Advance Nursing Practice Care of Patient in Family Care Setting
Student’s Name
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Professor’s Name
Date
Advance Nursing Practice Care of Patient in Family Care Setting
Please document the history questions you would ask the patient.
The history questions are effective in generating information about the patient and their family. The first question is on the history of respiratory illness such as tuberculosis or pneumonia in the family. The second question is the length of time the patient has been smoking. The purpose is to evaluate the length of smoking since it increases the risk of illness. The third question is whether the patient has experienced a drenching night or persistent coughing. It is vital to ask the patient if they have been diagnosed with a respiratory illness in the past. History questions should ask the patient their experience in changing the weather or working in a dusty environment. The last question would be to enquire about past illness and current medication.
What Physical Exam would you obtain?
The physical examination for a patient with coughing involves the use of a stethoscope to listen to the breathing sounds. Abnormal breathing sounds will indicate a possible illness (Hardeland & Tan, 2020). Fluids in the air sacs, due to infection, make crackling or bubbling noises during their movement. A person with pneumonia has dull thuds which will indicate that there is fluid in the lung or indicate that the lung is collapsed (Hardeland & Tan, 2020). Wheezing sound is also noted if the airways are inflamed or narrowed.
What labs/diagnostics would you order?
The diagnostic tests necessary for the patient include a chest X-ray or CT scan. The purpose is to check for the observable signs of TB in the lungs. For instance, the X-ray will be used to examine for inflammation in the lungs (Shah et al., 2020). The tests can be used to check for sputum or bacteria that can cause various diseases such as pneumonia. Pulse oximetry will be essential in measuring the amount of oxygen in the lungs (Shah et al., 2020). Blood tests (CBC) the blood tests are used to examine if the body is fighting an existing infection. The diagnostic tests are effective in confirming the infection or ruling out possible infections that present similar symptoms (Shah et al., 2020).
List your top four differential diagnoses. List your rationale for your top diagnosis.
The differential diagnosis includes;
1. Bacterial pneumonia infection
2. Bronchogenic carcinoma
3. Brucellosis disease
4. Mycoplasma pneumonia
What is a CURB Score?
CURB score is a scoring system developed from a multivariate analysis of 1068 patients that indicates the various factors that lead to the mortality rate in a patient (Nguyen et al., 2020). The abbreviation stands for confusion, urea, respiratory rate, blood pressure.
When his labs come back, his CMP shows that his BUN is 21. Based on that information and on his presentation, what is his CURB score and how did you arrive at that score?
CURB-65 Score = 1. The score indicates that the patient has a low risk of respiratory illness such as pneumonia. The mortality risk is at least 2.7 percent at 30 days.
The score is arrived at by giving one point to each of the following prognostic features including confusion, raised blood urea, raised respiratory rate, low blood pressure, and age 65 or more (Nguyen et al., 2020). The stratification for the risk of death is as follows 0 or 1 shows a mortality risk of less than 3 percent, 2 is an intermediate risk of between 3-15 mortality risk, while 3 to 5 is a high mortality risk of above 15 percent (Nguyen et al., 2020).
Based on his CURB score, should he be treated on an outpatient or inpatient basis?
The CURB score shows that the patient does not experience a high mortality risk (Brabrand & Henriksen, 2018). The patient can be treated on an outpatient basis. Patients between 0 and 1 can be treated on an outpatient basis since the mortality risk is below three percent.
His chest x-ray does indeed show infiltrates. What is your treatment plan for him?
The patient requires warm fluids since hot beverages can offer relief from the mucus accumulation that can prevent appropriate breathing (Newman, 2018). The second intervention is steam which will help the airways to open up, decrease congestion, and coughing. N-acetylcysteine is effective in loosening the mucus in the respiratory system (Newman, 2018). Chest tube replacement can be injected into the pleura space to eliminate congestion or excess mucus (Newman, 2018).
Name 3 health promotion topics that you should discuss with him
The health promotion topics to discuss with the client include helping smokers to stop smoking and the need for safe public smoking spaces, increasing access to healthy foods, and exercising regularly, and lifestyle changes and behavior change for disease management (Gomes‐Filho et al., 2020). The topics are vital in improving behavior change and improving the quality of healthcare outcomes.
