Psychiatric Case Study

Daytonite, BSN, RN · Sep 27, 2006

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.

KellieNurse06 · Sep 27, 2006

Mr. Bick, age 70, suffers from COPD. History of asthma 7 yrs. heavy smoker.
SOB on exertion for many years, but recently experiences dyspnea even at rest. Most recent hospital stay was for acute respiratory infection, w/c have made symptoms more severe. He has nonproductive cough.
Mrs. Bick wishes to be of some help during her recent husband's recent illness. She ask many questions and seems intelligent. She is concerned with becoming infected. Mr. Bick's physician orders intermittent positive-pressure breathing (IPPB) q 4x daily after acute infection subsides. The physician also orders physical therapy to start Mr. Bick on exercises that will improve his respiratory function. Mr. Bick returns from physcial therapy quite short of breath and wants to have oxygen for an hour afterward.
After a week of treatment, the physician tells the Bicks that Mr.Bick no longer needs acute care, and will discharge Mr.Bick today or tommorrow. The nurse requests the social services department to come and talk with the Bicks because Mrs.Bicks refused to take him home "while he is still so sick.
CO-NURSES,STUDENTS,I NEED HELP WITH THIS CASE STUDY.ANY GOOD IDEAS?
THANKS,
lab211

I am doing psych & advanced med surg right now......our psych lecturer told us on doing care plans for psych patients..you have to figure out what the patient is in need of......your case scenario to me.....sounds like maybe lack of knowledge regarding plan treatment (the wife) We were told to step back & look at the big picture & think of what the patient is lacking or needing that they aren't getting.......

suzy253, RN · Sep 27, 2006

what do you have written on your case study so far?

JentheRN05, RN · Sep 28, 2006

I have one word for you.

Educate.

lab211 · Sep 28, 2006

How this case study looks to me is that there are two clients in the picture here, Mr.Bick, and Mrs. Bick. What are there needs:

It is not indicated in the case study what are the post discharge plan of care for Mr. Bick. While in acute distress and an inpatient he received

positive pressure breathing treatments. This treatment is new news to me.

I do not recall that these treatments were really lectured on during my junior level med-surg rotation.The other therapy for him were the exercises

after which he required oxygen therapy.

Mr. Bick's needs:

continued oxygen self treatment at home

follow up by a home health care nurse

encouragment to quit or reduce smoking

encouragement of maintaining an exercise routine

psychotherapy

Mrs. Bick's needs:

to be educated that Mr. Bick does not have a infectious disease

knowledge of Mr. Bick's needs and the awareness to encourage

compliance to his regimen.

counseling or support group

How did I do? Please advise.

thanks,

lab211

Daytonite, BSN, RN · Sep 28, 2006

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.

lab211 · Sep 29, 2006

Thanks for your help!

Okay so the issue at hand was not a psychiatric issue but one of to educate the client(the wife) that her husband although is sick can return home. The hospital nurse should educate her that COPD and Asthma are not contagious diseases, Mr.Bick can continue self treatment at home(e.g nebulizer). And that her role is to learn how the treatments work so that she can encourage her husband to comply with the treatment regimen.

SHE PRETTY MUCH NEEDED ASSURANCE FROM HIS DISCHARGE NURSE.

thanks,

lab211

Daytonite, BSN, RN · Sep 29, 2006

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.

lab211 · Sep 29, 2006

Dear Daytonite,

Thank you. You have been very helpful. Out instructor does not expect for us to work out a complete nursing care plan. She is looking for us to answer the case study from the bigger picture. She said to answer in paragraph form. So, to me she is looking for brief answers and two the point. She does not have the time to grade 21 nursing care plans, not to mention the fact that we have 2-3 case studies a week as part of our lecture and starting clinicals soon.

Thank you for the in-depth nursing diagnosis. I will definitely learn form them.

lab211