Holistic Care Plan for Disease Prevention

Care Plan

Patient Initials NA

Subjective Data:

Chief Compliant

Severe wheezing, coughing every day, and shortness of breath.

History of Present Illness

Attacks of bronchial asthma since the patient was twenty. Over the two last months, the asthma attacks became more frequent – more than 4 times per week on average. Takes Albuterol inhaler as required and Theophylline oral.

PMH

A motor vehicle accident ten weeks ago.

Seizure two weeks after the trauma, phenytoin (anticonvulsant) started with the positive effect and resulted in complete seizure cessation.

Congestive heart failure of mild stage recognized three 3 years ago, the client started a low sodium diet and hydrochlorothiazide. A year ago, she started taking enalapril because the heart failure worsened. As a result, the symptoms improved last year.

Medical

• Theophylline SR Capsules 300 mg oral twice a day;
• Albuterol inhaler, when necessary;
• Phenytoin SR capsules 300 mg oral at bedtime;
• Hydrochlorothiazide 50 mg oral twice a day;
• Enalapril 5 mg oral twice a day.

Surgical History

None

Allergies

None

Significant Family History

• Father died at the age of 59 from kidney failure.
• Mother died at the age of 62 from heart failure.

Social History

• Smoking – none, alcohol – none;
• Caffeine (four cups every day);
• Diet colas every day.

Review of Symptoms:

General

Exercise intolerance

Cardiovascular

None

Respiratory

Shortness of breath, coughing and wheezing.

Psychologic

Eyes, head, nose, ear, throat, gastrointestinal, musculoskeletal, genitourinary, endocrine, neurological, hematologic – none

Objective Data:

Vital Signs: BP 171/94 mmHg; RR 31’; HR 122’; T 96.7 F; Wt 145, Ht 5’ 3”, BMI 25.7

After Albuterol – BP 134/79 mmHg, RR 18’; HR 80’

Physical Assessment Findings

Well-developed female client, anxious, pale.

Head, Eyes, Ear, Nose, Throat

• Pupils round, equal, react to light, accommodation;
• Oral cavity without lesions.

Cardiovascular

• Regular rate and rhythm;
• Normal S1 and S2.

Respiratory

Bilateral expiratory wheezes

Gastrointestinal

Soft, non-tender, non-distended no masses

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Genitourinary

Unremarkable

Rectal

Guaiac negative

Neurological

• Alert & oriented to person, place, & time;
• Cranial nerves intact.

Extremities

• Ankle edema + 1;
• No bruising;
• Normal pulses.

Laboratory and Diagnostic Test Results

• Na – 134 (normal);
• Cl – 100 (normal);
• K – 4.9 (normal);
• Cr – 1.2 (normal);
• BUN – 21 (normal);
• Glu – 110 (normal);
• ALT – 24 (normal, rejects hepatic dysfunction);
• AST – 27 (normal);
• Total Chol – 190 (desirable level);
• CBC – within normal range;

Theophylline – 6.2 (therapeutic range for asthma treatment is normal but low for acute bronchospasm; with phenytoin concomitant administration, theophylline blood concentration lowers);

Phenytoin – 17 (within the therapeutic range);

Chest X-ray – Blunting of the right and left costophrenic angles (may indicate pleural effusions).

Spirometry

Peak Flow – 75/min; after albuterol – 102/min (predicted peak flow for the 65 – year old female is 430 l/min; the albuterol test indicates potential for the reversion of bronchospasm, but the absolute figure suggests, the lungs are severely damaged with disabled expiratory capacities);

FEV1 – 1.8 L, FVC 3.0 L, FEV1/FVC 60% (predicted FEV1 for the 65 – year old female 5’3’’ is 2.12, the low observed level suggests bronchial obstruction; predicted forced vital capacity for a 5’3’’ individual is 3.6 L, which indicates parenchymal disability for the distension; FEV1/FVC below 70% indicates bronchial obstruction). Overall, the results show both obstructive and restrictive lung disorders.

Assessment

J45.51

Severe persistent asthma with (acute) exacerbation

The long history of bronchial asthma, recent worsening, and current exacerbation of symptoms is supported by the spirometry data. The patient has a poorly controlled condition with Theophylline and occasional Salbutamol. It may be suspected that recent administration of phenytoin has lowered the Theophylline plasma level, and the therapeutic range has become inadequate. This assumption may explain the current hospitalization, but as spirometry suggests, the disorder is associated with emphysema, thus it must have been a long history of poorly controlled disease.

J43

Emphysema

Poorly controlled repetitive episodes of bronchospasm and inflammation provoke activation of fibroblasts, these cells produce collagen and other fibrous strands. The alveoli do not exhale the air, so the gas becomes entrapped and distends the lung parenchyma to destruct the acinar walls. As a result, the lungs become stiff and fail to inhale easily and exhale smoothly. Moreover, obstructive problems are accompanied by restrictive pathology.

I50.42

Chronic combined systolic (congestive) and diastolic (congestive) heart failure

Pulmonary emphysema is a chronic condition, which elevates the pulmonary artery resistance of the pulmonary artery capillary network. As a result, the pulmonary artery pressure elevates. The right ventricle uses excessive force to pump the blood and hypertrophies. The hypertrophic cardiac muscle becomes restrictive and causes restrictive heart failure However, with time, the compensatory abilities exhaust, and systolic heart failure follows. Edemas and effusions are usual signs of congestive heart failure.

Plan of Care

Severe persistent asthma with (acute) exacerbation

To alleviate the current deterioration, it can be recommended to start an intravenous steroid. Steroids will reduce bronchial inflammation and contribute to the reduction of bronchospasm. Nasal oxygen therapy may improve oxygenation if the blood gas panel is altered. If the patient’s condition does not improve, intubation and bronchoscopy may be advised.

The client must begin a long-acting beta-agonist (instead of short-acting Salbutamol) in combination with an inhaled corticosteroid or an anticholinergic to prevent exacerbations. Salbutamol is an agent that relieves bronchospasm. However, due to its short-acting pharmacology effect, it fails to control the condition in the long term. Theophylline dosage may be increased to elevate the plasma level and achieve a more active concentration of the drug. The environmental control can be re-evaluated for the client, including the eradication of dust mites, animals, cockroaches, and mold. Allergen immunotherapy, performed by repetitive injections of antigen, is a promising approach if the allergy panel is positive. A monoclonal antibody therapy course is a new alternative for allergies treatment (CDC, 2017; Morris, 2017).

Emphysema

Pulmonary emphysema is a secondary condition due to bronchial asthma. It is an irreversible morphological condition, however, its clinical course can be improved. The key element of support is the adequate treatment of bronchial obstructive components, as described above. The second approach is ambulatory oxygen therapy, which supports oxygenation of the body. Lung volume reduction therapy may be discussed with thoracic surgery to improve the quality of life of the patient (Boka, 2016).

Chronic combined systolic (congestive) and diastolic (congestive) heart failure

The client has mild edemas and pleural effusions, which suggests the current therapeutic scheme is suboptimal. The patient’s heart failure depends on the pulmonary problem, so an improvement of her lung status may already alleviate the heart decompensation. Otherwise, it may enhance the diuretic therapy with spironolactone, which adds to the anti congestive activity of enalapril. Currently, a short dose of intravenous furosemide may help evacuate the pleural effusions. In any case, the patient must follow a low-salt diet, avoid heavy labor, and start aerobic exercise training (Ponikowski et al., 2016; WHO, 2016).