What is your follow-up plan?
The follow-up plan includes carrying out two sputum smear examinations, observing the response, and providing appropriate interventions. Another follow-up plan is chest radiograph and laboratory monitoring (Gomes‐Filho et al., 2020). It is essential to encourage the patient to stop smoking to avoid triggering the symptoms.
References
Brabrand, M., & Henriksen, D. P. (2018). CURB-65 score is equal to NEWS for identifying mortality risk of pneumonia patients: an observational study. Lung, 196(3), 359-361.
Gomes‐Filho, I. S., Cruz, S. S. D., Trindade, S. C., Passos‐Soares, J. D. S., Carvalho‐Filho, P. C., Figueiredo, A. C. M. G., … & Scannapieco, F. (2020). Periodontitis and respiratory diseases: A systematic review with meta‐analysis. Oral Diseases, 26(2), 439-446.
Hardeland, R., & Tan, D. X. (2020). Protection by melatonin in respiratory diseases: valuable information for the treatment of COVID-19. Melatonin Research, 3(3), 264-275.
Newman, S. P. (2018). Delivering drugs to the lungs: The history of repurposing in the treatment of respiratory diseases. Advanced Drug Delivery Reviews, 133, 5-18.
Nguyen, Y., Corre, F., Honsel, V., Curac, S., Zarrouk, V., Fantin, B., & Galy, A. (2020). Applicability of the CURB-65 pneumonia severity score for outpatient treatment of COVID-19. Journal of Infection, 81(3), e96-e98.
Shah, S. J., Barish, P. N., Prasad, P. A., Kistler, A., Neff, N., Kamm, J., … & CZB CLIAhub Consortium. (2020). Clinical features, diagnostics, and outcomes of patients presenting with acute respiratory illness: a retrospective cohort study of patients with and without COVID-19. EClinicalMedicine, 27, 100518.
Episodic/Focused SOAP Note
Student’s Name
Walden University Nursing 6531
September 12, 2018
Episodic/Focused SOAP Note
Patient Information:
LB, 58, male, white
S.
CC: Coughing
HPI: LB, a 58 y/o male white patient complains of intermittent coughing for the past four days. It started out as a dry cough but over the past two days, he has started coughing up thick pale yellow phlegm. He thinks he has had a fever but he has not actually taken his temperature. He is a smoker but has not been smoking very much the past few days as that seems to make the cough worse. He has also felt very tired. He has taken Tylenol off and on and it does help slightly. About a week and a half ago, he played poker with some friends and one of them was sick. His wife accompanies him and when you ask them both, they deny that he has had any confusion.
Home Medications: Lisinopril 20 mg daily; Metformin 500 mg twice daily, and Tylenol.
Allergies: Penicillin.
PMHx: Hypertension and Diabetes Mellitus Type 2.
Soc Hx: 40 pack year history of tobacco use (cigarettes); no alcohol or drugs.
Fam Hx: Both parents are diabetic but his elder sister has hypertension diagnosed at 48. The patient is unsure of the medical history of paternal or maternal grandparents.
ROS: GENERAL: No unintentional weight loss or gain, chills, fever, and body weakness. Positive for fatigue.
HEENT: Eyes: No blurred or double vision or yellow sclarae. Ears, Nose, Throat: No hearing difficulties, nasal congestion, running rose, or sore throat.
CARDIOVASCULAR: No edema, chest pain, pressure, or edema.
GASTROINTESTINAL: No vomiting, nausea, blood in the stool, diarrhea, or eating difficulty.
NEUROLOGICAL: No numbness, headache, dizziness, confusion bowel control change, or paralysis.
MUSCULOSKELETAL: No back, joint, or muscle pain.
O.
VS: 5’4”; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%
General: The patient appears healthy and without acute distress. He is concerned about the symptoms.
HEENT: Head- No abnormalities noted. Eyes- pupils equal, round and reactive to light. ENT- no drainage noted.
