Henry Williams is a 69-year-old African American and retired rail system engineer who lives in a small apartment with his wife, Ertha. Henry and Ertha had one son who was killed in the war 10 years ago. They have a daugh
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Henry Williams is a 69-year-old African American and retired rail system engineer who lives in a small apartment with his wife, Ertha. Henry and Ertha had one son who was killed in the war 10 years ago. They have a daughter-in-law, Betty, who is a nurse, and one grandson, Ty. Henry is concerned about Ertha because she is experiencing frequent memory lapses.
Monologue
Henry was admitted to the hospital last night after he called the doctor and told him that he could not catch his breath. Henry has several medical problems including COPD, hypertension, and high cholesterol. Henry provides important details of how he views his current life situation. Listen to Henry’s Monologue which if found in virtual clinicals week 5.
After listening to Henry’s monologue answer these questions.
1. What are Henry’s strengths?
Despite what is happing/has happened in Henry’s life is still moving fo rward in life using resources to help keep him going. He still pays attention and recognizes the positive things he has in life such as his grandchild.
2. What are your concerns for this patient?
My main concern with this patient is his difficulty catching his breath. I am also concerned because it seems like Henry is the primary caregiver for his wife due to her progressing memory loss. Henry is having his own medical complications and need to work on caring form himself. It may be difficult for him to care for his wife when he is having his own medical problems. This patient also has a lot of anxiety about his wife and his current condition.
3. What is the cause of your concern?
The patient needs to be able to breath, and the fact that he is not able to talk without need to pause several times to catch his breath is concerning. The
patient is also breathing very heavily/taking several deep breaths. The patient also stated that he smokes and started when he smokes and have several frequent bouts of asthma, bronchitis etc. Henery has is own medical problems and it seem like he is having difficulty taking care of himself as is. It not safe for him to care for his wife at the moment because he needs to focus on his health. The patient expresses that he is worried and concerned.
4. What information do you need?
When was the patient diagnosed with COPD, hypertension, and high cholesterol? What interventions does the patient do for the COPD, hypertension, and high cholesterol? What is the patient’s eating habits and weight? Is the patient active. How many packs a day does the smoke.
5. What are you going to do about it?
I think it is important that the patient does breathing exercises to help with his COPD. Incentive spirometry and coughing/deep breathing exercises. The patient needs to be educated on the harmful effects of smoking and work towards smoking cessation. The patient could have hypertension and high cholesterol due to smoking, but the patient may be overweight and inactive due to his breathing problems. It is important to teach the patient of having a well-balanced diet and staying active within his limits. I think a home health nurse, or a caregiver would be beneficial for both hennery and his wife. While Henry loves his wife and wants to take care of her, it is not the best option because he needs to focus on improving his health. Psychical support and a social worker would be good for this patient. Meals on wheels would be good for Henry and his wife, so he can have healthier meals and someone to come and check in on his wife and him.
6. What is Henry experiencing?
Henry is experience COPD exacerbations related to his history/long time smoking of cigarettes.
Brief Description of Client
Name: Henry Williams
Date of Birth: 1-5-19xx
Gender: M Age: 80 Weight: 194 lb (88 kg) Height: 72 in
Race: (Faculty can select) Religion: (Faculty can select)
Major Support: Ertha (wife) and Betty (daughter-in-law) Support Phone: Ertha 320-222-2345; Betty 320-222-1111
Allergies: Penicillin Immunizations: Up to date; influenza and pneumonia current
Attending Provider/Team: Katherine Nelson, MD
Past Medical History: Chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), asthma, hearing loss (wears hearing aids)
History of Present Illness: Admitted last night with an acute exacerbation of COPD. He was not able to catch his breath, called his physician and was told to go to the emergency room. His neighbor brought him to the emergency room. He expressed concern about who will care for his wife, Ertha, who has problems with memory loss and is confused at times.
