NURS2023 Health of Adults Case Study 1
Assignment Details
Assessment Aim:
According to the Nursing and Midwifery Board of Australia’s (2016) Registered nurse standards for practice, nurses need to be able to;
• Think critically and analyse nursing practice (Standard 1),
• Comprehensively conduct assessments (Standard 4),
• Develop a plan for nursing practice (Standard 5),
• Provide safe, appropriate, and responsive quality nursing practice (Standard 6),
• Evaluate outcomes to inform nursing practice (Standard 7).
Thus, the aim of this assessment is to provide students with an opportunity to analyse and evaluate a clinical case scenario so that the development of critical thinking and reflection is promoted. In this assessment, students will be required to interpret clinical information and draw upon their knowledge of pathophysiology, the nursing process and evidence-based nursing practice, and articulate new learnings in the case study report.
The case report must be presented using the headings provided below. A description of the content for each section of the report has been provided. It is important that all sections of the report are conceptually connected. For example, your knowledge of pathophysiology and pharmacology, and your understanding of this person, should underpin the identified nursing problems. In turn, evidence-based nursing care and interprofessional care that relate to the problems should be clearly discussed and must be relevant to the clinical scenario.
Case Report Format:
The case report must include the following:
Introduction - 200 words
Using the ISBAR clinical handover framework, introduce the person and provide a brief overview of their case. Provide an outline of the purpose and structure of the report.
Primary admission - 300 words
In this section provide a summary of the reasons why the person was admitted to hospital. For this, include a brief description of the pathophysiology of the person’s medical problems and their clinical manifestations. Support this discussion with contemporary, evidence-based literature.
Identify two (2) nursing problems - 300 words
Using the previous description of the pathophysiology and observed clinical manifestations, identify two (2) nursing problems that are to be prioritised for the person. Justify your selection and briefly describe why each is important in the person’s management. Support your discussion by utilising contemporary, evidence-based literature.
Nursing management - 1000 words – 500 words per problem
In this section, you will focus on the implementation of the nursing process to each of the identified problems from the section above. That is, for each identified problem you will need to include a discussion of;
• One (1) appropriate nursing assessment and its rationale,
• One (1) appropriate nursing intervention related to your assessment. Provide a rationale for each intervention,
• Nursing implications related to the medication management of the ongoing management of each problem. Support your discussion by utilising contemporary, evidence-based literature.
.
Discharge planning - 500 words
The discharge plan must focus on the interdisciplinary management for this person and should refer to the nursing problems addressed throughout the report. In this section, discuss the aim of discharge planning and the importance of using an interdisciplinary approach. Also, discuss the role of the RN in facilitating a multidisciplinary discharge plan for this person. Identify and justify the members of the multidisciplinary health care team and the role that they would play. For this, you should refer to the identified nursing problems discussed in the report.
Conclusion - 200 words
Summarise the major findings of this case report. The conclusion should not introduce new material that has not been previously addressed within the report.
Referencing
The content of the case report must be supported through referencing of current evidence-based literature and must include a reference list and intext citations. Students will be assessed on referencing and academic writing.
Solution
Introduction
A 35-year-old woman, Ms. Lucille Ballute presented to the emergency department with a history of exertional dyspnoea, even producing cough with thick, viscid sputum and wheezing that is audible. Her other complaint was a shortness of breath. She is even carrying some past medical history like OSA, COPD, chronic bronchitis, hypercholesterolaemia followed by GERD. Also she has regularly smoked 25 cigarettes every week for 15 years however stopped the habit a month ago.
This submission has been prepared as a tool to provide a comprehensive assessmentof Ms. Ballute's clinical condition along with nursing management and interdisciplinarycare plan. Using the ISBAR (Identify, Situation, Background, Assessment and Recommendation) clinical handover framework, a comprehensive assessment of her respiratory condition will be described considering her complicated medical background. This case demonstrates the importance of a comprehensive care approach, including pharmacological strategies to manage her COPD, an approach to her sleep apnoea, optimisation of her cardiovascular disease management, and tailored advice regarding her GERD and smoking cessation.
