Essay Sample on Nola Pender's HPM: External and Internal Cues for Nurse Practitioners

Introduction

In 1987, Nola Pender established a theory referred to as the HPM (Health Promotion Model) that included a nurse practitioner's action phase necessitating both external as well as the internal cues. According to Pender (1987), whereas the external cues involved the media, supportive associations, and other community resources, the internal cues involved the elevated sense of awareness, the potential for growth as well as individual awareness.

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Internal Cues

Based on the understanding of the concept mentioned above, the internal cues illustrated in the case scenario are characterized as physiological cues including the patient's state of weakness ("a frail woman"), her labored breathing, as well as her state of diverted attention particularly when she asks for her husband after enquiring about her understanding of the reason she is at the emergency room (ER). The other vital internal cues include the bloody vomit, decreased oxygen saturation (84 %), increased temperature of 101.8 F (instead of 98.6 F), hyperactive bowel sounds, as well as increased blood pressure of 178/98, which is more than 130/85 mmHg as noted by Alwardat et al. (2018). As such, the increased level of Ruth's blood pressure suggests a hypertensive crisis that positions the patient in a hypertensive emergency. Additionally, Ruth has an open wound located at the bottom of her right foot. This physiological cue suggests that Ruth has a diabetic foot ulcer that commonly occurs in patients diagnosed with diabetes mellitus type one (DT1).

External Cues

The external cues highlighted in the case scenario include the information offered by Ruth's neighbor. The information includes the symptoms of vomiting and nausea as reported by the neighbor, the neighbor's thought that stress might play a role in the patient's lack of appetite or refusal to eat, along with the medication, which the neighbor brought to the hospital. The cues associated with vomiting, as well as reduced intake of food over the previous seven days as reported by the patient's neighbor, suggest the development of hypoglycemia (American Diabetes Association, 2019).

Hypotheses

Empirical

The first prioritized mode of inquiry concerning Ruth's case scenario is the empirical diagnosis. The empirical diagnostic hypothesis is that Ruth is ailing from a celiac disease coupled with hypertensive emergency crisis and depression due to her chronic illness, which is diabetes mellitus type 1. According to Bender and Elias (2017), the empirical nursing diagnostic inquiry may be defined as the evidence that can be measured as well as the findings which can be documented through observation to make a proper nursing diagnosis. The information from the case of Ruth that can be measured ad documented which is relevant to the celiac disease diagnosis, includes both the external and internal cues highlighted in the section above.

Upon observation and assessment the information shows, vomiting, Ruth's past medical history including type 1 diabetes, the patient's age group (elderly population), bloody vomit, decreased oxygen saturation (84 %), increased temperature of 101.8 F (instead of 98.6 F), hyperactive bowel sounds, as well as increased blood pressure of 178/98 which suggests a hypertensive crisis. The other information that supports this hypothesis includes the unkempt mattered hair, a heavy smell of tobacco as well as stained food cloths, in addition to labored breathing which meets the criteria for diagnosing both hypertension and depression.

Aesthetic

The second prioritized mode of inquiry is the aesthetic diagnosis in the case scenario concerning Ruth. The aesthetic hypothesis is that Ruth has depression coupled with her chronic illness, which is insulin-dependent diabetes mellitus based on her old age. The cues leading to the diagnosis of depression are mainly grounded on the evidence including labored breathing, fatigue as evidenced by her state of frailness, as well as appetite changes which are characterized by her behavior of eating too little as described by her neighbor (Park & Reynolds, 2015). Park and Reynolds (2015) found that in most community settings, approximately five percent of persons aged more than 65 years meet the research diagnostic criteria of depression with rates of clinically significant depression projected at between 8 and 16 %.

Ethical

The ethical mode of nursing inquiry can be described as the focus on what ought to be performed or the emphasis on the matters of obligation to establish moral decisions as well as to account for those decisions (Lee, Kim, Meong & Seo, 2017). As such, the ethical hypothesis is that the patient will be treated at the primary health care facility where her neighbor has brought her regardless of the purpose of the treatment with the ER including stabilization, reference to a tertiary health care institution, and triage. In justifying this hypothesis, the principle elements leading to this proposition is that the patient presents with emergency hypertension and decreased oxygen levels. As such, Ruth requires immediate oxygenation, monitoring her oxygen saturation levels, as well as stabilization of the respiratory system to ensure a regular breathing pattern is attained. Additionally, as a nurse practitioner, even though the distance from the hospital is long (50 miles), in addition to the fact that I am experiencing fatigue, the best ethical decision would be to put the needs of Ruth first before focusing on my interest.

Sociopolitical

One of the sociopolitical hypotheses is that Ruth's behavior of not taking medication is associated with the current challenge of increased out-of-pocket spending for her care, which is a challenge for Medicaid beneficiaries particularly elderly persons with chronic conditions.

