NURS 3003 Dynamics of Practice: A Case Study of Transitioning Care

This case study focuses on Mrs. Mary, a 77-year-old widow with a history of medical issues including left-sided leg hemiparesis, atrial fibrillation, and a fear of hospitals. The essay evaluates her complex needs and proposes a multidisciplinary care plan to support her desire to stay at home. Specific needs addressed include assistance with daily living activities, managing shortness of breath, and addressing mobility restrictions. Interventions involve a multidisciplinary team consisting of a preventive health nurse, physiotherapist, dietitians, psychotherapists, and other healthcare professionals. Funding and resources for medications and equipment like nebulizers and inhalers are also considered, along with potential drug interactions. The care plan emphasizes patient empowerment, therapeutic relationships, and integrated residential care to improve Mrs. Mary's health conditions and quality of life.

Running head: NURSING
Topic: NURSING
Name of the Student:
Name of the University:
Author’s Note:

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Introduction
The case study revolves around Mrs. Mary who lives an independent life along with
her two pets. She has three sons but only her youngest son lives nearby along with his own
family. Her husband has died years ago due to an accident suffering from pneumonia and
osteomyelitis. Considering the present condition of Mary, she is afraid of hospitals and wants
treatment at home. Regarding the clinical complications of Mrs. Mary, she has suffered from
left sided leg hemiparesis. This has been followed by chances of stroke. Thus she has
difficulties in mobility. She has also suffered from shortness of breath, dizziness as well as
fatigue. Thus rapid electrocardiogram has been suggested for Mrs. Mary for her problems.
She also has under gone transoesophrengeal echocardiogram for her ailments pertaining to
the heart. Although her family members are supportive, her daughter in law wants her to be
admitted to a residential aged care facility. Thus from the given study, the physical problems
like mobility difficulties along with occasional difficulties in breathing have been diagnosed.
Moreover, excessive stress in Mrs. Mary’s life is evident from the fear of hospitals. Thus, the
following paragraphs would focus on the specific needs of the patient. Such needs would be
justified pertaining to the injuries faced by Mrs. Mary. Moreover, a multidisciplinary team
would be required for the provision of an effective care plan based on the complex needs of
Mrs. Mary and thus introduce interventions based on her needs. Furthermore, this essay
would highlight the amalgamation of the roles of the patient, nurses and the establishment of
an effective patient nurse relationship. It would also include the roles of the members of the
multidisciplinary team in proving support and care for the recovery of Mrs. Mary from her
illness. Such interventions highlighted would aim at improving her current health conditions.

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Evaluation of the complex needs and care by the patient
Such needs are substantial and long term. It is often used in the treatment of chronic
illnesses or disabilities. However, the care given to the patient is short term as well as severe
illness for a brief period of time (Gray et al., 2014).
According to (Ridgeway et al., 2014), patients having complex as well as chronic
conditions draw upon various ranges of social, personal as well as various health care
resources for management and coping up with the various demands involving complex care
of the patient. Various countries have faced challenges in providing patients better needs of
the patient. Such governments have played an important role in providing better equipment
for the primary care doctors for caring with patients and specially treating patients with
complex needs (Osborn et al., 2015).
In the given case study, Mary has been suffering from short breaths and the health
condition has declined for the past few years. She has been suffering from respiratory
disorders from a long period of time, which is for the past three years. Moreover, she has
spent almost five days recovering from recurrent episodes of shortness of breath, fatigue and
dizziness. Thus special care and interventions should be formulated for addressing the health
needs of Mrs. Mary depending upon the special needs ad care of the patient. Thus,
formulation of a proper complex care plan is required for the patient which basically involves
various treatment strategies and care plans for the escalation of health needs of the patient
(Jethwa & Onalaja., 2015).
Three specific needs of the patient and their justifications
There are three specific needs of the patient which are required for the nursing care
plan and intervention formulation for the patient. The first intervention inclusive of the

