Pulmonology Case Study
A 65-year-old Caucasian female presents with a chief complaint of cough for two weeks. She has been complaining of dry cough since the past two weeks and low grade fever that started two days ago, and was as high as 101 orally. She has had a decreased appetite but no nausea and vomiting. The cough occurs during the night and she needs to sit up in a chair to be able to breathe easier. The cough is mainly dry, rarely productive.
She had been prescribed inhalers in the past; they have been helpful but she does not use them on a routine basis. She has been prescribed antibiotics in the past as well and that seems to help when she is acutely ill. She has been suffering from shortness of breath for the past two weeks following any kind of activity mainly because of the dry cough. She thinks itâ€™s possible that thereâ€™s some problem with her â€œheart.â€ She is also complaining of slight sore throat, especially in the morning and feels she may have lung cancer.
The patientâ€™s symptoms have been worsening over the past two days.
She has had similar episodes in the past. The last was three months ago when she had to go to the emergency room and they told her that she needed to be hospitalized. She declined hospitalization at that time and was treated and released. She says they gave her antibiotics and an inhaler before discharging her. She mentioned that though it took some time to feel better, there was gradual improvement in her condition following that treatment. According to her, this is the worst episode that she can remember. Sheâ€™s very concerned today that she could have pneumonia and might require hospitalization.
She is seeking medical attention today because of the fever and prolonged nature of her illness.
Though she has been treated for this problem in the past with antibiotics and inhalers, she has not been hospitalized. The patient had a chest investigation the last time she had this problem. She states that she did not have pneumonia but did have â€œemphysema.â€ The healthcare professionals wanted to do pulmonary function tests, but she declined.
X-ray results: Hyperinflation of both lungs with an increased AP diameter. There is evidence of emphysema. .
She states that she had asthma as a child and is a cigarette smoker. She also had a hysterectomy way back in 1970s. Besides these, she has no known chronic medical problems.
Shortness of breath with activity. No diaphoresis. She has had a fever. No nausea and vomiting. Denies chest pressure sensation with physical activity. No palpitations.
The patient does not take any prescription medicines. She takes occasional over-the- counter Tylenol for pain.
Tylenol 650 mg, 2 PO as needed.
She is allergic to sulfa drugs that cause a rash.
The patient has been widowed for 20 years. She is receiving an annual pension of
$40,000.00 and has some money that she has saved in the bank. She has a high school diploma and owns her house. Though she has little disposable income, her finances are essentially stable. She has little knowledge of community resources that are at her disposal.
She has a primary care provider, whom she sees three to four times every year for a physical examination. The physician is very busy and does not spend much time with her. She has insurance but it does not cover all her prescription medications. She relies on a lot on samples.
She has two grown-up daughters who live in the nearby community. They are both in their forties and are alive and well. The patient would like her daughters to be more involved in her life, but she is not sure how to approach them about this. The patientâ€™s perception of self-efficacy has been declining over the past ten years. She feels that she could be feeling depressed because she does not get out of the house very often and this depression is only getting worse with each passing year.
The patient has very low level of day-to-day stress. However, she realizes that her depressive symptoms may be causing some of her physical symptoms.
She goes to church and has some contacts there. She sees her daughters once a month. These people are her support system, but she has no one to talk to on a routine basis.
â€¢ Diet habits
She has a healthy diet and her dietary intake is adequate. The patient has positive health beliefs and knows that she should be doing more to maintain a healthy lifestyle. She does not get adequate exercise because of her shortness of breath. She enjoys visiting her physician.
Smoking: She has smoked one pack per day for 40 years. Alcohol: She denies alcohol use
Substance Use: She denies any street drug use
She has always been a hairdresser; is retired now. She goes to church and occasionally attends some of their functions. Her hobbies include sewing. She is from the United States and lives in a suburban setting. Crime rate in her locality is low with easy access
to public transportation. There are a variety of community groups, but she is not aware of these resources.
Her two older sisters are alive and well, one with osteoporosis and one with breast cancer. Her 75-year-old sister was diagnosed with osteoporosis at the age of 55. Her 72- year-old sister was diagnosed with breast cancer at 60 years of age.
Vital Signs: BP: 130/72 left arm sitting regular cuff; T: 101 po; P: 100 and regular; R: 20, non-labored; Wt: 130#; Ht: 55â€.
