Psychiatric Case Study

What kind of specific help are you looking for? I don't feel it would be fair to you to complete your entire assignment for you without knowing what kind of problem you are having with it. I can give you guidance, a start, and some advice, but I need to know more about what you need to do with this case study and what has you stalled on it.

I still do not know what you are looking for. The title on your post says "Psychiatric Case Study". However, to me, this is an obvious medical patient and I don't see this as a psychiatric patient. I can also tell you from my years as a clinical nurse in the acute hospital that I have seen this kind of situation occur where a spouse is refusing to allow a patient to be discharged because they think the patient is too sick. This, to my way of thinking, is not a psychiatric problem.

Step #1 (COLLECT DATA)

Here are the patient's symptoms I picked up from your original post:

• COPD (symptoms include: tachypnea, dyspnea on exertion, barrel chest, prolonged expiration and grunting, crackles and wheezing on inspiration, decreased breath sounds, clubbed fingers and toes, decreased chest expansion, chronic cough with or without sputum production, accessory muscle use and mental status changes if there are problems with carbon dioxide retention)
  
• asthma (symptoms include: sudden dyspnea, wheezing and tightness in the chest, coughing that produces thick, clear or yellow sputum, tachypnea, use of accessory respiratory muscles, rapid pulse, profuse perspiration, diminished breath sounds, hyperresonant lung fields)
  
• acute respiratory infection (symptoms include: fever, diaphoresis. Pathophysiologically what is going on is the cells of the lung are becoming edematous, capillaries become engorged with blood resulting in stasis, the alveolocapillary membrances break down as alveoli fill with blood and exudates which result in atelectasis and can lead to collapse of the lung)
  
• history of smoking
  
• dyspnea
  
• dyspnea at rest
  
• non-productive cough
  
• need for oxygen for an hour after physical therapy
  
• primary caretaker interested in helping with patient's care
  
• primary caretaker worried about become ill with patient's infection
  
• primary caretaker expresses belief that patient is too sick to be discharged

These are all non-normal, or abnormal, data that you need to use to group and choose nursing diagnoses. These symptoms are objective observations or a subjective perceptions of the patient

Step #2 (FORMULATE NURSING DIAGNOSES)

I am using Nursing Diagnoses: Definitions & Classification 2005-2006 published by NANDA International and Nursing Diagnosis Handbook: A Guide to Planning Care, 7th Edition, by Betty J. Ackley and Gail B. Ladwig to help me. These are the nursing diagnoses and the nursing diagnostic statements I come up with:

• Impaired Gas Exchange R/T alveolar-capillary damage AEB dyspnea, diaphoreses, and carbon dioxide retentions
  
• Ineffective Airway Clearance R/T exudates in the alveoli and retained secretions AEB dyspnea, diminished breath sounds, crackles and wheezing on inspiration, non-productive cough and tachypnea
  
• Activity Intolerance R/T imbalance between oxygen supply and demand AEB dyspnea and the need for oxygen supplementation for an hour after physical therapy
  
• Readiness for Enhanced Therapeutic Regimen Management R/T primary caretaker's desire to learn AEB verbal expressions of wanting to help with care and concern of risk to self
  
• Risk for Ineffective Protection R/T treatment for respiratory infection

Step #3 (DEVELOP A PLAN OF CARE)

I would have nursing interventions listed under those nursing diagnoses for each one of the symptoms I used in the AEB part of the nursing diagnoses. I am not going to write those out for you. Outcomes also need to be developed as well. Those can be worked up from the information in the nursing diagnostic statements.

F.Y.I. . .IPPB, Intermittent Positive Pressure Breathing, is a rather older respiratory therapy modality. Today, most breathing treatments are given by aerosol (hand-held nebulizer). With IPPB, a machine pushes compressed gas, either room air or oxygen, into the patient's airway until a predetermined pressure is achieved. The patient is then allowed to exhale passively. When the patient begins to take his/her next inhalation, this inhalation triggers the machine to begin pushing the compressed gas into the patient until the preset pressure is reached. Some years ago these were very common breathing treatments given to patients by respiratory therapists with very distinctive transparent green Bird (may be spelled Byrd, for the person who invented it) machines that we would see them pushing around the hospital. Patients were given a hand nebulizer that contained medication and they had to keep their lips tightly sealed around the mouthpiece. The Bird machine did the rest of the work. The problem with this therapy is that it puts a lot of stress on an already compromised set of lungs. On the other hand, the forceful pressure of the IPPB was designed to open up those seldom used alveoli at the distal parts of the lung fields, get air behind them and help move out secretions that might be lingering there. PPB, positive pressure breathing, is still in use on ventilators. When you eventually have a patient who is on a ventilator you will see this modality being used, particularly in patients who are unable to initiate any spontaneous respiratory effort at all. Without being on a ventilator that is providing positive pressure, they would develop pneumonia and/or eventually die.

Yes, I saw that. However, when you are doing a written plan of care, the plan pertains to the patient. In a case scenario that is on paper, I can understand where things can get confused and you wonder who is to be treated. However, in real life, it will always be the patient. Teaching for the family/spouse are included in the care plan under nursing diagnoses for the patient that involve his/her care. You always have to keep your focus on who the patient is. In fact, problems like what happened with Mrs. Bick do occur. I've had patients who outright refused to be discharged and who were discharged and went right back through the doors of the ER because they felt they needed to be re-admitted. I've had patients where members of the family argued over the whether or not procedures were going to be done for the patient. Yet, there lies the poor guy, the patient, who is usually powerless to say or do anything in his own defense. What happens is that there are other ancillary personnel to help out with these problems. These problems then become collaborative problems of the patient that we, the nurses, cannot deal with independently. So, what happens is a discharge planner gets pulled into the case, or a risk manager, or some other professional who has the expertise to solve the problem. Nurses can't solve every single problem the patient has, but we can be facilitators and get the proper professional consulted and pulled into the case. Sometimes it takes getting a doctor's order to do that. Then you definitely have a collaborative problem. Now, you may not have discussed this yet in your classes, but these kinds of real situations do come up and this is how they get resolved.