Stan Reid: Health Assessment And Nursing Care Priorities

Task 1a

Patient Name: Stan Reid

Scenario: Stan is a 62-year-old man. He has a wife named Dot, who is 61 years old.

Admission complaints: Stan has developed breathlessness; therefore he needs to be admitted to the hospital. The presented conditions are productive cough, shortness of breath, breathing difficulty, and chest infection.

Family background: Stan lives in a small house, with his wife Dot. He and his wife raised 8 kids, 2 of whom are foster kids.

Current condition: Stan is presented with a productive cough and has thick sputum. He has been experiencing serious breathlessness in this morning.

Te Whare Tapa Wha is a holistic health model based on the traditional M?ori worldview. The concept has four main foundations: 1. Taha tinana (physical health); 2. Taha wairua (spiritual health); 3. Taha whanau (family health); and 4. Taha hinengaro (mental health). Although the Te Whare Tapa Wha model focuses on the M?ori community, it is a useful health assessment tool for all people (Purdy 2020).

Whanau can contribute to creating illness and assist in curing illness (Purdy 2020). Several aspects of Stan’s current family functioning and past family history can be identified as contributing factors to his current health condition.. All of Stan’s eight kids live far away, so he cannot rely on them for support. Evidence suggests that lack of support can decrease family functioning (Alexander & Robbins, 2019). In order to improve his health, Stan needs good family support..

Taha hinengaro is the conscience, mind, thoughts, and emotions. When taha hinengaro is strong, a person is more resilient and better able to cope with life’s challenges (McGruer et al., 2019). Certain lifestyle choices, such as a poor diet, can have an adverse effect on mental health. Stan’s financial condition is poor. His wife, Dot, works for minimum wage at the local supermarket. Dot makes ends meet with their food budget by making use of staff ‘specials’ at work, choosing mostly cheaper, processed foods. A diet based mainly on processed foods can have a negative impact on taha hinengaro. This is because processed food contains many chemical, which can cause neurological complication (Keung 2018).  Stan doesn’t have any hobbies or outside interests, besides keeping up with his kids and grandchildren. Now that they are all scattered around the country, he misses them. Being isolated from the rest of his family, with no other hobbies or interests to keep him engaged, has an adverse effect on taha hinengaro (Russell, 2018).

Taha tinana is about physical wellbeing – how the body grows, feels, moves, and how it’s looked after. Stan smokes and drinks heavily — 30-40 cigarettes and at least 5-6 cans of beer every day – which is extremely injurious to his physical health. Drinking too much alcohol can cause liver cirrhosis, and daily smoking can increase the risk of lung cancer, both of which are injurious to health (Green et al., 2017). Stan’s poor socioeconomic condition means that he cannot afford to buy the right foods to maintain a healthy diet. Their house is drafty and damp, which can exacerbate upper respiratory conditions. During his youth, Stan loved playing and being outdoors. Lately, however, he gets very little exercise outside of work. All of this correlates to a taha tinana that is out of balance. (Heaton 2018).

Task 1B

Taha wairua is about spiritual wellbeing. It is about the things that give life meaning. It can be about a religious faith or a spiritual connection to the universe and your ancestors. Stan finds joy being around his children and grandchildren. Now that they are not around, he feels lonely. Feeling isolated from family affects spiritual wellbeing, thus having an adverse effect on taha wairua. Stan and his wife recently attended a local church which they found very welcoming and friendly. They enjoyed the lively atmosphere of the church, and are considering attending services regularly. For Stan, being more active with the church will help to improve taha wairua (Bernay et al., 2016).

Stan has presented with symptoms of acute COPD exacerbation. Priorities of nursing care are as follows: airway clearance, treatment of infection, facilitate gas exchange, improve nutrition, prevent complication and slow progression of disease.

The first priority would be to clear the cough and improve breathing. Stan has developed breathing issues, as the sputum has clogged his trachea. This can lead to blockage of the bronchopulmonary tract, also it may lead to atelectasis (Franks et al. 2020). Therefore, it is important to clear the airway passage to restore normal breathing. Nursing interventions to achieve airway clearance include administering bronchodilators and corticosteroids as prescribed. Instruct the patient in direct or controlled coughing. Provide a pillow to support adequate lung expansion while sleeping and coughing to promote maximum inspiration (Franks et al. 2020).

