NRNP 6540 Week 5 Case Assignment: A 67-year-old With Tachycardia and Coughing
Case Title: A 67-year-old With Tachycardia and Coughing
Ms. Jones is a 67-year-old female who is brought to your office today by her daughter Susan. Ms. Jones lives with her daughter and is able to perform all activities of daily living (ADLs) independently. Her daughter reports that her mother’s heart rate has been quite elevated, and she has been coughing a lot over the last 2 days. Ms. Jones has a 30-pack per year history of smoking cigarettes but quit smoking 3 years ago.
Other known history includes chronic obstructive pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia. She also reports some complaints of intermittent pain/cramping in her bilateral lower extremities when walking, and has to stop walking at times for the pain to subside. She also reports some pain to the left side of her back, and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-tinged sputum. She states she has COPD and has been using her albuterol inhaler more than usual. She says it helps her “get the cold up.” Her legs feel tired but denies any worsening shortness of breath. She admits that she has some weakness and fatigue but is still able to carry out her daily routine.
Vital Signs: 99.2, 126/78, 96, RR 22
Labs: Complete Metabolic Panel and CBC done and were within normal limits
CMP Component Value CBC Component Value
Glucose, Serum 86 mg/dL White blood cell count 5.0 x 10E3/uL
BUN 17 mg/dL RBC 4.71 x10E6/uL
Creatinine, Serum 0.63 mg/dL Hemoglobin 10.9 g/dL
EGFR 120 mL/min Hematocrit 36.4%
Sodium, Serum 141 mmol/L Mean Corpuscular Volume 79 fL
Potassium, Serum 4.0 mmol/L Mean Corpus HgB 28.9 pg
Chloride, Serum 100 mmol/L Mean Corpus HgB Conc 32.5 g/dL
Carbon Dioxide 26 mmol/L RBC Distribution Width 12.3%
Calcium 8.7 mg/dL Platelet Count 178 x 10E3/uL
Protein, Total, Serum 6.0 g/dL
Albumin 4.8 g/dL
Globulin 2.4 g/dL
Bilirubin 1.0 mg/dL
AST 17 IU/L
ALT 15 IU/L
Allergies: Penicillin
Current Medications:
ï‚· Atorvastatin 40mg p.o. daily
ï‚· Multivitamin 1 tablet daily
ï‚· Losartan 50mg p.o. daily
ï‚· ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
ï‚· Caltrate 600mg+ D3 1 tablet daily
Diagnosis: Pneumonia
Directions: Answer the following 10 questions directly on this template.
Question 1: What findings would you expect to be reported or seen on her chest X-ray results, given the diagnosis of pneumonia?
Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia)? What’s the difference/criteria?
Question 3:
3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?
3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.
Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your treatment be for her based on her diagnosis, case scenario, and evidence-based guidelines?
Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?
Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential diagnosis for this? Explain your reasoning.
a. DVT (Deep Vein Thrombosis)
b. Intermittent Claudication
c. Cellulitis
d. Electrolyte Imbalance
Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to further evaluate this?
Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.
Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?
Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.
Response Amanda,
When a patient is dealing with a diagnosis of multiple myeloma, it is important to them to, of course, maintain a normal life pattern. According to Nightingale College (2022), Therapeutic communication in nursing consists of an exchange between patient and nurse using verbal and nonverbal cues. This allows the patients to understand better their condition and how to proceed with quality of life.
It’s also important to educate them that time will give the patient the strength they need to get there. Over the weekend, I recently had a patient who has been dealing with PAD to her right foot for several years and came in for a Femoral Popliteal Bypass. This patient was independent prior and very strong-willed. Unfortunately, after three surgeries within one week, she was not able to obtain blood flow to her right foot and has been in excruciating pain.
It isn’t easy to go from being so independent, carrying on with your daily living, to relying on others for help. She felt embarrassed to ask for help to get up to use the restroom because she couldn’t bear the weight on her right foot. She was tearful for most of my shifts with her; she fired every nurse before me. When you get the chance to sit with your patients and be honest, listen to them, and understand their frustration, because we are all human, you get to know them more profoundly and can advocate better for them. I built her trust and supported her to regain some normality.
