Case Study and Nursing Case Study

Excerpt from Case Study :

Advance Nursing Practice

In order to sustain life, the human body has to have oxygen. When a person cannot breathe, or there is not enough oxygen coming into the body through the act of breathing, it is not possible for life to continue. The respiratory system is what provides the person with the opportunity to breathe and take in oxygen. Carbon dioxide is also expelled that same way. If oxygen is not received, the brain cells will start dying, followed by other cells, organs, and tissues. Addressed here is a case study dealing with the respiratory system, conditions it may face, and how those issues can be treated.

Patient Initials: Unknown Age: 65 yo Sex: Female

Subjective Data:

Client Complaints: The patient complains of a dry cough that is rarely productive. She has had the cough for two weeks, and for the last two days has also been running a low grade fever (up to 101 when taken orally). Her appetite is decreased, but without nausea or vomiting. When the coughing occurs during the night, the patient must sit up in a chair in order to make breathing easier. She also has shortness of breath after activity, and her throat is slightly sore -- most often in the morning.

History of Present Illness: The patient has experienced similar difficulties in the past. The most recent episode was three months ago. The hospital informed her that she should be admitted to treat her condition, but she refused. Before she was discharged, she was provided with an inhaler and an antibiotic. While she did feel better with that treatment, it took a significant amount of time to do so.

Past Medical History: The patient takes no prescription medications for her breathing condition. For pain, she does take Tylenol PRN, and has taken antibiotics and used an inhaler in the past. She is allergic to sulfa drugs, which cause her to break out into a rash. She has never been hospitalized for breathing problems, and states that she did have "emphysema." When she was treated for this problem during a prior episode, she declined a pulmonary function test. She has a history of childhood asthma and smokes cigarettes. In the 1970s, she had a hysterectomy.

Significant Family History: The patient has two siblings. One is a 75-year-old sister who was diagnosed with osteoporosis at age 55. The other sister is 72 years of age, and was diagnosed with breast cancer at age 60.

Social/Personal History: The patient is retired from hairdressing. She goes to church, and occasionally attends church functions. She also enjoys sewing, and does not get out of her house that much. Stress levels are very low, due to her retired status and a low-stress environment at home. She eats healthy but does not get exercise due to the shortness of breath she experiences during activity. Three to four times per year she sees her primary care provider for a physical examination. She smokes one pack of cigarettes per day, and has done so for the last 40 years, but does not use alcohol or drugs. She has a high school diploma, owns her home, and receives an annual pension. Finances are stable, but she does rely on samples of medications. Her insurance does not cover all the prescriptions she needs.

Clients Support System: The patient has two grown daughters, and she sees them at least once every month. There are contacts and acquaintances at her church, as well, but there is no one she can talk to on a regular basis.

Description of Client's Support System: The patient has indicated that she would like her daughters to get more involved in her life, but does not know how to talk to them about this issue. Her daughters and the contacts she has at church are the only support system available to her.

Behavioral or Nonverbal Messages: The patient feels like she might be depressed, since she spends most of her time at home alone. She notes that the depressive feelings are getting worse as she ages, and they seem to be worse each year. The perception the patient has of self-efficacy has been on the decline over the last decade. There are community resources at her disposal, but she does not have knowledge of them. She does enjoy visiting with her physician during her checkups, but finds that her physician is very busy and does not spend a lot of time with her.

Client Awareness of Abilities, Disease Process, and Health Care Needs: The patient is concerned about her shortness of breath and cough. She fears that something could be wrong with her "heart," or that she may have lung cancer. She is also worried about pneumonia that might require staying at the hospital. Due to the prolonged nature of the cough and her fever, she is seeking medical attention. However, in the past she has declined both hospitalization and tests for this condition. She knows she should be doing more to maintain a healthy lifestyle, and realizes that feeling depressed could be contributing to some of the physical symptoms she is experiencing.

Objective Data:

Vital Signs: BP = 130/70, Temp = 101 po, P = 100 and regular, R = 20 and non-labored, Wt = 130 lbs, Ht = 55," BMI = 21.63.

Physical Assessment Findings:

HEENT: There is white material on the buccal mucosa, which does not wipe off with a tongue blade. These symptoms are associated with oral candidiasis.

Lymph Nodes: None

Lungs: Decreased breath sounds and dull percussion in the right lower lobe. There is also an end expiratory wheeze in right lower lobe. No rales or rhonchi present. Increased anterior-posterior diameter to chest wall. Hyperinflation is a common finding in all three conditions (asthma, bronchitis, and emphysema) which present as COPD. A dullness in the percussion implies consolidation, pleural fluid, or pleural scarring. Expiratory wheezing is generally associated with asthma, chronic bronchitis, COPD, or pulmonary edema. In addition, decreased breath sounds are also heard in ARDs, asthma, emphysema, and pleural effusion.

Heart: RRR without murmur.

Carotids: No bruits.

Abdomen: Benign.

Rectum & Genital/Pelvic: not examined.

Extremities, Including Pulses: 2+ pulses throughout, no edema.

Neurologic: Not examined.

Lab Tests and Results:

WBCs 15000 with +left shift (a normal WBC is found between 4500-1000). The patient's elevated level is called leukocytosis (Wijkstrom-Frei, et al., 2003). The term "shift to the left" is used when deciding whether a patient has an inflammatory process taking place. It means that an infection is in progress, and that the stabs or bands have increased (Wijkstrom-Frei, et al., 2003).

SAO2 = 98%

Chest X-ray = Hyperinflation of both lungs with increased AP diameter. Evidence of emphysema.

EKG = Normal sinus rhythm.

Client's Support System: Church contacts and daughters are the only support system.

Client's Locus of Control and Readiness to Learn: Positive health beliefs are present, and the patient knows she should do more to maintain a healthy lifestyle.

ICD-9 Diagnoses/Client Problems:

Other, Emphysema: 492.8

Organism unspecified, Pneumonia: 486

Asthma, unspecified type, unspecified: 493.90

Candidiasis of Mouth: 112.0

Tobacco use Disorder: 305.1

Screening for Depression: V79.0

Chronic Airway Obstruction, Not Elsewhere Classified: 496

Advanced Practice Nursing Intervention Plan:

The patient needs education as to the importance of having a pulmonary function test performed. Given her history, physical exam results, and symptoms, the test is absolutely necessary. It will determine how well her lungs are taking in and releasing air, and can diagnose a number of diseases, such as asthma, bronchitis, and emphysema (American Lung Association). It can also help the practitioner discover why the patient may be short of breath.

The patient should also have a social work consult, to help her understand the community services that are available to her. She can apply for benefits and programs through agencies that may be able to help her pay for medications, and the social workers can assess the patient's needs and determine if her support systems are adequate for the challenges she currently has and may face in the future with her medical conditions.

Oral candidiasis must also be treated in this patient. There can be several reasons for this condition, but antibiotic treatment is one of them (Mayo Clinic Staff, 2014). Because of her other symptoms, she has received antibiotics several times recently. The lesions of this condition can spread to the esophagus, which could be the cause of the sore throat the patient is experiencing (Mayo Clinic Staff, 2014). A throat culture can determine which bacteria the patient is dealing with, so treatment can begin. That will likely clear up the soreness in the patient's throat. Being educated about candidiasis and how to practice good oral hygiene will be important for this patient, so she can treat the condition and keep it from returning. Antifungal medications work well for this type of treatment, and the patient must replace her toothbrush when the infection clears up, so as not to re-infect herself after treatment (Mayo Clinic Staff, 2014).

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