NSG 6001 Week 2 Discussion

NSG 6001 Week 2 Discussion

NSG 6001 Week 2 Discussion

Chief Complaint: Mr. Barley arrived to the clinic with complaints of a productive cough and dyspnea for the past two winter seasons.

History of Present Illness: Mr. Barley is a 58-year old male arriving to the clinic complaining of dyspnea on exertion and a productive cough for the last two weeks. The patient states that his cough occurs seasonally during the last two winters. The patient explains that he coughs up a whitish phlegm. He also confirmed that his dyspnea is noticed when he walks quickly or when walking upstairs. Mr. Barley denies chest pain, fever, nausea, vomiting, diarrhea, weight loss, extremity swelling, orthopnea or paroxysmal nocturnal dyspnea. He also denies traveling recently and exposure to tuberculosis. Mr. Barley also denies psychosocial symptoms such as paresthesia, choking, de-realization feeling, trembling or shaking, dizziness, palpitations, sweating, chills, or flushing.

Onset: Started approximately two weeks ago

Location: Chest

Duration: Symptoms have persisted for the last 2 weeks; Similar symptoms for the past two winter seasons

Characteristics: Productive cough with “whitish phlegm” and dyspnea on exertion

Aggravating factors: Worsening with exertion

Relieving factors: Rest

Treatment: None noted

Severity: Patient seeking medical attention at the clinic due to progressively worsening cough and dyspnea.

Social History: Mr. Barley has been married to his wife for 35 years and they have two adult children. The patient’s occupation is farming but he denies exposure to dusts or chemicals because he raises his crops organically and wears protective clothing as needed. Mr. Barley admits that he has smoked one to two packs daily for the last 26 years and he drinks one beer every few days.

Family History: Mr. Barley states that his father died at age 79 of a stroke and his mother has been diagnosed with hypertension. He reports no other significant family health history.

Past Medical History: Mr. Barley denies taking any medications or having been admitted to the hospital. He states that he has had a history of cuts and stitches and a tonsillectomy when he was 12 years of age. The patient denies any chronic illness.

Physical Examination:

Vital signs: BP: 128/78 mmHg; P – 94 beats/minute; R – 22 breaths/minute; T – 98.9 Fahrenheit

General: Mr. Barley appears mildly short of breath.

HEENT: Normocephalic, atraumatic, conjunctivae and sclerae are normal, PERRL, oropharynx is normal. Neck: Supple without masses, lymphadenopathy or thyromegaly. Laryngeal height measures 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration.

Lungs: Increased AP diameter. Percussion is normal. Inspiratory crackles at the bases, and end-expiratory wheezing diffusely.

Heart: Regular rate and rhythm. 2/6 systolic murmur loudest at the right upper sternal border with radiation to the left lower sternal border. Denies chest pain or palpitations.

Abdomen: Bowel sounds normal, no hepatomegaly, no tenderness.

Extremities/Pulses: 1+ pitting pretibial edema

Neurologic: Denies paresthesia, de-realization feeling, trembling or shaking, dizziness or sweating.

Mr. Barley’s physical examination revealed several abnormalities, which include an increased anterior posterior diameter of his chest, laryngeal height measuring 2 cm from sternal notch to the top of the thyroid cartilage upon full expiration, inspiratory crackles at the lung bases, and end expiratory wheezing. Mr. Barley’s cardiovascular examination revealed a 2/6 systolic murmur loudest at the right upper sternal border with radiation to the left lower sternal border. The patient’s extremities show 1+ pitting pretibial edema. Other than the findings listed above, the patient’s physical examination is within normal limits.

Differential Diagnoses: Chronic obstructive pulmonary disorder (COPD); Asthma; Bronchitis

Diagnostic Tools: After Mr. Barley’s physical exam, the health care provider decided to order a pulmonary function test (PFT) to differentiate a diagnosis of chronic obstructive pulmonary disease (COPD) or asthma. According to Buttaro, Trybulski, Polgar-Bailey and Sandberg-Cook (2017), “spirometry is essential to the diagnosis and management of asthma and COPD” (p. 470). Mr. Barley underwent the recommended PFT and the post bronchodilator forced expiratory volume (FEV1) and forced volume capacity (FVC) ratio resulted at 69 percent, which is less than 70 percent indicating obstructed airway disease. The diagnosis of asthma was ruled out due to the FEV1 not changing after bronchodilator treatment.

