Case Study

Case Study

The poster presents the case study of Mr. Jin Wong, a 68 year old patient, diagnosed with Chronic Obstructive Pulmonary Disease or COPD, Diverticulitis and cataract in right eye. He is currently on several medications and is taken care by son and daughter in law.  He is a widower and pensioner. The risk factors for the patients are the hypertension, hypercholesterolemia, smoking, poor diet and poor vision. The comorbidities of the illness in patient are the diarrhea and constipation.  The patient at the present has poor activities of daily living and is on medication. The person believes in socialising, and entertainment.

The aim of the poster is to present the two priority nursing issues in detail out of the five nursing areas and discuss the same explicitly using the Maslow’s Hierarchy of Needs and the Miller’s Functional Consequences Theory as the framework.    The two nursing issues are discussed in details to determine the nursing priorities and support the same with evidences

• COPD- cough and breathlessness
• Diverticulitis- Diarrhoea and constipation
• Hypertension and hypercholesterolemia
• Vision and fall

^{The two nursing issues that will be presented in detail are}

• ^{Cough and breathlessness}
• ^{Poor vision}  

Cough and breathless is chosen as priority nursing issue as the patient already have COPD

• Spirometery results were FEV1: 55% (post- bronchodilator)
• Breathlessness after exertion
• Difficulty climbing stairs or driving and recent fall
• Lack of nutrition- as patient prefer only fast food
• Smoking
• The medical management for the patient- Atenolol for hypertension, Salbutamol for inhalation , bronchodilator- Tiotropium (Respimat)

Cough and breathlessness are life threatening

• Infective airway clearance results in progression of cough, breathlessness and even death  
• The patient continues to smoke which is the factor exacerbating COPD
• Risk of respiratory failure due to COPD and other comorbid conditions like diverculitis, diarrhea and constipation.
• The medication for different illness may have common side effects  and increase the complications  
• Metronidazole  is taken for bacterial or viral infections which is in patient medicine chart indicating high risk of infections in lungs
• Hypertension is already  present and may further increase due to COPD
• Fat rich diet taken by the patient may further exacerbate hypercholesterolemia and pulmonary hypertension
• Risk of lung infections  
• Impact on activities of daily living

According to Maslow hierarchy of needs, an individual can achieve certain needs motivationally and some of them take precedence over the others. The most basic need of the human is the physical survival.  A good physical health will motivate a person to meet other needs in the five tier pyramid such safety needs, belongingness and love, esteem needs and self-actualisation. Applying this theory cough and breathlessness if not addressed may make it difficult for patient to survive.   Further the patient has anxiety and hypertension which may impact upon the higher level psychological needs such as high self-esteem. Thus, it is the deficiency need to meet the growth and self fulfilment needs as per the above psychology theory.  As per the theory the physiological needs are the first level of needs

It may also be the client’s priority need as cough and breathlessness are hampering his activities of daily living. Using the self concept mode smoking is the physical stressors for the patients, which he was attempting to quit but in vain. In addition hypertension, indulges with functions like driving or climbing stairs. Overall it is affecting the role function mode and facilitates the patient to move to interdependence mode.    

According to miller’s functional consequences theory age related changes causes functional consequences such as aging and reduced physical actvity. In this case the patient had functional consequences due to COPD and persistent cough and breathlessness.  Smoking is the risk factor that is decreasing his functional role such as driving to common unity club. Appropriate interventions such as smoking cessation and oxygenation may improve the patient’s quality of life. The nursing issue will help the ageing patient experience the health fulfilment and sense of well being.

