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Asthma/COPD/TB/pneumonia chap 31, 32, 33

Terms in this set (253)

p. 611, Patient-Centered Care; Evidence-Based Practice; Safety
The patient is a 22-year-old college student who has had asthma since childhood. She is being managed with fluticasone (Flovent) 50 mcg/puff, 2 puffs twice daily; salmeterol (Serevent) 1 puff twice daily; albuterol (Ventolin) 1-2 puffs every 4-6 hours as needed for wheezing. She reports that she is using the fluticasone and salmeterol as prescribed but needs to use the albuterol about every 2 hours. She also tells you that she is having difficulty sleeping and feels "like my heart is skipping some beats." Her vital signs are BP, 136/88; P, 96 and irregular; R, 30, with slight wheezing on exhalation. Her oxygen saturation is 92%, and you notice that she has a slight tremor in both hands.
1. What additional physical manifestations should you assess?
2. What questions should you ask?
3. Should you administer oxygen? Why or why not?
4. At what "step" is her current asthma management?
5. What information indicates this step is effective or ineffective?

Suggested Responses:

1. What additional physical manifestations should you assess?
Her forced expiratory volume in the first 1 second (FEV1) should be assessed using a peak flowmeter.

2. What questions should you ask?
Ask her how many times a day she uses the albuterol, and ask her how long the extra rescue has been needed. Determine whether the albuterol reduces or eliminates her symptoms and for how long. Also ask her whether she experiences any asthma symptoms at night.

3. Should you administer oxygen? Why or why not?
She should use the relief inhaler first and then her oxygen saturation, and FEV1 should be reassessed. If her oxygen saturation comes up at all and her FEV1 improves, she does not need oxygen at this time.

4. At what "step" is her current asthma management?
She is currently at step 4 but has not topped out of this step.

5. What information indicates this step is effective or ineffective?
Her use of her relief inhaler so frequently indicates that step 4, as it is now practiced, is not effective. Either the dosage levels of the current drugs or their frequency needs to be increased.
The patient is a 55-year-old man who has moderate to severe COPD and is being seen for a regularly scheduled checkup in the clinic. He tells you that he has had to give up a few more of his favorite activities and then tells you that life "isn't fair." When you ask him about this, he tells you that he did smoke cigarettes for about 10 years during his 20s but quit when his first child was born. He then explains that his mother, a nonsmoker, died at age 62 of COPD but his father, who smoked his entire life, has only mild COPD at age 80. The patient goes on to say that his brother, also a smoker, is 58 and does not have COPD but that his identical twin brother, who never smoked, does have the disease. When you ask whether anyone else on either side of his family has or had COPD, he indicates that the following people had been diagnosed with COPD:
• Mother's younger brother (older brother and younger sister not affected)
• Mother's father
• Mother's mother's brother
• Father's two sisters, but none of their children
1. Draw this patient's family pedigree based on the information you have already received.
2. What, if any, pattern of inheritance can be identified from the pedigree?
3. What additional information regarding the possibility of genetic risk should you ask this patient?
4. Could genetic counseling be helpful to this patient? If so, what genetics professional should be consulted and why?

Suggested Responses:

1. Draw this patient's family pedigree based on the information you have already received.



2. What, if any, pattern of inheritance can be identified from the pedigree?
An autosomal pattern of inheritance is probable because males and females are just about equally affected. A dominant pattern of inheritance may be at work here, but because both sides of his family have affected individuals, this is not clear and a genetics professional should be consulted.

3. What additional information regarding the possibility of genetic risk should you ask this patient?
Additional questions would include: At what ages were the individuals with COPD diagnosed with the disease? Who among all family members is a smoker or has a history of smoking? Are any other respiratory problems present in members from either side of this patient's family?

4. Could genetic counseling be helpful to this patient? If so, what genetics professional should be consulted and why?
Yes; there are enough family members who have COPD, some at younger ages, to suggest a genetic influence. The patient and his identical twin brother both having the problem and being only in their 50s is highly suggestive of a possible genetic cause or contribution. The best genetics professional to assess risk for this patient and his family is a genetic counselor or clinical geneticist.
p. 651, Patient-Centered Care; Evidence-Based Practice
The patient is an 80-year-old female nursing home resident who had a stroke 6 months ago. She has been cognitively intact and has left-sided weakness and difficulty swallowing. Several days ago, she was found choking while eating her lunch. Other long-term health problems include diabetes and hypertension. Today, the nursing assistant reported that the patient did not recognize her this morning and had a temperature of 97.2 F. The gerontologic nurse practitioner who examined the patient diagnosed her with pneumonia in the right middle and lower lobes.
1. What risk factors does this patient have for pneumonia?
2. Her record shows that she received the pneumonia vaccination 8 years ago and the seasonal influenza vaccination on admission to the facility. Explain the possibilities for why these immunizations were not effective in preventing pneumonia.
3. The nurse practitioner prescribed ceftriaxone (Rocephin) 2 g IV piggyback stat, then 1 g every 12 hours; oxygen at 6 L by nasal cannula; vital signs hourly; and incentive spirometry every 2 hours. Which intervention should be performed first? Provide a rationale for your choice.
4. What could have precipitated this problem and what steps could be taken to prevent it from happening again?

