Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States 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.
HPI
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.
PMH
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
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Medication History
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
Allergies
NKDA
ROS
Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.
Physical exam
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18
Gen: 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. Abd: 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.
Laboratory and Diagnostic Testing
Na – 134
K – 4.9
Cl – 100
BUN – 21
Cr – 1.2
Glu – 110
ALT – 24
AST – 27
Total Chol – 190
CBC – WNL
Theophylline – 6.2
Phenytoin – 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the South University Online Library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, and Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
Please use the following template and APA formating.
**Please delete this statement and anything in italics prior to submission to shorten the length of your paper.
Patient Initials ______
Subjective Data: (Information the patient tells you regarding themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in chronologic order using symptom analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and history sexual history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security and family history of violence).
Review of Symptoms: (Review each body system – This section you should place POSITIVE for… information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ; ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:; Neurological:; Endocrine:; Hematologic:; Psychologic: .
Objective Data:
Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe review)
HEENT:
Lymph Nodes:
Carotids:
Lungs:
Heart:
Abdomen:
Genital/Pelvic:
Rectum:
Extremities/Pulses:
Neurologic:
Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.)
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).
References
Expert Solution Preview
Introduction:
Based on the given clinical case of a 65-year-old female patient with asthma and a history of congestive heart failure, the following is a holistic care plan for disease prevention, health promotion, and acute care. The care plan includes nursing actions based on current evidence and nursing standards of care from scholarly sources and government sites, along with an ICD-10 classification (diagnoses) for the patient’s conditions.
Patient Initials: K.M.
Subjective Data:
Chief Compliant: “I am having severe wheezing, shortness of breath, and coughing at least once daily. I can barely get my words out without taking breaks to catch my breath.”
History of Present Illness: The patient reports experiencing frequent asthma attacks for the past two months, with more than four attacks per week on average. She recently suffered a serious motor vehicle accident, followed by a post-traumatic seizure two weeks later, for which she was started on anticonvulsant phenytoin. She has been taking albuterol once daily.
PMH/Medical/Surgical History: The patient has a history of periodic asthma attacks since her early 20s. She was diagnosed with mild congestive heart failure (CHF) three years ago and has been on a sodium-restrictive diet and hydrochlorothiazide. Last year, she was also placed on enalapril due to worsening CHF, and her symptoms have been well-controlled since. She has no significant surgical history.
Significant Family History: The patient’s father died at the age of 59 of kidney failure secondary to hypertension, and her mother died at the age of 62 of CHF.
Social History: The patient is a nonsmoker and does not consume alcohol. She reports using caffeine in the form of four cups of coffee and four diet colas per day.
Review of Symptoms: Positive for shortness of breath, coughing, wheezing, and exercise intolerance. Denies headache, swelling in the extremities, and seizures.
Objective Data:
Vital Signs: BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’3”
Physical Assessment Findings: Pale, well-developed female appearing anxious. Pupils equal, round, and reactive to light and accommodation. Oral cavity without lesions. Tympanic membranes without signs of inflammation, no nystagmus noted. Regular rate and rhythm normal S1 and S2. Bilateral expiratory wheezes noted in the chest. Abdomen soft, non-tender, non-distended, no masses. +1 ankle edema on the right, no bruising, normal pulses. A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing:
Na – 134
K – 4.9
Cl – 100
BUN – 21
Cr – 1.2
Glu – 110
ALT – 24
AST – 27
Total Chol – 190
CBC – WNL
Theophylline – 6.2
Phenytoin – 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Assessment:
1. Uncontrolled asthma with frequent attacks
ICD-10 Code: J45.902
2. Post-traumatic seizure
ICD-10 Code: R56.9
3. Mild congestive heart failure
ICD-10 Code: I50.9
Plan of Care:
1. For uncontrolled asthma:
a. Perform a comprehensive asthma assessment, including a detailed history and physical examination, using tools such as the Asthma Control Test (ACT) to evaluate the level of asthma control.
b. Initiate a stepwise approach to asthma therapy, starting with a low-dose inhaled corticosteroid (ICS) such as fluticasone, and adding a long-acting beta-agonist (LABA) such as salmeterol if necessary to achieve asthma control.
c. Review and reinforce inhaler technique, including proper cleaning and maintenance, to ensure optimal therapy delivery.
d. Educate the patient on asthma triggers and avoidance strategies, including environmental controls, such as avoiding exposure to tobacco smoke, air pollution, and allergens.
e. Provide an action plan for asthma exacerbations, including initiating rescue therapy with albuterol as needed, and when to seek medical attention.
2. For post-traumatic seizure:
a. Evaluate the patient’s current medication regimen, including phenytoin, for optimal seizure control.
b. Provide patient education on seizure precautions, including medication adherence, hydration, and avoidance of triggers such as sleep deprivation and alcohol.
c. Evaluate the patient for any adverse effects of phenytoin, including changes in liver function tests and hematologic parameters.
d. Schedule follow-up appointments with the patient’s neurologist as needed for ongoing seizure management.
3. For mild congestive heart failure:
a. Review and optimize the patient’s current medication regimen, including sodium-restrictive diet and hydrochlorothiazide, and enalapril, as well as aspirin and statin therapy for cardiovascular risk reduction.
b. Monitor the patient’s weight and fluid status regularly to detect signs of CHF exacerbation.
c. Provide patient education on CHF self-management, including recognizing and reporting symptoms of exacerbation, adhering to medication and dietary regimens, and engaging in regular physical activity.
d. Schedule regular follow-up appointments with the patient’s cardiologist to monitor CHF management.
References:
1. Centers for Disease Control and Prevention. (2021). Asthma. Retrieved from
2. National Heart, Lung, and Blood Institute. (2021). Asthma. Retrieved from
3. American Heart Association. (2021). Heart Failure. Retrieved from
