Respiratory Discussion APN Week 2

For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.

The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases may be present in the quizzes, the midterm exam, and the final exam.

Learn how to access and navigate Aquifer.

This week, complete the Aquifer case titled “Family Medicine 28: 58-year-old man with shortness of breath”

Apply information from the Aquifer Case Study to answer the following discussion questions:

Discuss the Mr. Barley’s history that would be pertinent to his respiratory problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
Describe the physical exam and diagnostic tools to be used for Mr. Barley. Are there any additional you would have liked to be included that were not?
What plan of care will Mr. Barley be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
Rubrics

NSG 6001 Week 2 Discussion

Chief Complaint: Mr. Barley arrived to the clinic with complaints of a productive cough and dyspnea for the past two winter seasons.

History of Present Illness: Mr. Barley is a 58-year old male arriving to the clinic complaining of dyspnea on exertion and a productive cough for the last two weeks. The patient states that his cough occurs seasonally during the last two winters. The patient explains that he coughs up a whitish phlegm. He also confirmed that his dyspnea is noticed when he walks quickly or when walking upstairs. Mr. Barley denies chest pain, fever, nausea, vomiting, diarrhea, weight loss, extremity swelling, orthopnea or paroxysmal nocturnal dyspnea. He also denies traveling recently and exposure to tuberculosis. Mr. Barley also denies psychosocial symptoms such as paresthesia, choking, de-realization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushing.

Onset: Started approximately two weeks ago

Location: Chest

Duration: Symptoms have persisted for the last 2 weeks; Similar symptoms for the past two winter seasons

Characteristics: Productive cough with “whitish phlegm” and dyspnea on exertion

Aggravating factors: Worsening with exertion

Relieving factors: Rest

Treatment: None noted

Severity: Patient seeking medical attention at the clinic due to progressively worsening cough and dyspnea.

Social History: Mr. Barley has been married to his wife for 35 years and they have two adult children. The patient’s occupation is farming but he denies exposure to dusts or chemicals because he raises his crops organically and wears protective clothing as needed. Mr. Barley admits that he has smoked one to two packs daily for the last 26 years and he drinks one beer every few days.

Family History: Mr. Barley states that his father died at age 79 of a stroke and his mother has been diagnosed with hypertension. He reports no other significant family health history.

Past Medical History: Mr. Barley denies taking any medications or having been admitted to the hospital. He states that he has had a history of cuts and stitches and a tonsillectomy when he was 12 years of age. The patient denies any chronic illness.

Physical Examination:

Vital signs: BP: 128/78 mmHg; P – 94 beats/minute; R – 22 breaths/minute; T – 98.9 Fahrenheit

General: Mr. Barley appears mildly short of breath.

HEENT: Normocephalic, atraumatic, conjunctivae and sclerae are normal, PERRL, oropharynx is normal. Neck: Supple without masses, lymphadenopathy or thyromegaly. Laryngeal height measures 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration.

Lungs: Increased AP diameter. Percussion is normal. Inspiratory crackles at the bases, and end-expiratory wheezing diffusely.

Heart: Regular rate and rhythm. 2/6 systolic murmur loudest at the right upper sternal border with radiation to the left lower sternal border. Denies chest pain or palpitations.

Abdomen: Bowel sounds normal, no hepatomegaly, no tenderness.

Extremities/Pulses: 1+ pitting pretibial edema

Neurologic: Denies paresthesia, de-realization feeling, trembling or shaking, dizziness or sweating.

Mr. Barley’s physical examination revealed several abnormalities, which include an increased anterior posterior diameter of his chest, laryngeal height measuring 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration, inspiratory crackles at the lung bases, and end expiratory wheezing. Mr. Barley’s cardiovascular examination revealed a 2/6 systolic murmur loudest at the right upper sternal border with radiation to the left lower sternal border. The patient’s extremities show 1+ pitting pretibial edema. Other than the findings listed above, the patient’s physical examination is within normal limits.

