Comprehensive Care Plan

Published: 2017-08-10 09:36:31
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SECTION 1 - INTRODUCTION  (1-2 paragraphs)

Brief history of current hospitalization: A sixty-four year old patient presents with intermittent cough that is productive and became severe in the morning. He also has audible wheezes throughout inspiration and expiration and mild dyspnea. No fever or chills. He also reports chest pains and tightness especially while coughing. The pains were of sudden onset, described as dull aching and radiating from the parasternal area to his neck. He has been previously having about three episodes daily which would be relieved in about fifteen minutes apart from today that it was prolonged. He has not had any history of peptic ulcer disease or any known chronic illness. On examination, bilateral lung sound wheezes are felt.     

Reason for admission: admitted to offer mechanical breathing support and monitor any superimposed infection due to the productive cough.

Primary diagnoses: Bronchial Asthma

Secondary diagnoses: Acute Bronchitis

Complications & Co-morbidities: Status asthmaticus, possible pneumonia, and respiratory failure.

Significant past medical history: diagnosed with tuberculosis twelve years ago, allergic to penicillin.

Advance directives: The patient wishes that no further resuscitation is done to him should he fall into a coma with minimal chances of survival. He also disregards any form of invasive surgery done on him should he become incapacitated to make such a decision.  

Living arrangements, social status, & support systems: The patient lives with his wife, daughter and a grandson. His other two children frequently visits him as they all live within the state. He is also a beneficiary of the social support program for the elderly offered by his church. 

Spiritual and cultural needs: He is a devoted Christian who attends the Catholic Church near his home every Sunday.

SECTION 2 - PATHOPHYSIOLOGY

Bronchial Asthma is a form of chronic obstructive disease associated with an increased response of the airways to various stimuli which results in spasmodic narrowing of the airways. It presents clinically with a dry cough, wheezing, and dyspnea (Mims, 2015). In some cases, as seen in this patient, it may manifest as status asthmaticus in which the symptoms persist for a prolonged period. In most cases, according to Mims (2015), an atopic stimuli such as dust, fumes and gases causes a hypersensitivity reaction. Mast cells sensitized by IgE on the mucosal surface initiate an acute immediate response. They release immune mediators such as prostaglandins, histamine, platelet activating factors, and other chemotactic factors for neutrophils. The immune response leads to bronchoconstriction, mucus hyper secretion, edema, and accumulation of lecocytes (Doeing & Solway, 2013). Additionally the immune mediators cause inflammatory injury to the respiratory mucosa. The effect is the typical symptoms associated with the disease. In some cases, an upper respiratory tract infection may be superimposed to the illness causing severe complications that may lead to pneumonia. Therefore, this patient needs further evaluation to monitor for an infection or status asthmaticus.      

SECTION 3 - MEDICATION REGIMEN

Scheduled medications

 MEDICATION NAME

 DRUG

CLASS

ACTION / PHARMACOKINETICS

 DOSING

RANGES

COMMON

SIDE EFFECTS

NURSING PRECAUTIONS & MONITORING

RATIONALE FOR USE SPECIFIC TO PATIENT

Albuterol

Beta 2 agonist

Aerosol metered-dose inhaler to reduce severe bronchospasm.  

90mcg (Base)

            Tremor

            Anxiety

             Insomnia

             Paradoxical bronchospasms.

            Contraindicated if hypersensitive to milk proteins.

            Monitor potassium and glucose levels in the blood.

             Also check for paradox bronchospasms.

            The patient is experiencing severe coughing, dyspnea, and chest pains due to bronchospasms.

Prednisolone

Corticosteroid

Oral tablets to reduce inflammatory response of the mucosa

1 tablet (50mg) QID

            Glucose intolerance

             Myopathy

             peptic ulcers

             weight gain

            Precaution in diabetic patients, and those with documented hypersensitivity.

             Look out for myopathy, and recurrence of infections such as TB.

            Used for relieving the symptoms resulting from hypersensitivity.

Multivitamin

Vitamins and Minerals

Oral tablets for Nutritional supplements.

2 tablets QID

            Constipation

             Nausea and Vomiting

            Monitor for any form of anemia present

            The patient feeds poorly due to occasional pains and anorexia

Erythromycin

Macrolides antibiotics

A prophylaxis and treatment of any upper respiratory tract infection

1 tablet (250mg) QID.

