NUR250 Medical Surgical Nursing 2 Assessment 1

This document discusses the tasks involved in preparing a care plan for a patient with COPD exacerbation. It includes considerations for the patient, nursing assessments, care planning, and patient education. The priority nursing diagnoses and relevant interventions are also discussed.

NUR250 Medical Surgical Nursing 2 Assessment 1 Semester 1 2019
Based on the information provided in the above case scenarios complete the following
tasks.
Task 1. Consider the patient
What will you consider when preparing the care plan for your chosen patient?
I will be discussing Mr. Peter Newman’s case study. Considering the patient is a
requirement as the first step in the Clinical Reasoning cycle by (Levett-Jones, et al., 2010). In
general, clinical reasoning is the central point for repeated nursing and clinical practices
involving judgments and decisions made in the healthcare sector (Johnsen, Slettebø, & Fossum,
2016). The significance of this step of considering the patient is that it leads to the precision and
effectiveness of decision making by looking at all necessary data regarding the condition, effect,
presentation of the disease among many others (Gummesson, Sundén, & Fex, 2018; Johnsen et
al., 2016). In Newman’s Scenario there some issues that should be reflected in his presenting
chronic condition of infective exacerbation of Chronic Obstructive Pulmonary Disease (COPD).
Peter only has the dominant indicative sign as breathlessness. The effect of breathlessness
in the daily activities of Peter (especially driving) is subject to consideration, being one of the
primary symptoms of COPD. Peter is also a smoker and therefore it is not a coincidence that he
is suffering from the chronic condition. COPD has been determined to be unusual in non-
smokers (Kaufman, 2013). This calls for the consideration of Peter’s smoking history. Peter is
also a social drinker. From research by National Institutes on Alcohol Abuse and Alcoholism
(2007), people with alcohol addiction are thrice more likely to be smokers than the average
population. Peter’s social drinking behavior is a factor to consider as it decreases the lungs'
ability in keeping a healthy airway. It is argued that excess drinking leads to decreased levels of
glutathione, antioxidant that helps protect the lungs from damages of cigarette smoke. Peter’s
likeliness to give up drinking because of diagnosis of COPD is also subject to consideration as it
was discovered that those diagnosed with the condition do not give up alcoholism just because
they have were diagnosed with the condition. Furthermore, drinking affects social support
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NUR250 Medical Surgical Nursing 2 Assessment 1 Semester 1 2019
negatively and that is not limited in a family setting like Peter’s. (Chen, Fan,
Belza, Pike, & Nguyen, 2017).
Peter is 44 years old meaning he is living the best days of life and has many more
potential years to live when if in a healthy state. Age also has an impact on patient psychological
and clinical outcomes of patients of COPD (Holm et al., 2014). Moreover, he is a family man
providing to his wife and his two teenage kids. The family unit is an essential consideration since
patients draw energy and motivation from it. It is also to consider how the disease and the care
plan will impact on Peter’s family (Nakken et al., 2015). Peter works two weeks on –two weeks
off roaster as a FIFO truck driver and is not as efficient because of breathing problems. That is a
risk to himself as he can cause an accident or die on duty amidst illness. It is also important to
consider whether his work as a truck driver is a predisposing and aggravating factor to COPD.
Truck drivers usually are at more risk of developing COPD because of exposure to air pollution
(Marino, Caruso, Campagna, & Polosa, 2015). All these roles and responsibilities are most likely
going to be affected by his diagnosed condition and are therefore to be reflected.
Task 2. Nursing assessments
Identify three (3) nursing assessments you will conduct and explain why they are a priority for
you.
Nursing assessment involves collecting data about a patient. The received data is then
used to implement care and to provide optimal patient outcomes, by incorporating the best
available evidence. These are the principles of evidence-based nursing that are universally
accepted in any plan of care to a patient like Peter. Peter’s assessment should be completed and
documented to rationalize any intervention in his care plan in an accurate, computable and a
well-versed method of care. That necessitates the reference to the Clinical Reasoning Cycle in
providing a structure to Newman’s care (Levett-Jones, et al., 2010). The NICE COPD quality
standard necessitates practitioners in a healthcare facility to ensure a diagnosis of COPD
comprises more than one suggestive symptom (Gruffydd-Jones, & Jones, 2011).
