NR 603 Week 2 Case Discussion Pulmonary - Part 2 Follow up Visit Complete Solution
1. Determine appropriate treatment plan for Michelle. Discuss
... [Show More] medications, doses, Durable Medical Equipment, and any testing, and apply these directly to her case. Provide your rationale with evidence.
2. Decide whether she is safe to return home, include any prescriptions, or if a referral to a higher level of care is required. Discuss the criteria used to make your decision, how a referral is made and defend your position.
3. Discuss relevant education and follow up plan.
Michelle G. is experiencing an acute illness with Influenza A and exacerbation of her asthma. This is of concern and needs to be managed quickly and appropriately. In the United States and globally, seasonal influenza A and B are associated with a remarkable morbidity and mortality annually. Although, influenza is self-limiting and most people recover without complication, influenza can result in serious illness and death. Serious complications are more frequently seen in the immunocompromised, populations at age extremes, pregnant women, as well as in people with chronic medical condition such as asthma (Uyeki et al., 2019). Asthma is noted to be the most frequently observed disease process in patients with influenza that are admitted to the hospital and have a greater risk of being admitted to the intensive care unit (Schwarze et al., 2017). Influenza involves neutrophilic inflammation, edema, TH1 adaptive immune response, epithelial cell death and sloughing, and alveolar collapse resulting in fever, malaise, sore throat, cough, and rhinorrhea. Whereas, asthma involves eosinophilic inflammation, GC metaplasia, increased mucus production, TH@ adaptive immune response, bronchial epithelial hyperplasia, and airway remodeling resulting in wheezing, cough, tightness in the chest, and dyspnea (Veerapandian et al., 2018). These multitude of symptoms require both pharmacologic and non-pharmacologic management.
Treatment Plan:
According to the Global Initiative for Asthma (GINA) (2020) management of asthma exacerbations in the primary care setting involve quick assessment of exacerbation severity, is the patient talking in phrases, unable to lie down, is the patient tachypneic, use of accessory muscles observed, is the patient tachycardic, is oxygen saturation (O2sat) between 90 -95% on room air, and is peak expiratory flow (PEF) greater than 50% predicted or best value. Michelle can speak sentences, is experiencing mild dyspnea upon exertion, no mention of use of accessory muscles, inability to lie down or PEF measurement, however her O2 sat is 94% on room air, she is tachypneic, tachycardic, and inspiratory/expiratory wheezes, no rales, no rhonchi are auscultated, as well as it being observed that she is having mild work of breathing. According to GINA (2020), in a mild to moderate exacerbation and in office treatment should be initiated with a short acting beta adrenergic (SABA) 4 to 10 puffs via a metered dose inhaler (MDI) and a spacer. Treatment should be continued with SABA as needed and effectiveness of treatment and response should be evaluated at 1 hour or earlier. I would also want to obtain a PEF measurement upon her arrival so that I could compare the post treatment PEF.
Michelle’s flu symptoms started 2 days ago, and she is at the cusp of being too late to start the antiviral oseltamivir (Tamiflu). Oseltamivir should be initiated in 48 hours or less of onset of symptoms, this medication has been shown to lessen influenza symptoms and potentially shorten the duration of illness by approximately 24 hours (Uyeki et al., 2019). Although, early treatment is preferred and most beneficial, in patients at high risk for complications due to underlying illness should receive oseltamivir regardless of symptom duration (Gaitonde et al., 2019). Therefore, I would prescribe oseltamivir. The prescribing dose is, oseltamivir 75 mg 1 PO BID x 5 days (Uyeki et al., 2019). Although, according to Clinical Practice Guidelines by the Infectious Disease Society of America, suggest that in patients who are immunocompromised or require hospitalization the provider may want to consider prescribing the antiviral for a longer duration (Uyeki et al., 2019). It is also recommended that oral corticosteroids by initiated in asthmatic patients with exacerbation related to influenza (GINA 2020; Uyeki et al., 2019). According to GINA guidelines (2020) the recommended dose is prednisone 40 to 50mg daily for 5 to 7 days, preferably in the morning. Therefore, I would prescribe prednisone 40 mg 1 PO Q AM for 5 days. Furthermore, an increase in the frequency of SABA and low dose inhaled corticosteroid (ICS) should be implemented while the patient is sick and a spacer should be given for use with MDI’s (GINA, 2020). Therefore, I would provide Michelle with the spacer from the office that was used in her treatment upon arrival. Other than a PEF measurement and O2sat no additional laboratory or diagnostic test would be ordered. According to GINA (2020) chest radiography and blood gases are not routinely ordered for asthma exacerbations.
Symptomatic management can be implemented by the use of over the counter (OTC) medications such as acetaminophen, ibuprofen, decongestants, and cough syrups. Acetaminophen is an antipyretic that can reduce fever, Ibuprofen is an anti-inflammatory that can reduce body aches and fever. Acetaminophen and Ibuprofen can be used alternating the dose to provide better coverage. Adequate rest and hydration management is a standard recommendation for management of influenza. Additional symptomatic management includes nasal saline drops to loosening and reduce nasal congestion, as well as humidified air to reduce and prevent drying of the respiratory track (Arnold, 2020).
Decide whether she is safe to return home, include any prescriptions, or if a referral to a higher level of care is required. Discuss the criteria used to make your decision, how a referral is made and defend your position:
In determining whether it is appropriate to discharge Michelle to home I would evaluate her current PEF, O2 sat on room air, as well as reassess her lung sounds. In order for an asthmatic patient with an exacerbation in the office to be discharged to home there must be improvement of symptoms, PEF improvement of greater than 60 to 80% of predicted or personal best, O2 sat greater than 94%, and they patient must have adequate resources at home (GINA, 2020). Although, Michelle is acutely ill, she can speak in full sentences, has mild shortness of breath with exertion, and shows improvement she does not meet the requirements for a higher level of care through further emergent treatment or hospitalization (Uyeki et al., 2019). Michelle would be discharged to home with prescription medications, instructions for medication changes while acutely ill, a spacer for MDI, a peek flow meter, and recommendations for OTC medications for symptomatic management.
RX:
Oseltamivir 75 mg
Disp: # 10 (ten) [Show Less]