Posted: December 20th, 2021

case study

Question description

Assignment 2: Case Study and Care Plan
Overview/Description:
Throughout this course, you were provided case studies that focused on cardiovascular, pulmonary, genitourinary, and musculoskeletal disorders. You will pick one of these cases to analyze and create a comprehensive care plan for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research-based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for the title page, headings, citations, and references. The paper should be no more than 10 pages typed excluding title page and references.
Criteria:

Case Study Assessment

Analyze the disorder addressing the following elements: pathophysiology, signs/symptoms, progression trajectory, diagnostic testing, and treatment options.
Differentiate the disorder from normal development.
Discuss the physical and psychological demands the disorder places on the patient and family.
Explain the key concepts that must be shared with the patient and family to achieve optimal disorder management and outcomes.
Identify key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
Interpret facilitators and barriers to optimal disorder management and outcomes.
Describe strategies to overcome the identified barriers.

Care Plan Synthesis

Design a comprehensive and holistic recognition and planning for the disorder. 
Address how the patient’s socio-cultural background can potentially impact optimal management and outcomes.
Demonstrate an evidence-based approach to address key issues identified in the case study. 
Formulate a comprehensive but tailored approach to disorder management.

The case study was given by professor Case Study Analysis and Care Plan Creation  Pulmonology Case Study
HPI
A65-year-oldCaucasianfemalepresentswithachiefcomplaintofcoughfortwoweeks. Shehasbeencomplainingofdrycoughsincethepasttwoweeksandlowgradefever thatstartedtwodaysago,andwasashighas101orally.Shehashadadecreased appetitebutnonauseaandvomiting.Thecoughoccursduringthenightandsheneeds to situpinachairtobeabletobreatheeasier.Thecoughismainlydry,rarely productive.
Shehadbeenprescribedinhalersinthepast;theyhavebeenhelpfulbutshedoesnot usethemonaroutinebasis.Shehasbeenprescribedantibioticsinthepastaswelland thatseemstohelpwhensheisacutelyill.Shehasbeensufferingfromshortnessof breathforthepasttwoweeksfollowinganykindofactivitymainlybecauseofthedry cough.Shethinksit’spossiblethatthere’ssomeproblemwithher“heart.”Sheisalso complainingof a slightsorethroat,especiallyinthemorningandfeelsshemayhavelung cancer.
Thepatient’ssymptomshavebeenworseningoverthepasttwodays.
Shehashadsimilarepisodesinthepast.Thelastwasthreemonthsagowhenshehad to gototheemergencyroomandtheytoldherthatsheneededtobehospitalized.She declinedhospitalizationatthattimeandwastreatedandreleased.Shesaystheygave herantibioticsandaninhalerbeforedischargingher.Shementionedthatthoughittook sometimetofeelbetter,therewas agradualimprovementinherconditionfollowingthat treatment.Accordingtoher,thisistheworstepisodethatshecanremember.She’svery concernedtodaythatshecouldhavepneumoniaandmightrequirehospitalization.
Sheisseekingmedicalattentiontodaybecauseofthefeverandprolongednatureofher illness
PMH
Thoughshehasbeentreatedforthisprobleminthepastwithantibioticsandinhalers, shehasnotbeenhospitalized.Thepatienthadachestinvestigationthelasttimeshe hadthisproblem.Shestatesthatshedidnothavepneumoniabutdidhave “emphysema.”Thehealthcareprofessionalswantedtodopulmonaryfunctiontests,but shedeclined.

