Hi, I have a case study which I have to do where I have to create a care plan with 2 nursing problems/diagnoses and then complete an essay. Here is the scenario:
Mr Kumar is admitted to the ward with breathlessness, general weakness and a productivecough. He is 65years old, and smoked between 20-25 cigarettes a day since his late teens,but gave this up 6months ago. He has had a 10year history of what he described as being‘chesty’, with wheeziness and chest tightness. He had to retire from his job as a postman inhis mid 50s because of respiratory problems: chronic cough, frequent chest infections andincreasing breathlessness on exertion due to chronic bronchitis and he was eventuallydiagnosed with COPD which led to his retirement. He had suffered a myocardial infarctiontwo years previously and has occasional attacks of angina. Prior to this admission he hashad a two week history of worsening cough and wheeze which had not responded to a 7-day course of oral antibiotic therapy amoxicillin 500mg qds and oral steroid prednisolone 30mg od. He has become weaker and his ankles had started to swell. On admission Mr Kumar is mildly confused and tremulous. He is overweight with a pink appearance. He was started on oxygen 6L/min via a re-breathable mask by the paramedics.He has a weak, productive-sounding cough but is not able to bring up sputum. He is wheezy,tachypnoeic at 28 breaths/min and marked ankle oedema. His temperature is 37.6°C and he has an irregular pulse, with an apical rate of 125beats/min. His oxygen has been changed to24% by face mask, however, his saturations on pulse oximetry decreased to 75%. Therespiratory physiotherapist was on the ward and was able to carry out immediate chestphysiotherapy which helped Mr Kumar to cough up moderate amounts of green sputum. He was also prescribed 0.5mg ipratropium via an air-driven nebuliser. Arterial blood gases on admission breathing room air were: pO2 4.5kPa, pCO2 10kPa, pH7.25. An ECG was also done which confirmed atrial fibrillation and a chest x-ray shows overinflation but no evidence of pneumonia. His oxygen therapy has been changed to 28%. He isprescribed nebulisers salbutamol 5mg and ipratropium 0.5mg to be driven with compressed air.
Now these are the problems I have come up with:
- Impaired gas exchange related to impaired oxygen supply as evidenced by shortness of breath, hypoxia, tachypnoea and tachycardia
- Excess fluid volume related to Atrial Fibrillation as evidenced by ankle odema
I also came up with another problem which was : Ineffective airway clearance related to increased mucous production as evidenced by wheezing and weak productive-sounding cough
However I am unsure whether the ineffective airway clearance becomes a priority over the excess fluid volume as I am sure it is his AF which is causing the oedema in his ankle and if not managed, can lead to stroke or heart failure. But at the same time, it is also important to maintain airway, but if he has been able to cough up moderate amounts of sputum, doesn't that mean his airway is being maintained and although we have to still focus on his airways, it is not much of a priority as the excess fluid retention.
Am I on the right track? Does my chosen nursing diagnosis seem realistic, or is there anything else I may have to add on or remove?
Thanks in advance