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Case Study 2 JB

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by

Rebecca Speiran

on 9 December 2013

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Transcript of Case Study 2 JB

References:
4. Ineffective self-health management r/t perceived seriousness AEB smoking, not using prescribed inhaler, and refusal to start on daily regimen of medication
NICS
Help Mr. Bley enhance self efficacy or confidence in his own ability to manage his respiratory problems.
Involve his wife in the development & planning for self management & shared decision making.
Teach strategies on improving his smoking habits.
Develop a contract with Mr. Bley that will encourage him to change his behaviors.
Discuss with Mr. Bley what he feels are barriers to managing his health and how he can modify those barriers.
NOC 2
By the next visit, Mr. Bley is able to verbalize what he is doing to improve the current state of his health.
NOC 1
By the end of the current visit, Mr. Bley is on a daily regimen of medication.
NICs
Provide Mr. Bley with various formats of information about the medication regimen, including verbal and written instructions.
Explain to Mr. Bley that consistency in therapeutic regimen management provides optimal results.
Review factors of the Health Belief Model (perceptions of seriousness) with Mr. Bley to explain that his inhaler is important.
Involve Mr. Bley's wife to help encourage him to manage his medications.
Help Mr. Bley set up organizational changes to facilitate his usage of the inhaler.
Rebecca Speiran, Grace Yang, Danielle Johnson, Melanie Janson
Case Study 2 Mr. Jimmy Bley
Concept Map
Pathophysiology
of Pneumonia
R/t wound
Education
Mr. Bley needs to know about - Interaction between COPD, pneumonia, and continued smoking
Assessment Findings
In a patient with pneumonia you would expect to find:
SUMMARY:
Inspection
increased respiration rate
decreased expansion on the right side
cough present
#1 Impaired Gas Exchange r/t ventilation-perfusion
(airflow-blood flow) imbalance from pneumonia AEB abnormal breathing rate (respiratory rate: 24), fatigue, and report of coughing
DRUGS:
NICS:
Palpation
increased tactile fremitus over consolidation
increased skin temperature
Auscultation
increased vocal fremitus over consolidation (broncophony, egophony and whispered pectoriloquy)
coarse crackles in affected area
Bacterial pneumonia can be treated with antibiotics, while viral pneumonia is treated with antiviral drugs. Both can be treated with supportive medications that ease chest pain and calm coughing.
Education plan
- discussion with nurse in quiet room about how COPD has compromised his respiratory capacity
- explanation of what pneumonia is and how it is interacting with his COPD
- pamphlet about quitting smoking
Pneumonia is an infection of the lungs that can affect a lobe of a lung, one lung, or both lungs. Symptoms may include fever, chills, productive coughing, fatigue, and a sore throat. Causes of the disease include breathing in bacteria, viruses, and even the presence of fungi in individuals with impaired immune systems. Due to the infection material clogs up in the air sacs of the lungs, inhibiting the lungs from easily transferring oxygen to the blood. To diagnose the disease, doctors listen to the lungs for crackles, palpate, and request an X-ray to look for the presence of fluid in the lungs.
#2: Altered Tissue Integrity r/t injury in left shin AEB open 3cm x 4cm x 4cm wound, redness of skin, & non-intact nature of skin
Additionally, Mr. Bley has COPD which will present with...
NOC (short-term)Mr. Bley will verbalize understanding of oxygen supplementation and other therapeutic interventions within 2-3 days
NOC (short-term)
Within 24 hours, Mr. Bley's respiratory rate will decrease to be within the normal rate of 12-20 breaths per minute
NOC (long-term)
Within a month, Mr. Bley will be able to maintain clear lung fields and remain free of signs of respiratory distress
3. Activity intolerance r/t imbalance between oxygen supply and demand AEB verbal report of weakness, shortness of breath with exertion, and progression of COPD (FEV1 levels increased from 48% to 57% in 2 years).
NICs
Nurse will use traditional 6 minute walk distance to evaluate Mr. Bley's ability to walk
Nurse will instruct Mr. Bley in using conscious, controlled breathing techniques during exercise, including pursed-lip breathing, and inspiratory muscle use.
