A 58-year-old African-American woman presents complaining of worsening shortness of breath and palpitations for about 1 week.

A 58-year-old African-American woman presents complaining of worsening shortness of breath and palpitations for about 1 week.

Shortness of Breath

Probable Diagnosis

The patient most likely has decompensated heart failure. In heart failure, the heart does not pump enough blood to meet the metabolic requirements of the tissues. The ensuing tissue anoxia is what occasions the lethargy and weakness due to impaired metabolism (Groenewegen et al., 2020). These constitute part of the forward symptoms, which arise from inadequate perfusion of tissues and also include syncope and dizziness.

Additionally, heat failure leads to backward symptoms, such as pulmonary edema due to left ventricular failure, which leads to shortness of breath (Dharmarajan & Rich, 2017). The dyspnea worsens with increased severity of the condition, and is often accompanied by productive cough. Other symptoms include peripheral edema and paroxysmal nocturnal dyspnea. The neurohormonal compensatory mechanisms lead to palpitations and fluid retention through activation of the renin-angiotensin-aldosterone system (Groenewegen et al., 2020). The patient presented is in New York Class III.

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Possible Diagnoses

Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a rare lung condition in which the lung compliance function is restricted. Due to the impaired ventilator function of the lungs, the tissues suffer anoxia which occasions lethargy and dyspnea. Although patients present with dyspnea, it is typically long-standing (Lederer & Martinez, 2018). It is also not accompanied by palpitations, unless it eventually leads to cor pulmonale, a rare complication.

Valvular Heart Disease

Valvulopathies are common in the elderly subgroup due to degenerative processes. Depending on the valve affected, the clinical presentation varies. The aortic valve is commonly affected in the elderly, leading to stenosis and the attendant forward symptoms of dizziness, lethargy and syncope, as exhibited in this patient (Dharmarajan & Rich, 2017). Importantly, undiagnosed valvulopathies eventually lead to decompensated heart failure.

Management

Investigations

  • Chest Xray- It is the important initial test for picking out IPF, pulmonary infection or cardiomegaly.
  • Echocardiography- The best imaging modality for assessing cardiac function.
  • Inflammatory markers- They will be elevated in cholecystitis, but are not diagnostic.
  • UECs/CBC/GXM- Are vital as baseline workup.

Treatment

  • Diuresis- The patient is likely fluid overloaded due to the fluid retention hence diuresis is crucial. She will receive IV furosemide 40mg BD.
  • Oxygen supplementation to enhance oxygenation.
  • Propping up the patient.
  • Monitoring of input/output charting.
  • Medications- Enalapril 5mg OD for the heart failure, then addition of carvedilol 3.125 mg after 48hours or patient stabilization (Rossignol et al., 2019). A 58-year-old African-American woman presents complaining of worsening shortness of breath and palpitations for about 1 week.

References

Dharmarajan, K., & Rich, M. W. (2017). Epidemiology, pathophysiology, and prognosis of heart failure in older adults. Heart Failure Clinics13(3), 417-426. https://doi.org/10.1016/j.hfc.2017.02.001

Groenewegen, A., Rutten, F. H., Mosterd, A., & Hoes, A. W. (2020). Epidemiology of heart failure. European Journal Of Heart Failure22(8), 1342-1356. https://doi.org/10.1002/ejhf.1858

Lederer, D. J., & Martinez, F. J. (2018). Idiopathic pulmonary fibrosis. New England Journal of Medicine378(19), 1811-1823. https://www.nejm.org/doi/full/10.1056/NEJMra1705751

Rossignol, P., Hernandez, A. F., Solomon, S. D., & Zannad, F. (2019). Heart failure drug treatment. The Lancet393(10175), 1034-1044. https://doi.org/10.1016/S0140-6736(18)31808-7

Shortness of Breath Example 2

Week 2: COPD Case Study Part 2

List of problem

COPD

Short of breath Cough

Wheeze Hypertension Overweight BMI 27.7

Assessment

Chronic Obstructive Pulmonary Disease

COPD is chronic irreversible chronic inflammation leads to obstruction, and limitation the airflow the gases get trapped in the lung (Berg and Wright, 2016). Chronic bronchiolitis or emphysema is the most common cause of COPD (Berg and Wright, 2016). The common symptoms and signs dyspnea with rest or exertion, chronic productive cough, wheezing, flat of the diaphragm, tachypnea, barrel-chest, and tripod position (Dumphy, 2109).

