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Client Complaints
P.S. reports to the hospital complaining of a dry cough and dyspnea that began two weeks ago, a sore throat, and a fever that is 101 Fahrenheit orally.
HPI
P.S. is a woman of Caucasian origin, 65 years of age with a history of emphysema. She reported to the hospital today with complaints of dyspnea and a dry cough. Her fever is 101 Fahrenheit. Her dry cough has persisted for two weeks. She had similar symptoms in the past, the last episode occurring three months ago when she went for treatment in the emergency room and declined the hospitalization. The healthcare provider treated her with antibiotics that she could not remember and gave her an inhaler, which improved her condition.
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The shortness of breath, which began two weeks ago, occurs when performing any activity. P.S. also has had a dry cough for two weeks that occurred at night. The dyspnea and cough usually alleviate when sitting up in a chair. In addition, her appetite is also reduced.
PMH
P.S. has never been admitted before. She was diagnosed with emphysema but declined taking further tests. She has never been operated before. Additionally, P.S. currently does not take any prescribed medicines. She takes Tylenol 650 mg, 2 PO p.r.n. over the counter. P.S. also develops rashes after taking sulfa drugs and thus, is allergic to them.
Significant Family History
P.S. has sisters aged 75 and 72 years, who have osteoporosis and breast cancer respectively.
Social/Personal History
D.M. is a retired hairdresser. She has positive health beliefs and consumes healthy food. However, her shortness of breath makes it difficult for her to exercise. She admits smoking a pack of cigarettes every day, but she denies ever using alcohol and street drugs.
Description of Clients Support System
Her daughters and her contacts in the church constitute her support system. However, she does not talk to them occasionally.
Behavioral or Nonverbal Messages:
During the history taking, P.S. looks restless; she also appears depressed.
Client Awareness of Abilities, Disease Process and Health Care Needs
P.S. is aware of her healthcare needs, but she does not understand the disease process because she guesses the diagnosis to be pneumonia and cancer. Besides, she declined hospitalization before, which is an indication that she has little willingness to follow the orders from clinicians.
Objective Data
Vital Signs and BMI
The blood pressure of P.S. using the left arm when sitting is 130/72mmHg. Her temperature is 101 Fahrenheit, and her Pulse is 100 beats per minute and regular. Her respiration is 20 breaths per minute and non-labored. P.S. Weighs 130 pounds; her height is 55 feet. BMI is calculated as weight in kg over height squared in meters (Shah & Braverman, 2012). 130 pounds converted to kilograms is 58.9 kg, since one kilogram is 2.2 pounds. Her height is 1.4 meters, since one meter equals to 3.3 feet. Therefore, the BMI for D.M. is 58.967/ (1.397 times 1.397) = 58.967/1.951609. BMI= 30.2, which is obese.
Physical Assessment
The buccal mucosa in the oral cavity of P.S. has white material, which cannot be removed by the tongue blade. Her right lower lobe of the lungs has an end expiratory wheeze. Further, P.S. has decreased breath sounds in the right lower lobe, which are dull when percussed. On auscultation, rales and rhochi are not heard. Her anterior-posterior diameter to the chest wall is increased. No murmurs are heard on the chest wall; no bruits are heard on auscultating the carotid; and her abdomen is reduced. Her extremities have 2+ pulses throughout with no edema.
Lab Tests and Results
Her Complete Blood Count (CBC) shows that her White Blood Cells (WBCs) are 15, 000 with + left shift. P.S. also has a partial pressure of oxygen that is 98%, and her Radiological Studies indicates normal sinus rhythm.
Clients Support System
P.S. visits her daughters monthly. She also goes to church, where she meets with people who talk to her occasionally.
Locus of Control and Readiness to Learn
P.S. frequently visits her primary care provider. She declined hospitalization three months ago when she visited the hospital due to the same symptoms. Additionally, she buys Tylenol 650 mg, 2 PO, p.r.n, which is not prescribed, over the counter. She also has little compliance with the orders of the healthcare providers. Therefore, P.S. thinks she can determine her health outcome.
ICD-10 Diagnoses/Client Problems
ICD-10 has several classifications of diseases (World Health Organization [WHO], 2016). In the case of P.S, she has Emphysema, which is J43.9. She also has E66.9- overweight due to a BMI of 30 (unspecified), R 63.0-Loss of appetite, R11.0- Nausea and Vomiting, R07.3-Pain, R06.0-Dyspnea, and R07.0 Sore throat.
Nursing Intervention Plan
From the assessment, P.S. might be having emphysema. P.S. also has little willingness to follow orders from the health care providers. Therefore, the nurse can change her attitude towards seeking health services and complying with healthcare advice by counseling the patient, since counseling has been efficient in changing the attitudes of patients to therapeutic interventions (Dol, Jadhav, Pisal, Shaikh, & Shinde, 2015). Then, the nurse can assess her breathing pattern, because emphysema leads to dyspnea that can be fatal if not controlled (Salah, Hamdi, & Shehata, 2013).
The nurse can then collaborate with the laboratory to apply culture and sensitivity and then liaise with the doctor in decoding on the appropriate prescriptions. The prescription can include any suitable antibiotic to treat infections, since emphysema makes patients vulnerable to infection (Pauwels, Buist, Calverley, Jenkins, & Hurd, 2012). Then, instead of Tylenol 650 mg, 2 PO p.r.n, the nurse can recommend the prescription of corticosteroids, since they are efficient in treating inflammation (Abdallah, Madi, & Rana, 2015). Then, the nurse can encourage P.S. to sleep with pillows under the head and be sitting upright, because they help in relaxation and prevention of dyspnea (Kristjansdottir, Ragnarsdottir, Hannesson, Beck, & Asgeirsdottir, 2015).
Teaching, Education, and Follow-Up
Compliance with medication. The nurse can accentuate the importance of taking drugs as prescribed in order to prevent infection, which often happens to people with untreated emphysema (Pauwels et al., 2012).
Nutrition. The nurse can then liaise with the nutritionist who can assess and prevent the risk for malnutrition in P.S. Patients with emphysema have hypoxia that triggers the hypermetabolic state leading to malnutrition, if a patient does not observe a proper diet (El-Yazed, Eldaboosy, El-Bassiony, Hashim, & El Gendi, 2013).
Support system and Follow-Up. The nurse can plan a follow-up program for P.S. that will help to assess her adherence to the healthcare advice, her interaction in the community, and her compliance with the prescribed medications. The nurse can then tell her to call her daughters and teach them about the emotional benefits of caring for their mother. Most importantly, the nurse can explain to the daughters that depression can exacerbate emphysema symptoms (Gado, Basiony, Ibrahim, Affara, & Shady, 2015), and that it is essential for them to be concerned about their mother. Finally, the nurse can talk to the primary care provider about the condition of P.S. because the care provider is busy and might not notice the potential complications.
