1           Introduction

The underlying report is aimed at identifying the complex care needs of patient, such that care plan for the patient can be devised for three prioritized needs. The name of patient is Mrs Mary Tonkin, who is 79 years old women, who is living alone and has limited social ties. The patient has stayed for five days in hospital for treatment of Atrial Fibrillation (AF), which has resulted in dizziness and shortness of breath along with continuous episodes of fatigue in the patient. Along with AF, patient has complex history of chronic ailments. For instance, Mrs. Mary has suffered from Transient ischaemic attack in 2016, from which she has recovered and again suffered from right sided Cerebro Vascular Accident (CVA) in 2018, which requires continual assessment of neurological conditions of the patient. Other significant issues which make it compulsory to offer complex care to Mary are; Diverticulosis, Cholecystectomy (2000), Atrial fibrillation, Hypertension and Type 2 Diabetes Mellitus and Colles fracture from a fall at home with internal fixation. Based on the chronic condition of patient, the following medications are taken by her; Clopidegrol 75mg PO daily, Digoxin 125mcg PO daily – AF, Warfarin 3mg, Microzide 25mg PO daily and Metformin 500mg. The drugs taken by patient are not without side-effects and given the chronic condition of patient, in-house nursing care is recommended for the patient. The underlying report has chosen the three needs of Mrs. Mary, which require close consideration of multidisciplinary team members, such that effective care can be offered to the patient, along with monitoring for any complexity associated with medication side-effects and disease related complexities. Additionally, the role of registered nurse in provision of care services is also highlighted along with potential barriers to patient’s long term care.

2           Chronic and Complex Needs

The complex needs of patients are also regarded as long run care needs, which might be the result of chronic health care conditions experienced by patients. The complex needs are linked with combination of multiple health conditions of patients, which might include heart stroke, diabetes, chronic brain damage, Alzheimer’s, any physical disability, multiple tissue disorder, kidney failure and many others (Schoen et al., 2011). The condition involving multiple morbidities mainly require the involvement of multiple care providers, which is mainly accompanies by community or home based care mechanism (Phillips et al., 2008). The complex care is mainly person-centered and in order to enhance its effectiveness, it needs to be equitable, multidisciplinary, data based and team based. The multidisciplinary team members are needed to encourage lifestyle changes among case, such that patient can be helped to keep the level of diabetes under control (Schoen et al., 2011). Such that patient can be encouraged to become physically active, take nutritional food only, avoid sugary food and drinks and not to eat heavy meals after evening.

3           Justification of complex care needs of Mrs. Mary

Mrs. Mary is having complex care needs, as she is suffering from series of complex illnesses which have potential risk factors for long run wellbeing of the patient. For instance, the patient has suffered from Transient ischemic attack in 2016 and in 2018 she has suffered from cerebro vascular accident. CVA has caused hemiparesis, whereby patient is feeling weakness on left side of her body, especially leg. These kind of strokes are considered as serious, as they are followed by risk of another stroke, which is most likely during the first stroke of initial one (Hong, Abrams & Ferris, 2014). It is notable that chances of second stroke are mainly high for patients who have history of hypertension, diabetes, any heart related issue, are of older age and have suffered from Transient ischemic attack at any point in their lives (Kim, Subramaniam & Flicker, 2018). All of these risk factors are witnessed from the past medical history of Mary and thus it can be anticipated that she is at high risk of having another stroke. Therefore, she needs long term medical care based on this complex care need.

Additionally, the patient’s past medical history has also shown that Mary had conditions of Diverticulosis, Cholecystectomy, Atrial fibrillation, hypertension, diabetes and Colles fracture. All of these conditions are co-morbid and thus continuous care is needed to ensure that any severe condition can be controlled in effective way (Huyse et al., 2001). The potential risk factors for each of the medical condition are expected to be severe, as medication taken for the treatment of Mary are mainly blood thinners, which are; Warfarin and Clopidegrol. These medications put her at risk of bleeding and there is need to closely monitor the patient’s condition to avoid excessive blood thinning.

