Comprehensive Nursing Care Plan: A Clinical Case Study of a Patient

This case study provides a comprehensive overview of nursing care for a patient, Margarita Voulos, diagnosed with asthma, atrial fibrillation, hypertension and high cholesterol. The report details her presenting problem of breathlessness and explores the pathophysiology of her conditions. A nursing care plan is developed, focusing on breathing training and asthma management, with specific goals, interventions, rationales, and evaluation metrics. Patient education and discharge planning are discussed, emphasizing the importance of self-management skills, lifestyle modifications, and medication adherence. The report also reviews the medications prescribed—aspirin and beclomethasone dipropionate—including their mechanisms of action and potential side effects. This document is available on Desklib, a platform offering a wide range of study tools and solved assignments for students.

CLINICAL CASE
SCENARIO NURSING
CARE OF A PATIENT
WITH A MEDICAL
CONDITION

TABLE OF CONTENT
INTRODUCTION...........................................................................................................................4
TASK-1............................................................................................................................................4
Patient based on the case scenario...............................................................................................4
TASK-2............................................................................................................................................5
Care plan:.....................................................................................................................................5
TASK-3............................................................................................................................................8
Patient education and discharge planning....................................................................................8
TASK-4............................................................................................................................................9
Medications..................................................................................................................................9
CONCLUSION..............................................................................................................................10
REFERENCES .............................................................................................................................11

INTRODUCTION
The nursing care intervention is the actions a nurse takes to implement their patients with
medical care plan and includes the various treatments and teaching moments as well as
procedures. This report will examine the Margarita voulos patient case and its diseases and
current medical conditions. This report will also discuss the nursing care plan for Mrs voulos
with the functional, physical and psycho social aspects of care. This report will elaborate the
patients education and its discharge planning as well as medication work and its side effects.
TASK-1
Patient based on the case scenario
1) Margarita voulos is patients, and she was first diagnosed with the asthma and recently
complained of the breathlessness to her GP, despite taking her inhalers. She gets too early
breathless and exhausted after walk some short distance. She faced that type of issues due to
worked in pub and his husband as well. Mrs voulos was also diagnosed with the atrial fibrillation
and also commenced on the aspirin and metoprolol. She has a bad medical condition because she
suffers from various displease and it not good for health and well-being. She requires their own
health care with meditations. Mrs voulos also doing regular meditations that includes the
salbutamol prn and beclomethasone dipropionate and inhaler (Feliciano, 2021). She also refers
her by GP to the specialist respiratory services for management and assessment of her continuous
breathlessness. There are some investigation which were also carried out such as Mrs voulos
chest X-ray showed the bilateral hyperinflation, blood test 3 mg and there is no chest pain.
2) Pathophysiology is the medical discipline that can be explained their situations typically
which can be observed during the disease. It is he study of abnormal charges in the body function
that can causes, concomitant and consequences of disease processes. It investigates with the
biological processes that are related with the process of mental, physical, psychophysiological
disorders and conditions. It is the process in term of the pathogenesis and etiology. It is formally
considered as the subdiscipline in the physiology. It is the functional charges that accompany the
particular disease and syndrome. It is the study of effects and causes of injury and disease. It is
the wide range of biology medical practices (Luckett, 2022). There are some significant disease
such as all the organic disease and infectious as well as physiology disorders. There are some

significant test in the pathophysiology of disease such as blood analysis dissection, medical
diagnostic test, biopsy, etc.
3) The Mrs voulos patients past medical is that suffer from the Asthma, hypertension, high
cholesterol an atrial fibrillation. There are various disease which face by the Mrs voulos and its
affects the health and well-being of patient and it negatively affects its current situation due to
the past medical history because it medication situation was not good. Mrs voulos recently
complained with the breathlessness problem (Majellano, 2019). This problem is cause because
she was suffered from the asthma problems in their childhood so, Mrs voulos face this issues in
the current presenting situation and its is affects its well-being condition badly. Mrs voulos
husband also hard smoker as well as she was work in pub so, due to pollute environments she
faces the breathlessness problems and disease. Due to the polluted environments, she faces that
type of issues. Smokes can causes the heart disease, lung disease, diabetes, cancer, etc. it can also
lead cause of death, due to the breathlessness issues then it can also cause of death so, Mrs
voulos require medical health care and nursing care.
TASK-2
Care plan:
Case Study
2 Nursing
problems:
Continues Breathlessness problem commenced by Mrs voulos
Related to: The care plan is related to continue breathing problems face by Mrs voulos
care.
Goal of
care
Nursing interventions Rationale Evaluation
Exercise of
breathing
Provide breathing training and
breathing control exercise. The
management of the
breathlessness with the helps of
The inventions might
work with the helps of
various mechanisms that
can target the respiration
There are
various types of
evaluation of the
breathless

