Case Study- Asthma (COPD)

Subjective

Jose, a sixty-five-year-old man, came here from Mexico ten years ago. He presents with COPD; Hypertension seems to be under control and repeated admissions with the diagnosis of pneumonia. He suffers from dyspnea, coughing with dark yellow-green phlegm, a lively mood alternating between excitement and irritability, worry, and sometimes being confused about the time of day. Smoking over the past 38 years is part of his history. He also reported to have used an albuterol inhaler given by his son-in-law.

List additional focused assessments you would perform.

Critical Thinking: what cues are you looking for?

Subjective:

·         Shortness of breath,

·         Frequent productive cough,

·         Irritability, anxiety, and

·         Confusion about time

Objective:

Vital Signs: Temperature of 38.3°C, 125 bpm pulse rate, and labored breathing with a SaO2 of 88%.

Anthropometric: 5-foot-4, with weight of 120 pounds.

Physical Examination: Signs such as cold, dry skin with poor turgor, pursed-lip breathing, a patient presenting with dyspnea, and a flaring chest (Carolyn, 2020).

Blood Gases: A pH 7.32, PaO2 65 mmHg, PaCO2 54 mmHg and SaO288%.

Focused Assessments

·         Auscultation of lung sounds.

·         Assessment of oxygen saturation.

·         Evaluate the degree of medication adherence and inhalation, as these skills are vital steps in removing barriers to treatment.

·         Food intake and appetite status monitoring.

Critical Thinking

Several respiratory signs may point to the person suffering from respiratory difficulty, including frequent deep breathing and straining, which causes their facial muscles to contract.

·         Oxygen saturation has lowered, defining hypoxia.

·         It was probably caused by breathlessness and a general state of perplexity because of air deprivation.

·         COPD patients with an earlier smoking history are more likely to experience symptoms of their underlying disease.

Assessment

Assessment

Problems Identified

1.      Acute exacerbation of COPD

2.      Respiratory distress with hypoxemia

3.      The hazard of aspiration is accentuated in those who are not alert and hence cannot complete the coughs.

Identify a minimum of three nursing diagnoses.

Nursing Diagnoses

1.      Impaired gaseous exchange related to infective ventilation-perfusion as evidenced by patent having shortness of breath.

2.      Ineffective breathing methods related to respiratory distress and hypoxemia invariably, as evidenced by labored breathing.

3.      Risk for aspiration related to the mentally altered status and coughed-up material, as evidenced by labored breathing and the production of wheezing sounds (Betty et al., 2019).

Recommendation

Recommendation

SMART Goals

·         Within 24 hours, ensure that oxygen saturation is ≥ 92% on room air. Within 48 hours, proper breath control methods should be implemented, with a respiratory rate within normal limits and without any accessory muscle use.

·         Support the head of the patient upright to prevent aspiration.

·         Suction the airway to remove the secretions to clear the airway.

·         In the first three days after treatment, no aspiration incidents will occur since the chest sounds are clear again, and there is a bar of absence for any respiratory distress.

Probable Interventions (with rationales as to why they will help accomplish the goal)

Probable Interventions

1.      Give prescribed oxygen by mask with 100% oxygen, and the saturation maintained more than 92%.

2.      Teach and encourage them to harness the pursed-lip mechanism, which would lower respiratory rate and proper gas exchange.

3.      Keep the head of the bed raised and use mouthwash frequently to prevent the patient from aspirating.

4.      Contact the respiratory department to coordinate with them about nebulizer administration and inhaler instructions. In addition to that, they can also supervise patients’ pneumonia recovery.

5.      Promote smoking cessation activities by giving the related supplies, which will further nurture smoking cessation programs.

6.      Monitor and maintain hydration and nutrition at a balanced level for respiratory function and recovery. (Aranburu et al., 2022)

References

Aranburu-Imatz, A., López-Carrasco, J. de la C., Moreno-Luque, A., Jiménez-Pastor, J. M., Valverde-León, M. del R., Rodríguez-Cortés, F. J., Arévalo-Buitrago, P., López-Soto, P. J., & Morales-Cané, I. (2022). Nurse-Led Interventions in Chronic Obstructive Pulmonary Disease Patients: A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health, 19(15), 9101. https://doi.org/10.3390/ijerph19159101

Carolyn, J. (2020). Physical Examination and Health Assessment. Evolve.elsevier.com; Elsevier Education Portal. https://evolve.elsevier.com/cs/product/9780323809849?role=student

Betty, J. A., Gail, B., L., Mary, F., Martinez-Kratz, M., & Melody, Z. (2019, March 15). Nursing Diagnosis Handbook – An Evidence-Based Guide to Planning Care Diabetes | Myocardial Infarction. Scribd. https://www.scribd.com/document/549361517/Betty-J-Ackley-Gail-B-Ludwig-Nursing-Diagnosis-Handbook-an-Evidence-Based-Guide-to-Planning-Care