Social History: Retired engineer for transit system Primary Medical Diagnosis: COPD, cardiovascular disease Surgeries/Procedures & Dates: Appendectomy at age 15.
DAY 1 ADMISSION
Time: 0700
Person providing report: Nurse ending shift
Situation: Henry Williams is an 80-year-old male who was admitted last night with an acute exacerbation of COPD. He was brought in to the Emergency Department at 10PM and was admitted to our acute care unit at 11:30PM.
Background: Mr. Williams has a history of COPD, coronary artery disease, and he has a hearing deficit. He was very short of breath last night and called his physician, who told him to go the ED. A neighbor brought him in, and his family followed shortly after. His daughter-in-kaw Betty is a nurse, and his wife Ertha came in with her. Betty is concerned about their ability to care for themselves. She feels Henry may be depressed. She says he is not eating well and has lost interest in activities he previously enjoyed, like doing crossword puzzles and following his favorite football team. She also said that Ertha has memory loss and is often confused. Ertha and Betty went home after Mr. Williams was settled in his room. He had an albuterol treatment by respiratory therapy an hour and a half ago, and they should be back in about 30 minutes.
Assessment: Admission oxygen saturation was 82% on room air. He is now at 88% on 2 liters of oxygen by nasal cannula. Pulse is 112, respiratory rate: 28, blood pressure 134/88. IV of lactated ringers infusing at 50 mL/hour in right arm. He is alert and oriented, denies pain. He did not sleep well and seems very tired. His AM labs were just drawn. He is very worried about his wife who he says depends on him.
Recommendation: He is due for vital signs, AM assessment, and medications, oral and inhaled. Please administer the SPICES tool.
.
Entering Henry’s room:
Bed is flat. Henry is coughing and short of breath.
Vital signs: T 98.2, BP 138/90, P – 112, R - 28; Oxygen saturation – 84%, notice nasal cannula is lying in patient’s bed
Henry: Wheezing “I am really short of breath and so tired. I don't sleep well. I get anxious worrying about my wife.”
Describe the actions to take before entering the patient’s room. Before entering the patient’s room, I would want to get a good report from the previous nurse and gather a good health history on the patient. I would want to look at his recent vital signs and understand what the patient’s baseline is. I would also want to have my stethoscope, so when I enter the room, I can do a respiratory assessment.
What would the nursing actions be based on the initial assessment? What is your initial observation? And yes, be explicit. I want to state that who I am and my responsibility. While it is important to do a head to toe assessment, in this case it would be a priority to do a respiratory assessment. The patient oxygen saturation is low, so it is important to put the NC back in the patient nose and keep him on a continuous pulse ox monitor, so I can assess for improvement in his oxygen levels. I would also want to educate the patient on the importance of keeping his oxygen in his nose. Deep breathing exercises would benefit this patient as well.
After you have completed your initial assessment and nursing actions, you begin the complete assessment. While doing the complete assessment Henry says “Am I due for a breathing treatment? They said I would get something soon. Where are my pills and inhalers?”
Do you stop to get his breathing treatment? Explain your actions.
I would not want to admittedly leave to get the patient breathing treatments as this would take time and I need to focus on immediate intervention I could take to improve the patient’s breathing and oxygen saturation. Once I realized that the patient’s oxygen sat was low, I would want to admittedly put the patient on oxygen/ put the NC back in the patient’s nose. I would want to put the pulse ox on the patient and stay with the patient to make sure that his stats are improving. I would want to make sure that the head of the bead is elevated. I would not want to admittedly leave to get the patient breathing treatments as this would take time and I need to focus on immediate intervention I could take to improve the patient’s breathing and oxygen saturation. I would also help the patient perform deep breathing and coughing exercises to help improve his breathing. Once the patient is more stable, his breathing is improving, and his oxygen saturation is improved, I would see if the patient is due for breathing treatment and get those ready for the patient.
What medications are you going to administer?
