Medical Assessment Case Study: Patient Care and Treatment Plan

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Case Study
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This medical assessment case study focuses on a 58-year-old male patient, Jim, presenting with flu-like symptoms, including fever, inflammation, and muscle pain, alongside a history of hypertension. The assessment details his physical condition, including elevated heart rate and blood pressure, and outlines nursing problems such as the risk of infection, self-care deficits, imbalanced fluid volume, chronic hypertension, and nutrition deficit. The care plan includes interventions to prevent infection spread, address self-care needs, restore fluid balance, manage hypertension, and improve nutrition. The case study also covers medication management, patient teaching, and clinical judgment, emphasizing the importance of patient engagement, education on health risks, and the need for ongoing monitoring and adjustments to the care plan. The patient is prescribed oseltamivir, paracetamol, and a seasonal flu vaccine, with careful monitoring for any adverse reactions. Patient teaching emphasizes the ill effects of smoking, the importance of medication adherence, and the need for proper nutrition. The clinical judgment section highlights the patient's worsening condition, including shivering and low oxygen saturation, necessitating adjustments to the environment and treatment plan. This case study provides a comprehensive overview of patient assessment, care planning, and clinical decision-making in a healthcare setting.
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Running head: MEDICAL ASSESSMENT
Medical Assessment
Name of Student
Name of University
Author Note
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1MEDICAL ASSESSMENT
Assessment 1: Patient Assessment
The patient, Jim is an elderly 58 year old male who seems to be undernourished
suggestive of underprivileged living condition. He seems to have elevated body temperature
indicating feverish conditions along with inflammation and oedema in tonsils, ear and pharynx.
He is having incessant clear nasal and muscle pain all of which suggests flu like clinical
symptoms (Essen et al., 2014). The discharge sample is sent to the microbiological lab for
diagnosis and the results have yet to arrive. The patient’s heart rate is marginally elevated to 105
beats per minute (BPM) and respiratory rate (RR) is also seemingly normal, 18 respirations per
minute (RPM). The breathing of the patient is still difficult with bilateral wheezing with no
crackles visible in lungs, so no symptoms of bronchitis are observed. The cardiac output of the
patient has come down to threshold value and no sings or murmuring or gallops is observed. The
blood pressure of the patient is very high, 158/86mmHg, this could be due to hypertension,
which the patient seems to have a previous history of, but does not take medication in spite of
being previously prescribed (Bromfield & Muntner, 2013). Although the patient came in the day
before with chest pain, muscle soreness, fatigue and malaise which seemed to have been
controlled down but the patient still has rhinorrhea and muscle tenderness. The neurological test
of the patient seems to be positive; Jim seems alert and oriented and is responding to the
parameters of Glasgow Coma Scale (GCS) properly. The patient seems to be sweaty, which
could be due to his hypertensive habit. After his hospitalization, oseltamivir is commenced to on
suspicion of influenza (Dobson et al., 2015). Jim used be a vigorous smoker but due to his poor
economic conditions, he cannot afford much cigarette, but still smokes 5-10 sticker per day.
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2MEDICAL ASSESSMENT
Assessment 2: Care Planning
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3MEDICAL ASSESSMENT
Nursing problem: Risk of spread of infection
Underlying cause or reason: Influenza is a highly contagious virus spread via airborne
droplets and direct contact. Immuno-compromised patients in the hospital setting are at
higher risk of contracting disease resulting in adverse events.
Goal of care Nursing
interventions/actions
Rationale Indicators your plan is
working
To prevent
and control
the spread of
influenzawithi
n the
healthcare
facility and
the
community.
Assessment of
respiratory status,
depth, accessory
muscle usage and
breathing pattern.
Auscultation of the
lung field to check for
wheezing, crackles and
any other breath or
heart related sounds.
Infection may cause
bronchial swelling,
mucous
accumulation in air
sacs which causes
narrowing of air
passage which leads
to distress while
breathing. Care has
to be taken so that
the infection does not
spread further and
Patient is expected to
show signs of stability
and achieve
homeostasis.