Nursing management is important to assess Ms. Ballute’s respiratory status, assist in sputum clearance, and optimize medication compliance. Over the next few weeks, you will begin working with a health care team that may include cardiologists, pulmonologists and other specialists, who will begin coordinating treatment to help manage for university assignment help your chronic conditions and improve your overall quality of life.
Primary Admission
Ms. Lucille Ballute, 35-year-old retired woman and suffering from nausea, progressive breathlessness and fatigue, and a productive cough. The main clinical features include thick, viscous sputum and stridor which can indicate airway compromisation. However a deeper dive into her past medical history found some key contributors to her current condition.
One month prior to this admission, Ms. Ballute had been diagnosed with COPD. COPD is a progressive lung disease, and is often associated with chronic smoking — of which Ms. Ballute has a history. The disease causes the airways to narrow, produces excess mucus and makes expelling sputum from the lungs difficult, which all contribute to the patient’s breathlessness and cough. He has a flat diaphragm and signs of hyperinflation on chest x-rah, suggestive of chronic lung changes. Her ABG indicates hypoventilation with respiratory acidosis, as the PaCO2 is 49 mmHg, or raised and a characteristic of a patient with COPD exacerbation. So PaO2 is low (70 mmHg), struggle of entity O2 partial pressing and low FEV1 to demonstrate huge useful inability created by issue.
If detailed clinical presentation is available, it should be consistent with acute exacerbation of COPD which is commonly triggered by infection exacerbations, environmental pollutants, or medication noncompliance. In this instance appropriate usage or lack thereof of her culprit inhalers has led to deranged symptoms being further exacerbated by the 3 months of smoking cessation recent at the time of presentation which likely presented her to desaturation as well. In addition, her anxiety and agitation about oxygen therapy and smoking cessation also poses a clinical challenge in terms of managing her care.
Identify Two Nursing Problems
Two priority nursing diagnosis are developed according to Ms Ballute clinical presentation
Impaired Oxygenation: Ms. Ballute has poor oxygenation as indicated by her SpO2 of 85% on 2L O2 via NC and her increased work of breathing (respiratory rate of 39 breaths per minute). Her ABG results also point toward respiratory acidosis—commonly found in COPD exacerbations. There is a big concern about the low PaO2, as the lack of oxygenation is more probable to cause hypoxiemia which leads respiratory failure and process in the lungs.
Justification: Limited oxygenation is a relevant issue for COPD patients, especially in the setting of exacerbations. Untreated, it can cause hypoxia and multi-organ dysfunction. This nursing problem is seen as a high priority so that respiratory function does not continue to worsen (Alexandru et al., 2025)
Ineffective Airway Clearance: Ms. Ballute’s productive cough with viscous, tenacious sputum that has changed color to rust raises suspicion for infection or exacerbation of her airway obstruction. Furthermore, the patient is also tiring and short of breath with basic exertion, a finding indicative of impaired airway clearance (Mirra et al., 2024). This can displace oxygen half out of the blood and thus worsen the respiratory distress, and impair lung function.
Justification: Ineffective airway clearance is one of the common issues among COPD patients and has worsens during acute exacerbation. Accumulation of mucus in the airways exacerbates the condition and causes infection; thus, correct airway management is critical to improve respiratory status (Mirra et al., 2024).
The two nursing problems are interrelated and can be managed with an integrated plan of care focusing on oxygenation, airway clearance, and pharmacological management.
Nursing Management
When it comes to Ms Lucille Ballute who is a patient presenting with acute deepening of her (COPD) the careplan or nursing management plan should reflect two ongoing problems for a patient such as Ms Ballute, which includes impaired oxygenation and ineffective airway clearance. This means for every problem there is a well-defined nursing assessment to perform, an action to take, and a method of medicating. The goal is to increase her respiratory function, decrease her symptoms, and prevent subsequent complications. The nursing assessment is the initial between oxygen consumption and delivery that is necessary for impaired oxygenation management. This involves:
Problem 1: Impaired Oxygenation
Nursing Assessment: Ms. Ballute’s airway clearance is being assessed through monitoring her cough, sputum production, and breath sounds. Following the clinical guidelines, RN should perform focused respiratory assessment by using HAIPPA (inspection, palpation, percussion and auscultation). These include the presence of increased volumes of sputum, changes in the color of sputum or the presence of audible wheeze. Chest auscultation should pay special attention for the presence of crackles, wheezes or decreases in the breath sounds that could evidence the presence of mucus (Tollefson & Hillman 2022).
