Adult-gerontology primary care nurse practitioner’s analysis of the health issues
A high body mass index (BMI) and an elevated lipid level are the major concerns in the current study. Lipids, such as cholesterol play an important role in many systems of the organism: cardiovascular, nervous, hormonal, and so on (Goldberg, n.d.). However, a misbalance in the lipid profile may be detrimental to health as the elevated levels of low-density lipoprotein (LDL) may cause multiple disorders including atherosclerosis, and can increase the risk for the development of heart disease (Goldberg, n.d.).
The situation may be aggravated by the patient’s overweight because, when combined with dyslipidemia (an increased LDL cholesterol level), it promotes insulin resistance, as well as various lipid disorders including those associated with obesity (Hirakawa et al., 2016). The given issues must be addressed first because, based on the analysis of the family history, the patient may be predisposed to Alzheimer’s disease from which his father suffered.
Alzheimer’s is a genetic disorder that may develop in case a person inherits an altered gene from a parent. The recent research also reveals that the disease can be triggered and its development may be accelerated by hypercholesterolemia (which is also present in the patient’s family history) because cholesterol mediates the production of essential amino acids in the brain and defines the peptide balance (Ricciarelli et al., 2012). Due to the important role of cholesterol in the central nervous system, its excess presence in the organism may disrupt the metabolic processes. Therefore, it is critical for Mr. Wilson to improve his lipid profile promptly to prevent the onset of Alzheimer’s disease and other possible complications.
The clinical scenario for the patient
Currently, Mr. Wilson’s total cholesterol level is on the borderline high, i.e., 221 mg/dL compared to <200 mg/dL which is considered to be an indicator of health (Institute for Quality and Efficiency in Health Care [IQWiG], 2016). Additionally, the patient’s level of LDL is increased − 152 mg/dL (instead of <130 mg/dL), while the level of favorable high-density lipoprotein (HDL) that contributes to the decrease of health risks (e.g., heart attack and stroke) is, on the contrary, below the norm − 38 mg/dL (instead of 40> mg/dL) (IQWiG, 2016).
According to Félix-Redondo, Grau, and Fernández-Bergés (2013), “hypercholesterolemia is a major cardiovascular risk factor that increases the incidence of atherosclerotic diseases in adults” due to the concentration of cholesterol in arteries and the following development of fatty lesions in them (p. 154). Therefore, Mr. Wilson is currently at risk of cardiovascular disease development.
The complaint about the transient joint pain in knees, wrists, and fingers that appears in the patient every few months may be associated with his high BMI. As stated by Gay et al. (2014), non-traumatic joint pain is positively correlated with the advanced age of individuals and their overweight or obesity. Okifuji and Hare (2015) also observe a direct association between obesity and osteoarthritis − a musculoskeletal condition that provokes severe joint pain and often becomes a cause of total hip or knee replacements in patients. With a BMI of 28, Mr. Wilson is at risk of obesity development. Therefore, weight loss may be one of the major measures for osteoarthritis prevention in the patient.
Working/differential diagnoses
Working Diagnosis: Hypercholesterolemia
It is the condition associated with an increased level of cholesterol in the blood. The risk factors for its development include heredity, obesity, hypodinamia, and stress. Hypercholesterolemia is one of the main causes of atherosclerosis and its complications, and health risks relevant to this condition rise proportionally with the increase in the LDL cholesterol levels. In general, and especially at the initial stages, patients may not feel any symptoms of hypercholesterolemia. However, with the progression of hypercholesterolemia, the patient may show symptoms linked to hypertension and atherosclerosis (Grandjean, Gordon, Davis, & Durstine, 2013).
Differential Diagnosis: Dyslipidemia
The condition implies a misbalanced concentration of lipids in the blood. It is a factor in the development of atherosclerosis − a chronic disease characterized by the densification of the arteries’ walls and the consequent impairment of blood supply to the organs. The same factors that lead to the development of atherosclerosis participate in the progression of dyslipidemia: lifestyle (physical activities, exposure to stress, diet, etc.), abdominal obesity, diabetes, high blood pressure, age, and gender (males over 45 are at higher risk), heredity, family history of strokes and heart attacks (Grandjean et al., 2013).
