Reference no: EM132470920
F.T. is a 70-year-old African American man who comes to the emergency department (ED) complaining of increased shortness of breath. He states that he started using his albuterol inhaler every 4 hours a few days ago, but it does not seem to be helping. He has been having trouble sleeping or doing any activity because of his shortness of breath.
SUBJECTIVE Data:
PMH: COPD, hypertension, and benign prostatic hyperplasia. No history of allergies.
Medications: metoprolol (Lopressor) 50?mg/day PO, furosemide (Lasix) 20?mg PO daily, finasteride (Proscar) 5?mg/day PO, Advair inhaler (fluticasone and salmeterol) 2 puffs bid, and albuterol inhaler 2 puffs q4hr PRN. Does not use O2 at home.
Health Perception-Health Management: F.T. states he usually manages his COPD well with the Advair inhaler and occasional use of albuterol inhaler PRN. He thinks he caught a cold from his granddaughter last week. Increasing difficulty breathing, even with albuterol. Has a history of 30 pack-years of smoking, quitting 5 years ago.
Nutritional-Metabolic Pattern: Not eating, drinking very little over past 2 to 3 days.
Activity-Exercise: At present, cannot walk 100 feet without feeling short of breath, nor walk up one flight of stairs without stopping to catch his breath.
Sleep-Rest: Difficulty sleeping at present. Last night he slept upright in his recliner.
Cognitive-Perceptual: Denies any pain associated with shortness of breath. Feels slightly irritable because of lack of sleep.
Coping-Stress Tolerance: Denies any stress or emotional disturbance.
Discussion Questions
- What type of assessment would be most appropriate for F.T.: comprehensive, focused, or emergency?
- From the information provided by F.T., what other information would you ask him about his condition (time permitting)?
- How will you individualize the assessment based on his current physiologic condition?
- What considerations will you make based on his age? Ethnic/cultural background?
- Of the information provided, which subjective assessment findings are of most concern to you?
- F.T. cannot use his inhaler appropriately while he is talking with you. Is this an appropriate time to teach him about the proper use of his inhaler?
- What should be included in the physical assessment? What do you think will be the priorities in your physical assessment?