...Nursing Care Plan The patient is , a 72 year old man who has been admitted for dyspnea or shortness of breath. reported that he has been coughing for the past week and his coughing has accompanied sputum discharge. His past medical history includes emphysema and chronic bronchitis. He used to smoke but has stopped since a year ago for economical reasons as well as it is also bad for his asthma. His bowel movements have also been irregular since his admission. He also reported that he is feeling depressed and fearful about the future. Further examination revealed that he has crackles in his left lower lobe with diffuse expiratory wheezing throughout his chest. Chest percussion also revealed his left lower lobe to be dull. Needs / Problems Goals Interventions Evaluation Dyspnea or shortness of breath Use the visual analog scale (VAS) to make an objective assessment of dyspnea. The VAS is a 100-mm vertical line with end points of 0 and 10. zero is equated with no dyspnea and 10 is equated with the worst brethlessness the client has experienced ( & , 2004) Dyspnea is difficult to quantify and to treat (Potter & Perry, 2004). Interventions need to be individualized for each patient, and more than one therapy is usually implemented. The underlying process that causes or worsens dyspnea must be treated and stabilized initially. Three additional therapies have to be implemented: pharmacological measures, physical techniques,...
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...Cotabato Regional and Medical Center opened the door of opportunity to experience things that broadened our knowledge and enhanced our skills. We were exposed to different cases of various clients. We became accustomed with the routines in the hospital and interacting with our patients, even with their watchers. We encountered some difficulties and struggles, yet that didn’t hinder us in giving our best to do our job. That exposure gave us an opportunity to handle different cases. With all those we’ve encountered, we chose one to be the subject of our case study. We are presenting to you Bronchial Asthma which is the case of our patient at Medicine Ward Room C whom we will call Mr. Theodore for the purpose of confidentiality. Bronchial asthma is a disease caused by increased responsiveness of the tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the bronchial airways. Bronchial asthma is the more correct name for the common form of asthma. The term 'bronchial' is used to differentiate it from 'cardiac' asthma, which is a separate condition that is caused by heart failure. Although the two types of asthma have similar symptoms, including wheezing (a whistling sound in the chest) and shortness of breath, they have quite different causes. Bronchial asthma is a disease of the lungs in which an obstructive ventilation disturbance of the respiratory passages evokes a feeling of shortness of breath. The cause is a sharply elevated resistance to airflow...
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...Health Assessment Case Study Introduction The focus of this case study is to examine further focused assessments that should be undertaken after Mr S's initial presentation of acute exacerbation of asthma. Reasoning for recommended focused assessments will be discussed with consideration of Mr S's presentation of symptoms, history, pathophysiology and risk factors for asthma exacerbation. Research on current asthma assessment protocols will guide recommendations, and assessment parameters will be described. Follow up care and self-management options for Mr S will also be explored. Asthma Asthma is a chronic inflammatory disease of the lungs. It is characterised by airflow obstruction and lung inflammation (Johnson, 2010). Asthma symptoms include wheezing, chest tightness, shortness of breath and cough (Johnson, 2010). Potential triggers for asthma include allergens, viral respiratory infections, irritants, stimuli such as cold air or exercise and gastro-oesophageal reflux (Estes et al, 2013). Airway obstruction in asthmatics is variable and reversible. However poorly managed asthma can leave lasting structural changes in the cells and tissues of the lower respiratory tract, resulting in airway remodelling and permanent fibrotic damage (Kaufman, 2011). There is currently no cure for asthma, therefore the disease needs to be managed (NACA, 2014). Pathophysiology and assessment parameters It is important to understand the underlying pathophysiology of Mr Saunders’ presentation...
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...My case study is on a patient by the name of LaToya. LaToya is a fifty-one year-old black female. She was admitted to the medical-surgical department where I work, with a diagnosis of exacerbation of chronic obstructive pulmonary disease. She has a 66 pack-year history, meaning she smoked the equivalent of 365 packs of cigarettes for 66 years, and occasional drug and alcohol use. LaToya is divorced and lives alone in an older apartment building. Chronic obstructive pulmonary disease (COPD) is a lung disease that limits your airflow. COPD may include chronic bronchitis, emphysema, or both. Chronic bronchitis is the production of increased mucus caused by inflammation. Bronchitis is considered chronic if you cough and produce excess mucus most days for three months in a year, two years in a row. Emphysema is a disease that damages the air sacs and/or the smallest breathing tubes in the lungs. COPD is a progressive disease that makes it hard to breathe and the symptoms will get worse over time. Most cases of COPD occur as a result of long-term exposure to lung irritants that damage the lungs and the airways. Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. One of the greatest challenges for LaToya is to stop smoking. According to the Center for Disease Control (2012), the most important step a smoker can take after getting a COPD diagnosis is to quit. Not only will it make breathing easier, but it will cut down on the risk of severe...