Differential Diagnosis: Hypoalphalipoproteinemia
It is the condition in which the concentration of HDL in the organism is reduced. The abnormal lipid and abdominal fat level, blood pressure, and sugar content associated with it are among the major causes of coronary heart disease. Hypoalphalipoproteinemia occurs in case the HDL level is less than 40 mg/dL in men and less than 50 mg/dL in women. Researchers observe that this condition can significantly accelerate the development of atherosclerosis because it leads to the impairment of reverse cholesterol transportation (Singh, 2016).
Plan of care for health promotion & disease prevention
The analysis of blood on lipid concentration is considered the main method of diagnostics for hypercholesterolemia. Since the patient’s lipid profile is already known, it may be suggested to conduct the biochemical blood test in order to measure the level of sugar, total protein, creatinine (the product of protein breakdown), uric acid (the product of purine decay) and, in this way, detect any concomitant organ damage (Grandjean et al., 2013).
As noted by Hirakawa et al. (2016), BMI and cholesterol or lipid levels in the organism are closely linked to individuals’ lifestyles and diets. For this reason, Mr. Wilson’s intervention should necessarily include a cognitive-behavioral therapy aimed to motivate him to normalize the body mass. A referral to a physiotherapist and a nutritionist can be recommended to the patient as he should be instructed on the importance of low-fat diet and physical activities in the prevention of negative consequences.
The specialist may choose an appropriate exercise regime for Mr. Wilson (e.g., through a physician-monitored exercise test) considering the severity of the symptoms and concomitant diseases. More likely, the model that focuses on large muscle groups and requires a dynamic activity must be prescribed. After this, a diet with a limited intake of animal fats, enriched with vitamins and dietary fiber should be designed for him taking into account the selected physical activity regime (Grandjean et al., 2013).
Unfortunately, recent research findings indicate that even when educated on all relevant health risks and benefits of lifestyle interventions, patients most often do not change their health-related behaviors (Sulander et al., 2012). Thus, although the emphasis on behavioral intervention should be made and it must be regarded as an important initial therapy, Mr. Wilson’s diagnosis will largely benefit from a drug intervention (Hirakawa et al., 2016).
According to Grandjean et al. (2013), HMG-CoA reductase inhibitors also known as statins are considered to be one of the most effective measures for cholesterol control. They reduce the synthesis of cholesterol by the liver, as well as the level of lipids and intracellular cholesterol, have an anti-inflammatory effect, and prevent damage to new vascular sites. Statins can also reduce the incidence of atherosclerosis-related complications and the severity of vascular lesions. However, these drugs can cause damage to the liver and muscles. Therefore, when taking statins, it is necessary to conduct blood tests regularly to detect any liver damage products in a timely manner (Grandjean et al., 2013).
Psychological consultation may also be recommended for the patient due to the reported exposure to stress. The recent research findings show that both physical and mental stresses can cause serious alterations in the immune system, and provoke the increase in serum cortisol, adrenaline, and cholesterol levels (Maduka, Neboh, & Ufelle, 2015). Therefore, the decrease in stress exposure may benefit Mr. Wilson’s lipid profile. Since a share of the patient’s stress is linked to the necessity to perform family responsibilities, a consultation with the family members and their consequent involvement in the process of the patient’s intervention may have a favorable impact on his health.
What AGPCNP core competencies are relevant to the plan of care you developed?
“Provides leadership to facilitate planning and delivery of care by the healthcare team” (American Association of Colleges of Nursing [AACN], 2010, p. 19)
The developed intervention plan addresses multiple areas of concern: physical health, psychological condition, behavior, and health knowledge. It is apparent that the involvement of several specialists is required for better results. Thus, not only must the nurse prescribe appropriate therapeutic devices but also act as a leader and coordinator. She/he must inform all the relevant parties about the current condition of the patient and provide them with the necessary information. Additionally, she/he should assist the patient in making appointments with the specialists, and guide him throughout the process of intervention.
Plan for long-term management of healthcare problems
In order to achieve better results in disease prevention, the implementation of the existing support system or the development of a new one is always needed. The preventive intervention is a long-term endeavor that requires constant supervision of the patient, as well as his motivation. For this reason, the work with family members is also included in the plan as they may help to make needed alterations in Mr. Wilson’s habitual environment and, in this way, can stimulate favorable behavioral changes in him. Therefore, the intervention plan considers the social determinants of the patient’s health − distinct lifestyle issues defined by environmental, community, family, and biological factors (Dunphy, Winland-Brown, Porter, & Thomas, 2015).
