A 56-year-old white man

A 56-year-old white man

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A 56-year-old white man presents with an accelerated decline in lung function. Last year you ordered an albuterol inhaler prn and that seemed sufficient. Today he is dyspneic, pale, and seems almost listless. He continues to smoke and his pack-year history is 40 years.

CC: “I have to sleep in my recliner because I can’t lie in bed, and I have no energy to do anything—I don’t even have energy to eat.”

Physical exam:

 

Blood pressure: 132/94

Pulse rate: 120 beats/min

Respiration rate: 36/min.

Height: 5΄9΄΄

Weight: 160 lbs

AP to lateral diameter: 1:1

Cough with clear mucoid sputum

Diminished breath sounds

Hyper-resonance over lung fields on percussion and use of accessory muscles during respiration

Pulmonary function tests: Postbronchodilator FEV1 < 0.6

FEV1/forced vital capacity < 0.7

Chest x-ray film: Small heart, hyperinflation, and flat diaphragm

Arterial blood gases: Arterial hypoxemia and respiratory acidosis

Questions:

 

  1. What additional subjective data do you think the patient will share?

 

  1. What additional objective data will you be assessing for?

 

  1. What National Guidelines are appropriate to consider?

 

  1. What tests will you order?

 

  1. Will you be looking for a consult?

 

  1. What are the medical and nursing diagnoses?

 

  1. Are there any legal/ethical considerations?

 

  1. What is your plan of care?

 

medical

nursing

complementary therapies

  1. Are there any Healthy People 2020 objectives that you should consider?

 

  1. Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting him and the family involved in the care to reach optimal health?

 

  1. What additional patient teaching may be needed?

 

  1. What billing codes would you recommend?

Sample Answer

Assignment Case Study

  1. What additional subjective data do you think the patient will share?

The additional subjective data needed included the history of the present illness. The patient indicated of having accelerated decline in the lung function; however, there are no information on how the condition started and past medical interventions. Also, more data should be provided on whether the patient has any past surgical history. The patient has been smoking for the past 40 years and this information is important for the making the right diagnosis. However, the information on other social aspect, and family history is missing and needs to be provided. The family history is important since it helps in determining whether the patient has a hereditary condition.

  1. What additional objective data will you be assessing for?

The objective data needed in this case include the review of system which helps in determining whether other organs have been affected. The systems of most importance in this case include the respiratory system, the cardiovascular system, neurological system, integumentary system and urinary tract system. Furthermore, the assessment to determine whether the patient is having arrhythmias, edema in the extremities which provides information about the vascular sufficiency in the patient (Blebea, 2017).

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