Question

F.F., a 68-year-old man, is admitted to a medical floor with an acute exacerbation of chronic obstructive pulmonary disease (COPD). His other medical history includes hypertension and type 2 diabetes. He has had pneumonia yearly for the past 3 years and has been a two-pack-a-day smoker for 38 years. His current medications include enalapril (Vasotec), hydrochlorothiazide, metformin (Glucophage), and fluticasone/salmeterol (Advair). He appears a cachectic man who is having difficulty breathing at rest. F.F. seems irritable and anxious; he complains of sleeping poorly and states that lately he feels tired most of the time. He reports cough productive of thick yellow-green sputum. You auscultate decreased breath sounds, expiratory wheezes, and coarse crackles in both lower lobes anteriorly and posteriorly. His vital signs (VS) are 162/84, 124, 36, 102° F (38.9° C), and Spo2 88%. uestions to Answer: Indicate the expected outcome associated with each medication. F.F. is receiving. What common side effects of bronchodilator therapy do you need to assess for? When you apply the nicotine patch, you take the opportunity to ask F.F. if he would like information on smoking cessation. He tells you he is interested, because he has to “stop while he is in here.” How can you support his continuing cessation after discharge? You deliver F.F.’s dietary tray, and he comments on how hungry he is. As you leave the room, he is rapidly consuming the mashed potatoes. When you pick up the tray, you notice that he has not touched anything else. When you question him, he states, “I don’t understand it. I can be so hungry, but when I start to eat, I have trouble breathing and I have to stop.” Describe 4 interventions that might improve his caloric intake. What other interprofessional team members could you involve in F.F.’s care and how? The UAP reports that F.Fs blood glucose level is 366 mg/dL (20.3 mmol/L). What action do you need to take and why? Scenario (cont’d): The next morning, F.F. is sitting in the bedside chair and appears to be experiencing less difficulty breathing. He states his cough remains productive of yellow-green sputum, although it is “easier to cough up” than it was the previous day. You auscultate decreased breath sounds and a few coarse crackles in both lower lobes posteriorly. His VS are 150/78, 94, 24, 99.7° F (37.6° C). His Spo2 is 92% with O2 on at 2 L per nasal cannula. Arterial Blood Gases pH 7.33 Paco2 58 mm Hg HCO3 32 mEq/L (32 mmol/L) Pao2 65 mm Hg Sao2 92%

Questions to Answer:

6. Indicate the expected outcome associated with each medication. F.F. is receiving.
7. What common side effects of bronchodilator therapy do you need to assess for?
8. When you apply the nicotine patch, you take the opportunity to ask F.F. if he would like information on smoking cessation. He tells you he is interested, because he has to “stop while he is in here.” How can you support his continuing cessation after discharge?

You deliver F.F.’s dietary tray, and he comments on how hungry he is. As you leave the room, he is rapidly consuming the mashed potatoes. When you pick up the tray, you notice that he has not touched anything else. When you question him, he states, “I don’t understand it. I can be so hungry, but when I start to eat, I have trouble breathing and I have to stop.”

9. Describe 4 interventions that might improve his caloric intake.
10. What other interprofessional team members could you involve in F.F.’s care and how?
11. The UAP reports that F.Fs blood glucose level is 366 mg/dL (20.3 mmol/L). What action do you need to take and why?

Scenario (cont’d):

The next morning, F.F. is sitting in the bedside chair and appears to be experiencing less difficulty breathing. He states his cough remains productive of yellow-green sputum, although it is “easier to cough up” than it was the previous day. You auscultate decreased breath sounds and a few coarse crackles in both lower lobes posteriorly. His VS are 150/78, 94, 24, 99.7° F (37.6° C). His Spo2 is 92% with O2 on at 2 L per nasal cannula.

Arterial Blood Gases

pH	7.33
Paco2	58 mm Hg
HCO3	32 mEq/L (32 mmol/L)
Pao2	65 mm Hg
Sao2	92%

Questions to Answer:

12. Interpret F.F’s ABG values.
13. Has F.F.’s status improved or not? Defend your response.
14. What interventions would you include in your plan of care for F.F. today?
15. What topics do you need to address with F.F to reduce his risk for readmission?

F. F. s discharged after 6 days with instructions to follow up with the primary care provider in 1 week.

Answer 1

a) Indicate the expected outcome associated with each medication. F.F. is receiving.

Enalapril -  to treat high blood pressure (hypertension) .

Hydrochlorothiazide - to treat high blood pressure,lessen symptoms such as shortness of breath.

Metformin (Glucophage) -control blood sugar levels.

Fluticasone/salmeterol - prevent and treat wheezing, shortness of breath, coughing, and chest tightness caused by chronic obstructive pulmonary disease (COPD).

b) What common side effects of bronchodilator therapy do you need to assess for?

• Nervous or shaky feeling
• Increased heart rate or palpitations
• Upset stomach
• Trouble sleeping
• Muscle aches or cramps

c) When you apply the nicotine patch, you take the opportunity to ask F.F. if he would like information on smoking cessation. He tells you he is interested, because he has to “stop while he is in here.” How can you support his continuing cessation after discharge?

Encourage the client to make a plan that work for him.

explain the client the necessity of cessation of smoking.

Make sure he has the support of his family and friends.

Consider a nicotine replacement therapy.

Help him to make the strategies to overcome the craving.

Ask him to take proper rest and to relax during his activities though it is physical or mental.

d) You deliver F.F.’s dietary tray, and he comments on how hungry he is. As you leave the room, he is rapidly consuming the mashed potatoes. When you pick up the tray, you notice that he has not touched anything else. When you question him, he states, “I don’t understand it. I can be so hungry, but when I start to eat, I have trouble breathing and I have to stop.”

1. Describe 4 interventions that might improve his caloric intake a Eat several small, nutrient-rich meals to avoid becoming breathless while eating. b Choose foods that are easy to prepare to conserve energy for eating. c  Prepare meals that appear palatable and well presented. d   Avoid foods that cause gas or bloating. A full abdomen can make breathing uncomfortable.