Continuous Monitoring of Vital Signs: Ms. Ballute on 2L O2 has an SpO2 of 85%, which is concerning because it is below the ideal range of 88-92% in COPD patients with risk of hypercapnic respiratory failure Pulse oximetry is to be done constantly or in any event, every four hours to be used to target the measure of oxygen therapy who are getting oxygen therapy and can do oxygen therapy.
Respiratory assessment: The HAIPPA framework (History, Assessing, Inspection, Palpation, Percussion and Auscultation) should be used to conduct a thorough respiratory assessment. This assists in recognizing evidence of respiratory resignation, such as increased effort of breathing, wheezing and abnormal lung sounds (Wittels 2022). For example, if Ms. Ballute’s respiratory rate rises significantly, this could suggest worsening respiratory distress that would need a change in care.
Arterial Blood Gas (ABG) Monitoring: Ms. Ballute is diagnosed as having respiratory acidosis based on her ABG findings, specifically elevated levels of PaCO2 (49 mmHg) and decreased PaO2 (70 mmHg). These findings indicate that Ms. Ballute’s lungs aren’t efficiently getting rid of CO2, causing respiratory acidosis. Monitoring of ABGs is crucial in determining ventilation status, and in adjusting oxygen therapy. AWC Nurses will be vigilant with changes in ABG values to catch early signs of respiratory failure
Nursing Interventions The first action regarding the management of impaired oxygenation would be to administer an appropriate amount of supplemental oxygen (Pich 2020). Oxygen should be titrated to achieve a desired SpO2 of 88-92% for patients at risk of hypercapnic respiratory failure according to the Horizon Hospital and Health Service policy on oxygen therapy (Safari 3) Oxygen therapy should be titrated to keep Ms. Ballute as high as she can go while remaining compliant with the nasal cannula; the RN should also work to ensure she is compliant with the nasal cannula.
Drug Management: Ms. Ballute takes a few inhaled drugs including Ventolin (salbutamol), Pulmicort (budesonide), and Atrovent (ipratropium). Both bronchodilators and anti-inflammatory agents, these medications promote airflow and reduce bronchospasm. The RN should teach Ms. Ballute the proper technique to use for her inhaler so she can receive the maximum benefit of the drug.
Problem 2: Ineffective Airway Clearance
Nursing Intervention: Encourage Ms. Ballute to perform different lung expansion exercises that is deep breathing and coughing) to facilitate airway clearance. Chest physiotherapy and postural drainage may aid in breaking up thick sputum. And be well hydrated, to thin the mucus. If Ms. Ballute’s sputum becomes more copious, obstructive, the RN will need to determine if a nebulizer treatment is needed to further loosen the mucus.
Oxygen Therapy: The main treatment for impaired oxygenation in COPD patients is supplemental oxygen. Preserving an SpO2 of 88-92% is the goal as this is optimal for preventing hypercapnia. For Ms. Ballute, the RN would titrate the oxygen delivery device to maintain her SpO2 with an approximate range as prescribed. This may include administration via a nasal cannula or face mask, depending on patient comfort and oxygen needs. Checklist for high flow nasal cannula. It is crucial that you look out for oxygen toxicity, which can result from oxygen being given usually for prolonged periods at greater concentrations than needed (Helms et al., 2024).
Positioning Proper positioning can help optimize ventilation and oxygenation. Ms. Ballute should be placed in semi-Fowler’s position, to allow proper lung expansion and reduce the work of breathing. This opens up diaphragm and takes pressure off via lungs. If the patient is experiencing complications, e.g., significant fatigue, comfort adjustments should be made to ensure that she is not too reclined or supine, as this would exacerbate breathing difficulty (Australian commission on Safety and
Quality in Health Care 2022).