Differential Diagnoses: Chronic obstructive pulmonary disorder (COPD); Asthma; Bronchitis

Diagnostic Tools: After Mr. Barley’s physical exam, the health care provider decided to order a pulmonary function test (PFT) to differentiate a diagnosis of chronic obstructive pulmonary disease (COPD) or asthma. According to Buttaro, Trybulski, Polgar-Bailey and Sandberg-Cook (2017), “spirometry is essential to the diagnosis and management of asthma and COPD” (p. 470). Mr. Barley underwent the recommended PFT and the post bronchodilator forced expiratory volume (FEV1) and forced volume capacity (FVC) ratio resulted at 69 percent, which is less than 70 percent indicating obstructed airway disease. The diagnosis of asthma was ruled out due to the FEV1 not changing after bronchodilator treatment.

I believe it would be useful to include a chest x-ray in Mr. Barley’s diagnostic tools. A chest x-ray may exclude causes or problems other than COPD (Reis et al., 2018). It may also detect treatable causes of dyspnea other than COPD. Lab diagnostics including a complete blood count, metabolic panel, thyroid-stimulating hormone and B-type natriuretic peptide (BNP) would also be useful to rule out anemia, electrolyte imbalances, hyperthyroidism or cardiac issues (Buttaro et al., 2017; Reis et al., 2018). I would also inquire to have Mr. Barley’s pulse oximetry taken to determine his oxygen saturation at rest and during exertion.

Plan of Care: The health care provider decided to treat Mr. Barley’s mild COPD by prescribing an albuterol metered-dose inhaler and advising the patient to quit or decrease smoking. Mr. Barley must be educated on how to use an inhaler and he should demonstrate its use back to the provider or nurse to ensure he is receiving the appropriate dose. Mr. Barley should also be educated on albuterol’s most frequent adverse effects, such as tremors, nervousness, and insomnia (Medscape, 2018). An additional goal of COPD treatment would be to prevent complications. Mr. Barley’s health care provider recommended immunizations for influenza, pneumococcus, and TdaP to avoid specific infections. Patients with COPD have a high risk of exacerbations from the influenza virus, which is associated with an “increased death rate, impaired pulmonary function, poor quality of life, and substantial economic burden” (Arabyat, Raisch & Bakhireva, 2018, p. 163). Therefore, preventing episodes like the influenza virus is essential in the management of COPD patients. It is important to educate Mr. Barley on what to watch for COPD exacerbations and side effects of medication therapy. According to the 2017 GOLD report, an exacerbation is “an acute worsening of respiratory symptoms that results in additional therapy” (Global Initiative for Chronic Obstructive Lung Disease, 2017). Exacerbations of COPD involve worsening of breathlessness, cough or sputum, oxygen saturation levels, limitation of daily activities, use of accessory respiratory muscles, cyanosis, deteriorated mental status, peripheral edema or hemodynamic instability (Reis et al., 2018). If the patient’s symptoms are not controlled, a long-acting bronchodilator, beta-2 agonist, anticholinergic, theophylline or combination therapy may be added to the patient’s medication regimen. The use of systemic glucocorticoids or admitting patient to the hospital may be indicated depending on the severity of the patient’s COPD exacerbation. Mr. Barley should be followed periodically by his primary care physician and pulmonologist. He should also have PFT’s performed every three months to reassess and monitor for progression of disease (Reis et al., 2018). If the patient is willing, it is beneficial to refer him to a smoking cessation and respiratory rehabilitation program.

