Med Surg 3 Case Study

Document Type:Case Study

Subject Area:Nursing

Document 1

The disease risks generated from these non-modifiable factors include; heart disease, diabetes, hypertension, stroke, and asthma. In is clear that the more one ages, the more the risk of suffering from these diseases. Nonetheless, the Hispanic adults are at a high risk of suffering from heart disease and the associated risk factors such as diabetes, obesity, and hypertension as compared to the White Mexican-American adults. On the other hand, men are the most affected people in the particular population. According to the argument put forth by (Wells, et al. There will also be the diagnosis based on the clinical suspicion based on the medical history and the presented symptoms. Besides, since he is a smoker, it is recommended for the spirometry confirmation to be conducted on him to identify the forced vital capacity (FVC) and FEV or the volume of air held by the patient for one second.

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The patient’s current presentation/physical finding confirmation to the admitting diagnosis Based on M. A’s present presentation of the physical findings, it is evident that the patient is suffering from the diagnosed COPD. Apparently, M. Besides, the pulse is also very high given that the normal ranges are supposed to be from 60 to 100 beats in every minute for a male adult. In addition, the respiratory rate is extremely high given that the normal range when a male adult is resting is supposed to range from 15 to 16 breaths per minute(Coxson, et al. The Oxygen Saturation 90% on room air is very low as compared to the normal range of 94 -99% in a healthy male adult. Such signs are related to abnormal vitals to the Primary diagnosis and expected of such a patient.

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The patient’s medications Esomeprazole (Nexium) 40mg PO daily This medication is prescribed because of a persistent cough in this patient although it is also used in cases of esophagus and stomach problems like ulcers and acid reflux. In the case of severe side effect, it is necessary to see a doctor. Enalapril (Vasotec) 5 mg PO daily The medication is prescribed because of a patient presenting the symptom of high blood pressure. It functions through lowering of the blood pressure. The associated side effects for the patient are urinating less or more than usual, fever, swelling, flu symptoms, feeling like dying, weakness, loss of appetite, pounding heartbeats, weight gain, and body aches, as well as pale skin(Wells, et al. The lab studies related to this medication are heart function, eye effect, and patient’s blood flow.

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The side effects of this medication for the patient are; easy bleeding, pale skin, fever, nausea, itching, loss of appetite, stomach pain, dark urine, and confusion. The patient takes meals within 30 minutes of taking the particular medication(De Marco, et al. The lab studies in relation to this medication are about the necessary dosage to be taken in different health situations. Pathophysiology of the medical diagnosis M. A. Neutrophil influx is caused by cigarette smoke, which is needed for the excretion of MMPs, this recommends, as a result, that macrophages and neutrophils are needed for the generation of emphysema. Besides, macrophages, CD8plus T lymphocytes perform the responsibility in the pathogenesis of smoking-persuaded airflow restriction(Menezes, et al. For more maintenance of the inflammation hypothesis, a stepwise rise in alveolar inflammation is located in the surgical specimens from COPD patients.

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The diagnosis of COPD with spirometry is where a ration of the forced expiratory volume in a second over the forced vital capacity (FEV1/FVC) is below 70% of the foreseen level for a coordinated control. The process is a diagnostic for an essential obstructive defect. Goal: The desired goals include the maintenance of the airway patency with the clearing of sounds(Menezes, et al. The patient would also improve the airway clearance by coughing effectively and having expectorated discharge. Intervention: To achieve this goal, the nursing interventions that would be associated are; auscultate breath sounds due to the fact that breath sounds are manifested in moist crackles. There would also be monitoring of the respirations and noting of the rate of a cough.

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The patient is also helped to be comfortable on a sit. Goal:The intended goal of this diagnosis is having effective self-management of the patient’s health condition. Interventions:The nurse will provide some respiratory therapy and monitor his vital signs regularly. There is the provision of fluids. Deficient knowledge in the patient is assessed and the patient education offered on how to take care of himself and educating him of the symptoms showing the high level of COPD. The patient is informed about what he needs to avoid, such as smoking of the cigarette, and working hard(Magnussen, et al. Coxson, H. O. , Dirksen, A. , Edwards, L. D. , Marcon, A. , Accordini, S. , Antonicelli, L. , Bugiani, M. &Pirina, P. New England Journal of Medicine, 371(14), 1285-1294.

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