Suggested Responses:

1. What risk factors does this patient have for pneumonia?
Major risk factors include being an older adult, having left-sided weakness, swallowing difficulties, and a recent aspiration event. Being a nursing home resident increases her risk for any type of infection.

2. Her record shows that she received the pneumonia vaccination 8 years ago and the seasonal influenza vaccination on admission to the facility. Explain the possibilities for why these immunizations were not effective in preventing pneumonia.
Most likely the pneumonia is bacterial, which would not be prevented by the influenza vaccination. Although she received the pneumonia vaccine 8 years ago, it is less effective when more than 6 years have passed. Most importantly, this pneumonia started with aspiration, not a contagious inhalation organism. The pneumonia vaccine contains only typical antigens that are usually spread by the airborne route.

3. The nurse practitioner prescribed ceftriaxone (Rocephin) 2 g IV piggyback stat, then 1 g every 12 hours; oxygen at 6 L by nasal cannula; vital signs hourly; and incentive spirometry every 2 hours. Which intervention should be performed first? Provide a rationale for your choice.
First apply oxygen to improve her oxygen saturation and reduce her confusion. This intervention should take only a few minutes to complete and, if she becomes less confused, may make it easier to perform the other interventions. Start the ceftriaxone as soon as the oxygen is in place. If for some reason it will take time to assemble and start the oxygen equipment, have someone else do that while you start her IV and get the antibiotic going. This infection is not going to clear on its own; an antibiotic is required. The sooner an antibiotic is started, the sooner it can begin to control the infection.

4. What could have precipitated this problem and what steps could be taken to prevent it from happening again?
Most likely her difficulty swallowing from left-sided weakness caused the choking and aspiration that led to this infection. She should be evaluated for her risk for aspiration, and aspiration precautions should be taken. (These include the ones listed in text Chapter 30, Chart 30-5, p. 577.)
p. 658, Patient-Centered Care; Safety; Evidence-Based Practice
The patient is a 48-year-old man who is being released from prison after 15 years of incarceration. On his final physical, he is found to be 20 pounds underweight for his height and has a productive cough. He smokes three packs of cigarettes daily and is exposed to a great deal of secondhand smoke in the prison environment. On release, he is going to live with his 70-year-old aunt. A tuberculin skin test injected 3 days ago shows an 8-mm area of induration around the injection site. His records indicate that his last skin test, performed 18 months ago, did not result in any reaction.
1. What risk factors does this patient have for TB?
2. Does the PPD response indicate a negative test, old TB, or currently active TB?
3. What other tests should be performed with this patient?
4. Should he still be released to live with his aunt? Why or why not?
5. If he does have active TB, would directly observed therapy be appropriate for this patient? Why or why not?
6. If he does have active TB, what are the teaching priorities for this patient and his aunt?

Suggested Responses:

1. What risk factors does this patient have for TB?
Major risk factors include communal living, especially in prison, and being a heavy smoker.

2. Does the PPD response indicate a negative test, old TB, or currently active TB?
If the patient does not have HIV infection or AIDS, this response is suspicious for exposure (10 mm of induration is considered a true positive) and should be followed up. Because his test was negative 18 months ago, this reaction could indicate a recent exposure but does not diagnose actual active TB.

3. What other tests should be performed with this patient?
He should have a chest x-ray and, if possible, the QuantiFERON-TB Gold enzyme-linked immunosorbent assay.

4. Should he still be released to live with his aunt? Why or why not?
If he does not have drug-resistant TB, he could still be released to live with his older adult aunt if adequate preparations are made.

5. If he does have active TB, would directly observed therapy be appropriate for this patient? Why or why not?
There is no reason to believe that he would not be adherent to a self-administered program of TB drug therapy. Therefore directly observed therapy (DOT) is not recommended at this time.

6. If he does have active TB, what are the teaching priorities for this patient and his aunt?
The most important priority is to teach the patient to take the drugs exactly as prescribed and for as long as prescribed. Because the aunt has not been living with this patient for the past 15 years, she may not have been exposed to the organism. Therefore the aunt and the patient should be taught to use appropriate Airborne Precautions until his cultures are negative. This is especially important because the aunt is 70 years old.