SOAP Note Treatment of COPD PDF

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COPD...

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Treatment of COPD (Subjective) S: an 89-year old male who was a two-pack a day smoker for 69 years. He quit smoking 12 years ago. He has come in for a routine general health evaluation. He does not take any routine daily medications. He reports ongoing challenges with ‘belching’ but other than that, and he conveys that he is feeling pretty good. The patient reports productive coughing, worse in the am with thick clear to white sputum. States he get SOB more easily than before. (Objective) O: Pursed lip breathing with faint “whistling” sounds with respiratory effort (Assessment) A: Course and diminished breath sounds in bilateral lower lobes (Plan) P: Diagnosis of COPD Chronic obstructive pulmonary disease (CPD) is indicated by chronic, increasing airflow restriction. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). COPD is stereotypically judged as lingering bronchial inflammation and/or emphysema. (Arcangelo et al., 2017). Cigarette smoking is the most significant universal hazard for COPD. (Arcangelo et al., 2017). The signs and symptoms of COPD comprise chronic coughing, which will have productive sputum creation and increasing shortness of breath that gets worse with working out; patients with COPD may also have tightness in the chest area or have distinct wheezing sounds. (Arcangelo et al., 2017). During a physical assessment, patients with COPD might develop loud wheezing when breathing, bluish skin, drum-shaped chest cavity, short diaphragms, and indicators of cor pulmonale (edema to the extremities and an engorged heart. (Arcangelo et al., 2017). Therapeutics: pharmacologic interventions: This patient will benefit from the use of “beta2-adrenergic agonists, anticholinergics, corticosteroids, methylxanthines, and phosphodiesterase four inhibitors”. (Arcangelo et al., 2017, p. 397). Patients that have COPD will require a minimum of one short operating bronchodilator for home use of severe indicators. (Arcangelo et al., 2017). Educational: This patient stated at the beginning of his exam that he stopped smoking 12 years ago, which is great because I would encourage him to stop immediately. He is an older patient, and in danger of heart disease from the use of some of these medications, inhalers might be a safer alternative. (Arcangelo et al., 2017). This patient will need education about the use of the drugs, compromising warning, dosages, how it works, adverse effects, and the medications' mode of dispensing. (Arcangelo et al.,

2017). All patients need to seek advice from a health care provider before taking any alternative or complementary remedies. (Arcangelo et al., 2017). Consultation/Collaboration: Due to the risk of heart disease as a potential side effect, this patient should see a cardiologist and also a pulmonologist to monitor his lung functions. References: Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A. (20161108). Pharmacotherapeutics for Advanced Practice, 4th Edition [VitalSource Bookshelf version]. Retrieved from vbk://9781496374066

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