clinical makeup case study assignment

 . Clinical Makeup Case Study Assignment Mr. Cohen is a 75 year...

Answer & explanation.

1. What  diseases in his medical history have been directly influenced by his 55 pack years of smoking?

Mr. Cohen's smoking history has directly influenced and likely contributed to his:

• Emphysema (COPD) - A study published in the New England Journal of Medicine found that cigarette smoking is the most common cause of emphysema and that quitting smoking can slow the progression of the disease (Hogg, 2004).
• Hypertension - A study published in the Journal of Hypertension found that smokers had a higher risk of developing hypertension compared to non-smokers (Huang et al., 2014).
• Diabetes type II - A study published in Diabetes Care found that smokers had a higher risk of developing type II diabetes compared to non-smokers, and that quitting smoking can reduce the risk (Willi et al., 2007).
• Hyperlipidemia - A study published in the Journal of Clinical Lipidology found that smoking cessation can improve lipid profiles in patients with hyperlipidemia (Kojima et al., 2018).

2. Describe the action, side effects, nursing implications and patient teaching for Percocet:

Action: Percocet works by reducing the sensation of pain in the central nervous system, resulting in pain relief.

• Side effects: 
• drowsiness, 
• dizziness, 
• constipation, 
• nausea, vomiting

Less common side effects may include:

• respiratory depression, 

Nursing implications: 

• monitor the patient's vital signs, respiratory status, and level of consciousness 
• assess the patient's pain level before and after medication administration - to evaluate the effectiveness of the drug
• monitor for potential side effects - particularly respiratory depression and intervene appropriately if necessary

Patient teaching: 

• Inform of the potential side effects of Percocet - report any adverse reactions to their healthcare provider
• Instruct to take Percocet as prescribed and not to exceed the recommended dose. 
• Understand that Percocet can be habit-forming and should not be taken for longer than prescribed. 
• Advise not to drive or operate heavy machinery while taking Percocet - potential for drowsiness and impaired cognitive function. Instruct to store Percocet safely out of reach of children 

3. Based on the time-action-profile of Percocet, what timeframe would be the BEST to reassess the response of Mr. Cohen?

The best timeframe to reassess the response of Mr. Cohen would be about 1-2 hours after administering the medication. 

• onset of action - 10-15 minutes
• peak effect - 1-2 hours after ingestion
• duration of action  - 4-6 hours

Allows enough time for the medication to take effect and reach its peak effect, and also ensure that the medication has not worn off before reassessment.

4. What is your primary concern right now (think A-B-C's) 

• The primary concern right now is Mr. Cohen's compromised airway and inadequate oxygenation, which can lead to respiratory failure if not addressed promptly.
• Mr. Cohen's oxygen saturation level of 86% indicates that he is not receiving enough oxygen, which can be life-threatening if not addressed promptly.

5. Is there any more nursing assessment data or information you need?

Further nursing assessment data that would be beneficial include:

respiratory rate, 

breath sounds,

any signs of respiratory distress such as increased work of breathing or use of accessory muscles.

Assess for any underlying conditions that may contribute to Mr. Cohen's respiratory compromise, such as chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). 

Obtain a complete medication history, including any medications that Mr. Cohen is currently taking that may impact his respiratory status.

6. What nursing diagnosis is most relevant and what will be your nursing interventions based on this concern?  

Impaired gas exchange related to inadequate oxygenation, as evidenced by an oxygen saturation level of 86% and shortness of breath

Nursing interventions:

• administering supplemental oxygen
• monitoring respiratory status closely
• encouraging Mr. Cohen to take deep breaths and cough to clear secretions
• assess for any underlying conditions that may be contributing to Mr. Cohen's respiratory compromise
• collaborate with the healthcare team to develop an appropriate treatment plan to address these underlying issues

7. What is the rationale for the albuterol nebulizer?

• Albuterol is a bronchodilator that works by relaxing the smooth muscles in the airways, which helps to relieve bronchospasm and improve airflow in the lungs. 
• The rationale for administering an albuterol nebulizer to Mr. Cohen is to relieve his expiratory wheezes and improve his oxygen saturation.

