Nursing Diagnose - Chest Infection - COPD and Cardiac Failure - Nursing Assignment Help

Assignment Task:

Abstract

The aim of this paper is to construct nursing diagnose carried out by self for patient under the care Urgent Reposes Team. To accomplish my finding I will be discussing a single patient who was referred to the team with chest infection and who then further developed oedema to his feet and both legs. 

Introduction

The Urgent Response team that I work for is designed to help patient to stay at home when they have emergency health condition or clinical unwell with infection. This may be patient with long term condition or new offset of new condition. Further to that URS team also undertake home IV treatment at home saying patient stay in hospital. Whereby patient are cared in their own home avoid hospital admission. Some off the condition that the team manage at home are patient with, Chest infection, Cellulitis, Urine infection, or patient with long term condition COPD and cardiac failure.  The team also manage patient with uncontrolled clinical observation  such has high or low  Blood Pressure,  increase Hearth Rate, uncontrolled  Sugar levels,  low Saturation, Temperature)   who can be nurse at home.  Aim of the team to manage and care for this patient in their own home with increased input form nursing staff.

The staff in team need carry out in depth assessment for each patient that is referred to the team. In the essay I will be discussing a patient who was referred to team by his Gp following home visit. This patient had chest infection and had self-discharged himself against advice consultant from Southampton General Hospital (SGH). The team was asked to monitor patient condition and manage the patient in his own home. Patient that being discussed in this case study will be referred as RB and Gp as Dr E. 

Case Study 

Patient RB, was referred by Dr E for clinical monitoring following a recent admission to hospital with chest infection and fluid overload. He self-discharged from hospital and has been unwell since coming back home. Dr E vi would like him to be admitted to hospital, but patient RB has refused admissions back to hospital. He wants to be treated at home and if needs then he will go into hospital if his condition does not improve.  When the referral was taken form Dr E Gp had made aware that the patient was still for resuscitation.  Dr E had update at the time of referral that DNCACRP was in place, but patient wish was and he is adamant he wants to be resuscitated.

On the first home visit full history was taken and recoded. Patient was recently sent to hospital due to recent AF, Fluid overload. The doctors from UHS had put patient on furosemide, steroids, and antibiotics to treat his condition at home.    While in hospital he hadn't been eating and drinking well. 

Further he was getting fed up with waiting in hospital and decided to self-discharge home. Dr E visited patient today and said patient should be in hospital.  On Gp Dr E referral he has started him back on oral antibiotics and steroids which his daughter is picking them up later today. Patient will self-manage with his medication with support from his daughter.

On home visit extend medical and social history was undertaken as follows. 

1. Chronic Kidney Disease - Stage 3: 01/04/2019
2. Urinary Incontinence: 01/04/2019
3. Chronic Obstructive Pulmonary Disease (COPD): 01/04/2019
4. Diverticular Disease (DD): 01/04/2019
5. Drug reaction - Ramipril: 01/04/2019
6. Ischaemic Heart Disease:
7. Diabetes Mellitus Type 2

8. Persistent atrial fibrillation: 02/04/2019
9. Benign prostatic hypertrophy (BPH): 01/04/2019
10. Gallstones: 01/04/2019
11. Gout: 01/04/2019

Patient baseline observation showed that he was able to mobilise and get himself diet and fluids and only walk very short distance. The family have brought his bedroom downstairs and his mobility has deteriorated. He is able to walk with a walking stick. He has deteriorated since his wife died 2 years ago and has slowly deteriorating in health.                                                       

Patient RB mental and psychological observation showed that patient was alert and orientated and able to make wise decisions and full capacity.

His home environmental assessment showed patient RB lives in a house alone. He has 7 daughters who visit regularly. They support patient with care needs. They did question to me about care and would to be referred to Social services/URS social.

Falls history showed that patient RB has had no falls in the past. He says he just gets nervous when walking and relies on someone with him. His mobility showed that when mobilising he walks with a walking stick. He has recliner chair which he uses and is able to mobilise. His daughter said that he is struggling to walk now and asks for the wheelchair when he walks to the toilet.

Patient is able to take the medications himself with the family who put them into separate pots.

Bowel and bladder observations patient RB has no concerns with bowels. Bowels open daily, if patient RB has been given Movicol to help with constipation. Patient RB is able to pass urine with no problems. He wears pads but knows when he needs to go. He wears them for 'just in case and his bladder so he regularly gets urine infections.

Patient RB had very poor diet and fluid intake whereby his appetite has deteriorated since hospital but prior to that his weight has gone down. GP is aware of the weight loss. Since being on steroids his weight has improved. Patient is on supplement drinks once a day.

 By undertaking comprehensive the baseline one can then identified as how his condition has changed over the period of time. Then patient management care and nursing plan can be written to manage patient in his own home .

On admission patient (NEWS 1) score was (2) on admission 12/4/2019.

Respiratory Rate: 22breaths per/min

Temperature: 36.1 c

Blood oxygen saturation: 95 % on air  

Herat rate: 57 BPM  

Pulse Rhythm regular   

Sitting Blood pressure: 128/72 and Pain levels: 0/10  

Following assessment, care plan was drawn up to manage patient in his own home. Care plans that was generated 

• Clinical monitoring for chest infection

•   Undertake daily NEWS score  using scale 1 daily twice day

• To offer and assist patient with personal care needs 

• To support patient with daily  diet and fluids

• To support and daily review medication has been taken by patient.

• The care plan for daily weights was not written thus staffs were not aware that patient was putting on weight. ( Not carried )

•   Patient RB was seen over periods of 2 days by other staff.  On the 3rd day I was asked to review patient RB as his condition had not improved.

3 day review By Harvinder Sidhu 

On my assessment I found that patient sitting in his arm chair. History was gained form patient and daughter.  Daughter update that her father had reduce diet intake since coming out of hospital further spending most of the time sitting in arm chair and struggling with his mobility no improvement in his condition over the last 48 hours. When he mobilise he was getting short breath. 

On my visit I carried chest auscultation and full set observation was taken. Patient RB had wide spread crackles on both lungs and on percussion consolidation to both lower lobes of lungs. He was getting SOB when mobilising.  Patient RB had oedema on both feet to his just below knee. He also had presented on my assessment with high temperature (Fever) with productive cough. Patient had started on second course of oral antibiotic and he condition had not improved. I conclude that he was not responding to treatment.   On the 1st day of assessment staff had not undertaken patient weight and had not notice that patient had oedema on both feet and extending to both legs.

Further to that on my review patient RB was having difficulty in breathing and had increasing coughing  with excessive sweating . He also was bringing green sputum. He was sitting upright and unable to lie down flat due to him getting breathlessness. He expressed that in the night he has been having episodes sudden short breathlessness and that he is at time afraid to sleep. On checking his jugular venous pressure (JVP) was raised. It has been noted that the most common cause of raised JVP is congestive cardiac failure, in which the raised venous pressure reflects right ventricular failure (Epstein et al, 2003). To ascertain the raised JVP I used reference Appendix 1.

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