My second priority would be to treat his chest infection. Stan has a history of frequent chest infections and exacerbation of his COPD. Currently, Stan has a temperature of 38.1 degrees and is expectorating thick green sputum, which indicates an infection. Nursing intervention for sepsis or infection can include checking the blood volume and tissue perfusion of Stan, and preventing further complications (Branco et al., 2021). During an infection, inflammatory responses in the smooth muscles of the airways can affect normal breathing function (Branco et al., 2021). This can be life-threatening. In such situations, sputum formation increases and breathing difficulty becomes more severe. Assessment includes evaluating airway obstruction with spirometry, measuring body temperature, and observing the colour and odour of sputum (Franks et al. 2020).

As a third priority, I would take measures to facilitate gas exchange. According to his assessment, Stan has reduced airflow and a wheezing and crackle sound during auscultation, which suggests breathing inefficiency. Stan is also confused, restless, and has a low arterial blood gas (ABG) level, which could be indicative of CO2-retention. These observations indicate that Stan has diminished airflow with a compromised ability to take in oxygen and eliminate carbon dioxide, indicating hypercapnia (Dave et al., 2021). Impaired gas exchange increases a patient’s ventilatory demands, as lungs must work harder to clear excess carbon dioxide. Treatment for this condition includes monitoring the ABG level (Yang et al., 2017). Nursing intervention to blow off Co2 can include encouraging deep breathing, turning and properly positioning the patient (Yang et al. 2017). The rate, rhythm, and depth of respiration should be monitored, as well as the use of accessory muscles. Continuous monitoring of oxygen saturation is needed, as well as auscultation for lung sounds every 2 to 4 hours. It is also necessary to assess the ability to cough and clear secretions, noting sputum amount, colour, and texture. Treatment includes supplemental oxygen to maintain saturation above 90%. Encourage coughing and deep breathing exercises (Yang et al., 2017).  Use pillows and other devices to keep the patient comfortable and positioned correctly, with the body aligned properly for easier ventilation and proper gas exchange (Yang et al., 2017). 

Task 1C

Malnutrition and weight loss are common in patients with COPD. Dyspnoea and chronic cough can cause loss of appetite (Muntean 2018). A person with COPD has damaged lungs, which burns more calories while breathing than a healthy body (Muntean 2018). High calorie needs, and not being able to meet them with a balanced diet, can lead to muscle wasting and cachexia (Smallwood 2018). Nutritional intervention is necessary to help Stan improve his breathing, immune system and energy levels.

Appropriate disease handling may reduce progression of COPD, relieve indications, and prevent further complications. Cure focus to inhibit more injury, lower the chance of deterioration, and relive some of the complications. Treatment choices include pulmonary rehabilitation, drugs and oxygen therapy (Sahin et al. 2018). Hence, the nurse intervention includes properly administering the drug, checking the vital signs of Stan, providing adequate oxygenation, checking his SpO2 level and reporting to the doctor in case of adverse events (Sahin et al., 2018). Chest X-ray along with plasma examinations seems to be necessary to verify progression. It is crucial to look on the fluctuations in temperature as well as any indications of exacerbation of COPD (Ko et al. 2016)

1. Have you noticed any changes in the colour or do you have any new spots or lesions on your skin?
2. Are there any changes to the size, shape or colour of an existing mole?
3. Do you usually use any sunscreen while being at your work or being outside?

Throughout New Zealand skin cancer is very much prevalent; also, skin melanoma has the highest rates across the world. Cancer Society of New Zealand reports’ indicates that almost 500 patients die each year from skin melanoma across New Zealand (Cancer Society Auckland Northland, 2020). Most (90%) of this skin cancer is related to increased sun exposure.

