A Care Plan for a Critical Analysis for a Respiratory Clinical Case Study
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A Care Plan for a Critical Analysis of a Respiratory Clinical Case Study
This is a 65-year-old Caucasian woman who said that she was involved in a motor vehicle accident being hospitalized10 weeks. Besides, she complains of wheezing, shortness of breath along with difficulty in speaking. This occurs due to pausing during the breathlessness episode; she explained. The patient reported that she also took albuterol for asthmatic attacks. She took it today.
On history taking, the patient complains of severe wheezing, shortness of breath and coughing. She reports the frequency of coughing to be at least once in a day.
History of present illness
The patient had an accident ten weeks ago. She was treated and discharged home after stabilizing on Theophylline SR capsules 300mg PO BID and Albuterol inhaler PRN for the management of asthmatic symptoms at home. However, in 10 weeks, the symptoms worsen, and she opts to seek treatment for severe wheezing, shortness of breath and coughing for at least once in a day. History of admission due to an accident is relevant to this case study. Asthmatic attacks are initiated by a variety of triggers ranging from environmental allergens to other stressors such as cold and accidents. In this case, the accident could have created stress from impact to the respiratory system hence initiating the onset of this attack. Research has proven that stress triggers asthmatic attacks. The patient did not express directly in her report the effect this accident had on the body and other social conditions. However, psychologically it must have made an impact triggering these episodes over the past ten weeks. Most important, an accident triggers the release of chemical mediators of inflammation which becomes the source of the asthmatic attack. On top of that, the injury inflicted may result in infection which initiates the release of chemicals of inflammation at a later date. Due to the stress caused by the accident chemicals mediators of inflammation are released following the two mentioned pathological response. The chemical mediators of inflammation initiate constriction of bronchioles creating escalating the symptoms of shortness of breath and wheezing (Boulet& Boulay, 2013). Due to inflammation, vascular fluid also infiltrates into the bronchioles and its accumulation in the trachea results in increased episodes of coughing as reported by the patient to get rid of the fluid from the respiratory tract. Separately, asthma symptoms trigger anxiety in themselves. Since this patient was discharged ten weeks before the attack; the accident might not be a major trigger, but stress is associated with it. We do not know the other circumstances under which this woman lives to rule out the accident as part of the present health complication.
The past medical history this patient indicates that she sustained. No condition influenced by any injury sustained was given. However, posttraumatic seizures occurred following the incident. These could be associated with a direct pathological disorder (Thapa, 2013). Much was not explained by this patient regarding the evolution of these seizures, but they could be associated with brain tissue damage caused by accident. These seizures began two weeks after the accident. The patient reported no surgical history. The past medical history indicates that she had episodes of asthma since earlier 20s and a diagnosis of heart failure three years ago.
The Family History
The patient’s father died at the age of 59 years due to kidney disease emerging from hypertension. This client’s mother died at the age of 62 years due to congestive heart failure (CHF). She drinks four cups of coffee daily as well as four diet colas. Coffee contains caffeine which is a trigger of asthmatic attacks.
The social history indicates that the patient is a nonsmoker and a nonalcoholic. However, the social history indicates that the patient uses 4 cups of coffee and 4 diet colas per day. Coffee contains caffeine which is one of the triggers for asthmatic attacks.
• Theophylline SR capsules 300mg PO BID (asthma)
• Albuterol inhaler PRN (Asthma)
• Phenytoin SR capsules 300mg PO QHS
• HTCZ 50mg BID (hypertension)
• Enalapril 5mg PO BID (hypertension)
Review of the System
General: The patient is restless and anxious with profound signs of respiratory distress
Integumentary: +1 ankle edema observed. Skin is intact. There are scars sustained in the previous accident at the extremities.
Head: No obvious scars from previous road accident and headache reported by the patient
Eyes: There is pallor but no edema of the eyelids or reduced visual acuity
Cardiovascular: Blood pressure beyond normal limits evidenced by BP of 171/94mmHg. Pulse is within normal ranges
Respiratory: There is shortness of breath, wheezing, and cough of at least once in a day
Gastrointestinal: Abdomen is nontender, and no distention noted
Neurological: Cranial nerves intact
Endocrine: No lymph node enlargement
Psychological: The patient is anxious about the drastic changes in her condition
There is obvious swelling in extremities along with evidence of seizures.
Physical examination: BP 171/98; HR 122; RR 31; T 96.7 F, WT 145; Height 5ft 3 inches. After taking Albuterol breathing treatment Vitals are BP 134/79; HR 80; R18.
