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    Sample Patient Profile

    Uploaded by

    Hanako Shiga
    Mr. JT, a 61-year-old man with COPD, presented to the emergency room with worsening dyspnea, cough, and sputum production over 3 days. Examination found decreased breath sounds and significant respiratory distress. Labs and imaging showed hyperinflation and scarring consistent with COPD. He was treated with oxygen, bronchodilators, and medications for his COPD and hypertension. The goals of his care are to improve lung function and symptoms through smoking cessation, oxygen therapy, and proper management of inflammation, infection, and secretions.

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    © All Rights Reserved
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    Sample Patient Profile

    Uploaded by

    Hanako Shiga
    83 views2 pages
    Mr. JT, a 61-year-old man with COPD, presented to the emergency room with worsening dyspnea, cough, and sputum production over 3 days. Examination found decreased breath sounds and significant respiratory distress. Labs and imaging showed hyperinflation and scarring consistent with COPD. He was treated with oxygen, bronchodilators, and medications for his COPD and hypertension. The goals of his care are to improve lung function and symptoms through smoking cessation, oxygen therapy, and proper management of inflammation, infection, and secretions.

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    Sample patient profile template for ward

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    Mr. JT, a 61-year-old man with COPD, presented to the emergency room with worsening dyspnea, cough, and sputum production over 3 days. Examination found decreased breath sounds and significant respiratory distress. Labs and imaging showed hyperinflation and scarring consistent with COPD. He was treated with oxygen, bronchodilators, and medications for his COPD and hypertension. The goals of his care are to improve lung function and symptoms through smoking cessation, oxygen therapy, and proper management of inflammation, infection, and secretions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    83 views2 pages

    Sample Patient Profile

    Uploaded by

    Hanako Shiga
    Mr. JT, a 61-year-old man with COPD, presented to the emergency room with worsening dyspnea, cough, and sputum production over 3 days. Examination found decreased breath sounds and significant respiratory distress. Labs and imaging showed hyperinflation and scarring consistent with COPD. He was treated with oxygen, bronchodilators, and medications for his COPD and hypertension. The goals of his care are to improve lung function and symptoms through smoking cessation, oxygen therapy, and proper management of inflammation, infection, and secretions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Bedside Clinic Guidelines

    Pt. Room Number: ER cubicle 4


    Patient Name: Mr. J T
    Problem / Case: COPD

    Brief Patient History


    J.T. is a 61 yo man with COPD who presents to the emergency room with a three-day history
    of progressive dyspnea, cough, and increased production of clear sputum. He usually coughs
    up only a scant amount of clear sputum daily, and coughing is generally worse after rising
    in the morning. The patient denies fever, chills, night sweats, weakness, muscle aches, joint
    aches, and blood in the sputum. He treated himself with albuterol MDI, but respiratory dis-
    tress increased despite multiple inhalations.
    Upon arrival at the emergency room, there were few breath sounds heard with auscul-
    tation, and the patient was so short of breath that he had difficulty climbing up onto the
    examiner’s table and completing a sentence without a long pause. He was placed on 4 L oxy-
    gen via nasal cannulae and given nebulized ipratropium and albuterol treatments.

    Past Medical History


    • HTN x 10 years
    • COPD diagnosed 6 years ago
    • Occasional episodes of acute bronchitis treated as outpatient with antibiotics
    • Mild CVA 4 months ago, appears to have no residual neurologic deficits
    • (–) history of TB, occupational exposure, heart disease, or asthma

    Laboratory Procedures
    Laboratory Blood Test Results
    Na 147 meq/L Plt 160 x10 103/mm3 Bilirubin, total 0.3 mg/dL
    K 4.1 meq/L WBC 9.1 x10 103/mm3 PT 14.2 sec
    Cl 114 meq/L PMNs 62% Alb 4.0 g/dL
    HCO3 25 meq/L Lymphs 27% Protein, total 6.8 g/dL
    BUN 29 mg/dL Eos 3% Alk phos 78 IU/L
    Cr 1.1 mg/dL Basos 1% Ca 8.8 mg/dL
    Glu, fasting 98 mg/dL Monos 7% PO4 3.5 mg/dL
    Hb 19.3 g/dL AST 14 IU/L Mg 2.5 mg/dL
    Hct 55% ALT 31 IU/L AAT 137 mg/dL

    Arterial Blood Gases (on 4 L O2 by Cannulae)


    • pH 7.32
    • PaO2 65 mm Hg
    • PaCO2 54 mm Hg
    • SaO2 90%

    Pulmonary Function Tests


    • FEV1 1.67 L (45% of expected)
    • FVC 4.10 L (85% of expected)
    • FEV1/FVC 0.41 (expected 0.77)

    Chest X-Rays
    • Hyperinflation with flattened diaphragm
    • Large anteroposterior diameter
    • Diffuse scarring and bullae in all lung fields but especially prominent in lower lobes bilaterally
    • No effusions or infiltrates
    • Large pulmonary vasculature

    Surgical Management
    The patient hasn’t undergone any surgical management.

    Pharmacological Management
    • HCTZ 25 mg po Q AM
    • Amlodipine 5 mg po QD
    • Theophylline 200 mg po BID
    • Albuterol 180 µg MDI 2 inhalations QID PRN
    • Ipratropium 36 µg MDI 2 inhalations QID
    • The patient has been compliant with his medications. However, he admits that he does not
    like to use ipratropium because it causes “dry mouth” and makes him feel “edgy.”.

    Course of Management
    The goal of COPD management is to improve a patient’s functional status and quality of life by
    preserving optimal lung function; improving symptoms and preventing recurrence of exacerbation.
    Smoking cessation greatly decreases episodes of exacerbation. Oxygen therapy also helps to maintain
    the patients lung functions. His medications helps control and manage the inflammation and infection
    that comes with COPD. Sputum viscosity and Secretion clearance should also be properly managed to
    improve symptoms.

    Nursing Diagnosis and Management


    1. Impaired gas exchange related to decreased lung compliance and altered level of consciousness
    as evidenced by dyspnea on exertion.
    2. Ineffective airway clearance related to secretions in the bronchi as evidenced by crackles on
    auscultation.
    3. Disturbed sleep pattern related to breathlessness as evidenced by increasing irritability.

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