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declining condition of Mrs. Mary’s health is incorporation of nursing interventions regarding
difficulties in carrying out regular movements. She also has been having difficulties
regarding maintenance of her daily activities. The specific need is assistance regarding the
incorporation of activities of daily living. Moreover, she has been suffering from short
breaths and her doctors have confirmed the presence of atrial fibrillation thus requiring an
echocardiogram. Thus, the second need would be assistance for shortness of breaths. Thirdly,
the specific need of the patient would be assistance regarding restricted mobility issues. It is
because she has been suffering from problems due to mobility due to her left leg injuries. As
a result of which she has hemiparesis requiring specific nursing interventions.
Intervention for management of her daily activities
In the given case study, Mrs. Mary has shown declining health conditions. Such
conditions have made it difficult for her to carry out her daily activities like gardening and
cleaning and thus preventive health care nurse is required. The nurse would include various
regular exercises according to the permissible limits of Mrs. Mary (Verway et al., 2014).
Moreover, weight management is an important duty of the preventive health nurse. Moreover
she should help in communicating with the patient for the establishment of a healthy
therapeutic relationship while following a holistic care of plan. The health activity focused
here is inability of physical activity (Clarke & Foster, 2015). Thus a multidisciplinary team of
health care professionals would be required consisting of a physiotherapist, dieticians,
psychotherapists, fitness and health workers, community workers, health policy makers who
would be fruitful in the propagation of the enhanced PA or physical activity levels among the
patients. The health professionals in the activation of the various interventions for physical
activities would be directed towards working for the development of the common goals.
Moreover, they would help in the creation of a forum for the solution of problems which
hinder the mobility of Mrs. Mary. Creation of various innovative ideas would help in the

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improvement of the pain of the patient. Thus incorporation of these different ideas would also
help in the motivation of the patient and ultimately help her in the promotion of the daily
activities. The multidisciplinary team for enhancing the mobility of Mrs. Mary would help in
providing an integrated residential care at home (Aldred et al., 2016). It has been found that
integrated care is often associated with enhanced client satisfaction, which increase the home
based services and often includes reduced delays in the hospital services which is often
delivered to patients (Low & Fletcher, 2015).
Intervention for her heart diseases (atrial fibrilation)
According to the case study Mrs. Mary has suffered from a brief period of atrial
fibrillation. Thus, she would need an effective care plan and the help of a multidisciplinary
team consisting of related healthcare professionals for her care and support (Bose et al.,
2015). For such problems related to the atrial fibrillation cases ,a specialized AF nurse would
be needed who would provide interventions for risk factor control, effective patient education
and help in the enhancement, compliance and empowerment of the patient. The nurse would
help in the follow up accordingly. Similarly, she would function mainly in controlling the
medical treatment procedures (Qvist et al., 2016). The MD team would necessarily consist of
cardiologist helping the patient with her heart disease. Moreover, a primary care doctor
would be needed who would provide the routine of the patient and help in preventive
healthcare including basic tests and physical exams. The cardiologist would help in the
diagnosis and treatment regimens of the patient. Moreover clinical nurse specialists,
physician assistants, nurse practitioners would be needed. Dieticians would help in the
advocacy of heart healthy eating habits (Welbourne et al., 2016). They can also make the
patient understand about the various patient directed inserts and the instructions of the labels
including the drugs and their required prescribed doses.

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Thus the administration of a proper care plan and intervention would an important
step of the MD team where the primary aim would be guiding the patient in a proper way
towards recovery and help in the escalation of the present health conditions of the patient,
Mrs. Mary in the given scenario (Wal et al., 2015).
Interventions for hemiparesis and mobility
In the case it has been highlighted that Mrs. Mary has been suffering hemiparesis on
the left leg. Hemiparesis is a medical condition where there is weakness and paralysis like
condition on only one side of the body. Thus a person suffering from hemiparesis would
often suffer from the inability to move her arms and legs. It is thus a serious condition of
hemiparesis which would be considered as a major nervous system disorder.
According to Prochazka (2017), a neuroscience nurse would be helpful in the given
case study as she is a professional who would help the patients suffering from various
neurological disorders ad help in the healing of injuries like spinal trauma, illnesses like
paralysis and Parkinson’s disease, epilepsy, as well as multiple sclerosis. Hemiparesis
basically involves weakness of the body part which occurs mainly before or after stroke and
is often due to neurological dysfunction. Thus the function of the neurological nurse would
be enhancing the various processes of the neurological system which would ultimately help
in escalating the ability of the patient. A rehabilitation nurse would be required who would
help in the evaluation and treatment for the patients and would help the patient in gaining
independence regarding the body movements. The focus of the nurse would be enhancement
of the prevention, medical care and prevention of complications of the family and the patient
education.
The healthcare professional for the treatment of Mrs. Mary would be a physiotherapist
who would help in lifting the patient’s legs form the table of examination when the patient is

