Caring for a Patient with Respiratory Distress - Analysis, Nursing Diagnoses

Assignment Task

Task

The purpose of this case study assignment is to demonstrate your knowledge and understanding about being a Registered Nurse (RN), who is caring for a patient with one presenting health condition. It is important that all RNs have knowledge/understanding of common health conditions as well as recognise early signs and symptoms, to prevent health deteriorations in patients’, being cared for in various health care settings. 

Overview of Assignment Requirements

The RN from the early shift has provided you with an ISBAR handover. You are the RN on the late shift and have accepted responsibility to care for the case patient. Firstly, you will consider the patient situation by reading through all the case study information. Secondly, from this information you will identify cues/information that have been collected by the RN. Identify and give rationales for missing information, specifically two nursing assessments and two nursing interventions. Recall knowledge anatomy, physiology, pathophysiology and nursing interventions/care from Fundamentals of Nursing Practice 1. Thirdly, the assignment will require you to process information by analysing the case information and identify two nursing diagnoses. Establish two nursing interventions to meet the care needs of the patient. Evaluate the nursing interventions that you have identified with literature. Explain what National safety and quality health service standards (NSQHSS) you would use as a RN to govern your nursing care for this case patient. Finally, reflect on what you have learnt and how you will improve to be competent in caring for a patient with this health condition.

Part A - Consider the patient situation, collect cues/information, process information & identify the problem/issue

I - Hi my name is Sam Greenway, I am the RN who has cared for Cosmo in the Respiratory Ward during the early shift. I will provide an ISBAR handover before I go on my lunch break. Are you ready to receive handover? Mr. Cosmo has a date of birth 24 ^th May 1961 and MRN 14025374.

S – Cosmo was transferred to the ward from ED at 0800 accompanied by wife Athena, who reports that “Cosmo’s breathing has been bad”.

B - Cosmo has a two-month history of SOB on exertion and a five-day history of increasing respiratory distress on exertion, but yesterday he could not catch his breath after resting. Athena called the ambulance as he looked very unwell. Cosmo has been coughing up small amounts of sputum that is thin and white in colour. The patient denies fever, chills, night sweats, weakness, muscle aches, joint aches, and blood in the sputum.

Cosmo has a past medical history of HF diagnosed 15 years ago. Is a current smoker (1 ppd), makes his own plum wine and enjoys a glass each day with dinner. No known allergies to food or medications. Medications that Cosmo has been taking for 15 years include Spironolactone and Metoprolol.

Cosmo recently retired but worked as a production line worker at Holden Cars moving cars out of the paint spraying booth. He owns a 2 000m ² property with Athena that has a fruit orchard and herb garden. He usually assists his wife with gardening and harvesting, but recently has been too tired to walk the property. Cosmo enjoys having his large family over for weekend dinners. He admits that recently he has no appetite and has lost 2 kg in the past month.

A – Cosmo is SOOB in a chair and has a RR of 28 breaths/minute and still appears to be SOB and HR of 105 beats/minute and regular. Cosmo height is 165 cm and weight 55 kg. Blood tests for electrolytes and FBC have been sent. ABG taken and sputum sample has been sent. Cosmo had a shower requiring a shower chair due to his SOB and has been assisted with dressing into a clean hospital gown and assisted with a shave, but managed to brush his own teeth. Cosmo was given lunch but only managed to drink a cup of coffee over 20 minute period, due to breathlessness, stating that he was not hungry.

R – Cosmo needs to be transported to radiology for a CxR at 1400 and respiratory laboratory at 1600 for PFT. Check blood, ABG and sputum results that were sent at 1200.

Consider the patient situation

• Introduce your case patient (Name, DOB & MRN), current health condition and past medical history

Collect cues/information

• Identify nursing assessments that have been performed on the case patient and describe what information was collected from these assessments.
• Identify nursing interventions that have been performed on the case patient and describe how and why these nursing interventions were performed

Gather new information

• Identify further nursing assessments that as a RN you would perform, to collect additional information about the patients current health issue.
• Describe what information these assessments would collect and why they are important for RN to consider when making decisions about providing nursing care to the case patient.

Recall knowledge

• Identify the body systems involved in both the presenting and past medical history conditions.
• Describe relevant, anatomy, physiology and pathophysiology for both the presenting and past medical history conditions (what happens to the body system to change from a health state to a diseased state).

Process information

• Identify the abnormal findings in case information above and explain why these are abnormal
• What is most relevant information from the case and why

Identify the problem/issue

• Identify a nursing diagnosis for your case patient after processing case information presented.

Part B - Establish goals, take action, evaluate outcomes and reflect on process & new learning

At 1830 you returned from your dinner tea break and found Cosmo distressed with his breathing. Cosmo is highly anxious, breathing shallow rapid breaths. You reassure Cosmo that you are going to help him and he is safe and to try to slow his breathing. You perform an A to E assessment with the following findings:

• Airway – clear, productive cough at time expectorating sputum white in colour, no tracheal deviation
• Breathing – RR: 35 breaths/minute, swallow breaths, poor breath sounds throughout right and left lungs, course crackles heart in RUL and LLL, laboured effort of breathing including use of accessory muscles at rest, SpO2: 88% on room air
• Circulation – pulse 108 beats/minute, regular and weak in strength, BP: 118/66 mmHg, peripheries pale and capillary return close to 3 seconds, IV access in right cubital fossa, site dry and intact dressing, 250mls of light yellow coloured urine in bottle, no foul smell
• Disability – Alert and orientated but unable to speak in full sentences, PEARL +3, normal power in all 4 limbs, denies pain in chest, last BGL prior to dinner was 4.6 mmol/L
• Exposure – Temp: afebrile 36.6°C, diaphoretic, swelling in ankles

Establish goals

Identify further nursing interventions that as a RN you would perform, to alleviate signs and symptoms the case patient is experiencing.

Describe how these nursing interventions would be performed by a RN

Take action

Explain and give rationales why you would implement the nursing interventions you have identified above (use anatomy, physiology and pathophysiology in your explanation)

Evaluate outcomes

• Evaluate the nursing interventions that you have identified, to determine if they would be effective in improving the patients’ identified problem/issues.
• Explain what National safety and quality health service standards are used by the RN, who provided nursing care for this case patient, on both the early and late shifts.

Reflect on process and new learning

• What have you learnt from this case study that can be used when caring for other patients?
• What do you need to improve on to be competent in caring for a patient with this condition?
• How do you plan on achieving this? Outline the steps you will take to achieve this. 

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