Critical Assessment

The nurse used the nursing process of care to assess, diagnose, plan, implement, and evaluate Mr. Kumar’s condition and consequent medication needs in this case study. Mr. Kumar appeared with shortness of breath, overall weakness, and frequent coughing. The healthcare provider went on to question about Mr. Kumar’s age, which determined the sort of medication and treatment to be administered. Mr. Kumar’s age was revealed to be 65 years old after further investigation, with a history of smoking cigarettes between the ages of 20 and 25. He eventually quit smoking six months ago; these indicate the nature of the negative symptoms of smoking that drove the patient to cease smoking. Mr. Kumar has had a ten years history of what he explicitly explained as “chesty” with wheeziness and chest tightness. The health provider at this phase should very different causes of the patient description of illness which may include symptoms of COPD, asthma, acute bronchitis, bronchospasm. Mucus in the airways, something stuck in the throat or growth in the airway. Physical examination by the health care provider was essential to alleviate any life-threatening ordeal such as airway obstruction inhibiting breathing which may result in death (Kirby, 2016, p A5202).

Further exploration of patient description reveals that Mr. Kumar had prolonged cough, frequent chest infection, increased breathlessness as a result of chronic bronchitis which led to his retirement. The health care provider as required, run pulmonary tests which measured the amount of air Mr. Kumar inhaled and exhaled subsequently. These were done to ascertain whether there was enough oxygen in his blood. Spirometry was also done as a confirmatory test as it can detect COPD even before a client present with the symptoms (Kirby, 2016, p A5202).

Mr. Kumar had been diagnosed with Myocardial Infarction two years ago which occurred when the blood flow decreases or stops to some parts of the heart causing substantial damage to the muscles of the heart. Its symptoms include chest pain, nausea, shortness of breath and feeling tired (O’Gara, 2013, p 485). The patient also had a history of occasional attack of angina which is characterised by dizziness, fatigue, sweating and pain in the chest, to diagnose angina the health provider ordered several tests which include Electrocardiogram, stress test and cardiac computerised tomography scan. Before admission, Mr. Kumar had been observed to have a worsening cough, wheeze which was not responsive to medication and upon physical examination, the patient had swelling ankles which signify overweight and decreased blood circulation (O’Gara, 2013, p 485).

Upon Mr. Kumar’s admission, he was mildly confused and tremulous which could suggest the presence of hypoglycemia, Graves’ disease, substance withdrawal syndrome and pheochromocytoma. The most likely cause of confusion and tremulous state of Mr. Kumar was be attributed to Cigarettes cessation which causes withdrawal syndrome as a result of addiction. Cigarettes associated therapy for cessation must be well incorporated to ensure a multicomponent approach of alleviating Mr. Kumar condition before admission. Overweight nature of the patient needed both lifestyle interventions which includes regular physical exercises, healthy eating habits and controlled cholesterol consumption. Stress monitoring was incorporated in Mr. Kumar’s management to contribute to his recuperation (WHO, 2017) significantly.

Pulse oximetry reduction was successfully managed by the respiratory physiotherapist who conducted immediate chest physiotherapy to enable Mr. Kumar a cough up sufficient amount of green sputum for tests. He was also administered 0.5mg ipratropium through an air driven nebuliser.

In making a clinical decision on patients’ management, the water flow score model is necessary, which gives estimated risks for the development of a pressure sore on a patient. In determining what kind of care to offer to Mr. Kumar the following parameters are fundamental: weight, visual risk areas, sex, age, and malnutrition as well as mobility status.

The Diagnosis Phase

The nursing care plan also comprises of the diagnosis phase where the health practitioner makes an informed decision with the help of the patient about the patient’s medical condition. The diagnosis may either be single or multiple depending on the previous assessment. The phase helps to determine whether the patient is at risk of developing more complications as a result of the current medical condition as well as the actual description of the underlying disease and to evaluate whether the patient will be ready for the subsequent health improvement procedures. The step further provides the health practitioners with the guide to abide by during the treatment (Lavin, 2015, p 6).

