Case study and nursing case study
Excerpt from Example:
Enhance Nursing Practice
In order to preserve life, the body has to have fresh air. When a person cannot inhale, or there isn’t enough fresh air coming into your body through the act of breathing, it is not feasible for life to keep. The respiratory system is what supplies the person together with the opportunity to inhale and ingest oxygen. Co2 is also removed that same way. If oxygen is not received, the brain cells begins dying, followed by other skin cells, organs, and tissues. Resolved here is a example dealing with the respiratory system, circumstances it may face, and how individuals issues can be treated.
Patient Inventeur: Unknown Grow older: 65 yo Sex: Girl
Client Issues: The patient gripes of a dried out cough that may be rarely successful. She has experienced the coughing for two weeks, and for the past two days is running a low grade fever (up to 101 when ever taken orally). Her urge for food is decreased, but with out nausea or vomiting. If the coughing occurs during the night, the patient must sit straight up in a seat in order to make breathing easier. In addition, she has shortness of breath after activity, and her throat can be slightly sore – generally in the morning.
Good Present Disease: The patient has skilled similar problems in the past. The most up-to-date episode was three months in the past. The hospital up to date her that she should be admitted to take care of her condition, but your woman refused. Just before she was discharged, the lady was furnished with an boire and a great antibiotic. While she performed feel better with that treatment, it was a little while until a significant amount of time to do so.
Previous Medical History: The sufferer takes simply no prescription medications on her breathing condition. For soreness, she truly does take Tylenol PRN, and has taken antibiotics and used an inhaler in past times. She is allergic to sulfa drugs, which may cause her to be able to out in a rash. This wounderful woman has never recently been hospitalized intended for breathing problems, and states that she do have “emphysema. ” Once she was treated for this problem during a prior instance, she rejected a pulmonary function check. She has as well as of child years asthma and smokes smokes. In the 1970s, your woman had a hysterectomy.
Significant Genealogy: The patient has two siblings. The first is a 75-year-old sister who had been diagnosed with osteoporosis at age fifty five. The additional sister is 72 years of age, and was diagnosed with breast cancer at age sixty.
Social/Personal History: The patient can be retired coming from hairdressing. The girl goes to church, and occasionally attends church functions. She also loves sewing, and does not get out of her house that much. Stress levels are very low, due to her retired position and a low-stress environment at home. The girl eats healthier but does not get workout due to the a suffocating feeling she experience during activity. Three to four instances per year the girl sees her primary care provider for the physical examination. She smokes one load up of cigarettes every day, and has been doing so the past 40 years, although does not use alcohol or perhaps drugs. She gets a high college diploma, has her house, and gets an annual pension. Finances happen to be stable, although she will rely on types of medications. Her insurance would not cover each of the prescriptions the girl needs.
Clientele Support System: The patient has two grown daughters, and she sees these people at least once on a monthly basis. There are contacts and acquaintances at her church, too, but there is no one the girl can talk to on a regular basis.
Description of Customer’s Support System: The patient has mentioned that she would like her daughters to obtain more involved in her life, although does not discover how to talk to them about this concern. Her daughters and the associates she has at church are the only support system offered to her.
Behavioral or Nonverbal Messages: The person feels like the girl might be stressed out, since she spends most of her time at home exclusively. She paperwork that the depressive feelings are receiving worse while she ages, and they are most often worse each year. The belief the patient has of self-efficacy has been on the drop over the last 10 years. There are community resources in her fingertips, but the girl does not know about them. The lady does get pleasure from visiting with her medical doctor during her checkups, although finds that her doctor is very active and does not spend a lot of time with her.
Customer Awareness of Capabilities, Disease Procedure, and Healthcare Needs: The person is concerned about her shortness of breath and coughing. She concerns that a thing could be wrong with her “heart, ” or that she may possibly have lung cancer. She is also concerned about pneumonia which may require staying in the hospital. Because of the prolonged mother nature of the cough and her fever, she actually is seeking medical assistance. However , before she has dropped both hospitalization and tests for this state. She understands she must be doing more to maintain a normal lifestyle, and realizes that feeling stressed out could be adding to some of the physical symptoms the girl with experiencing.
