Nursing Clinical Case Report Health Assessment

Question: Discuss about the Nursing Clinical Case Report for Health Assessment. Answer: Introduction Mr. Smith as I name my patient to encode confidentiality is a 73 years old man who lives alone, he gets support from a lodge, the general support being showering, meals, and cleaning. When his presentation to the ED is finally in a position he is the diagnosis shows that there is the increase in shortness of breaths as per the outcome from the background server of COPD. As per the results the condition is constant at homes at 2.5 O2 at home, while the initial OBS is at the position of HR 85, GCS 15, also in inclusion Sats 100% holding with 2.5 L O2. The general implications show that he is Afebrile but tachypnoeic which is the reason for the rapid abnormal breathing.This paper will tackle the clinical case of Mr. Smith also exhausting diagnostic tests and general results. It is an aim of the provision of patient education, discharge planning summary to be in the description. Case management discussion Patients medical condition When an ECG diagnosis is made the outcome in HDU comes out clearly as that the p mitral and the general sinus tachycardia in conjunction with the serial cardiac troponins are in the estimate levels of 38 and 37. (Frick et.al 2014). The overall measure of a troponin test will measure the levels of troponin T or rather it is the troponin I proteins which are in the blood. (Brown et.al, 2012). When the proteins are facing release them, the heart muscle also seems to receive the impact and are at the risk of suffering damage. Social, economic background On the outlook to provide a relevant report of the patient, the need for having their social and general economic environment will act as a guide to being able to find reasons behind the controlling the infection. At a different situation, the condition can be preventable but due to the difference in social, economic levels; this can be difficult. Mr. Smith is working as a farmer for the last 25 years before the disease. (Yourngstorm et.al, 2015). In the incident where the wife dies, thus now faces life in the act of receiving the life in the home. He lives alone, and he is receiving an extension of services from a nearby lodge which he finds refuge in for the time of his illness before he faces admission. As part of his medication, he is under the management ADLs, which he successfully manages them while his is under a correct supervision. (MacPherson et.al, 2016). It is the mobilized and also the short distance travel which sees him receiving it due to the continuous oxygen therapy that becomes part of him in the condition. At a later date, he comes to have a transfer from his first place to a second place where he lives for some time. It is then in a description that the son has one adopted grand-daughter. Most of the time he is socializing with the family through the phone. In a critical medical condition, he receives a transfer to a medical ward where he is going for an Acute Care. Current medical diagnosis Acute Exacerbation of the COPD In this instance, our patient is in a diagnosis, and the outcome results are that he is in infection of dyspnea, which as a result at a different instance increasing in a cough as part of the result, the resulting there is an increasing sputum production as it came out in the diagnosis. (Forbes et.al, 2014). In addition to that, there is hypoxic and emphysema with an inclusion of a wheeze. From his aspect, it is found that he denies chest pain during a session with the medical officers. Also, he is in an opposing state of other conditions like hemoptysis and fevers which are chills. Mr. Smith's situation to have other conditions like gastrointestinal and urinary symptoms are not in acceptation. As a conclusion, the nursing departments are trying to find other possible causes for it is difficult to conclude from the data in a collection from him. (Bass et.al 2015). The condition known as Hypoxemia is a condition which happens when there is an impairing of a gas exchange in the lungs; this has an effect of causing a very low level of oxygen in the lung of the patient in a subject. Thus the general effect is in transmission to the blood streams which now carries low oxygen content in the blood. Pneumonia In consideration, pneumonia is an infection which affects the bottom part of the respiratory tract which as a result has the causative agents to be bacteria, fungi, and viruses, at other instances protozoa and parasites, have been found to be causative agents of the illness. The inflammation which is, as a result, is what causes the infection of the lungs. (Patney