Risk factors are older than 35 years old with history with smoking (Gentry & Gentry,2017). The positive pertinent findings are shortness of breath with activity, intermittent cough but frequent and worse in the AM and productive whitish-yellow phlegm, former smoker (20 pack-year, Also he has RR-20, weight 258 pounds, O2sat 94% on RA. Lungs are clear to auscultation bilaterally with faint forced expiratory wheezes on bilateral bases. The negative pertinent findings are pulse 66, BP 156/94, heart S1 and S2 with no murmurs, and Respirations unlabored.

ICD-10 code is J44.9

Diagnosis test

Chest x-ray helps to determine the progress of COPD and reveal hyperinflation and helps to rule out other respiratory conditions (GOLD, 2019).

Arterial blood gas provides gas levels to determine (GOLD, 2019).

CBC with differential evaluates the hemoglobin and hematocrit and red blood cell to rule out anemia (Dumphy, 2109).

Medication

Albuterol 90 mcg inhalation Aerosol

2 puffs (180mcg) every 4 to 6 hours as needed for shortness of breath (GOLD, 2019). Disp 1 = 200 metered inhalation

Refill 0

Albuterol is short-acting beta2-agonists. This is the first line of treatment to treat and manage COPD. SABA relaxes the airway smooth muscle (GOLD, 2019). This medication relieves the acute episodes of bronchospasm (Dumphy, 2019). It is based on the guideline this patient is grading as GOLD B.

Tiotropium 2.5 mcg inhalation

2 puff (5.0 mcg) with the spacer every day (GOLD, 2019). Disp 1 = 60 metered inhalation

Refill 0

Tiotropium prevents the effects of acetylcholine, which causes the bronchoconstrictor. This medication recommended for GOLD grade B for patients with COPD (GOLD, 201). This medication also causes to relax the muscle of the airway (GOLD, 2019).

Patient education

Discuss the mechanism of underlying disease progression, the risk factors, and prevention of exacerbation. Educate how to use the inhaler with a spacer and demonstrate proper inhaler technique and a returning demon at the clinic (Dunphy, 2019). Instruct the patient to avoid extremes temperature changes and avoid secondhand smoking. Instruct the patient to lose weight, change diet, and exercise 30 minutes five times a week. Instruct the patient to get Influenza vaccination to reduce the upper respiratory infection. Discuss environmental triggers to prevent exacerbation of COPD (Dunphy, 2019).

Encourage patients to perform chest physiotherapy and adequate hydration to help with secretion.

Referral

No referral is recommended at this time. COPD patient has to develop a close and supportive relationship with the primary care provider, decease the progress of this disease (Dunphy, 2019).

Follow up

The patient will need to return to the clinic if the symptoms get worse or go to the ED for shortness of breath. The patient will need to follow up monthly basis to refill of medication and continue to manage this condition (Dunphy, 2019).

REFERENCES

Berg, K., & Wright., J. (2016). The pathology of chronic obstructive pulmonary disease: Progress in the 20th and 21st centuries. Archives of Pathology & Laboratory Medicine, 140(12), 1423-1428. Retrieved from https://www.archivesofpathology.org/doi/full/10.5858/arpa.2015-0455-RS

Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2019). Primary care: The art and science of advanced practice nursing-An interprofessional approach (5th ed.). Philadelphia: F.A.Davis.

Global initiative for chronic obstructive lung disease. (2017). Pocket Guide to COPD Diagnosis, Management, and Prevention. Retrieved from https://goldcopd.org/wp-content/uploads/2016/12/wms- GOLD-2017-Pocket-Guide.pdf

Final Care Coordination Plan for Patient with Shortness of Breath Example 3

Jane Doe is a 77year old, African American, female, who is a recent widower and has no children, was admitted to the hospital due to complaints of shortness of breath, chest pain, and fatigue. She was diagnosed with Congestive Heart Failure (CHF) during this admission and we are creating a care coordination plan for Jane Doe to control signs and symptoms of CHF and prevent further admissions to the hospital.

Three Health Care Issues

  1. CHF

The interprofessional team, this includes physicians, nurses, specialists, case management, the patient, and family if available, to create a care plan to improve signs and symptoms of CHF that is individualized. Jane Doe will be educated on CHF, follow-ups, medication adherence, low-sodium diet and fluid restrictions, and maintain weight by self- management as these elements are known to improve patient outcomes.

