Ms. Catherine Stallard Case Study - Medical Science Assignment Help

Assignment Task:

Task:

Introduction:
Hi this is Gayatri. I am second year nursing student from flinders university. Today I am going to give handover Ms. Catherine stallard. Her date of birth is 27 Feb. 1953 and her care receipt number is 18889041 house 3 room no 308. She is Australian born and speaks english. Talking about her family history Catherine used to live with her mother in Adelaide hills. She IS SINGLE NO CHILDREN. Catherin father passed away when she was 13 years old because of stroke. Catherine has 3 siblings, john Pamela who she doesn’t have any contact with. And another brother who passed way in 2014 because of cancer. SACAT (South Australian Civil and Administrative tribunal) team appoint JOHN her brother as a guardianship. So he is the one to take all the decision. But the SACAT TEAM order that do not mention to Catherine that brother john has guardianship. Here I have evidence of consent that I have obtained from patient. And registered nurse who was there with me as a evidence.
Situation:
Catherine was admitted 08 of October 2018 in this nursing home for high level of care. She has moderate cognitive impairment complain of continuous chronic pain on her both LOWER legs and back, also she has been treated with chronic pulmonary obstruction (COPD), Unmanaged type 1 diabetes mellitus that was difficulty to monitor and manage at home which is unsafe for her health.
There are few reasons to admitted in this facility, she used to live with her mother at home, there were some reports of financial abuse, very poor management of medication manly with type 1 diabetes mellitus.
On 07 august 2018 Catherine suddenly collapse at home and transfer to Queen Elizabeth hospital. As Catherine has no formal services at home. cathie referred to Hampstead rehabilitation center by her treating team where she has assessed for by age care assessment team (ACAT) and considered unsafe to return home to the care of her mother. She attempts suicide via insulin overdose so referred to mental health in 2017. she has 34 hospital admissions for management of diabetes. Catherine’s mother herself was 89 years old her mother realised that she can no longer look after her safely at home. She don’t have any advance care directives. She is not for resuscitation.
Background;
Catherine is 69 years’ old who is living in Anglicare SA nursing home since 2018 to till mow. She has a past medical history of depression, osteoporosis, stroke, vascular dementia, left cataract surgery in 2016, NOF in 2013, distal radial fracture because of fall. Encephalopathy, CHARCOT foot.
So here I would like to talk more about COPD: as this diagnosis is the main reason for admitting Catherine in facility.
COPD- is major leading cause of death in Australia.it is chronic lung disease which block the airways and make difficult in breathing. people will be experiencing shortness of breath, chest wheezing and sputum production and dyspnea. Patient have symptoms such as mucus production, blue fingernails, weakness, swollen ankles, feet or leg, chest tightness, wheezing however my patient having these symptoms which are shortness of breathing , swollen ankle and feet and chest wheezing.
 

There are risk factor of COPD for Catherine:

