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Case Study

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by

kyler wedgeworth

on 28 July 2014

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Transcript of Case Study

Diagnosis
Diagnosed with empyema which is pus build up in lungs. Specifically his left lung which requires chest tubes to even stay inflated.
Evaluation
Pt has massive infection of left lung. Now is too weak to walk or even really move except his arms without help due to infection. Left lung is not salvageable but refuses removal.
The Nursing Process
The Five Common Threads
Communication
Does not communicate well due to vocal cord damage. Damage he furthered when he pulled his own ventilation tube out in the middle of the night. Pt is very good at nonverbal communication however.
Case Study
A1C Daniel Morrison

Planning
Ordered to receive antibiotics such as meropenem IV used for its ability to penetrate better into certain tissues such as the lungs, Vancomycin, and Levofloxacin. Pt also prescribed Ipratropium which is commonly used in COPD patients but for him it helps his condition. Also ordered 3 chest tubes, and one central line installed for ease of medication administration. Was also ordered to have left left lung removed to help his recovery.
Implementation
Initially Pt went along with the plan for his recovery but as soon as he was feeling better he adamantly denies any further medical treatment making implementation of any plan impossible.
Intro
Pt has been at Keesler before for empyema due to aspirating grits. He walked out thinking he was better but has returned because of his worsening condition.
Assessment
Pt very grumpy person who originally sought our help but now wishes to die. He demands to go home but is physically unable to do so. Pt has right to refuse medical treatment but legally we cannot leave him somewhere on his own. This is known as "dumping." Pt also has history of diabetes.
Psychosocial
Very grumpy person with a fighting spirit. Confrontational when it comes to military medical care.
Cultural Sensitivity
None- Very suspicious person. Trusts no one.
Teaching
Told multiple times he would die without the proper medical treatment yet he still refused and was found mentally competent. After a lot of back and forth, the doctors finally gave him a real look at what he would face and he still refused.
Collaboration
The VA and the hospital staff had to cooperate together in order for this patient to receive the care he needed and to transfer him back where he came from. There was also a lot of cooperation between the nursing staff, the doctors, the respiratory techs, and the medical techs.This man's care was so vast that almost every department was involved.
Full transcript