HEENT: White material on the buccal mucosa; does not wipe off with tongue blade. Lymph Nodes: None
Lungs: Decreased breath sounds, dull to percussion right lower lobe. End expiratory wheeze in right lower lobe. No rales or rhonchi. Increased anterior-posterior diameter to chest wall.
Heart: RRR without murmur Carotids: No bruits Abdomen: Benign
Rectum: Not examined
Genital/Pelvic: Not examined
Extremities, Including Pulses: 2+ pulses throughout, no edema
Neurologic: Not examined
Patient Initials: ______ Age: _65_ Sex: Female
The client’s chief complaint was a dry cough for two weeks. She also stated having experienced low grade fever, loss of appetite, and a slightly sore throat that she attributed to lung cancer.
HPI (History of Present Illness):
The patient is a 65-year-old female with a history of respiratory tract infection who presented with low grade fever, slight sore throat, and persistent dry cough. The chief complaint of the patient was dry cough that set in 2 weeks ago. The dry cough occurred at night and presented with difficulty of breathing and loss of appetite. The dry cough also caused the patient to have shortness of breath following any kind of activity for the past two weeks. She had the same symptoms three months ago where she recovered gradually and was given antibiotics and an inhaler. She had not been following her inhaler medications. Similarly, antibiotics had been very useful during her acute illness. These symptoms had been worsening for the past two days. She was concerned that could have been having pneumonia. Therefore, she sought treatment due to the low grade fever and the prolonged dry cough.
PMH (Past Medical History—includes current medications, any known allergies, any history of surgery or hospitalizations):
Currently, the patient does not take any prescribed drugs. However, she occasionally takes over-the-counter Tylenol for pain management. She is allergic to sulfa drugs that cause her rash. The patient has never been hospitalized and she was just given antibiotics and inhalers during her last respiratory illness episode. However, she had hysterectomy in 1970s. Additionally, she was diagnosed with emphysema during this last illness. A chest X-ray showed a hyperinflation of both lungs with increased AP diameter. She had asthma and was a cigarette smoker during her childhood.
Significant Family History:
She reports significant medical background of her 75 and 72-year old sisters. Her elder sister was diagnosed with osteoporosis at 55 years of age while the 72-year old sister was diagnosed with breast cancer at the age of 60.
Social/Personal History (occupation, lifestyle—diet, exercise, substance use)
The patient is a retired hairdresser whose hobby is sewing. She has been widowed living in her own house for 20 years. However, she is financially stable due to the support of the annual pension of $40,000.00 and her bank savings. The patient also lives in suburban area in the United States where crime rate low and hence, she can enjoy the services offered by the community resources. Therefore, she is stable and can operate independently. The patient has a high school diploma qualification and is active in church activities. However, her depression aggravates due to physical isolation because her two daughters, who live in the nearby community, are not involved in her life.
The patient has good health-seeking behavior. Consequently, she takes healthy meals and visits her physician frequently. However, she cannot perform daily exercise due to her shortness of breath. The patient had smoked one packet per day for 40 years and denied abuse of any other substance.
Description of Client’s Support System:
The patient has the support of her family, the church, and healthcare provider. Her primary care provider, a physician, sees her three to four times annually for physical examination. She also gets support from the contacts in the church and her daughters whom she can see at least once a month. Financially, the patient is under cover of a health insurance policy that covers some of her medications. Also, she gets annual pension of $40,000.00. However, she lacks enough knowledge of the community resources available to her.
Behavioral or Nonverbal Messages:
The patient does not adhere to her medications. She did not use last prescriptions of antibiotics and inhalers fully. The patient is also worried about her medical conditions that she attributes to lung cancer.
Client Awareness of Abilities, Disease Process, and Health Care Needs:
The client lacks sufficient knowledge about her disease process. She adduced that her medical presentations were due to lung cancer. She cannot accept admission to hospital and she does not know how to convince her daughters to get involved in her life.
Vital Signs including BMI:
She had the following vital signs;
- Blood pressure-130/72mmHg
- Temperature-101 F
- Respiratory rate-20 (non-labored)
- Height-55 inch
Physical Assessment Findings:
She has a white material on the buccal membrane that cannot be wiped off with a tongue blade. All her lymph nodes are sound. However, she had decreased breath sounds and a dull percussion on the right lower lobe. She also had expiratory wheeze in her right lower lobe. Her anterior-posterior diameter of chest wall was increased with RRR lacking murmur carotids. The abdomen had no bruits.
