Holistic Health Assessment Issues - Case Study Example

Holistic Health Assessment Case Study I. Biographical patient details anonymised. Details about the case will be given forthwith. The patient (let's call her Mary) is a 36-year-old female, a known asthmatic since the age of nine (9). She has called an ambulance today due to having a dry cough and sob for three (3) days. She is unable to talk. Her respiratory rate is 35 breaths per minute. She is unable to complete a peak flow. Her lips are cyanotic, and her sp02 on air is 89%. Her blood pressure is 95/62. She looks pale. Her temperature is 37.5 C. Her ABG result is the following: her ph is 7.30, and her po2 is 7.8kPa. Her Co2 is high at 6.5 kPa. Consequently, the patient needed venting and went to the intensive care unit. She has been vented previously twice in hospital. She has no other medical problems. She normally takes salbutomol & salmeterol inhalers. II. Brief discussion of presenting complaint. Asthmatics are always difficult cases to examine because there is the issue of oxygenation. This is a common problem that one sees pop up over and over again in the course of an asthmatic's life. Basically the reason that the patient called the ambulance was because she was in dire trouble. She could not breathe. This was a difficult situation. The patient had been having these dry coughs with sobs for three (3) days. Obviously this placed her in a very difficult situation. Nonetheless, she had to do something in order to breathe better. Thus the ambulance was called so that she could go to the hospital to have a vent put in. III. History and examination details of the case. Mary, since she is 36, is at the point in her life where she has lived with this illness of asthma for 25 years. More or less she is a seasoned trooper. In this case, she knew what she had to do, which was to call the ambulance. On her part it was probably a smart move because if she had not done so she might have died. So, on that note, the patient must be given some credit. Also, the fact that Mary is 36 may also affect her psychology. She may ask questions at this point such as, "Will I ever lead a normal life" and "What have I done to deserve this" Since her thinking and metacognition skills are greater than that of a child, she probably has several very difficult and wrenching questions for the nurse in the care unit. These questions may be more related to spirituality and the affective domain rather than questions about the physical problem she is having. More will be discussed about this in the section dealing with pathophysiology. For now, one will focus on the rest of her symptoms. The dry cough and sob indicates that her throat was severely close to closing up. Thus, she needed to go to the hospital in order to clear her airway thoroughly so she could breathe. The patient is not able to talk. This is problematic since the seasoned nurse knows that as long as one is able to talk, one is able to breathe well. However, if someone cannot talk, this is an indication that he or she can no longer breathe. This is because one needs to be able to breathe to talk. The patient's respiratory rate is very low, at 35 breaths per minute. The average breath rate is about 12 to 13 breaths per minute for an adult. Thus, having a breath rate of 35 per minute is very unusual and should be looked upon with caution. That is almost like breathing about three times as hard as if the patient were breathing normally. The fact that the patient is unable to complete a peak flow signifies that her breath is not significant or strong enough in order to get a reading on the peak flow meter. This is not a good sign because it demonstrates the patient's inability to breathe. The fact that Mary's lips are cyanotic is not a good sign either. This means she is starting to lose oxygen flow to other parts of her body. Any time one sees that the patient's lips or nails are cyanotic (turning blue), this is a sign that the oxygen that the patient is receiving is decreased. Thus, if the patient does not receive oxygen in a short amount of time, it could mean certain death for the patient. The patient's sp02 on air is 89%. This is also a bad sign because usually when one takes a Pulsox test, the ideal amount of oxygen that the patient should be getting is 90% or above. Usually the cutoff point for when a patient is doing very terribly with the Pulsox is 87%. However, 89% is approaching that threshold, and it would not have been a good idea to let her breathing get to that point. In that sense, she was justified in calling the ambulance. Without the intervention of hospital personnel having put in the vent, she could have been in serious trouble. The patient's low blood pressure indicates that the patient did not have hypertension. Further it indicates that she was probably very weak. The patient was pale. The pallor of an individual can tell a lot about a person. Since the patient's coloring