NURS2004: Development of a Person-Centred Care Plan - Albert Clarke Case Study - Nursing Assignment Help

Assignment Task:

Introduction: 
Albert is a 72-year-old man who is admitted to the hospital following an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). He is admitted to the Respiratory Ward. 

Personal details 
 
• Patient: Albert Clarke 
• Preferred name: Albert 
• DOB: 14/08/1947 
• Age: 72 years 
• Address: 5 Bentley Ave, Greenhaven SA 5119 
• Weight: 60 kg 
• Height: 182 cm 
• BMI 18.1 
• MRN: 74937694 
 
Family/Significant others 
Wife, Sandra, 65 years old who is well. Two adult children living interstate. 
 
Hobbies 
Gardening, Golf uses a golf cart due to breathlessness, chess 
 
Background 
Albert presented to the Emergency Department of the local metropolitan hospital with worsening symptoms of shortness of breath, productive cough with increased production of sputum and a temperature of 39 degrees Celsius. Diagnostic testing was undertaken and Albert received a diagnosis of acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD), secondary to community-acquired bilateral lower lobe pneumonia. Albert was transferred to the Respiratory Ward for treatment. 
 
Past medical history 
• Ex-smoker – 30 per day, quit 10 years ago 
• Hypercholesterolaemia (current Cholesterol reading 5 mmol per litre) 
• Myocardial infarction (MI) - 3 year ago – stent inserted, nil further issues 
• Chronic Obstructive Pulmonary Disease – diagnosed 5 years ago 

Past surgical history 
 
• Appendectomy, at age 15, nil further issues 
• Coronary artery stent insertion following MI - 3 years ago, nil further issues 
 
Past family history 
• Nil significant 
 
Allergies 
• Micropore™ tape - blisters 
 
Medications 
• Atorvastatin, 40mg, Nocte 
• Aspirin, 100mg, OD 
• Salbutamol, PRN 
• Trivia  1 capsule inhaled once a day 
 
Socioeconomic 
• Lives at home independently with his wife in the family home

Development of a person-centred care plan 
 
Albert is day 0, the day of admission to the Respiratory Ward, following the diagnosis of acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD), secondary to community-acquired lower lobe pneumonia. Currently, Albert is orientated to time, person and place and is able to follow commands. Albert has a pain score of 0/10. He is tired, appears breathless and does not want to sit out of bed. Albert refused lunch and only had a cup of tea for afternoon tea. Albert’s observations are written below. Albert is reviewed by the respiratory registrar Dr Tara Line, and she notices that he is not speaking in full sentences and is leaning over his tray table in bed. He appears diaphoretic and lethargic. A chest x-ray has ruled out inhalation of foreign body and confirmed bilateral lower lobe pneumonia. 

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