nr 603 i-human case study, Study notes of Nursing

Download nr 603 i-human case study and more Study notes Nursing in PDF only on Docsity! Patient Report: Susi Green Date: August 4, 2024 Patient Information: Name: Susi Green Age: 42 years Gender: Female Occupation: Office Manager Medical History: Asthma, Hypertension Chief Complaint: Susi Green presents with complaints of dyspnea, which has progressively worsened over the past three days. History of Present Illness: Susi's dyspnea began approximately three days ago and has been gradually worsening. Initially, she noticed shortness of breath during physical exertion, such as climbing stairs. However, over time, she has started experiencing dyspnea even while at rest. She describes the sensation as a tightness in her chest with difficulty in inhaling deeply. Additionally, she reports a dry cough and occasional wheezing, especially at night. Relevant Medical History: Asthma: Diagnosed at age 15, Susi has managed her asthma with inhaled corticosteroids and a rescue inhaler (albuterol). Asthma is a chronic inflammatory disease of the airways, characterized by variable and recurring symptoms, airflow obstruction, and bronchospasm. Understanding her asthma history is crucial for evaluating her current respiratory status. Hypertension: Diagnosed two years ago, Susi's hypertension is controlled with medication (amlodipine). Hypertension, or high blood pressure, can have implications on cardiovascular health and potentially contribute to respiratory symptoms. Medications: Inhaled corticosteroids (Fluticasone): Used to control chronic asthma by reducing inflammation and preventing asthma attacks. Rescue inhaler (Albuterol): A bronchodilator used for quick relief of asthma symptoms by relaxing the muscles around the airways. Amlodipine (5 mg daily): A calcium channel blocker used to manage hypertension by relaxing blood vessels and improving blood flow. Physical Examination: Vital Signs: Blood Pressure: 130/85 mmHg (within acceptable range for a hypertensive patient under control) Heart Rate: 88 bpm (within normal range) Respiratory Rate: 22 breaths per minute (elevated, indicating potential respiratory distress) Temperature: 98.6°F (37°C) (normal) Oxygen Saturation: 94% on room air (slightly low, indicating possible respiratory compromise) General Appearance: Susi appears slightly anxious and is in mild respiratory distress, as evidenced by her rapid breathing and use of accessory muscles. Respiratory Examination: Inspection: Use of accessory muscles, indicating increased effort to breathe. Palpation: No tenderness in the chest area, ruling out musculoskeletal causes of chest pain. Percussion: Resonant lung fields, suggesting that there is no fluid accumulation or consolidation in the lungs. Auscultation: Bilateral wheezing and diminished breath sounds at the bases, consistent with bronchospasm and airway obstruction typically seen in asthma exacerbations. Assessment: Primary Diagnosis: Asthma exacerbation, characterized by increased symptoms of wheezing, shortness of breath, and reduced lung function. Differential Diagnosis: Acute bronchitis: Inflammation of the bronchial tubes often presenting with cough and mucus production. Heart failure: Could cause dyspnea due to fluid buildup in the lungs. Pulmonary embolism: Sudden blockage in a lung artery that could lead to sudden dyspnea. Plan: Medications: Increase the dosage of inhaled corticosteroids to better control inflammation. Prescribe a short course of oral corticosteroids (Prednisone 40 mg daily for 5 days) to quickly reduce airway inflammation. Continue current antihypertensive therapy to manage blood pressure. Oxygen Therapy: Administer supplemental oxygen if oxygen saturation drops below 92% to maintain adequate tissue oxygenation. Pulmonary Function Test: Schedule spirometry to assess lung function, measure the degree of airway obstruction, and guide further treatment. Follow-up: Reassess in 3 days to evaluate the effectiveness of the treatment and make necessary adjustments. Education and Counseling: Instructed Susi on the correct use of inhalers to ensure she receives the maximum benefit from her medications. Discussed potential asthma triggers (e.g., allergens, exercise, respiratory infections) and strategies to avoid them.