and Wartson, 2015). When Mr. Smith our confidential patient is in a diagnosis and is a fund with bacterial pneumonia, the general causative agent for this is the Pseudomonas microbes which will affect the bronchioles also the alveoli of the individual. Background Following closely to the medical history of the patient it is clear that he is in a critical condition, and the relevant measures are taken to control the situation. The first medical history is found to be hypertension which is seen to be consistent with a resting BP of estimation accuracy of 140/90 mmHg and is in consideration to go higher. (Gacono, 2015). It is due to go at critical levels because of the excessive smoking habits which are found to be the causative agent in the study discussion. GORD, which is the Gastro-Oesophageal Reflux Disorder, in return it also found in the medical history of the patient in an address. In August 2014 he was reported to have in possession of Echocardiogram which it is in the left ventricle hypertrophy. Also, hypokinesis is found, and it is the realization that there is a mild elevation of RSVP this is the abbreviation of the Right Ventricular systolic pressure.In a general description of an echocardiogram which is a test is a general test which uses the sound waves to make or in a provision of images. It is of the heart with the sound waves acquired. The administration of IHD which it is now a drug eluding stent is to give to the patient. The CAD this is the coronary artery disease occurs when his arteries which are responsible for supplying blood to the heart is experiencing the hardening and thus end up having a narrow path. The drug eluding is in use it is a peripheral or rather a coronary stent which is now in possession of the narrow road hence it slowly takes the initiative of releasing the drugs into the proliferation of the cells previously were impermeable. A diagnosis done below the knee DVT has an indication of warfarin, but this later ceases when the patients were in admission. It is in the doing in August in the year 2014. (Brayde and Raby 2015). The impact of the verge of 2015 yet another infection known as the cellulitis is in recognition. In an accompanying statement, this is on the note than the other accompanying distress which the eruption of the erythematous and the edematous counterpart dorsal is a finding on his feet. The condition undergoes treatment, and this is in a doing with oral flucloxacillin with the subsequent improvement in the verge of experiencing subsequent improvement in that situation. As a short description, cellulitis is known to be an infection which causes inflammation of the connective tissues preferably the one in a location of the legs. The causative agent is bacteria; this presents itself a painful area which is inflamed and has its location on the surface of the skin. Another important discovery is to come, and the development of the spontaneous L, which is a pneumothorax at the basal L of the lung comes out vividly, and this is to be for completion in 2014 as part of the medical history. In details, pneumothorax has its definition as the air in the pleural space of the thoracic cavity; it is the general causative communication to the accumulation of the air in the pleural membrane in the patient's chest cavity. In a different perception, it may be open or rather in a final aspect. The verge of a closed pneumothorax is a found to have the association with the external wound. It is the most of the standard form will show up as a spontaneous accumulation of air in the general pleural cavity which results to have no future antecedent event. The causative agent for this is the rapture of the small blisters found on the visceral pleural spaces. In general, the condition occurs preferably and is also common in male individuals who are underweight and at a greater range they are cigarette smokers. To be precise, the age is a factor, and it has an estimation of between the ages of 20 to 40 years. A different diagnosis in the aspect, aspergillosis which it is a condition which is preferably an association of infection to the tissues and mostly common to the lungs. In his history in an interview with the medical officers. It is a realization that he has a nil known condition to be allergic to all the drugs containing the compound. (MIMS, 2014). In a deep interception to his smoking habits, it is found to be an ex-smoker with a very long history of the same. The general outcome is that he started to advance and smoke one carton of cigarettes in a week the character became a forgotten case in 2010. He manages to emerge NIL in the history of ETOH which is the alcohol