Community Nursing Handover: Partnership in Chronicity Report

This report details a community nurse's role in managing patients with chronic conditions. It addresses two specific cases: Mr. Duong, who has diabetic nephropathy and undergoes peritoneal dialysis, and Mrs. Ally, who experiences pain and requires assistance with daily activities. The report outlines nursing goals for Mr. Duong, including glycemic control, hypertension management, and catheter care, along with strategies to evaluate outcomes. For Mrs. Ally, the nurse focuses on pain assessment, medication compliance, and medical history review. The report also includes an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) handover for two clients and a daily planner for all four clients, incorporating appointment order, travel time, and breaks. The author provides references to support the information presented.

Running head: PARTNERSHIP IN CHRONICITY 1
Partnership in Chronicity
Name of Author
Institution
Date of Submission

PARTNERSHIP IN CHRONICITY 2
Partnership In Chronicity
Question One: Role of the Community Nurse
The primary role of a community health nurse is provide treatment to patients. Similarly,
a community health nurse provides education to patients in the community about how to live
healthily and reduced the incidences of diseases and mortality rates. Community nurses help in
the patient screenings, assessments and act as first responders to health issues affecting patients
like the case of Mr Duong and Mrs. Ally.
Question Two: Recommendations for Mr. Anh Duong
Goals
According to the case of Mr. Duong provided he is suffering from diabetic nephropathy
and is currently undergoing home therapy peritoneal dialysis. Given his condition, some of the
nursing goals that should be achieved to reduce and manage the progression of diabetes
nephropathy include achievement of strict glycemic control, efficient regulation of hypertension
and regulation of the rennin-angiotensin system and protection of cardiovascular complication
risks that may result from the comorbidities. There is also a goal to ensure effective use and
understanding of the catheter by Mr. Duong.
Reduction of the catheter-related infections like the reddening of the catheter area
requires administer empirical antibiotics that can cover the patient against both gram positive and

PARTNERSHIP IN CHRONICITY 3
gram negative bacterial strains (Akoh, 2012). Subsequently, the realization of a strict glycemic
control can be a major milestone as a nursing intervention for the case of Mr. Duong. Notably,
hyperglycemia is a major contributor to the onset and progression of diabetic kidney disease
(CKD). Evidence indicates that glucose control can reduce the loss of glomerular filtration rate
(GFR) and the progression of the kidney disease to end stage status (Gibbons & Goebel-Fabbri,
2017). There is a need for regular assessment of hyperglycemia signs manifested by Mr. Duong.
These signs would include blurring of vision, increased fatigue, high urination frequency, and an
increased feeling of thirst and hunger. The assessment of the glucose levels can also accompany
these interventions before meals. Further, educating Mr. Dung about the necessity for adherence
to prescribed diets will help in blood sugar control. Similarly, I would advice Mr. Duong to
engage increase their physical activity and avoid temptations of a sedentary lifestyle (MacIsaac,
Jerums & Ekinci, 2017). Mr. Duong should also be administered with oral hypoglycemic
medications for effective blood glucose management.
Treatment of hypertension among diabetic nephropathy cases ensures a reduction in the
rate of renal dysfunction and improves mortality rates. Administration to medication therapy is
the only approach to manage hypertension in Mr. Duong. Reduction in the blood pressure is also
achievable by the use of a stepped care algorithm and strict medication compliance by the
patient. The pharmacological therapy should include angiotensin-converting enzyme inhibitors,
and the angiotensin receptor blockers used as a combination therapy (Van Buren & Toto, 2011).
Mr. Duong should also require control of cardiovascular risk factors through the administration
of pharmacological therapy, diet counseling, and promotion of the physical activity.
Additionally, there is a need for inclusion of a multidisciplinary approach to help Mr. Duong

PARTNERSHIP IN CHRONICITY 4
experienced better health outcomes (Patney, Whaley-Connell & Bakris, 2015). These
professionals include physicians, nurses, nephrologists, and urologists.
Strategies to Evaluate the Outcomes
Firstly, as a nurse, it would be significant to put into place a continuous glucose
monitoring framework for Mr. Duong to enable the frequent assessment of the glycemic control
initiative in place. The monitoring should also entail the evaluation of their understanding about
medication compliance, educating them to report any case of adverse medication side effect that
they experience promptly to allow for fast interventions, dietary knowledge for hypertension and
glucose control objectives. Mr. Duong should also demonstrate effective use and understanding
of catheters used in the dialysis process to prevent the development of infections.
Further, the evaluation of the outcomes would proceed through the evaluation of the
clinical parameters that include blood pressure, body weight, and assessment of any edemas.
Similarly, some of the disease biomarkers would have to be evaluated that include the levels of
HbA1c glycosylated hemoglobin.
Fort the next appointment I would have to check the vital signs that include the blood
pressure, assessment of the catheter insertion area, any physical changes like edema, patient
concerns and assessment reports from the multi-professional team.
Identification in case 4 of Mrs. Ally
My name is XXXX YYYY; I am a community nurse from XXXXX facility. My client is
a 38-year-old female, Mrs. Ally Peterson who experiences pain and being assisted for daily

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activities. My role would be to evaluate the pain levels, assess the medication compliance, and
previous medical history. Similarly, I would get the views of Mrs. Ally with regards to the
treatment and any adverse effects they could be experiencing. Subsequently, I would request
Mrs. Ally to give their consent for the mentioned nursing activities to ensue.

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References
Akoh, J. A. (2012). Peritoneal dialysis associated infections: An update on diagnosis and
management. World journal of nephrology, 1(4), 106.
Cotovio, P., Rocha, A., & Rodrigues, A. (2011). Peritoneal dialysis in diabetics: there is room for
more. International journal of nephrology, 2011, 914849. doi:10.4061/2011/914849
Gibbons, C. H., & Goebel-Fabbri, A. (2017). Microvascular complications associated with rapid
improvements in glycemic control in diabetes. Current diabetes reports, 17(7), 48.
MacIsaac, R. J., Jerums, G., & Ekinci, E. I. (2017). Effects of glycaemic management on diabetic
kidney disease. World journal of diabetes, 8(5), 172.
Patney, V., Whaley-Connell, A., & Bakris, G. (2015). Hypertension management in diabetic
kidney disease. Diabetes Spectrum, 28(3), 175-180.
Van Buren, P. N., & Toto, R. (2011). Hypertension in diabetic nephropathy: epidemiology,
mechanisms, and management. Advances in chronic kidney disease, 18(1), 28-41.