Cardiovascular: S1, S2 heard on auscultation, no murmurs. Pt denies chest discomfort or pain.
Gastrointestinal: Bowel sounds are present without any abnormalities, soft, non-tender and non-distended. Pt denies flair ups or abnormal bowel movement.
Neurological: Sensory intact, normal upper and lower extremities. Patient complains of fatigue.
Musculoskeletal: Symmetric muscle movement, no limping, and normal spine movement.
Diagnostic results: Positive for streptococcus.
Chest X-ray, sputum culture, CBC with differential, and Mantoux test.
Diagnosis
Primary:
J18.9 Bacterial pneumonia- Bacterial pneumonia is an infection of the lungs caused by bacteria. The common bacteria is Streptococcus (pneumococcus). The bacteria can live in the lungs without causing illness (Hanada et al., 2018). The symptoms include coughing, fever, fatigue, loss of appetite, loss of energy, and shortness of breath. Patients experience a yellow or bloody cough (Hanada et al., 2018). Patients can contract bacterial pneumonia from various sources such as community or infected persons.
Differential:
J20.9 Acute bronchitis: Acute bronchitis is a viral infection that leads to inflammation of the bronchial tubes. Infection of the bronchial tubes leads to swelling and accumulation of mucus making it hard to breathe (Wopker et al., 2020). Symptoms include sore throat, coughing, mild headache, fatigue, and soreness of the chest. Breathing difficulties can put the patient at risk of death (Wopker et al., 2020).
J44. 9 Chronic obstructive pulmonary disease: COPD is a condition that leads to blockage of airways making it difficult to breathe. The symptoms include persistent coughing, shortness of breath, and wheezing (Agustí & Hogg, 2019). Patients with COPD experience chest pressure, dry cough, or phlegm.
J45 Asthma: Asthma is a condition that leads to the accumulation of mucus that blocks the airways. The accumulation leads to difficulty in breathing and causes a wheezing sound (Dharmage et al., 2019). The symptoms include shortness of breath, chest pain, cough with phlegm, and fatigue. The condition is triggered by various factors such as dust, pollen, or allergic materials. Patients need to avoid the triggers since they can undermine the health of a patient (Dharmage et al., 2019).
Z11. 1 Tuberculosis: TB is an infection of the lungs caused by Mycobacterium tuberculosis. The symptoms include night sweats, coughing, fever, loss of appetite, and shortness of breath (Harding, 2020). When individuals cough they dispel the germs that can lead to infections among people who inhale the air.
P. Treatment of bacterial pneumonia involves antibiotics. The patient to take amoxicillin 500mg three times a day. Patients to avoid going to public places to avoid spreading the disease. Examine the symptoms and report back to the clinic in case of abnormalities. Controlling the symptoms such as fever and inflammation is essential. Treatment at home involves taking sufficient fluids to loosen secretions. The patient should avoid taking cough medication without consulting a physician. In case the patient experiences fever, it would be important to take aspirin and ibuprofen. The patient to return to the clinic after two weeks for follow-up and Assessment. The treatment plan will include educating the patient about the symptoms and the need to take precautions. Breathing complications can put the patient at risk of death.
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Preceptor Signature and Date
References
Agustí, A., & Hogg, J. C. (2019). Update on the pathogenesis of chronic obstructive pulmonary disease. New England Journal of Medicine, 381(13), 1248-1256.
Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of asthma in children and adults. Frontiers in pediatrics, 7, 246.
Hanada, S., Pirzadeh, M., Carver, K. Y., & Deng, J. C. (2018). Respiratory viral infection-induced microbiome alterations and secondary bacterial pneumonia. Frontiers in immunology, 9, 2640.
Harding, E. (2020). WHO global progress report on tuberculosis elimination. The Lancet Respiratory Medicine, 8(1), 19.
Wopker, P. M., Schwermer, M., Sommer, S., Längler, A., Fetz, K., Ostermann, T., & Zuzak, T. J. (2020). Complementary and alternative medicine in the treatment of acute bronchitis in children: A systematic review. Complementary therapies in medicine, 49, 102217.