Nurse will see Mr. Bley once a week to assess progress
Nurse will walk with Mr. Bley once a week to ensure that he is exercising
Nurse will teach Mrs. Bley about importance of exercise
NOC
By 2 months Mr. Bley is able to walk up 2 flights of stairs without SOB..
NOC
By 3 weeks Mr. Bley is able to mow for 15 minutes without rest
NICs
Nurse will work with Bley family to simplify ADLs for Mr. Bley
Nurse will provide emotional support & encouragement to Mr. Bley to gradually increase activity.
Nurse will teach Mr. Bley an exercise regimen
Nurse will give Mr. Bley an information packet on the hazards of smoking
Nurse will monitor Mr. Bley's response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, nasal flaring, appearance of facial distress and skin tone changes.
NICs
- Teach Mr. Bley how to perform pursed-lip breathing and inspiratatory muscle training to improve his respirations
- Teach the Mr. Bley energy conservation techniques and the importance of finding time to rest to decrease fatigue.
- Explain to Mr. Bley how severe the issue of impaired gas exchange is and tell him about consequences
5. Deficient Knowledge r/t information misinterpretation AEB patient verbalized - "not really sure... what happened in my lungs", not interested in quitting smoking, patient describes emphysema as "not that bad"
6. Noncompliance r/t reluctance to accept responsibility for changing detrimental health practices AEB continuing to smoke heavily and acknowledging no interest in quitting smoking.
Pathophysiology of
Pneumonia Continued...
7. Social isolation r/t hearing loss AEB not hearing ambulances while driving and fighting with wife over hearing loss.
Common issues found in patients with pneumonia include...
NOC
Before Mr. Bley leaves the hospital he will understand how to care for his wound.
NICs
- Auscultate Mr. Bley's breath sounds every 1 to 2 hours to ensure that there are no crackles or wheezes that could indicate a severe breathing issue
- Turn Mr. Bley every 2 hours to avoid the development of atelectasis
- Schedule nursing care to provide rest and minimize fatigue
NICS
-Teach Mr. Bley how to apply topical treatment for the wound site & implement a written treatment plan.
-Instruct Mr. Bley and his wife on how to change the dressings and on keeping a clean environment and observe the completion of a dressing change.
-Initiate a consultation with a would specialist in order to establish the most comprehensive wound care management for Mr. Bley.
NICs
- Assist Mr. Bley with identifying and avoiding situations that lead to impairment of gas exchange such as situations that put him in a stressful position
- Instruct Mr. and Mrs. Bley to keep the home temperature above 68 degrees and to avoid cold temperatures which can impair Mr. Bley's ability to exchange oxygen.
- Refer Mr. Bley to home health aide services that can assist him in daily activities that neither him nor Mrs. Bley can complete without complications.
Monitor respiratory rate, depth, and ease of respiration. Auscultate for breath sounds every 1-2 hours.
Stay with client when they express fear and provide verbal and nonverbal comfort.
Assess pain on a 0-10 scale and administer opioids to keep pain level down.
COPD
Chronic Obstructive Pulmonary Disease
Pneumonia
(right lower lobe)
Hearing Loss
1. Impaired Gas Exchange
3. Fear
2. Acute Pain
NOC
By 3 weeks the wound will be completely healed and reduced in size.
NOC
Within 3 days Mr. Bley's wound will indicated a decrease in redness.
NICS
-Monitor the wound site daily for changes in color
-Alter positioning of Mr. Bley so that there is no pressure on the wound.
-Implement a topical treatment and choose dressings that provide a moist wound-healing environment.
Wound in Left Shin
NICS
- Discuss with Mr. Bley possible precautions to take in order to prevent re-injury.
-Instruct Mr. Bley and his wife on the importance of following the wound care plan.
-Discuss with Mr. Bley and ensure that he understands that the wound is at high risk of infection and that it is properly cared for.
-Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: an evidence-based guide to planning care (9th ed.). Maryland Heights, Mo.: Mosby.
Inspection
wound on left shin, 3x4x4cm
deep red
Gefland, J. L. (2012, March 12). Lung Disease and Respiratory Health . In Web MD. Retrieved March 12, 2013, from http://www.webmd.com/lung/pneumonia-reducing-your-risk
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