Nursing Case Study: Assessment, Pathophysiology, Medication, and Care Plan

This nursing case study focuses on the assessment, pathophysiology, medication, and care plan for Mrs El Nadir. It covers the primary and secondary assessment, discusses the pathophysiology based on clinical assessment, and provides suggestions for current pharmacological intervention. The care plan and various intervention strategies are also included.

NURSING CASE
STUDY

Table of Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
Primary and secondary assessment of Mrs El Nadir..............................................................1
Pathophysiology which is based on clinical assessment .......................................................3
Medication that prescribed earlier and suggestion for current pharmacological intervention5
Care plan for Mrs El Nadir and various intervention strategies.............................................6
CONCLUSION................................................................................................................................6
REFERENCES................................................................................................................................7
Books and Journals.................................................................................................................7

INTRODUCTION
Health is defined as the state of any person which is physically, mentally and emotionally
well. As per this, the health also defined as individual who is free from disease and illness is also
called as health. Some of care of patient is taken by nurses in their workplace. They play various
role and responsibilities in a healthcare sector regards with patient compliance and provide him
comfortability. In addition to this, the nursing care plan provide an path in type of nursing care to
a individual, family and community as per requirement. The nursing care plan include
assessment, diagnosis, expected outcomes, intervention, rationale and evaluation. As per this, in
this report the case study is based on individual who is facing complication from their health
issues. They have complex past history, family history and social history, in this individual
depend of medication for longer period of time (Anstey and et. al., 2017). They face various
issue regarding with health and their disease state is very poor. In this, the reports cover the
primary and secondary assessment of patient. Their pathological condition and discuss the
pharmacological intervention with management and strategies which provide way to prevent
potential complication.
MAIN BODY
Primary and secondary assessment of Mrs El Nadir
As per this case study, there is number of complication which is facing by Mrs El Nadir
and now she is admitted in hospital and their situation is critical. However, in this they need
proper caring in hospital. This caring is gone through primary and secondary assessment. In this
the primary assessment is vital priorities for any patient which have difficulty in breathing which
include quick and instant determining of Mrs El Nadir who deal with febrile illness most of
efficiently done by asking patient if they feel feverish. In context with Mrs El Nadir, they deal
with increase coughing, increase dyspnoea and increase productive cough, fatigue and
breathlessness and facing issue regarding with respiration. There are sign which is taken in
primary assessment to control the patient which is facing respiratory distress, in this it is
decreased level of consciousness, inability to maintain respiratory efforts and cyanosis
(Beaumont and et. al., 2018). The cyanosis is defined as bluish discolouration of skin and
mucous membrane, this is experienced by excessive deoxy-heamoglobin in blood which is
caused de-oxygenation. Usually this is divided into two parts, central which cover lips, tongue
1

and core parts, peripheral which include fingers. Moreover, Mrs El Nadir also deal with issue of
hypertension and coronary obstructive pulmonary disease from last 8 years which is life
threatening for her. This is critical condition and life threatening situation for Mrs El Nadir
because they have complain of dyspnoea include airway obstruction with syndrome of coronary
which is acute in nature. The deal with hypertension for long 20 years which may lead to cause
heart failure, and pulmonary embolism, pneumonia and chronic obstructive pulmonary disorder,
asthma, anaphylaxis, this all are treated during the assessment which is initial and starting.
The secondary assessment for Mrs El Nadir as per rising complication must be create and
take an intervention for the patient life safety while patient dealing with various disease and
critical situation then proper care and medication is used. Before discussing the condition, there
is an overview which is related with normal ageing which results various hormonal changes and
structural changes are observed in chest wall or thoracic spine that can limit chest expansion,
decrease respiratory expansion, decrease the muscle strength and interfere with effective airways
clearance. This approach may be chance for compensation response to hypoxia during state of
increase physiologic demand which is regards with pneumonia or heart failure. As per this some
of the respiration assessment for older in context with Mrs El Nadir are mentioned below:
 Perform ongoing assessment for respiration rate, analyse Mrs El Nadir depth and
breathing pattern with the pulse oximetry reading every 30 to 45 minute. This help to
analyse saturation pattern which may be unstable.
 Compare respiration with the resident past baseline and typical rate which help to know
various depth and breathing pattern (Bradford and et. al., 2020).
 Help in the assess of patient who is facing difficulty in breathing for example there re
various heart failure or abdomen ascites which are in position of greatest comfort. This
help to enhance respiratory rate in patient for example Mrs El Nadir who is facing same
problem and various complication regards with this.
 As per this, the kyphosis and scoliosis also restrict the chest expansion. So this approach
is useful in order to reduce the complication.
 In addition, the non-uniform respiration pattern lead create an case of apnea which is
comes under the symptoms of disease in adults. This is must reported by practitioner to
take immediate intervention for restriction.
2

