Primary Assessment
How old was the patient?
91
What was the patients chief complaint?
increase in SOB
describe the patients general appearance?
GENERAL APPEARANCE: PATIENT PLEASANT, CALM AND COOPERATIVE, GOOD HYGIENE AND COMMUNICATION SKILLS.
which type of cells increase mucus production?
goblet cells
Patient offered supplemental oxygen but patient denied. Placed on SPO2 monitoring, pulse oximeter applied.
When did the patient begin to experience the worsening respiratory distress?
~0800 on the morning of arrival to the ED
Name the three system I chose as my ROS?
respiratory, cardiac, immune
What are 3 ways COPD can manifest in?
EMPHYSEMA, CHRONIC BRONCHITIS, ASTHMA, BRONCHIECTASIS, AND CYSTIC FIBROSIS.
Normal sinus rhythm
Who called 911?
neighbour
What were 2 of the hypothesis i took into consideration for the cardiovascular system?
MI/ CHF/ARRHYTHMIAS
what are 4 clinical findings of COPD
SOB
EXPIRATORY WHEEZE
PURSED-LIP BREATHING
HOOVER’S SIGN
PROLONGED EXPIRATION
RAPID, SHALLOW BREATHES
MUSCLE FATIGUE AND WEAKNESS
FATIGUEÀ DECREASE IN ACTIVITY TOLERANCE
CHRONIC COUGH WITH SPUTUM
BARREL CHEST
Name 2 physiological changes that occur as people age?
CHANGES SUCH AS DECLINES IN MUSCLE MASS, BONE MASS, AND TOTAL BODY WATER
DECREASES IN GLOMERULAR FILTERATION RATES, CHANGES IN IMMUNOLOGICAL RESPONSE, DECREASE IN MOBILITY, DECREASE IN LUNG COMPLIANCE, AND CHANGES IN CARDIOVASCULAR CAPACITY
Name one drug the patient is allergic to?
oxazepam, morphine, codeine
What were the three hypothesis proposed for the immune system?
pneumonia/ urosepsis/ TB
what are 2 diagnostic tests used to diagnose COPD?
pulmonary function test
xray
ct scan
abgs
What did the patient rate their lower back pain out of 10?
Name an aggravating factor of the respiratory distress?
moving/ambulating, "talking lots"
which side of the lungs did the patient have greater decreased entry
right
name 3 medications used to treat COPDE
ventolin
atrovent
pulmicort
prednisone