Brian's story

Brian is 65 years old and lives with his dog 'Spider' in a town flat on the first floor of a block of units in a government housing estate.

About a year ago Brian had to move to town from his home community because his increasing health needs could not be readily met in his community. He misses his community, the close bonds with family and friends back home and is worried about his family's welfare in his absence.

Brian has been a smoker for 30 years. He smokes 20 cigarettes per day and has a history of recurrent chest infections, hypertension, sleep apnoea and gout. He has a persistent cough that he calls a 'smoker's cough'. Recently he has noticed his cough is getting worse and producing greenish coloured sputum.

Over the last few days he has been finding it increasingly difficult to walk up stairs and to look after himself. He now has to stop every few minutes to catch his breath and decided it was time to come to the Emergency Department at the hospital where you are practicing.

On your shift today, the Emergency Nurse gives you the following handover as part of Brian's admission to the setting where you are practicing today as a registered nurse: Brian presented to the Emergency Department because his respiratory function has been deteriorating over the last few days. After medical review, his provisional medical diagnosis is an acute chest infection exacerbating suspected chronic obstructive pulmonary disease. He is being admitted for treatment and further investigation of his respiratory function.

Brian's current medications include allopurinol, cilazipril and metoprolol and in the emergency department he has had first doses of ampicillin and a combination bronchodilator by metered dose inhaler which are to continue until review. The doctor also ordered low flow oxygen via nasal prongs, chest physio after the bronchodilator therapy and a high energy, high protein diet.

The Emergency nurse also tells you that Brian has reported he hasn't had a shower for two days because he gets "too puffed out' and that he is very worried about his dog 'Spider' who has been left locked up alone in his flat. He also is concerned that his family back in the community doesn't know that he's not well and had come to hospital.

Your task in Assessment 1 is to critically discuss some of the key nursing issues related to Brian's care on your shift. Details of the specific nursing issues to address are identified on the following pages.

Tasks

Based on Brian's case and the information you have available, address the following seven (7) items.

Do not make up or assume information in relation to Brian's case. Only use what you know from the case study information on the previous page.

Item 1: Clinical presentation No Textbooks are to be used in this section Brian is part of your patient allocation for your shift today. You haven't met or seen him as yet. An important first step in the clinical reasoning process is to anticipate what you might see, hear and feel when you first meet Brian.

Using current, reliable journal articles to support your thoughts and ideas (Textbooks are not appropriate sources in this section)

- Describe what you might expect to see, hear and/or feel when you do your initial assessment of Brian AND

- Explain why you might expect to see, hear or feel these findings

Item 3: Nursing management - Medication management

Two important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications and to monitor the patient to ensure they are responding to prescribed medications as they should.

- Briefly explain why Brian has been prescribed ampicillin and a combination bronchodilator by metered dose inhaler on this admission

- Explain how you will monitor Brian to ensure he is responding to these medications as he should

Item 4: Nursing management - Rationale for prescribed treatments and nursing interventions

Brian has been prescribed several treatment interventions to stabilise his current health problems and improve his overall health status. From your assessments so far, you recognise that Brian should be nursed in an upright or tripod position and to ensure that he has supplemental oxygen, supervision and assistance when showering, toileting and mobilising around the ward.

Using current, reliable journal articles to support your thoughts and ideas (Textbooks are not appropriate sources in this section)

- Explain why Brian has been prescribed:

o Chest physio (postural drainage, percussion and vibration, effective coughing) after administration of the prescribed bronchodilator therapy

o A high energy, high protein diet

- Explain why you have decided that today Brian needs

o To be nursed in an upright position

o Supplemental oxygen, supervision and assistance when showering, toileting and mobilising around the ward

Item 5: Safe, effective nursing care

Nurses have a professional responsibility to ensure that patients in their care remain safe and well in health care settings.

Using current, reliable journal articles to support your thoughts and ideas (Textbooks are not appropriate sources in this section)

- Explain the strategies you will implement to keep Brian safe and well in the hospital environment during your shift today

AND

- Strategies you will implement to monitor Brian to ensure you can identify if Brian is not responding to prescribed treatments and/or your nursing care as he should

Item 6: Health promotion

Brian requires a chronic obstructive pulmonary disease management plan to be put in place before he can be discharged home. Part of any management plan is patient teaching and strategies to promote health and minimise exacerbation of his health problems.

- Identify two (2) health promotion topics you will address with Brian during your shift today that are part of Brian's chronic obstructive pulmonary disease management plan.

AND

- Explain why these 2 topics are appropriate for Brian as part of a chronic obstructive pulmonary disease management plan.

Item 7: Culturally responsive nursing care

An important part of nursing practice is to be responsive and sensitive to the cultural practices, beliefs and values of patients in your care.

- Explain why Brian's cultural background might impact on how he interprets, understands and complies with prescribed treatments and health promotion information that is given to him this admission.