Assessment task 3:
Written analysis of case-based scenario
Length: 1600 words
Mark loading: 40% of overall course grade
You are required to submit a fully referenced academic paper in an essay format on the following case study. Your essay should demonstrate your knowledge and application of best evidence-based nursing practice in relation to assessment, nursing care and evaluation of care for the six (6) aspects as described below.
Robert Snider a 68-year-old male has been admitted to the medical ward after being diagnosed with community-acquired right middle lobe pneumonia. Robert lives alone and is now retired after working all his adult life in a coal mine. His medical history includes a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), hypertension and is a current smoker of 20 cigarettes per day.
The following data was assessed when Robert was admitted to the ward:
The Doctor has prescribed Robert oxygen therapy to achieve and maintain a SaO2 94% and intravenous antibiotics.
Your assignment should be directly related to the scenario and cover the following aspects of assessment, nursing care planning and evaluation of care provided:
(Please note: These six aspects can be used as headings if you wish)
The essay is based on the case study of a 68-year-old male, Mr Robert, admitted to the medical ward after being diagnosed with right middle lobe pneumonia. He has a past medical history of hypertension, chronic obstructive pulmonary disorder and currently smokes 20 cigarettes per day. He is feeling anxious, fatigued and restless. He is suffering from shortness of breath with minimal effort. On examination, the vitals are Blood pressure: 105/60 mm Hg, Heart rate: 102 beats per minute, Respiratory rate: 33/minute, SaO2: 88% Room air, faint crackles audible over the right middle lobe, and Chest X-Ray showing Consolidation Right middle lobe.
The essay demonstrates the knowledge and application of evidence-based nursing practice concerning assessment, nursing care, and evaluation of care for the case's essential aspects.
Promotion and facilitation of adequate oxygenation:
Assess the breathing sound and monitor the rate of respirations. Analyse the expiratory and inspiratory ratio. On admission, the Respiratory rate was 33/minute; hence detailed respiratory examination should be done, including depth and breathing pattern. Note for crackle, wheezes and Ronchi. Evaluate the degree of dyspnoea. As Mr Robert is experiencing anxiety and restlessness, the precipitating factors should be analysed. Monitor ABGs and oxygen saturation levels. As on admission, the Spo2 was 88%, watch to manage oxygen therapy for preventing falls below 88-92% (Restrepo et al., 2018). Humidified oxygen needs to be administered titrated to achieve saturation of 94% as advised by the physician. Humidified oxygen prevents drying out the airways, decreases moisture loss, and improves compliance (Jacobs et al., 2020).
To facilitate the oxygenation and maintain the open airway position, the bed's head elevates to at least 30 -45 degrees. To reduce the air-trapping, promote the abdominal pursed-lip breathing exercises (Candela et al., 2019). The upright position improves oxygen delivery, and breathing exercise helps in preventing airway collapse. Assist him in turning every 2-3 hours to maximise the ventilation and mobilise secretions (Restrepo et al., 2018). Provide warm liquids as tolerated to decrease the viscosity of secretions and facilitate expectoration. The suction of the secretions should be done if needed (Candela et al., 2019).
Provision of general nursing care:
Community pneumonia may be associated with pain due to acute inflammation and frequent, persistent coughing. Assess the pain on the scale with characteristics and location. Provide comfort through back rubs, massage and position change (Gustafsson & Nordeman, 2018). Encourage relaxing activities. Assist Mr Robert in chest splinting techniques useful during the period of cough to decrease the discomfort. Advise him to report the pain if increasing in intensity and administer analgesic as prescribes or required. To reduce the exertion, provide cam and quiet environment, provide diversional and stress managing activities example, music (Candela et al., 2019). Provide balancing physical activities with a period of rest to avoid excessive physical stress and increase metabolic demands. Monitor the bed linen and coverings. Prefer frequent washing of sheets and changing clothes to maintain hygiene. Control the environmental factors, including beddings, blackest and clothing, as per the patient's temperature and hygiene. Demonstrate the technique for proper sputum spoiled tissues discarding and hand washing to the patient for preventing the cross-infection
Prevention of possible hospital-acquired complications:
Due to prolonged periods of the non-movement and inadequate primary defence system, there is an increased risk of hospital-acquired complications. These complications may include cross-infection, fall risk, DVT and oxygen therapy complications. Monitor the vitals, level of consciousness and conduct the physical examination, check for temperature, cyanosis, oedema, red, warm skin and pain or tenderness over the calves (Mudge et al., 2018). Obtain the sputum examination by Gram stain test and sputum culture. Examine the sputum. The presence of greenish and yellow secretions indicates a possible positive pulmonary infection. Limit the number of visitors to restrict exposure (Mudge et al., 2018). Emphasise proper oral hygiene as the drug's immunosuppressive effect may increase the risk of candidiasis (Gustafsson & Nordeman, 2018). Administer specific antimicrobials as specific to the organism identified in the sputum test. Facilitate during the patient every two hours and encourage him for ambulation as tolerated to avoid the risk of blood pooling and preventing deep venous thrombosis (Yin & Shan, 2015). Recheck ABG, Hgb and chest X-ray regularly based on physician prescription .keep a check in the physician prescription including target oxygen saturation levels, oxygen delivery device, range of oxygen flow and percentage of inspired oxygen and to avoid oxygen toxicities. (Allibone et al., 2018). As per the recommendations, provide O2 at 24% through Venturi mask at 2-3 L/minute or through a nasal cannula at 1-2 L/minute (Gustafsson & Nordeman, 2018).