Aims

Based on the above discussion the nursing priorities are-

• Maintain the airway clearance  
• Assist the patient in facilitating gas exchange
• Smoking cessation
• Improve diet and nutrition
• Patient education
• Management of daily activities

• The airway clearance will be ensured by direct or control coughing which will prevent fatigue due to undirected coughing
• According to recent and old literature smoking cessation is the single mote cost effective interventions for COPD patients to prevent its progression.
• Breathing pattern will improved by insipiratory, muscle training, diaphragmatic raining to increase the alveolar ventilation.
• To control the rate and depth if the respiration the patient will be educated on pursued lip breathing
• The patient may be educated on the well balanced diet on reducing cholesterol and COPD exacerbations. The patient may be presently asked to have high protein diet to reduce the hypercolesteroloemia
• The patient to be educated to immunised against influenza as he is prone to infections
• Patient education on smoking cessation and referral to home counselling services to help in successful smoking cessation
• Patient to be educated on appropriate medication intake and its side effects  

Poor vision and fall is chosen as the second nursing priority issue

Assessment

Aged and diagnosed with Cataract

Severity of Issue

It may not be life threatening but falls may cause injuries that may lead to debilitating conditions in elders and even death.

Justification

• Increased risk of fall due to cataract and low vision
• Changes in the eyes due to  ageing and poor visual acuity
• Limits healthy ageing and growth
• May decrease patient’s self dependency
• Age, COPD and medications involve optic nerve as a part of poly neuropathy that also affects vision and balance

Maslow Hierarchy of Needs

Without fulfilling the basic needs the patient cannot meet the higher level needs of psychology and Self-actualisation needs. Vision is the basic need of the person as it impacts the mental and the physical health.  It is as important as biological needs like sex, sleep, food, drink, and air. Vision is considered the deficit in meeting the higher level of needs as per Maslow’s hierarchy of needs. In the Maslow’s hierarchy of needs, the second important level of basic need is safety and security. In this level a person must feel freedom from fear and remain ensured of stability and security. In case of Mr. Jim, poor vision does not give freedom of safety as there is risk of fall and injury.  It may prevent him from fulfilling the other needs in the hierarchical needs such as trust, intimacy and belongingness needs.   If this deficiency is addressed then the patient’s activities will be directed towards meeting the next set of needs.  Once engaging the patient in the meeting the higher level needs it becomes the salient needs and stronger.

It may be the patient’s second preference when compared to the cough and breathlessness. Unlike the first nursing issue it is not life threatening but hamper the activities of daily living like  difficulty walking, and driving climbing stairs. COPD is already a physical stressor which further increases the risk of fall as per the patent’s self concept mode. Overall it is affecting the role function model and may cause interdependence in patient.

According to functional consequences theory, age related changes like poor vision due to  has increased risk of fall. It greatly affects the activities of daily living which is the negative consequence.  It is the role of the nurse in this regard to identify the interventions that may result in the positive consequences. According to this theory, nurse must differentiate between the normal age related changes and the modifiable factors.  In this case, Cataract is the modifiable factor causing vision problem as it is the disease condition. Thus, the patient can be helped to adapt to the various changes and rebalance the relationships  

Nursing Care Priorities

• Assessment of ability to see and perform activities
• Reduce risk of injury
• Management of daily activity
• Assess fall risk and ROM

 Evidence

• The patient and the family will be informed to consult opthalamologist to reduce visual complications
• Daily activity will be placed in a manner that will decrease the fall and energy expenditure
• Educating patients on the exercises will strengthen the patients muscle  and walking aids will be recommended to reduce falls
• The patient may be helped with the exercise training and walking aids. It will help strengthening the muscle to reduce injury due to fall. Assisting to use walking aids will reduce risk of fall   
• The family will be informed to maintain adequate lightening in house for allowing longer accommodation time for eyes
• Prepare the patient and the family for cataract surgery to help them make informed choices
• Referral to the social worker to help financially for surgery

Conclusion

• COPD is the chronic illness and the symptoms are life threatening
• Hypercholesterolemia, hypertension, poor diet  are interrelated with COPD exacerbation
• Interventions for COPD especially diet may also improve conditions of diarrhea and constipation
• COPD is multifaceted problem due to complexities and comorbidities and cough is considered first nursing priority
• Vision is the second nursing issue as COPD patients and use of steroids leads to poor vision. Cataract was the main factor of poor vision and potential risk of factor
• Maslow’s hierarchy of needs guides patient focused care considering the patients needs in given condition
• Miller’s functional consequences theory helps promotes patient’s wellness, by recognising his potential for growth  

References

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