Complexity

Complexity for this case study client is a multi-faceted relationship between physical and psychosocial factors contributing to Jonathan J. Rambo’s current health status. The interrelation of multisystem involvement, cognitive and affective influences and his social supports all contribute to form his current state of being and his selection as the author’s case study client for complexity.

Understanding the complex nature of Mr. Rambo’s condition begins when assessing his physical status. Mr. Rambo presented with a hospital admittance of unstable angina and his potassium levels were elevated to 5.8. Characterized by an imbalance between myocardial oxygen supply and demand, unstable angina, results from coronary artery narrowing caused by a non-occlusive thrombus that has developed on a disrupted atherosclerotic plaque. However, the results of Mr. Rambo’s angiogram showed a normal ejection fraction and no new lesions or notable occlusions since his previous stent repair (Mar ’08- BMS to RCA, Aug ’08- DES x 2 RCA, Nov ’08- no changes noted). These finding along with his history lead his physicians to question presence of diastolic heart failure. Patients with diastolic heart failure are typically elderly, usually obese and frequently have hypertension and diabetes. Mr. Rambo still experienced variable chest pain throughout his admittance with no ECG changes.

In poorly controlled diabetic like Mr. Rambo, small vessel disease greatly contributed to total plaque burden and the inability to perfuse most of the myocardium, likely accounting for the difficulty in controlling his chest pain. Along with Type II DM (now requiring insulin) and cardiac issues, small vessel disease influences Mr. Rambo’s chronic renal dysfunction with chronically elevated urea and creatinine levels. Diabetic nephropathy is a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli (National Institute for Health and Clinical Excellence, 2008).

Another major contributory factor to Mr. Rambo chronic renal disease, is the vessel changes associated with long-standing uncontrolled HTN. In many cases, renal ultrasound will be performed, since hyperkalemia is highly suggestive of renal failure. Hyperkalemia is the most common immediately life-threatening metabolic complication of renal failure and may develop suddenly when GFR is severely reduced (Krause, 2006). An abdominal ultrasound for Mr. Rambo revealed kidneys with thin cortices consistent with renal disease.

Contributing to the presence of already serious disease in Mr. Rambo, he possesses several criteria occurring in combination (HTN, Obesity, elevated triglycerides, and impaired fasting blood sugar) giving rise to metabolic syndrome. The presence of these conditions has a favorable effect on the incidence of cardiovascular events. These conditions however, have had greater prominence for Mr. Rambo in contributing to his recent hospital admittance with ACS. The loss of Mr. Rambo’s wife and main social support is likely to have resulted in changes in multiple lifestyle areas. Living with chronic pain and diagnosed with depression prior to his wife’s passing from a chronic illness, Lane, Chong, and Lip(2005) purport that people in this type of dire situation are less adherent to their medication regimen and in modifying their lifestyle appropriately (e.g., diet, exercise) thereby increasing the likelihood of recurrent cardiac events. Many patients like Mr. Rambo with heart failure and comorbidities will not experience meaningful improvements in survival with aggressive therapy, and the goal of management should be symptomatic improvement and palliation as is now the case for Mr. Rambo.

In accordance with the authors contention of complexity Safford, Jeroan, Allison, and Catrina (2007) also views complexity from multiple axis of influence as well. They discuss the usage of the Vector Model as a way to view five domains (Figure above right) that cover a holistic viewpoint. The greater the influence of the axis, the more complex a client’s condition is. The model showcases that if multiple forces of complexity are recognized, it can aid to see a diagrammatic representation of multiple areas of health concern so they can be better understood in terms of severity of complexity and how it may influence the client’s state of health.

Many diabetes and hypertensive patients have multiple medical problems, contributing to complexity (Safford, brimacombe, Zhang, Rajan, Xie, Thompson, Kolassa, Maey, & Pagach, 2009). Additional challenges along this axis are imposed by disease severity (ACS, CRD, obesity, chronic pain). Complexity is also introduced along the behavioral axis, because diabetes and HTN imposes considerable self-care demands. These self-care demands can be especially difficult for patients who lack social support, contributing to complexity along the socioeconomic vector (Safford,et al, 2009).

Reference

Krause, R. S. (2006). Renal Failure, Chronic and Dialysis Complications. Retrieved March 2, 2009, from http://emedicine.medscape.com/article/777957-overview

Lane D. A., Chong A. Y, Lip G. (2005). Psychological interventions for depression in heart failure. Cochrane Database of Systematic Reviews 2005, Issue 1. Retrieved Monday March 2, 2009, from http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003329/fra me.html

National Institute for Health and Clinical Excellence(2008). Clinical guideline: Chronic kidney disease. Retrieved March 2, 2009, from http://www.nice.org.uk/nicemedia/pdf/CG073NICEGuideline.pdf

Safford, M. M., Allison, J. J., and Kiefe, C. I. (2007). Patient complexity: More than comorbidity. The vector model of complexity. Society of general internal medicine. 382-390.

Safford, M. M., Brimacombe, M., Zhang, Q., Rajan, M., Xie, M., Thompson, T. Kolassa, J., Maney, M., and Pogach, L. (2009). Patient complexity in quality comparisons for glycemic control: An observational study. Implementation Science 2009, 4(2). Retrieved March 2, 2009, from http://www.implementationscience.com/content/4/1/2