Chronic Obstructive Pulmonary Disease in Primary Care - Case Study Example

Case Study Question 1 In order to care and prioritize care for the five patients, the nurse will utilize primary assessment tools in prioritizing the care of the patients. Primary assessment is very vital during assessment and provision of nursing care because it is important in identification of serious and life-threatening conditions (Timby & Smith, 2010). In this case, as assessment of the patients will be done and prioritized using the ABCDEFG algorithm which will involve assessment of the airway first, followed by breathing, circulation, disability, exposure, fluids and lastly glucose assessment. After the primary assessment, the patient whose condition is more critical and has a likelihood of deteriorating fast will be reviewed first. In this case study, Mr. Steven who presented with acute appendicitis and had an appendectomy will be the first priority. The reason why the patient was given the first priority is that his condition is likely to deteriorate very fast into a serious condition. The patient has a temperature of 39.2 and complains of abdominal pain and after a surgery such as appendectomy; these are signs and symptoms of an infection which can lead to intra-abdominal sepsis and abscesses (Hughes, Harrison & Paterson, 2013). Intra-abdominal sepsis and abscesses is presented with abscess and peritonitis. Abscess which is characterized by fever and pain can result to pulmonary symptoms and urinary symptoms. Peritonitis is characterized by abdominal pain and high temperature. In case of peritonitis, the patient can become hypotensive, have septic shock and even tachycardia and thus the nurse should review the patient first (Hughes, Harrison & Paterson, 2013). Monitoring of the patient’s vital signs should be done hourly to make that sure that they are within the acceptable limits. Additionally, the patient will be frequently examined to check the pain score and temperature. The patient will be administered with antibiotics to treat the developing infection and the incision site will be examined for any signs of abscess, swelling or bleeding. The nurse will inform the surgical team regarding the patient’s state for the surgical team to review the patient and give a prescription to control the pain. Additionally, several tests such as blood count will be done to determine if the patient has developed an infection. The second priority will be Peter who had ERCP and gallstones removal × 3 times following persistent epigastric pain for two days and currently is complaining of nausea and mild right shoulder tip pain. The significance of Peter being the second priority is that he just had surgery and the initial hours after surgery are very important because complications can arise if the patient is not monitored and cared for appropriately. The nurse will review the patient; assess the level of pain and nausea as well. The cause of the pain and nausea is because the patient had ERCP and may have had complications of ERCP. ERCP is used is diagnosis and treatment of conditions of pancreatic duct and also gallstones. The insertion of the device can cause complications such as damage to the bile duct and leakage, inflammation to the pancreas, infection in addition to bleeding. In addition, medications used in relaxing the ampulla of Vater can cause side effects like nausea, dry mouth and such. The shoulder tip pain is as result of laparoscopic surgery and resulted from the irritation of the sub-diaphragm, or insufflations gas used during surgery (Talley, Lindor & Vargas, 2010). In this case the patient’s pain might have resulted from the damage on the bile duct or on the stomach wall caused by the devise that was inserted. The pain may also have been caused by inflammation of the pancreas or an infection which are also complications of ERCP. The nausea may be due to side effects of drugs used to relax the ampulla of Vater during ERCP (Talley, Lindor & Vargas, 2010). The nurse will notify the respective physician to review the patient and assess the exact cause of the pain and give a prescription for the pain relieve and control of the nausea. Philip who was admitted for infective exacerbation of COPD will be the third priority. This is because COPD can make it hard for the patient to breath and the condition may worsen causing chest tightness, breath shortness, wheezing as well as increased coughing with a lot of mucus production which can further worsen the patient’s breathing ability (Barnet, 2012). The reason the patient was chosen as a third priority is because during exacerbations, there is increase of airway inflammation which causes increased hyperinflation, decreased expiratory airflow and deterioration of gas transfer. The can result to inadequate ventilation which can cause low blood oxygen levels and if the situation prolongs narrowing of arteries within the lungs occurs causing elevated blood pressure within the pulmonary arteries and this can cause cor pulmonale (Barnet, 2012). Even though the patient is due for his IV hydrocortisone 100mg and Piperacillin with Tazocin IV, the nurse should inform the physician to review the patient antibiotic regimen to prevent further worsening of the patient’s condition. The nurse will monitor the patient’s oxygen saturation to make sure that it is within the acceptable range and also the nurse will monitor arterial blood gas to assess if the patient has or is at risk of developing acidosis. The forth priority will be John who was admitted with chest pain and has a history of angina and coronary heart disease. Excessive heparin infusion can lead to bleeding and thus the patient’s APTT need to be monitored and maintained within the therapeutic level. Additionally, John is 78 years old and hence an older patient and according to Shcherba, Billet & Jacobs (2013) older people are at risk of bleeding during heparin infusion because of changes allied to age in their bodies. He is on IV heparin infusion and aspirin and since heparin can cause bleeding which can even result to intracranial hemorrhage, the nurse should assess the patient regularly to measure APPT level to maintain the level in a safe range of 50 to 75 seconds to prevent excessive anticoagulation and an increased risk of bleeding (Herbert, 2010). Additionally, the nurse should monitor any sign of bleed for instance examine the urine and also nurse will monitor the patient’s level of chest pain and use ECG to monitor cardiac changes. The nurse also needs to perform a full blood count to examine the patient’s platelet count and asses