In this case, therefore, the nurse studied Mr. Kumar’s condition in detail and came up with a comprehensive list of all the possible diseases he may have been suffering. The breathlessness was possibly as a result of lung conditions such as chronic obstructive pulmonary disease, asthma, lung cancer, emphysema and bronchiectasis. Heart conditions such as an abnormal heart rhythm and a heart attack may also present with shortness of breath as one of the outstanding symptoms (Partti, 2016, p 657). Chronic anxiety and fear may also result in panic attacks that may also result in breathlessness. For instance, a patient may experience frequent instances of feeling faint, general body weakness, shaky limbs and an abnormally pounding heart. Considering that Mr. Kumar is overweight, it is evident that his body uses more effort to make simple activities like breathing and walking (Partti, 2016, p 657).

The two most evident acute nursing problems include respiratory complications and prospective heart diseases. The difficulty in breathing related to respiratory complications as characterised by chest tightness, wheeziness, chronic cough, frequent chest infections, chronic bronchitis, OCPD and a weak cough which was challenging to produce sputum. The second nursing problem is heart complications as evidenced by previous cases of myocardial infarction, angina attacks and an irregular pulse. His ankles have also started swelling which would be an indication of a more significant underlying condition (McPeake, 2015, p 225).

The Planning Phase

The step comprises of the coming up with a plan for action by both the nurse and the patient to ensure the best treatment and medication for the patient. However, depending on the number of diagnoses previously made during the diagnosis phase, the nurse will identify the risk factors and conditions among the many which will require immediate attention as opposed to others that do not predispose the patient to the risk of the loss of life. The nurse assigned each condition a SMART goal in the search for an appropriate treatment plan (Theo, 2014, p338). The goals of Mr. Kumar’s care were specific; where the nurse identified who would be involved in the provision of care, what she wanted to accomplish in terms of administering medication, where the drug would be administered, how frequently the medication would be issued as well as why it was being administered and the aim of the medication. Each condition was thus assigned a medication that was primarily designed to cure it. The treatment goals were also measurable since the healthcare provider established criteria to track progress towards attaining the previously set treatment goals. The measurable aspect of the goals enabled the healthcare provider to view the set goals as more severe aspects of the medication and health-improvement process, to reach the set goals at the pre-determined time intervals as well as keep making little efforts that in the long-run, amounted to the overall achievement of the goals. The nurse, therefore, determined how much of the drugs and money were required as well as in what quantity the patient would need them (Jeong, 2015, p 538).

The set goals were further expected to be attainable. The nurse identified ways to achieve the set goals some of which included the necessary skills, abilities, attitudes and the financial capacity of the hospital and other members of staff to take care of Mr. Kumar comprehensively. The health practitioner also identified the existing opportunities that would make the process a little easier and more cost-effective. The goals were also realistic since the health provider presented a well-defined objective, which was to find a permanent solution to Mr. Kumar’s medical condition (McPeake, 2015, p 225). For this reason, the nurse found it easier to work towards treating Mr. Kumar as well as the willingness to provide her best version of the treatment. She also stayed motivated by her objective throughout the treatment process thus she was able to identify herself with the various conditions she was treating Mr. Kumar. As a result, Mr. Kumar received the most appropriate medical care for his ailments.

The treatment goals were further considered timely since the nurse had already identified a time-frame within which to execute them while providing the best possible services. The time-frame helped to equip the goals with a sense of urgency thus making it easy for the health practitioners to focus on the most urgent medical needs of Mr. Kumar. The members of staff mostly worked on set goals by first considering when the patient needed their services most thus they made an unconscious decision to offer the medical services as soon as possible. Considering that both the nurse and other members of staff present had dealt with similar cases before, they found it relatively easy to cater for Mr. Kumar’s needs. The goals were also expected to be tangible regarding one’s ability to experience its effects with any of the five common senses which include sight, taste, touch, smell and hearing (Butcher, 2013, p 57).