Therefore, considering the type of work Stan performs, there might be a high chance that he is exposed to the sun’s ultraviolet radiation for radiation, which can increase the risk of having skin cancer (Chang & Daly, 2019).

1. Do you feel pain in muscles or joints or ligaments while performing work?
2. Do you have any pain in your hip?
3. Can you cope with your daily activity?

The musculoskeletal system mainly involves the soft tissues, ligaments, tendons, muscles, and bones. Evidence, suggests as people get older the prevalence of musculoskeletal injury increases (Briggs et al., 2018). One of the major causes is the degradation of bone with aging. Also, heavy work, especially weight-bearing work can increase the prevalence of musculoskeletal injury. Also, a poor diet, mainly a low in calcium diet can increase the loss of bone density, which can lead to musculoskeletal injury (Tai et al. 2015). Stan does not follow a proper diet; as a result, there is a chance that his diet may be low in calcium, which can increase the chance of musculoskeletal injury. Also, his previous fall injury can lead to a musculoskeletal injury. Previous fall experience can lead to injury in the joint or ligament, which may not be properly healed.

1. Do you cough often?
2. Do you feel shortness of breath while taking rest?
3. Can you breathe properly?

In case of COPD, normal breathing function gets severally hindered due to the inflammation and remodelling of the smooth muscles in the airways. As a result, this makes the normal breathing difficult. Also, in COPD condition sputum produces inside the alveoli’s, which will increase the chance of coughing. Also, due to poor gaseous exchange inside the lungs, a person will face difficulty in breathing (Yang et al., 2017).

1. Do you have any recent fall incidents?
2. Do you have a tendency to forget things?
3. Do you feel loss of conciseness?

In his teenage time, Stan has encountered several traumatic falls from the bike. Such a condition has an increased chance to damage normal neurological function. However, the symptoms may not be immediate but may develop in the later stage of life. Also, a sudden fall can increase the chance of brain damage. As a result, it is important to check the neurological function of Stan (Lewis et al. 2016).

1. Do you feel tired during work?
2. Do you feel pain in the chest?
3. Do you have a breathing problem?

Taha Whanau (family health)

Cardiovascular disease is common in an aged person. Also, chest tightness, breathing problems and chest pain can be associated with cardiovascular issues. Also, Stan does not perform the exercise and has poor diet, both of which can be considered as a risk factor for the cardiovascular condition (Lewis et al. 2016).  

1. Does your skin get cold?
2. Does your skin get pale?
3. Do you feel tired?
4. Do you have chest tightness?
5. Do you have breathing issues?
6. Do you have palpitation?

Peripheral issues are associated with poor peripheral blood circulation. COPD patient has a higher chance of developing a peripheral vascular disease (PAD). Therefore, as Stan has COPD, he has a high chance of developing PAD (Terzikhan et al., 2018). COPD patient also has a high chance of developing vascular issues. Stan also has a high chance of developing this issue because he already has a breathing problem, and follows a poor diet, which can increase the chance of plaque build-up(Lewis et al. 2016).

1. Do you have a normal bowel movement?
2. Do you have a digestionproblem?
3. Does your stomach ache?

Stan has stress, do not perform exercise, and has a poor diet, which may be low in fibre. All of which can increase the chance of gastrointestinal problems or blotted stomach(Lewis et al. 2016).

1. Do you have pain during urination?
2. Do you bleed while urinating?
3. Do you have a bad smell from the genital area?

Genitourinary is a very common condition among aged patients. It is related to the poor hygiene of a person. As Stan’s family has poor hygiene practices, the presence of genitourinary increases(Lewis et al. 2016).

1. Do you have increased bleeding?
2. Do you have any other chronic conditions?
3. Do you eat food rich in iron?

Aging, use of certain drugs, and autoimmune condition can increase the chance of Hematologic Diseases. Stan has a low level of haemoglobin (88 g/L), which can lead to anaemia(Lewis et al. 2016).

1. Do you have any hormonal problem?
2. Does your family have hyperthyroidism?
3. Do you have any history of blood infection?

