
the rate or reset the rhythm by using a procedure known as cardioversion which can be done
either with electric shocks or with drugs. This is done in the hospital under the constant
monitoring of the heart rate. The medications can also be used dofetilide, propafenone, sotalol
etc. (Kirchhof and et.al., 2020).
PATHOPHYSIOLOGY
Pathophysiology is a kind of disordered physiological process which is associated with
any kind of disease or injury. It involves an interaction between initiating triggers, often in the
form of rapidly firing ectopic foci located inside one or more pulmonary veins, and an
abnormal atrial tissue substrate capable of maintaining the arrhythmia (Staerk & et.al., 2017). It
has been observed that patients with progressive cognitive impairment also have tendency to
suffer from AF and Olga was diagnosed with mild cognitive impairment because of which her
chances of suffering from AF increased. It focuses upon history of patient in order to understand
problems because of which patient is facing such problems. Atrial Fibrillation is one of the most
common type of sustained cardiac arrhythmia in which heart beat can either become too fast or
too slow with an irregular rhythm. There are various kinds of symptoms that can help a patient to
identify that they are suffering from Atrial Fibrillation (Ko & et.al., 2016). It is extremely
important to treat AF as soon as possible because if medical attention is not given on time, then it
can convert into a stroke. Not only this, it can further increase mortality rate of patients as well.
It plays a vital and important role in patients with heart diseases. Not only this, patients that have
medical or family history of AF they have more and more chances of suffering from atrial
Fibrillation. In Olga’s case, she felt that her heart was racing and when test was done it was
identified that she has low blood pressure i.e. 90-60. Other than this her heart rate was 125 and
irregular (monitor showed AF) RR 23 Histh, SpO2 96% on room air. When she did not feel good
even after 30 minutes then she pressed her medical buzzer.
CLINICAL INTERVENTION
Clinical interventions are designed actions for achievement of desired outcome. When
health related outcomes are required to be achieved then in such cases clinical interventions
plays a vital and important role.
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Reduce Right hip pain clinical intervention: In order to prevent right hip pain to occur again
three step clinical intervention can be followed: first is nursing assessment to identify level of
pain and identify whether it is muscular or with bones. Second is to identify medical therapies
that can be used or implemented for reduction of pain (Andrade & et.al., 2018). Third is to
provide physical training to patient so that they can exercise daily, participate in training
programs which will eventually help them in reducing pain. Other than these three steps there are
various kinds of medical treatment that can be given to Olga so that pain felt by her in her right
hip can be reduced. One of the most common way is by giving systematic analgesia medication.
This medication can help in reducing awareness of Olga of pain and will further provide her a
calming effect. It is a short time period clinical intervention. Other than this, she can also be
provided with physiotherapy specifically related to her hip area so that pain can be reduced and
her movement can be increased. Physiotherapy is often termed as complementary or alternative
medicine. Other than this Transcutaneous Electrical Nerve Stimulation can also be used for
treatment of acute pain in right hip area. All of these clinical interventions can help Olga to feel
relief in her lower portion of right hip area.
Controlled atrial fibrillation Clinical intervention: It is extremely important to control atrial
fibrillation because not doing so can convert atrial fibrillation into a stroke. There are various
kinds of clinical interventions that can be carried out to reduce atrial fibrillation are
cardioversion, catheter ablation, pulmonary vein isolation ablation etc. and in case of severe AF
insertion of pacemaker can be done. One of the most common type of intervention is to provide
appropriate medication such as Bisoprolol and apixaban. Cardioversion is another one of the
most common type of clinical intervention that can be both chemical and electrical. Electrical
cardioversion is given to patients so that heart rate can be brought back to normal by giving
electrical shock on chest in order to stop heart activity for short movement in order to bring banc
heart rate back to normal. Whereas medical cardioversion uses medication known as anti-
arrhythmic that helps in restoring normal rhythm (Andrade & et.al., 2018). Another clinical
intervention which is most commonly preferred in such case is prescribing anti-arrhythmic
medications such patients can be prescribed two types of medicines first type of medications are
to prevent future episodes of atrial fibrillation such as: Dofetilide, Flecainide, Propafenone,
Amiodarone, and Sotalol. Second type of medication is to bring heart rhythm back to normal.
But these kinds of medications have its own side effects such as: Nausea, Dizziness, and Fatigue.
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Clinical intervention to maintain blood pressure: It is extremely important to maintain overall
blood pressure of patient because low BP is dangerous and can increase cognitive impairment
and Atrial fibrillation chances. In order to maintain normal blood pressure medications can be
prescribed to patient such as fludrocortisone (Andrade & et.al., 2018). But normally alternative
treatment works really well in treatment of low blood pressure such as: using more salt in meal
but before increasing slat in diet it is important to consul GP because for older patients’ excess
sodium can lead to heart failure. Other than this, drinking more water is another alternative to
increase blood volume and maintain blood pressure.
CONCEPT MAP
CONCLUSION
From the above case study, it has been identified that it is extremely important for
medical practitioners to focus upon deteriorating heath of patients because it can further led to
various other medical problems. In order to reduce chances of deteriorating it is important to
constantly monitor health of patient with the help of a kind of medical alert system. Such kind of
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Olga Novak- 85year
old woman
Osteoarthritis Mild cognitive
impairments Atrial fibrillation
Hip pain Dizzy and nauseous Rapid heart rhythm
glucosamine and
chondroitin etc.
Donepezil ,
galantamine etc.
Flecainide,
Propafenone etc.

system helps in providing a way to patients so that they can alert their medical practitioners and
family members that their overall health is deteriorating.
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REFERENCES
Books and Journals
Andrade, J. G., & et.al., (2018). A randomized clinical trial of early invasive intervention for
atrial fibrillation (EARLY-AF)-methods and rationale. American heart journal. 206. 94-
104.
Chow, Y. Y., & Chin, K. Y. (2020). The role of inflammation in the pathogenesis of
osteoarthritis. Mediators of inflammation, 2020.
Goodman-Casanova, J. M. & et.al., (2020). Telehealth home support during COVID-19
confinement for community-dwelling older adults with mild cognitive impairment or
mild dementia: survey study. Journal of medical Internet research. 22(5). e19434.
Kirchhof, P. & et.al., (2020). Early rhythm-control therapy in patients with atrial
fibrillation. New England Journal of Medicine. 383(14). 1305-1316.
Ko, D., & et.al., (2016). Atrial fibrillation in women: epidemiology, pathophysiology,
presentation, and prognosis. Nature Reviews Cardiology. 13(6). p.321.
Kozlowski, D. & et.al., (2017). The role of emotion in clinical decision making: an integrative
literature review. BMC medical education. 17(1). 1-13.
Lippi, G., Sanchis-Gomar, F., & Cervellin, G. (2021). Global epidemiology of atrial fibrillation:
An increasing epidemic and public health challenge. International Journal of
Stroke. 16(2). 217-221.
Sanford, A. M. (2017). Mild cognitive impairment. Clinics in geriatric medicine. 33(3). 325-337.
Staerk, L., & et.al., (2017). Atrial fibrillation: epidemiology, pathophysiology, and clinical
outcomes. Circulation research. 120(9). pp.1501-1517.
Vina, E. R., & Kwoh, C. K. (2018). Epidemiology of osteoarthritis: literature update. Current
opinion in rheumatology. 30(2). 160.
Yang, Q., Steinfeld, A., & Zimmerman, J. (2019, May). Unremarkable ai: Fitting intelligent
decision support into critical, clinical decision-making processes. In Proceedings of the
2019 CHI Conference on Human Factors in Computing Systems (pp. 1-11).
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