I saw the hopelessness in her husband as he wanted her to get a BKA to “end the pain.” The right pain management was vital; it may not take it away entirely, but it will allow her to function as normally as she could until she decides what was right for her if she wanted to do a BKA or go home and allow time to heal and recover. You want the patient to feel free to express their ideas or feelings regarding their own care and accept what’s to come.
Educating the husband on making sure he took care of himself while his wife was in the hospital, reminding him that it was okay for him to leave, go home, get fresh air, and go to work so that he could arrange for whatever necessities he needed to for when she was ready for a safe discharge. When the family sees the care their loved ones are receiving, they would feel comfortable leaving the bedside, so it truly starts with the nurse and the patient; that first impression lasts a lifetime. Bedside manners are essential when dealing with ill patients, especially with the actively involved families.
Palliative care is an excellent resource for families, just as much for patients who are critically ill. It’s a service that can be provided in a hospital or the privacy of your own home. This will give families the support they need during a difficult time (National Institute on Aging, 2022).
References
National Institute on Aging (2021). What are Palliative care and Hospice Care? https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-careLinks to an external site.
Nightingale College (2022). Therapeutic Communication Techniques: How Good Nurses Can Provide Better Patient Care for Best Results. Retrieved from: https://nightingale.edu/blog/therapeutic-communication.htmlLinks to an external site.
Week 8 Case Study
CC: Mrs. Derrick is a 78-year-old female who comes to the office with complaints of increasing symptoms of lethargy; fever, night sweats, a 15 lb. weight loss over 6 months; bleeding gums when she brushes her teeth; purplish patches in the skin; and shortness of breath.
HPI:
She states that she has had a sensation of deep pain in her bones and joints.
She notes that her employment history includes working at a dry-cleaning shop for 15 years, with an exposure to dry cleaning chemicals (benzenes are known to be a possible cause of leukemias)
PE shows enlarged lymph nodes and swelling or discomfort in the abdomen.
You diagnose this patient with acute lymphoblastic leukemia (ALL).
Address the following in your SOAP note:
What additional history about her past work environment would you explore?
What additional objective data will you be assessing for?
What tests will you order? Describe at least four lab tests.
What are the differential diagnoses that you are considering? Describe two.
List at least two diagnostic tests you will order to confirm the diagnosis of ALL.
Will you be looking for a consultation? Please explain.
As the primary care provider for this patient with ALL:
- Describe the education and follow-up you will provide to this patient during and after treatment by the hematologist-oncologist.
- Describe at least three (3) roles as the PCP for the ongoing care of the ALL patient.
Chronic Obstructive Pulmonary Disease Paper Sample 2
Chronic Obstructive Pulmonary Disease
The most likely diagnosis for R. W. is chronic obstructive pulmonary disease (COPD). The patient’s current presentation with progressive difficulty in breathing while performing simple tasks is one of the major COPD symptoms. He also struggles to do manual work. The patient also reports cough, fatigue, having lost some wight recently and wheezing experiences. On physical examination, the patient has clubbing of fingers, use of accessory muscles for respiration and upon lung percussion, the patient exhibits hyperresonance. An exam of his pulmonary function reveals that he has an FEV1 of 58%.
Physical signs are quite sensitive and specific to severe disease. Mild to moderate COPD has poor sensitivity to physical examination and findings such as use of accessory muscles for respiration may suggest that he has severe disease. However, the formal diagnosis and staging of COPD is made with spirometry. The patient is at Stage II of the disease based on his spirometry results. Stage II is classified as FEV1 of 50-79% (Marçôa, 2018 Chronic Obstructive Pulmonary Disease Paper). The patient’s FEV1 is 58%.
The goals of treatment are to improve the patient’s quality of life and functional status. This can be done by improving symptoms and preserving optimal lung function (Mosenifar et al., 2020). Another goal is to prevent exacerbations and optimize the drug therapy. This can be achieved by smoking cessation which is aided by nicotine replacement. Impairment can be reduced by giving oxygen therapy to reduce the chances of developing hypoxemia (Mosenifar et al., 2020).
Patients exhibit reduced impairment characterized by the inability to perform normal activities, often without developing symptoms. Oral and inhaled medications are used to reduce dyspnea which in turn improves exercise tolerance. Another aim of pharmacotherapy is to reverse causes of airway function limitation, which is often attributable to such factors as airway inflammation, congestion of the bronchial mucosal, edema, increased secretions within the airways, and “bronchial smooth muscle contraction” (Mosenifar et al., 2020).