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...Airway/Breathing (Oxygenation) Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study STUDENT Worksheet JoAnn Walker, 84 years old Overview This case study incorporates a common presentation seen by the nurse in clinical practice: community acquired pneumonia with a history of COPD causing an acute exacerbation. Principles of spiritual care are also naturally situated in this scenario to provide rich discussion of “how to” practically incorporate this into the nurse’s practice. Concepts (in order of emphasis) I. Gas Exchange II. Infection III. Acid-Base Balance IV. Thermoregulation V. Clinical Judgment VI. Pain VII. Patient Education VIII. Communication IX. Collaboration I. Data Collection History of Present Problem: Pneumonia-COPD JoAnn Walker is an 84-year-old female who has had a productive cough of green phlegm 4 days ago that continues to persist. She was started 3 days ago on prednisone 60 mg po daily and azithromycin (Zithromax) 250 mg po x5 days by her clinic physician. Though she has had intermittent chills, she first noticed a fever last night of 102.0. She has had more difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement. Therefore she called 9-1-1 and arrives at the emergency department (ED) by emergency medical services (EMS) where you are the nurse who will be responsible for her care. Personal/Social History: JoAnn was widowed...
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...Nursing has always been a profession that embraces diversity towards rendering holistic patient care. However, with the constant changes in nursing practice; patient safety has been at risk due to nurse’s competence towards detecting impending patient deterioration that may lead to further complications or even death. It is said that the most important practical lesson that can be given to nurses, is to teach them what to observe (Nightingale 1969). Having the ability to observe and interpret critical situations are the essential key features applied in clinical practice. Effective observation of ward patients is the first step in identifying the deteriorating patient and effectively managing their care (Odell, Victor & Oliver 2009, p. 1993). Studies have shown that poor vital sign recording, lack of knowledge, failure to respond to abnormal signs, lack of knowledge, lack of supervision and failure to report deterioration or seek advice, have all contributed to the suboptimal care of ward patients (Odell, Victor & Oliver, cited in McGloin et al. 1999; McQuilla et al. 1998; Smith & Wood 1998; Hodgetts et al. 2002, p. 1993). With constant observation established, patient safety is implemented and surveillance is then incorporated to be able to identify and prevent possible medical errors and adverse events that may be encountered. The purpose of surveillance is the early identification of risk and the need for intervention and to alert nurses to both anticipated and unanticipated changes...
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...Cardiovascular The cardiovascular system is consists of the heart and network of arteries, veins, and capillaries that transport blood throughout the body. There are two primary circulatory loops in the human body: the pulmonary circulation loop and the systemic circulation loop. The heart is a muscular organ about the size of a closed fist that functions as the body’s circulatory pump. It takes in deoxygenated blood through the veins and delivers it to the lungs for oxygenation before pumping it into the various arteries. The condition marked by the heart’s inability to pump enough blood to the rest of the body is called a heart failure, although it is generally long term or chronic, it may have a sudden onset. In the case study presented here the client complains: “I have shortness of breath, fatigue, cough, and swelling in feet”. Based on the above information during the initial interview the examiner will collect an additional subjective data in order to gain in depth understanding of what is the cause of the exhibited symptoms, and to rule out certain issues. Subjective data: 1) Dyspnea. (Shortness of breath) What kind of activities and amounts bring on shortness of breath. Did these activities bring the shortness of breath 6 months ago? Does shortness of breath come on suddenly? Is it constant or comes and goes? Is it changed by the position change, for example lying down? Does it wake you up at night? Does the shortness of breath interfere with ADLs? 2) Fatigue...
