Nursing Case Management Case Study Nursing

Nursing care is a dynamic field of practice. The way it looks today is far out greater intense and very structured. It advances itself by the use of nursing theories and evidence based practice. Policies and procedures constantly change with the advancement of technology and science. While caring for the patient in the given case studies, a nurse involved utilizes practical knowledge, a culture care model and transpersonal caring relationship to attain a caring environment (Smith & Parker, 2015).

The aim of this study is to provide a detailed account of the nursing care for a patient who is experiencing a breakdown in health. One aspect of their care will be discussed in relation to the nursing process. The model used to provide an individualised programme of care will be discussed and critically analysed.

1. The nurse is asked to implement a new, complex, and invasive procedure and is concerned that this may violate the state’s nurse practice act.

D.Z., a 65-year-old man, is admitted to a medical floor for exacerbation of his chronic obstructive pulmonary disease (COPD; emphysema). He has a past medical history of hypertension, which has been well controlled by Enalapril (Vasotec) for the past 6 years. He has had pneumonia yearly for the past 3 years, and has been a 2-pack-a-day smoker for 38 years. He appears as a cachectic man who is experiencing difficulty breathing at rest. He reports cough productive of thick yellow-green sputum. D.Z. seems irritable and anxious; he complains of sleeping poorly and states that lately feels tired most of the time. His vital signs (VS) are 162/84, 124, 36, 102 F, SaO2 88%. His admitting diagnosis is an acute

History of Present Illness: Mr. Olson is a very pleasant 57-year-old gentleman with multiple medical problems to include severe COPD, who is here today for an initial consultation for his shortness of breath. He is followed by a pulmonologist Dr. William Goodman, at the Veteran Affairs Administration. His last evaluation there was in February 2015. Mr. Olson states he has had ongoing dyspnea on exertion over the last two years. He complains of minimal cough. He does note some sinus problems for which he is on Flovent. In the past, he has had pulmonary function testing that did demonstrate reversible airflow obstruction, therefore he likely has some component of asthma overlay. He states that occasionally has chest tightness and chest heaviness. He has gained about 25 pounds over the last year. He is currently using Spiriva, albuterol as needed as well as Symbicort. He is also using supplemental oxygen at 2.5L per minute at night as well as on an as needed basis during the day. Mr. Olson admits to continued tobacco use with about a half pack to a pack a day. He states that when he is feeling depressed, he will smoke more.

D.Z.is a 65-year-old man admitted to medical ward with an exacerbation of chronic obstructive pulmonary disease (COPD; emphysema). Past medical history (PMH) indicates hypertension (HTN), well managed with enalapril (Vasotec) past six years, diagnosis (Dx) of pneumonia yearly for the past three years. D.Z. appears cachectic with difficulty breathing at rest. Patient reports productive cough with thick yellow-green sputum. He seems anxious and irritable during subjective data collection. He states, he has been a 2-pack-a-day smoker for 38 years. He complains of (c/o) insomnia and

Throughout my clinical rotation, the only concern for this patient was pain management and discomfort from the chest tube site. The patient was given Ketorolac for a pain of 4/10 using the numeric pain sale. The patient was also at risk for pneumonia and pressure ulcers from immobility and not coughing/deep breathing. Nursing interventions were getting the patient up to the chair and using the incentive spirometer ten-times per hour. Another concern was SOB and fatigue with activities.

A cousin of mine, Susan, approached me after her father received open heart surgery. Susan’s father, age 59, has been a chronic smoker since the age of 19. What went from two cigarettes a day quickly become two packs a day, with no end in sight. During July of 2015 he complained of feeling dizziness, shortness of breath,

CHIEF COMPLAINT: This is a post op note from a procedure performed July 21, 2015 by David Lin, MD.

Rationale: L.J. exhibits symptoms of COPD that include shortness of breath and productive cough. He has a smoking history of 65-pack-year and smoking has been identified as the primary cause/trigger of the disease (Nagelmann et al., 2011).

Mrs. Wilson is seen in her room at Glenbridge Nursing Home on 02/28/2018. She had an episode last night of chest pain. She is so ebullient and distracted that it is hard to get a straight history, it came on when she was asleep but she may been sitting up. She was seen by a nurse, a sat was taken. I am not sure if there were other orders taken, but there is none on the chart. She says that she spent most of this morning in the bed and still feels tired, but she does not think she broke out in a sweat. She was more short of breath. She is calling it is a "stroke." I had tried to begin tapering her diazepam by discontinuing the morning dose and apparently all daytime clorazepate was discontinued by error and she gets it only at night.

1. The nurse teaches a patient with chronic bronchitis about a new prescription for Advair

Joshua is a 31-year old who presents from CRU from UPC. He is ACOT for wanting to leave valley hospital against medical advice. He was admitted to Valley Hospital on voluntary basis for increased depression and anxiety. BHR have a hx of OD and hanging. He is allergic to vicodin. Upon admission, his vital signs were within normal limits. He is partially cooperative, he stated, "I just want to go to bed." He will benefit from meeting with the provider and discussing medication management.

Nutrition education plays a major role in patient care. When a patient is admitted into the Veterans Affairs Hospital (VA) for treatment they may be put on a specific therapeutic diet. For example, if the patient is diagnosed with diabetes they are put on a carbohydrate consistency diet of 1800 calories per day or, if the patient has hypertension they may prescribe a 2.5g sodium restriction diet. All patients at the VA are assessed by a Registered Dietitian who make the recommendations on which therapeutic diet the patient would benefit from. Following a diet while inpatient is relatively simple because all meals are prepared and served to the patient. The dietitian along with the kitchen staff take care of what types of foods should avoid

Due to delay in meeting with Mr. Reid, the adjuster approved submitting the report after our initial meeting.