Introduction
This case study is about an assessment on patient M.T. (not the patient’s real name). 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 her 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 her 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 woman who lives alone in a single-roomed house in the outskirts of New York. 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 a not so good health and medical history. M.T. suffered from hypertension in his middle ages, developed Ischaemic heart diseases (IHD) shortly thereafter, struggled with diabetes and stroke as he continued to age. Besides, M.T. has been diagnosed with CCF/LVE and malignant Neoplasm which was in its primary stage. More recently he has been diagnosed with Chronic Obstruction Pulmonary Disease (COPD). However, it was difficult to establish the allergies from which the patient was suffering from.
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 anaemia, 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 CCF/LVE 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.
In all fairness, I can say that Mr. M.T’s case was a classic CHF as I treated it. The challenge was to give aggressive sufficient treatment so as to save him and also avoid the danger of intubation. The elevated blood pressure made me resort to aggressive administration of sublingual nitroglycerin. Considering that the patient was previously on furosemide but has not taken it for a number of days, I found it appropriate to use IV furosemide. In the same breath, I used modest, periodic doses of IV morphine sulphate because of the severity of M.T.’s SOB case.
Health
According to the World Health Organization, “Health refers to a state of absolute physical, mental, spiritual and social well-being and not just the absence of disease or infirmity.” In other words, health refers to being more than free from illness, disease as well as debilitating conditions. It thus means that optimal health comprises high-level physical, mental, emotional, social, and spiritual wellness in the boundaries of an individual’s heredity together with personal abilities. The human body is made of 10 systems which have specific individual functions, namely: the nervous system, the digestive system, the endocrine system, the lymphatic system, the muscular system, the excretory system, the circulatory system, skeleton system, the reproductive, and the subject of this case study – the respiratory system. When all these systems are working in tandem with each other, it renders it impossible for the body to get sick and thus a person is said to fully healthy. Good health thus means balance between the inside and outside of an individual’s body (Gallander, 2006).
What determines good health?
There are a host of factors that influence a person’s health, commonly referred to as determinants of health. The determinants are both interactive and outside a person’s control meaning that they range from those at an individual level to those at the greater society level.
1. Age, sex and genetic factors – these are inborn factors that greatly influence an individual’s lifespan as well the likelihood of developing particular diseases and illnesses. These biological factors are not within the control of an individual.
2. Individual lifestyle – These include such factors as diet, physical exercise, drinking and sexual behaviour, smoking among others. Individuals often have power over such factors by deciding to choose a healthy lifestyle practice which serves to enhance their health.
3. Social and community networks – better health is associated with greater positive support from the family, friends circle and the community at large. This is say that the sense of care and respect that happen in these social relationships go a long way in assisting individuals to cope with health challenges and also as an effective buffer against any health problems, Shortness of breathing being one of them.
4. Overall socio-economic, cultural and environmental state – these factors are many, interactive and occasionally exceed the extent of an individual’s control. In order to make these factors to have positive health results, both integrate and multi-level interventions of public and private health are needed.
5. Income and social status – It is observed that the health status of individuals gets better as their income and social status improves. This translates that higher income and social status often results in increased control as well as discretion. Income is a key determinant of living standards of individuals because it affects such aspects as safe housing and ability to afford balanced diet.
6. Education – as the level of an education particularly on health issues, the more the health status of an individual improves. Similarly, education has close correlation with socio-economic status of people. For instance, education increases one’s probability of landing a job and having income security thus making them able to handle health expenses. Furthermore, education improves individuals’ ability to not only access but also understand important health information which they then put into practice in their lives.
7. Physical environment – because their decreased spread of diseases and reduced depression in a clean environment, the health of individuals in the locality is often of good standards. This is characterized by safe adequate water supplies, drainage and efficient solid waste disposal systems and sanitation. On the other hand, the spread of disease and negative influence on the both the mental and emotional wellbeing of people is greatly compromised in dirty environments. Similarly, air and noise pollution have adverse effects on the health of people and also causes physical accidents. The home is also significant to health of people because there is bound to ill health if the home environment is dirty, poor housing, poor lighting and ventilation. These are more likely to result in such health problems respiratory diseases and premature eyesight failure. In terms of social environment the health of people of who are marginalized on grounds of gender, ethnic/religious affiliations, and income status will be not admirable as compared to harmonious communities where people embrace their differences and encourage conflict resolution through dialogue.
8. Employment and working conditions – people who have the luxury of a job such as control over their particular working conditions, are healthier than those without employment or a reliable source of income. Similarly, health of people is affected by the social organization of the work itself, the management styles along with the social relationships at the workplace.
9. Health services – those in access to health services that help prevent and treat their health issues are more healthy than those without access and means to health services.
10. Culture – the health status of individuals is also influenced by the traditions, customs and beliefs of both their families and the communities from which they come from.
Staying healthy
In order to promote and maintain good health, one needs to combine physical, social, mental and spiritual well-being. It is a consistent process that is influenced by the evolution knowledge on health and practices in addition to personal strategies complimented by organized interventions. A person can can stay healthy by eating nutritious foods, doing exercise, and seeking regular medical check-ups. This is because prevention together with early detection are wonderful defense mechanisms aagainst disease and illness.
References
D’Amico, D. &Barbarito, C. (2012). Health and Physical assessment in Nursing (2nd ed.)
Pearson: Prentice Hall.
Gallander, Geneva. (2006). Healthy Living. Utah, ECKO House Publishing.
Gutten, J. (2007, February 9). Clinical Assessment in Nursing. British Journal of Community
Nursing, vol.12, 54-60.
The World Health Organization. (2008). The determinants of health. Retrieved from http://www.who.int/hia/evidence/doh/en/print.html
