Testing this blog in June

PLEASE READ

Hi folks - please be sure to read through the whole posting before commenting. Some of what you might suggest may be further down in the assessment! If you don't find it there, then please comment! Thanks.

MR RA Case Info

A 65 YO AA male arrives in respiratory distress. The paramedics transporting him by ambulance have brought his medications including Furosemide.

RA is a frail, 65 YO man on oxygen who is obviously short of breath at rest with pursed lip breathing.

RESEARCH

Hey guys, Furosemide research is below. What else should we research before we ask the assessment questions? Anything? Maybe some respiratory disorders?
What is Furosemide (Lasix)?
Therapeutic Class:
--- Diuretic
Indications
--- Edema due to heart failure, hepatic impairment or renal disease
--- Hypertension
Adverse Effects
--- CNS: blurred vision, dizziness, headache, vertigo
--- EENT: hearing loss, tinnitus
--- CV: hypotension
--- GI: anorexia, constipation, diarrhea, dry mouth, dyspepsia, nausea, pancreatitis, vomiting
--- GU: excessive urination
--- Derm: photosensitivity, pruritis, rash
--- Endo: hyperglycemia, hyperuricemia
--- Fluids & Electrolytes: dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis
--- Hemat: APLASTIC ANEMIA, AGRANULOCYTOSIS, hemolytic anemia, leukopenia, thrombocytopenia.

SUBJ - BIOGRAPHICAL DATA (text book pg 75)

Name: RA
Age: 65
Gender: Male
Ethnic origin: AA
ASK --- Is there anyone here with you?
ASK --- Marital status:
ASK --- Usual or past occupation:
ASK --- Present occupation:
Address: Skip for this case study
Phone Number: Skip for this case study
Birth date: Skip for this case study
Birth place: Skip for this case study

SUBJ - REASON FOR SEEKING CARE (text book pg 76)

I can see from your chart right here what brought you in – but …
ASK --- Can you tell me in your own words what brought you in today? Or, what was going on when you called the ambulance? That would help me out.

SUBJ – PRESENT HEALTH

We know he has shortness of breath so we’ll ask him OLDCARTS about that:
--- Onset: when did you start having shortness of breath?
--- Duration: when did it start?
--- Duration-2: Does it come and go? Is it continuous?
--- Character: Can you describe it to me? What does it feel like?
--- Associated: Is there anything else going on?
--- Relief/Aggravation: Does anything make it better? Worse?
--- Treatment: Have you taken anything to help it?
--- Subjective: What do you think is going on?

If he answers yes to any of the below we should do OLDCARTS on those as well.

Thorax and Lungs - from Lab Book Page 171:
--- Do you have a cough?
--- Do you have any chest pain while breathing?
--- Do you have any past history of lung disease?
--- Do you smoke cigarettes? How many per day?
--- Are there any conditions at home or work that affect your breathing?
--- When was your last TB test / or Chest X-Ray?
--- Have you had a flu vaccine?
--- Have you had a pneumonia vaccine?
--- How many pillows do you sleep on at night?
--- Do you have sputum? Can you describe it?

Heart and Neck Vessels – from Lab Book Page 185:
Let me know if you think some of these might make sense – I picked out a few
If you think I should nuke these, let me know
--- Do you have any chest pain or tightness?
--- Do you seem to tire easily?
--- Is your facial skin ever blue or ashen?
--- Do you have any swelling of feet or legs?
--- Do you awaken at night to urinate?

SUBJ – PAST HEALTH (text book pg 77-78)

I rearranged these – from pg 78 – in an order that seemed more relevant - let me know

Current Medications / O2
--- Are you on oxygen at home? How much?
--- What medications are you on?
--- What is it for?
--- Dosage
--- Number of times per day
--- Are you taking it as prescribed?
--- Do you notice any differences after you take your medication?
--- What supplements or OTC are you taking?

Serious chronic illnesses or allergies
--- Do you have any past history of lung disease?
--- Do you have any past history of cardiac disease?
--- Hypertension
--- Diabetes, sickle cell anemia (skip?), cancer, seizure disorder (skip?)
--- Any allergies?
--- Any drug allergies? What happens when you take that drug?