COPD increases the chance of endocrine disease, due to respiratory infection (Corlateanu et al. 2016). Prevalence of COPD can hamper the production of hormone secretion in the body. It was mentioned that Stan has problem in sleeping. Moreover, low level of oxygen can cause hypoxia, which can cause changes in the thyroid production and imbalance in the IGF-1 level (Corlateanu et al. 2016). Also, prevalence of blood infection can increase the level of cortisol level, thus altering the endocrine function.  

COPD or Chronic obstructive pulmonary disease (COPD) is a long term condition, where the normal breathing function gets hampered due to inflammation and sputum formation in the airways (Yang et al., 2017).

Pathophysiology of COPD involved the functional modification of the airways, leading to airway inflammation. .Due to this peripheral airways gets narrowed, which can obstruct the airflow inside the trachea. Moreover, the lung function decreases as exacerbation progress.. Most of the times chronic bronchitis leads to the formation of the emphysema (Yang et al., 2017). This causes tissue destruction of the smooth muscle, loss of alveoli, capillary vessels, and tissues of terminal bronchioles (Yang et al., 2017). This condition leads to an ineffective gas transfer. Also, the destruction of these tissues gives rise to sputum formation. Mucocilliary clearance is mainly responsible for the dysfunction of the mucus production and cilia, which will lead to increased formation of sputum (Yang et al., 2017). Inflammation is related to cytokine activity and increased levels of macrophages and neutrophils. Moreover, in some extent cytotoxic t cells and eosinophil is also responsible for such inflammation. Also, oxidative stress due to the presence of free radicals from the smoking can also increase the production of the inflammatory cells (Yang et al., 2017).  This lead to the breakdown of the connective tissues due to ineffective protease activity. Additionally, effective gas transfer leads to hyperinflation in the lung, all of which obstruct the airways leading to breathing difficulty (Yang et al., 2017).

Taha Hinengaro (mental health)

For this patient it is important to perform a respiratory assessment physical examination test, as he has breathing problem followed by COPD condition. A respiratory assessment will include inspection, palpation, percussion, and auscultation of the patient. Also, the health history of the patient needs to be assessed (Dey & Rautray, 2021).

Inspection seems to be a valuable tool for a nurse throughout the respiratory examination since it provides a plethora of information. The amount of discomfort, usage of auxiliary muscles, respiratory posture, chest shape, respiratory rhythm, as well as other indicators further than the chest may all be assessed visually (Singh 2016).

Tenderness, asymmetries, diaphragmatic extension, crepitus, as well as vocal fremitus could all be evoked with palpation that is a tactile assessment of a chest. Trauma and costochondritis might cause local soreness. Hence, it is crucial to palpate regions of discomfort, bruising, or lesions upon both the front as well as rear of a chest to determine tenderness (Singh 2016) .

Percussion seems to be a method wherein the nurse makes noises by tapping upon a individual’s chest wall. Hitting on a chest wall generates noises according on the quantity of air inside the lungs, just like softly tapping on a vessel with the hands makes varied noises. As a result, any dullness and hyper-resonance, which is symptomatic of lung disease, including pleural effusion and pneumothorax, can be detected (Singh 2016).

Airflow via a trachea-bronchial tree is measured by auscultation. This is essential to differentiate between normal or atypical respiratory signs, such as crackles, wheezes, as well as pleural rubbing, to establish an accurate diagnosis (Singh 2016).

Performing such assessment is necessary to check the condition of the patient’s breathing function. It will help the nurse to locate the actual breathing problem. As these four tests have different purposes, each of these tests will help to identify different problem related to respiratory system. Hence, findings from these tastes will provide enough data to determine the actual complication of the patient (Singh 2016). Nurse can monitor if the lung is fully expanding during the breathing activity, chest pain, or presence of any wheezing sound (Yang et al., 2017). As a result, such assessment will help to identify changes in the normal breathing function. Thus, it can help to diagnose the actual problem (Yang et al., 2017). Upon this assessment findings, the nurse can determine wither the patient require urgent therapeutic intervention or not. Also, such examination can help the professional to locate any unusual lesions inside the chest that can limit normal lung function (Dey &Rautray, 2021).

