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Meet Our Patient:
Transcript of Meet Our Patient:
Sophia, Kayla, Rachel, Brandy, Ashley, Karen, Emily, Darlene & Lisa
Personal & Social History
A.D. is a 69 y/o Caucasian male who has been married to his wife for 46 years. He is a retired Army veteran and Florida native who loves fishing, traveling, American History and playing cards. He has two adult children and three grandchildren. He lives in Port St. Lucie and attends the local Catholic church every Sunday.
Past Health, Mental & Psychosocial History
Type 2 Diabetes Mellitus
Irritable Bowel Syndrome
Hard of Hearing
Other Pertinent History
One year history of suboptimal diabetes control and diagnosed with COPD 5y ago
Starting smoking in mid-twenties and has smoked 40 packs of cigarettes per year with a recent decrease to 3-5 cigarettes per day
Does not monitor BGL at home and denies following a diabetic diet regimen with expressed doubt in medication and treatment of DM
Current A1C is 9%
Reason for visit:
Severe dizziness and shortness of breath with increasing fatigue when standing or walking
Trace edema in right ankle and +1 edema in left ankle
Productive cough with moderate to large amounts of thick, tenacious, green sputum
P: 115 bpm, irreg
RR: 36 breaths/min
BP: 186/60 mmHg
O2 sat: 87%
Auscultation reveals diminished breath sounds with expiratory wheeze and rhonchi throughout all lung fields
PaO2- 54 mmHg
PaCO2- 59 mmHg
HCO3- 30 mg/dL
SOB, COPD Exacerbated
Plan Of Care
Diet/nutrition, oxygen therapy, exercise regimen, patient education on disease and risk factors for exacerbation, lifestyle modifications, education and management of diabetes mellitus
American Diabetic Association recommends:
Carbohydrates (individualized) 45-65%
Protein Intake 15-20%
Dietary Fats (low in sat. fat & cholesterol) <10%
Fiber Intake 20-35 g/day
Sodium 1000mg/1,000 kcal (avoid table salt)
Low sugar or use of sweeteners (if necessary)
No more than 2 alcoholic beverages/day
Respiratory: Albuteral Sulfate (3 mL) performed Q6H by respiratory therapist and Solu-Medrol PO daily
Medication regimen: indication for use, side effects, administration
Priority Plan of Care for Mr. A.D.
Ineffective Breathing Pattern
By EOS, patient will maintain effective respiratory rate and pattern, within acceptable range of 12-20 breaths per minute
By EOS, patient will clear secretions effectively and reduction of congestion with clear breath sounds.
Risk for Ineffective Therapeutic Regimen Management
By EOS, patient will initiate necessary lifestyle changes and participate in treatment regimen.
1. Administer 2L oxygen via NC, as ordered, and follow prescribed respiratory treatments to improve patients breathing and prevent hypoxia.
3. Increase PO fluid intake to 2,000 mL/day to loosen viscosity of sputum.
1. Explain/reinforce explanations of disease process and ways to prevent exacerbations of COPD and uncontrolled diabetes mellitus.
COPD, Pneumonia, Uncontrolled Type 2 DM
productive cough, SOB, low O2 sat, diminished breath sounds with rhonchi and wheeze, BLE trace edema, dyspnea, pursed lip breathing and BGL of 298 mg/dL
P: 76 bmp
R: 18 breaths/min
O2 Sat: 99% (2L via NC)
18, even, labored
diminished, shallow with bilat lower lobe rhonchi and expiratory wheeze
moist, productive cough with moderate, thick, green sputum, present mostly in the morning
2L O2 via nasal cannula
Integumentary & Musculoskeletal Status
Color consistent with race/pale and dusky
Dry, warm, intact & elastic skin
IV Site: #20 RAC, CDI
0.9% NS @ 60ml/hr + Cleocin Phosphate
Gastrointestinal & Genitourinary Status
Abdomen round, soft, non-tender
Hypoactive bowel sounds
Last BM 9/16/14: formed, soft, brown
PT denies flatus, N/V
Diet: diabetic/heart healthy; well tolerated
Neurological & Psychosocial Status
Eyes 5mm, brisk, PERRLA
Equal bilateral upper & lower extremity strength
Patient is on a Heart Healthy/Diabetic Diet
Moderate carbohydrate, low sugar
Small meals & frequent snacks at regular, scheduled times
Monitor blood glucose AC & HS
Tolerated meals well; consumed 80%
Respiratory Infection: Clindamycin, Tobramycin
IV Fluids: Sodium Chloride (0.9% NS) at 125ml/hr with Lasix PO 20mg daily
Oxygen: 2 L 02 via NC
Calm, cooperative, pleasant
Pain: 2/10 -- low back d/t bed rest
Apical: 66, regular
Periph: +2 equal bilat
Pedal: +1 equal bilat
BUE: trace edema
Right Ankle: trace
Left Ankle: +1
CRT < 3 sec.
Bedrest, unable to assess gait
UE/LE full ROM
No swelling or tenderness in joint
PT wearing SCDs
Voiding with urinal
Urine clear, yellow
No burning, pain, difficulty urinating
Periods of incontinence
identified Streptococcus pneumoniae, the causative agent for respiratory infection
9% with estimated average BGL at 212 mg/dL
Flattening of the diaphragm as result of hyperinflation and evidence of pulminary infection
Slight cardiac enlargement
improve oxygenation, control blood glucose levels, improve quality of life
Diabetic diet and exercise regimen
Prevention of infection and foot safety
Blood glucose monitoring
Signs and symptoms of COPD exacerbation
Incentive spirometer and TCDB breathing exercises
R/T SOB, secondary to disease process
AEB dyspnea, pursed lip breathing
3. Keep head of bed elevated to increase diaphragm and monitor pulse oximetry Q4H/PRN to verify if treatment is effective.
2. Encourage use of respiratory adjuncts, such as incentive spiratory and TCDB to facilitate a deeper respiratory effort and improve breathing pattern.
Home Care 2x/week
Focus will be on ensuring a diabetic diet and glucose monitoring is being incorporated, as well as, ways to prevent exacerbation and infection.
Mr. A.D. will be sent home with oxygen therapy (2 L via NC) to be used as needed. He will be educated on proper use and safety with oxygen therapy.
Ineffective Airway Clearance
R/T smoking, retained secretions, COPD disease process AEB excessive sputum, labored breathing, rhonchi/wheeze
1. Monitor respirations and breath sounds, noting rate and adventitious sounds for distress and/or accumulation of secretions.
2. Instruct patient to TCDB every 2-4 hours and ambulate early, as tolerated.
R/T chronic disability, secondary to COPD, smoking and lack of knowledge of diabetic condition
3. Discuss importance of avoiding those with active respiratory infections and stress need for routine influenza and pneumococcal vaccines.
2. Review the harmful effects of smoking and advise ways to start a smoking cessation program.
With successful education and active participation in care, Mr. A.D. will maintain a stable blood glucose level and prevent future COPD exacerbation.
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