X-rayreport:
X-rayresults:HyperinflationofbothlungswithanincreasedAPdiameter.Thereis evidenceofemphysema.
Shestatesthatshehadasthmaasachildandisacigarettesmoker.Shealsohada hysterectomywaybackin the 1970s.Besidesthese,shehasnoknownchronicmedical problems.
ROS
Shortnessofbreathwithactivity.Nodiaphoresis.Shehashadafever.Nonauseaand vomiting.Denieschestpressuresensationwithphysicalactivity.Nopalpitations.
MEDICATIONS
Thepatientdoesnottakeanyprescriptionmedicines.Shetakesoccasionalover-the- counterTylenolforpain.
Tylenol650mg,2POas needed.
ALLERGIES/REACTIONS
Sheisallergictosulfadrugsthatcausearash.
SOCIALHISTORY
Thepatienthasbeenwidowedfor20years.Sheisreceivinganannualpensionof
$40,000.00andhassomemoneythatshehassavedinthebank.Shehasahighschool diplomaandownsherhouse.Thoughshehaslittledisposableincome,herfinancesare essentiallystable.Shehaslittleknowledgeofcommunityresourcesthatareather disposal.
Shehasa primarycareprovider,whomsheseesthreetofourtimeseveryyearfora physicalexamination.Thephysicianisverybusyanddoesnotspendmuchtimewith her.Shehasinsurancebutitdoesnotcoverallherprescriptionmedications.Sherelies onalotonsamples.
Shehastwogrown-updaughterswholiveinthenearbycommunity.Theyarebothin theirfortiesandarealiveandwell.Thepatientwouldlikeherdaughterstobemore involvedinherlife,butsheisnotsurehowtoapproachthemaboutthis.Thepatient’s perceptionofself-efficacyhasbeendecliningoverthepasttenyears.Shefeelsthatshe couldbefeelingdepressedbecauseshedoesnotgetoutofthehouseveryoftenand this depressionisonlygettingworsewitheachpassingyear.
Thepatienthasverylowlevelofday-to-daystress.However,sherealizesthather depressivesymptomsmaybecausingsomeofherphysicalsymptoms.
Shegoestochurchandhassomecontactsthere.Sheseesherdaughtersoncea month.Thesepeoplearehersupportsystem,butshehasnoonetotalktoonaroutine basis.
HABITS
•  Diethabits
Shehasa healthydietandherdietaryintakeisadequate.Thepatienthaspositive healthbeliefsandknowsthatsheshouldbedoingmoretomaintainahealthylifestyle

Smoking:Shehassmokedonepackperdayfor40years. Alcohol:Shedeniesalcoholuse
SubstanceUse:Shedeniesanystreetdruguse
 WORKHABITS
Shehasalwaysbeenahairdresser;isretirednow.Shegoestochurchandoccasionally attendssomeoftheirfunctions.Herhobbiesincludesewing.SheisfromtheUnited Statesandlivesinasuburbansetting.Crimerateinherlocalityislowwitheasyaccess
topublictransportation.Thereareavarietyofcommunitygroups,butsheisnotawareof theseresources. Shedoesnotgetadequateexercisebecauseofhershortnessofbreath.Sheenjoys visitingherphysician.
FAMILYHISTORY
Hertwooldersistersarealiveandwell,onewithosteoporosisandonewithbreast cancer. Her75-year-oldsisterwasdiagnosedwithosteoporosisattheageof55.Her72- year-oldsisterwasdiagnosedwithbreastcancerat60yearsofage.
PHYSICALEXAMINATION
VitalSigns:BP:130/72leftarmsittingregularcuff;T:101po;P:100andregular;R:20, non-labored;Wt:130#;Ht:55”.
HEENT:Whitematerialonthebuccalmucosa;doesnotwipeoffwithtongueblade. LymphNodes:None
Lungs:Decreasedbreathsounds,dulltopercussionrightlowerlobe.Endexpiratory wheezeinrightlowerlobe.Noralesorrhonchi.Increasedanterior-posteriordiameterto chestwall.
Heart:RRRwithoutmurmur Carotids:Nobruits Abdomen:Benign

Smoking:Shehassmokedonepackperdayfor40years. Alcohol:Shedeniesalcoholuse
SubstanceUse:Shedeniesanystreetdruguse
 WORKHABITS
Shehasalwaysbeenahairdresser;isretirednow.Shegoestochurchandoccasionally attendssomeoftheirfunctions.Herhobbiesincludesewing.SheisfromtheUnited Statesandlivesinasuburbansetting.Crimerateinherlocalityislowwitheasyaccess
topublictransportation.Thereareavarietyofcommunitygroups,butsheisnotawareof theseresources.
FAMILYHISTORY
Hertwooldersistersarealiveandwell,onewithosteoporosisandonewithbreast cancer. Her75-year-oldsisterwasdiagnosedwithosteoporosisattheageof55.Her72- year-oldsisterwasdiagnosedwithbreastcancerat60yearsofage.
PHYSICALEXAMINATION
VitalSigns:BP:130/72leftarmsittingregularcuff;T:101po;P:100andregular;R:20, non-labored;Wt:130#;Ht:55”.
HEENT:Whitematerialonthebuccalmucosa;doesnotwipeoffwithtongueblade. LymphNodes:None
Lungs:Decreasedbreathsounds,dulltopercussionrightlowerlobe.Endexpiratory wheezeinrightlowerlobe.Noralesorrhonchi.Increasedanterior-posteriordiameterto chestwall.
Heart:RRRwithoutmurmur Carotids:Nobruits Abdomen:Benign