did not look very good, it is obvious that something was amiss. Being pale is one of the signs that there is something wrong with someone medically. An arterial blood gas (ABG) result will also demonstrate various elements that are necessary to evaluate as the practicing nurse. The analysis of the ABG is as follows. With a pH of 7.30, the patient is most likely acidotic. With a po2 of 7.8kPa, this indicates that the patient's breathing is disturbed. This means that the patient would be hypoxemic , which means that there is a deficiency in the amount of oxygen reaching body tissues (Answers, 2010, p. 1). Additionally, since the patient's oxygen is so low, this type of reading indicates that the patient definitely would need oxygen. This goes without saying. The patient's Co2 is high at 6.5kPa. This creates a serious respiratory issue. A high score on the Co2 indicates that the patient was probably overventilating, which was probably the case at 35 breaths per minute. Additionally, the patient was probably trying desperately to find equilibrium in the pH of her blood. A high Co2 level also indicates that the patient was probably undergoing some sort of failure with regards to her respiratory system. It comes as no surprise, then, that the patient had to be vented in the ICU. The patient has a history having been vented twice before. This is not unusual for an asthmatic who has severe issues trying to keep the airway open. No other underlying medical problems are known at the moment. However, it may be advisable for the patient to undergo a thorough medical examination in order to rule out any kind of respiratory illness that would make her breathing fail on occasion. The patient currently takes salbutomol and salmeterol inhalers. These can be useful medications but another thing she may want to consider is to ask her doctor if her medications need to be altered or changed, or changed entirely. This is because, if her medications are not working effectively, something must be done in order to counteract having to go into the hospital again. As such, a change or adjustment in medications may be just the thing the patient needs in order to live her best life again. IV. Demonstrate a full holistic assessment of the person utilising a structured framework of assessment. The three aspects which should be focused upon by the nurse are the spiritual/affective, physical/psychomotor, and mental/cognitive domains when educating the patient about his or her illness-in any circumstance. The particular circumstance one is dealing with here, however, is asthma, and thus the nurse needs to plan accordingly what would be the best course of action to take in order to improve the patient's quality of life. First, the nurse must consider the spiritual or affective side of the patient. Is the patient getting enough rest Second, the nurse must consider the physical or psychomotor side of the patient. What is the patient's diet like, and how could this affect his or her overall state Third, the nurse must consider the patient's mental or cognitive domain. How are medications affecting the patient, and does this play a significant role in the difficulties that she is currently having V. Provide rationale for choice of assessment framework/s and support with evidence. Demonstrate a critical use of contemporary, relevant supporting evidence based knowledge that has informed your decision making (e.g. health outcome measures, also reference to guidelines/protocols). The spiritual/physical/mental model has been used in a wide variety of settings. "Complete physical, mental and social well-being and functioning" are capstones of the competent nurse (Nursing Theories, 2010, p. 1). Best practices in nursing takes care of a patient's affective domain as well as the cognitive and psychomotor domains. "Thus, the practice of nursing involves all three domains of learning-cognitive, psychomotor and affective. The education of nurses for any role" include these three domains (Get Involved, 2010, p. 1). The nurse needs to be astute in assessing clients who have asthma, as well as decide how best to educate the patient and his or her team. "For every client with asthma, the nurse needs to assess his/her understanding" of the illness in order to educate the patient and his or her care team (Adult Asthma Care Guidelines for Nurses, 2010, p. 1). One of the asthma care guidelines for nurses is to "promot[e] control of asthma" (Assessment of Asthma Control, 2010, p. 1). Nurses are supposed to encourage their patients to try to manage their illness. VI. Discussion of related normal/abnormal pathophysiology elicited from assessment (pick out the most pertinent points that will enhance the discussion in a coherent and logical fashion). Pathophysiology is to be discussed in this section. "Asthma is the chronic disease which involves inflammation of the pulmonary airways and bronchial hyper responsiveness" (Asthma Pathophysiology, 2010, p. 