I believe it would be useful to include a chest x-ray in Mr. Barley’s diagnostic tools. A chest x-ray may exclude causes or problems other than COPD (Reis et al., 2018). It may also detect treatable causes of dyspnea other than COPD. Lab diagnostics including a complete blood count, metabolic panel, thyroid-stimulating hormone and B-type natriuretic peptide (BNP) would also be useful to rule out anemia, electrolyte imbalances, hyperthyroidism or cardiac issues (Buttaro et al., 2017; Reis et al., 2018). I would also inquire to have Mr. Barley’s pulse oximetry taken to determine his oxygen saturation at rest and during exertion. Respiratory Discussion APN Wk2

Plan of Care: The health care provider decided to treat Mr. Barley’s mild COPD by prescribing an albuterol metered-dose inhaler and advising the patient to quit or decrease smoking. Mr. Barley must be educated on how to use an inhaler and he should demonstrate its use back to the provider or nurse to ensure he is receiving the appropriate dose. Mr. Barley should also be educated on albuterol’s most frequent adverse effects, such as tremors, nervousness, and insomnia (Medscape, 2018). An additional goal of COPD treatment would be to prevent complications.

Mr. Barley’s health care provider recommended immunizations for influenza, pneumococcus, and TdaP to avoid specific infections. Patients with COPD have a high risk of exacerbations from the influenza virus, which is associated with an “increased death rate, impaired pulmonary function, poor quality of life, and substantial economic burden” (Arabyat, Raisch & Bakhireva, 2018, p. 163).

Therefore, preventing episodes like the influenza virus is essential in the management of COPD patients. It is important to educate Mr. Barley on what to watch for COPD exacerbations and side effects of medication therapy. According to the 2017 GOLD report, an exacerbation is “an acute worsening of respiratory symptoms that results in additional therapy” (Global Initiative for Chronic Obstructive Lung Disease, 2017).

Exacerbations of COPD involve worsening of breathlessness, cough or sputum, oxygen saturation levels, limitation of daily activities, use of accessory respiratory muscles, cyanosis, deteriorated mental status, peripheral edema or hemodynamic instability (Reis et al., 2018). If the patient’s symptoms are not controlled, a long-acting bronchodilator, beta-2 agonist, anticholinergic, theophylline or combination therapy may be added to the patient’s medication regimen. The use of systemic glucocorticoids or admitting patient to the hospital may be indicated depending on the severity of the patient’s COPD exacerbation.

Mr. Barley should be followed periodically by his primary care physician and pulmonologist. He should also have PFT’s performed every three months to reassess and monitor for progression of disease (Reis et al., 2018). If the patient is willing, it is beneficial to refer him to a smoking cessation and respiratory rehabilitation program.

References

Arabyat, R.M., Raisch, D.W. & Bakhireva, L. (2018). Influenza vaccination for patients with chronic obstructive pulmonary disease: Implications for pharmacists. Research in Social and Administrative Pharmacy, 14(2), 162-169. doi: https://doi.org/10.1016/j.sapharm.2017.02.010

Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier

Global Initiative for Chronic Obstructive Lung Disease. (2017). Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (2017 report). Retrieved from: https://goldcopd.org/gold-2017-global-strategy-diagnosis- management-prevention-copd/

Medscape. (2018). Albuterol. Retrieved from: https://reference.medscape.com/drug/proventil- hfa-ventolin-hfa-albuterol-343426#4

Reis, A.J., Alves, C., Furtado, S., Ferreira, J., Drummond, M. & Robalo-Cordeiro, C. (2018). COPD exacerbations: Management and hospital discharge. Pulmonology. doi: https://doi.org/10/1016/j.pulmoe.2018.06.006

Response 1

Hello Yoandris,

Great job on your post! Your description of Mr. Barley’s visit and physical examination depicted him well. I found that the case study was missing some pertinent subjective information such as the type of treatment Mr. Barley was using at home to help him remedy his cough and shortness of breath. I also found that the case study did not describe the severity of Mr. Barley’s shortness of breath. I am assuming that Mr. Barley was not in acute distress due to the duration of his symptoms and because he did not go to the emergency room. I appreciate your discussion of medications that are used frequently for patients with chronic obstructive pulmonary disorder (COPD).

