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PATIENT, KEY, LINKS, 2, 2, 3, 3, 4, 1, 5, 5, 6, 6, 7, 7, 8, 8, 9, 9, 10,…
PATIENT
MEDICATIONS
Acetaminophen - treats fever and mild pain (Sanoski, 2021).
"My right side hurts, where the chest tube is". Patient experiences 7/10 chest pain around the chest tube insertion site.
Amox-clav - kills bacteria to stop infection (Sanoski, 2021).
Increased WBCs and neutrophils are indicative of an infection (Mayo Clinic Staff, 2020).
Salbutamol - treats bronchospasm caused by COPD by opening the airways (Sanoski, 2021).
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Fluticasone - decreases severity and frequency of asthma attacks; helps with difficulty breathing (Sanoski, 2021).
Ipratropium - helps manage airway obstruction caused by COPD by dilating the airways (Sanoski, 2021).
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Pantoprazole - reduces stomach acid to reduce acid reflux (Sanoski, 2021).
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Potassium chloride - electrolyte replacement helps prevent potassium deficiency which may be caused by medication or diet.
Patient is likely on this supplement because using diuretics can cause potassium levels to decrease due to filtration.
Furosemide - treats hypertension and edema by removing excess fluid in the body (Sanoski, 2021)
Sennosides - treat constipation by increasing water levels in the large intestine through osmosis (Sanoski, 2021).
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Zopiclone - treats insomnia and difficulty falling asleep by interacting with GABA receptors in the brain (Sanoski, 2021).
Patient experiences difficulty falling asleep as evidenced by previous charting and PRN medication record.
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LAB RESULTS
CO2: 39mmol/L (range 20-32mmol/L) measures the amount of CO2 levels in blood; helps indicate lung function (Cleveland Clinic, 2022).
Troponin I: 0.05 (range 0.01-0.04) elevated troponin I levels indicate cardiac muscle damage (Cleveland Clinic 2022).
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WBC: 14.7. An elevated level of WBCs indicates the body is trying to fight off an infection (Mayo Clinic Staff, 2020).
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Neutrophils: 12.7. An elevated level of neutrophils indicates the body is trying to fight off an infection (Cleveland Clinic, 2022).
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HEALTH HISTORY: COPD
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COPD causes difficulty breathing and shortness of breath. It is a combination of chronic bronchitis and pulmonary emphysema. Chronic bronchitis is an inflammation of the lining of the airways, resulting in an overproduction of mucus (CDC, n.d.). In emphysema, the bronchioles become damaged, breaking down the walls and disrupting the exchange of O2 and CO2 (CDC, n.d.).
Symptoms include shortness of breath, coughing that produces mucus, chest tightness, and wheezing (CDC, n.d.).
The main cause of COPD is long-term smoking (American Lung Association, 2021). Other factors heightening the risk of developing COPD are genetics, exposure to lung irritants such as pollutants, and asthma (CDC, n.d.).
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DISCHARGE PLANNING
MAiD
GOAL 1: This option does not lead to discharge in a traditional sense. The patient has discussed MAiD as an option with the physician. The patient has chosen to sign the forms and go with this option should gravity tubing not improve their condition.
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