I would expect to be administering bronchodilators, inhalers (albuterol), oral/inhaled steroids etc.
Henry states “I don’t know how to use this medication”. Write how you would teach Henry the correct technique?
For inhalers, I would instruct Henry to sit upright, press down on the inhaler quickly to release the medicine and then breath breathe in slowly. Additionally, I would instruct the patient to breathe in slowly for 3 to 5 seconds, while holding his breath for 10 seconds. If taking two puff it is best to wait one minute between puffs. It is important to instruct the patient to rise their mouth with water afterwards to prevent a dry mouth.
How do you know he understood what was taught? I would have the patient correctly verbalize how to take his inhaler.
After completing your assessment, the Henry states, “I wish I could sleep better. I haven’t been eating well either. ”I’m just not managing all that well.”
Henry answers:
Sleep: I have trouble falling asleep. And I’m up often during the night. I’m really tired most days.
Eating: Ertha doesn’t cook anymore. I buy frozen meals and lots of already prepared meals, cans of soup, that kind of thing. Sandwiches too.
Incontinence: No
Confusion: Ertha’s confused. Not me.
Falls: Not really. I’m a little shaky sometimes though, especially when I first get up.
Skin Breakdown: None
Ertha enters room as you are finishing the assessment: “Betty just dropped me here…who is she again?” Ertha wanders around room. Henry states “Ertha, sit down. You are making me nervous.”
How would you responds.
I would explain what is going on and educate the patient.
The patient’s breathing problems could be why he is having trouble sleeping at night.
Discuss how you identified the key assessment data?
I need to assess the patient lung function because he has COPD exacerbations, and this is the main complication. With COPD it is common for patients to have a cough, shortness of breath, wheezing etc. which are all present in this patient.
What interventions would you implement?
Help the patient with his breathing…Oxygen, incentive priority, deep breathing and coughing exercises, breathing treatments, smoking cessation. A low fat/cholesterol diet to help improve his cholesterol. Education about medications and treatment plans.
Psychical support and community resources to help him and his wife post discharge. Chest physiotherapy uses percussion and vibration to mobilize secretions. Raising the foot of the bed slightly higher than the head can facilitate optimal drainage and removal of secretions by gravity.
Raising the head of the bed to promote better breathing. Incentive spirometry, coughing/deep breathing exercises
At this time what are the main problems you have identified throughout this case study?
The main problem identified is that the patient is having difficulty breathing and managing his symptoms because he does know a lot about his condition or treatment interventions. It is concerning that the patient is the primary caregiver for his wife, when he is having difficulty managing his own illness. The patient is a smoker which could be contributing to his high blood pressure, high cholesterol, and COPD. He seems to have anxiety and depression due to his condition and his wife’s condition. The sleeping problems are a concern and could be related to his breathing difficulties.
DAY 5 DISCHARGE
Person providing report: Nurse ending shift
Situation: Henry Williams is an 80-year-old male who was admitted through the Emergency Department 5 days ago with an acute exacerbation of COPD.
He is being transferred to a rehab facility today due to generalized weakness and slow progression with his pulmonary rehab.
Background: Mr. Williams has been living at home with his wife Ertha. Besides his COPD he has a history of cardiovascular disease and hearing loss. Since admission, he has received albuterol treatments and oral prednisone in addition to the medications he was previously taking at home. He has improved but still gets short of breath with his ADL’s. His wife Ertha is experiencing some dementia and Mr. Williams is her primary caregiver. He seems depressed and worried about her and how they will manage. Their daughter-in-law Betty has been caring for Ertha since Henry was hospitalized. After discharge from rehab, the plan is for them to move to an assisted living facility.
Assessment: Vital signs stable with oxygen saturation in low 90’s. He uses 2 liters per nasal cannula PRN at night and for shortness of breath with activity. Transfer forms have been faxed to the rehab facility. His AM meds were given and the rest are not due until 8PM.
