Please list only information that pertains to each problem under each problem. 3. What is your assessment and plan for each problem? 1. Provide pharmacological and nonpharmacological care (don't forget to be specific). Will you discontinue any medication that the patient is currently taking and/or add any new medications? 2. Include your therapeutic goals for each problem (use the subjective and objective information listed above to help you) 3. How will you monitor each problem and each medication included in your plan? 4. When will you suggest following up with the patient? 5. Is there any laboratory monitoring that will need to be conducted to assure the safety of the patient? 6. What educational information regarding disease and or medication does the patient need? Problems Subjective/Objective Assessment/Plan Moderate Persistent Asthma/Acute Asthma Exacerbation Complaining of increased SOB, wheezing, poor exercise tolerance Wakes up at least twice a week with SOB and wheezing Chest tightness in the morning Allergic to Cats (wheezing) Roommate boyfriend has a Check O2 sat Order ABG, Chest X-ray Prednisone 40mg po qday for 7 days Start on Serevent Diskus 1 puff (50mcg) inhaled q12h Change dosage of Proventil HFA 2 puffs, every 4-6 hours, PRN for wheezing and SOB Increase dosage of fluticasone to 88mcg BID. Therapeutic goals Remove asthma triggers from BK’s environment (cat dander from boyfriend’s apartment) Able to participate in all activities of daily living (School, exercise and quality sleeping) Preventing repeated asthma attacks (SOB,
cat in his apartment Audible wheezing, suprasternal muscle retractions RR 28 Diffuse wheezes bilaterally on exhalation and occasionally on inspiration Peak Flow: 200L/min (baseline 340 L/min) Patient taking Albuterol (Proventil®) HFA 2 puffs every 6 hours Patient taking Fluticasone (Flovent®) HFA 44mcg one puff BID wheezing, and chest tightness) Providing the best medicine treatment with the fewest possible side effects
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- Spring '14
- Asthma Case Study