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MedSurg Case Study
Transcript of MedSurg Case Study
pathophys Medications Dysphagia & aspiration RELATES ENTIRELY TO
DYSPNEA History of multiple episodes of aspiration pneumonia Chronic hypoxemia--
SpO2 95% on
4L via NC Compensated respiratory acidosis--
& lactic acid 16 exacerbations
days in August '12 Cushing's disease
steroid use Prednisone-related hyperglycemia (And their impact) Uncontrollable hand tremor from Advair &Albuterol WBC and Neuts% indicate infection Chest X-ray indicated
increased airspace opacity
in posterior lung bases Ineffective Airway Clearance R/T: Bronchospasms, edema, sputum...
AEB: abnormal lung sounds, changes in respirations depth & rate, persistent unproductive cough... Related Education:
Use of supplemental humidification
Deep breathing exercises (reinforced)
Increase liquid intake (warm, btw meals) Impaired gas exchange R/T: COPD and Pneumonia diagnoses
AEB: dyspnea, decreased oxygenation, reduced activity tolerance... Related Education:
Slow, deep, pursed-lips breathing (reinforced)
Use of prone position as tolerated
Use of home pulse oxymeter with supplemental oxygen Risk for infection [spread] R/T: inadequate secondary defenses, immunosupression, chronic disease, & existing infection Education Reinforced:
Completing antibiotic regimen Identified cardiac signs and symptoms requiring notification of health care provider. Stressed impact of heart rate on respiratory rate Discussed respiratory medications, side effects, drug & food interactions, and adverse reactions Discussed self-management plan to reduce hand tremor ...or information misinterpretation AEB: development of preventable complications R/T lack of information regarding prescribed medications.... (cc) photo by theaucitron on Flickr (cc) photo by theaucitron on Flickr Joe's heart rate is 124 bpm after 4-5 cups of coffee, complains that steroid makes his hands shake Deficient knowledge regarding
treatment and self-care needs Discharge Plan Evaluation of home safety Focused Assessment (cc) image by jantik on Flickr -Levaquin
-Home Health Teaching
and discharge plan appropriate, continue to reinforce patient learning Evaluate Joe for counseling, therapy, or support group to deal with issues of anxiety, depression, or grief related to COPD