medication for patients to care
and provide them better
treatment for patients (Cortés-
Martín, 2022). The nurse can
build the concepts on the
effect's breathlessness patients
such as breathing, thinking and
functioning.
of patents by enhance the
breathing. It can also
improve with the helps of
chest wall vibration and
better breathing exercise
such as respiratory
muscles training, body
positioning training and
lip breathing as well as
diaphragmatic breathing
for the patient care.
problems which
helps in measure
the outcome
such as primary
outcomes and
secondary
outcomes. The
primary
outcomes are
referred as that
breathlessness
can be measured
by the self
reported
instruments.
There are some
secondary
outcomes for
evaluation of
breathlessness
problems such
as performance
perimeters such
as walking test
and international
physical
activities test
consist, safety
outcomes such
as dropout rates,
adverse events

and quality of
life with the
short form item
survey and
measure with the
helps of hospital
anxiety and
depression scale.
Nursing
problem:
Diagnosed with asthma problems
Related to: The nurse care is related with the asthma problem which commenced was
commenced by the Mrs voulos.
Goal of
care
Nursing interventions Rationale Evaluation
Asthma
nursing care
There are various interventions
for the nursing assessments
with assess the clients vitals
signs as needed in the Distress
(Lin, 2019). it can also assess
with the respiratory rate and
rhythm. It can also assess the
patient level of anxiety, assess
the relationship of inspiration
to the expiration and assess the
breath sounds and adventitious
sounds such as stridor and
wheezes. The nursing
intervention can be assessed for
The changes in the
respiratory rate indicate
the early sign of the
distress and increase in
BP also result in
respiratory failure
(Kaplan, Hardjojo, Yu &
Price, 2019). The fatigue
may also indicate the
distress and it leads the
respiratory failure.
The diagnosed
asthma can be
measured by the
FeNO test.
Patient can
breathe into the
machine and it
checks the level
of nitric oxide in
patient breathe
and it can be
sign of the
inflammation in
lungs (Menzies-
Gow, 2018).

the signs of dyspnoea, use of
accessory muscle and chest
retractions.
There are
spirometry
instruments
which helps in
measure the
asthma and it is
used to diagnose
asthma.
TASK-3
Patient education and discharge planning.
Patient education is referred as the process of influence the patient behaviours and includes
some changes in the patient attitudes, knowledge and skills to maintain and helps in improve
their health. The patient education are most important for their recovery and provide the
sustainable benefits. It helps in enhance the doctor and patient relationship and patients are also
participated in their own health care for their health and well-being. There are various education
topics such as health promotion, nutrition, exercise, immunization, smoking cessation, disease
management, stress management, diabetes, etc. Mrs voulos face the breathlessness problem so,
she also requires the education regarding their health and preventions at home ad their whole life
when ever she suffers from disease uncertainly. Nurse can educate that Mrs voulos that she can
put it hand on their chest and other hand on their stomach and then close eyes. It helps in focus
on breathing as well as breath slowly in through nose and throughout (Reedy, 2021). So, it helps
in make smooth and relaxed their patients. It also includes in the patients' preparation for
discharge to aid healing and relevant from breathless illness. Patient education is most important
for the value based care system and patients are able to focus on their health care.
Exercise and meditation also includes in the patient preparation and their education for
discharge such as breathing exercise and inactivity exercise for prevent the health issues at home
without any medical treatments.

