Plan of Care of a Patient with Respiratory Condition
Plan of Care of a Patient with Respiratory Condition
Patient Initials: C.F Gender: Female Age:65
Subjective Data
Chief Compliant: Patient reports that she has been experiencing severe wheezing, shortness of breath and cough
History of Present Illness: Patient reports having frequent asthmatic attacks for the duration of 2months. The symptoms have been coughing, severe wheezing and shortness of breath for the two months. Also, has had a post-traumatic seizure following a vehicle accident, relieved by phenytoin.
PMH/Medical/Surgical History: Patient hospitalized 10 weeks ago due to motor vehicle accident. She is a known asthmatic since the age of 20 years, has mild congestive heart failure diagnosed 3years ago. Currently, she is on the following medications: Theophylline 300 mg, Albuterol inhaler PRN Phenytoin 300 mg, HTCZ 50 mg BID, and Enalapril 5 mg BID.
Significant Family History: Has a family history of congestive heart failure (Mother), hypertension and kidney failure (Dad)
Social History: Reports that she denies taking alcohol or smoking. However, she says that she takes 4 cups of coffee.
Review of Symptoms: Positive response when asked about wheezing, coughing (respiratory) and exercise intolerance (musculoskeletal)
However, she denies having headache, swelling in the extremities and seizures
Objective Data:
Vital Signs: BP – 171/94 (hypertension) (Normal ranges 110/70 to 135/90mm/Hg); P- 122 (Normal range between 60-100b/min) R- 31 (hyperventilation) (Normal range between 16-24 breaths/min); T-96.7 (normal since standard range between 97.8F and 99F) Wt.-145; Ht- 5′ 3″; BMI-25.69kg/m2 (Normal range between 16.5-24.5kg/m2)
Physical Assessment Findings:
HEENT: No abnormality noted on the head, eyes, ear, nose and throat
Lymph Nodes: Not enlarged
Carotids: No significant observation
Lungs: Bilateral expiratory wheeze indicative of asthma
Heart: Regular heart rate with normal rhythm, S1 and S2 were heard
Abdomen: It is soft, non-tender with no palpable mass
Genital/Pelvic: No significant observation
Rectum: Guaiac test negative
Extremities/Pulses: +1 ankle edema possibly due to congestive heart failure
Neurologic: He is well oriented to time, person and place
Laboratory and Diagnostic Test Results
Na – 134 slightly below the normal range (135-145) – Useful in indicating the renal function. It is possibly low due to the use of HCTZ in the treatment of congestive heart failure
K – 4.9 within the normal limits (3.5-5.0) – Useful for assessing the kidney function
Cl – 100 within the normal limits (96-106) – essential for determining the kidney function
BUN – 21 slightly above the standard range (3-20) – Useful for indicating the kidney functions. Slightly raised possibly due to water depletion effect of the HCTZ
Cr – 1.2 within the normal range (0.6-2) – vital for indicating the kidney function
Glucose – 110 Normal since the standard RBS is the below 140
ALT – 24 within the standard range (7-55)
AST – 27 within the normal range (8-48)
Total Cholesterol – 190 Normal since the standard since below 200mg/dl
CBC – within the normal limits
Theophylline – 6.2 within the normal range (5-15mcg/mL) – useful for determining the therapeutic concentration of theophylline to prevent toxicity
Phenytoin – 17 within the normal range (10-20mcg/ml)
Chest Xray – Blunting of the right and left costophrenic angles possibly due to pleural effusion that is secondary to the congestive heart failure
Peak Flow – 75/min low due to the presence of Asthma; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% – slightly below the standard value (65%) for the patient’s age group
Assessment
The potential patient’s diagnoses in the order of priority comprise but not limited to the following:
- Unspecified Asthma (J45.901) as evidenced by the wheezing breath sounds and the medical history of asthma
- Unspecified Congestive heart failure (I50.40) as evidenced by the past medical history of congestive heart failure
- Hypertension (I10) as demonstrated by a high blood pressure reading and the potential risk of the same due to the familial history of hypertension (Centers for Medicare & Medicaid Services, 2016)
Plan of Care
Asthma
The patient has had asthmatic attacks since the age of 20years according to the past medical history. Also, the wheezing breath sound coupled with the shortness of breath are symptoms indicative of this diagnosis (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Diagnostics to Order
Primarily, spirometry tests are the initial tests since they facilitate the confirmation of asthma as a diagnosis. Also, laboratory tests such as blood gases analysis are vital in confirming this diagnosis (Winkelman, Ignatavicius, Workman, &Ignatavicius, 2013).
