Introduction
This case study is about an assessment on patient M.T. It starts by assessing M.T.’s general appearance. It looks unto the M.T.’s age, gender, gait, weight, residence, family, financial status, and ability to participate in a conversation. Then, the case study delves into M.T.’s current medical conditions, and M.T.’s family’s medical history. For M.T.’s disease, the study explains what happens as a result of that disease, and the medication that M.T is receiving. The case study then describes about health; it explains what is meant by being healthy, the factors that determine good health, the ways that M.T. can do so as to ascertain they stay healthy, the societal groups which are likely to be more healthy that their counterparts, and subsequently, the services that are available to M.T. so as to enhance his health. It also discusses the roles of District Nurse, PN, health visitor, and GP in supporting M.T., and the role of voluntary sector and social services in helping M.T. in recovering his health. The case study also assesses the availability of support from M.T.’s family and/ or careers. Also, based on the availability of M.T.’s family, the study considers the role of statutory and voluntary sector. The study then assesses what would be appropriate health for M.T. In conclusion, the case study describes the lesson that I have learned from the assessment on patient M.T. To sum it all up, the case study describes how the assessment on patient M.T will have an influence in my nursing practice in the future.
General Appearance Assessment
In an attempt to carry out a holistic assessment of M.T., it was first established that he is an 85 year-old. An observational process then followed to get details on M.T.’s gait, weight, his ability to talk as well as to participate in a conversation. It was learned that M.T. presently is has a condition of Shortness of Breath (SOB). It was also gathered that the elderly man has had not so good history. M.T. suffered from hypertension in his middle ages, developed CvA- cerebrovascular disease shortly thereafter, struggled with diabetes and stroke as he continued to age, and more recently was diagnosed with Chronic Obstruction Pulmonary Disease (COPD).
Shortness of Breath (COPD) condition
Shortness of Breath (SOB) is commonly known as Dyspnea. According to the American Thoracic Society, SOB refers to “A subjective experience where one has breathing discomfort which entails qualitatively distinct sensations which vary in intensity. In other words, a patient with shortness of breath experiences the feeling of air hunger or as if they are out of breath. Many causes and risks are attributed to the shortness of breath condition. These include heart problems such as irregular heart beats and pericardial effusion, lung problems like anemia, chronic bronchitis, lung cancer, and pneumonia, anxiety and airway obstruction.
The patient suffering from SOB often present one of the most challenging intervention problems for both the direct oversight physician and the out-of-hospital healthcare provider. Dramatic patient improvement can be achieved if intervention is afforded to the patient at early stage following checking in at a hospital.
For a physician like myself dealing with this condition, the greatest challenge comes in the form of heavy reliance on the health history together with physical findings that have been obtained so as to form a working diagnosis for the patient. In this respect, there is always the danger of having disseminated misperceptions pertaining to the relationship of chosen signs and symptoms and the final diagnosis. The physician ought to be aware of the need of weighing the risk-t0-benefit ratio for every intervention favoured to be used meaning that there are those treatments that are designed for certain conditions but are contraindicated for other conditions at the same time.
Evaluation of the patient
When I was presented with the case of the 85 year old M.T. experiencing great respiratory distress, I applied the appropriate procedure for a direct medical oversight physician like myself. First, I undertook to create an initial differential diagnosis of the patient’s possible etiologies. As such, my initial intervention was to rapidly establish and address his life-threatening conditions. Like many typical patients suffering from SOB, I employed the major diagnosis, the bronchospasm versus heart failure (CHF). While following the established protocols which constitute these couple of entities, I was aware of other potentially life-threatening causes of SOB such as pneumonia or pulmonary embolus.
Protocols for treatment
It is worth noting that the development of protocols relating to the treatment of elderly patients with shortness of breath has been challenging for the longest time. This translates that in attending to my elderly patient, M.T., I did not have one protocol that was best placed to tackle his respiratory distress. This informed the necessity to build protocols for the varied problems that called for different treatments including COPD and CvA- cerebrovascular disease that was present in the medical history of my patient. For each protocol, I made sure that it was accompanied with particular indications as well as exclusions for its use. In addition, I included the guidelines that serve to determine the severity of M.T.’s respiratory distress. This early intervention was highly necessary because of the severe state of dyspnea patient M.T. showed.
References
D’Amico, D. &Barbarito, C. (2012). Health and Physical assessment in Nursing (2nd ed.)
Pearson: Prentice Hall.
Gutten, J. (2007, February 9). Clinical Assessment in Nursing. British Journal of Community
Nursing, vol.12, 54-60.