Bronchodilation is another goal and bronchodilators must be prescribed in the pharmacological treatment as the backbone of any COPD treatment regimen. These drugs are used to provide symptomatic relief and to decrease morbidity and mortality. Inflammation is also a crucial factor in the pathogenesis of COPD and therefore anti-inflammatory agents should be considered in pharmacotherapy.
Chronic infection is also common in patients with COPD as there is frequent colonization of the lower airways. The use of antibiotics to minimize the risk of infection and prevent exacerbation of the conditions should be considered. Another goal of therapy is to reduce the severity of symptoms. The patient should be able to do his manual work without experiencing any difficulties and should also have to sit behind his desk and perform his duties without experiencing any symptoms (Mosenifar et al., 2020).
The patient has a diagnosis of stage II COPD as evidenced by the symptoms presented in this case study. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2019) recommends COPD treatment with medications that provide relief from symptoms and prevent the exacerbation of disease. These are the cornerstones of COPD management since there is no definitive cure for the disease. Bronchodilators such as beta2 agonists, theophylline and anticholinergics are central to management of COPD at every level of disease severity and should be prescribed (Oba et al., 2018).
Inhaled short acting beta 2-agonists such as albuterol are preferred as they take a shorter time, around 3 to 5 minutes to start working. They are usually referred to as rescue medicines because of their quick relief to breathlessness. As such, patients can use them before engaging in activities that tend to worsen their symptoms. They, however, do not have a 24-hour lasting effect. For this reason, long-acting agents (LABA) such as salmeterol are used for long term control of the disease (Arcangelo & Peterson, 2017).
Inhaled long-acting anticholinergic medication (LAMA) such as glycopyrronium can also be prescribed but not in instances where quick relief is the desired goal. Combination therapy (LAMA/LABA) is used to achieve optimal bronchodilation over a long period of time (Bollmeier & Hartmann, 2020). Inhalation corticosteroids (ICS) can also be prescribed to reduce airway inflammation and the swelling that may narrow the airway.
They take longer to be effective and are used for long term control and to prevent exacerbation of the disease. Long term antibiotics such as azithromycin can be prescribed to minimize the risk of infection that may cause exacerbations of symptoms. A nicotine patch can also be recommended to help with the cessation of smoking. A combination therapy of salmeterol and inhaled corticosteroid (LABA/ICS) is ideal and is considered first line therapy.
The GOLD guidelines (2019) recommend that patients should be assessed 4-12 weeks after initiation of the treatment regimen and then routinely every three to 12 months thereafter. The NP should assess the patient to determine the need for medication adjustment and recommend a more intensive regimen should the patient exhibit exacerbation of COPD symptoms. The parameters that could be used to monitor the success of therapy are FEV1, respiratory rate, oxygen saturation, vital signs, and breathe sounds.
The goal is to achieve an FEV1 value of more than 70% using spirometry. The absence of wheezes and crackles indicate no labored breathing and minimal resistance to airflow. The target SpO2 is between 88% to 92% in COPD patients. The NP to assess the patient for the presence of risk factors such as smoking which may lead to exacerbation of symptoms. The NP should also ask about adherence to medication and the response to the medication. Poor adherence to medication is common among COPD patients. A history of exacerbation of symptoms should be taken to know the effectiveness of the treatment (GOLD, 2019).
The patient should be educated about the medication prescribed. When prescribing, a review on how to take the medicines should be done with the patient. Bronchodilators and corticosteroids are taken via the inhalation route using inhalers. The patient should be taught on how to use the inhalers as incorrect use may lead to the patient not getting the full dose. The patient should bring their inhaler with him during the next visit and a review on how to use it done. The patient should also be aware of the side effects of the medications. Beta 2-agonists cause a fast heartbeat which lasts a few minutes and go away after repeated use of the medication (Arcangelo & Peterson, 2017).
The patient should be made aware of this as this may cause feelings of anxiety which worsens breathlessness. LABA should not be used in combination with other medications that contain LABA as this can lead to an overdose. Also, the patient should not use the drugs at higher doses than recommended. Anticholinergics causes a dry mouth (Arcangelo & Peterson, 2017). Inhaled steroids may cause a sore throat and infection in the mouth. The patient should therefore be encouraged to use a spacer when taking steroids to minimize these side effects and rinse the mouth after ingestion.
