NUR250 Medical Surgical Nursing 1


Topic: Nursing care of a patient with a respiratory problem

Case:  Meet Neville

Shift handover:

Neville is a 62 year old man with moderate, established chronic obstructive pulmonary disease (COPD) and a long history of smoking.

He was admitted 2 days ago with worsening dyspnoea, cough and increasingly purulent sputum production. He reports he developed a cold a few days before admission but his usual preventative medications didn’t relieve symptoms and he is now unable to take more than a few steps before having to rest.

Since admission, his upper respiratory symptoms have improved but he reports his dyspnoea and shortness of breath on exertion have not yet returned to what is normal for him. He remains tachycardic and his blood pressure is slightly elevated. Nasal prong oxygen remains in place.

Medical orders are for nasal prong oxygen @ 2L/min to maintain oxygen saturations 88-92%; spirometry before and after nebulisers; high protein, high carbohydrate diet; push oral fluids, fluid balance chart, food chart and second daily weighs.

Current medications are ipratropium bromide and salbutamol nebulisers, oral prednisone, oral amoxicillin, prn paracetamol and coloxyl. Pneumococcal and flu vaccines have been ordered to be administered before discharge once his condition has improved.

Neville has tried to stop smoking on a number of occasions. He has cut down to 10 cigarettes per day but is having difficulty stopping completely. He lives with his wife who continues to be very supportive.


Based on the handover you received at the beginning of your shift today, other information included below and current reliable evidence for practice, address the following 5 tasks.

Do not make up or assume information in relation to or about Neville, the photo is not an indication of his age or appearance. Only use what you know from the information you received today.

Task 1: Understanding nursing problems

After handover you consider and plan the nursing care that Neville requires today.

You recognise that there are 5 key nursing problems for Neville today:

  • Ineffective airway clearance
  • Impaired gas exchange
  • Risk of impaired ventilation
  • Imbalanced nutrition: less than body requirements
  • Risk for infection

In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice

  • Explain the specific underlying cause/s (aetiology) or reason/s for each of the nursing problems above.

Task 2: Care planning

In addition to the nursing problems above, you also recognise that Neville requires fundamental nursing care today and your role and responsibility as the nurse caring for Neville today is to keep him:

  • Safe
  • Clean and dressed
  • Warm and comfortable
  • Fed
  • Hydrated
  • Rested
  • Mobile
  • Toileted

Based solely on the handover you have received select five (5) fundamentals of care from the list above and develop a plan of care for each one identifying:

  • The related nursing problem
  • The underlying cause or reason (ie, what the problem is related to)
  • Goal of care
  • Specific bedside nursing interventions you will do
  • The rationales for your nursing interventions and actions
  • Indicators that your plan is working

Task 3: Medication management

Three important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications, the nursing responsibilities associate with administering each medication and how to monitor the patient to ensure they are responding to prescribed medications as they should.

In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice,

  • Briefly explainwhy Neville has been prescribed: o Oral prednisone
  • ipratropium bromide via nebuliser oOral amoxicillin


  • Identify and explain
  • The specific nursing responsibilities associated with administering each medication and monitoring Neville for expected, side and adverse effects

Task 4: Patient teaching

During Neville’s hospital admission, it is part of the nurse’s role to review his current knowledge and understanding related to his condition and to update or provide new information.

Topics that need review/updating or new information are:

  • How to effectively use a metered dose inhaler (MDI) and spacer
  • Why he needs to stop smoking
  • Early indicators that his COPD is deteriorating that require medical review
  • Promoting adequate nutritional intake to meet his metabolic needs
  • Energy conservation strategies

Identifythe specific information you will need to explain to Neville about the topic


  • Explain
  • Why the topic is an important aspect of Neville’s care
  • How you will ensure that Neville knows and understand why it is important and, if appropriate to the topic, what he needs to do

Task 5: Clinical judgement and handover

There are two parts to Task 5.

Part A:

When you come back from your meal break, a colleague tells you that they have given Neville a prn salbutamol nebuliser as he requested it because he was short of breath.

The first thing you do is to check on Neville to find out if his breathing is more comfortable now. On checking Neville you notice:

Neville is

  • Restless, anxious and mumbling incoherently
  • Plucking randomly at his bed linen
  • Dyspnoeic and, his
  • Skin is flushed and diaphoretic and
  • Nasal prong oxygen is still in place

On further assessment you find:

  • Oxygen saturations are now 98% on nasal prong oxygen @ 2L/min
  • Heart rate elevated to 110 beats/minute
  • Respiratory rate has dropped to 8-10 breaths/minute
  • The nebuliser mask and tubing is connected to the oxygen outlet
  • Identify
  • What you think is happening
  • Your immediate nursing actions and interventions oThe reason for your actions and interventions

Part B:

An important legal requirement of nursing practice is to effectively and succinctly communicate relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.

Once Neville’s condition has been stabilised, the doctors arrange to transfer Neville to the High Dependency Unit for bipap and closer monitoring.

Using the ISBAR format, information from the handover you initially received and the additional information above:

  • Write a handover that clearly and succinctly outlines the important information the high dependency unit needs to know about Neville

Your handover must:

  • Demonstrate person-centred care
  • Adhere to the legal and professional standards for documentation
  • Be in appropriate professional language
  • Contain NOabbreviations or nursing jargon
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