            Dyspepsia

            Allergic reactions

            Pruritus

            Ventricular arrhythmias

            Continuous monitoring of the heart function to avoid any associated adverse effect

            Due to the productive cough, the patient may be having a superimposed infection that needs to be controlled

 PRN medications (administered within the last 48 hours):

 MEDICATION NAME

 DRUG

CLASS

ACTION / PHARMACOKINETICS

 DOSING

RANGES

COMMON

SIDE EFFECTS

NURSING PRECAUTIONS & MONITORING

RATIONALE FOR USE SPECIFIC TO PATIENT

Acetaminophen

Analgesics

Oral tablets that inhibits synthesis of prostaglandins in CNS and block the generation of pain impulse peripherally 

1 tablet (160mg) TID

            Liver failure

            Pancytopenia

            Dizziness

            Pruritic maculopapular rash

            Monitor for any signs of liver disease.

             Used in caution for patients with G6PD deficiency or chronic malnutrition

            Used due to the severe chest pains that were being experienced. Cant use NSAIDs as they may exacerbate the condition

Albuterol

Beta 2 agonist

Aerosol metered-dose inhaler to reduce severe bronchospasm.  

90mcg (Base)

            Tremor

            Anxiety

             Insomnia

             Paradoxical bronchospasms

            Contraindicated if hypersensitive to milk proteins.

            Monitor potassium and glucose levels in the blood.

            The patient is experiencing severe coughing, dyspnea, and chest pains due to bronchospasms.

SECTION 4 - LAB & DIAGNOSTIC TEST DATA

Labs:

Full Blood Count- The patient indicates an elevated white blood cell count without left shift. Differential count indicates eosinophilia. A CBC and differential count is critical in evaluation of bronchial asthma to rule out infectious causes. According to Mims (2015), it may demonstrate leukocytosis with or without a left shift. However, due to the albuterol medication which is a beta 2 agonist, demargination may cause an increase in peripheral white cell count.   

Arterial Blood Gas-The FEV of the patient is at 28% which calls for urgent intensive care. The value of ABG may be used to evaluate how severe the asthmatic attack is and determine the significance of admission for intensive care. The determination is of clinical significance if the Forced Expiratory Volume is less than 30% of the predicted value and the patient is experiencing dyspnea or fatigue (Melani, 2013).    

Diagnostic Tests:

Pulmonary Function Testing- this test is executed by measuring the Peak expiratory Volume to evaluate the function of the lungs in accordance to the presenting symptom. In this patient, the decrease in in peak flow as a fraction of the predicted value is in accordance with the spirometry values. It is at 55%. According to Rance (2011), admission is recommended for patients whose FEV1 or PEF is between 50% to 70% of the predictive value after treatment. This is the reason why this patient had to be admitted. Spirometry is then used to monitor how the disease progresses, and helps in treatment adjustment according to improvement realized.   

Point of Care Testing:

A POCT done on the patient was checking for his blood glucose regularly to evaluate the effect of medications. They random sugars were slightly elevated but fasting blood sugar indicated a normal level. According to Melani (2013), serum glucose levels may be elevated in asthmatic patients due to psychological stress and use of the beta 2 agonists and corticosteroids.  

Pulse oximetry- this test, usually done at the bedside, provides a continuous assessment of oxygen saturation as reduced levels may cause hypoxia.

SECTION 5 - ASSESSMENT

Physical Examination

Constitutional- He is oriented person, place, and time. She appears well-developed and well-nourished. Non toxi appearance. No distress.

Last Vitals

BP- 109/56

Pulse- 108

Temp- 37 degrees Celcius

Respiratory Rate- 20

Height- 160cm

Weight-72.1kg

SpO2- 94%

Review of Systems

All other systems were reviewed and there were negative findings

HENT

Head- Normocephalic and atraumatic

Eyes- Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light

Neck- Normal range of motion. Neck supple. No JVD present

Cardiovascular- Regular rhythm and normal heart sounds. Tachycardia present

 Pulmonary/chest-Effort normal, no respiratory distress, she has wheezes, she has rhonchi

Abdominal- Soft. Bowel sounds are normal. She exhibits no mass, no tenderness.

Musculoskeletal- Normal range of motion, She exhibits no edema or tenderness.    

Neurological- She is alert and oriented to time, person, and place. Total GCS score is 15

Skin- Skin is warm and dry. No rash noted

Psychiatric- She has a normal mood and affect. Her behavior is normal

Nursing notes and vitals reviewed.

 SECTION 6 - NURSING PLAN OF CARE

NURSING PROBLEM /

NURSING DIAGNOSIS

(NANDA)

 OUTCOME / GOAL

 NURSING

INTERVENTIONS

RATIONALE(S)

EVALUATION

   Ineffective breathing pattern

To maintain a normal Pattern of breathing evaluated through a normal rate of respiration (below 20bpm), and absence of dyspnea

            Evaluation of the vital signs while the patient is in distress

            Evaluate the respiratory depth and rhythm

            Evaluate the level of anxiety

            Listen for abnormal breathe sounds such as wheezes.