Therapeutic Management
Central to the effective management of asthma is various drugs. Thus, the nurse must administer them to relieve the asthmatic symptoms. Currently, the patient is on albuterol (a short-term acting Beta-agonist), which is equally effective but the nurse must also add other drugs such as long-term acting beta adrenergic agonists like Salmeterol, leukotriene modifiers like montelukast, anticholinergics such as ipratropium and mast cell stabilizers such as cromolyn. All these drugs are effective in the relieving the symptoms of caused by the pathophysiologic changes of Asthma (increased mucus secretion, airway obstruction) (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Education and Counseling
The priority management strategy is prevention. Thus, the nurse must teach the patient how to prevent the exacerbation of an asthmatic attack. Such interventions include reinforcing the need to avoid an environment full of allergens such as dust, cockroaches, and rodents. Additionally teaching the patient about medication adherence is also an important component of a teaching plan (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Referral and Consultation
The patient is a candidate for physician consultation since her peak flow is less than 70% (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Congestive Heart Failure
The patient is also a likely candidate for congestive heart failure since she reports that she has been living with this diagnosis for 3years. Moreover, the predisposition to the condition is also evident in the family history. Genetics plays a significant role in causing cardiovascular conditions (Kitchens, 2015).
Diagnostics to Order
Firstly, the nurse must order for an echocardiogram since it helps in determining the activity inside the heart chambers. Besides, ordering an electrocardiogram is also essential in establishing comorbid arrhythmias, which are common (Kitchens, 2015).
Therapeutic Management
Currently, the patient is on ACE inhibitors and thiazide diuretic. The two are essential drugs that a patient with mild heart failure must be put on. However, the nurse may consider changing the diuretic to a loop diuretic such as furosemide due to the presence of edema despite the use of HCTZ. Additionally, the nurse should also consider the option of adding amiodarone given the possibility of developing an arrhythmia. Also, the nurse should also refer the patient to a cardiologist to assess the need for an implantable cardioversion therapy due to the risk posed by this condition in advance stages (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Education and Counseling
The nurse must emphasize the need for maintaining a sodium restricted diet and drug adherence (Kitchens, 2015).
Hypertension
The patient has a high blood pressure reading as evidenced by the high blood pressure reading. Furthermore, she is a likely candidate given the family history of this condition (Winkelman, Ignatavicius, Workman, &Ignatavicius, 2013).
Diagnostics to Order
The nurse must order the routine tests for hypertension including but not limited to urinalysis, and serum electrolyte levels like sodium and potassium levels (Bunker, 2014).
Therapeutic Management
If the patient has secondary hypertension, the nurse should treat the underlying cause to correct hypertension. Otherwise, the nurse can administer antihypertensive for a primary type of high blood pressure (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
Education and Counseling
The nurse must advise the patient on the importance of refraining caffeine, which has the potential of increasing blood pressure. Furthermore, emphasizing the need for medication adherence and lifestyle modification is another nursing action (Bunker, 2014).
References
Bunker, J. (2014).Hypertension: diagnosis, assessment and management. Nursing Standard, 28(42), 50-59. http://dx.doi.org/10.7748/ns.28.42.50.e8682
Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2013).Primary care: A collaborative practice (4th ed.). St. Louis, Mo.: Elsevier Health Sciences.
Centers for Medicare & Medicaid Services,. (2016). Medicare Coverage Database – Centers for Medicare & Medicaid Services. Cms.gov. Retrieved 29 November 2016, from https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx?KeyWord=hypertension&bc=AAAAAAAAAAAQAA%3d%3d&
Kitchens, J. (2015). Heart Failure, An Issue of Critical Nursing Clinics(1st ed.). Philadelphia: Elsevier Health Sciences.
Winkelman, C., Ignatavicius, D., Workman, M., &Ignatavicius, D. (2013). Clinical companion, Ignatavicius Workman, Medical-surgical nursing (1st ed.). St. Louis, MO: Elsevier Saunders.