Oxygen Therapy Monitoring and Response Continuous monitoring is critical to monitor the clinical response to O 2 therapy Comparing arterial blood gas (ABG) or oxygen saturation via pulse oximetry (SpO 2 ) results before and after therapy can provide an overview of effectiveness (Cathain & Gaffey 2022). Nurses should assess Ms. Ballute’s oxygen saturation and response to oxygen therapy and titrate her flow rate accordingly. If the SpO2 does not rise to the desired reange despite oxygen supplementation, then an investigation is warranted, including investigating if there is a cause for oxygen desaturation, including mucus plugging or increasd bronchospasm (Cathain & Gaffey 2022). If Ms. Ballute becomes uncooperative or intolerant of oxygen therapy, the nurse should prove Ms. Ballute with education surrounding the aforementioned to increase compliance, as well as offer addressing the underlying anxiety related to her disease process.
A big part of improving Ms. Ballute's oxygenation, Ms. Ballute should be taught proper technique and adherence to her inhalers. Nurses must teach about the proper use of her bronchodilators, corticosteroids, and other medications as ordered. Putting inhalers to improper use reduces their effectiveness, resulting in more exacerbations. Educational interventions also need to address the long-term management of COPD, such as smoking cessation and minimising exposure to environmental triggers
Medication Management: Ms. Ballute is currently being maintained on bronchodilators (Atrovent, Ventolin) and corticosteroids (Pulmicort). These medications can also loosen and clear mucus from the lungs. They also should make sure that medicines given on time and the prescribed doses are correct.
Discharge Planning
The purpose of this discharge plan for Ms. Lucille Ballute is for the patient to be transitioned to the home environment in a safe manor as she learns to manage her Chronic Obstructive Pulmonary Disease (COPD) and prevent future exacerbation. This requires careful coordination among the multidisciplinary team, which includes the respiratory therapist, dietitian, social worker, and the registered nurse (RN).
Role of the RN in Discharge Planning
The RN plays a pivotal part in giving education to Ms. Ballute regarding the management of COPD, the importance of adhering to medications, and the implementation of lifestyle changes. Ms. Ballute needs education about taking prescribed inhalers appropriately and consistently to prevent further exacerbation.
Smoking cessation will be an important part of discharge education (Jongebloed et al., 2024) . While Ms. Ballute recently stopped smoking, she is making the switch to vaping, which could further complicate her condition. Once the patient is ready, the RN should explain the harms associated with vaping, especially in patient with COPD and also refer patient to smoking cessation program which facilitates long-term follow-up. The RN will also teach Ms. Ballute to identify early warning signs of exacerbations (eg, increased breathlessness, changes in sputum) and when to seek medical attention.
Another common area of discharge education is with medication adherence. The RN will need to make sure Ms. Ballute knows the medications that have been prescribed including bronchodilators and corticosteroids. This includes things such as learning how to properly use inhalers and the potential side effects of the medications. Written instructions for her medication regimen should be clear, as would allow ready access to important information at home (Uzer & Uzun 2019).
Multidisciplinary Team
1. Respiratory therapist: It is an essential part of Ms. Ballute’s rehabilitation. They will instruct her on maneuvers including diaphragmatic breathing and use of incentive spirometry to promote lung function (Uzer & Uzun 2019). In the home, they will also help with pulmonary rehabilitation, focusing on exercises to build endurance and help her better manage COPD at home.
2. Dietitian: Ms. Ballute has a BMI of 27, and weight management will be important. The dietitian can help develop a nutrition plan with Ms. Ballute to promote healthy weight loss and support lung health. Nutrition is vital for those who have COPDManagement of the disease takes proper nutrition, which is needed for overall strength and energy levels.
3. Social Worker: The social worker ordered will help resolve any psycho-social issues, in particular Ms. Ballute’s anxiety regarding her condition, and the transition from smoking to vaping. They will help provide emotional support and help people navigate community resources such as cessation program of smoking
Coordination with Primary Care Provider
The RN should follow up with Ms. Ballute’s GP to ensure there are follow up appointments. These appointments will help her medical team keep track of her health, make treatment adjustments when appropriate, and manage complications. The availability of essential resources like emergency contact numbers will aid in Ms. Ballute's recovery.