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usually at the supine position. The patient is supposed to lift the affected extremity where the
absence of the pressure is often involved in the apathy of the patient. Moreover an
occupational therapist would be required who would help in the improvement of the
performance of tasks which are included for the enhancement of the daily living as well as
the working environments. Thus an occupational therapist would help in development of the
physical, developmental issues of the patients. Moreover, a respiratory therapist would also
be helpful for Mrs. Mary as it would help in restoring the normal respiratory functions among
patients with airway as well as breathing problems.
Additional resources for funding the patient and supporting her care
From the case study it is evident that Mrs. Mary has frequent breathing problems
where she experiences frequent shortness of breath .Thus a nebulizer would be required for
facilitating their breathing rates (Leaker et al., 2014). Moreover, it would help in the
reduction of swelling and inflammation in the bronchial tubes which would help in the
reduction of the mucus thus helping in breathing. Moreover, an inhaler would be required for
the easy breathing for her breathing rates. Since she has been already undergoing
medications, like clopidegrol for preventing heart attacks as well as strokes in people
suffering from heart diseases, warfarin for preventing blood clots or prevent them from
getting worse, digoxin used with other medications especially in cases of atrial fibrillation.
Thus it is mainly used for treating irregular heartbeats, macrolide for the treatment of
infections due to gram positive and negative bacteria which would be required for her
enhancement in health. Digoxin inhibits P glycoprotein which ultimately leads to decrease in
renal clearance of digoxin. Warfarin is an enantiomer and substrate for CYP 2CP which can
lead to increased bleeding of gastrointestinal tract. Clopidegrol is a pro-drug which requires
activation by CYP 2C19 Theophylline is metabolized by CYP 1A2 which is used mainly or

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chronic obstructive pulmonary diseases. Most important side effects of the drug is drug
interactions which leads to severe diseases conditions. These medications are associated with
various side effects like headaches, nausea, nose bleeding, stomach ache, dyspepsia, along
with frequent abdominal pains. Moreover, drugs like warfarin often have various effects like
severe bleeding, change in the color of urination, bloody stool, severe stomach pain along
with joint discomfort and swelling especially when there are cases of injury Thus these drugs
often have various side effects which should be maintained in proper doses by the nurse for
effective treatment and control of the various side effects of the disease. She has also shown
problems regarding mobility due to hemiparesis in her right leg. Moreover, specialized
equipment would be required for her bath safety to prevent additional accidents due to fall.
Mrs. Mary would have financial problems in arranging for all the equipment for her
disabilities along with increasing expenses for her ailments. In Australia, there is the
department of human services who provide help for older people regarding financial
assistance through methods of payment like aged pension, mobility allowance, disability
support pension, carer payments and other related options. Organizations like the National
Legal aid would help the people along with the costs for resolving the legal problems. The
various services would involve information, advice, negotiation, representation. Moreover,
apart from the subsidies she could pay with the help of the financial support from her sons
and her family members who work outside and earn enough for the treatment of their mother.
Role of the registered nurse in assisting the needs of the patients
According to Mariani and Doolen (2016), the roles of a registered nurse (RN) is not
only limited to provision of care to patients. Among the various roles, they might be
important for the administration of the various daily duties, strictly considering the
administration of medicine, consulting with the various healthcare providers. They would
also be involved in the monitoring of the various healthcare needs of the patients (Smolowitz