References

Arabyat, R.M., Raisch, D.W. & Bakhireva, L. (2018). Influenza vaccination for patients with chronic obstructive pulmonary disease: Implications for pharmacists. Research in Social and Administrative Pharmacy, 14(2), 162-169. doi: https://doi.org/10.1016/j.sapharm.2017.02.010

Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier

Global Initiative for Chronic Obstructive Lung Disease. (2017). Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (2017 report). Retrieved from: https://goldcopd.org/gold-2017-global-strategy-diagnosis- management-prevention-copd/

Medscape. (2018). Albuterol. Retrieved from: https://reference.medscape.com/drug/proventil- hfa-ventolin-hfa-albuterol-343426#4

Reis, A.J., Alves, C., Furtado, S., Ferreira, J., Drummond, M. & Robalo-Cordeiro, C. (2018). COPD exacerbations: Management and hospital discharge. Pulmonology. doi: https://doi.org/10/1016/j.pulmoe.2018.06.006

Response 1

Hello Yoandris,

Great job on your post! Your description of Mr. Barley’s visit and physical examination depicted him well. I found that the case study was missing some pertinent subjective information such as the type of treatment Mr. Barley was using at home to help him remedy his cough and shortness of breath. I also found that the case study did not describe the severity of Mr. Barley’s shortness of breath. I am assuming that Mr. Barley was not in acute distress due to the duration of his symptoms and because he did not go to the emergency room. I appreciate your discussion of medications that are used frequently for patients with chronic obstructive pulmonary disorder (COPD). I thought that it was appropriate that Mr. Barley begin with a beta2 agonist such as an albuterol metered-dose inhaler to alleviate his symptoms. It is essential that Mr. Barley is educated on how to self-administer his albuterol properly and the adverse effects of his medication. Adverse effects of albuterol include tremors, nervousness, tachycardia, and insomnia (Medscape, 2018). As you have stated, it is also very important to thwart “flare-ups” or complications in COPD patients. This can be done by preventing infections with immunizations, proper hygienic precautions, and the cessation of smoking. Mr. Barley should also be followed up with periodically by his primary care physician and pulmonologist to evaluate and assist him in managing his disease. Pulmonary function tests must be performed to monitor for progression of disease. Buttaro, Trybulski, Polgar-Bailey and Sandberg-Cook (2017) state that the spirometry tool is crucial to the diagnosis and management of asthma and COPD (p. 470).

References

Arabyat, R.M., Raisch, D.W. & Bakhireva, L. (2018). Influenza vaccination for patients with chronic obstructive pulmonary disease: Implications for pharmacists. Research in Social and Administrative Pharmacy, 14(2), 162-169. doi: https://doi.org/10.1016/j.sapharm.2017.02.010

Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier

Medscape. (2018). Albuterol. Retrieved from: https://reference.medscape.com/drug/proventil- hfa-ventolin-hfa-albuterol-343426#4

Response 2

Hello Alejandra,

Great job on summarizing the case study provided to us this week. My post discussed similar findings with the physical examination and plan of care. I found that the case study did not take account of all the subjective factors, such as the home treatment he was possibly using and the severity of his symptoms. It was under my impression that Mr. Barley was not in acute distress from the assessment and because he did not go the emergency room. When the diagnosis of chronic pulmonary obstructive disorder (COPD) was confirmed with Mr. Barley’s physical examination and diagnostic tests, the provider explained in detail the nature of the disease, it’s treatment, and possible complications. If a severe COPD exacerbation should occur, it is important that providers educate patients on when to seek immediate medical attention. The National Heart, Lung, and Blood Institute (2018) recommend that COPD patients pursue emergency care if they have difficulty catching their breath or talking, lips or fingernails turn blue or gray, mental status has changed, rapid heartbeat, or if the recommended treatment for symptoms is not working. I thought it was great that you pointed out depression as a concern in Mr. Barley’s treatment plan. Buttaro, Trybulski, Polgar-Bailey and Sandberg-Cook (2017) state that it is often difficult to identify depression in older adults because of the aging process and changes that occur in appetite, sleep wake cycles, and their inability to continue life pursuits (p. 101). Living with any chronic illness can cause fear, anxiety, depression, and stress. It is important that health care providers initiate conversations regarding their feelings and listen closely to evaluate their psychosocial status properly.

References

Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier

The National Heart, Lung, and Blood Institute. (2018). COPD. Retrieved from: https://www.nhlbi.nih.gov/health-topics/copd

Which of the school nurse’s observations are consistent with the diagnosis of asthma?