history. Anatomy of the Respiratory System A closer look of the cardiovascular system helps us get to provide a lasting solution to the problem. The cardiovascular system and the general respiratory system thy have a mutual relationship which is that they work together. The general steps are that by providing gaseous exchange which is that CO2 comes out during exhalation and O2 is taken in during inhalation, this comprises of the pulmonary system. (Arkowitz et.al, 2015). It also has the function of transporting gasses throughout the body which is the general composition of the cardiovascular system. The primary units being the alveoli is the proving aspect to the responsibility for the removal of O2, which goes into the blood while CO2 comes out. A summary of the process can be an initiation of ventilation which is the movement of air into the lungs and out. Diffusion is the actual flow of the respiratory gasses between air spaces in the lungs and the overall system of the blood stream. (Carr et.al, 2016). Perfusion on the ot her end will take the definition of the movement of blood into and out of the beds of the capillary of the respiratory organs which are the lungs and the tissues. Thus respiratory failure occurs when the general levels if the carbon dioxide, and oxygen have no evident change. Pathogenesis of the COPD The primary causative substance is cigarette smoke which both activate the impact from both passive and active smokers. The increase of antioxidants caused by the smoke is the toxic sting aspect in the process. (Lewis et.al 2014). The inhibition of the activity by of the anti-protease will result in an inflammation of the respiratory epithelium leading to an infection. The existence of chronic bronchitis and the emphysema is a contributing factor to the problem. Emphysema will begin to have effect with a destruction of alveolar septa that is the point of interception of the increasing portion of the pulmonary capillary beds will be experiencing an increase in volume with the air being part of the acinus. The last step will be the destruction of the alveolar walls which eventually loses the elasticity. Nursing Management In the first aspect of the nursing management ways, the establishment of the ineffective airway to be about the obstruction of an unproductive cough. As per the general assessment findings are as follows, BP 152/80 mm Hg while the heart rate is 71 beats/minute. (Smeltzer et.al 2014). The oxygen saturation is in the estimation of 2.5 L oxygen to the nasal spec is the percentage of 98 this implies that it is a rate of 20 breaths per minute. The overall auscultating his chest will be the reason for the wheezing sound of the patient. Recommendation As part of the proposal the administration of cough enhancement which was encouraged to escalate his sitting position slightly flexible, to allow the adequate chest expansion. (Tollefson, 2015).Also, he is given bronchodilators to curb the problem of calibration and to retain secretion and increase the ease of breathing. In the situation where he is seen to have an impairment which is related to SaO2, which is 90%. The patient is dragonized for it at 83% with the use of RA. (Mindell and Owens 2015). The intervention of nurses comes in, and he is recommended to monitor the respiratory and oxygenation status, in general, to be able to assess the essential need for intervention. The pharmacological nursing management. To acquire his exacerbation of the resulting OCPD, he then is receiving a treatment of an oral glucocorticoid. Prednisolone, which in estimation is to give at 25mg oral per day, is in use to severe conditions of exacerbations to be able to reduce the airway inflammation by establishing a preventing mechanism from the release from the mast cells. In turn, the bronchodilators will be in a position to promote the synthesis of bronchial beta2 receptors which will see the increase of the effectiveness of the receptors. The other aspect of inclusion of fluticasone or the salmeterol which is to give the recommendation of 250/25 2 puffs in a day given twice. (Porth and Martfin, 2009). With this, it will be long acting more sympathomimetic beta2 agonists, which will be in moving part like the adrenergic receptors in the smooth muscle of the lung. IT will activate the suppression of histamine which will release and help the elevation of the ciliary muscles contraction in the lungs of the pati ent. As part of the management of his pneumonia, the recommendation for the use of a daily dose of 1gm of IV cephalosporin which will reduce the infection of the other drugs which might have an effect on the lungs. The relevant diagnostic tests and