Henry Williams Part 1

Scenario Overview

Patient: Henry Williams

Diagnosis: COPD exacerbation

This scenario is part of the Henry Williams Unfolding Case. The scenario can be used as a standalone scenario or as part 1 of the case.

The Unfolding Case

Henry Williams is a 69-year-old African American, a retired rail system engineer who lives in a small apartment with his wife, Ertha. Henry and Ertha had one son who was killed in the war 10 years ago. They have a daughter-in-law, Betty, who is a nurse, and one grandson, Ty. Henry is concerned about Ertha because she is experiencing frequent memory lapses.

The scenarios focus on the physical and psychosocial changes that Henry encounters over the next few weeks. His failing health and his concern for his increasingly forgetful wife lead him through various transitions that affect his family and his living situation. The objectives focus on assessment and appropriate use of assessment tools such as SPICES: An Overall Assessment Tool for Older Adults, the Geriatric Depression Scale, the Pittsburgh Sleep Quality Index, the Katz Index of Independence in Activities of Daily Living (ADL), the Modified Caregiver Strain Index, and the Transitional Care Model : Hospital Discharge Screening Criteria for High Risk Older Adults. The objectives also focus on psychosocial issues with Henry’s wife, and their daughter-in-law’s concern for their living arrangements and making appropriate community referrals.

Brief Summary of Present Scenario

This scenario takes place a few hours after Henry was admitted through the emergency room with an acute exacerbation of COPD. His O2 saturation has been at 88 percent. He is alert, oriented, and appears depressed. The admission has not been completed due to his shortness of breath. His neighbor brought him and Ertha in. Their daughter-in-law, Betty, is taking care of Ertha while Henry is at the hospital because of her problems with confusion. The students will have cues to report labs and arterial blood gas results to the physician. They will also have cues to address Ertha’s confusion. The assessment tools recommended for this scenario include SPICES: An Overall Assessment Tool for Older Adults (required) and the Geriatric Depression Scale (optional).

Learning Objectives

Upon completion of the scenario, the student should be able to:

· Assess the patient’s individual aging pattern and functional status, using standardized assessment tools, to include:

· SPICES: An Overall Assessment Tool for Older Adults

· Geriatric Depression Scale (optional)

· Use communication techniques to recognize, respond to, and respect an older adult’s strengths, wishes, and expectations

· Implement appropriate interventions based on the assessment data collected (e.g., low SpO2 and critical lab values)

· Identify geriatric syndrome(s) evident in the simulation using the ACES framework

Patient Case Introduction to Students

Time: 0730, day 1 after admission

Change of shift report:

Henry Williams is a 69-year-old retired rail system engineer who lives in a small apartment with his wife. He was admitted during the night with progressive shortness of breath. His oxygen saturation on admission was 82% on room air. He has a history of COPD and coronary artery disease, and is hard of hearing. His oxygen saturation has improved and is now running 88% on oxygen 2 L/min by nasal cannula. His respiratory rate has been 24-30/min.

Henry is concerned about his wife, Ertha, because she is experiencing frequent memory lapses. Ertha went home with their daughter-in-law, Betty, and they have just returned.

Due to his shortness of breath the admission is not complete. A fall risk assessment has been done and indicates a moderate fall risk, but he still needs an overall assessment. Blood pressure has been 134/88 mmHg, pulse was 112/min, and respirations were 28/min. He is alert and oriented. The morning labs were just drawn, and the physician wants to know the arterial blood gases. Henry denies pain and says he is just tired.

Patient Details

Patient Data: Male- Age: 69 years. Weight: 88 kg (194 lbs). Height: 183 cm (72 in).

Allergies: Penicillin

Past Medical History: Chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), asthma, hearing loss (wears hearing aids).

History of Present Illness: Patient was admitted last night with an acute exacerbation of COPD. He was not able to catch his breath and his doctor told him to go to the emergency room. His neighbor brought him to the emergency room. He is concerned about his wife, Ertha, who has problems with memory and seems confused at times. His daughter-in-law Betty is a nurse. She mentioned that Henry appears depressed, and noted that his appetite has diminished over the past two months and he has lost some weight. He has also lost interest in his previous activities, such as following major league football and working on crossword puzzles. Betty will look after Ertha while Henry is here.

Social History: Retired.

Primary Medical Diagnosis: COPD, cardiovascular disease.

Surgeries/Procedures & Dates: Appendectomy at age 15.

Provider’s Orders

· Bed rest, bathroom privileges with assistance

· Regular, low fat diet

· I & O

Respiratory treatment:

· Albuterol nebulizer treatment 2.5 mg and ipratropium bromide 0.5 mg in 3 mL normal saline every 20 minutes x 3, followed by albuterol 2.5 mg and ipratropium bromide 0.5 mg in 3 mL normal saline every 2 hours (decrease frequency, as tolerated)

· Titrate oxygen to maintain SpO2 at or above 90%

· Lactated Ringer’s solution IV at 50 mL/h

· Complete Blood Count (CBC)

· Brain Natriuretic Peptide (BNP)

· Basic Metabolic Profile (BMP)

· Arterial Blood Gases (ABG’s)

· Chest X-Ray

Continue home medications and add:

· Prednisone 40 mg PO daily x 10 days

· Lisinopril 12.5 mg PO daily

· Metoprolol tartrate 50 mg PO daily

· Acetylsalicylic acid 81 mg PO daily

· Rosuvastatin calcium 20 mg PO every evening

· Montelukast 10 mg PO every evening

Home medications:

· Fluticasone propionate 250 mcg every 12 hours nebulized

· Albuterol 2 puffs as needed for acute onset of shortness of breath

Nursing Diagnoses

· Ineffective breathing pattern related to exacerbation of COPD

· Activity Intolerance related to situational life changes

· Anxiety related to worries about wife

· Risk for powerlessness related to lack of participation in previous life activities and weight loss

Overview of Proposed Correct Treatment

· Wash hands

· Introduce self

· Identify patient

· Review lab and x-ray results

· Obtain vital signs

· Obtain SpO2

· Perform focused respiratory assessment

· Assess pain

· Administer albuterol and ipratropium bromide nebulized treatment per orders

· Perform an overall assessment using the SPICES tool

· Call results and assessments to provider using SBAR communication

Case Considerations

Henry has been admitted with an exacerbation of COPD, and the priority focus of assessments in this scenario is the physical assessment and treatment that will stabilize Henry’s breathing, including administering ordered medications.

After the breathing is stabilized the next priority is to complete the admission, including conducting a comprehensive assessment to ascertain Henry’s individualized aging pattern and risk profile. The SPICES assessment tool is an efficient and effective tool that will help to identify common geriatric syndromes and develop a plan of care based on current best practices.

The assessments should also focus on the causes of Henry’s exacerbation of COPD, and it is important for the nurse to be familiar with current research evidence and understand how his difficult life situation (e.g., his declining physical health and his wife’s problems with memory) may affect his health.

Some of Henry’s answers indicate that his mood may be affected by his difficult situation; the Geriatric Depression Scale could be used to further investigate this.

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