Case study 1 Flashcards
Mr.John Stevens is a 76 year old retired miner. He lives with his disabled wife, for whom he is the main carer, in a two bedroomed single storey house. He smokes 20 cigarettes per day, having started smoking in his early teens. He has been admitted to a medical ward with an acute exacerbation of COPD. The antibiotics and oral steroids prescribed five days ago by a G.P have so far been ineffective. Mr.Steven’s wife informs staff that her husband has been unwell for the last 2 to 3 weeks but that he has become increasingly breathless over the last few days despite treatment from her G.P. He has been unable to sleep and has been sitting in the chair at night. He has a productive cough and what his wife describes as a “rattly”chest. On admission, Mr Stevens is acutely breathless at rest, unable to speak in full sentences, using his accessory muscles and appears to be tired and a little confused.
Mr.John Stevens is a 76 year old retired miner. He lives with his disabled wife, for whom he is the main carer, in a two bedroomed single storey house. He smokes 20 cigarettes per day, having started smoking in his early teens. He has been admitted to a medical ward with an acute exacerbation of COPD. The antibiotics and oral steroids prescribed five days ago by a G.P have so far been ineffective. Mr.Steven’s wife informs staff that her husband has been unwell for the last 2 to 3 weeks but that he has become increasingly breathless over the last few days despite treatment from her G.P. He has been unable to sleep and has been sitting in the chair at night. He has a productive cough and what his wife describes as a “rattly”chest. On admission, Mr Stevens is acutely breathless at rest, unable to speak in full sentences, using his accessory muscles and appears to be tired and a little confused.
Describe all of the subjective data that you would note/collect when interviewing Mr Stevens including any specific techniques you could employ.
the information that I would be gathering would be his past health history, who his doctor is, what medications he is on at the moment or any he may have recently stopped taking. Age, D.O.B, family health history. How many cigarettes does he smoke (including the strength). Occupation, any lung tests or exams performed. Cough- sounds, production of mucus or phlegm- colour, odour, sample. S.O.B. Orthopnea.
Describe all of the objective data that you would collect and describe in detail what clinical assessment would perform on Mr Stevens.
A full respiratory assessment would need to performed on Mr Stevens, included in this would be performing the GCS on him. This would include asking gathering data from him, inspecting, palpating and auscultating the anterior and posterior chest regions, doing a symmetrical chest expansion,
All his vital signs would also need to be checked and documented.
Noting patient position, documenting use of accessory muscles. Looking facial expressions such as if in any pain, pallor or cyanosis. Due to the patient being confused it would be best to also do a mental status test also.