There are some reason that patient education should be strategic priority such as clinical time
savings, chronic illness prevention, health care cost reduction, patient experience improvements
and hospital reimbursements (Carette, 2019). There are various education strategies that drive
improve their health statue, nurse can teaching their patients about the lifestyle, medications, self
monitoring devices such as blood pressure monitor and glucose meter and lifestyle
modifications during the shift in preparation for discharge home.
Medication strategy is more helpful for the breathless patients because they can do utilize this
strategy and education at their home after discharge. Medications strategy assist the patient to
implement the education into their daily routine life. Patient education is most important with
medication to implement into daily routine because it helps in improve self care and patients
skill's by provide the information about their breathless treatments it helps in improve their
medication adherence and empowerments. It also helps in reduce patients medical expenses in
the aspects of long term care and it helps in prevent patients from diseases as well as helps in
improve their health and lives (Black & Duval, 2019). By train patient in the self management
and skills of their breathlessness disease by adopting to the medication treatments and change its
lifestyles. The patient education is the right of patients. Nurse and health care members are
responsible for provide the home care information and guidelines to their patents during
preparation for discharge home.
TASK-4
Medications
There are two medication that Mrs voulos has been prescribed such as beclomethasone
dipropionate 100 mcg 2 puffs BD and Aspirin 100 mg daily.
Aspirin 10 mg daily: its helps in reduce the COPD disease and breathlessness disease of Mrs
voulos and its helps in reduce the laboured breathing ad moderate breathing. These medicines are
prescribed by the medical health care profession because it helps in relieving the pains and
problems and it also helps in prevent the health tissue death.
Mrs voulos prescribed these medicines because she faces problems in breathing so, it helps in
relieving from pain. It helps my patients to reduce the risk of cardio vascular event in voulos
with high risk and also helps in manage various risk. Margarita was diagnosed with the atrial

fibrillation so, she commenced with the metoprolol and aspirin. Doctors also recommand for
asthma.
Side effects: There are various side effects of this medication such as indigestion, nausea,
vomiting, stomach bleeding so, Mrs voulos follow the instruction on doctor guidelines and label.
It can also occur the mild headache. The aspirin taking can increase the risk of bleeding and it
also includes the Bleeding from the gastrointestinal tract. Stomach bleeding is the serious side
effects and it can affect the patient health.
Beclomethasone dipropionate 100 mcg 2 puffs BD:
Beclomethasone dipropionate is an inhaler used as maintain the treatment of asthma attacks and
it used in the various inflammatory conditions such as allergic and asthma to reduce symptoms.
It indicated for relief (Prick, 2022). It works to provide the relaxation to patients in their
breathing problems. Patient prescribed 2 puff, and they require to waist for two minutes between
them.
Mrs voulos was diagnosed with the Asthma and complained of breathlessness problem so,
patients prescribed this medication for their relief and health improvements. She finds the
breathless and exhausted because they are not able to do their daily activities, and she is only
able to manage and walk the short distancing and outdoors.
Side effects: There are various side effectiveness of this medication and its negatively adverse
on patients such as irritated throat because of inhalers, hoarseness and cough can also occur
because body adjust to the medication. It may also occur the voice change and bad taste in
mouth. This medication is prescribed because doctor guide that there are great benefits than the
risk of side effects and some are not get use of side effects. There are some other side effects that
can affects the patients such as trouble swallowing, difficulty with breathing, congestion and
body aches or pain. The main side effects of Beclomethasone dipropionate is sign of the allergic
reactions such as swelling patient face, lips, throat, tongue and face difficulty in breathing.
CONCLUSION
As the conclusion, this report discussed the margarita voulos case and create the care plan
for patient. This report also elaborated the patient education and discharge planning for patients
which are mots important for them. This also analysed the patients medications and its side
effects.

REFERENCES
Books and Journals
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with advanced cancer: a systematic review and meta-analysis. JAMA network
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Prick, J. C. M., and et.al., (2022). Development of a patient decision aid for discharge planning
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Reedy, F., and et.al., (2021). Professionals’, patients’ and families’ views on the use of opioids
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