Assignent Solutionnurs

1. The primary diagnosis for this patient would be COPD. The pertinent positives for the case include chronic productive cough, increasingly difficult activity, expiratory wheezing, and a history of cigarette smoking (Koblizek et al., 2016). The pertinent negative findings for the case are fatigue and increased work of breathing, which our patient is not experiencing (Koblizek et al., 2016).
2. The ICD.10 code for this diagnosis is J44.9, Chronic obstructive pulmonary disease, unspecified.
3. Medication
Olodaterol 5 mcg/24hr
DISP: 1 inhaler
SIG: Take 2 puffs inhalation daily
RF: 0
Levalbuterol 45 mcg/inh
DISP: 1 inhaler
SIG: Take 2 puffs inhalation every 4 hours as needed for shortness of breath
RF: 2
Rationale: The patient should continue his home medication, Metoprolol ER 50 mg by mouth daily. The patient is in group B subsection in helping to manage his COPD based on his symptoms and spirometry scores. Group B should be started on a long-acting bronchodilator (LABA). Not one LABA is recommended over another (Global Initiative for Chronic Obstructive Lung Disease, 2022). The LABA that was selected was Olodaterol. Those with severe breathlessness may need a second bronchodilator, which is why levalbuterol was added to the patient’s medication for as-needed use (Global Initiative for Chronic Obstructive Lung Disease, 2022).
Additional Testing: No additional testing is currently needed for this patient. The patient’s oxygen saturation is good. If it was lower (less than 92 %), we could add more testing, such as oximetry and arterial blood gas (Global Initiative for Chronic Obstructive Lung Disease, 2022). Another testing that should be done in subsequent visits would be the COPD assessment test to help properly manage the patient and see if current treatment is helping (Global Initiative for Chronic Obstructive Lung Disease, 2022).
Referral: A referral to pulmonary rehab should be considered. Pulmonary rehab is beneficial for any COPD patient at any severity and helps build exercise tolerance and improve health (Global Initiative for Chronic Obstructive Lung Disease, 2022).
Patient Education: COPD action plan should be given to each patient and needs to be personalized to meet each patient’s needs (Global Initiative for Chronic Obstructive Lung Disease, 2022). Other education should include the importance of getting the flu, pneumonia, pertussis, and COVID-19 vaccinations (Global Initiative for Chronic Obstructive Lung Disease, 2022). Proper inhaler demonstration should be shown by using the teach-back method to ensure that the patient knows how to use the inhaler. Education about medication should be provided, such as albuterol agents can cause tingling in the extremities and increased heart rate.
Follow-up: Patient follow-up should be in one month to ensure that the medication is working for this patient and then again at the three-month mark to ensure that the patient is stable (Global Initiative for Chronic Obstructive Lung Disease, 2022).
4. Problem list: Hypertension, former smoker, chronic cough, wheezing, activity intolerance, and obesity.
5. No change in the treatment as of now. The patient should keep a daily log of his blood pressure that is random. Often, patients are nervous at a clinician’s office and can have white coat hypertension or stressors such as an illness. Supplement blood pressure readings can help provide more diagnostic information and measure more accurate blood pressure and diagnosis (Weinfeld et al., 2021). It will be assessed at the follow-up appointment along with the management of COPD. At that time, it will be determined if his blood medications need to be adjusted.
References:
Global Initiative for Chronic Obstructive Lung Disease. (2022). Pocket guide to copd diagnosis, management and prevention: A guide for healthcare professsionals. https://goldcopd.org/wp-content/uploads/2018/02/WMS-GOLD-2018-Feb-Final-to-print-v2.pdf (Links to an external site.)
Koblizek, V., Novotna, B., Zbozinkova, Z., & Hejduk, K. (2016). Diagnosing copd: Advances in training and practice – a systematic review. Advances in Medical Education and Practice, 219. https://doi.org/10.2147/amep.s76976 (Links to an external site.)
Weinfeld, J., Hart, K., & Vargas, J. (2021). American family physician, 104(3). https://web-s-ebscohost-com.chamberlainuniversity.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=1&sid=ade0dd7e-520f-4c65-ad08-e91683aefc44%40redis