Case Study Assessment of a Patient with Breathing Difficulties

[Surname, first name, student number; scheduled lab time/day, tutor full name]
 Use this template for your task 2 written assignment
 Ensure you update the header with your own unique details
 Ensure you use Australian spell check
 Ensure you update your reference list, and this is always on a separate page
at the end of the document
 Use your verbal handover tool as a trigger to structure your handover, noting
some information may/may not be relevant; e.g. under identification stating
the patients full name and age is sufficient if the URN is unknown.
 Short succinct sentences would be appropriate in Part 1.
 Review the course FAQ’s that relate to Task 2 on Blackboard (under ‘Getting
Started’ tab)
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
Part 1
Identification
The name of the patient is John Williams. The date and time of the admission
were not identified and the NOK did not contact. Also, the NOK was not aware of
the transfer of the patient. However, the family of the patient was present during
the admission. The date of birth of the patient was also not specifically
mentioned in the paper.
Situation
The patient was admitted to the hospital with some breathing issues. He was
facing difficulty in breathing and was from some respiratory failure due to
shortness of breath. From the provisional diagnosis of the patient’s situation it
was found that he had pleural effusion. It is sometimes referred to as “water on
the lungs”. In this condition, build-up of excessive fluid between the layers of the
pleura present in the outside of the lungs. Pleura are thin membrane that helps
in lining the surface of lungs and the inside of the chest wall. The patient also
had an intercostals drainage tube inserted at the left side lung which is inserted
through the chest wall and into the pleural space of the patients’ lung. It works
as the drainage system.
Background
On the background analysis of the patient it was found that worked as a police
officer and now he is a retired person. The background analysis produced the
fact that he is a patient of stomach cancer. He was previously admitted to the
hospital with a breathing difficulty of six weeks right after undergoing a
gastrectomy for his stomach cancer. In this context, gastrectomy is a medical
surgery which is processed to remove a part of the stomach which is affected by
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
cancer. In this medical surgery procedure various side-effects are found in the
patients and among them difficulty in breathing is common. Also, John is a
patient of Chronic Obstructive Pulmonary Disease (COPD). On the other hand,
John is a smoker as well as a social drinker. At the same time, he is having a
regular bowel bladder habit. He has a symptom of shortness in breath with a
wheezing sound. The NIMC medications for John include variety of medicines for
his multiple health issues. He takes prn Panadol to provide pain relief. Along with
this, he consumes multivitamin tablets to address weakness and other lack of
vitamin related issues. John consumes Salbutamol 5 mg NEB prn and this
medicine helps in opening up the medium and large airways of the lungs which is
generally provided to the patients of COPD. Every four hour in a day, he
undergoes IVC flushes. He takes 5ml N\Saline 0.9% which consists of 9g sodium
chloride per litre. When pain indication shows more pain than 7 out of 10, then
he needs to take a prn 5 mg Morphine SC to get relief. Also, in order to fight any
infection caused by bacteria, he takes Amoxicillin 1 gm after 6 hours. However,
no alert regarding medicine or allergic symptoms have been found from the
background analysis of the patient.
Assessment
The observation of 10 hours has been completed for the patient and upon the
assessment of the vital signs it has been found that his body temperature is 37.6
degree Celsius which is a little bit higher than the normal body temperature
range. His heart rate (HR) is 78 which lie within the normal range of heart rate.
His SPO2 rate is 96% which is absolutely normal. Upon the assessment of the
respiratory rate (RR) of the patient, it has been found that his RR is 24 per
minute which is at the marginal rate of normal respiratory rate. Also, his AE is
equal. On the pain rating scale, it has been analysed that his pain level lies
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