References

Alexander, J. F., & Robbins, M. (2019). Functional family therapy. In Encyclopedia of Couple and Family Therapy (pp. 1232-1240). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-319-49425-8_161

Bernay, R., Graham, E., Devcich, D. A., Rix, G., & Rubie-Davies, C. M. (2016). Pause, breathe, smile: A mixed-methods study of student well-being following participation in an eight-week, locally developed mindfulness program in three New Zealand schools. Advances in School Mental Health Promotion, 9(2), 90-106. https://doi.org/10.1080/1754730X.2016.1154474

Branco, M. J. C., Lucas, A. P. M., Marques, R. M. D., & Sousa, P. P. (2020). The role of the nurse in caring for the critical patient with sepsis. Revista brasileira de enfermagem, 73. https://doi.org/10.1590/0034-7167-2019-0031 

Taha Tinana (physical health)

Briggs, A. M., Woolf, A. D., Dreinhöfer, K., Homb, N., Hoy, D. G., Kopansky-Giles, D., Åkesson, K., & March, L. (2018). Reducing the global burden of musculoskeletal conditions. Bulletin of the World Health Organization, 96(5), 366–368. https://doi.org/10.2471/BLT.17.204891

Brooke, M. E., Spiliopoulos, N., & Collins, M. (2017). A review of the availability and cost-effectiveness of chronic obstructive pulmonary disease (COPD) management interventions in rural Australia and New Zealand. Rural and Remote Health, 17(4), 1-7. https://search.informit.org/doi/abs/10.3316/informit.156125684798910

Cancer Society Auckland Northland. (2020). Auckland – Cancer Society NZ. Cancer Society Auckland Northland. Retrieved 9 February 2022, from https://www.cancer.org.nz/about-us/find-a-cancer-society-office-near-you/auckland/.

Chang, A. B., Bell, S. C., Torzillo, P. J., King, P. T., Maguire, G. P., Byrnes, C. A., … &Grimwood, K. (2015). Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand-Thoracic Society of Australia and New Zealand guidelines. Medical Journal of Australia, 202(1), 21-23. https://www.mja.com.au/system/files/issues/cha00287.pdf

Chang, E., & Daly, J. (2019). Transitions in Nursing eBook: Preparing for Professional Practice. Elsevier Health Sciences. https://books.google.co.in/books?hl=en&lr=&id=woKlDwAAQBAJ&oi=fnd&pg=PP1&dq=Medical+nursing+book+new+zealand&ots=ZOIdaTXQW6&sig=0-Mq5zqZR4hHruvN_DCXE_7zBRQ&redir_esc=y#v=onepage&q&f=false

Corlateanu, A., Covantev, S., Mathioudakis, A. G., Botnaru, V., &Siafakas, N. (2016). Prevalence and burden of comorbidities in chronic obstructive pulmonary disease. Respiratory investigation, 54(6), 387-396. https://doi.org/10.1016/j.resinv.2016.07.001

Dave, C., Wharton, S., Mukherjee, R., Faqihi, B. M., Stockley, R. A., & Turner, A. M. (2021). Development and Relevance of Hypercapnia in COPD. Canadian respiratory journal, 2021. https://doi.org/10.1155/2021/6623093

Dey, N., &Rautray, P. (2021). Understanding and Evaluating the Needs of a Respiratory Assessment Device for Community Health. In Design for Tomorrow—Volume 2 (pp. 633-642). Springer, Singapore. https://doi.org/10.1007/978-981-16-0119-4_51

Franks, L. J., Walsh, J. R., Hall, K., & Morris, N. R. (2020). Measuring airway clearance outcomes in bronchiectasis: a review. European Respiratory Review, 29(156). DOI: 10.1183/16000617.0161-2019

Green, M. J., Leyland, A. H., Sweeting, H., & Benzeval, M. (2017). Causal effects of transitions to adult roles on early adult smoking and drinking: Evidence from three cohorts. Social Science & Medicine, 187, 193-202. https://doi.org/10.1016/j.socscimed.2017.06.018

