Respiratory Care Plan

Respiratory Care Plan

Subjective Data: 65-year-old female patient reports she is having severe wheezing, shortness of breath and coughing at least once daily.  She also reports that she can barely get her words out without taking stopping to take breaths. She confirms that she has taken her albuterol once today. Patient was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today.

Chief Compliant: Severe wheezing, shortness of breath and coughing

History of Present Illness: Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.

Medical History: History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.

Surgical History: Patient denies

Medications:

Theophylline SR Capsules 300 mg PO BID

Albuterol inhaler, PRN

Phenytoin SR capsules 300 mg PO QHS

HTCZ 50 mg PO BID

Enalapril 5 mg PO BID

Allergies: NKDA

Significant Family History: Father died at age 59 of kidney failure secondary to HTN. Patient’s mother died age 62 of CHF.

Social History: Patient denies smoking and alcohol intake; Admits to daily caffeine intake: 4 cups of coffee and 4 diet colas per day.

Review of Symptoms: Patient is positive for shortness of breath, coughing, wheezing and exercise intolerance. She denies headache, swelling in the extremities and seizures.

Objective Data:

BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”

VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18

Physical Exam

General: Well developed female appearing anxious.

Integumentary: Pale skin.

HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted.

Cardiovascular: Regular rate and rhythm normal S1 and S2.

Respiratory: Bilateral expiratory wheezes.

Gastrointestinal: abdomen soft, non-tender, non-distended no masses. Guaiac negative.

Genitourinary: Unremarkable.

Musculoskeletal: +1 ankle edema, on right, no bruising, normal pulses.

Neurological: A&O X3, cranial nerves intact.

Endocrine: Unremarkable

Hematologic: Unremarkable

Psychological: Patient anxious

Laboratory Test Results:

(Fischbach & Dunning, 2017)

Diagnostic Testing:

Chest Xray – Blunting of the right and left costophrenic angles abnl

Peak Flow – 75/min; after albuterol – 102/min Peak flow: 80-100

FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% COPD Stage 2 – Moderate

Assessment:

J45.31 Mild persistent asthma with acute exacerbation

I50.40 Combined systolic (congestive) and diastolic (congestive) heart failure

J44.9 Chronic obstructive pulmonary disease, unspecified

Plan of Care:

J45.41 Moderate persistent asthma with acute exacerbation

Education: Asthma is a disease that affects your lungs. It can cause difficulty breathing including wheezing, breathlessness, coughing and chest tightness. Asthma attacks can be controlled with medications and avoidance of triggers in the surrounding environment.

The CDC recommends:

When using cleaners or disinfectants in the home, remember:

• Carefully follow manufacturer’s instructions when using any cleaning products.
• People with asthma should try to stay away when cleaners are being used in the home and immediately following their use.
• Open doors and windows when using cleaning products.
• Avoid using sprays and aerosols. Instead, apply the product to cloth or paper towel first.
• Wear protective gear such as gloves and goggles.
• Avoid disturbing dust because it can be an asthma trigger.

To reduce mold exposure in the home:

• Dry damp or wet items within 24 to 48 hours to avoid mold growth.
• Fix water leaks, such as leaky plumbing, as soon as possible.
• Replace absorbent materials, such as ceiling tiles and carpet, if mold is present.
• Use an air conditioner or dehumidifier to maintain low indoor humidity.
• Scrub mold off hard surfaces with detergent and water. Dry completely.
• Empty and clean refrigerator and air conditioner drip pans regularly.
• Run the bathroom exhaust fan or open the window when showering

Dust Mites:

• Use allergen-proof mattress and pillowcase covers.
• Wash bedding weekly.
• Vacuum carpets, area rugs, and floors regularly. If possible, the person with asthma should stay out of rooms while they are vacuumed, swept, or dusted.
• Keep relative humidity levels in the home low, around 30- 50%.

Pet Fur:

• For individuals who are allergic to pets, the best way to decrease asthma symptoms is to remove the pet from the home and thoroughly clean all surfaces in the home.
• If a pet cannot be removed from the home of someone who is allergic decrease exposure by:
• Keeping pets out of bedrooms,
• Washing furry pets,
• Using an air cleaner with HEPA filter, and
• Use allergen-proof mattress and pillow covers.

(CDC, 2019)

Goals: Prevent exacerbations by following the above guidelines. Limit caffeine intake.

Therapeutic Management: Patient should make sure to take prescription medications as prescribed and avoid asthma triggers. If symptoms do not improve or worsen, they should reach out to their physician. (CDC, 2019)

Evaluation: Follow up with primary care physician to assess current treatment plan and any exacerbations experienced. (CDC, 2019)

I50.40 Combined systolic (congestive) and diastolic (congestive) heart failure

Education: Heart failure happens when the heart cannot pump enough blood and oxygen to support the organs in your body. High blood pressure is a risk factor. Symptoms include shortness of breath, weight gain with swelling located in the feet and ankles, trouble breathing when lying down and/or feeling weak. (CDC, 2019)

Goals: Take medications as prescribed, reduce sodium in diet and daily physical activity. Treat any underlying health conditions and ongoing care. (Hajar, 2019)

Therapeutic Management: Early diagnosis and treatment of heart failure is important. Patient will need to take medications as prescribed and follow advised diet and physical activity recommendations. (CDC, 2019)

Evaluation: Follow up with primary care physician to access symptoms patient is experiencing and review fluid intake, weight gain and vital signs reported by patient.

J44.9 Chronic obstructive pulmonary disease, unspecified

Education: Chronic obstructive pulmonary disease (COPD) is caused by airflow blockage and breathing-related problems. With COPD less air moves through the airways due to:

• Tiny air sacs in the lungs losing their ability to stretch and shrink back while breathing.
• The walls between many of the air sacs can become destroyed.
• The walls of the airways become thick and inflamed (irritated and swollen).

(CDC, 2019)

Goals: Relief of symptoms and preventing disease progression.

Therapeutic Management: Patients should avoid smoke and other air pollutants. Take prescribed medications as instructed. Avoid any illness that affect the lungs by receiving flu vaccines and pneumococcal vaccines. Use supplemental oxygen if appropriate. (CDC, 2019)

Evaluation: Arterial blood gases and spirometry can help evaluate the function of the lungs. Follow up with primary care or pulmonologist to discuss personalized pulmonary program to help the patient breath better.

References

Centers for Diseases Control and Prevention (CDC). (2019). Asthma. Retrieved from https:/www.cdc.gov/asthma/default.htm

Centers for Diseases Control and Prevention (CDC). (2019). Chronic obstructive pulmonary disease. Retrieved from https:/www.cdc.gov/copd/index.html

Centers for Diseases Control and Prevention (CDC). (2019). Heart Failure. Retrieved from https:/www.cdc.gov/heartdisease/heart_failure.htm

Fischbach, F. & Dunning, M. (2017). A manual of laboratory and diagnostic tests (10^th ed.).

Hajar, R. (2019). Congestive Heart Failure: A History. Heart Views, 20(3), 129–132. https://doi-org.su.idm.oclc.org/10.4103/HEARTVIEWS.HEARTVIEWS_77_19

Holgate, S. T., & Douglass, J. (2010). Asthma: Vol. 3rd ed. Health Press Limited.

Philadelphia, PA: F.A. Davis. ISBN:9780803667181