Case Study: Patient Needs, Goals, and Interventions

This case study focuses on a patient with multiple chronic conditions, including chronic obstructive pulmonary disease (COPD), bipolar depression, and post-surgical pain, requiring comprehensive nursing care. The assignment addresses the patient's safety needs, including infection control and risk assessment, and emphasizes the importance of considering cultural and spiritual needs in the care plan. It explores strategies for health restoration, maintenance, and promotion through therapeutic communication, medication management, and patient education. The student provides a nursing diagnosis, sets short-term and long-term goals using the SMART format, and outlines specific nursing interventions to achieve these goals, ensuring a holistic approach to patient care and well-being. The case study highlights the challenges of managing complex medical histories and the importance of individualized care plans.

Running Head: CASE STUDY
CASE STUDY
Name of the Student
Name of the University
Author’s Note

1CASE STUDY
Question 1
Ms. H.E has a medical history of diseases such as chronic obstructive pulmonary disease
(COPD), bipolar depression, overactive bladder, gastro-esophageal reflux disease (GERD),
hyperlipidemia, hypothyroidism and recently she has gone through a surgery on her lower back.
All these tendencies show that she needs medical intervention as all the diseases are chronic and
their medications can have severe side effects resulting to more severe health complications.
Currently, she has been suffering in pain and she rates it as a 3 out of 10 due to her surgery.
The three safety needs for the client includes infection control because of her recent surgery,
assessing the types of risk for her injury, and refraining and guarding her from self-harm that
might get triggered as she is suffering from bipolar depression. All her medications have adverse
effects on her health, which might increase the chances of suicidal tendencies because she is
already suffering from mental disorders (Nkanunye & Obiechina, 2017). She should be assisted
for her daily tasks as her back is not stable and she is vulnerable to falls.
Question 2
A patient needs spiritual and cultural assistance depending on their perspective and religious
beliefs. Ms. H.E has a number of chronic diseases that can make her evaluate about her life and
make decisions about performing rituals as she is suffering. Cultural competent care is an aspect
in a medical setting that helps in understanding the cultural, social and religious needs of patients
so that they can provide guidance and assistance accordingly (Timmins & Caldeira, 2017). This
prioritizes the needs of the patient and also the requirement of delivering quality care by the
healthcare providers. The care plan for this client will include measures to include spiritual and
cultural needs to make her feel at ease. Interventions can be implemented to bring her close to

2CASE STUDY
her faith because she is suffering from bipolar depression and it is a mental disorder so it will
make her feel emotionally calm. To include cultural intervention, her family will be included in
taking decisions about her wellbeing (Collier, Sorensen & Iedema, 2016).
Question 3
Strategies have to be implemented to focus on the client’s wellbeing such as looking for health
restoration, maintenance and promotion. All this can be maintained if therapeutic communication
and patient centered care is given the utmost importance by the healthcare providers. Her
thorough check up should be done as she has a long list of health complications that is affecting
her everyday life. The medication has its side effects that is further increasing the dilemma,
which makes it necessary that all her medications should be prescribed keeping in mind the
negative consequences. Her health can be maintained with the help of efficient monitoring and
surveillance so that any issues can be immediately looked after. Health can be promoted by
guiding and assisting about her conditions and the precautions she should take to minimize the
negligence (Friedberg et al., 2014).

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References
Collier, A., Sorensen, R., & Iedema, R. (2016). Patients' and families' perspectives of patient
safety at the end of life: a video-reflexive ethnography study. International Journal for
Quality in Health Care, 28(1), 66-73.
Friedberg, M. W., Chen, P. G., Van Busum, K. R., Aunon, F., Pham, C., Caloyeras, J., ... &
Crosson, F. J. (2014). Factors affecting physician professional satisfaction and their
implications for patient care, health systems, and health policy. Rand health
quarterly, 3(4).
Nkanunye, C. C., & Obiechina, G. O. (2017). Health communication strategies as gateway to
effective health promotion and well-being. Journal of Medical Research and Health
Education, 1(3), 13.
Timmins, F., & Caldeira, S. (2017). Assessing the spiritual needs of patients. Nursing Standard
(2014+), 31(29), 47.