Question

Case study (questions 13–16)

Today, Jun-Wei is not out of bed when Susan arrives at work. He is very wheezy and seems unable to manage his puffer. He says he thinks he has a cold. Susan helps him to get ready for the shower and he manages to wash himself with much more effort than usual. He says he is not hungry and doesn’t want to go out today. He seems sad.

The organisation has procedures that state the following:

• Client personal information is recorded on a personal details form.

• All client information goes into the client’s file that is locked in the filing cabinet in the staff office.

• Client progress notes are to be updated by every staff member at the end of each shift.

• Money spent is to be recorded in the petty cash records in the finance folder in the staff office.

• Changes in clients’ needs or health are to be reported as soon as possible, by phone, to the area manager.

• Incident reports are to be completed if a client is put at risk or puts themself at risk.

Question

13. In what ways have Jun-Wei’s personal care and health needs changed?

14. What actions should Susan take about Jun-Wei’s changing care needs?

15. Imagine that you are Susan. Complete a case note that describes the situation and what actions have been taken.

16. What documentation needs to be completed to appropriately record the assessments, activities and events described in relation to Jun-Wei’s care? List at least five assessments, activities or events and the appropriate documentation actions.

Answer 1

13) Jun-Wei is experiencing a change in personal care and health needs due to the following -

• Ineffective breathing pattern related to wheezing.
• Ineffective Airway clearance related to excessive secretion secondary to cold.
• Activity intolerance related to inadequate oxygenation and dyspnea.
• Imbalanced nutrition less than body requirements related to reduced appetite, decreased energy level and wheezing.
• Disturbed sleep pattern related to wheezing.
• Anxiety and fear related to acute breathing difficulties suffocation.

14) Susan should take the following actions for Jun-Wei's changing care needs;

• Assess the client frequently, observing respiratory rate and depth.
• Assess the breathing pattern for shortness of breath, pursed lip breathing etc.
• Assess by auscultating for presence of crackles and wheezes and its intensity etc.
• Place the client in a fowler position.
• give oxygen if required.
• Encourage oral fluid to thin the secretions and replace the fluid lost through rapid respiration.
• Give frequent oral care to remoisten the dry oral mucosa.
• Teach and encourage deep breathing excercise, coughing techniques.
• administer prescibed medication.
• Remain with the client during acute episodes of breathing difficulty and provide care in a calm andreassuring manner.
• Provide quite and calm environment.Encourage relaxation techniques.
• Stop or slow any activity that leads to a significant change in respiratory rate.
• Assist the clint in scheduling a gradual increase in daily activities and exercise.
• Instruct the client in energy conservation techniques,such as pacing activities throughout the day, interspersed with adequate rest periods, and alternating high energy and low energy task.
• Advise client to eat small and frequent meals that are high in protein and calories.
• Advise the client to avoid gas producing foods.
• Monitor clients food intake,weight.

15) Case note:

Iam susan , writing this case note for the shift on 20-2-2018 at 2pm , In my shift ,when i arrived ,found Mr.Jun-Wei on bed stll sleeping and he verbalised that " He is very wheezy and seems unable to manage his puffer. He says he thinks he has a cold". On observation Jun-Wei has breathing difficuty with a audible wheesling sound, looks sad and tired ,took shower with more unusal efforts.

I assessed his condition continuosly by observing vital signs, respiratory rates and pattern. Gave him fowler position ,assisted in his activities ,taught him deep breathing exercise, provided calm environment and encouraged to have small frequent meals.

16)

• Changes in clients’ needs or health are to be reported as soon as possible, by phone, to the area manager.
• Client progress notes, are to be updated by every staff member at the end of each shift.

Assessment ;

Respiratory rate was rapid, wheeslingsound heard, looks sad and anxious, activity intolerance, poor appetite.