Hospitalizations / Doc visits
--- Have you ever been hospitalized?
--- Have you had any surgeries?
--- When was your last examination?

Accidents or injuries (WE might SKIP THIS?)
--- Any accidents or injuries?

Childhood illnesses (I THINK WE SKIP THESE???)
--- Bronchitis, Measles, mumps, rubella, chicken pox, pertussis, strep throat
--- Rheumatic fever, scarlet fever, poliomyelitis?

Immunizations (I THINK WE SKIP THESE??? – we have TB, flu and pneumonia vaccinations above)
--- MMR, polio, DPT, Hep B, HPV

SUBJ – FAMILY HISTORY - textbook pg 78

--- Parents: Diseases? Alive? Cause of death?
--- Siblings: Diseases? Alive? Cause of death?
--- Children: Diseases? Alive? Cause of death?
--- For each, you might specify: respiratory disease, heart disease, hypertension, stroke, diabetes, blood disorders, cancer, sickle cell, arthritis, allergies, kidney disease, TB
--- Others listed, but might not apply to our patient? --- Obesity, alcoholism, mental illness, seizures

SUBJ – REVIEW OF SYSTEMS (ROS)

I stole the ROS from our complete health history document/assignment. I parked it at the end of this page (scroll all the way down). We might not have to go through the whole thing. We'll see. It is there if we need it.

SUBJ - FUNCTIONAL ASSESSMENT

I stole this from our complete health history ...
Usual daily food intake?
Weight change in the last 6 months?
Adequacy of dentition, chewing, swallowing, ability to feed self?
Who prepares food?
Who is present at mealtimes ?
Alcohol and illicit drug use?
Tobacco: (type, amount, duration of use)?
Do you exercise?
Limitations inability (dyspnea, fatigue, joint pain)?
Sleep/Rest Pattern/Problems?
Where do you sleep?
How old is your house?
Who do you live with?
Who helps you when you need help?
Current health of family members?
Losses or stressors in last six months?

OBJ - GENERAL SURVEY - text pg 148

--- Any visible signs of dyspnea?
--- Position – sitting normal? Tripod?
--- Any signs of acute distress?
--- Appears age?
--- Level of consciousness?
--- Skin color, tone, lesions?
--- Facial features symmetric with movement?
--- Height and weight looks normal?
--- Looks nourished?
--- Body looks symmetrical?
--- Posture looks normal? – oops, bad word
--- Gait
--- Behavior – facial expression, mood and affect, speech, dress, personal hygiene

OBJ – MEASUREMENTS - text pg 150

--- Measure chest for AP-T
--- Height, weight
--- BMI, waist to hip ratio (skip these?)

OBJ – VITAL SIGNS – text pg 151

Is the order below appropriate for the situation?
--- O2 saturation
--- Pulse with 1+ 2+ 3+
--- Respirations, regular?, Depth?
--- BP
--- Temperature

OBJ – THORAX and LUNGS – text page 449

Do each of the following for anterior and posterior chest
Inspect
--- Shape and configuration of chest wall (AP-T ratio)
--- Use of neck muscles?
--- Tripod position? (noted earlier)
--- Skin color
--- Skin lesions?
Palpate
--- Skin turgor?
--- Symmetric chest expansion?
--- Tactile fremitus
--- Palpate for tenderness
Percuss
--- Percuss for resonance, dullness
--- Diaphragmatic excursion (skip this?)
Auscultate
--- Breath sounds?

OBJ – HEART and NECK VESSELS – text pg 497

Does it make sense to do this for this client?
Maybe part of it?

NECK VESSELS
Palpate - Carotid artery
Auscultate - Carodid artery - bruits?
Inspect - Jugular Venous Pulse (Check for JVD for CHF... fluid volume overload is a sign of CHF and would be evident)

PERICORDIUM
Inspect - Anterior Chest
Palpate Apical Pulse
Palpate for Thrills
Auscultate - for normal/abnormal heart sounds

OBJ – PERIPHERAL VASCULAR SYSTEM – text pg 536

Does it make sense to do this for this client?
Maybe part of it?