Long-acting beta 2-agonists (LABA) should not be used for long periods. Paradoxical bronchospasm, laryngeal spasm, swelling, and stridor may occur and should be treated immediately with an inhaled, short-acting bronchodilator. Treatment with the LABA should be discontinued and an alternative therapy of LABA started. An alternative to LABA would be anticholinergic bronchodilators such as glycopyrronium. These drugs have a slower onset of action and therefore cannot be used for quick relief. For this reason, Patel et al. (2019 Chronic Obstructive Pulmonary Disease Paper) recommends a switch from LABA/ICS to LAMA/LABA.
The patient should be aware of health promotion that pertains to self-monitoring and knowing his risk factors for COPD. Mosenifar et al., (2020) recommends that the patient should be educated on the common risk factors of COPD which include smoking and the benefits that cessation would have on their health. Repeated reinforcement and education on the technique of use of the inhaler is critical in ensuring effective management of the patient’s condition. This greatly influences adherence to medication as it will help improve the patient’s satisfaction with the inhaler. The patient should be educated on pulmonary rehabilitation programs. It should be multidisciplinary and exercise therapy should be a mandatory component.
Patient should perform endurance exercise regularly to reduce dyspnea and enhance tolerance to daily activities (Mosenifar et al., 2020). Breathing retraining techniques can also be taught to the patient so as to prevent dynamic airway compression and improve the ventilatory pattern. The plan should be reviewed with the family so that they may actively participate in the patient’s management. The patient should also be educated on symptoms to look out for and to seek early medical attention.
Metoprolol is a cardioselective beta-blocker and therefore would not affect the choice of treatment for this patient. However, the patient must discontinue the use of Metoprolol immediately as it has been associated with “worsening dyspnea and of the overall burden of COPD symptoms, as measured by the shortness-of-breath questionnaire and the COPD assessment test,” (Dransfield et al., 2019).
References for Chronic Obstructive Pulmonary Disease Paper
- Arcangelo, V. P., & Peterson, A. M. (2017). Pharmacotherapeutics for advanced practice: A
practical approach (4th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams &
Wilkins. - Bollmeier, S. G., & Hartmann, A. P. (2020). Management of chronic obstructive pulmonary disease: A review focusing on exacerbations. American Journal of Health-System Pharmacy, 77(4), 259–268. https://doi.org/10.1093/ajhp/zxz306
- Dransfield, M. T., Voelker, H., Bhatt, S. P., Brenner, K., Casaburi, R., Come, C. E., Cooper, J. A. D., Criner, G. J., Curtis, J. L., Han, M. K., Hatipoğlu, U., Helgeson, E. S., Jain, V. V., Kalhan, R., Kaminsky, D., Kaner, R., Kunisaki, K. M., Lambert, A. A., Lammi, M. R., … Connett, J. E. (2019). Metoprolol for the Prevention of Acute Exacerbations of COPD. New England Journal of Medicine, 381(), 2304-2314.
- Global Initiative for Chronic Obstructive Lung Disease. (2019). Retrieved from https://goldcopd.org/wpcontent/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf
- Marçôa, R., Rodrigues, D. M., Dias, M., Ladeira, I., Vaz, A. P., Lima, R., & Guimarães, M. (2018). Classification of chronic obstructive pulmonary disease (COPD) according to the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: comparison with GOLD 2011. COPD: Journal of Chronic Obstructive Pulmonary Disease, 15(1), 21-26.0
- Mosenifar, Z., Harrington, A., Nikhanj, N. S., & Kamangar, N. (2020). Chronic Obstructive Pulmonary Disease (COPD). Practice Essentials, Background, Pathophysiology. https://emedicine.medscape.com/article/297664-overview.
- Oba, Y., Keeney, E., Ghatehorde, N. & Dias, S. (2018). Dual combination therapy versus long‐acting bronchodilators alone for chronic obstructive pulmonary disease (COPD): a systematic review and network meta‐analysis. Cochrane Database of Systematic Review. https://doi.org/10.1002/14651858.CD012620.pub2
- Patel, A. R., Patel, A. R., Singh, S., Singh, S., & Khawaja, I. (2019). Global Initiative for Chronic Obstructive Lung Disease: The Changes Made. Cureus, 11(6), e4985. https://doi.org/10.7759/cureus.4985