Implementing plan

These involve the process the health care provider follows through the already decided plan of actions (Moorhead, 2014, p59). The plans always focus on achievable outcomes. The health care provider had a task of continuously monitoring Mr. Kumar health improvement. In the management of COPD, the health care provider was aimed at improving Mr. Kumar’s functional status and ensuring optimal quality of life by ensuring normal functioning of the lungs and preventing re-occurrence of exacerbations. The health provider had a choice of providing alternative medication such as oxygen therapy when appropriate or initiate smoking cessation which has proven to reduce mortality significantly. Currently, no other medicines that have been shown to substantially improve lung functioning other than lung transplantation, which was also an option in Mr. Kumar’s case. However educating the patient about the disease, its complications and preventive measures will encourage the client to actively participate in the therapy (Moorhead, 2014, p59).

Comprehensive COPD management plan included sessions of patient education, development of a self-treatment plan for exacerbations and monthly continuous follow-up calls by the health care provider have indicated to reduce hospitalisation rates and lesser emergency visits. Multicomponent COPD management structure has proven to be cost-effective. Mr. Kumar’s was stable, and therefore there was no need to refer him to an intensive care admission which is characterised by confusion, respiratory acidosis, and respiratory muscle fatigue and worsening hypoxemia. Oral and inhaled type medications were initiated to restore Mr. Kumar’s lungs condition. Reducing dyspnea and improving exercise culture was also effective in the management of COPD condition. Diet as an alternative medication is paramount in Mr. Kumar’s condition. For instance, the insufficient nutritional status related with low body mass is connected with compromised pulmonary status, and diaphragmatic mass and higher mortality rates. However nutritional intervention forms an integral part of comprehensive care in COPD patients.

Mr. Kumar was also diagnosed with myocardial infarction which is characterised by the decreased flow of blood in the heart and failure of some part of the heart to get blood supply. Myocardial management was targeted against reducing the effects of reduced blood flow to the afflicted areas of the heart muscles. A blood clot often precipitates this condition in the coronary arteries which supply oxygenated blood to the myocardium muscles. As a result of existing relationship between myocardial ischemia duration and extent of heart muscles damage, public health professionals encourage patients experiencing suspected coronary syndrome should be referred for intensive care treatment. Patients with the coronary syndrome, prescribed with nitroglycerin are required to promptly take one dose and seek emergency services when their symptoms do not improve within 2-5 minutes. Chewing on- enteric-coated aspirin is highly recommended unless there is any case of contraindication (Moorhead, 2014, p59).

Relief of pain for angina condition is equally important, not only to the humane reasons but for pain associated with sympathetic activation that leads to vasoconstriction and in the long run increases the workload of the heart. The pain associated with myocardial infarction is likely to respond to any intervention that triggers the relationship between oxygen supply and demand like beta blockers, oxygen and nitrates (Nobel, 2016, p 68).

The Evaluation Phase

The nurse completes the treatment by evaluating whether her team accomplished the pre-determined medical goals they had set at the beginning of the treatment process. The healthcare provider determined whether the treatment was successful by assessing if Mr. Kumar’s condition improved, stabilised or whether the condition deteriorated. The evaluation can further be simplified by determining whether the patient is still admitted to the hospital, was discharged or whether he died or became incapacitated (Craig, 2013, p 587). Where the patient either died or did not register any improvement at all, the health practitioner concluded that the pre-determined healthcare goals had not been met or some inhibiting factors made it difficult for the patient to reap the full benefits of the treatment. However, the nurse would consider the nursing care plan as effective if the patient’s condition gradually improved and eventually Mr. Kumar was discharged from the hospital.

Medications such as nitroglycerin may make the patient’s condition worse due to its extreme side effects which include a headache, dizziness, general body weakness, nausea and vomiting as well as a fast heart rate. In very severe cases, the patient may experience low blood pressure characterised by fainting, lightheadedness, blurred vision and fast and shallow breathing. On the hand, lung surgery to either remove the affected part of the lung or a transplant may result in unfavourable side effects such as rejection of the foreign organ by the body or septicemia resulting from infections attained at the surgical site (Craig, 2013, p 587). Medication used to treat bronchitis may also present with cases of a dry mouth, dizziness and tremors as well as a sore throat after administration. It is therefore crucial for the healthcare provider to frequently check Mr. Kumar’s reaction to the various medications and re-administer new medication where necessary. The nurse could also opt to seek more information from the other team members as well as the specialists in both the respiratory and cardiac treatment departments. The nurse and her team were also responsible for the patient’s adherence to the medication since Mr Kumar was unconscious at the time of admission. Therefore, they had to ensure that he had taken all the prescribed medication at the right time without fail and that he did not miss his IV fluids as well as the oxygen gas mask (Craig, 2013, p 587).