            Initial hypoxia and hypercapnia results in increased BP, RR, and HR (Doeing & Solway, 2013).

            An early sign of impending respiratory distress is change in the rate and rhythm of the process (Mims, 2015).

            The patient may become anxious for being unable to breathe well (Mims, 2015).

              Worsening condition of asthma may be indicated by abnormal sounds in the respiratory pathway. 

The patient was free from respiratory distress after medication. His new RR was 18bpm while the HR reduced to 84bpm

  Ineffective Airway Clearance

The patient should be able to maintain the patency of the airway evidenced by clear breath sounds and ability to cough out secretions appropriately.

            Look for color changes in the buccal mucosa and lips

            Evaluate the color, amount, and viscosity of the secretions.

            Monitor the saturation of oxygen using the pulse oximetry

            Monitor the white blood cell count

            According to Mims (2015), cyanosis may occur due to inadequate peripheral oxygenation.

            Normal sputum is usually clear or gray in color without any odour (Doeing & Solway, 2013).

            Oxygenation problems may be indicated by saturation levels below 90% (Melani, 2013) 

            If it is increased, there could be a superimposed infection(Doeing & Solway, 2013)

The patient was able to maintain a patent airway after two days of admission. There was no wheezing and the secretions were being coughed out effectively.

 Deficient knowledge about the              disease

The patient, together with the close relatives be informed about the disease, its management during attacks, and the community support available to such patients

            Evaluate the patients knowledge of care for asthmatic attacks or status asthmaticus

            Evaluate the knowledge of the patient on their particular inflammatory triggers

            Educate the client about environmental triggers and how they can be avoided

            Educate on how to use the nebulizers and nasal sprays correctly 

            Such knowledge helps in saving time by handling care for themselves

            Identifying these triggers help the patient to avoid attacks by avoiding them.

            Environmental triggers such as exercises, smoking, and air pollution may increase the frequency of attacks (Rance, 2011).

            To ensure appropriate delivery of the medication in required doses

The patient was taught about various aspects of Asthma and it was evident by him informing his family members about the disease. He was also using the pressured metered dose on his own.

  7 - DISCHARGE PLANNING/EDUCATION 

Discharge to (level of care):

Discharge home. The level of care provided by the family members is sufficient as the dyspnea is reduced and infections controlled. Additionally, the community nurses will be visiting him after every month to assess his progress 

Post-Acute Care Follow-up/Transitional Care:

The nurses in charge are required to ensure he is compliant to all medications provided. He will also visit the respiratory clinic after one month for evaluation. The family members will be required to always have someone near him so that should he have an attack, he will be helped to control it.

Support:

Support from the family members whom he stays with in the house will be sufficient as his condition is chronic. Additionally, the program initiated by his church for socially supporting the elderly will come in hand to ensure he has a peace of mind.      

Educational Needs:

Most of the information about his disease was provided in the hospital. However, the community nurses will be mandated to offer continuous medical education to this man and his family whenever they visit him at home. Particularly, he needs more education about his diet and nutritional support 

Barriers to Learning:

The continuous medical education may be impended by the age differences between the patient and the available nurses. He sees them as too young to advise him. However, they will use their expertise to give have him comply with their advice.  

Other Discharge Needs/Services:

Before being discharged, the family members will be informed about the disease and how they can control any attack that comes up. The patient will require close monitoring and should therefore never be left alone in the house. They will also be required to ensure he feeds adequately to avoid malnutrition.  

References

Doeing, D., & Solway, J. (2013). Airway smooth muscle in the pathophysiology and treatment of asthma. Journal of Applied Physiology114(7), 834-843. http://dx.doi.org/10.1152/japplphysiol.00950.2012

Melani, A. (2013). Management of Asthma in the Elderly Patients. Clinical Interventions in Aging, 913. http://dx.doi.org/10.2147/cia.s33609

Mims, J. (2015). Asthma: definitions and pathophysiology. International Forum of Allergy & Rhinology5(S1), S2-S6. http://dx.doi.org/10.1002/alr.21609

Rance, K. (2011). Helping Patients Attain and Maintain Asthma Control: Reviewing the Role of the Nurse practitioner. Journal of Multidisciplinary Healthcare, 299. http://dx.doi.org/10.2147/jmdh.s22966

sheldon

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