Discharge Planning Project This patient is a 53 year old female patient who arrived to the emergency department on March

4, 2014 for complaints of chest pain lasting approximately two weeks. The patient did not voluntarily come to the hospital, but was tricked to being brought by her sister who was concerned that she was complaining of chest pain for several days. The patient has a past history of HTN, COPD, and GERD and also has diet controlled diabetes. The patient explains the pain as being sharp in nature and a pain level of approximately a 5/10. The pain is noted to be under her right breast and is associated with right arm muscle spasms. The patient has not taken anything to relieve the pain, and for the last few days was attributing the pain to her GERD although she denies any reflux symptoms. In the Emergency department, the patient had an EKG and chest x-ray which were unremarkable. She was given a dose of nitroglycerin and 325 mg of aspirin which relieved her pain mildly. The patients vitals remained stable and she did not complain of SOB but was admitted to the floor for management and care. The patients discharge diagnosis was an exacerbation of her COPD. The patient verbalized that she is aware of the reason why she was hospitalized and was given several patient teachings on the different chronic conditions she lives with including hypertension, type 2 diabetes, GERD, smoking cessation, acute coronary syndrome, and COPD. There are not any core measures associated with her discharge diagnosis. Teaching for COPD: Pathophysiology: Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, refractory (non-reversible) asthma, and some forms of bronchiectasis. In patients with COPD, the alveoli become stretchy as opposed to elastic in a patient with healthy lungs. When the alveoli are over stretched, it becomes more difficult for them to return to their normal size when the patient exhales so they do not empty efficiently and retain more air, resulting in air trapping. With the combination of extra air in the lungs and the patients increased effort to breathe, the result is the patient feeling of shortness of breath. Causes and contributing factors: COPD exacerbations most commonly start from a lung infection often caused by a virus or bacteria such as a cold or some other illness. Exposure to harmful pollutants such as cigarette smoke, pipes, cigars, second hand smoke, air pollution, dust and chemical fumes can also contribute to the onset of an exacerbation of COPD. Symptoms: Shortness of breath, noisy breathing (wheezing, whistling, gurgling), increased anxiety, chest breathing, cough, changes in skin or nail color, difficulty sleeping and no interest in eating. Diagnosis: The doctor will diagnose the patient based on their report of their signs and symptoms as well as using a spirometer test. The patient is encouraged to report if they are a smoker, exposed to chemical pollutants or irritants, and report when the symptoms started. Medications for discharge:

Discharge Planning Project Albuterol (2.55 mg q 20 min for 3 doses then 2.510 mg q 14 hr prn): Used to control and prevent reversible airway obstruction caused by asthma or COPD; adrenergic. Last does was not given, but expected dose is to use as instructed by provider. Patient teaching: Instruct patient to take albuterol as directed. If on a scheduled dosing regimen, take missed dose as soon as remembered, spacing remaining doses at regular intervals. Do not double doses or increase the dose or frequency of doses. Caution patient not to exceed recommended dose; may cause adverse effects, paradoxical bronchospasm (more likely with first dose from new canister), or loss of effectiveness of medication. o Advise patients to use albuterol first if using other inhalation medications and allow 5 min to elapse before administering other inhalant medications unless otherwise directed. o Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth and clean the mouthpiece with water at least once a week. o Instruct patient to notify health care professional if there is no response to the usual dose or if contents of one canister are used in less than 2 wk. Asthma and treatment regimen should be re-evaluated and corticosteroids should be considered. Need for increased use to treat symptoms indicates decrease in asthma control and need to reevaluate patient's therapy. o Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain. o Inform patient that albuterol may cause an unusual or bad taste. o Instruct patient in the proper use of the metered-dose inhaler or nebulizer Side Effects: nervousness, restlessness, tremor, headache, insomnia, paradoxical bronchospasms (excessive use of inhalers), chest pain, palpitations, hypokalemia, hypoglycemia, N/V, hypertension. Budesonide (budesonide 0.5 mg/2ml Neb inhalation suspension) 2 ML, Nebulizer inhalation, Twice Daily. Maintenance treatment and prophylactic therapy of asthma; corticosteroid. Last dose was 3/5/14 at 10 am, patient is to take medication 2x daily. Patient teaching: Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Advise patient not to discontinue medication without consulting health care professional; gradual decrease is required. o Advise patients using inhalation corticosteroids and bronchodilator to use bronchodilator first and to allow 5 min to elapse before administering the corticosteroid, unless otherwise directed by health care professional. o Advise patient that inhalation corticosteroids should not be used to treat an acute asthma attack but should be continued even if other inhalation agents are used. o Patients using inhalation corticosteroids to control asthma may require systemic corticosteroids for acute attacks. Advise patient to use regular peak flow monitoring to determine respiratory status. o Advise patient to rinse mouth with water after treatment to decrease risk of developing local candidiasis.