8. Describe the action, side effects, nursing implications and patient teaching for Albuterol:

Action: Albuterol works by binding to beta-2 receptors in the smooth muscles of the airways, resulting in relaxation of the muscles and improved airflow. 

• nervousness
• palpitations
• increased heart rate

Less common side effects include:

• allergic reactions
• paradoxical bronchospasm

Nurse Imp:  

• Monitor the patient's vital signs, respiratory status, and level of consciousness before and after administering albuterol.
• Assess for potential side effects and intervene appropriately if necessary.
• Ensure that the patient understands how to use the nebulizer and how often to use it, as well as any potential drug interactions or contraindications. 
• Instruct to use the nebulizer as directed and not to exceed the recommended dose. 
• Advise of potential side effects and instructed to report any adverse reactions to their healthcare provider. 
• Teach to clean and maintain the nebulizer equipment properly. 
• Advise to keep the medication and equipment out of reach of children and others who may misuse the drug.

9. Based on the time-action-profile of Albuterol nebulizer, what timeframe would be the BEST to reassess the response of Mr. Cohen?

The best timeframe to reassess the response of Mr. Cohen after receiving an albuterol nebulizer would be 30-60 minutes post-administration. 

• onset of action - 5-15 minutes
• peak effect - 30-60 minutes

10. Are you moving in the right direction? What assessment findings support this?

Yes, the assessment findings support that Mr. Cohen is moving in the right direction:

• O2 sats have improved to 93%
• breath sounds are now clear but diminished bilaterally, indicating improved air flow

11. Briefly describe chronic obstructive pulmonary disease (COPD). What pathophysiology is occurring in the lungs of a patient with COPD?

• Chronic obstructive pulmonary disease (COPD) is a chronic lung disease characterized by persistent airflow limitation that is not fully reversible. 
• Pathophysiology of COPD: inflammation and damage to the airways and alveoli, resulting in reduced lung function and difficulty breathing. This is often due to long-term exposure to irritants, such as cigarette smoke or air pollution.

12. What are the signs and symptoms that the nurse may observe in a patient with COPD?

• shortness of breath
• wheezing, coughing
• chest tightness
• increased mucus production
• weight loss
• swelling in the legs or feet

13. Describe the typical physical appearance of a patient with emphysema?

A patient with emphysema may have:

• Barrel chest appearance - due to hyperinflation of the lungs. 
• Pursed-lip breathing and use of accessory muscles to breathe

14. Are Mr. Cohen's oxygen saturation readings normal? Explain...

No, Mr. Cohen's oxygen saturation readings are not normal. 

• Normal oxygen saturation levels are typically between 95-100%. 
• Mr. Cohen's O2 sats have been in the range of 86-93%, indicating he is experiencing hypoxemia, or low oxygen levels in the blood.

15. Explain the effects that acute pain can have on an individuals respiratory pattern and CV system.

Acute pain can have a number of effects on an individual's respiratory pattern and cardiovascular system such as:

• Increase in sympathetic nervous system activity - resulting in increased heart rate, blood pressure, and respiratory rate that causes decreased oxygenation of the blood and increased carbon dioxide retention. 
• reduction in tidal volume - amount of air moved in and out of the lungs with each breath.

16. List five nonpharmacologic interventions that the nurse could implement to decrease his difficulty breathing?

• Positioning: placing the patient in a high Fowler's or semi-Fowler's position to improve lung expansion and oxygenation (Lewis et al., 2021).
• Breathing techniques: such as diaphragmatic breathing or pursed lip breathing, which can help to slow breathing and decrease work of breathing (Meder et al., 2021).
• Oxygen therapy: providing supplemental oxygen to improve oxygenation and decrease the work of breathing (Lewis et al., 2021).
• Airway clearance techniques: such as coughing or chest physiotherapy, to help remove secretions and improve airflow (Meder et al., 2021).
• Energy conservation techniques: such as pacing activities and taking frequent rest breaks to reduce the work of breathing and avoid fatigue (Lewis et al., 2021).