Recommendation: Check discharge orders and prepare for discharge to rehab facility. He needs vital signs and a focused assessment and completion of his medication reconciliation form. And please administer the Geriatric Depression Scale and Caregiver Strain Index before his family arrives. When the family arrives assess need for teaching about medications. Call the rehab facility and give them a report when you have completed all your assessments
Entering the room you see Henry is in the chair, dressed and waiting for discharge. He appears withdrawn and sad.
VS, O2 sat-90% on room air, pulse-88, RR-18, BP-130/82
“I am afraid of going to that rehabilitation center. I hear people never go home…. Well, it’s time to leave the hospital today and I am worried about everything! The nurses keep talking to me about the rehabilitation center like it will be a great place for me, but I won’t have Ertha and I won’t be home so what is so good about this? I know it’s temporary and I need the rehab but still, it seems so permanent and I won’t probably see our home
again. Betty is arranging for us to go to an assisted living apartment when there is an opening. Poor Betty, she doesn’t even live close by.
Geriatric Depression Scale: Henry’s answers:
1. Satisfied with life? NO, not right now
2. Dropped activities? YES
3. Life is empty? NO
4. Get bored? NO
5. Good spirits most of the time? NO, not right now.
6. Afraid that something bad is going to happen to you? NO
7. Happy most of time? NO
8. Feel helpless? NO
9. Prefer to stay at home? NO
10. Problems with memory than most? NO
11. Wonderful to be alive now? Not sure
12. Feel worthless? NO
13. Feel full of energy? NO
14. Feel situation is hopeless? NO
15. Do you think that most people are better off than you are? NO
Modified Caregiver Strain Index: Henry’s answers:
Sleep disturbed: Sometimes Caregiving inconvenient: No Physical strain: Yes Confining: Sometimes
Family adjustments: Sometimes Changes in plans: Yes
Demands on time: Sometimes Emotional adjustments: No Behavior upsetting: Yes Person changed: Yes
Work adjustments: No Financial strain: Yes Overwhelmed: Sometimes
Betty and Ertha arrive. When Ertha and Betty come into the room, Henry’s anxiety increases.
Betty: “Dad we are here to take you to rehab. Are you breathing OK?”
Betty: “Can we get his medications straightened out? I don’t want any problems after we leave.”
Ertha (wandering in room) “Henry take me home.”
Prior to discharge you will need to do the medication reconciliation. Complete the medication reconciliation form that is in the patient’s chart. Review the medications with Henry. What would be pertinent teaching points for his prescribed discharge medications?
Albuterol nebulizer treatment 2.5 mg and ipratropium bromide 0.5 mg in 3 cc NS q 20 minutes x 3, followed by albuterol 2.5 mg and ipratropium bromide 0.5 mg in 3 cc NS q 2 hours (Help Pt breath petter and improve respiratory function).
Prednisone 40 mg daily x 10 days – ati-inflammatory drug that helps with inflammation of the conducting air passages in the lungs.
Prednisone can help sooth the delicate lining of the lungs, thus making the lungs more resistant to bronchospasms and help improve breathing.
Fluticasone propionate 250 mcg & salmeterol 50 mcg oral inhaler q 12 hours – help prevent asthma attacks and improve breathing.
Albuterol – Treat/prevent bronchospasms and improve breathing. Lisinopril – Treats high blood pressure.
Metoprolol tartrate 50 mg po daily – Treats high blood pressure. Acetylsalicylic acid 81 mg po daily – Reduce exacerbations of COPD. Rosuvastatin calcium 20 mg every evening – Treats/reduces high cholesterol.
Montelukast sodium 10 mg every evening – Prevents asthmas attacks.
How will you apply what you learned today to your clinical practice?
Throughout this case study, I wrote a lot of education/teaching that I would do with the patient. Patient education is an important part of nursing and I can become more proficient by educating my patient’s during clinical.
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