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NUR250 Medical Surgical Nursing 2 Assessment 1 Semester 1 2019
After reflecting on the requirements by the Clinical reasoning cycle,
the initial assessment of Peter’s infective exacerbation will entail a careful history taking, signs,
and symptoms (Kelly, 2009). It includes smoking and drinking behaviors, work environment, the
duration of the worsened symptoms, number of previous exacerbations, additional disorders, and
use of mechanical ventilation in the past, and the current treatment (Lea & Susan, 2013). Peter
has an exacerbation of COPD to mean that his condition keeps worsening from the stable state
and outside the day- to day variants. The critical thing with COPD is that it can proceed slowly
and lung functioning might weaken before the symptoms of the disease become apparent
(Kaufman, 2013). The lung function may go down up to 50% before the patient realizes.
Assessment is necessary for Peter as most smokers cough always and is short of breath, and they
do not regard that with so much caution as they often let go signs of continued airflow blockade
as natural consequences of smoking (Kaufman, 2013).
Secondly, when new aggravating symptoms are presenting, it is easy to establish the
diagnosis of the condition in combination with the pulse oximetry and blood gas analysis which
can then be used to determine how severe the exacerbation is (Kelly, 2009). That together with
clinical examinations and chest X-ray can help rule out diagnoses similar to the Infective COPD
like CVD, pneumothorax, pneumonia or pulmonary embolus (Lea & Susan, 2013).
Thirdly, assessing the impact of the exacerbation on Peter both socially and
physiologically is useful in establishing the need for more support during the exacerbation and
recovery (Kelly, 2009; Lea & Susan, 2013). In our case, Peter is showing poor performance in
his workplace because of problems in breathing. He might lose his job out of the poor
performance and the risks involved, and as a result, he might not be able to support his family.
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NUR250 Medical Surgical Nursing 2 Assessment 1 Semester 1 2019
Task 3. Care planning
Identify three (3) priority nursing diagnoses for your chosen case scenario and explain why
they are relevant.
Care planning falls under the ‘take action” step in the Clinical Reasoning Cycle. Here, the
course (s) of action is selected from a different alternative available (Levett-Jones, et al., 2010).
There is the implementation of actions steps needed to meet the treatment goals of the patient.
According to Cao, Dong and Cao (2018), COPD is now ranked third as a leading cause of
indisposition and death in the world. A study by Papadopoulos et al. (2011) shows that the
condition is treatable and preventable as the pulmonary component is pigeonholed by fully
adjustable airflow constraint. Another research by Yoo (2015) contradicts this statement and
declares that COPD cannot be cured and that when symptoms worsen, physical inactivity is a
consequence and death is almost inevitable. The goals of COPD exacerbation management for
Peter are plummeting the impact of the current exacerbation and the potential of occurrence of
exacerbations in the future. It will involve, solving precipitating factors, increasing gas exchange,
lessening pulmonary swelling and minimizing air ensnaring to improve expiratory flow (Lea &
Susan, 2013). Several members of the healthcare team are to be involved, and that necessitates
all concerned practitioners to be updated with the goals of treatment as mentioned above. The
following three diagnoses have been selected to manage Peter’s exacerbations of COPD.
(i) Pharmacotherapy
(a) Bronchodilators
They are regarded as the cornerstone of COPD management (Beeh, 2016). Whether
the treatment is being undertaken at home or in hospitals, the initial intervention for
Peter should be the dose of a prescribed short-acting inhaled bronchodilator. When
the bronchodilators are in action, they induce reverse bronchoconstriction,
consequently decreasing lung volume and raising expiratory flow, and inhibiting
hyperinflation (Lea & Susan, 2013. Peter should, however, be monitored against
their side effects such as anxiety and hypokalaemia linked with [beta]2-agonists
bronchodilators, retention of urine, dry mouth and constipation connected to
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NUR250 Medical Surgical Nursing 2 Assessment 1 Semester 1 2019
anticholinergic agents used such as ipratropium (Lea & Susan,
2013. Peter’s bronchodilator therapy should be optimized.
(b) Systemic glucocorticosteroids
When these drugs are used during Peter’s COPD exacerbation, the recovery time can
be lessened, lung function improved, and hypoxemia decreased. The
glucocorticosteroids reduce pulmonary swellings thus increasing airflow (Abroug, et
al., 2014). Better still, they may eliminate the risk of early relapse, failure of
treatment, and time spent in hospitals. The common steroid that Peter can be
prescribed to is oral prednisolone. It is good to note that these steroids must be used
together with other exacerbation therapies like inhaled bronchodilators discussed
above (Lea & Susan, 2013).