The respiratory passage
of the patient should be
cleared.
The patient is expected
to have clear breathing
without any obstruction
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4MEDICAL ASSESSMENT
Monitor patient for
coughing symptoms,
sputum generation and
note the amount.
Position patient in such
a way that they can get
air, as in Fowler’s
position.
Change patient
position every couple
of hours.
Administer
bronchodilators if
necessary.
Perform postural
draining if necessary
Administer or
encourage more fluid
cause more
complication, since
the patient is already
suffering from
hypertension.
If any breathing
sound is observed
like wheezing in case
of the patient, then it
means that the air
passage is blocked.
This may cause
edema and
bronchospasmic
symptoms in the
patient (Lionakis et
al., 2012).
If mucous colour is
yellow or greenish
then it can be
confirmed that the
sounds and optimal gas
exchange will seem to
take place.
The mucous secretion
will stop.
The headache and
muscle tenderness will
decrease.
The feverish symptoms
will go away and
normal body
temperatures will be
observed.
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5MEDICAL ASSESSMENT
intake.
Commence deep
breathing exercises.
Make sure that the
patient is in
comfortable
conditions.
Keep the patient in
isolation, since this a
very contagious
diseases (Ang et al.,
2010).
Instruct the patient to
be careful about his
hygiene and wash
hands with in contact
with his own mucous.
Administer detailed
patient is undergoing
pathogen infection
(Iwasaki & Pillai,
2014).
Fowler’s position
help the patient
achieve maximum
spreading of lung
tissues to increase air
intake (Cicolini,
Gagliardi & Ballone,
2010).
The pulmonary
secretions can be
removed if the
positions are
changed.
Bronchodilators
smoothen the
muscles and helps in
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6MEDICAL ASSESSMENT
antibiotic treatment as
soon as the reports
from microbiology lab
arrive.
decreasing spasms
and improve
ventilation (Lionakis
et al., 2012).
.
Draining the posture
helps in clearing out
the mucous by the
help of gravity and
moves the secretions
so that they can be
expelled out from the
body(Cicolini,
Gagliardi & Ballone,
2010).
Expanding the lungs
helps in better
breathing and
movement of the
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7MEDICAL ASSESSMENT
mucous.
Deep breathing also
helps moving the
mucous as well as
helping the patient
overcome any
possible anxiety.
Keeping the patient
in an isolated
condition will ensure
that other patients in
the ward do not get
infected by the
pathogen.
Washing hands will
ensure that the
nursing staff as well
as doctors do not get
affected from the
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8MEDICAL ASSESSMENT
patient.
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9MEDICAL ASSESSMENT
Nursing problem: Self care deficit
Underlying cause or reason: The patient is homeless, living below poverty conditions
where sanitation is very low.
Goal of care Nursing
interventions/actions
Rationale Indicators your plan is
working
Provide
medication
for his
hypertensive
condition and
teach patient
about
smoking
He needs to be made
aware of the ill hazards
of smoking in his
condition to improve
his health. Jim needs to
be convinced to take
medication for his
hypertension condition
and made aware of the
repercussions of
avoiding it.
Smoking will induce
his hypertensive
condition and the
progression might
cause cancer
The hypertension
symptoms will
decrease.
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10MEDICAL ASSESSMENT
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: The febrile condition followed by influenza infection, has
rendered the patient to lose a lot of fluid. His current living conditions also do not allow
him to stay hydrated.
Goal of care Nursing
interventions/actions
Rationale Indicators your plan is
working
Restore fluid
and ionic
balance to
maintain
homeostasis
Examination needs to
be conducted for
checking the
electrolytes in urine.
Commence saline
water through
intravenous
Intake of fluid helps
diluting the mucous
and easy expulsion
from the nasal cavity
(Guppy et al., 2011).
The result of the
electrolyte analysis
Reduction of sweating
in the patient. The
patient will seem less
stressful.
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11MEDICAL ASSESSMENT
administration. will determine the
ionic balance of the
patient’ body and
suggestive kidney
failure can be
detected (Greenway,
Liu, Yu, & Gupta,
2011).
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