Patient Initials ______
Subjective Information
XYX is a Caucasian woman aged 65, who was cleared from a healthcare facility in the last 10 weeks after a road accident, but reports back to the clinic. She says that she has been suffering from shortness of breath, severe wheezing, as well as coughs. She is unable to speak without having breaks to hold her breath and says that she had an albuterol therapy today.
History of Current Illness
The woman claims of common asthmatic attacks for the past 2 months, which occurs at an average of 4 times a week. Also, she has had grave MVA in the past 10 weeks and a post-traumatic infection 2 weeks after the accident. Additionally, she is suffering from anti-convulsing phenytoin and no further infections evident since the beginning of therapy.
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PMH, Surgical and Medical History
The woman’s past has been periodic periods of asthma, which began at her 20s. She has suffered slight congestive heart failure, which was diagnosed in the past three years. She was instructed not to use sodium diet or hydrochlorothiazide. In the past twelve months, she was also instructed to use enalapril because of the waning CHF, whereby the signs were well managed within the year. However, the patient has no past history of surgical operations. Further, the medical history of the patient shows the presence of theophylline SR Capsules 300 mg PO BID, PRN, Allergies, Phenytoin SR capsules 300 mg PO QHS, Enalapril 5 mg PO BID, Albuterol inhaler, HTCZ 50 mg PO BID, ROS as well as NKDA.
Family History
The patient’s father passed away at 59 years, suffering from failure of kidney and minor HTN. Also, her mother passed away at the age 62 suffering from CH.
Social History
The woman is not a smoker or an alcoholic. Moreover, she takes four cups of caffeine and four food colas every day.
Symptoms Review
General : The patient looked nervous.
HEENT:
PERRLA, TM deprived of symptoms of inflammation, oral opening without cuts, and no nystagmus evident.
Chest: Consensual expiratory puffs.
Cardio: Rhythm normal S1 and S2 and Regular rate.
Abdomen: non-tender, soft, no masses and non-distended.
GU: Average.
NEURO: cranial nerves intact, A &O X3.
EXT: normal beats, +1 ankle edema on right, no stains.
Rectal: Guaiac negative.
Objective Information
Important Signs
HR-122
BP-171/94
Wt-145
T-96.7 F
RR-31
Ht-5’ 3”.
Diagnostic and Laboratory Test Results
Cl - 100
K - 4.9
Na - 134
Cr - 1.2
BUN - 21
Glu – 110
AST - 27
Total Chol – 190
Theophylline - 6.2
CBC - WNL
ALT – 24
Phenytoin – 17
Peak Flow – 75 per minute; after albuterol – 102 per minute.
X-ray for Chest – Blunting of the left and the right costophrenic angles.
FVC=3.0 L, FEV1 = 1.8 L; Therefore, FEV1/FVC=60 percent.
Findings from Physical Assessment
The readings after treatment using Albuterol were;
HR-80
BP-134/79
RR-18
Therefore, the patient was found positive for shortage of breathe, wheezing, coughing, as well as exercise intolerance. Nonetheless, she does not suffer from headache, swelling in the extremities and seizures.
Plan of Care
Respiratory Clinical Case
Even in more organized environments of Emergency Departments (ED), healthcare professionals with accessibility to diagnostic imaging and lab tests finds it hard to determine the exact cause of breathing problems of a patient. Therefore, it is challenging for the EMS providers to quickly determine the root of a breathing problem and administer the most proper therapy while evading dangerous treatments (Patel et al., 2016). However, the most common causes of breathing problems as evident in pre-historic setting are pneumonia, heart failure and COPD (Patel et al., 2016). Treatment of these infections use the history of the patient and the physical assessments and findings. In this case, there was presence of cough and abnormal breathe sounds like wheezing.