Lab Tests and Results:
She had 15, 000 white blood cell count and 98% saturation of oxygen. Her EKG had normal sinus rhythm.
Client’s Support System:
The patient has a primary care provider who can attend to her at home. Her two daughters and the church members can give her emotional support. Financially, she receives annual pension of $40,000.00 and is also health insurance cover.
Client’s Locus of Control and Readiness to Learn:
The client is ready to learn about the disease process and would like her fever and dry cough treated.
ICD-9 Diagnoses/Client Problems:
She had experienced emphysema-code J 43.8. Emphysema results from chronic smoking (Centers for Disease Control and Prevention, 2015). The patient’s history shows 40 years of smoking. The symptoms of emphysema are shortness of breath, cough, and wheeze (Jankowich, & Rounds, 2012). The patient had these symptoms and this corroborated that she had emphysema.
The associated symptoms portrayed by the patient were;
- Low self-efficacy
- Depression due to isolation
- Lack of physical exercises
- Shortness of breath
- Low appetite
- Low grade fever
- Dry cough and wheezing
- Smoking for 40 years
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
The nurse will work with the patient to assist her develop problem-solving skills to involve her daughters in her life. She will also be taught Social skills that would enable her to approach others and her daughters easily (World Health Organization. 2015). These skills will boost her self-esteem that will revive her self-efficacy.
Depression due to isolation
The nurse will discuss with her the community groups available for her such as community groups for older widows so that she can frequently leave her house and interact with others (World Health Organization. 2015). Particular nurse home visits will be organized so that the nurse can follow up the patient and motivate her further.
Lack of physical exercises
Patient education will be focused on the importance of exercise. A plan to register her in a women’s sport group will engage her in exercise after recovery. The nurse will discuss with the patient the various options available for performance of exercise and the patient allowed to choose.
Shortness of breath
The nurse will aim at reducing pain through administration of tranquilizers such as acetaminophen. The nurse will also assist with positive airway pressure techniques such as bilevel positive airway pressure so that the patient can improve breathing (Gasparini, Zuccatosta, Bonifazi, & Bolliger, 2012). Appropriate carers such as respiratory therapists and physicians will be consulted to provide further guidance on the actions to provide cure.
The nurse will provide good oral hygiene before and after every meal. Extensive oral hygiene will make the oral mucosa more moistened and the taste buds will be activated (Jankowich, & Rounds, 2012). Hence, food will be tasty.
Low grade fever
The nurse will administer and monitor the IV infusions prescribed by the physician so that the treatment plan becomes effective. The patient will also be provided with adequate amount of fluids and food to prevent dehydration (Jankowich, & Rounds, 2012). The patient will be encouraged to rest to reduce body heat. Lastly, the nurse will provide good oral hygiene to prevent oral herpetic lesions.
The nurse will provide the drugs as prescribed by physician to treat the lower respiratory tract infection (Jankowich, & Rounds, 2012). The patient will also be provided comfort in quiet environment with elevated head that enables position shift. Comfort reduces stress and therefore, the patient will make maximum inspiration and expiration to clear the airways.
Smoking for 40 years
The nurse will apply behavioral theory to fully educate the patient on how to substitute other activities for time used for smoking. The activities include the community services and groups that will involve much of her time. Therefore, there will be no positive reinforcement to smoke and craving for smoke will thin out (World Health Organization. 2015).
Centers for Disease Control and Prevention, (2015). Smoking and COPD. U.S. Department of Health & Human Services. Retrieved from http://www.cdc.gov/tobacco/campaign/tips/diseases/copd.html on November 4, 2015.
Gasparini, S., Zuccatosta, L., Bonifazi, M., & Bolliger, C. T. (2012). Bronchoscopic Treatment of Emphysema: State of the Art. Respiration, 84(3), 250-263. doi:10.1159/000341171
Jankowich, M. D., & Rounds, S. I. (2012). Combined pulmonary fibrosis and emphysema
syndrome: a review. CHEST Journal, 141(1), 222-231.
World Health Organization. (2015). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings. The Lancet.