the patient’s vital signs after every four hours. The last priority will be Melinda who is presented with sudden onset of severe headache. The CT scan revealed a Grade 1 subarachnoid hemorrhage from a cerebral artery aneurysm. A cerebral aneurysm is a bulging, weak region within the wall of the artery that delivers blood to the brain (Thompson & Fitridge, 2011). The treatment of the aneurysm was successful and the patient’s CGS is normal at 15 and hence the nurse should continue monitoring the vital signs of the patient and monitor any signs of low blood pressure, stroke and reduction in neurological status because Nimodipine causes hypotension. Question 2 In such a situation, the nurse is supposed to assess the patient and inform the physician and the medical team to assess the patient since the worsening nausea the patient might indicate the patient’s worsening condition due to infection, damage to the bile duct and leakage or side effects of the medications used in relaxing the ampulla of Vater. Since the patient has had no antiemetic, the nurse ought to request for an antiemetic medication through a telephone. The antiemetic will control the worsening nausea (Talley, Lindor & Vargas, 2010). When informing the medical team and the physician, the nurse will use ISBAR communication tool which according to Australian Commission on Safety and Quality in Health Care (2010) creates a sense of urgency for a communication intervention. Therefore, the ISBAR communication will include; Introduction, Situation where the nurse will briefly provide the patient’s situation, Background where the nurse will provide pertinent information regarding the situation which should include the medications the patient had already taken and the test result, Assessment where the nurse will indicate the patient’s condition and what the indication’s of the condition and finally Recommendation where the nurse will briefly and clearly indicate what he/she would like the medical team and the physician to do. Accordingly, the nurse will be able to successfully communicate regarding the patient’s current condition to the physician and medical team. Communication plays a key role in determining the outcome of acutely sick patients and hence successful communication will ensure that the patient’s safety is not compromised (Australian Commission on Safety and Quality in Health Care, 2010). Question 3 The patient has APTT higher than 150 and this indicates that there is excessive anticoagulation and hence the patient is at risk of bleeding. According to Herbert (2010), heparin is a potentially harmful treatment because it places the patient at risk of bleeding by changing blood coagulation, elevating vascular permeability and by hampering platelet function. Excessive bleeding can even result to intracranial hemorrhage which is fatal (Herbert, 2010). Since the patient is at risk of bleeding and developing clot, the nurse is supposed to stop the heparin infusion and monitor the patient and only restart the patient’s heparin infusion after the 6 hours as per the ward protocol because by then the patient’s risk of bleeding will have reduced. In addition, the nurse should regularly monitor the patient for any sign of bleeding by for instance looking for any traces of blood in the patient’s urine whenever the patient goes to the toilet and also performing serial ECG and serial blood tests. If the patient is bleeding or APTT level continues to increase, the nurse should inform the physician and the medical team for further review and management. Question 4 Melinda is complaining of feeling faint on getting out of bed and her blood pressure is 80/40mmHg which indicates low blood pressure. According to the CT, the patient had (grade1) subarachnoid hemorrhage from a cerebral artery aneurysm and this is contributing to the patient low blood pressure of 80/40mmHg. Additionally, the patient is taking Nimodipine which works by narrowing the blood vessel and thus reduces flow of blood and hence it could be contributing to hypotension (Thompson & Fitridge, 2011). The hypotension consequently is causing the patient to feel faint on movement. Accordingly, the nurse should inform the patient the possible causes of the low blood pressure and the faint feeling. Since the patient is feeling faint, the nurse should do a neurological assessment to assess if there is a serious underlying disorder that requires urgent treatment and to identify the nature of the presenting symptom in terms of being the symptom being true vertigo, syncope or presyncope (Thompson & Fitridge, 2011). It is necessary for the nurse to do measure a postural blood pressure and manual blood pressure as well to ensure there is no error and get an accurate blood pressure measurement. If the patient’s blood pressure after the assessment is still 80/40mmHg, the nurse should inform the respective doctor through ISBAR communication, indicating the blood pressure reading and what should be done. The nurse should also report the results of neurological assessment and continue monitoring the neurological status and vital signs of the patient to ensure that the Melinda’s condition does not deteriorate further. . References Australian Commission on Safety and Quality in Health Care (2010).The OSSIE Guide to Clinical Handover Improvement. Sydney: Australian Commission on Safety and Quality in Health Care. Barnet, M. (2012). Chronic Obstructive Pulmonary Disease in Primary Care. Brisbane: John Wiley & Sons. Herbert, M. (2010). Heparin should be administered to every patient admitted to the hospital with possible unstable angina. West J Med. 173(2): 138-140. Hughes, M, Harrison, E & Paterson, B. (2013). Post-operative antibiotics after appendectomy and post-operative abscess development: a retrospective analysis. Surg Infect (Larchmt). 14(1):56-61. DOI: 10.1089/sur.2011.100. Shcherba, M., Billet, H. H., & Jacobs, G. L. (2013). Venous thromboembolic disease in older adult. In W. S. Aronow, J. L. Fleg, & M. W. Rich.(Eds.), Cardiovascular disease in the elderly (5thed.). Boca Raton, FL: Taylor and Francis Talley, S, Lindor, K & Vargas, H. (2010). Endoscopic Techniques in Management of the Liver and Biliary Tree: Endoscopic Retrograde Cholangiopancreatography and Biliary Manometry. Austria: Blackwell Publishing Ltd. DOI: 10.1002/9781444325249.ch7. Timby, B. K., & Smith, N. E. (2010). Introductory medical surgical nursing (10th ed.). Philadelphia: Lippincott. Thompson, M & Fitridge, R. (2011). Mechanisms of Vascular Disease: A Reference Book for Vascular Specialists. Adelaide: University of Adelaide Press. Read More