Vital Signs: BP = 130/70, Temp = 101 po, P = 100 and regular, R = twenty and non-labored, Wt = 130 lbs ., Ht sama dengan 55, ” BMI = 21. 63.
Physical Assessment Findings:
HEENT: There is light material within the buccal mucosa, which would not wipe off with a tongue blade. These kinds of symptoms happen to be associated with oral candidiasis.
Lymph Nodes: None of them
Lungs: Lowered breath seems and lifeless percussion inside the right reduced lobe. There is an end expiratory wheeze in right reduce lobe. Zero rales or rhonchi present. Increased anterior-posterior diameter to chest wall structure. Hyperinflation is a frequent finding in most three conditions (asthma, bronchitis, and emphysema) which present as COPD. A fatigue in the choc implies consolidation, pleural smooth, or pleural scarring. Expiratory wheezing is generally associated with breathing difficulties, chronic bronchitis, COPD, or perhaps pulmonary edema. In addition , lowered breath appears are also read in ARDs, asthma, emphysema, and pleural effusion.
Center: RRR with no murmur.
Carotids: No bruits.
Rectum Genital/Pelvic: not reviewed.
Extremities, Including Pulses: 2+ pulses during, no edema.
Neurologic: Not examined.
Medical tests and Outcomes:
WBCs 15000 with +left shift (a normal WBC is found between 4500-1000). The patient’s raised level is known as leukocytosis (Wijkstrom-Frei, et ‘s., 2003). The word “shift for the left” can be used when choosing whether a sufferer has an inflammatory process going on. It means that an infection is progress, and the stabs or bands have got increased (Wijkstrom-Frei, et ing., 2003).
SAO2 = 98%
Chest Xray = Hyperinflation of both lungs with increased AP diameter. Evidence of emphysema.
EKG = Normal sinusitis rhythm.
Customer’s Support System: Church contacts and children are the just support program.
Client’s Locus of Control and Readiness to Learn: Great health values are present, and the patient is aware of she should do more to maintain a healthy way of life.
ICD-9 Diagnoses/Client Problems:
Different, Emphysema: 492. 8
Patient unspecified, Pneumonia: 486
Asthma, unspecified type, unspecified: 493. 90
Candidiasis of Mouth area: 112. 0
Tobacco make use of Disorder: 305. 1
Screening for Major depression: V79. zero
Chronic Airway Obstruction, Certainly not Elsewhere Categorized: 496
Advanced Practice Nursing Intervention Strategy:
The patient requirements education for the importance of using a pulmonary function test performed. Given her history, physical exam results, and symptoms, the test is completely necessary. It will determine how well her lungs are taking in and releasing air, and will diagnose many diseases, such as asthma, bronchitis, and emphysema (American Lung Association). It can also help the specialist discover so why the patient could possibly be short of inhale.
The patient must also have a social function consult, to help her understand the community providers that are available to her. She may apply for rewards and courses through organizations that may be capable of help her pay for prescription drugs, and the cultural workers may assess the person’s needs and determine if her support systems are sufficient for the challenges your woman currently has and may confront in the future with her health conditions.
Oral candidiasis must also be treated with this patient. There may be several factors behind this condition, although antibiotic treatment is one (Mayo Medical clinic Staff, 2014). Because of her other symptoms, she has received antibiotics a couple of times recently. The lesions on this condition may spread for the esophagus, that could be the cause of the sore throat the patient is experiencing (Mayo Medical clinic Staff, 2014). A can range f culture can determine which usually bacteria the individual is dealing with, so treatment can begin. Which will likely get rid of the pain in the patient’s throat. Staying educated regarding candidiasis as well as how to practice good oral health will be very important to this sufferer, so the lady can deal with the condition and keep it coming from returning. Antifungal medications work well for this sort of treatment, and the patient must replace her toothbrush when the infection clears up, as a way not to re-infect herself following treatment (Mayo Clinic Staff, 2014).
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