Another hypothesis is that Ruth's social behavior of heavy smoking has resulted in a hypertensive emergency, along with the depression exhibited by the patient. The sociopolitical mode of inquiry is primarily grounded on the personal and moral dimensions of the patient as well as the economic and administrative spheres presented as cues in a given medical case scenario (Van Graan, Martha & Koen, 2016). The social context presented in Ruth's case scenario includes her heavy odor of cigarette smoke suggesting a social lifestyle of smoking, as well as the dirty appearance and mattered hair features.

The political context in Ruth's case scenario includes the chart indication of only the Medicaid form of insurance for the patient. There is evidence suggesting increased unplanned exploitation of resources in the health care sector, which impacts the health of patients within the elderly population. For instance, according to the study led by Fong (2019), Medicare beneficiaries, particularly the elderly patients ailing from chronic illnesses like diabetes and cardiovascular illnesses, are currently faced with an excess out-of-pocket annual expenditure of approximately $237 and $317 respectively.

Evaluation Plan for the Prioritized Hypothesis

The prioritized hypothesis for Ruth's case scenario includes the empirical mode of nursing inquiry. The empirical diagnosis evaluates in the case scenario includes celiac disease coupled with a hypertensive emergency crisis. As such the evaluation plan for this hypothesis includes first to conduct a caloric biopsy including small intestinal biopsy, to determine the presence of celiac disease (CD). In support of this intervention, Paul, Kinra, Nandi and Prasad (2019) noted that small intestinal biopsy is the standard evaluation procedure for the diagnosis of celiac disease. Additional laboratory tests to confirm the hypothesis will include serological screening tests for coeliac antibodies by utilizing either the IgG or IgA antibodies, along with genotypic testing for the HLA-DQ2/DQ8 haplotype ().

Moreover, the patient's internal, as well as external cues, should be evaluated to assess the presence of hypertension. The empirical hypothesis of hypertensive emergency crisis is principally based on the severely elevated blood pressure recorded at 178/98. The evaluation process will involve the assessment of Ruth's physical examination as well as her history of present illness (DT1). The patient's medical history will be evaluated including a family history of CVD (Cardiovascular disease), the medications that the Ruth has been taking, the use of pressor effect drugs, history of associated cardiovascular risk factors, as well as her smoking history. The physical examination will include the measurement of Ruth's weight and height, the examination of any signs of HMOD (Hypertension Mediated Organ Damage) including palpation of peripheral arteries and neurological examination (Williams et al., 2018). Furthermore, the physical examination will involve the evaluation of secondary hypertension including skin inspection, auscultation of renal and heart arteries, examination of signs of thyroid illness, the assessment of renal enlargement due by palpating the kidney as well as the comparison of femoral with radial pulse rate to identify radio-femoral delay associated with aortic coarctation (Williams et al., 2018).

Additionally, Routine laboratory tests will be conducted including eGFR (estimated glomerular filtration rate) and blood creatinine, blood uric acid blood triglycerides, glycated HbA1c and fasting blood glucose level, hematocrit and hemoglobin tests, blood potassium and sodium evaluation, as well as the laboratory test of blood lipids including HDL cholesterol, LDL cholesterol, along with total cholesterol content of the patient (Williams et al., 2018). Additional tests that are vital for Ruth include blood liver function tests, in addition to urine analysis. According to Williams et al. (2018), the urine analysis evaluation involves the following: urinary protein analysis conducted by the dipstick test or albumin: creatinine ratio, as well as microscopic examination of the urine.

The evaluation of depression will also be conducted based on the following symptoms exhibited by Ruth:

• The heavy odor of cigarette smoke
• Food stained clothing
• Ruth's frailness which suggests physical weakness
• Diminished intake of food
• Her alteration in both physical and mental speed perceived by her neighbor

As such, the evaluation criteria for depression in Ruth's case scenario involves the DSM-5 criteria for depression (Schmidt & Tolentino, 2018) as illustrated below:

• Significant weight loss due to inadequate dieting
• A slowdown of thought along with the reduced physical movement. This evaluation is based on the patient's response to the asked question of her knowledge concerning the reason for her presence in the ER.
• Fatigue due to loss of energy
• Her mood will also be evaluated by inquiring about the state of her daily mood behavior from her neighbor.
• The patient's feelings of worthlessness or inappropriate guilt will also be assessed.
• Psychomotor agitation
• Insomnia

References

Alwardat, N., Di Renzo, L., de Miranda, R. C., Alwardat, S., Salimei, P. S., & De Lorenzo, A. (2018). Association between hypertension and metabolic disorders among elderly patients in North Jordan. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 12(5), 661-666. Retrieved from: https://doi.org/10.1016/j.dsx.2018.04.011

American Diabetes Association. (2019). 12. Older adults: standards of medical care in diabetes-2019. Diabetes Care, 42(Supplement 1), S139-S147. Retrieved from: https://doi.org/10.2337/dc19-S012

Bender, M., & Elias, D. (2017). Reorienting esthetic knowing as an appropriate "object" of scientific inquiry to advance understanding of a critical pattern of nursing knowledge in practice. Advances in Nursing Scienc...