1). Out of the tripartite sections of assessment, obviously the most important type of assessment to be used forthwith would be the respiratory assessment. According to the Physical Assessment Checklist (2010, p. 1), the kinds of elements included in the respiratory assessment include, but are not limited to: the inspection of the thorax and respiratory movements; respiratory rate, depth, rhythm, and effort; use of accessory muscles/retractions; shape of chest; and audible wheezes-and in addition, the nurse should palpate, percuss, and auscultate various areas. VII. Ensure you demonstrate the use of both new history taking and examination skills (e.g. discuss inotropic support, analgesia, sedation). All the patient's vital signs should be assessed. Further, the patient's history should be well-read so that there are no surprises as to what the patient has experienced in the past. Patient history (new and old) should be accurate and without any kind of mistakes. Excellent examination skills are key. "Patients with asthma may present [several different types of] complaints" (Powell, 2005, p. 1). The nurse may want to look inside the patient's mouth in order to see if there is any swelling or redness. Any kind of physical assessment should include several elements. The physical assessment should include a respiratory assessment, a cardiovascular assessment, and a gastrointestinal assessment (Physical Assessment Checklist, 2010, p. 1). Anything less would be absolutely unacceptable. Medication control is also absolutely necessary in the treatment of asthma. "Asthma medication plays a key role in gaining good control of [one's] asthma" (Asthma Medications, 2010, p. 1). Lung function is especially important in controlling asthma. "Lung function tests can help determine your level of asthma control. Decreased lung function is a sign you need to adjust your medications" (Asthma: Three Steps to Better Asthma Control, 2010, p. 1). VIII. Identify and critically review therapeutic interventions. Therapeutic interventions would include advising the patient on rest, diet, and medications. The patient should be encouraged to have a good schedule of rest. "[B]ed rest is important for [asthmatic] patients" (Is Bronchitis Contagious, 2010, p. 1). This will impede the disease from taking an adverse toll on the patient. Lack of rest can exacerbate asthma. Thus it is crucial that the patient get adequate rest. Critically speaking, having a good eight (8) hours of sleep each night is necessary. This might be combined in tandem with a one-hour nap at some point during the day. Diet can have an especially profound effect on asthmatics. Certain foods may exacerbate asthma. Thus, the patient should have a list of foods which her doctor advises her to avoid, such as fish and eggs for example (Asthma Diet-Which Food to Avoid in Asthma, 2010, p. 1). As such, she must avoid these foods religiously and realize that her health is dependent upon following these guidelines. "Food triggered asthma is unusual. Although[,] food allergies may trigger asthma in a small number of people" (Asthma and Diet, 2010, p. 1). This is why it is important to have all the proper tests done to make sure that foods eaten are not the cause of the asthma. Finally, the patient must have her current medications evaluated by her doctor. Obviously since she was having breathing problems, she was either not taking her medication or it wasn't effective. Thus, something must change. Either the patient must be compliant with her current medications or her doctor must alter or prescribe something new as the doctor sees fit, depending on how the doctor views her case. The doctor may ask oneself if this was an isolated incident. Indeed this may have been a singular incident and the doctor may see no necessity for a change in medication. "For 49% [of patients], the main reason for not prescribing these [long-term controller] medications was the belief that this was the role of the primary care provider or asthma specialist. Practice setting, prior training, and annual patient volume were not associated significantly with prescribing LTCM" (Scarfone, 2006, p. 821). On the other hand, the doctor may feel the current medication(s) that the patient is taking are not effective in combating her asthma. Thus the doctor may seek to alter or add to her medications, whether the adjustment is slight or drastic. IX. Demonstrate how valid relationships between assessment, decision making, care planning/delivery and review are developed (this is where the role of the nurse becomes apparent). The role of the nurse is obviously not just functional in a care setting. Also, from a practical view, the nurse is also educator (AAP, 1999, p. 1050). The nurse must educate the patient, the patient's family, and anyone associated with the patient, about the signs and symptoms of asthma. Notwithstanding, ways to deal with asthma are also encouraged to be shared with the