Discharge Planning Project o Caution patient to avoid smoking, known allergens, and other respiratory irritants. o Advise patient to notify health care professional if sore throat or mouth or symptoms of anaphylaxis (rash, severe itching, swelling of the face, mouth, and tongue, trouble breathing or swallowing, chest pain, anxiety or feeling of doom) occur. o Instruct patient whose systemic corticosteroids have been recently reduced or withdrawn to carry a warning card indicating the need for supplemental systemic corticosteroids in the event of stress or severe asthma attack unresponsive to bronchodilators. o Advise female patients to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Side Effects: headache, otitis media, anaphylaxis, GI upset, flu like symptoms, bronchospasm, cough oropharyngeal fungal infections. Tiotropium Resp Tx (Spiriva Cap Resp Tx) 1 Cap, inhalation, every day. Long-term maintenance treatment of bronchospasm due to COPD, reducing exacerbations in patients with COPD; anticholinergic. Last dose was 3/5/14 at 10 am, patient is to take medication as ordered1 cap inhalation once per day. Patient teaching: Instruct patient to take medication as directed. Capsules are for inhalation only and must not be swallowed. Take missed doses as soon as remembered unless almost time for the next dose; space remaining doses evenly during day. Do not double dose. o Advise patient that tiotropium is not to be used for acute bronchospasm attacks, but may be continued during an acute exacerbation. o Instruct patient in proper use and cleaning of the Handihaler inhaler. Review the Patient's Instructions for Use guide with patient. Capsules should be stored in sealed blisters; remove immediately before use or effectiveness of capsules is reduced. Tear blister strip carefully to expose only one capsule at a time. Discard capsules that are inadvertently exposed to air. Spiriva should be administered only via the Handihaler and the Handihaler should not be used with other medications. When disposing of capsule, tiny amount of powder left in capsule is normal. o Advise patient to notify health care professional immediately if signs and symptoms of angioedema (swelling of the lips, tongue, or throat, itching, rash) or signs of glaucoma (eye pain or discomfort, blurred vision, visual halos or colored images in association with red eyes from conjunctival congestion and corneal edema) occur. o Caution patient to avoid spraying medication in eyes; may cause blurring of vision and pupil dilation. o Advise patient that rinsing mouth after using inhaler, good oral hygiene, and sugarless gum or candy may minimize dry mouth; usually resolves with continued treatment. Side Effects: dry mouth, constipation, tachycardia, paradoxical bronchospasm, urinary difficulty, urinary retention, hypersensitivity reaction including angioedema. Azithromycin (Zithromax Z-pak 250mg oral tablet) take as directed, by mouth, as directed by physican. Used for upper respiratory and lower respiratory infections; macrolides. Patient was not given last dose in the hospital, patient has Z-pak at home, is directed to continue taking as order through 3/8/14.

Discharge Planning Project Patient teaching: Instruct patients to take medication as directed and to finish the drug completely, even if they are feeling better. Take missed doses as soon as possible unless almost time for next dose; do not double doses. Advise patients that sharing of this medication may be dangerous. o Instruct patient not to take azithromycin with food or antacids. o May cause drowsiness and dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. o Advise patient to use sunscreen and protective clothing to prevent photosensitivity reactions. o Advise patient to report symptoms of chest pain, palpitations, yellowing of skin or eyes, or signs of superinfection (black, furry overgrowth on the tongue; vaginal itching or discharge; loose or foul-smelling stools) or rash. o Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without advice of health care professional. o Instruct parents, caregivers, or patient to notify health care professional if symptoms do not improve. Side Effects: Abdominal pain, N/V, diarrhea, Steven-Johnsons syndrome, hepatotoxicity, pseudomembranous colitis, toxic epidermal necrolysis, ototoxicity, hyperkalemia, dizziness, drowsiness, fatigue, photosensitivity. Prednisone (prednisone 50mg oral tablet) 1 tab, by mouth, every day. Used systemically and locally in a wide variety of chronic diseases including: inflammatory, allergic, hematologic, neoplastic, autoimmune disorders; corticosteroid. Patient had her last dose on 3/5/14 at 10 am. Patient is to continue taking as ordered through 3/8/14. Patient teaching: Instruct patient on correct technique of medication administration. Advise patient to take medication as directed. Take missed doses as soon as remembered unless almost time for next dose. Do not double doses. Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening. o Glucocorticoids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately. o Caution patient to avoid vaccinations without first consulting health care professional. o Review side effects with patient. Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur. Patient should also report unusual swelling, weight gain, tiredness, bone pain, bruising, nonhealing sores, visual disturbances, or behavior changes. o Discuss possible effects on body image. Explore coping mechanisms. o Instruct patient to inform health care professional if symptoms of underlying disease return or worsen. o Advise patient to carry identification describing disease process and medication regimen in the event of emergency in which patient cannot relate medical history.

Discharge Planning Project o Explain need for continued medical follow-up to assess effectiveness and possible side effects of medication. Periodic lab tests and eye exams may be needed. Side Effects: Depression, euphoria, hypertension, anorexia, N/V, acne, decreased wound healing, ecchymosis, fragility, hirsutism, petechial, adrenal suppression, muscle wasting, osteoporosis, cushingoid appearance. Home Assessment: The patient is being discharged to her home where she lives with her 14 year old son. Her living situation is safe. Her reliable mechanisms of self-care include herself, her sister, and her mother who are available to help her with food, transportation, and care when she is feeling ill. The patient does not verbalize any concerns she has about being discharged home. Follow up: The patient has a follow up appointment for her COPD exacerbation on March 10, 2014 with Dr. Eric Svestka. The address of his facility was provided to the patient on her discharge paperwork. There are currently no required follow up appointments with any other health care specialists or other team member services. The patient verbalizes that she understands the importance of follow up hospital visits and will attend her appointment. Summary: The patient has been seen for an exacerbation of her COPD. In order to prevent readmission, it is important to educate the patient on cessation of smoking as this is one of the primary risk factors for COPD and its exacerbations. The patient has also been educated on her medications which are prescribed to control her symptoms and reduce the occurrence of exacerbations. The patient was scheduled a follow up appointment for continuity of care and to help prevent a potential re-admission. The patient was also given additional information on her other chronic conditions to help her understand her disease processes and how to properly manage them. The patient verbalized understanding of all educational information and did not have any questions upon discharge of the hospital.