4           Prioritization of care needs for Mrs. Mary

Three needs which are identified for Mrs. Mary in order of high to low priority are as follows;

1. Post stroke care and Physio Therapy to recover from Hemiparesis
2. Lifestyle modification and diet changes to control diabetes
3. Counseling and psychological care

5           Justification for Prioritizing care needs for Mrs. Mary

5.1         Post Stroke Care and Physio Therapy to recover from Hemiparesis

The identification of physical therapy as one of the high priority needs is based on the notion that physical weakness is highly depressing for the patient. It is notable that Mary has had suffered from Colles fracture from fall at home and hemiparesis can further increase the chances of fall. Additionally, 79 years old patient is likely to have osteoporosis which can be worsen from trips and falls. In similar way, it is addressable that Mary is taking medicines for blood thinning, and any injury from fall can lead to uncontrollable bleeding. Mobility is also important for patient for avoid condition of bed bound, such that posture changes can be encouraged and bed sours can be avoided, which are common issues followed by CVA (Hong, Abrams & Ferris, 2014). In order to recover from hemiparesis, it is highly important for Mary to get physio therapy at regular intervals. The issues of mobility, balance and coordination can be improved through physical training and exercises, such that patients can learn to balance and walk with ease.

5.2         Lifestyle modification and diet changes to control diabetes

The care for diabetes has been prioritized as second most important need of Mrs. Mary, which needs consideration of multidisciplinary team members. The reason for prioritizing it is based on the fact that patient’s HbA1C 2 months ago was 11.8, which indicates that value of blood sugar is too high for case patient. If timely care is not taken for diabetes, then it can result in severe health conditions, such as; heart stroke, eye problem, kidney failure and nerve damages among other conditions (Hickam et al., 2013). Likewise, high sugar level in older age can lead to Alzheimer’s disease. It is notable that Mrs. Mary has recently been forgetful about things and also has family history of Alzheimer’s, showing that she is at greater risk to suffer from this condition, if level of diabetes is not controlled (Herman et al., 2005). The lifestyle changes and diet changes are thus highly needed to control diabetes.

5.3         Counseling and psychological care

It is notable that Mrs. Mary has gone through hard time lately, as her husband died of chronic illness and she has left alone at the home. Her complex health condition is further an addition to her deteriorating mental health conditions, and she is a sufferer of hypertension. Patient has also suffered from cardiac arrest, which causes psychological trauma. Given her chronic health care condition and her social isolation, it is anticipated that Mrs. Mary is traumatic and she needs mental health assistance. Counseling and psychological care is also important for enhancing the will power of patient, as there is significant connection between patient’s mental health condition and success of treatment through medication (Craven & Bland, 2006). Therefore, this need also needs substantial contribution of multidisciplinary medical team.

6           How MDT will meet these needs?

6.1         Delivery of care to recover from Hemiparesis

In order to deliver best possible post stroke care to patient, firstly the services of physiotherapist are needed. The home care packages of physiotherapist are widely important in this regard, whereby physiotherapist will be needed to maintain close communication and collaboration with other stakeholders involved in care delivery of Mrs. Mary. Along with providing physiotherapy, the therapist will also help the patient with different exercises and posture building (Coleman 2003). The exercises will help Mary to strengthen her muscles, such that she can move with ease around the house. Additionally, the session to improve balance and coordination will also be delivered by the physiotherapist. It is important to mention here, that any exercise and physical therapies are beneficial when they are accompanied by healthy and nutritional diet. In order to assure that patient is taking needed diet, the coordination is needed with nutritionist who will serve Mrs. Mary with life style modification and diet changes. Finally, in order to continue the exercise routine, the willpower of patient is highly important, which will require physiotherapist to coordinate with psychologist and therapeutic recreation specialist.

In addition to physical therapy the community nurse along with others will be responsible to offer inclusive post stroke care to Mrs. Mary (Australian Primary Healthcare Nurses Association, 2020). The vitals of patient will be checked on regular intervals to identify any changes which could be alarming to health condition of Mrs. Mary. The medications will be provided to patient on continual basis under the supervision of nurses. Additionally, she will also be monitored for any serious side effects of drugs which are being taken by her.

6.2         Care to encourage lifestyle modification and diet change

In order to keep control of blood sugar level of patient, the nutritionist services will be obtained, who will encourage the patients to take food which can help to control the glucose level. As patient is taking metformin daily, so chances of hypoglycemia could also arise. It will need the nurse to monitor HbA1C on regular intervals, along with assuring that right proportion of nutrients are given to patient to avoid any complex condition. In addition to this, the life style modification will be encouraged with assistance of therapeutic recreation specialist, physiotherapist and nutritionist. The mobility of patient will be encouraged through exercises and physical activities, as active lifestyle is recommended for patients with diabetes. The clinical nurse specialist can also play role in this regard, as they are trained to recognize the behavioral aspects of patients who live with chronic conditions (Productivity Commission, 2008). These nurses will be needed to offer education and coaching to patient regarding the needed living style and diet to live a normal life with type 2 diabetes. One instance is of personalized care plan devised for Mrs. Mary which will be implemented with the help of nutritionist to assure that patient diet and life style are well aligned with health standards for diabetic patient.