• She was X-smoker
• Catherine was X-smoker and use to work in the chemical factory and there was air pollution which could be the cause of COPD. Catherine used to smoke more than 20 cigarettes in a day 30 years which extremely effects on her lungs
• Cigarette smoking caused inflammation in the central airways. And increased peripheral airways, lung parenchyma which affects in normal lung function.
• She used to work at chemical factory which is occupational exposure. Long term of exposure to air pollution and chemical dust and fumes contribute to the development of COPD.
• Alpha 1 deficiency: A small number of COPD called alpha 1 deficiency. This form of COPD is caused by a genetic condition that affects the body ability to produce protein called alpha-1 antitrypsin, an enzyme inhibit to protect the lung parenchyma from injury.
• AGE; is another factor affecting of COPD. People when become older more than 40 years then occurs sign and symptoms. It is more common in female than male.
• Allergies:
• Catherine has allergic reaction from some medications.
• Ramiprill drug reaction is cough
• Ferro-tab tablet reaction is nausea and drowsiness
• GLUTEN; CAUSE DIARROHEA
• Social status:
• she does shopping with her mother. Cleaner assistance comes every fortnight from MAC agency. She loves to do gardening she normally goes to church once a month. To take her church agency staff or social worker appoint for escorting to the church. Involves in church service on Sunday and celebrate Christmas and birthday.she like classical music, classic ballet and in afternoon she love to watch SBS and channel 7 on her television.
• Medication:
• Salbutamol and Ventolin
• PREDNISOLONE AND Seretide inhaler 25 mcg
• Seretide inhaler
• Novorapid (inulin aspart)
• QUETIAPINE
• ASSESSMENT;
• Physical assessment;
• CNS; Catherine is alert and oriented with time and place and people. She complain about pain on her lower legs and back that is why she is having strong S8 MEDICINE Nospan Patch (drug dependent analgesic).
• CVS; Catherine vital sign are blood pressure, saturation percentage, pulse and temperature. Strongly need to check her saturation level and respiration rate. With oxygen 99% without 92-95%. Her BGL are monitored TDS(8;00, 12;00 and 17;00)
• GI; resident has got MOVICOL MEDICINE FOR THE BOWEL FUNCTION,
• Renal system; Resident has oedema on both legs and she is wearing pull up medium size for continence.
• INTEGUMENTARY SYSTEM; Resident has got wound on tebial part for long time. Nurses are doing wound assessment and doing dressing 3 days intervals, she has hematoma on her leg and then it was burst and become wound however wound healing process is good condition.
• Metabolism; BGL parameter min 3.5- max 20, BD BGL check, BGL 25 mmol- In diabetic, pancreas cannot produce adequate amount of insulin which leads to increase circulatory glucose level. Catherine is in high protein and fiber diet such as bread , nuts, pasta, seeds, fruit and vegetables. High protein diet sources are egg, cheese, meat, fish and peas.
• Mobility: Catherine use 4ww to walk to the dinning and lounge area and can work indoor and outdoor at any distance.
• She is sleeping well
• Sensory system: She have poor eyesight so she is wearing a reading glass, Hearing aids on in bilateral side.
• Heat pack PRN
• Pain assessment: History of pain on lower leg and back pain, nil pain reported during assessment, she is on regular paracetamol 1000 mg QID, Oxycodone 5 mg PRN, Massage for bilateral shoulder back, Massage by RN twice a week for 10 min.
• Wound dressing every 3 dressing every 3 days with Inadine, meloline, mesorbe and soft crepe bandage
• Cognitive assessment
• Neurological assessment.
• Vaccine: she had both covid vaccine and flu vaccine for this year.
• Diagnostic investigation;
• Arterial blood gas (Abg) is use to check arterial oxygen and carbon dioxide level in the blood
• Potential of hydrogen is acidic people who are suffering from COPD.
• Pulmonary function test by using spirometry
• Chest x ray scan will show until it is severe the image may show enlarge the lungs or blur the lungs scan.
• Regular saturation monitoring and respiration
• Screening alpha 1- antitrypsin, sputum culture.
• So in this assessment I would like to talk more about charcot foot to link with type 1 DM.
• Charcot foot which is a rare but serious complication of diabetes and neuropathy
• that can affect persons with peripheral neuropathy, as one of the past medical history of Catherine was peripheral neuropathy. Especially those with diabetes mellitus. Charcot affects the bones, joints, and soft tissues of the foot or ankle. The bones become weak and can break and the joints as she has history of Osteoporosis which makes bone density weaker and increase chance of Fracture.
• In the early stages, the foot is red, feels warm to the touch, and there is significant swelling of the extremity.
• Recommendation:
• Deep breathing and coughing exercise
• Spirometer exercise
• Evaluate the leg at night for proper circulations.
• Life style invite cathie for activities as she loves gardening so engage in her light gardening work.
• Encourage to stay in semi setting position
• Oxygen therapy as per needed
• Encourage and recommend high protein diet.
• Continues vital sign monitoring especially saturation,
• Chest examination specially need to ask to do expand to check barrel chest.
• Head to examination
• Encourage to have warm cloths because of high risk in winter and and early springs.
• Catherine is living in nursing home so I would like to recommend to have medicine on time
• Need to listen abnormal breathing sound such as wheezing crackles.uProper management of wound chart
• Physio therapy needs to provide 20 minutes massage for a week and to review her mobility
• Pulmonary rehabilitation programme – this program generally combine education, exercise, training, nutrition counselling.

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