Reason For The Clinical Presentation (Essay Sample)

Reason for the clinical Presentation
This clinical report analyzes the condition of patient who experiences challenges with of chronic obstructive pulmonary disease (COPD). The report is based on clinical reasoning, an essential practice that positively impacts the patient’s outcomes. According to Alfaro-LeFevre (2015), clinical reasoning and judgment in nursing plays a significant role in utilizing the accumulated knowledge and skills over time. This contributes to the ability to analyze and synthesize patient presentation, both objective and subjective data, and provide evidence-based nursing interventions to improve the patient outcomes (Clinical Human Factors Group, 2016). According to Boyle et al. (2020), clinical reasoning is also based on professional applications of the relevant steps to facilitate decision making and formulating a clear care plan. Therefore, this clinical report provides the patient's background information based on the objective and subjective data obtained from the assessment procedures, results, and the relevant interventions that suit the treatment process.
Patient Background Information
This case study is about a 75-year old man of Scottish origin who has made numerous visits to the GP surgery with exacerbations of Chronic Obstructive Pulmonary Disease (COPD) in the past. The patient had been in a relationship before although he confirms that he divorced his wife 40 years ago. The wife is yet to retire and continues to engage in businesses, living with the three children and a grandchild. The wife works as a secondary school teacher. The ex wife moved from the countryside to a local town with the children after the separation. The patient is a retired computer technician and has no other investment. He is a member of the local church but makes rare visits and has no association with any social group within the society. The patient was diagnosed with COPD five years ago and has been using supplementary oxygen at the rates of 2L/minute. His condition tends to worsen during damp and cold conditions. He smokes cigarettes more during cold season, up to 30 cigars daily. The client claims that he cannot do without smoking as he finds interest and pleasure on this behaviour. He was previously in a relationship but divorced and currently lives alone without close family contacts. The patient reports that his condition worsened when he relocated his accommodation upstairs in his house. According to his statement, his condition sometimes worsens when he does some common household chores, like laundry and cooking. This makes him to constantly use the oxygen cylinder. His closes contact is a former colleague who resides miles away who also smokes. However, he reports that his friend does not suffer from a similar condition.
According to his medical history, he had a minor tonsillectomy surgery 30 years ago. Before being diagnosed with COPD, he was told that he had asthma. He has never been admitted in the hospital because of COPD related complications. There are no known allergies, although he reports that his father had been diagnosed with asthma which was well-managed. Other medical history includes his mother’s death ten years ago that had resulted from hypertension, heart disease and diabetes. According to the patient, the patients began two days ago after relocating and progressively worsened. He reports experiencing similar symptoms six months ago, with acute, chronic obstructive pulmonary disease, COPD although he was never hospitalized. Currently uses a gas cylinder in the night due to shortness of breath and wanting to sleep. The patient denies any fever, chills, wheezing, sputum production or coughs. He also denies any chest pain, palpitations, abdominal pain or nausea. However, he accepts vomiting and having diarrhoea some weeks ago. He also reports difficulty in breathing at rest, mild fatigue, feeling chilled and increased urinary frequency.
The past medical history is significant for the COPD because of the historical aspect of hypertension, asthma, diabetes and the past minor surgery that the client had undergone. The patient’s current medications include the use of hydralazine 50mg by mouth thrice a day, hydrochlorothiazide 25mg by mouth once daily. He is also currently under Vilanterol 100-25mcg daily inhaled, aspirin 81 mg by mouth daily, mononitrate 60 mg, rosuvastatin 40 mg by mouth daily.