In conclusion, Mr Kumar is a patient with several complex needs that all need urgent medical care. However, the nurse had to identify the medical needs regarding how life-threatening they were to Mr Kumar thus according to the most urgent, immediate attention. The nurse used the nursing care plan which comprises of the assessment, diagnosis, planning, implementation and evaluation processes of care. Each procedure was equally crucial in ensuring that Mr Kumar had experienced the best medical attention and services available.

Appendix 1: Medical Care plan

Assessment phase

It includes getting the patients’ medical history and usually involves skills like observation, probing and conducting medical test

Diagnosis phase

The health practitioner makes an informed decision with the help of the patient about the patient’s medical condition

Planning phase

The step comprises of the coming up with a plan for action by both the nurse and the patient to ensure the best treatment and medication for the patient

Implementation phase

It involves the process the health care provider follows through the already decided plan of actions. The programs always focus on achievable outcomes

Evaluation Phase

It completes the treatment by evaluating whether her team accomplished the pre-determined medical goals they had set at the beginning of the treatment process

References

Butcher, H.K., Bulechek, G.M., Dochterman, J.M.M. and Wagner, C., 2013. Nursing Interventions Classification (NIC)-E-Book. Elsevier Health Sciences.

Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I. and Petticrew, M., 2013. Developing and evaluating complex interventions: the new Medical Research Council guidance. International journal of nursing studies, 50(5), pp.587-592.

Jeong, K., Ji, C., Koo, C., Hong, T. and Park, H.S., 2015. A model for predicting the environmental impacts of educational facilities in the project planning phase. Journal of Cleaner Production, 107, pp.538-549.

Kirby, M., Tan, W.C., Hague, C., Leipsic, J., Bourbeau, J., Hogg, J.C. and Coxson, H., 2016. CT Total Airway Count Explains Airflow Limitation In COPD Patients Without Emphysema. In C48. COPD: IMAGING (pp. A5202-A5202). American Thoracic Society.

Lavin, M.A., Harper, E. and Barr, N., 2015. Health information technology, patient safety, and professional nursing care documentation in acute care settings. OJIN: The Online Journal of Issues in Nursing, 20(2), p.6.

McPeake, J., Sherriff-Short, M., Smart, G., Daniel, M., Kinsella, J. and Qasim, T., 2015. 896: THE CREATION OF THE FIRST ICU PATIENT AND FAMILY ADVISORY COUNCIL IN THE UK. Critical care medicine, 43(12), pp.225-226.

Moorhead, S., Johnson, M., Maas, M.L. and Swanson, E., 2014. Nursing Outcomes Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health Sciences.

Nobel, L., Tjia, J., Saczynski, J.S., Waring, M.E., Anatchkova, M.D., Ash, A., Kiefe, C.I. and Allison, J., 2016. Angina Characteristics as Predictors of Trajectories of Quality of Life Following Acute Coronary Syndrome in the Transitions, Risks and Actions in Coronary Events-Center for Outcomes Research and Education cohort (TRACE-CORE).

O’Gara, P.T., Kushner, F.G., Ascheim, D.D., Casey, D.E., Chung, M.K., De Lemos, J.A., Ettinger, S.M., Fang, J.C., Fesmire, F.M., Franklin, B.A. and Granger, C.B., 2013. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), pp.485-510.

Patti, K., Vasankari, T., Kanervisto, M., Perälä, J., Saarni, S.I., Jousilahti, P., Lönnqvist, J. and Suvisaari, J., 2015. Lung function and respiratory diseases in people with psychosis: a population-based study. The British Journal of Psychiatry, pp.bjp-bp.

Theo Dassen PhD, R.N., 2014. Prevalence of care dependency and nursing care problems in nursing home residents with dementia: a literature review. International Journal of Caring Sciences, 7(2), p.338.

World Health Organization (WHO, 2017). Obesity and Overweight factsheet from the WHO. Health.