Rectum:Notexamined
Genital/Pelvic:Notexamined
Extremities,IncludingPulses:2+pulsesthroughout,noedema
Neurologic:Notexamined
LABRESULTS/RADIOLOGICALSTUDIES/EKGINTERPRETATION
CBC-WBCs15,000with+leftshift
Pulseoximeterreading:SAO2:98%
RadiologicalStudies
CXR–SameasX-ray
EKG
Normalsinusrhythm
My finished work using the professors case study:
Patient Initials:  Age: 65  Sex: F
Subjective Data: Client Complaints
The patient presented with complaints of persistent coughs, which had lasted for two weeks. She has had a dry cough and fever, which is reported to have begun two days ago. She has a general loss of appetite with no signs of nausea and vomiting. Her cough increases during the night and is hardly productive. She has been suffering from shortness of breath for a period of two weeks due to this cough. She also reports a slight sore throat, which intensifies in the morning hours. She was scared of a possibility of a lung cancer.
HPI (History of Present Illness)
The patient’s current condition has lasted two weeks now, during which she has experienced a dry cough, sore throat and shortness of breath. Since she has had such symptoms, her condition has worsened in the past two days.
PMH (Past Medical History
The patient has been treated in the past for this problem with the use of inhalers and antibiotics. She has, however, not been admitted to the hospital. She also had a chest examination previously when she reported a similar problem in the past. She indicated that she had emphysema. She was requested to undergo pulmonary function tests, which she refused. She has previously used an inhaler to help with the breathing complications.
Significant Family History
The patient’s family members have not reported a history of terminal illnesses at a young age. Her two older sisters are okay. She has a 75-year old sister, however, who was diagnosed with osteoporosis at 55 and a 72-year-old diagnosed with breast cancer at 60.
Socially, the patient has faced some problems. She has been a widow for 20 years. She receives an annual pension of $40,000 and has some savings in the bank. She expressed little awareness of the available community healthcare resources. She has a medical service provider whom she visits at least three times in a year.  She is also health insured. She does not show signs of stress and has a good support system from her sisters and two daughters. She has been smoking a pack of cigarettes for the past 40 years. She reports no use of alcohol or drugs.
Objective Data
Vital Signs including BMI
The client’s vital signs were computed as follows
BP: 130/72 left arm sitting regular cuff; systolic is slightly above the normal range, T: 101 po; temperature is elevated and requires further investigation, P: 100 and regular; the pulse is within normal limits for patients age, R: 20, non-labored; pulse is within normal limits, Wt: 130#; Ht: 55” patients weight and height fit her BMI chart weight.
Physical Assessment Findings:
•  Lymph Nodes: None, this is within normal range
•  Lungs: Decreased breath sounds, dull to percussion right lower lobe. End-expiratory wheeze in the right lower lobe. No rales or rhonchi. Increased anterior-posterior diameter to the chest wall, suspicious for pneumonia in the right lower lobe.
•  Heart: RRR without murmur, within normal range
•  Carotids: No bruits, normal finding
•  Abdomen: Benign, suggested soft, non-tender, and non-distended
•  Rectum: Not examined, should cover all basis and a rectal exam should be performed.
•  Genital/Pelvic: Not examined, follow up with OB- GYN referral should be made.
•  Extremities, including Pulses: 2+ pulses throughout, no edema, this is a normal finding
•  Neurologic: Not examined, the practitioner should evaluate neuro function to be safe.
Tests and Results
•  CBC- WBCs 15, 000 with + left shift, further investigation to rule out infection and type should be completed
•  Pulse oximeter reading: SAO2: 98%, this is a normal finding.
Radiological Studies
•  CXR – Same as X-ray, an MRI should be scheduled to r/o pneumonia.
•  EKG is normal sinus rhythm, which is a normal finding cardiologist would approve.
Client’s Locus of Control and Readiness to Learn
The patient is generally well-aware of the environment, and can make independent and informed decisions. A performed teach back of education should be completed to make sure the patient and healthcare provider are on the same page.
ICD-10 Diagnoses/Client Problems
Chronic Obstructive Pulmonary Disease with suggested infection looking at her elevate CBC count, indicating the need for blood cultures, and an antibiotic, as well as, a referral to a pulmonary specialist (Kon, Hansel & Barnes, 2016)
Advanced Practice Nursing Intervention Plan
Ø  The patient should sleep in a cool area to promote unlabored breathing
Ø  further scans (MRI scan) to establish finer details of her condition
Ø  Phosphodiesterase-4 inhibitors
Ø  Theophylline may be a good choice for this patient.
Ø  Referral to a pulmonary specialist.
Ø  Blood cultures
Ø  Start appropriate antibiotics  
Ø  When listening to the patient’s lungs the nurse should note abnormal sounds such as rhonchi, wheezes, and crackles.
Ø  Respirations should be monitored for rate and sounds. Inspiratory and expiratory rate and percentage should be noted.
Ø  Characteristics of a cough should be noted this will help to Help with the degree of cough effort and effectiveness.
Ø  Fluids should be increased depending on age and heart condition, and tolerance to 3000 ml per day the recommend liquid should be warm or tepid and should be taken throughout the day, not just at meal settings.
Ø  ABG’s should be monitor along with pulse oximetry and chest x-ray (Weinberger, Cockrill & Mandel, 2015).
References
Kon, O. M., Hansel, T. T., & Barnes, P. J. (2016).Chronic obstructive pulmonary disease: (COPD). Oxford: Oxford University Press.
Weinberger, S. E., Cockrill, B. A., & Mandel, J. (2015).Principles of pulmonary medicine. Philadelphia: Saunders/Elsevier.
now your assignment is Overview/Description:
Throughout this course(refer to my finished work), you were provided case studies that focused on cardiovascular, pulmonary( refer to my finished work and the professors case study to make sure I did not leave out important info), genitourinary, and musculoskeletal disorders. You will pick one of these cases to analyze and create a comprehensive care plan for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research-based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for the title page, headings, citations, and references. The paper should be no more than 10 pages typed excluding title page and references.
Criteria:

Case Study Assessment

Analyze the disorder addressing the following elements: pathophysiology, signs/symptoms, progression trajectory, diagnostic testing, and treatment options.
Differentiate the disorder from normal development.
Discuss the physical and psychological demands the disorder places on the patient and family.
Explain the key concepts that must be shared with the patient and family to achieve optimal disorder management and outcomes.
Identify key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
Interpret facilitators and barriers to optimal disorder management and outcomes.
Describe strategies to overcome the identified barriers.

Care Plan Synthesis

Design a comprehensive and holistic recognition and planning for the disorder. 
Address how the patient’s socio-cultural background can potentially impact optimal management and outcomes.
Demonstrate an evidence-based approach to address key issues identified in the case study. 

Criteria

Weight

Case Study Assessment

Analyzed the disorder addressing the following elements: pathophysiology, signs/symptoms, progression trajectory, diagnostic testing, and treatment options.
Differentiated the disorder from normal development.
Discussed the physical and psychological demands the disorder places on the patient and family.
Explained the key concepts that must be shared with the patient and family to achieve optimal disorder management and outcomes.
Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.
Interpreted facilitators and barriers to optimal disorder management and outcomes
Described strategies to overcome the identified barriers.

10
10
10
10
10

10
10

Care Plan Synthesis

Designed a comprehensive and holistic recognition and planning for the disorder. 
Addressed how the patient’s socio-cultural background can potentially impact optimal management and outcomes.
Demonstrated an evidence-based approach to address key issues identified in the case study.
Formulated a comprehensive but tailored approach to disorder management

20
20
20
10

APA Style/Format: Free of grammatical, spelling, or punctuation errors. Citations and references are written in correct APA Style.

10

Total

150

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