Other Competencies
Other relevant competencies are as follows: “Prescribes medications with particular attention to the high potential for adverse drug outcomes and polypharmacy in vulnerable populations”; “Designs and implements interventions to prevent or reduce risk factors that contribute to a. the decline in physical or mental function, b. impaired quality of life, c. social isolation, d. excess disability,” etc. (AACN, 2010, pp. 18-19).
Cultural, legal, and ethical considerations that apply to this case scenario
Mr. Wilson belongs to an ethnic minority group, and it is observed that, compared to whites, racial and ethnic minorities usually receive health care services and refer to hospitals less frequently (Dilworth-Anderson, Pierre, & Hilliard, 2012). Partially it may be caused by social and income inequality and disparities in the access to care associated with them. However, in the case of Mr. Wilson, the culturally defined differences in the perception of diagnosed health problems and health beliefs existing in his family may be a barrier to a successful implementation of the intervention plan.
For instance, Dilworth-Anderson et al. (2012) note that cultural values assigned to a particular disease may interfere with patients’ seeking of assistance outside the family, e.g., Alzheimer’s disease and other conditions may be regarded as a natural part of the aging process, etc. In this way, an open dialog with Mr. Wilson, assessment of his health beliefs, and family education is essential in dealing with possible issues that may be linked to the patient’s cultural background.
References
American Association of Colleges of Nursing. (2010). Adult-gerontology primary care nurse practitioner competencies. Web.
Dilworth-Anderson, P., Pierre, G., & Hilliard, T. S. (2012). Social justice, health disparities, and culture in the care of the elderly. Journal of Law, Medicine & Ethics, 40(1), 26-32.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis Company.
Félix-Redondo, F. J., Grau, M., & Fernández-Bergés, D. (2013). Cholesterol and cardiovascular disease in the elderly. Facts and gaps. Aging and Disease, 4(3), 154–169.
Gay, A., Culliford, D., Leyland, K., Arden, N. K., & Bowen, C. J. (2014). Associations between body mass index and foot joint pain in middle-aged and older women: A longitudinal population-based cohort study. Arthritis Care & Research, 66(12), 1873–1879.
Goldberg, A. C. (n.d.). Overview of cholesterol and lipid disorders. Web
Grandjean, P. W., Gordon, B., Davis, P. G., & Durstine, J. L. (2013). Hyperlipidemia and dyslipidemia. In J. K. Ehrman, P. M. Gordon, P. M. Visich, & S. J. Keteyian, (Eds.). Clinical exercise physiology (pp. 155-176). Champaign, IL: Human Kinetics.
Hirakawa, Y., Lam, T., Welborn, T., Kim, H., Ho, S., Fang, X.,…Woodward, M. (2016). The impact of body mass index on the associations of lipids with the risk of coronary heart disease. Preventive Medicine Reports, 3, 79-82.
Institute for Quality and Efficiency in Health Care. (2016). High cholesterol: Overview. Web.
Maduka, I. C., Neboh, E. E., & Ufelle, S. A. (2015). The relationship between serum cortisol, adrenaline, blood glucose and lipid profile of undergraduate students under examination stress. African Health Sciences, 15(1), 131–136.
Okifuji, A., & Hare, B. D. (2015). The association between chronic pain and obesity. Journal of Pain Research, 8, 399–408.
Ricciarelli, R., Canepa, E., Marengo, B., Marinari, U. M., Poli, G., Pronzato, M. A., & Domenicotti, C. (2012). Cholesterol and Alzheimer’s disease: A still poorly understood correlation. IUBMB Life, 64(12), 931-935.
Singh, V. N. (2016). Low HDL cholesterol (hypoalphalipoproteinemia). Web.
Sulander, T., Heinonen, H., Karisto, A., Valve, R., Pohjolainen, P., Seppälä, U., & Fogelholm, M. (2012). Weight and health behaviour changes among ageing people with medication for hypertension and high cholesterol level. ISRN Public Health, 1-5.