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...PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Nursing Assessment 1. Part of Nursing Process 2. Nurses use physical assessment skills to: a) Obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolve b) To identify and manage a variety of patient problems (actual and potential) c) Evaluate the effectiveness of nursing care d) Enhance the nurse-patient relationship e) Make clinical judgments Gathering Data Subjective data - Said by the client (S) Objective data - Observed by the nurse (O) Document: SOAPIER Assessment Techniques: The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the abdomen which is Inspect – Auscultation – Percuss – Palpate. A. Inspection – critical observation *always first* 1. Take time to “observe” with eyes, ears, nose (all senses) 2. Use good lighting 3. Look at color, shape, symmetry, position 4. Observe for odors from skin, breath, wound 5. Develop and use nursing instincts 6. Inspection is done alone and in combination with other assessment techniques B. Palpation – light and deep touch 1. Back of hand (dorsal aspect) to assess skin temperature 2. Fingers to assess texture, moisture, areas of tenderness 3. Assess size, shape, and consistency of lesions and organs 4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep C. Percussion – sounds produced by striking body surface 1. Produces different notes depending on underlying mass (dull...
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...AMA Computer Learning Center St. Augustine School of Nursing A Case Study Presented to the faculty of AMA Computer Learning Center Guagua, Pampanga Cerebrovascular Accident Submitted to: Mr. John Eric T. Salvador B.S.N, R.N Submitted by: Almario, Jeanette Cayanan. Gemmalyn Joy Quitaleg, Mary Jane Santos, Cariza Joy M. 3k-PN October ‘09 Table of Content Page Introduction 1 Personal History 2 Lifestyle and Diet 3 Complete Physical Assessment 4-9 Neurological Assessment 10-11 Laboratory Procedure 12-13 Diagnostic Procedure 14 Anatomy and Physiology 15-17 Pathophysiology of Cerebrovascular Accident 18-19 Drug Study 20-21 Diet and Activity 23 SOAPIE (actual) 24 SOAPIE (potential) 25 Conclusion 26 Recommendations 27 Bibliography 28 NCP (actual/ potential ) 29-33 Introduction A stroke is damage to part of the brain when its blood supply is suddenly reduced or stopped. A stroke may also be called a cerebral vascular accident, or CVA. The part of the brain deprived of blood dies and can no longer function. Blood is prevented from reaching brain tissue when a blood vessel leading to the brain becomes blocked (ischemic) or bursts (hemorrhagic). The symptoms of a stroke differ, depending on the part of the brain affected and the extent of the damage. Symptoms following a stroke come on suddenly...
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...clinical manifestations of this respiratory illness will be explored and discussed, while looking specifically at the case study Zachy, a seven-year-old boy suffering from asthma. These findings, once explored will be linked to this unique case, ensuring an in-depth understanding of the effects asthma has on a pediatric patient can be determined. Asthma is a non-curable respiratory disease that disrupts the lung functionality of an individual due to chronic airway inflammation. Although this disease is unable to be cured, medication has a been adapted to ensure that this respiratory illness is controlled (Fehrenbach, Wagher & Wegmann, 2017). When investigating the incidence of Asthma...
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...Clinical Case Study Assignment 2014 Jennifer Ahonen Cambrian College a00050951 BSN 2144: Nursing Practice Frances Carvalho & Jillian Smythe March 21, 2014 Clinical Case Study Assignment 2014 The purpose of this paper is to utilize the data collected in the Gordon’s Functional Health Patterns Assessment Tool (Appendix A). After data collection, it will be analyzed and a priority nursing diagnosis will be used to make a care plan (Appendix B). Patient X is an 82 year old male, who presented to the emergency department from his home at Extendicare York with a fever of 38.9 degrees Celsius, a blood pressure of 75/40 mm Hg, blood glucose level of 3.7, diaphoretic and a three day history of diarrhea, nausea and generalized weakness. The admitting diagnosis for this 82 year old male was Pneumonia. Pneumonia is an acute inflammation of the lower respiratory tract due to an infectious agent that impairs gas exchange due to alveolar edema and congestion (Thiem, Heppner, & Pientka, 2011). There are many factors that predispose individuals to pneumonia; however, in the case of this patient the predisposing factors are age and the presence of chronic diseases. The patient’s complete history and demographics can be found in Appendix A. The classic clinical manifestations of pneumonia consist of a temperature above 38 degrees Celsius, diaphoresis, cough, and shortness of breath, chest pain, tachycardia, purulent sputum, fatigue, nausea, vomiting, and diarrhea (Thiem, Heppner...