Based on the historical data of the patient’s health, the standard treatment methods will be applied, such as albuterol nebulization, nitroglycerin, morphine, Lasix and Continuous Positive Airway Pressure (CPAP) contingent on the alleged source of the problem. In every case of breathing problems, oxygen by either face mask or nasal cannula should be given and its effect on overload is regulated. Using capnography may help to evaluate and monitor the suitability of the status of the ventilator of the patient (Pandor et al., 2015). Also, nitroglycerin is a venous and arterial vasodilator that decreases consumption of oxygen and cardiac assignment. It may reduce coronary spasm, and blood pressure. It is extremely operational in respiratory edema and should be applied belligerently in this case because the blood pressure of the patient is above 110/70 mmHg (Stamler & Went, 2014). However, the healthcare professionals should reduce the dosage because higher dosage of nitroglycerin subjects a patient to headaches. Also, it causes deep hypertension to patients with a low MI and with right ventricular involvement.
According to Morgan et al. (2016), Albuterol combined with ipratropium leads to bronchodilation and reducers airways secretions. The patient has a history of asthma and the two bronchodilators are extremely useful because they reduce a way obstruction and wheezing. Although the anticholinergic ipratropium is helpful in asthma, it ought to also be applied in other cases like the COPD because it is more helpful than albuterol. However, its outcomes have been worse for patients with breathing problems as a result of heart failure. Therefore, bronchodilator therapy should be used for the wheezing patient with asthmatic history. Moreover, patients with breathing problems because of severe pulmonary edema in heart failure have high heart rate and blood pressure. Morphine has been previously used because it decreases anxiety and reduce pulmonary blocking by reduction of cardiac demand (Logan et al., 2017). Conversely, there is no evidence of the beneficial effects of morphine and it is suspected to be harmful.
However, Lasix is a common effective treatment of cases of heart failure. Mondor (2016) asserts that it increases excretion of water and sodium by the kidneys. Beginning of action with blood pressure and functioning of kidney is typically in a short time and it is marked with an increase in urine output. Although Lasix is effective for treatment of patients with heart failure because of the volume loading of pulmonary edema, there are situations in which it is harmful to patients with breathing problems. A small delay for administration of Lasix till a more decisive treatment of heart failure can be done (with laboratory studies and X-ray for ED chest) reduces the risks allied to proper use of Lasix without shelving the prospective reasons for diagnosis. Its use should ensure maximum dosage of nitroglycerin and be open to careful attention to patients with a high probability of heart failure. In this case, the patient has previously suffered from heart failure and it is recommended that healthcare practitioners avoid Lasix, morphine as well as actually bronchodilators while offering additional nitrates, oxygen as well as CPAP.
References
Logan, R., Barko, K., Shelton, M., Becker-Krail, D., Parekh, P., Depoy, L., & McClung, C. (2017, November). Circadian Rhythms and Opiates: Role of the Circadian Transcription Factor NPAS2 to Regulate Morphine Conditioned Reward. In Neuropsychopharmacology (vol. 43, pp. S453-s453). Macmillan Building, 4 Crinan St, London n1 9xw, England: nature publishing group.
Mondor, E. E. (2016). Assessment of Respiratory System. Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume , 452.
Morgan, S., Matthews, P., Papas, M. A., Davis, B., & Megargel, R. (2016). 126 An Observational Study of Albuterol Administration by Basic Life Support Providers. Annals of Emergency Medicine , 68 (4), S50.
Pandor, A., Thokala, P., Goodacre, S., Poku, E., Stevens, J. W., Ren, S., & Penn-Ashman, J. (2015). Pre-Hospital Non-Invasive Ventilation for Acute Respiratory Failure: a Systematic Review and Cost-Effectiveness Evaluation. Health Technology Assessment , 19 (42), 1-102.
Patel, B. K., Wolfe, K. S., Pohlman, A. S., Hall, J. B., & Kress, J. P. (2016). Effect of Non-invasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome: a Randomized Clinical Trial. Jama , 315 (22), 2435-2441.
Stamler, J. S., & Went, G. T. (2014). U.S. Patent No. 8,664,269 . Washington, DC: U.S. Patent and Trademark Office.