Inspect arms and legs
Palpate arms and legs - for bilateral pulses (rate the pulses +1 etc. -- we would see bounding pulses with CHF)
Palpate for edema

OBJ - FUROSEMIDE ASSESSMENT - from Nursing Central

Jen had a good idea to assess for effects of furosemide. We should check to see if we captured this stuff above - if not, we might want to know about it! This is from Nursing Central.

• Assess fluid status. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify physician or other health care professional if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs

• Monitor blood pressure and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension

• Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies

• Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs

• Assess for allergy to sulfonamides

Dyspnea Research ...

Mike did some research re Dyspnea ...
From my surfings on the web regarding shortness of breath(non-academic sites)

Over 950 reasons exist for causes of shortness of breath.

Some of the more common causes include:
▫ anaphylaxis
▫ anxiety
▫ asthma
▫ bronchitis
▫ carbon monoxide poisoning
▫ chronic obstructive pulmonary disease
▫ cystic fibrosis
▫ collapsed lung (pneumothorax)
▫ congestive heart failure
▫ COPD
▫ emphysema
▫ exercise
▫ high fever
▫ hyperventilation syndrome
▫ pneumonia
▫ pulmonary embolism

Questions we might want to ask:
▫ sudden onset, severe, chest pain/tightness (MI, pneumothorax, pulmonary embolism, atelectasis)
▫ episodic with wheezing or coughing (asthma, infection)
▫ gradually getting worse over time (in periods of weeks or months, not days or hours) exposure to noxious fumes, smoking (COPD, chronic bronchitis)
▫ worked in or around asbestos, wood dust, industrial fumes or in a coal mine (occupational lung disease)
▫ with swollen feet or ankles, and harder to breath when lying flat (congestive heart failure)
▫ with tiredness, dry cough, chest pain and worse with exertion (interstitial lung disease, sarcoidosis, pulmonary hypertension)
▫ With pale skin and tired all the time (anemia)
▫ with rapid breathing, dizziness, numbness or tingling in hands or mouth (hyperventilation)
▫ with fever
o With painful cough or blood and mucous (infection, cancer)
o Cold symptoms and a mucous-producing cough (bronchitis, pneumonia)
o With dry cough and chest pain (histoplasmosis (fungal infection)
o With chest pain, chills, coughing up pus (lung abcess)

Questions put another way:
▫ How long have you had SOB? – acute or chronic
▫ Sudden onset?
o if sudden - respiratory distress syndrome, pulmonary embolism, pneumothorax, lung collapse
o If gradual onset - chronic diseases such as congestive cardiac failure, emphysema and fibrosis.
▫ What makes it worse? – exertion, lying flat
▫ Recent history of bleeding - anemia
▫ Past medical history? - previous respiratory illness (pneumonia, tuberculosis, chronic bronchitis); previous heart problems (heart disease, heart attack, heart valve disease); HIV infection ( at high risk for Pneumocystis carinii pneumonia); previous high blood pressure; deep venous thrombosis; rheumatic fever.
▫ Medications
▫ Cigarette smoking
▫ Drug history - cocaine, amphetamines, injected narcotics
▫ Alcohol? - aspiration pneumonia, klebsiella pneumonia
▫ Occupational history?
▫ Allergies?
▫ Family history? - asthma, cystic fibrosis, emphysema, alpha-1-anti-typsin deficiency, tuberculosis, heart attacks.

Related symptoms questions:
▫ With cough? – lung disease, heart disease
▫ Color and quantity of sputum, if any? - large volume pus-like - bronchiectasis or pneumonia; foul smelling dark colored - lung abscess; pink frothy secretions - left ventricular heart failure; blood - lung disease
▫ With audible wheeze? - asthma, chronic bronchitis, emphysema, airways obstruction (by a foreign body or tumor), left ventricular heart failure
▫ With chest pain? - lung disease, heart disease
▫ With fever? - at night - tuberculosis, pneumonia, mesothelioma
▫ Orthopnea? - suggests left ventricular heart failure.
▫ With stridor? - obstruction of larynx, trachea or large airways by a foreign body, tumor or infection
▫ With ankle swelling? - heart failure.
▫ With heart palpations? - heart arrhythmia
▫ Fever and pus-like sputum? - pneumonia
▫ Chest pain with blood in sputum? - pulmonary embolism