 Mrs El Nadir as a patient they tire during the assessment. Moreover, the demand of the
assessment should be considered. As per this, they both pathway for symptoms of
shortness of breath such as SOB and various symptoms which is associated with lower
respiration infection.
Pathophysiology which is based on clinical assessment
As per the discussion in case study Mrs El Nadir facing various complication and their
previous of medication is also sensational and critical. Recently, she is facing respiration
problem and factor which is primary and secondary assessment are discussed above. The recent
problem is critical because she is underlying in age of 70 and her rate of respiration is increases,
increase dyspnoea and many more.
Pathological condition of past
Coronary obstructive pulmonary disease:
Mrs El Nadir has various disease as per this they have lots of complication. In this, she
was facing coronary obstruction pulmonary disease. The pathophysiology is well determined and
this make effect on lungs. In addition, the COPD is an umbrella term for various chronic lungs
disease, in this the COPD have two categories one is chronic bronchitis and another one is
emphysema. These affect the various parts of lungs but they both create difficulty in breathing in
an individual. With relation to Mrs El Nadir she also faced difficulty in respiration due to this,
moreover, in COPD when air inhaled and move down to trachea and it contain two tubes term
bronchi and this bronchi is also divided into smaller tubes refers as bronchioles. At last,
bronchioles have little air sac defined as alveoli. In end the alveoli are capillaries which are small
and tiny blood vessels. In this, oxygen moves from lungs to blood through various capillaries.
The carbon dioxide moves from blood into capillaries and then through lungs carbon dioxide is
exhaled (Drummond and et. al., 2019). As above mentioned emphysema is an disease which is
associated with alveoli. The fibre which is responsible for wall of alveoli are damaged. This
damage create elasticity and they do not recoil when carbon dioxide is exhale. This results as
coronary obstructive pulmonary disease. This state the various complication which is associated
with Mrs El Nadir for longer period of time.
Hypertension:
Mrs El Nadir was facing hypertension for last 20 year and as per age this create
complication. With relation to this, hypertension is one of the most important cause of premature
3

morbidity and mortality, and in this to reduce the risk of cardiovascular events in people who is
associated with hypertension. The pathophysiology of hypertension is defined as, the blood
pressure is refers as systolic blood pressure, which reflects the blood pressure when heart create
contraction and relaxation, in case of hypertension these systolic pressure, diastolic pressure and
or both enhance then this increase can create the condition of hypertension. There are sveral risk
factor which is associated with this. Some of them are discussed below:
 Increasing age, as per the relevant data there are 60 percent of population ages over 50
facing the issue of hypertension.
 Being overweight.
 Excess salts consumption and many more (Fukuda and et. al., 2019).
As per this Mrs El Nadir is also associated with this and it was create complication in
various aspect.
Osteoarthritis left hip:
In Osteoarthritis, the cartilage of the hip joint are wears away over the time. In addition,
the cartilage wears away. It become frayed and rough and the protective joint space as per the
bones is minimise. This results as rubbing bone to bone and create painful condition for patient.
In osteoarthritis develop slowly and the pain gone worse day to day and create hurdle in sitting
and standing for longer period of time. The main causes of osteoarthritis is increasing age, family
history of osteoarthritis, previous injury to the hip joint, obesity, improper formation of the hip
joint during the birth. This condition is also known as dysplasia of hip. As per this, Mrs El Nadir
facing this problem from last couple of month which make them more painful.
GORD:
The gastro-oesophageal reflux disease is defined as the reflux of gastric content into the
oesophagus provokes symptoms and several of complex situation and create the threatening of
quality of life. There are various symptoms which is associated with this disease such as
heartburn and regurgitation but gatsro-oesophageal reflux disease also related with various
disease include asthma, chronic cough and laryngitis (Goto and et. al., 2018). The main
pathophysiology is this reflux disease is multifactorial, and evolvement of oesophageal sphincter
relaxation and other lower oesophageal sphincter pressure abnormalities. Lastly, the reflux of
acid from body is notice along with bile, pepsin and pancreatic enzyme which lead to mucosal
4