(ii) Oxygen Therapy
There is an increase in oxygen requirement in the body of Peter during exacerbations
(Brill, & Wedzicha, 2014). In the case of low cardiac output and complicated
exacerbations, Peter should be set to a higher SaO2 (Lung Foundation of Australia,
2018). This can even be supplemented with either invasive or noninvasive mechanical
ventilation for better results. Peter should also be monitored not to suffer from excessive
oxygenation as that could lead to hypercapnia and acidosis. This can be enhanced by
checking arterial blood gases between half an hour and an hour after oxygen therapy is
initiated (Lea & Susan, 2013). Oxygen therapy would help Peter deal with problems of
shortness of breath.
(iii) Prophylactic Therapy
Peter should receive prophylactic therapy for deep vein thrombosis. In most cases,
Patients of COPD have right ventricular hypertrophy and large pulmonary arteries (Lea
& Susan, 2013). This put them at risk for blood clots especially if they are desiccated,
immobilized and polycythemic- all of which are possible during exacerbations.
Prophylactic antibiotics are to be preferably used when Peter is under home treatment.
They treat exacerbations in case of bacterial signs of infection (Lea & Susan, 2013;
Lyon, Colangelo, & DeSanto, 2018). Some of the causative bacteria during COPD
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NUR250 Medical Surgical Nursing 2 Assessment 1 Semester 1 2019
exacerbation are Streptococcus pneumonia, Haemophilus influenza,
and Moraxella catarrhalis (Beasley et al., 2012). The specific antibiotic choice should
be determined based on the GOLD rules and planned to reduce the resistance to
antibiotics (Qureshi, Sharafkhaneh & Hanania, 2014).
Task 4: Patient education
Identify specific education your chosen case scenario will require to manage their condition
post discharge effectively.
According to Paterick, Patel, Tajik, and Chandrasekaran (2017), to improve health care
outcomes, medical practitioners must spend ample time with their patients. The teaching by the
physician must be enthusiastic, motivated and responsive to the personal needs of the client
(patient). Vaishali et al., (2014) advice that it is essential to educate patients about the disease,
the choice of rehabilitation, and its role in controlling of COPD. It is crucial to integrate patient
education in the standard of healthcare practice whereby the patients like Peter can advance their
self-management skills and consequently the quality of life. One particular area that Peter needs
to be educated should he want to improve the quality of his life and get over the disease is his
smoking behavior. Peter should be educated on a smoking addiction reduction technique
involving the use of electronic cigarettes. These are devices operated by batteries and designed to
vaporize nicotine which eventually helps smokers quit or reduce tobacco consumption (Polosa et
al., 2016). Yoo (2015) advises that the most operational and efficient way of avoiding COPD is
the cessation of smoking. Peter should be educated on the reduced risk of developing COPD and
hospitalization from acute exacerbation should he stop smoking. According to Josephs,
Culliford, Johnson & Thomas (2017) smoking cessation in COPD minimizes speeded forced
expiratory volume. Yoo (2015) comments that cessation of smoking reduces mortality rates and
that necessitates an active and proficient educational program that advises on the positive
outcomes of doing so.
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NUR250 Medical Surgical Nursing 2 Assessment 1 Semester 1 2019
Task 5: Team care
Identify and define the Allied Health team members that should be involved in the patient’s
care during admission and in preparation for discharge
From a study, team-based care is tested and proved to be a significant element of high-
quality care. When there is team decision making, definitely there is an exchange and evaluation
of thought to reach the best solution (Hern, Talen, Babiuch & Durazo-Arvizu, 2009). In the
management of Peter’s exacerbation of COPD, several allied health professionals can be
involved in his care during admission and in preparation of discharge. They include physiologist,
physiotherapist, nurses, general practitioner, respiratory nurse, practice nurse, occupational
therapist, practice pharmacist, specialist respiratory/COPD practitioners, hospital-based medical
practitioners, and exercise instructor. The respiratory nurses and Practice nurse play a significant
role in patient education, improvement of patient self-management before discharge and
controlling care after admission. Occupational therapists should perform therapies on Peter
(Valenza et al., 2015). Practice pharmacist is involved in the prescription of medication and
prophylactic treatments during care after admission. Specialist respiratory/COPD practitioners,
physiologist, physiotherapist, general practitioner are engaged in the in general care and any
operations involved including mechanical ventilation upon admission and discharge.
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NUR250 Medical Surgical Nursing 2 Assessment 1 Semester 1 2019
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