Respiratory Clinical Case study and care Plan Creation Name South UniversityMarch 21, 2017.Respiratory Clinical Case Analysis Patient Initials: P.E Age: 65 Sex: Female.Subjective Data: The patient P.E complaints that she had shortage of breath, she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today. Client Complaints: Shortage of breath, and coughing. HPI: P.E has frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy. Treatment tried Theophylline SR Capsules 300 mg PO BID, Albuterol inhaler, PRN, Phenytoin SR capsules 300 mg PO QHS, HTCZ 50 mg PO BID, Enalapril 5 mg PO BID. PMH: P.E has history of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on Enalapril due to worsening CHF; symptoms well controlled the last year.Past Surgical History: Serious MVA 10 weeks ago.Social/Personal History: Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHFSocial: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day. Medication History: Theophylline SR Capsules 300 mg PO BIDAlbuterol inhaler, PRNPhenytoin SR capsules 300 mg PO QHSHTCZ 50 mg PO BIDEnalapril 5 mg PO BIDAllergies: NKDA.Review of Symptoms: General: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abdomen: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact.Objective Data:Vital Signs including BMI: BP 171/94 mmhg
HR 122 RR 31x’ T 96.7 F.
Wt 145, Ht 5’ 3” BMI: 25.7 (Overweight) VS after Albuterol breathing treatment – BP 134/79, HR 80 x’, RR 18 x’Physical Assessment Findings: Positive for shortness of breath, coughing, wheezing and exercise intolerance. Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abdomen: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact.HEENT: Normal.Lymph Nodes: absent. Carotids: Normal, not bruit Lungs: Bilateral expiratory wheezes.Heart: Tachycardia, Regular rate and rhythm normal S1 and S2.Abdomen: soft, non-tender, non-distended no masses.Genital/Pelvic: Unremarkable.Rectum: Guaiac negative.Extremities/Pulses: +1 ankle edema, on right, no bruising, normal pulses.Neurologic: A&O X3, cranial nerves intact. PERRLALab Tests and Results: Na – 134 (Low)K – 4.9 (Normal)Cl – 100 (Normal)BUN – 21 (Normal)Cr – 1.2 normalGlu – 110 (Normal)ALT – 24 (High) AST – 27 (High)Total Cholesterol – 190 (Borderline )CBC – WNLTheophylline – 6.2 (Normal limits)Phenytoin – 17 (Normal limits)Chest X-ray – Blunting of the right and left Costophrenic angles: AbnormalPeak Flow – 75/min; after albuterol – 102/min: (Low Peak Flow, and good response to albuterol).
FEV1 – 1.8 L
FVC 3.0 L
FEV1/FVC 60% – (Air way obstruction)ICD-10 Diagnoses/Client Problems:1. – J45.901 Unspecified asthma with (acute) exacerbation2. – J45.41 Moderate persistent asthmawith (acute) exacerbation 3. – V89.2XXA unspecified motor-vehicle accident.4. – R56.1.Post traumatic seizures.5. – I50.20 unspecified systolic (congestive) heart failure. Advanced Practice Nursing Intervention Plan:After reviewing the patient, PMH, Physical Assessment Findings and lab results for P.E there are a few areas of concern to note in her health assessment. But I have to focus in the main patient health problem: Moderate persistent asthma with (acute) exacerbation.Asthma is a chronic disease that continues to be a serious public health problem. It has been estimated that a total of 39.5 million of people had been diagnosed with asthma in Unite State. In response to the problems the population has been faced with asthma, the Center for Disease Control and Prevention (CDC) launched the National Asthma Control Program (NACP) (Center of Disease Control and Prevention, 2013).In Florida more than 2.6 million of adults and children have lifetime asthma, and approximately 1.6 million had current asthma in 2012. The number of people with asthma that visit emergency department has increased in the past five years. Non-Hispanic black Floridians had the highest Emergency Department visit and hospitalization rates. In Florida the collaborative practices are established between state, local public health and the different health institutions, with the objective to provide better care to patients with asthma. Primary health cares (MD, PA, APRN) has the responsibility to develop an individualized an action plan to ensure that the patient understands daily medication, avoid asthma triggers, and how identify warning signs that require quick-relief medications (Scott, & Armstrong, 2013). Inhaled Corticosteroids (ICs) are the most effective controllers for asthma, and their early use has revolutionized asthma therapy. This type of drugs reduces the number of inflammatory cells and their activation in the airways. ICs reduce eosinophils in the airways and the sputum, and the numbers of activated T lymphocytes and surface mast cell in the airway