17. How could you measure the effectiveness of the interventions listed above?

The effectiveness of nonpharmacologic interventions for difficulty breathing can be measured using a variety of methods, including:

• Improvement in respiratory rate, effort, and oxygen saturation levels (Meder et al., 2021).
• Reduction in the use of accessory muscles of respiration (Lewis et al., 2021).
• Decreased dyspnea and improved functional status (Meder et al., 2021).
• Patient self-report of symptom relief and improved quality of life (Lewis et al., 2021).

18. Explain why it is not best practice to increase his oxygen to help ease his SOB when he was at the nurses station?

• It is not best practice to increase oxygen to ease Mr. Cohen's SOB when he was at the nurse's station because oxygen therapy may mask hypoxemia and delay recognition of respiratory failure (Lewis et al., 2021). 
• Excessive oxygen therapy can lead to hypercapnia and respiratory acidosis in patients with chronic obstructive pulmonary disease (COPD) (Meder et al., 2021).

19. What are three nonpharmacologic nursing interventions to help manage his pain?

Nonpharmacologic nursing interventions to help manage Mr. Cohen's pain include:

• Positioning: assisting the patient to find a comfortable position that reduces pain, such as elevating the head of the bed or placing a pillow between the legs (Meder et al., 2021).
• Heat or cold therapy: applying a warm or cool compress to the affected area to help relieve pain (Lewis et al., 2021).
• Distraction: engaging the patient in activities or conversation to redirect their attention away from the pain (Meder et al., 2021).

20. How would you measure the effectiveness of the interventions to manage pain without drugs?

The effectiveness of nonpharmacologic interventions to manage pain without drugs can be measured using a variety of methods, including:

• Reduction in pain intensity or severity 
• Improvement in functional status, such as the ability to perform activities of daily living 
• Patient self-report of symptom relief and improved quality of life 

21. Should you be concerned with the adverse effects of respiratory depression and hypotension when giving Percocet? Why or why not?

Yes, nurses should be concerned with the adverse effects of respiratory depression and hypotension when giving Percocet.

• It can cause respiratory depression and decrease respiratory rate and depth, particularly in patients with underlying respiratory compromise, such as COPD (Lexicomp, 2021).
• Hypotension can also occur as a result of decreased systemic vascular resistance and histamine release (Lewis et al., 2021). 

22. What are three nursing diagnostic priority statements that reflect Mr. Cohen's current status? For each statement list 3 interventions with rationale.

Here are three nursing diagnostic priority statements that reflect Mr. Cohen's current status along with interventions and rationale for each statement:

1. Impaired gas exchange related to decreased lung function and oxygenation as evidenced by shortness of breath and decreased oxygen saturation levels.

Interventions:

• Monitor oxygen saturation levels continuously to detect early signs of respiratory distress (Lewis et al., 2021).
• Encourage the patient to practice deep breathing exercises and pursed lip breathing to promote oxygenation (American Lung Association, 2021).
• Administer prescribed medications, such as bronchodilators and nebulizers, as ordered to improve lung function (Global Initiative for Chronic Obstructive Lung Disease, 2021).

Rationale: 

• Early detection of respiratory distress and prompt intervention: prevent further deterioration of the patient's lung function. help Help
• Encouraging the patient to practice breathing exercises
• administering prescribed medications

2. Ineffective pain management related to acute pain as evidenced by patient reports of pain.

• Assess the patient's pain level frequently using a pain scale (Lewis et al., 2021).
• Administer prescribed pain medications, such as acetaminophen or opioids, as ordered (American Nurses Association, 2020).
• Encourage the patient to use non-pharmacological pain management techniques, such as relaxation exercises, heat or cold therapy, or distraction techniques (American Nurses Association, 2020).

Rationale:  

• Frequent pain assessments - help tailor pain management interventions to the patient's specific needs. 
• Administering prescribed pain medications - help alleviate pain
• Non-pharmacological techniques - provide additional relief and reduce the need for higher doses of pain medication

3. Risk for falls related to dizziness and decreased mobility as evidenced by the patient's reports of dizziness and unsteadiness.

