Question

• 1. Document assessment data of Toua Xiong, including a focused history, physical examination (including vital signs), focused respiratory assessment, pain level assessment, and assessment of the oral cavity. Note any abnormal findings.
• 2. Document the medication(s) that were administered.
• 3. Document the patient education provided to Toua Xiong. Include cause of candidiasis infection and teaching regarding proper administration and care of dry powder and metered-dose inhalers, proper administration of Mycostatin, and oxygen therapy.

Answer 1

1)Xiong is a 64-year-old male. He has a history of COPD, which is diagnosed 5 years ago.Patient is also complaining about the difficulty of swallowing and pain in his throat and mouth, and it has bothered him while eating or drinking for the last 3 to 4 days. He also mentioned that his mouth and throat is being coated in a white substances .He has been using his two inhalers as prescribed. Vitals sign showed - BP: 105/63, Resp Rate: 24 breaths/ min audible wheezes are heard externally with equal bilateral chest rise with no visible chest deformities, Pulse: normal and strong 100 bpm, O2: 93% and on nasal canula it is 1L/min, Temp: 99 degrees farenheit. Lung auscultation showed audible wheezes with inspiration. Heart sounds were normal rate and rhythm, S1 and S2 heard with no murmurs or extra heart sounds. Patient has a pain state of 5/ 10, and it becomes worse when he tries to eat or drink. Pain become worse during eating food and drink.

2) Following are the mediccations that are administered.

Ipratopium inhalation 36 mcg/ dose à metered dose inhailor
Fluticasone/salmeterol 250/50 mcg/doseà metered dose inhailor
1L/ min oxygen via nasal canula

3)Patient condition assures the need to blow out the residual air in the lungs before inhaling first puff. Affix mouth around mouth piece of inhailer completely . Breathe the medication in deep and fast and hold as long as possible, exhale and then rinse the mouth with water and spit it out.
Candidiasis infection is a superficial infection in the mouth and tongue. It is an overgrowth of an organism that causes changes in the normal bacteria in mouth. It can result from improper use of inhaled medication, such as not rinsing your mouth after each use, which leads to a yeast build up due to providing a warm and moist environment for it to develop in.
Mycostatin administration: measure directed amount for each treatment. Apply only after brushing and hold it in the mouth for about 2 minutes before swallowing.
It is important to alert the fire department about the use of oxygen to treat the COPD . In case if there is ever a fire or power outage in the area. Oxygen is highly flammable and combustable substance and it is important to stay clear from anyone who smokes. The oxygen is prescribed for the patient in liters/minute for rest, sleep, and activity .