Case Study 1 – 264 Clanfield Road, Canberra, 2611 – UR: 748695
You are a Student Registered Nurse, currently attending clinical placement. Today
you are working with Sally, a Registered Nurse (RN) with the local Community
Nursing unit and are attending a regular appointment with Steven Wilkes. This is a
follow up appointment for Steven, as he was recently discharged from hospital after
experiencing exacerbation of Chronic Obstructive Pulmonary Disorder (COPD).
You are sitting with Steven and undertaking a health interview. His date of birth is
22/10/1953. He has no known allergies.
Steven is a 69-year-old man who lives alone. He completed Year 10 and has since
been employed with the local council in the roads department.
Steven was diagnosed with COPD approximately 20 years ago and has since been
retired.
Steven has described to be experiencing the following comorbidities, secondary to
the COPD diagnosis:
hypertension,
osteoarthritis, and
hypercholesteremia.
Steven is 178cm tall and weighs 95kg, giving a BMI of 30kg/m2
After finishing school, Steven married Beth, Steven describes their relationship as
volatile, highlighting “that it may have been related to my drinking which was also
placing my job at risk”. Steven explains that around his 29th birthday, the marriage
broke down after a five year period, resulting in divorce. Beth and Steven have no
further contact.
Steven has no children and his sister, Anne, who was his only sibling, was killed in a
motor accident caused by a drink driver during the divorce. Steven tells you that “this
was the catalyst for me to cease alcohol intake, and I have not had any alcohol
since then”. You note that Steven is a previous smoker, with a 40 pack-year history.
Steven continued to work with the council, in the roads department, for over 30 years
until retiring due to medical reasons. Steven tells you that his “breathing became a
real problem and I just couldn’t do it anymore”.
Since his retirement Steven explains that he has been doing some wood carving,
which he sells at the local markets. He shows you a piece he is working on currently.
Steven is also a member of a lawn bowls team and is a popular member of the club.
Steven describes to be looking forward to returning to bowls as his health improves.
He tells you that “occasionally I feel down about my diagnosis and general health .
… but I am looking to the future and wants to work on getting my health ,better”.
You observe that Steven does not dwell on this statement and changes the subject
promptly.
With two (2) goals AND a health education action plan containing two (2) objectives. EACH objective will use the SMART goals and have two (2) strategies.