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et al., 2015). Moreover, they would be involved in the education of the family members and
the education of the individuals would be involved in the management along with best
support given to the doctors along with various healthcare professionals. In the following
case study, a registered nurse would be involved in checking the weight, height of the patient
at home. They would monitor the follow up of the patients along with the incorporation of
medications and the physical activities within time (Wonjar & Whelan, 2014). A registered
nurse would also maintain and fulfill the duties of a regular critical care home nurse
monitoring their work and also deal with the various needs of the patient with the equipment
and their proper instructions for use (Kumaran & Karney, 2014). Among the various
qualities a registered nurse should acquire in this case study; critical thinking and problem
solving are the two main characteristics which are required for the treatment. Establishment
of proper therapeutic relationship with the patient and following of a holistic care approach
would be important in the provision of care and support to the patients (Philips et al., 2014).
The nurse should take the help of National disability Insurance Scheme for further assistance.
The National Disability Insurance Scheme (NDIS) actually aims in providing community
linking as well as individualized support for the people having significant as well as
permanent disability. Social workers should have the skills, knowledge expertise for the
provision of support for various levels including planners, community development as well as
direct practice roles. Thus various functions of the social workers are early intervention
supports, therapeutic supports, behavior support along with specialized assessment of
abilities, skills and needs along with the assistance of accommodation and tenacity. Social
workers play an important role in the control of diseases through effective planning through
family counselling and offering various sources of group education. Moreover they work for
the community for escalating the development of various sources which ultimately help in the

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assistance of the patients and help them in meeting the needs through effective pan of care
and interventions for a better quality of life.
Potential barriers to this care
Involvement of various social factors in the consideration of provision of effective
care include patient participation which would include involvement of the patient and her
family in the various decision making processes about the various treatment processes and
the incurring expenses. Moreover this participation has found to help the enhanced patient’s
compliance with the various secondary preventive actions which would help in the
improvement of the overall health of the people involved (Vahdat et al., 2014). Regarding the
social factors affecting the care given to the patient, health services are important in the
backdrop of the cultural background. Heath users or patients and their families who are
involved as an integral part of the provision of care would like the proper value of autonomy
as well as participation towards the various subjects of care. Indigenous health care attention
is an important aspect to keep in mind as the patient might belong to an indigenous
background (Simmons & Alexander., 2015). Indigenous care methods are based on different
approaches in places all across the world. They are usually based on the different rituals and
the values which are directly linked to the nature as well as religion. Many services however
have different service rationales which are based on the biomedical approach to varied health
issues which focus on mainly the biological bodies (Shum et al., 2017).
Consideration of issues related to the patient’s medication needs
For the effective maintenance of the doses for the medications given to the patient, the
nurses should strictly monitor the dose and punctuality of the medications. Moreover, she
should form a checklist consisting of the dietary requirements of Mrs. Mary and the various
physical exercises which need to be conducted for the recovery from her health conditions.
Since she is afraid of hospitals the nurse should remember and provide the various

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requirements effectively using a patient centered approach through effective residential care
treatments. Apart from recording the medical history of the patients and her symptoms, she
should take the help of the healthcare professionals of her multidisciplinary team for
advocacy of the overall health and well-being of the patient (Sherwood & Zomordi, 2014).
Moreover, the nurse would be involved in performing various diagnostic tests and help in the
enhancement of the education of the patients, informing them about the various ways of
management of the illness. Moreover regarding the medications of the patient, the nurse
should also educate patients about the management of the illnesses and would involve the
support of the advice given to patients reading the use of various doses of the medications
(Papastravrou, Andreou & Efstathiou, 2014).
Conclusion
Thus from the aforementioned paragraphs it can be understood that Mrs. Mary is a 77
year old patient whose main symptoms are short breaths followed by atrial disorders along
with difficulties in mobility due to hemiparesis. Thus a proper care plan and intervention
would be required which would be formulated through a team of effective healthcare
professionals belonging to a multidisciplinary team. Moreover she would also require the
help of an registered nurse who would help in the strict monitoring of her doses and help in
adhering to her usual dose of medications as she has a forgetful memory due to her advanced
age. The three main clinical needs identified in the case of Mrs. Mary are including
considerations for her restriction in the daily activities, difficulties in heart problems as well
as mobility issues due to hemiparesis. Thus, specific role of the healthcare professionals
involved in the multidisciplinary team would involve incorporation of proper plan of care in
her regimen for her recovery from the disease. Thus all the interventions, combined with the
various processes for the treatment along with the implementation of the care plan and the

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medication dose would help in escalating the overall health quality of Mrs. Mary and help her
to pursue a normal life.