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References:

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L. & Camera, I.M. (8th Ed.). (2011). Medical Surgical Nursing: Assessment and Management of Clinical Problems. Missouri: Elsevier-Mosby.

Mr. Brody Acheived Wellness!

Extrapersonal Stressors

  • Primary Prevention: Mr. Brody's job as an attorney is a high stress one, coupled with the stress of planning a wedding. Patient would normally smoke when stressed but also reports open communication with his fiance.
  • Secondary Prevention: Now that patient is hospitalized, educating the patient about stress reduction strategies and quitting smoking is very important. Providing both the patient and his family with ways to cope with external stressors and how to quit smoking will be very important prior to discharge, once the patient is medically stable.
  • Tertiary Prevention: Once discharged, the patient should share his stressors with his family, and employ them as support systems for his high stress job as well as the challenges that come with quitting smoking.

Interpersonal Stressors

  • Primary Prevention: Patient is transitioning from divorced to being re-married. He may be experiencing stress due to the role transition. Patient would talk about these concerns with his fiance and facilitate open communication
  • Secondary Prevention: Nurse will encourage open communication between Mr. Brody and his future wife, as well as his ex-wife and children. Nurse will include the family in the decision making as appropriate and approved by Mr. Brody.
  • Tertiary Prevention: Patient will continue open communication with his family regarding concerns for the role transition. He will successfully transition in the role of husband.

Intrapersonal Stressors

  • Primary Prevention: Normally during high stress, patient would smoke. A better primary prevention strategy would have been to use healthy alternatives to stress.
  • Secondary Prevention: Now that patient is hospitalized and potentially feeling stress secondary to his hospitalization, it is a good time to teach patient coping mechanisms.
  • Tertiary Prevention: Once discharged, patient will continue to use alternative methods to smoking to relieve sress.

Sociocultural Stressors

  • Primary Prevention: Patient is a lawyer and lives in the upper sociocultural class. Patient's job is high stress and he uses cigarettes as a means to cope. Education on healthy coping skills such as exercise and meditation can help the patient achieve a healthy status.
  • Secondary Prevention: Hospitalization can be stressful and educating patient now about coping mechanisms will ensure his transition back to a stressful career.
  • Tertiary Prevention: After hospitalization, patient will continue to use learned methods to reduce stress. He will continue to refrain from smoking cigarettes.

Vincent Brody

DOB: 06/28/2016

Physiological Stressors

  • Primary Prevention: Primary prevention would have been to quit smoking to prevent COPD. Interventions to include educating patient about methods to quit smoking.
  • Secondary Prevention: Now that patient has presented with symptoms & pneumothorax, secondary intervention is to insert chest tube to bring lung function back to normal. Medications for COPD such as bronchodilators and oxygen may be administered.
  • Tertiary Prevention: After discharge, patient will continue to promote self health behaviors by refraining from smoking cigarettes and using oxygen or COPD medications as appropriate and ordered by physician.

Stressors:

  • Physiological: COPD Exacerbation, Pneumothorax
  • Sociocultural: Pt is a lawyer, he has two sons, is divorced but engaged to be remarried in the Spring.
  • Intrapersonal: Pt is likely stressed about his condition and may be experiencing an internal conflict regarding smoking cigarettes.
  • Interpersonal: There may be stress among role transition as he moves from divorced, to engaged to re-married.
  • Extrapersonal: Pt is stressed out about planning his wedding and has a high stress job.

Patient Assessment & Interventions

67 Y/O Male, 70 KG, 68" Tall, NKDA.

Direct Admit from PCP For COPD Exacerbation

Assessment Data:

Hx: Diff sleeping, increased sputum, fatigue on exertion

VS: 133/80, HR 87, RR 25

Neuro: WDL. Cardio: WDL. GI: WDL. GU: WDL. Skin Intact, diaphoretic.

Respiratory: Current smoker X 50 yr, 2 packs a day. Clubbed fingers, barrel chest, resp reg with productive cough. Wheezes bil UL, dim RLL, Absent LLL. RR 25, 93% on 2LNC.

1530: Proventil breathing tx done by RT. Solumedrol administered. Pt O2 dropped to 86% on 2LNC.

1535. MD notified.Orders to titrate oxygen >92%. 87% on 5LNC. Non-Rebreather 10L 87%. HR 118, RR 30

1540: MD notified of continued worsening status of oxygenation. RN informed of CXRAY results confirming Left Pneumothorax. Orders to prep for emergency bedside chest tube insertion, obtain thoracotomy tray and chest tube, give Morphine 2 MG IV X1 NOW. Morphine administered to patient.

Orders:

D5 1/2NS + 20K @ 100 CC/HR

Reg diet, Enc intake. Activity as tolerated

VS q4, SPO2 Mont, O2 1-2 L NC, IS Q2H

Proventil 2.5/2.5 q4h by RT, due 1600

Solumedrol 125 mg IVP q6H, due 1500

CBC Done

CXRAY Done.

ABGS: (Uncomp. Resp Acidosis)

pH: 7.32

paCO2: 52

HCO3: 25

SaO2: 76

COPD Pathophysiology

Chronic Obstructive Pulmonary Disease (COPD) is a disease that is due to inhalation of toxic chemicals (primarily cigarette smoke). This constant inhalation on smoke causes inflammation and increased mucus secretion. In turn, the alveoli are essentially "blocked" and the transfer of CO2 and oxygen cannot occur. The CO2 can build up in the lungs causing a hyperinflation and barrel chest appearance.

As the disease progresses, problems with oxygenation such as hypoxemia and hypercapnia may occur. Excess sputum production also leads to a chronic cough.

Overtime, these patients begin to experience COPD exacerbations. An exacerbation of COPD is usually brought on due to an underlying acute viral or bacterial illness and is exhibted by a change in the patients cough, dyspnea or sputum (Lewis, Dirksen, Heitkemper, Bucher & Camera, 2011).

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