Self-management is an intervention that puts the patient in control. The patient is required to have CHF knowledge, meaning they understand the disease and signs of symptoms, how to eat a low sodium diet, fluid restrictions, and be able to recognize fluid overload and when to seek additional health care (Zakrisson, A., Arne, M., Hasselgren, M., Lisspers, K., Ställberg, B., & Theander, K, 2019). To make behavioral changes support groups are key element in success.

Support groups allow patients to see that they are not alone and can be persuaded by trustworthy people to see and accept positive changes. There are many community resources available. There are many online support groups and information such as, https://www.heartfailurematters.org, but for the older population it may be difficult to use technology. The American Heart Association also offers support groups online and in person for patients and caregivers. They also have print out educational pamphlets available such as care sheets for Self- check management and about the disease itself.

2.  Physical Activity and Nutrition

Poor physical activity and nutrition is linked to increase risk of CHF. Several reviews have found that sedentary behavior consistently increases the risk of both non-fatal and fatal cardiovascular diseases and CHF in the general adult population. As patients are educated on an exercise program following a cardiovascular event, preventative care works too. CHF patients should partake in an exercise program to improve quality of life (Tan, M. K. H., et al., 2019). Nutrition is also linked to heart conditions. The African American culture tends to eat a “southern diet.”

These are foods that include fruits and vegetables but are prepared in an unhealthy fashion. This diet is high in added fats, sugars, and sodium, with prominent use of high-fat meats for main dishes and the use of deep frying and other cooking techniques that add excess calories and sodium (Mercedes R. Carnethon, Jia Pu, George Howard, Michelle A. Albert, Cheryl A.M. Anderson, Alain G. Bertoni, Mahasin S. Mujahid, Latha Palaniappan, Herman A. TaylorJr, Monte Willis, and Clyde W. Yancy, 2020). Jane Doe must be educated on how to prepare the foods she likes in a healthier fashion.

Jane Doe can meet with a Dietician to obtain the resources to learn how to cook foods she likes. She is an elderly woman and may need help obtaining groceries and preparing meals. Transportation, affordability of food, and physical activity has to be examined. There are community resources to help with physical activity and nutrition. Occupational or physical therapist can be prescribed to help improve physical activity. Home care can help will activities of daily living such as grocery shopping, cooking, and cleaning. And there are organizations such as meals on wheels that will bring healthy meals to the patient’s home.

3.  Access to Health Care

According to the American Heart Association, an estimated 7.3 million Americans with cardiovascular disease (CVD) are currently uninsured. As a result, they are far less likely to receive appropriate and timely medical care and often suffer worse medical outcomes, including higher mortality rates (AHA, 2018). Efforts are being made to extend health care coverage to all Americans; so that patient have a continuum of care and better outcomes.

The Affordable Care Act has expanded on rural and urban populations. The patient also needs to be able to go to appointments. If transportation is an issue, there are community resources such as senior citizens transportation. There are bus services available to transport senior citizens places they need to go. If Jane Doe lives in a rural community transportation can be more of a barrier. Telemedicine is on the rise. This is where patients can grant access to health services through telephone or video conferencing. This will help with follow up visits and continued monitoring with Jane Doe’s health care team.

Health Policy Provisions

The Affordable Care Act, also known as OBAMACARE, is an act signed into law in 2010, which allowed persons to have an increase in access to health care, lowered costs, and incentivized care coordination to decrease gaps in care (ACA, n.d). This expanded Medicaid program to cover all adults in the poverty level. What this means is that more people have been granted easier access to health services. It allows for people to be able to seek care and afford treatments available to improve health outcomes.

According to the US department of Health and Human Resources, Health Insurance Portability and Accountability Act (HIPAA) establishes national standards that protect individuals’ medical records and other personal health information.

The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients’ rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections (HHS.gov, 2020). This allows the patient to be involved and in control of where and with who their health information is being shared. Paving the way for efficient care coordination.

Healthy People 2020

According to Healthy People 2020, it is important to recognize the impact that social determinants have on health outcomes of specific populations. Over the past two decades Healthy People has been focusing on health disparities and how to eliminate them while providing equity of healthcare and improve the health of all groups. In order to accomplish this goal, Healthy People have been performing ongoing studies; which examine American influential factors of availability and access to healthcare.