mucosa. Its major effect is to switch off the transcription of multiple activated genes that encode inflammatory proteins (Fauci et al, 2008).Inhaled Corticosteroids are usually given twice a day. ICs rapidly improve the symptoms of asthma, and lung function improves over several days. They are effective in preventing asthma symptoms, such as exercise-induced asthma and nocturnal exacerbation, but also prevent severe exacerbation. ICs reduce airway hyperresponsiveness (AHR), but maximal may take several months of therapy. Early treatment prevents irreversible change in airway function that occurs with chronic asthma. Withdrawal of ICs results in slow deterioration of asthma control, indicating that they suppress inflammation and symptoms but do not cure the underlying condition. ICs are given as a first-line therapy for patients with persistent asthma. In case that the symptoms are no control in low doses, it is usually to add a long-acting inhaled Beta 2 agonists (LABA) (Fauci et al, 2008).Inhaled Corticosteroids: (as cited by Lacy, Armstrong, Goldman, Lance, 2010, p. 1847)BeclomethasoneBudesonide and FormoterolCiclesonideFluticasoneMometasoneTriancinoloneLocal side effects of inhaled corticosteroids are dysphonia, oropharyngeal candidiasis, and cough. On the other hand, systemic side effects of inhaled corticosteroids include adrenal suppression and insufficiency, bruising, osteoporosis, growth suppression, cataracts, glaucoma and pneumonia. Other side effects are metabolic abnormalities relating to glucose, insulin, and triglycerides. Additionally, the patient may have psychiatric disturbances such as euphoria and depression (Brunton, Chabner, Knollman, 2011).Our goals in the asthma treatment is to prevent and troublesome symptoms. To ensure that patients do not have limitations in their activities. Achieving the minimum use of short-acting beta-agonist. It is also important the patient be free from side effects of medications or hat these are minimum. Maintain lung function as close to normal and prevent recurrent exacerbations (Lacy, Armstrong, Goldman, Lance, 2010).A peak flow meter is an easy portable device that measures lung function. Patients suffering from asthma can use this device to track their progress. The purpose of this exercise is to identify the peak flow zones of the patient so that a coded system based on results and patient symptomatology can be established to adjust appropriate asthma interventions. (McCance & Huether, 2014). There are three peak flow zones and they are determined by the peak flow rate and symptoms. The green zone is a peak flow rate between 80 to 100 percent, and is equivalent to stable. Typically, there should be no signs or symptoms of asthma and the patient should continue to take preventive medication. The yellow zone is a peak flow rate between 50 to 80 percent, and it indicates that the patient should be cautious and might need to change or increase asthma medication. A patient in the yellow zone may have signs and symptoms of asthma such as chest tightness, coughing, and wheezing. The red zone is a peak flow meter of 50 or less percent and it indicates danger of a medical emergency. The patient might have severe shortness of breath, wheezing and coughing. It is recommended for the patient to seek emergency care (Mayo Clinic, 2014).Additional treatment considerations include the following: Recognized the exacerbating effects of environmental factors such as allergens, air pollution, smoking, and weather (cold and humidity).Use potential medication exacerbating with caution (Aspirin, NSAIDs, and Beta Blockers).Always consider medication compliance and technique as possible complicating factors in poorly controlled asthma. Treatment of coexisting condition (Rhinitis, sinusitis, GERD), may improve asthma.Follow-up: The follow-ups in 3-5 days.ReferencesMcCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby. Brunton, L. , Chabner, B. , Knollman, B. , 2011). Goodman & Gilman’s. The pharmacological basis of therapeutics (12th ed.) New York, NY: McGraw HillFauci, A. , Braunwald, E. , Kasper, D. , Hauser, S. , Longo, D. , Jameson, J. L. , Loscalzo J. (2008). Harrison’s. Principles of internal medicine. (17th ed.) New York, NY: McGraw HillLacy, C. F., Armstrong, L. L., Goldman, M. P., Lance, L. L. (2010). Drug information handbook (19th ed.) Hudson, OH: Lexi-Comp APhA.Mayo Clinic (2014). Test and procedure. Peak flow meter. Retrieve from http://www.mayoclinic.org/tests-procedures/peak-flow-meter/basics/results/prc-20013057Scott, R. , & Armstrong, J. H. (2013). Burden of asthma in Florida. Florida Health. Retrieves from http://www.floridahealth.gov/diseases-and-conditions/asthma/_documents/asthma-burden2013.pdf