HEENT: No abnormalities detected
Lymph Nodes: No lymph nodes enlargement or inflammation noted
Carotids: Carotid artery is bulging. This is due to increased pressure as evidenced by a blood pressure of 171/98 mmHg.
Lungs: Bilateral expiration wheezes
Heart: Regular rate and rhythm
Abdomen: Soft and none tender. No abdominal distension noted
Genital/Pelvic: No scars, No masses or any other notable genital growths or injury
Rectum: Normal patency and Sphincter Muscles tonicity intact
Extremities/Pulses: 1+ edema.
Neurologic: Cranial nerves assessment indicates that they are all intact
Laboratory and Diagnostic Test Results
• Na -134: This is within normal limits of ranging between 135- 145 mmol/L
• K – 4.9: Within normal limits which range from 3.5- 5 mmol/L
• BUN -21
• Cr -1.2: This is within normal limits which range from 0.8-1.3mg/dL
• Glu – 110
• ALT -24
• AST -27
• Total Cholesterol-190: This indicates presence of low-density lipoproteins which ranges from 85 -125mg/dL
• Theophylline – 6.2
• Phenytoin – 17 chests X-ray. 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%
General condition: Pale, but well developed anxious female.
Assessment: ICD -10 codes priority diagnoses: Acute Asthma ICD 10 Code: J45), Congestive Cardiac Failure (ICD 10), Secondary Hypertension (ICD 10 Code: 115.9)
Plan of Care: In the assessment, diagnoses of Asthma along with Congestive Cardiac Failure and Pulmonary Hypertension.
(a) Asthma action plan (ICD Code: J45)
• This patient has an asthmatic attack hence the priority for this patient is to nebulize her with salbutamol diluted in normal saline at a ratio of 1:1 mills to alleviate the priority symptoms of asthmatic attack
• After the patient has stabilized, long-term bronchodilator such as dexamethasone which has a longer half-life is necessary.
• Adhering to medication instructions with the appropriate diagnostic evaluations for theophylline, albuterol and phenytoin effects are mandatory. Currently, there are few abnormalities discovered in diagnostic testing. Theophylline has been reported to develop resistance hence its effectiveness should be evaluated.
• A balanced diet is important too. There are various prototypes emerging when asthma symptoms are initiated. Knowing these types could facilitate controlling sudden, frequent onsets as in this case study. The care plan must include a concise knowledge of which one affects the patient and best course of intervention (Peters, 2014).
• Air Ionizer is an alternative treatment, which shows great benefit. The healthcare practitioner must be open to hearing the patient and relatives concerns. Mild exercise must be encouraged (Mamane, Raherison, Tessier & Baldi, 2015).
(b) Mild congestive cardiac failure. ICD 10 Code: I50.9
• The care plan for this condition bringing ICD-10 codes into operation denotes involvement of both respiratory and cardiovascular categories. Shortness of breath is a clinical manifestation of both conditions.
• As such, this care plan is concerned with limiting these symptoms. Asthmatic attacks put pressure on the heart. From the etiological perspective, this CHF is caused by hypertension.
• Therefore, the care plan must include addressing medication adherence for hypertension along with education on relieving stressful situations (Kuck, 2014).
Hypertension is under not under control in this patient. There is need to increase the dose of HCTZ from 50mg to 75mgs and Enalapril from 5mgs to 10 mg. A low sodium diet should be continued to improve water excretion via the kidney. This should be done to control edema of extremities from progressing from +1 to +3.
Boulet, L., & Boulay, M. (2013). Asthma-related comorbidities. Expert review of respiratory medicine, 5 (3): 377–93.
Kuck, K. (2014). New devices in heart failure: a European Heart Rhythm Association report: developed by the European Heart Rhythm Association; endorsed by the Heart Failure Association, Europace. 16 (1): 109–28.
Mamane, A. Raherison, C. Tessier, J., & Baldi, I (2015). Environmental Exposure to Pesticides and Respiratory Health. European Respiratory Review. 24 (137): 462–73
Peters, S. (2014). Asthma Phenotypes: Nonallergic (intrinsic) Asthma. The Journal of Allergy and Clinical Immunology, in Practice, 2 (6): 650–2.
Thapa, A. (2013). Post-traumatic Seizures—a Prospective Study from a Tertiary Level Trauma Center in a Developing Country. European Journal of Epilepsy.19 (4) 211-216
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