I thought that it was appropriate that Mr. Barley begin with a beta2 agonist such as an albuterol metered-dose inhaler to alleviate his symptoms. It is essential that Mr. Barley is educated on how to self-administer his albuterol properly and the adverse effects of his medication. Adverse effects of albuterol include tremors, nervousness, tachycardia, and insomnia (Medscape, 2018). As you have stated, it is also very important to thwart “flare-ups” or complications in COPD patients. This can be done by preventing infections with immunizations, proper hygienic precautions, and the cessation of smoking.

Mr. Barley should also be followed up with periodically by his primary care physician and pulmonologist to evaluate and assist him in managing his disease. Pulmonary function tests must be performed to monitor for progression of disease. Buttaro, Trybulski, Polgar-Bailey and Sandberg-Cook (2017) state that the spirometry tool is crucial to the diagnosis and management of asthma and COPD (p. 470). Respiratory Discussion APN Wk2

References

Arabyat, R.M., Raisch, D.W. & Bakhireva, L. (2018). Influenza vaccination for patients with chronic obstructive pulmonary disease: Implications for pharmacists. Research in Social and Administrative Pharmacy, 14(2), 162-169. doi: https://doi.org/10.1016/j.sapharm.2017.02.010

Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier

Medscape. (2018). Albuterol. Retrieved from: https://reference.medscape.com/drug/proventil- hfa-ventolin-hfa-albuterol-343426#4

Response 2

Hello Alejandra,

Great job on summarizing the case study provided to us this week. My post discussed similar findings with the physical examination and plan of care. I found that the case study did not take account of all the subjective factors, such as the home treatment he was possibly using and the severity of his symptoms. It was under my impression that Mr. Barley was not in acute distress from the assessment and because he did not go the emergency room. When the diagnosis of chronic pulmonary obstructive disorder (COPD) was confirmed with Mr. Barley’s physical examination and diagnostic tests, the provider explained in detail the nature of the disease, it’s treatment, and possible complications.

If a severe COPD exacerbation should occur, it is important that providers educate patients on when to seek immediate medical attention. The National Heart, Lung, and Blood Institute (2018) recommend that COPD patients pursue emergency care if they have difficulty catching their breath or talking, lips or fingernails turn blue or gray, mental status has changed, rapid heartbeat, or if the recommended treatment for symptoms is not working. I thought it was great that you pointed out depression as a concern in Mr. Barley’s treatment plan.

Buttaro, Trybulski, Polgar-Bailey and Sandberg-Cook (2017) state that it is often difficult to identify depression in older adults because of the aging process and changes that occur in appetite, sleep wake cycles, and their inability to continue life pursuits (p. 101). Living with any chronic illness can cause fear, anxiety, depression, and stress. It is important that health care providers initiate conversations regarding their feelings and listen closely to evaluate their psychosocial status properly. Respiratory Discussion APN Wk2

References

Buttaro, T.M., Trybulski, J., Polgar-Bailey, P. & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed.). St. Louis, M.I.: Elsevier

The National Heart, Lung, and Blood Institute. (2018). COPD. Retrieved from: https://www.nhlbi.nih.gov/health-topics/copd

ADDITIONAL INSTRUCTIONS FOR THE CLASS – NSG 6001 Week 2 Discussion

SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – NSG 6001 Week 2 Discussion

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. NSG 6001 Week 2 Discussion

• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. NSG 6001 Week 2 Discussion

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. NSG 6001 Week 2 Discussion

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. NSG 6001 Week 2 Discussion

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. NSG 6001 Week 2 Discussion

• Guarantee

• Zero Plagiarism
• On-time delivery
• A-Grade Papers
• Free Revision
• 24/7 Support
• 100% Confidentiality
• Professional Writers

• Services Offered

• Custom paper writing
• Question and answers
• Essay paper writing
• Editing and proofreading
• Plagiarism removal services
• Multiple answer questions

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. NSG 6001 Week 2 Discussion

Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper