Additional Objective Data To Healthcare Provider Assignment
Primary Care Assignment Two
Background
The client is a 56yo white male. Upon visiting the clinic, the client reports an accelerated decline in lung functioning capacity. Last year the healthcare provider had ordered an albuterol inhaler prn, which seemed adequate for the client. During today’s clinic visit, the client was pale, dyspneic, and almost listless. The client reports that he currently smokes a cigarette. He has a smoking history of approximately 40 years. His chief complaint during today’s clinic visit was being forced to sleep on the recliner since he cannot lie in bed. The client reported needing more energy to complete various activities, including eating. A physical examination enabled the healthcare provider to collect a comprehensive patient’s medical history. This paper includes additional subjective data that the client should provide, additional objective data that the healthcare provider should gather, National Guidelines to be considered, tests to be ordered, a consultant to be involved during the client’s treatment, medical and nursing diagnoses, legal/ethical considerations, plan of care, including medical, nursing, and complementary therapies, Healthy People 2020 objectives to be considered during the client’s treatment, application of Circle of Caring in the client’s treatment to achieve optimal health, required additional patient teaching and recommended billing codes. Additional Objective Data To Healthcare Provider Assignment
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Required Additional Subjective Data that the Patient would Share
Subjective data guides healthcare providers in making a differential diagnosis. Based on the provided subjective data, including difficulty sleeping and reduced energy, the client suffers from Chronic Obstructive Pulmonary Disease (COPD). However, the client should provide additional subjective data to guide the healthcare provider in confirming this diagnosis. According to Patimah et al. (2018), COPD is characterized by a lack of energy, shortness of breath, fatigue, chest tightness, and sputum production. Therefore, the client should either confirm or deny other symptoms of COPD, including shortness of breath, particularly with physical activities, chest tightness, wheezing, chronic cough accompanied by sputum production, unintended weight loss, frequent respiratory infections, and swelling in various parts such as ankles, legs, or feet.
Additional Objective Data that the Healthcare Provider would assess
Objective data plays a significant role during COPD diagnosis and treatment. Thus, the healthcare provider should focus on gathering additional objective data, including abnormal sounds such as wheezes, distant heart sounds, and crackles that might be heard on auscultation. The healthcare provider should also document changes in nutrition, significant loss in body weight loss, and muscle atrophy. According to Kim et al. (2019), COPD progress is attributed to metabolism changes, including a decrease in lean body mass and an increase in fat percentage, leading to loss of muscle mass. The healthcare professional should also document the client’s oxygen saturation. COPD leads to a decrease in oxygen saturation, making the patient tachycardic (Elvekjaer et al., 2020). Furthermore, the clinician should document if gray or blue fingernails or lips were observed, particularly during exertion. The inability to speak fluently or complete full sentences caused by dyspnea should also be documented. Chronic bronchitis causes swelling in the legs, ankles, and feet in people diagnosed with COPD. Lastly, the healthcare provider should document reddening in the face. Gasping for air makes the faces redden in persons diagnosed with COPD. Therefore, documenting these physical examination findings will enable the healthcare provider to confirm the client’s diagnosis of COPD.Additional Objective Data To Healthcare Provider Assignment
Appropriate National Guidelines
The national guideline to be considered while treating this patient is the Global Initiative for Chronic Lung Disease. In most cases, healthcare providers adhere to this guideline when treating individuals diagnosed with COPD (Balkissoon, 2020). The guideline provides clinicians with essential information regarding COPD, including clinical manifestations, management approaches, and preventive strategies.
Tests to be ordered
Diagnostics tests are ordered to conform subjective and objective data. In this case, the healthcare provider would order a spirometer or pulmonary function test (PFT). This test measures the functioning capacity of the lungs (Kouri et al., 2020). Healthcare providers use forced vital capacity (FVC) in determining the type and severity of the client’s lung disease. Another test that should be ordered is an arterial blood gas test. This test measures the level of gases in the blood, including carbon dioxide and oxygen. The concentration of these gases indicates the working capacity of the. Thus, this test would determine the severity of the client’s COPD and if oxygen therapy is required. Furthermore, a chest X-ray should be ordered to detect emphysema, one of the primary causes of COPD. Additionally, the results of an X-ray can be used to rule out heart failure or other lung conditions. More so, a CT scan. A CT scan is recommendable for this patient. The results of this test will be used in detecting emphysema. These results can also be used to determine if the client can benefit from COPD surgery. Additionally, a CT scan is used to rule out lung cancer. Moreover, arterial blood gas analysis can be ordered to assess how the lungs oxygenate the blood and eliminate carbon dioxide from the blood. Lastly, lab tests should be ordered for this patient. Although these tests do not help diagnose COPD, they can be used in ruling out another potential diagnosis. For example, lab tests can help the healthcare provider to rule out the genetic disorder alpha-1-antitrypsin deficiency that predisposes some individuals to COPD. This test is usually ordered in persons with a family history of COPD. Additional Objective Data To Healthcare Provider Assignment
A Consult to be involved during the Client’s Treatment Process
A consultant will be involved in the patient’s treatment process. During the clinical interview, the client reported some symptoms, such as breathing difficulty. Additionally, diminished breath sounds were detected during auscultation. These symptoms indicate a decrease in lung function capacity. Furthermore, this client already has arterial hypoxemia with respiratory acidosis, necessitating immediate oxygen supplementation. Therefore, a consultation is needed to develop the most appropriate treatment plan for this client, reducing the likelihood of developing further health complications.
Medical and Nursing Diagnoses
Presented clinical manifestations, physical examination results, and diagnostic findings indicate nursing and medical diagnoses. The medical diagnosis for this client is COPD, which is characterized by an accelerated decline in lung functioning capacity and lack of energy. On the other hand, this client has two potential nursing diagnoses, including impaired gas exchange and an ineffective breathing pattern. These nursing diagnoses result from the client’s medical diagnosis, COPD. Additional Objective Data To Healthcare Provider Assignment
Legal/Ethical Considerations
Ethical and legal considerations guide the treatment of individuals diagnosed with COPD. In most cases, COPD is diagnosed in elderly adults with other comorbidities, including cardiovascular disease, diabetes Mellitus, metabolic syndrome, osteoporosis, lung cancer, sleep disorders, and depression. Therefore, patients with COPD require prolonged treatment, which is expensive, imposing a huge financial burden on an individual or family member. The costly and demanding treatment raises the ethical dilemma of whether to continue or discontinue the patient’s treatment. To overcome this dilemma, healthcare providers apply ethical principles, including patient autonomy, beneficence, and non-maleficence. The ethical principle of patient autonomy holds that an individual has a right to make all significant decisions regarding his or her treatment (Char et al., 2020). Thus, healthcare providers should consider the patient’s autonomy while making decisions regarding his treatment. Additionally, the client’s decision should be respected even if it might not lead to the best outcomes. Secondly, healthcare providers should adhere to the ethical principle of beneficence. This ethical principle states that medical professionals should focus on benefiting their patients through the treatment they provide (Char et al., 2020). Therefore, the clinician should ensure that administered treatment effectively manages the patient’s symptoms, resulting in positive health outcomes, improved quality of life, and a longer lifespan. Furthermore, the ethical principle of non-maleficence should be considered while developing a treatment plan for this client. The ethical principle of non-maleficence states that healthcare providers should not harm their patients (Char et al., 2020). Hence, the healthcare provider should avoid treatment interventions exposing the patient to potential harm, including health complications or death.
In addition to ethical guidelines, the treatment of COPD should be based on established legal measures. Healthcare providers should ensure that the care plan meets treatment goals, including controlling shortness of breath, minimizing cough and sputum production, and slowing the progression of this disease. Additional Objective Data To Healthcare Provider Assignment
Plan of Care
An appropriate plan of care for COPD patients contributes to achieving treatment goals. The treatment plan for this client includes medical, nursing, and complementary therapies.
Medical Treatment
Pharmacological treatments for COPD are categorized into two major groups: anticholinergic medications and beta2 agonists. According to Sandhu and Vastardi (2022), anticholinergic medications and beta2 agonists are FDA-approved first-line treatments for COPD. The two drugs are administered through inhalation. They alter the airways’ smooth muscle tone, improving FEV1 and enhancing exercise tolerance. Healthcare providers also administer bronchodilators regularly to minimize symptoms and a lower likelihood of exacerbations or hospitalizations. Secondly, short-acting beta2 agonists (SABA) are given to individuals with COPD as required to manage intermittent dyspnea (Reddel et al., 2022). Furthermore, individuals diagnosed with COPD are given long-acting muscarinic antagonists (LAMA) and long-acting beta2 agonists (LABA). These medications are usually given to individuals with increasing dyspnea. Inhaled corticosteroid (ICS) is also considered an effective therapy for bronchodilators as a step-up therapy, resulting in positive health outcomes. Oral Phosphodiesterase-4 inhibitors are another class of drugs prescribed to individuals with COPD to reduce inflammation. Additionally, this medication is added to the drugs above in cases of severe obstruction in airflow. Lastly, COPD patients are prescribed triple inhaled therapy (LABA+ LAMA+ ICS) once daily. FDA recently approved LABA+ LAMA+ ICS for treating COPD. Additional Objective Data To Healthcare Provider Assignment
Nursing Treatment
Nursing intervention for COPD patients includes supplemental oxygen therapy. The therapy is usually recommended for COPD patients with oxygen saturation below 88% or PaO2 below 55 mmHg (Elizabeth & Syafaah, 2022). Oxygen therapy aims to maintain oxygen saturation greater than 90%. Another nursing intervention for individuals diagnosed with COPD is endurance exercise, which is recommended to increase exercise and work capacity.
Complementary Therapies
Complementary therapies for patients with COPD aim to reduce reported symptoms and prevent the disease from progressing. The most complementary therapy for individuals diagnosed with COPD is smoking cessation. According to Bartlett et al. (2018), smoking cessation is the most effective intervention for treating individuals diagnosed with COPD. Smoking cessation reduces the acceleration of lung function decline among individuals with COPD. Additional Objective Data To Healthcare Provider Assignment
Healthy People 2020 Objectives to be considered
Healthy People 2030 includes objectives that enhance respiratory diseases’ prevention, detection, and treatment. Therefore, this objective should be considered in detecting, treating, and preventing the acceleration of this patient since he presented with COPD, a respiratory disease. Consequently, the client would achieve positive health outcomes and improved quality of life.
The Circle of Caring
The Circle of Care is considered a holistic model, which demonstrates social and behavioral change (SBC) applicable in several service continuums. Bose et al. (2022) reported that SBC is applicable in various disciplines, including behavioral and social sciences. These changes can be applied before, during, and after providing the service to enhance health outcomes. The model aims to improve service interactions. The SBC model is used in motivating the clients to access services (before services). The model also aims at improving the interactions between the provider and the client (during services). Furthermore, the model boost maintenance and adherence (after services). Additionally, the model considers cultural norms and social aspects likely to impact the utilization of services and delivery. Lastly, the model supports communication between the healthcare provider and the clients or their family members. Additional Objective Data To Healthcare Provider Assignment
The Circle of Caring model is applicable in this case. The client is encouraged to change his social life and behaviors. Specifically, the client is encouraged to quit his smoking pack, which he has used for the last 40 years. Smoking cessation is an effective treatment therapy for people diagnosed with COPD since it lowers the acceleration of the decline in lung functioning capacity (Martinez et al., 2020). Additionally, the healthcare provider would involve the client and his family before, during, and after the treatment therapy. The patient and family members will provide the necessary support if they are involved during the treatment process resulting in positive health outcomes.
Require Additional Patient Teaching
Patient teaching is required to achieve positive health outcomes for this patient. First, the patient should be counseled regarding smoking cessation. The healthcare provider should inform the patient that quitting smoking is the most effective intervention since it slows the progression of the disease (Bartlett et al., 2018). The client should also be educated on the importance of promoting efficient ventilation and minimizing exposure to open cooking fires. This action increases the oxygen supply, preventing the disease from progressing. Additionally, the client and his family should be educated on how to use the inhaler technique appropriately. Proper use of the inhaler technique will ensure that all medications are delivered to the patient’s lungs. Additionally, the client should be educated on adjusting his diet and increasing the number of calories to prevent unintended weight loss, common in individuals with advanced COPD. The patient should be taught how to eat small meals frequently to meet nutritional requirements irrespective of his deteriorating health condition. Additionally, the client should increase the intake of nutrient-dense foods, including eggs. To meet nutritional requirements, the patient should also take food supplements and daily multivitamins. The client should also be taught several breathing techniques, including pursed-lip breathing, to enable him to breathe easily and meet oxygen requirements. These techniques will be helpful when the client is experiencing shortness of breath or difficulty breathing. The client should also be educated on the benefit of adhering to guidelines provided by the healthcare provider regarding adhering to the prescribed dosage. According to Rogliani et al. (2017), poor adherence to the prescribed medication regimen results in adverse health outcomes in individuals with chronic illness. Thus, adhering to the prescribed medication and dosage would enable the patient to achieve positive health outcomes. Furthermore, the client would be advised to keep off from people with colds and flu and receive the flu vaccine annually to reduce the likelihood of contradicting flu. Lastly, the client should seek medical care immediately if the reported symptoms especially breathing difficulty, accelerate to prevent his health condition from deteriorating. Additional Objective Data To Healthcare Provider Assignment
Recommended Billing Codes
Recommended Billing Codes for a person diagnosed with COPD vary depending on the severity of the reported symptoms. The billing code for this client is J44.1, which is applied in individuals with chronic obstructive pulmonary disease accompanied by acute exacerbation. During the clinical interview, the client reported shortness of breath, inability to sleep, and reduced energy, indicating COPD with acute exacerbation.
Conclusion
The client presented to the clinic with an accelerated decline in lung functioning capacity, inability to sleep on the bed, and reduced energy. These symptoms indicate the likelihood of COPD. However, additional subjective and objective data were required to confirm this diagnosis. The additional subjective data required shortness of breath, particularly with physical activities, chest tightness, wheezing, chronic cough accompanied by sputum production, unintended weight loss, frequent respiratory infections, and swelling in various parts such as ankles, legs, or feet. On the other hand, required additional subjective data include changes in fingernails or lips or the client’s oxygen saturation. Additionally, diagnostics such as chest X-rays, CT scans, and pulmonary function tests (PFT) would be ordered to confirm the client’s diagnosis. The Global Initiative would guide the client’s treatment for Chronic Lung Disease. Additional Objective Data To Healthcare Provider Assignment
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References
Balkissoon, R. (2020). Journal Club—COPD2020 Update. Global Initiative for Chronic Obstructive Lung Disease 2020 Report and the Journal of the COPD Foundation Special Edition, Moving to a New Definition for COPD: “COPDGene® 2019”. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, 7(1), 64.
Bartlett, Y. K., Sheeran, P., & Hawley, M. S. (2018). Effective behavior change techniques in smoking cessation interventions for people with chronic obstructive pulmonary disease: A meta‐analysis. British Journal of Health Psychology, 19(1), 181–203.
Bose, D. L., Hundal, A., Seth, K., Hadi, S. U., Singh, S., Singh, S., … & Salve, S. (2022). PROTOCOL: Social and behavior change communication interventions for strengthening HIV prevention and research among adolescent girls and young women in low‐and middle‐income countries: An evidence and gap map. Campbell Systematic Reviews, 18(1), e1211.
Char, D. S., Abràmoff, M. D., & Feudtner, C. (2020). Identifying ethical considerations for machine learning healthcare applications. The American Journal of Bioethics, 20(11), 7–17.
Elizabeth, E., & Syafaah, I. (2022). Hyperoxia in the management of respiratory failure: A literature review. Annals of Medicine and Surgery, 104393.
Elvekjaer, M., Aasvang, E. K., Olsen, R. M., Sørensen, H. B., Porsbjerg, C. M., Jensen, J. U., … & Meyhoff, C. S. (2020). Physiological abnormalities in patients admitted with acute exacerbation of COPD: an observational study with continuous monitoring. Journal of clinical monitoring and computing, 34(5), 1051-1060.
Kim, S. H., Shin, M. J., Shin, Y. B., & Kim, K. U. (2019). Sarcopenia associated with chronic obstructive pulmonary disease. Journal of bone metabolism, 26(2), 65-74.
Kouri, A., Gupta, S., Yadollahi, A., Ryan, C. M., Gershon, A. S., To, T., … & Chow, C. W. (2020). Addressing reduced laboratory-based pulmonary function testing during a pandemic. Chest, 158(6), 2502–2510.
Martinez, F. J., Han, M. K., Allinson, J. P., Barr, R. G., Boucher, R. C., Calverley, P. M., … & Wedzicha, J. A. (2018). At the root: defining and halting the progression of early chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine, 197(12), 1540–1551.
Patimah, S., Kusnanto, K., & Rayasari, F. (2018). The effect of progressive muscle relaxation with pursed lips breathing towards fatigue, depression and lung function of COPD patients in provincial hospital of Jayapura. Int J Sci Res, 6(10), 1339-1353.
Reddel, H. K., Bacharier, L. B., Bateman, E. D., Brightling, C. E., Brusselle, G. G., Buhl, R., … & Boulet, L. P. (2022). Global Initiative for Asthma Strategy 2021: executive summary and rationale for key changes. American Journal of Respiratory and Critical Care Medicine, 205(1), 17-35.
Rogliani, P., Ora, J., Puxeddu, E., Matera, M. G., & Cazzola, M. (2017). Adherence to COPD treatment: myth and reality. Respiratory medicine, 129, 117-123.
Sandhu, S., & Vastardi, M. A. (2022). Bronchodilators. In Absolute Allergy and Immunology Board Review (pp. 293–296). Springer, Cham. Additional Objective Data To Healthcare Provider Assignment