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
- Black,K
- Asthma Case Study