A collaborative approach is taken in Ms. Ballute's discharge planning to enable her to symptom highlight and self-manage COPD at home. The RN prepares the plan of care to address education, medication adherence, smoking cessation and utilizing a multidisciplinary treatment team so that Ms. Ballute has the means to prevent exacerbations and increase quality of life.
Conclusion
Overall, this case study highlights the significance of thorough nursing management for individuals with COPD, especially during episodes of exacerbation. If the nursing team appropriately identifies which nursing problems Ms. Ballute may have face such as impaired oxygenation or the inability to clear an airway, they may easily stabilize Ms. Ballute’s condition and ensure the best course of her recovery. Appropriate use of evidence-based treatments, including judicious use of supplemental O(2), on medications, and airway clearance approaches, are critical to restoring her pulmonary function and preventing further decline.
Discharge planning process is also an important component of care, including teaching Ms. Ballute about managing COPD, taking medications, and making lifestyle changes. RN is a driver to make sure she is ready to care for this condition at home. Working with a multidisciplinary team of providers — including respiratory therapists, dietitians and social workers — allows for a well-rounded treatment plan catered to her needs. This team practice approach creates access to everything that Ms. Ballute may need to stay healthy and will intervene before her illness exacerbates.
Finally, by educating Ms. Ballute about her condition and collaborating with her to manage her COPD, the nursing team is able to improve Ms. Ballute's quality of life while also preventing possible hospital admissions, enabling greater health and wellness long-term.
References
Alexandru, F. C., Camelia, C. P., Maritescu, A., Stoicescu, E. R., Carunta, V., & Oancea, C. (2025). The impact of chronic obstructive pulmonary disease severity on psychological and functional outcomes: A cross-sectional analysis. Journal of Clinical Medicine, 14(6), 1865. doi:https://doi.org/10.3390/jcm14061865
Australian commission on Safety and Quality in Health Care. (2022). Documentation of Information. National Safety and Quality Health Service Standards. ACSQHC. Retrieved March 31 2024, from https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating- safety-standard/documentation-information
Cathain, E. O. and M. M. Gaffey. (2022). Upper Airway Obstruction. Florida: StatPearls. Retrieved March 31 2024, from https://www.ncbi.nlm.nih.gov/books/NBK564399/
Helms, J., Catoire, P., Abensur Vuillaume, L., Bannelier, H., Douillet, D., Dupuis, C., . . . Hraiech, S. (2024). Oxygen therapy in acute hypoxemic respiratory failure: Guidelines from the SRLF-SFMU consensus conference. Annals of Intensive Care, 14(1), 140. doi:https://doi.org/10.1186/s13613-024-01367-2
Jongebloed, H., Cole, E., Dean, E., & Ugalde, A. (2024). The role of general practice nurses in supporting people to quit smoking: A qualitative study. PLoS One, 19(7) doi:https://doi.org/10.1371/journal.pone.0306555
Mirra, D., Esposito, R., Spaziano, G., Sportiello, L., Panico, F., Squillante, A., Bruno D’Agostino. (2024). MicroRNA monitoring in human alveolar macrophages from patients with smoking-related lung diseases: A preliminary study. Biomedicines, 12(5), 1050. doi:https://doi.org/10.3390/biomedicines12051050
Pich, J. (2020). Health Assessment. Fundamentals of Nursing – concepts, process and practice (5th Australian ed., pp. 584-667). Pearson Australia.
Tollefson, J. and E. Hillman (2022). Clinical Psychomotor Skills: Assessment Tools for Nurses. (online). Cengage Learning Australia.
Uzer, F., & Uzun, R. (2019). General health status and smoking cessation rates of individuals admitted to smoking cessation outpatient clinic. Turkish Thoracic Journal, Suppl.1, 20, 113. doi:https://doi.org/10.5152/TurkThoracJ.2019.113
Wittels, K. A. (2022). Basic airway management in adults. Retrieved March 31 2024, from https://www.uptodate.com/contents/basic-airway-management-in-adults#
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