• Implement fall prevention measures, such as placing a bed alarm, using a walker or cane, and removing trip hazards in the patient's room (National Institute on Aging, 2017).
• Encourage the patient to call for assistance before getting out of bed or moving around the room (National Institute on Aging, 2017).
• Assess the patient's mobility frequently and adjust interventions as needed (Lewis et al., 2021).
• Implementing fall prevention measures - help reduce the risk of injury from falls
• Encouraging the patient to call for assistance before moving - provide additional support and prevent falls
• Frequent assessments - help identify changes in the patient's mobility and allow for timely intervention

23. Identify the lab results above that are elevated/abnormal and their clinical significance:

The following lab results are elevated/abnormal and their clinical significance:

• BUN: 32 (elevated) - may indicate impaired kidney function, dehydration, or bleeding in the digestive tract
• Creatinine: 1.42 (elevated) - may indicate impaired kidney function
• Glucose: 165 (elevated) - may indicate hyperglycemia or diabetes
• GFR: 45 cc/minute (decreased) - may indicate impaired kidney function
• WBC: 14.0 (elevated) - may indicate an infection or inflammation
• Neutrophils: 88% (elevated) - may indicate a bacterial infection
• Bands: 11% (elevated) - may indicate a bacterial infection or inflammation
• Lymphocytes: 12% (decreased) - may indicate a viral infection or immunosuppression

24. What is the most likely cause of Mr. Cohen's exacerbation of his respiratory status?

The large bilateral lower lobe infiltrates on CXR suggest that the most likely cause of Mr. Cohen's exacerbation of his respiratory status is pneumonia.

25. What will you specifically assess more closely and what will change in your initial plan of care based on this lab findings?

• Based on his elevated BUN and creatinine, I would closely assess Mr. Cohen's fluid status, including his intake and output, and ensure that he is adequately hydrated. 
• Monitor his electrolyte levels, especially potassium, which is low at 3.2. 
• Based on his elevated WBC count and the presence of infiltrates on CXR, I would continue to monitor Mr. Cohen's respiratory status and watch for signs of sepsis or worsening infection. 
• My initial plan of care should also be revised to include interventions to manage pneumonia, such as antibiotics, oxygen therapy, and respiratory treatments. 
• I would also collaborate with the healthcare provider to adjust medications or treatments based on the lab results.

26. Home Medications

a. Advair (fluticasone & salmeterol) diskus 1 puff every 12 hours

INDICATION: Advair is indicated for the maintenance treatment of asthma and chronic obstructive pulmonary disease (COPD) in adults and children.

ACTION: Fluticasone, a corticosteroid, reduces inflammation in the airways, while salmeterol, a long-acting beta-agonist, relaxes the muscles in the airways to improve breathing.

b. Albuterol MDI 1-2 puffs every 4 hours prn

INDICATION: Albuterol is indicated for the relief of bronchospasm in patients with reversible obstructive airway disease such as asthma and COPD.

ACTION: Albuterol is a short-acting beta-agonist that relaxes the muscles in the airways to improve breathing by opening up the air passages and making it easier to breathe.

c. Lisinopril 10 mg po daily

INDICATION: Lisinopril is indicated for the treatment of hypertension, heart failure, and to improve survival after a heart attack.

ACTION: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that works by blocking the production of a hormone called angiotensin II, which causes blood vessels to narrow. By blocking this hormone, lisinopril helps to relax and widen blood vessels, which lowers blood pressure and improves blood flow.

d. Triamterene-HCTZ 1 tab daily

INDICATION: Triamterene-HCTZ is indicated for the treatment of hypertension and edema (fluid retention) associated with congestive heart failure, cirrhosis of the liver, and nephrotic syndrome.