These include: high-quality education, nutritious food, decent and safe housing, affordable and reliable public transportation, culturally sensitive health care providers, health insurance coverage, and clean water and non-polluted air (Healthy People, 2020). Healthy People 2020 promote preventative measures to improve people’s lives.

For example, the Community Preventative Services Task Force is working to reduce costs for patient medications, improving patient-provider interaction and patient knowledge, such as team-based care with medication counseling, and patient behavioral and nutritional counseling (Healthy People, 2020). Costs for services can be reduced by eliminating out of pocket expenses such as copayments or deductibles.

Ethical Decisions

As the interprofessional health care team, the care coordination plan must address the needs and wants of Jane Doe and the ethical responsibilities of care. What the health care team thinks may be right for the patient may not line up with what the patient believes or wants. The patient has the right to refuse medications or treatments. It is the health care team’s job to inform and educate the patient on all aspects of their disease and treatments. It is important to act in best practice to ensure the safety and cause no harm to the patient.

As the care plan is implemented it is also important to make sure that the wishes and goals of the patient are being met. Everyone comes from different backgrounds and morals or beliefs but in health care, the healthcare team must respect the patient’s beliefs and values in order to have a successful care plan. In a study data was collected and implied that when allocating services, healthcare professionals need to find a balance between responsibility and accountability in their role as care-manager to reduce conflicting interests and ethical dilemmas (Tønnessen, S., Ursin, G., & Brinchmann, B. S,2017).

Priorities of Care Coordination

The priorities of planning care coordination are as follows. The nurse and physician must have open communication and speak with the patient and family to obtain insight on their values, beliefs, and wants. The patient and families knowledge of the disease process must be evaluated and reinforced. Then from there, coordinating services and other disciplines can be implemented.

Health care is ongoing; even after discharge from hospitals or other facilities such as rehabilitation centers or nursing homes. Continued evaluation of the patient is essential to improve patient outcomes; through follow-ups and implementing the proper interventions to reach patient specific goals. For Jane Doe, her home needs to be accessed. It is the healthcare team’s job to figure out how she will obtain the right nutrition, exercise, transportation, medications, weight-management, and resources. Along with being able to afford care and lifestyle.

References

American Heart Association (AHA). (2018). Access to Care. Retrieved from https://www.heart.org/en/get-involved/advocate/federal-priorities/access-to-care

Healthcare.gov. Affordable Health Care Act. N.d. Retrieved from https://www.healthcare.gov/glossary/affordable-care-act/

Healthy People 2020. (2020). Healthypeople.gov. Retrieved from https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities#5

HHS.gov. Health Information Privacy. 2020. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

Mercedes R. Carnethon, Jia Pu, George Howard, Michelle A. Albert, Cheryl A.M. Anderson, Alain G. Bertoni, Mahasin S. Mujahid, Latha Palaniappan, Herman A. TaylorJr, Monte Willis, and Clyde W. Yancy. (2020). Cardiovascular Health in African Americans: A Scientific Statement from the American Heart Association. Circulation. Retrieved from https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000534

Tan, M. K. H., Wong, J. K. L., Bakrania, K., Abdullahi, Y., Harling, L., Casula, R., . . . Jarral, O. (2019). Can activity monitors predict outcomes in patients with heart failure? A systematic review. European Heart Journal. Quality of Care & Clinical Outcomes, 5(1), 11-21. doi:10.1093/ehjqcco/qcy038. Retrieved from https://search-proquest.com.library.capella.edu/docview/2303856022?pq-origsite=summon

Tønnessen, S., Ursin, G., & Brinchmann, B. S. (2017). Care-managers’ professional choices: ethical dilemmas and conflicting expectations. BMC health services research, 17(1), 630. https://doi.org/10.1186/s12913-017-2578-4. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590170/

Zakrisson, A., Arne, M., Hasselgren, M., Lisspers, K., Ställberg, B., & Theander, K. (2019). A complex intervention of self‐management for patients with COPD or CHF in primary care improved performance and satisfaction with regard to own selected activities; A longitudinal follow‐up. Journal of Advanced Nursing, 75(1), 175-186. doi:10.1111/jan.13899. Retrieved from https://onlinelibrary-wiley-com.library.capella.edu/doi/full/10.1111/jan.13899