Nursing Case Study

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.

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

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

Another Consultation Report dated 12/06/2016, indicated that the claimant presented with exacerbation of COPD, acute bronchitis, and pseudomonas aeruginosa. The CT scan of the chest revealed bilateral lower lobe atelectatic changes, fibrosis, and a small 1 cm left lower lobe nodular density. A pulmonary consultation was recommended. His blood pressure was 142/79 mmHg. The physical examination revealed bilateral decreased breath sounds and scattered wheezes. His glucose was 189. DuoNeb, IV Solu-Medrol, and IV antibiotics were prescribed.

Imaging: High resolution CT scan of the chest dated July 2015, which was compared, to a previous CT in 2013 shows extensive interstitial disease with honeycomb pattern, right lung greater than left with associated bronchial wall thickening. There seems to have been significant progression since 2013.

Mr. HS is a 78-year-old retired male, who presented to the emergency room at Northeast Methodist Hospital initially on February 11, 2011, with complaints of shortness of breath and coughing. He was diagnosed as having a COPD Exacerbation and was placed on antibiotic therapy and was released home. He was also advised at that time to complete the entire course of antibiotics and return to his primary treating physician if his condition did not improve.

A review of his medical record indicates that he was recently started on prednisone for his breathing. He has recent weight loss and poor appetite. He continues to go for chemotherapy every 2 weeks, followed by Dr. Wertheim. He continues to suffer from chronic anemia related to his cancer, chronic COPD with shortness of breath and new onset BPH.

Respiratory: Lungs sounds clear throughout. Respiration even and unlabored. Chest wall symmetrical. Patient is a smoker.

The patient presents for routine follow up. States overall he has done not okay. He has been seen and evaluated for his chronic hoarseness telling that he needed to rest his vocal chords. States that it may be getting a little better if he has quit singing for several weeks. The patient states that he still continues to be quite short of breath. States that he feel he does have COPD from his tobacco use. States that he does have a lot of drainage and coughing early morning with sputum production. He has denied any dizziness, syncope, chest pain, or other difficulties. Appetite is well. Bowel and bladder function is without difficulties. He has also continued on his verapamil, lisinopril, aspirin, and daily

Richard was seen today on ongoing management of his severe COPD. Reassuringly, he has continued to improve significantly to the point where he feels that he is nearly back at his baseline level. His sputum results did show Mycobactrerium avium complex and this is unlikely to be of clinical significance given his good progress, but given his nodules in the past, we have discussed another CT scan of his chest in about three months’ time.

History of Present Illness: Mr. Knowlton is a very pleasant 81-year-old man who was referred for cough and shortness of breath. He had pulmonary function testing that demonstrated a mild restrictive ventilatory defect with significant reduction in his diffusing capacity of carbon monoxide. Mr. Knowlton states that his exertional dyspnea has been present over the last year or so. He notes that he has particular difficulty with incline and steps. He states that with one set of stairs, he is significant winded and sits down to rest before he can walk again. He has noted that this dyspnea has been a progressive decline. He also states that he has an associated cough over the last three to four months that his occasionally

Polycystic kidney disease (PKD) is a disease that causes cysts to grow on the kidney. You can see the cysts in the picture above. The disease can cause pain, headaches, high blood pressure, and can even make cysts spread to other organs such as the liver. In extreme cases, a kidney transplant may be required. The disease can be inherited from a parent or can be caused from spontaneous gene mutations. PKD can also be contracted if the person had serious kidney problems in the past.

The first issue and one that must be settled early on is that of possible abortion. The mother and father have both said that they are not going to allow that to happen because of personal religious beliefs, but it is important to ask again prior to starting any other consultation. Once this is settled, most likely negative as parents who follow the Catholic tradition are staunch defenders of unborn fetuses, the team can discuss with the parents the issues that they may face, and what can be done for the baby and themselves.

The lack of sustained response to Alvesco would argue against the previous presumptive diagnosis of either cough variant asthma or eosinophilic bronchitis. To be completely sure of this, I will trial Ray on a course of a ten-day course of prednisolone and he will contact me thereafter. If there has been

The patient is a 74-year-old gentleman who presents to the ED complaining of nausea, vomiting and intolerance of foods for a week prior to presentation. His medical history is significant for having had a AAA repaired via endovascular stent, hypercholesterolemia, hypertension, atrial fibrillation, glaucoma, rheumatoid arthritis on chronic steroids and coronary bypass grafting, hernia repair and cholecystectomy. On presentation his blood pressure was 117/86 with pulse of 72, respirations of 16, temp of 97.2 and oxygenating well on room air. It is to be noted he is 5 feet 6 inches with a weight 105 pounds with a BMI 16.8. Review of his laboratory data reveals him to have a hyperkalemic metabolic acidosis. His hemoglobin on presentation was