patient and her team of family, friends, and medical personnel. "[In] nursingthere still seems to be a general lack of competency in this vital area of [assessment in] patient care" (Castledine, 2004, p. 1233). The link between assessment and decision-making becomes apparent here. "Assessment appears to inform decision-making" (Humanitarian Needs Assessment and Decision-Making," 2010, p. 1). If the nurse notices something is unusual, or even if something is normal, she should make a note of it and then follow up on it, i.e. make a decision and take action on that decision. Similarly, care plans should be reviewed to make sure that proper assessment has been made. "Clinical judgment is needed in conducting the assessment for asthma" (Initial Assessment and Diagnosis of Asthma, 2010, p. 1). Also, in review, it should be noted what worked and what didn't. X. Consideration of any legal and ethical issues (although there may not be any) that relate to the assessment or working in the wider healthcare team. Ensure you have taken a holistic approach to the health and well being of your identified patient. Legal and ethical issues that may occur in the course of treatment may include the fact that the patient does not want to receive any adjustments in medication. Although she is on a vent, she may very well refuse interventions. However, it must be made clear to the patient that if some types of change or changes are not made, she may suffer the dire consequences by paying for them with her life. Expressed consent and implied consent both are situations which apply to adults. The "conscious, mentally competent adult has the right to accept or refuse emergency medical care. Thus, always make sure that the patient consents before beginning emergency care. Expressed consent is made by conscious, mentally competent adults. Implied consent is assumed if a patient is unresponsive or unable to make a decision" (Terms to Understand and Rules to Abide By, 2010, p. 1). The well-being of the patient should always be taken into consideration. Especially if the patient's wishes seem contraindicated to their current situation, nonetheless, the patient is a grown adult and if she refuses treatment there is really not much-short of admission into a psych ward or the change of power of attorney-that the hospital staff can do about it. In all cases, the patient's wishes should be followed. This can be a difficult part of nursing to accept. "A competent patient may refuse medical treatment even if it is necessary" (When Patients Refuse Treatment, 2010, p. 1). To accept the fact that, even in light of one's job, the patient still refuses treatment, is no doubt a difficult issue. Nonetheless this is a risk that a health care professional must take in order to attempt to save someone's life. REFERENCES Adult asthma care guidelines for nurses. (2010). [Online Article]. http://www.guideline.gov/summary/summary.aspxdoc_id=11504. Accessed 1 March 2010. American Academy of Pediatrics Web Site. (1999). The role of the nurse practitioner and physician assistant in the care of hospitalized children. [Online Article]. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/5/1050. Accessed 1 March 2010. Answers Web Site. (2010). [Online Article]. www.answers.com/topic/hypoxia. Accessed 1 March 2010. Assessment of asthma control. (2010). [Online Article]. http://www.guideline.gov/summary/summary.aspxdoc_id=11504. Accessed 1 March 2010. Asthma and diet. (2010). [Online Article]. womenfitness.net.p11.hostingprod.com/asthmaanddiet.htm. 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[Online Article]. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgibook=asthma&part=A188. Accessed 1 March 2010. REFERENCES (CONT'D.) Is bronchitis contagious (2010). [Online Article]. isbronchitiscontagious.net. Accessed 1 March 2010. National League for Nursing Web Site. Get involved. [Online Article]. http://www.nln.org/getinvolved/AdvisoryCouncils_TaskGroups/alldomains.htm. Accessed 1 March 2010. Nursing theories. (2010). [Online Article]. http://www.currentnursing.com/nursing_theory/nursing_theorists.html. Accessed 1 March 2010. Physical assessment checklist. (2010). [Online Article]. http://www.lehman.edu/deannss/nursing/pdf/physical-assessment- checklist.pdf. Accessed 1 March 2010. Powell, D.L. (2005). [Online Article]. http://www.sh.lsuhsc.edu/fammed/OutpatientManual/Asthma.htm. Accessed 1 March 2010. Scarfone, R.J., Zorc, J.J., & Angsuco, C.J. (2006). Emergency physicians' prescribing of asthma controller medications. [Online Article]. Pediatrics. 2006 Mar;117(3):821-7. http://www.ncbi.nlm.nih.gov/pubmed/16510663. Accessed 1 March 2010. Terms to understand and rules to abide by. (2010). [Online Article]. http://emt-training.org/medical-legal-ethical.php. Accessed 1 March 2010. When patients refuse treatment. (2010). [Online Article]. http://findarticles.com/p/articles/mi_qa3958/is_200403/ai_n9375652/. Accessed 1 March 2010. Read More