Promotion of adequate hydration and nutrition:
Patients with respiratory distress are at higher risk of developing nutritional imbalance due to dyspnoea, medications, and increasing fatigue with restlessness as present in Mr Roberts' case. There may be a lack of interest and aversion to eating food and taking fluids, resulting in fluid deficit and malnutrition (Hikichi et al., 2018). Nursing assessment should include retaining the nutrition needs, assessing the dietary habit and food intake. Analyse if there any difficulty In swallowing or eating in general. Measure the weight and keep a record of it. Patient with compromised oxygenation may have higher calorie need due to laboured breathing and forced action of respiratory muscle; hence body needs should be evaluated accordingly. Measure urine I&O every hourly for understanding the fluid deficit if present. Examine the skin for evidence of dehydration, including skin temperature and tugor; if fluid loss is evident, initiate intravenous fluid replenishment through the crystalloid solution that is 0.9% sodium chloride solution (Gustafsson & Nordeman, 2018). Auscultate for bowel sound, analyse if constipation is present. This may indicate poor dietary fibres and fluid intake. Encourage and counsel the patient to eat frequent meals with high calories value—emphasis on the rest period of at least 1 hour before every meal. Instruct Mr Robert to increase the fluid intake to at least 2500 ml if tolerated by him (Collins et al., 2019). Fluid intake is required to maintain the fluid and electrolyte balance and avoid hyponatremia and hypovolemia. If Mr Robert cannot tolerate the oral intake of food, then enteral nutrition should be facilitated after consulting with a physician (Collins et al., 2019).
Provision of emotional and psychological support:
As Mr Robert has been suffering from a debilitating and restricting chronic condition, he might be suffering from negative emotions, including fear, confusion and anxiety (Rzadkiewicz & Nasiłowski, 2019). Long-suffering and compromised quality of life may cause depression. Carefully monitor the psychological functioning, Asses the level of psychological status, including the severity of anxiety and depression in Mr Robert. Perform the mental health assessment to evaluate the risks, quality of life, and satisfaction questionnaire to assess everyday activities' limitations, deprivation of basic needs, and deterioration in the quality of life. Evaluate the activity tolerance and daily lifestyle changes required. Monitor the cognitive changes such as personality, behaviour and memory (Rzadkiewicz & Nasiłowski, 2019).
Create an environment in which patient can feel comfortable and safe to communicate. Comfort and support the patient by showing empathy, positive body language and care. Educate the patient to perform self-care and self-management. Identify the type of psychosocial support is required by him (Palmer et al., 2018). As Mr Robert lives alone, he should be educated regarding self-care skill development, problem-solving and decision making and integrate these skills in routine activities for appropriate behaviour and indulgence. Establish effective communication and relationship to encourage optimism and hope for mental and psychosocial well-being. Consult psychologist, psychotherapist and psychiatrist for appropriate therapy, including cognitive behaviour therapy for desired behaviour changes. Identify the community resource for mental health referrals and assist Mr Robert (Tselebis et al., 2016).
Education and Discharge planning:
It is essential to evaluate the patient's understanding and knowledge regarding self-care and therapeutic regime at the time of discharge. During discharge, setting goals is essential. If COPD symptoms are mild and controlled, the goal is to increase the exercise regime (Collinsworth et al., 2018). In Mr Robert case, there is an acute exacerbation of COPD, and hence the prime focus during discharge education should be on preserving the current pulmonary function and ensuring treatment adherence to avoid complication and relieving symptoms. During the discharge, inter-professional health team members are required to include physical therapists, dieticians, physiotherapists, psychologists, or counsellors (Palmer et al., 2018). The nurse needs to provide education regarding the lifestyle changes required; for example, the extremes of temperature should be avoided, high altitudes should be avoided as they increase the hypoxemia (Conley et al., 2018).
The physical activity should be adjusted as tolerates, and stressful emotional disturbances should be avoided. Walk slowly and gradually increasing the activity to build strength. Counselling should be provided for smoking cessation as Mr Robert is smoking 20 cigarettes a day and should be referred to community outreach agencies and programs (Palmer et al., 2018). Encourage treatment regime; take the long term medications as prescribed and quick relief emergency inhaler when required. Take small frequent nutritious meals—Maintain constant healthy body weight. Do not drink before eating, as it can put pressure on the diaphragm. He should also be advised on how to prevent the risk of infections. This includes washing the hands frequently, avoiding crowd gatherings and wearing a mask when going out. Refer to the flu shot and pneumococcal vaccine (Conley et al., 2018).
Through the case study of Mr Robert, male suffering from acute exacerbation of COPD, we analysed various aspects of essential nursing assessment, care required and evaluation pertinent to relevant topics. These topics include Education and Discharge planning, emotional and psychological support, adequate hydration and nutrition, hospital-acquired complications and proper oxygenation. Through the case, it can be evaluated that the care to the chronic obstructive pulmonary disorder patient should be holistic and focused on complete well-being.