the overall results. Chest X-ray as at 13/06/16, was found to be a hyper-expanded lung representing the scarring confluent and the consolidation of the collapsing lungs.Cardiac troponin, his levels are sought to be at 37 and 38 this purely indicates that there is myocardial damage thus the patient is under the suspicion of having an acute coronary syndrome. (Brown et.al, 2012). The biochemistry of his blood is at the rates of lower hemoglobin as 127g/L while the lower M.C.H is 26.1 pg. The general result is used to give proper medication to the patient. Summary and conclusion In summary and conclusion of the report in general, the patient though he has in the receiver of the treatment it is an essential aspect that he will need some help which is inclusive of the support services at his will. (Lehne, 2015). A follow-up activity for the monitoring of the changes should be done every time at least in once a week to be able to establish a practical consideration of the COPD. Also being able to refer the patient to an occupational therapist for an arrangement to shower a chair even for a minute will be a satisfying condition to garner the courage to help the patient. References Brown, D Edwards, H 2012, Lewis's Medical-surgical Nursing: assessment and management of clinical problems, 3rd Edition, Elsevier Australia, NSW. MIMS 2014, MIMS Online, Australia, viewed 26 September 2014 Porth, CM Matfin, G 2009, Pathophysiology: concepts of altered health states, 8th edn, Lippincott Williams and Wilkins, Philadelphia Smeltzer, S, Bare, B, Hinkle, J Cheever, K 2010, Burnner Suddarths textbook of medical-surgical nursing, 12th edn, Lippincott Williams Wilkins, Philadelphia. Tollefson, J 2010, Clinical psychomotor skills: assessment tools for nursing students, 4th edn, Cengage Learning, Australia. Lehne, R 2013, Pharmacology for nursing care, 8th edn, Elsevier Saunders, Missouri. Lewis, S.L., Dirksen, S.R., Heitkemper, M.M. and Bucher, L., 2014.Medical-surgical nursing: assessment and management of clinical problems, single volume. Elsevier Health Sciences. Mindell, J.A. and Owens, J.A., 2015.A clinical guide to pediatric sleep: diagnosis and management of sleep problems. Lippincott Williams Wilkins. Davey, G.C., 2014.Psychopathology: research, assessment and treatment in clinical psychology. John Wiley Sons. Bass, C. and Halligan, P., 2014. Factitious disorders and malingering: challenges for clinical assessment and management.The lancet,383(9926), pp.1422-1432. Frick, P.J., Ray, J.V., Thornton, L.C. and Kahn, R.E., 2014. Can callous-unemotional traits enhance the understanding, diagnosis, and treatment of serious conduct problems in children and adolescents? A comprehensive review.Psychological Bulletin,140(1), p.1. Bo, K., Berghmans, B., Morkved, S. and Van Kampen, M., 2014.Evidence-based physical therapy for the pelvic floor: bridging science and clinical practice. Elsevier Health Sciences. Forbes, H. and Watt, E., 2015.Jarvis's Physical Examination and Health Assessment. Elsevier Health Sciences. Olson, D., Russell, C.S. and Sprenkle, D.H., 2014.Circumplex model: Systemic assessment and treatment of families. Routledge. McPherson, R.A. and Pincus, M.R., 2016.Henry's clinical diagnosis and management by laboratory methods. Elsevier Health Sciences. Carr, A. and McNulty, M. eds., 2016.The handbook of adult clinical psychology: an evidence based practice approach. Routledge. Arkowitz, H., Miller, W.R. and Rollnick, S. eds., 2015.Motivational interviewing in the treatment of psychological problems. Guilford Publications. Portney, L.G. and Watkins, M.P., 2015.Foundations of clinical research: applications to practice. FA Davis. Andersen, B.L., DeRubeis, R.J., Berman, B.S., Gruman, J., Champion, V.L., Massie, M.J., Holland, J.C., Partridge, A.H., Bak, K., Somerfield, M.R. and Rowland, J.H., 2014. Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation.Journal of Clinical Oncology,32(15), pp.1605-1619. Brydie, A. and Raby, N., 2014. Early MRI in the management of clinical scaphoid fracture.The British journal of radiology. Youngstrom, E.A., Choukas-Bradley, S., Calhoun, C.D. and Jensen-Doss, A., 2015. Clinical guide to the evidence-based assessment approach to diagnosis and treatment.Cognitive and Behavioral Practice,22(1), pp.20-35. Gacono, C.B. ed., 2015.The clinical and forensic assessment of psychopathy: a practitioner's guide. Routledge. Goyal, M., Demchuk, A.M., Menon, B.K., Eesa, M., Rempel, J.L., Thornton, J., Roy, D., Jovin, T.G., Willinsky, R.A., Sapkota, B.L. and Dowlatshahi, D., 2015. Randomized assessment of rapid endovascular treatment of ischemic stroke.New England Journal of Medicine,372(11), pp.1019-1030.