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...The human brain is the most complex, most sophisticated body organ which makes us superior among other living creatures. It is the vessel of the greatest power ever invented. Since it is a treasure not any pleasure could ever equal it is encapsulated on a hard mass of bone to keep its treasure. The human brain can be divided into four major divisions: The cerebrum, the diencephalon, the cerebellum and the midbrain. The first division is further subdivided into four parts. The frontal lobe, the parietal lobe and the occipital lobe. In the frontal lobe, the precentral gyrus (motor cortex) controls voluntary motor activity. The Broca’s area coordinates the complex muscular activity of the mouth, tongue, and larynx and makes expressive motor speech possible. The frontal area also controls attention and concentration, motivation, ability to formulate goals, the ability to plan, the ability to initiate and maintain action, ability to self monitor and the ability to use feedback (executive functions). These areas contribute to reasoning, problem solving and emotional stability. The parietal lobes interpret temperature, touch and pleasure. Concept formation and abstraction happens and are formulated in this area. The parietal lobes form two sides; the left parietal lobe and the right parietal lobe. The left parietal lobe assists with right and left orientation and mathematics, while the right parietal lobe is used for awareness, as to shape (steriognosis) and size...
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...BSBMED301B: Assignment 1 What you have to do Using the learning resource provided answer the following questions: Question 1 Using your knowledge of word components, give the correct medical term for each of the definitions below. Definition Medical Term 1. rectal hernia Rectocele 2. excision of the stomach Gastrectomy 3. inflammation of the kidney Nephritis 4. enlargement of the liver Hepatomegaly 5. incision to remove a stone Lithotomy 6. fixation of the intestine Enteropexy 7. artificial opening in the colon Colostomy 8. incision into the abdomen Laparotomy 9. absence of one or both testes Anarchism 10. rupture of the uterus Hysterorrhexis 11. excision of the prostate gland Prostatectomy 12. visual examination of the vagina Colposcopy 13. surgical repair of a testicle Orchiopexy 14. discharge of milk Galactorrhea 15. difficult labour or delivery Dystocia 16. suture of the tongue Glossorrhaphy 17. surgical puncture of the abdomen Abdominocentesis 18. pus in the urine Pyuria 19. pertaining to above the kidney Suprarenal 20. narrowing of the urethra Urethral Stricture Question 2 Give the meaning of each of the abbreviations below. Abbreviation Medical Meaning 1. LUQ Left upper quadrant 2. GI Gastrointestinal 3. OGD Oesophago-gastro duedenoscopy 4. CVS Chorionic villus sampling 5. STD Sexually transmitted disease 6. IUD Intrauterine device 7. TURP Transurethral resection of the prostate 8. DRE Digital rectal...
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...In order to maintain balance and avoid unnecessary destruction of tissue, protease inhibitors such as alpha-antitrypsin exist in the body (Leischner, n.d.). The main pathologic process in emphysema is caused by a combination of injury by irritant substances and a deficiency of protease inhibitors. Irritants affect protease inhibitors by hampering their protective function of the lung tissue and causing inflammation that ultimately destroys the tissue (Prendergast, 2010). The most common irritant that causes emphysema is cigarette smoking, but there are others such as occupational dust and chemicals, pollution, second hand smoking, and combustion fumes (McPhee et al.,...
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...Historical Perspectives of the Diagnosis of Asthma in Children 1. Introduction: The causes of Asthma: Looking at some recent reports of asthma disease, most of the acute exacerbation because cold and phlegm caused by dysfunction of the lungs which occurred in sputum of asthma. Chronic repeatedly patients mostly offset organs function. Its complex etiology occurs due to some reasons of genetic, physical fitness, diet, environment, age, and other factors related to work and rest, and emphasize internal and external consistency due to infestation. Asthma patients in the onset of the disease is often accompanied by an abnormal increase in serum IgE, IgE is the primary antibody of Ι type hypersensitivity, when its binding to the antigen, mast cells and basophils release of large amounts of biologically active substances, causing a series Asthma disease symptoms, but also by the synthesis of IgE Ts cell regulation (Huang Zhiying 2011). The physiological basis of Asthma: There are many different causes of bronchial obstruction, which is the synonymous of asthma, such as bronchospasm, abnormalities, new growths, swelling of the bronchial mucosa and so on. Some causes may result in mechanical obstruction by new growth, foreign bodies and congenital abnormalities. There are also some secondary obstructions such as mucous secretions, bronchial mucosa swelling and bronchospasm. The reaction of bronchi to irritation with a kind of inside defense mechanism by human body. To antagonize...
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