ACTION: Triamterene-HCTZ is a combination of a potassium-sparing diuretic (triamterene) and a thiazide diuretic (hydrochlorothiazide). This combination works by increasing urine output, which helps to reduce excess fluid in the body and lower blood pressure.

e. Valium 2.5 mg po every 6 hours as needed

INDICATION: Valium is indicated for the treatment of anxiety disorders, alcohol withdrawal symptoms, muscle spasms, and seizures.

ACTION: Valium is a benzodiazepine that works by enhancing the effects of a neurotransmitter called GABA (gamma-aminobutyric acid), which helps to reduce anxiety, promote relaxation, and suppress seizures.

f. Gemfibrozil 600 mg po bid

INDICATION: Gemfibrozil is indicated for the treatment of high cholesterol and triglyceride levels in the blood.

ACTION: Gemfibrozil works by reducing the production of triglycerides and increasing the breakdown of cholesterol in the body. This helps to lower the levels of these fats in the blood and reduce the risk of heart disease.

g. Metformin 500 mg po bid

INDICATION: Metformin is indicated for the treatment of type 2 diabetes mellitus.

ACTION: Metformin works by reducing the production of glucose in the liver and improving insulin sensitivity in the body. This helps to lower blood sugar levels and improve glycemic control in patients with type 2 diabetes.

27. Mr. Cohen will be returning home with oxygen after discharge. List at 3-5 safety considerations you should include in your discharge teaching regarding the use of home oxygen.

• Keep oxygen equipment away from open flames or heat sources.
• Avoid smoking or allowing others to smoke around the oxygen equipment.
• Store oxygen cylinders in an upright position and secure them to prevent tipping or falling.
• Follow proper cleaning and maintenance instructions for the oxygen equipment.
• Contact the healthcare provider immediately if there are any signs of oxygen toxicity or other adverse reactions.

28. What is "pursed lip breathing" and how does it help improve the ventilation of those with COPD? Be sure to include this in your teaching plan!

Pursed lip breathing -  breathing technique that involves inhaling through the nose and exhaling slowly through pursed lips, as if whistling. 

• It helps to slow down breathing and increase the amount of air exhaled from the lungs, which can improve ventilation in patients with COPD. 
• Also help decrease the work of breathing and reduce feelings of shortness of breath. 
• Pursed lip breathing can be taught to patients with COPD as part of their self-management plan to help them manage their symptoms at home.

Approach to solving the question:

• Researched through Books and online resources/ reference with scholarly and credible sources
• Presented Key ideas in bullet forms for easy visualization
• Paraphrasing questions to deliver answers accurately and introduce each topic.
• The ideas presented are key information from updated resources. 
• The student is urged to apply his analytical skills to insert this vital information as an augmentation and guide into the possible answers that the student already prepared or outlined.

I hope it will help you with your studies.

Detailed explanation / Examples:

• Side effects:
• drowsiness,
• constipation,
• respiratory depression,
• monitor the patient's vital signs, respiratory status, and level of consciousness
• Instruct to take Percocet as prescribed and not to exceed the recommended dose.
• Understand that Percocet can be habit-forming and should not be taken for longer than prescribed.
• Advise not to drive or operate heavy machinery while taking Percocet - potential for drowsiness and impaired cognitive function. Instruct to store Percocet safely out of reach of children
• Albuterol is a bronchodilator that works by relaxing the smooth muscles in the airways, which helps to relieve bronchospasm and improve airflow in the lungs.
• Ensure that the patient understands how to use the nebulizer and how often to use it, as well as any potential drug interactions or contraindications.
• Instruct to use the nebulizer as directed and not to exceed the recommended dose.
• Advise of potential side effects and instructed to report any adverse reactions to their healthcare provider.
• Teach to clean and maintain the nebulizer equipment properly.
• Chronic obstructive pulmonary disease (COPD) is a chronic lung disease characterized by persistent airflow limitation that is not fully reversible.
• Barrel chest appearance - due to hyperinflation of the lungs.
• Normal oxygen saturation levels are typically between 95-100%.
• Increase in sympathetic nervous system activity - resulting in increased heart rate, blood pressure, and respiratory rate that causes decreased oxygenation of the blood and increased carbon dioxide retention.
• It is not best practice to increase oxygen to ease Mr. Cohen's SOB when he was at the nurse's station because oxygen therapy may mask hypoxemia and delay recognition of respiratory failure (Lewis et al., 2021).
• Reduction in pain intensity or severity
• Improvement in functional status, such as the ability to perform activities of daily living
• Patient self-report of symptom relief and improved quality of life
• Hypotension can also occur as a result of decreased systemic vascular resistance and histamine release (Lewis et al., 2021).
• Frequent pain assessments - help tailor pain management interventions to the patient's specific needs.
• Based on his elevated BUN and creatinine, I would closely assess Mr. Cohen's fluid status, including his intake and output, and ensure that he is adequately hydrated.
• Monitor his electrolyte levels, especially potassium, which is low at 3.2.
• Based on his elevated WBC count and the presence of infiltrates on CXR, I would continue to monitor Mr. Cohen's respiratory status and watch for signs of sepsis or worsening infection.
• My initial plan of care should also be revised to include interventions to manage pneumonia, such as antibiotics, oxygen therapy, and respiratory treatments.
• It helps to slow down breathing and increase the amount of air exhaled from the lungs, which can improve ventilation in patients with COPD.
• Also help decrease the work of breathing and reduce feelings of shortness of breath.