injury. As per the case study, Mrs El Nadir facing this issue. This is past condition which is
carried by patient in longer term which make them more diseased.
She was also go through the surgery of Laparoscopic Hysterectomy is an surgical
procedure which help to remove the uterus from body. This is an small incision which is made in
button and small camera is inserted, and visualise through the camera.
Medication that prescribed earlier and suggestion for current pharmacological intervention
As per this case study, there are various medication which is provided earlier to Mrs El
Nadir. In this drugs are lisinpril which is prescribed for the high blood pressure. In this
paracetamol is used which is act as non-steroidal non-inflammatory drug which is useful in
minimisation of pain. Omeprazole and salmeterol are used in order to reduce the oesophageal
reflux and useful for the prevention of asthma and COPD. As per this to manage the blood
pressure which is excess, given in case study the blood pressure is approx 185/110 mmHg and
Heart rate 128 bpm. So in this context, the lisinpril is prescribed in such a way to reduce the
blood pressure (Mahmood and et. al., 2019).
In various cases the lisinpril show high rate of mechanism of action in which it create
hypotension. This is defined as lower blood pressure. The rate of respiration is also high where
the report show 36 breathe per minute and normal breathe is about 12 to 16 breath per minute.
As per the current pharmacological intervention, the pharmacology is defined as the study of
drug in this there are two response which is measured such as drug to body called
pharmacodynamic and other one is body to drug called pharmacokinetic. However, the present
intervention which is ampicillin that is antibiotic in nature. Prednisolane that is used in allergy
and autoimmune disorder or in works as anti inflammatory. Salbutamol which is works as lungs
airways is help to clear the airways and provide sufficient oxygen to lungs and many more drug
which is used in current session, according to Indian pharmacopoeia this drug have high
therapeutic value and have great response in disease. But these drug are going through liver for
first pas metabolism and Mrs El Nadir have reach to age 70 and liver is not capable to metabolise
all the drug. The possibility of adverse drug reaction is their, so this current pharmacological
intervention is beneficial for adult one but its is create complication to Mrs El Nadir for their
treatment. As per this, the chance of hepatic failure is rises.
5

Care plan for Mrs El Nadir and various intervention strategies
The treatment and intervention strategies which is required to Mrs El Nadir is very
helpful because this provide life saving concept to her. As per the discussed she is dealing with
various complication which is associated with life threatening. Their is some lifestyle plan which
is control then the high blood pressure should be managed. Some of the lifestyle changes are
mentioned below which is required by her for better recovery:
Eat healthy diet which consist less sodium and potassium.
Doing regular exercise and physical activity.
Maintaining healthy weight and do not try to get fat or obese.
Limit the amount of alcohol if habit of drinking (Ooi and et. al., 2017).
Medication:
the kind of medication which is required to patient it depend on their reports and
measurement and as according to overall health. This is difficult to choose the most effective
medication in context with Mrs El Nadir because she is dealing with lot of disease and there is
major of chances to create adverse drug reaction and hypersensitivity. In this case they must try
to balance their blood pressure between 130/80 mm Hg. Medication which is used in this are
diuretic, which consist of thiazide and loop diuretic and potassium sparing agent such as
spironolactone and many more. Other is angiotensin converting enzyme say that ACE inhibitor
and angiotensin II receptor blocker and calcium channel blocker in this amlodipine and tiazac are
used. In overall, this is an primary approach which is used by Mrs El Nadir for their treatment
and other. Their social background is good and she is usually pray to god and always positive in
their life. The nursing care is important for their better recovery (Pfister and et. al., 2020).
CONCLUSION
As per the above discussion, the case study provide the brief about the complication
which is life threatening concern. The individual is facing number of disease as a same time.
This create several complication and number of issue. As per this the intervention which is absed
on pharmacological derivation are provide and recommendation is also given in order to proper
medication and diagnose which help patient for their treatment.
6

REFERENCES
Books and Journals
Anstey and et. al., 2017. An update on masked hypertension. Current hypertension
reports, 19(12), pp.1-8.
Beaumont and et. al., 2018. Effects of inspiratory muscle training in COPD patients: A
systematic review and meta‐analysis. The clinical respiratory journal, 12(7), pp.2178-
2188.
Bradford and et. al., 2020. Danger in the vapor? ECMO for adolescents with status asthmaticus
after vaping. Journal of Asthma, 57(11), pp.1168-1172.
Drummond and et. al., 2019. Immune mechanisms of hypertension. Nature Reviews
Immunology, 19(8), pp.517-532.
Fukuda and et. al., 2019. Guidelines for the treatment of pulmonary hypertension (JCS
2017/JPCPHS 2017). Circulation Journal, 83(4), pp.842-945.
Goto and et. al., 2018. Machine learning approaches for predicting disposition of asthma and
COPD exacerbations in the ED. The American journal of emergency medicine, 36(9),
pp.1650-1654.
Mahmood and et. al., 2019. Non-pharmacological management of hypertension: in the light of
current research. Irish Journal of Medical Science (1971-), 188(2), pp.437-452.
Ooi and et. al., 2017. Improving communication of medication changes using a pharmacist-
prepared discharge medication management summary. International journal of clinical
pharmacy, 39(2), pp.394-402.
Pfister and et. al., 2020. A multicenter, cross-sectional quality improvement project: The
perioperative implementation of a hypertension protocol by
anesthesiologists. Anesthesia & Analgesia, 131(5), pp.1401-1408.
7