NU 580 Assignment 2: Case Study A 56-year-old white man presents with an accelerated decline in lung function.
Assignment Case Study
- What additional subjective data do you think the patient will share?
The additional subjective data needed included the history of the present illness. The patient indicated of having accelerated decline in the lung function; however, there are no information on how the condition started and past medical interventions. Also, more data should be provided on whether the patient has any past surgical history. The patient has been smoking for the past 40 years and this information is important for the making the right diagnosis. However, the information on other social aspect, and family history is missing and needs to be provided. The family history is important since it helps in determining whether the patient has a hereditary condition.
- What additional objective data will you be assessing for?
The objective data needed in this case include the review of system which helps in determining whether other organs have been affected. The systems of most importance in this case include the respiratory system, the cardiovascular system, neurological system, integumentary system and urinary tract system. Furthermore, the assessment to determine whether the patient is having arrhythmias, edema in the extremities which provides information about the vascular sufficiency in the patient (Blebea, 2017).
- What National Guidelines are appropriate to consider?
The national guideline on the Chronic Obstructive Pulmonary Diseases (COPD) is a
ppropriate in this case. The guideline provides information on how to manage the COPDs and the relevant preventive measures (Ruppel et al., 2018). Also, the national lung education guideline will be used.
- What tests will you order?
The patient is having dyspnea, therefore, the first test to order will be the full haemogram. The test will help in
determining whether the patient is have septicemia and also measure the hemoglobin concentration and packed cell volume. Secondly, an electrocardiogram test will be ordered to determine the possibility of the ventricular hypertrophy, arrhythmia and other outcomes associated with insufficient vascular system functioning (Kessen & Williamson, 2020). The patient is fatigued and has no energy. Ordering for a cholesterol level test will also be necessary in this case. The other tests to consider include renal function test.
- Will you be looking for a consult?
The interdisciplinary collaboration is important in the patient’s management. The goal in the collaboration is to identify the needs of the patients comprehensively and respond to them accordingly. Therefore, the consult will be needed in this case to understand the best way to handle the failing lungs and other symptoms present in the patient.
- What are the medical and nursing diagnoses?
The medical diagnosis for this case is COPD. The patient has a history of smoking and currently experiences fatigue and low energy (Criner & Han, 2018). He coughs with clear mucoid sputum and has arterial hypoxemia and respiratory acidosis. The nursing diagnosis include lack of sleep as the patient indicates that he struggled to sleep in his recliner. Also, inadequate intake of food is another nursing diagnosis. The patient indicated that he did not have energy to eat and this is a major concern because the body relies on the food to produce energy that supports basal metabolic activities and others. The third nursing diagnosis is dyspnea. The patient is having difficulties in breathing due to the failing lungs and this is why he is hypoxic.
- Are there any legal/ethical considerations?
Legal and ethical considerations must be observed when handling all the patients. The patient’s bill or right accords them autonomy and the right to know all the interventions initiated on them. Therefore, the healthcare providers have to liaise with the patient in developing the treatment plan. The patient has been smoking for a long time; therefore, the nurse must engage with him in developing a collaborative plan to address the issue and produce the most beneficial outcome in the patient. The legal consideration include seeking informed consent from the patient and consulting with other healthcare provides to avoid any possibility of negligence in the care delivery process.
- What is your plan of care?
Medical
The medical care plan will include reviewing the ECG and the other laboratory test results to determine the best medication. In case of septicemia, the patient will be initiated on antibiotics. Also, the patient will be given bronchodilators to improve the inhalation and ensure that he gets enough oxygen. The patient has been on albuterol inhaler prn and that seemed sufficient. The medication will have to be reviewed and introduce hydrocortisone and steroids that will relieve the lungs.
Nursing
The nursing plan is to let the patient have a bed rest. The patient has low energy and is restless. The bed rest will help improve his condition and allow him gain energy. Secondly, the patient’s vitals will be taken after every six hours to monitor his progress so that alarming signs can be identified in time. Also, a relaxation response will be induced in the patient to help improve the functioning of the breathing system (Bausewein et al., 2017).
Complementary therapies
The complementary therapy will include acupuncture and muscle relaxation. The interventions will be initiated carefully considering the current status of the patient. The patient cannot engage in intense exercise because of the dyspnea and fatigue.
- Are there any Healthy People 2020 objectives that you should consider?
The Healthy People 2020 objectives to consider include attaining high quality of life and preventing premature death. Also, the objective of promoting longer lives free of the preventable diseases will be considered (Finney Rutten et al., 2019). The goal in the care delivery will be to improve the health status of the patient and promote a sustainable and long-last life for the patient through behavioral modifications.
- Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting him and the family involved in the care to reach optimal health?
According to the Circle of Care, the patient’s wife or child should be involved in the treatment process. The addition voice provides clarity and helps in identifying risky behavioral patterns depicted by the patient. The wife and children are the closest family members who can provide the right linkage and help the patient cope with the proposed health promoting interventions.
- What additional patient teaching may be needed?
The patient will be taught on the need to consume the right diet. Proper dietary intake provides the body with the right nutrients and energy for daily activities. Secondly, the need to cease smoking will be emphasized since it has a greater impact on the patient’s health status and treatment outcomes. Thirdly, the patient will be educated on the need to engage in regular physical exercise to improve the functioning of both the cardiovascular and the respiratory systems.
- What billing codes would you recommend?
The recommended billing codes for this case is J96.90 which indicated respiratory failure leading to hypoxemia. The patient’s dyspnea is as a result of the respiratory failure. Furthermore, the patient has hypoxemia.
References
Bausewein, C., Schunk, M., Schumacher, P., Dittmer, J., Bolzani, A., & Booth, S. (2017). Breathlessness services as a new model of support for patients with respiratory disease. Chronic Respiratory Disease, 15(1), 48-59. https://doi.org/10.1177/1479972317721557
Blebea, J. (2017). The pathophysiology and hemodynamics of chronic venous insufficiency of the lower limb. Handbook of Venous and Lymphatic Disorders, 51-60. https://doi.org/10.1201/9781315382449-5
Criner, R. N., & Han, M. K. (2018). COPD care in the 21st century: A public health priority. Respiratory Care, 63(5), 591-600. https://doi.org/10.4187/respcare.06276
Finney Rutten, L. J., Blake, K. D., Greenberg-Worisek, A. J., Allen, S. V., Moser, R. P., & Hesse, B. W. (2019). Online health information seeking among US adults: Measuring progress toward a healthy people 2020 objective. Public Health Reports, 134(6), 617-625. https://doi.org/10.1177/0033354919874074
Kessen, B., & Williamson, K. (2020). The ECG in clinical medicine. Electrocardiogram in Clinical Medicine, 1-11. https://doi.org/10.1002/9781118754511.ch1
Ruppel, G. L., Carlin, B. W., Hart, M., & Doherty, D. E. (2018). Office spirometry in primary care for the diagnosis and management of COPD: National lung health education program update. Respiratory Care, 63(2), 242-252. https://doi.org/10.4187/respcare.05710