Heaton, S. (2018). The juxtaposition of M?ori words with English concepts.’Hauora, Well-being’s philosophy. Educational Philosophy and Theory, 50(5), 460-468. https://doi.org/10.1080/00131857.2016.1167583

Keung, S. (2018). Te taha hinengaro: Using talanoa to facilitate an interconnected analysis of psychosocial development shared by M?ori and Pasifika young men in Rugby League (Doctoral dissertation, Auckland University of Technology).  https://openrepository.aut.ac.nz/handle/10292/11941

Ko, F. W., Chan, K. P., Hui, D. S., Goddard, J. R., Shaw, J. G., Reid, D. W., & Yang, I. A. (2016). Acute exacerbation of COPD. Respirology, 21(7), 1152-1165. https://doi.org/10.1111/resp.12780

Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences. https://books.google.co.in/books?hl=en&lr=&id=f-MCDQAAQBAJ&oi=fnd&pg=PP1&dq=Medical+surgical+nursing+book+&ots=KLTBy-KtLL&sig=fFNHQ0AE2vJGt7JEDvRWdEq_Iow&redir_esc=y#v=onepage&q=Medical%20surgical%20nursing%20book&f=false

McGruer, N., Baldwin, J. N., Ruakere, B. T., & Larmer, P. J. (2019). M?ori lived experience of osteoarthritis: a qualitative study guided by Kaupapa M?ori principles. Journal of primary health care, 11(2), 128-137. https://doi.org/10.1071/HC18079

Muntean P. E. (2018). A 50-year-old male with fever, cough, dyspnoea, chest pain, weight loss and night sweats. Breathe (Sheffield, England), 14(1), 43–48. https://doi.org/10.1183/20734735.013317

Purdy, S. C. (2020). Communication research in the context of te whare tapa wh? model of health. International Journal of Speech-Language Pathology, 22(3), 281-289. https://doi.org/10.1080/17549507.2020.1768288

Purdy, S. C. (2020). Communication research in the context of tewhare tapa wh? model of health. International Journal of Speech-Language Pathology, 22(3), 281-289. https://doi.org/10.1080/17549507.2020.1768288

Russell, L. (2018). Te oranga hinengaro: Report on M?ori mental wellbeing results from the New Zealand mental health monitor & health and lifestyles survey. Health Promotion Agency/Te Hiringa Hauora.  https://hpa.org.nz/sites/default/files/Final-report-TeOrangaHinengaro-M%C4%81ori-Mental-Wellbeing-Oct2018.pdf

Sahin, H., Varol, Y., Naz, I., & Tuksavul, F. (2018). Effectiveness of pulmonary rehabilitation in COPD patients receiving long?term oxygen therapy. The Clinical Respiratory Journal, 12(4), 1439-1446. https://doi.org/10.1111/crj.12680

Singh, S. (2016). Respiratory symptoms and signs. Medicine, 44(4), 205-212. https://doi.org/10.1016/j.mpmed.2016.02.001

Smallwood, N. E. (2018). Palliative care for patients with chronic obstructive pulmonary disease: understanding current practices and exploring a new model of integrated care (Doctoral dissertation, University of Melbourne). ORCID ID: 0000-0002-3403-3586

Tai, V., Leung, W., Grey, A., Reid, I. R., &Bolland, M. J. (2015). Calcium intake and bone mineral density: systematic review and meta-analysis. BMJ, 351. https://doi.org/10.1136/bmj.h4183

Terzikhan, N., Lahousse, L., Verhamme, K. M., Franco, O. H., Ikram, M. A., Stricker, B. H., &Brusselle, G. G. (2018). COPD is associated with an increased risk of peripheral artery disease and mortality. ERJ open research, 4(4). DOI: 10.1183/23120541.00086-2018

Yang, I. A., Brown, J. L., George, J., Jenkins, S., McDonald, C. F., McDonald, V. M., … &Dabscheck, E. (2017). COPD?X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update. Medical Journal of Australia, 207(10), 436-442. https://doi.org/10.5694/mja17.00686