Chapter 8 Respiratory System   Question:  What plan would you outline for this patient that seems

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Chapter 8 Respiratory System

Question: 

What plan would you outline for this patient that seems to present with COPD? 

-What medications (name, dosage, route, frequency, and duration (if applicable like antibiotics), education on medication/ adverse effects, etc.? 

-What Diagnostic testing and reasoning (why are you ordering it, what are you looking for? with reference)

-What is symptom management for a patient with COPD?

-What patient education would you give to a patient with COPD? (med, testing, diet, social, reasons for emergent evaluation?)

-Does this patient need a referral for further consultation with another specialist?

-When will the patient follow up with you and/or another specialist?

(All details of the plan should include a rationale that is supported with references from the healthcare literature)

Chief Complaint

A 58 y.o. female presents with fatigue and difficulty catching her breath. Although she has frequently coughed for months, the fatigue and shortness of breath have come on over the past 2 months. She has been treated twice in the past year for bronchitis, which included a severe cough with yellow sputum, shortness of breath, and fever. Once treated, the shortness of breath resolved until recently. She is a former smoker, describing a 40-pack-a-year history and finally quitting successfully on her 58th birthday.

Past Medical History

Negative for asthma and other respiratory conditions
Type 2 diabetes, hypertension, and increased lipids
Surgeries: hysterectomy at age 55; an appendectomy in her teens; cataract removals earlier this year

Current Meds

Metformin 500 mg BID
HCTZ 25 mg daily
Atenolol 25 mg daily
Atorvastatin 10 mg daily

Psychosocial History

Works 2 days a week as a sales associate in the local department store and volunteers 1 day a week at the local library. Has recently taken a leave from her volunteer role and has decreased from 8-hour to 4-hour work days at the store because of the fatigue. Used to walk daily but has quit this lately, as she says, “It is all I can do to make the bed some days!”

Physical Examination

Vital signs: T 98, BP 138/86, HR 92, RR 34, HT 64, WT 155 lbs.
General: Appearance in no acute distress. Alert and oriented. Well groomed. Articulate and seems to be a good historian. Fluid movements.
HEENT: Normal.
CV: RR&R. S1/S2 without audible extra sounds or murmurs.
Respiratory: Initially some crackles, which cleared with forceful cough. Decreased breath sounds, slight wheeze noted. Slight increased AP ratio.
Skin: Intact, pink, resilient. No rashes or lesions noted.
MS: Full ROM, non-pitting edema ankles/feet bilaterally. Pulses 2+ bilaterally.

SCIENCE
HEALTH SCIENCE
NURSING
NUR 642

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