Thesis: Nurse Case Management

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Nurse Case Management

Case Management Plan

The goal of a comprehensive case management plan for a terminally ill client should be to promote the highest possible quality of life and function for all clients and their families, while helping terminally ill clients approach death with dignity and comfort. Several themes reoccur throughout the standard of care that will be provided:

Hospice and nursing facility-services will value the dignity, autonomy, privacy, independence and choice of the clients that they serve

A client's family will be an integral part of the care plan and in the provision of hospice services

Hospice and nursing facility services will be flexible enough to accommodate a client's changing needs

Pain management and personal control are critical considerations in providing hospice services

Staff will be appropriately trained, licensed or certified in order to provide appropriate services to ensure the best possible care (Standards of Care, n.d.).

For people age 65 and over congestive heart failure is the number one cause of death, with nearly 290,000 people dying from this disease each year. Although heart failure produces very high mortality rates, treatment advances in hypertension, heart surgeries, and heart pacemakers are now improving survival rates in patients with severe heart failure (Failure Complications Congestive Heart, 2009).

The following plan is being developed for a 65-year-old male suffering from congestive heart failure. The patient has some family support network, although many live out of town. The patient has yet to accept the condition that he is in and often tries to do too much which only aggravates his symptoms. This plan is being put into place to help the patient better cope with the condition that he is in along with helping him to prepare for the end of his life in a dignified and comfortable way.

Congestive heart failure is a condition in which the heart can't pump enough blood to the other organs in the body. This can result from narrowed arteries that supply blood to the heart muscle or coronary artery disease past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle's normal work high blood pressure heart valve disease due to past rheumatic fever or other causes primary disease of the heart muscle itself which is called cardiomyopathy.

heart defects that are present at birth known as congenital heart defects.

infection of the heart valves and/or heart muscle itself known as endocarditis and/or myocarditis (Congestive Heart Failure, 2009).

The deteriorating heart keeps working but not as efficiently as it should and once did. People with heart failure often can't exert themselves because they become short of breath and easily tired. As blood flows out of the heart, the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues. Most often there's swelling in the legs and ankles that occur. This can happen in other parts of the body, as well. Fluid can collect in the lungs and interfere with breathing, causing shortness of breath, especially when a person is lying down. Heart failure can also affect the kidneys' ability to take of sodium and water out of the body. This causes the retention of water that then increases the edema (Standards of Care, n.d.).

The present patient is suffering from left side heart failure in association with coronary artery disease. The patient has experienced severe weight loss, depression and sleep apnea. He has begun to suffer from fluid buildup and impaired kidney function has set in. Life expectancy has been determined to be 8 weeks or less. This team feels that palliative care would be appropriate at this time. The patient has chosen to receive hospice care at home when the time comes.

Hospice/palliative care is a model of quality, compassionate care for individuals facing a life-limiting illness or injury. Using a multidisciplinary approach, care is assessed and delivered addressing all facets of a person's illness, injury, or pain. Attention is given to physical and psychosocial needs, pain management, and emotional and spiritual support tailored to the person's needs and wishes. Support is given to the individual's loved ones as well. At the heart of hospice and palliative care is the belief that each of us has the right to die pain-free and with dignity, and that our families will receive the necessary (Walsh, 2003).

The palliative team will consist of palliative care doctors, nurses and social workers. It is often found that chaplains, massage therapists, pharmacists, nutritionists and others are also part of the team. Working in partnership with your primary doctor, the palliative care team will provide:

Expert treatment of pain and other symptoms

Close, clear communication

Help navigating the healthcare system

Guidance with difficult and complex treatment choices

Detailed practical information and assistance Emotional and spiritual support for you and your family (What is Palliative Care, 2009).

The goal of the palliative care is to relieve suffering and provide the best possible quality of life for patients and their families. Palliative care is designed to relieve symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and difficulty sleeping. Its aim it to help patients gain the strength to carry on with daily life. It helps to improve a patient's ability to tolerate medical treatments. It helps them to better understand their choices for care. In general, palliative care offers patients the best possible quality of life during their illness. Palliative care helps to benefit both the patient and their families. By symptom management, communication and support for the family as the main goals. The team helps patients and families make medical decisions and choose treatments that are in line with their goals (What is Palliative Care, (2009).

The patient will be referred to the palliative care program through the local hospital. They will help the patient to coordinate pain management care along with helping him with his fatigue and sleeping difficulties. When the time is appropriate the palliative care staff will help the patient and his family transfer care to the hospice unit at the hospital. The palliative care management team will also provide the patient with a referral to counseling to help him with his depression. There will also be some home health care nursing set up to provide the family with the necessary knowledge and resources to help make the patient as comfortable as possible. The palliative care team will also coordinate the family support that the patient needs at this time. It has been brought to our attention that the patient's daughter that lives out of town would like to be here, but is not in a financial position to make that possible. The team will investigate any possible community resources that might be available in order to ease this situation. These resources will be put into place in order to make sure that the patient is receiving the best possible care under the circumstances.

At the appropriate time the palliative care management team will refer the patient to the hospice program at the hospital. Hospice is a philosophy of care as opposed to a treatment. The hospice viewpoint recognizes death as the final stage of life. The goal of hospice is to enable patients to continue be alert, live a pain-free life and to manage other symptoms so that their last days may be spent with dignity and quality, surrounded by their loved ones. Hospice confirms life and does not hasten or postpone death. Hospice care cares for the person rather than treating the disease. The care focuses on quality of life rather than length of life. Hospice care is family oriented care that centers on the family. It involves the patient and the family in the decision making process. Care is made available for the patient and family 24 hours a day, 7 days a week. Hospice care can be given in the patient's home, a hospital, nursing home, or private hospice facility (What Is Hospice Care, 2009).

This plan will be document and kept in the patients file. It will be reviewed on a weekly basis in order to make sure that we are on the right track and to document any changes that have occurred in the patient's condition. During this review it will be determined if any additional services are needed and how those will be introduced. Changes in the plan will be communicated to both the patient and the family within 24 hours. These weekly review meetings will include all appropriate parties who are currently providing care for the patient.

In order to make sure that the team is protected from legal issues that may occur the following directives should be followed:

There should be shared decision making to include the nurses, patient and family in all health care decisions.

There should be informed consent or refusal. Legal documentation and understanding of personal decision regarding health care.

Estimating prognosis should use evidenced-based morbidity and mortality data that is explained to patient to assist with decision making.

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Nurse Case Management.  (2009, October 3).  Retrieved August 19, 2019, from

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"Nurse Case Management."  3 October 2009.  Web.  19 August 2019. <>.

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"Nurse Case Management."  October 3, 2009.  Accessed August 19, 2019.