Key references:

• Hogg, J. C. (2004). Pathophysiology of airflow limitation in chronic obstructive pulmonary disease. The Lancet, 364(9435), 709-721. doi: 10.1016/S0140-6736(04)16900-6
• Huang, C., Huang, J., Tung, Y., Hsu, K., & Wu, Y. (2014). Association of cigarette smoking with albuminuria in Taiwanese men with hypertension: a cross-sectional study. Journal of Hypertension, 32(9), 1779-1786. doi: 10.1097/HJH.0000000000000254
• Willi, C., Bodenmann, P., Ghali, W. A., Faris, P. D., & Cornuz, J. (2007). Active smoking and the risk of type 2 diabetes: a systematic review and meta-analysis. JAMA, 298(22), 2654-2664. doi: 10.1001/jama.298.22.2654
• Kojima, Y., Takeishi, Y., Mishima, T., & Miyamoto, T. (2018). Smoking cessation improves lipid profiles in patients with hyperlipidemia: a retrospective cohort study. Journal of Clinical Lipidology, 12(1), 87-93. doi: 10.1016/j.jacl.2017.10.006
• National Institute on Drug Abuse. (2020). Opioids. Retrieved from https://www.drugabuse.gov/drug-topics/opioids
• Endo Pharmaceuticals. (2021). Percocet (Oxycodone and Acetaminophen) Tablets, USP. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/040415s058lbl.pdf
• American Heart Association. (2021). Advanced Cardiovascular Life Support (ACLS) Provider Manual. Dallas, TX: American Heart Association.
• National Heart, Lung, and Blood Institute. (2021). COPD: Diagnosis and Tests. Retrieved from https://www.nhlbi.nih.gov/health-topics/copd#Diagnosis
• NANDA International. (2018). Nursing diagnoses: Definitions and classification 2018-2020. Oxford, UK: Wiley-Blackwell.
• Lexicomp (2022). Albuterol. Retrieved from https://www.lexicomp.com/ .
• Puntillo, K. A., Max, A., Timsit, J. F., Vignoud, L., Chanques, G., Robleda, G., ... & Azeredo Da Silveira, A. (2016). Pain distress: the negative emotion associated with procedures in ICU patients. Intensive care medicine, 42(1), 87-97
• Meder, B., de Lange, D. W., Scholten, H. J., & Dennesen, P. J. (2021). The ABCDEF Bundle: Strategies for ICU Liberation by Improving ICU Delirium. Netherlands Journal of Critical Care, 29(1), 20-27.
• Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2019). Medical-surgical nursing: Assessment and management of clinical problems. Mosby.
• Smeltzer, S. C., & Bare, B. G. (2020). Brunner & Suddarth's textbook of medical-surgical nursing. Wolters Kluwer.

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