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Running head: Discharge Planning

Discharge Planning
Renee Dabydeen
University of South Florida

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This 60-year-old female patient was admitted to Bayfront medical center on 8/27/2015
via EMS due to the results of her shortness of breathe (SOB). The patient stated that she
has had SOB in her past due to her previous diagnosis of COPD however; in the last three
days the SOB has become increasingly worse. Patient describes SOB as constant and
states that she feels like I couldnt catch a breath. Aggregating factors include any
moderate activity such as walking or washing dishes. Relieving factors include rest and
using pillows while in bed to elevate her head when she sleeps. Without elevation patient
states she has a coughing fit which leads to her SOB. Patient treatment includes sitting
up in the up- right position or putting head between knees. Patient states that the inhaler
was helping: with SOB however, on admission the inhaler was not helping to treat her
SOB. PT has no complaints of pain, only complains of weakness and dizziness.
The patient is aware of the reason they were hospitalized (verbal understanding). Patient
teaching was specific to chronic obstructive pulmonary disease (COPD).
Patient Teaching:
Pathophysiology: Chronic obstructive pulmonary disease (COPD) is a disease
state characterized by chronic airflow obstruction. COPD is a progressive disorder
that can range from mild to very severe; however the rate of loss of lung function
often slows markedly if smoking cessation occurs. During COPD exacerbation it
is important to seek medical help right away.
Causes: Emphysema- this causes destruction of the fragile walls and elastic fibers
of the alveoli. Small airways collapse when exhale, impairing airflow out of your
lungs. Chronic bronchitis- in this condition, bronchial tubes become inflamed and
narrowed and your lungs produce more mucus, which can further block the
narrowed tubes.
Contributing Factors: The risk of COPD increases with cigarette smoking
intensity, which typically quantified as pack-years. Patient with COPD usually
have smoke > or equal to 20 pack-years of cigarettes. Individuals with airway
hyperresponsiveness and certain occupational exposures including coal mining,
gold mining and cotton textiles are at increased risk for COPD as well.
Symptoms: Common symptoms include cough and phlegm production.
Exertional dyspnea is a common and potentially disabling symptom in COPD.
Exercise involving upper-body activity can be difficult. COPD exacerbation, signs
of respiratory distress may be prominent including tachycardia, tachypnea, use of
accessory muscles of respiration and cyanosis.
Diagnosis: Pulmonary function testing, the presence of airflow obstruction is
determined by reduced ratio of the forced expiratory volume in to force vital
capacity
Common Medications: Bronchodilators, Corticosteroids, and supplemental
oxygen
Nutrition: Cardiac diet- low sodium, low in fat, low in cholesterol. If needed a
dietician can speak with patient
Rehabilitations: Pulmonary rehabilitation, smoking cessation, breathing
exercises and physical exercise

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Additional treatment: Lifting head of bed or placing pillows under head to
elevate, tripod positioning, encourage patient to plan rest periods, conserving as
much energy as possible
Community Resources: If needed smoking cessation clinic in the area. COPD
Foundation website and contact information.
Discharge Instructions: (Patient must verbalize understanding prior to
discharge) Take your medications regularly be aware of adverse effects, be alert to
COPD exacerbation, and follow diet that is physician recommended. Be able to
demonstrate breathing exercises including tripod positioning and use of incentive
spirometer. Explain why it is important to keep head elevated and how it helps the
comfort of the patient. Educate the patient on the importance of smoking
cessation and resources available to be successful in smoking cessation. Inform
physician of any signs of exacerbation or SOB. Educate family members on
exacerbation of COPD and the need to contact the physician.
Core Measures date completed in ()-Labs (CBC) within 24 hours on admission, Chest Xray (8/28/2015) Smoking cessation Education (8/30/2015). Discharge on Lisinopril
(9/1/2015). Discharge on albuterol (9/2/2015). Discharge on Carvedilol (9/1/2015)
Medications for Discharge
Lisinopril (PO)- Alone or with agents in the management of hypertension,
angiotensin converting enzyme
Patient Teaching:
Instruct patient to take medication as directed at the same time each day, even if
feeling well. Take missed doses as soon as remembered but not if almost time for
next dose. Do not double doses. Warn patient not to discontinue ACE inhibitor
therapy unless directed by health care professional.
o Caution patient to avoid salt substitutes containing potassium or foods
containing high levels of potassium or sodium unless directed by health
care professional.
o Caution patient to change positions slowly to minimize orthostatic
hypotension. Use of alcohol, standing for long periods, exercising, and hot
weather may increase orthostatic hypotension.
o Advise patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to consult with
health care professional before taking other medications, especially cough,
cold, or allergy remedies.
o May cause dizziness. Caution patient to avoid driving and other activities
requiring alertness until response to medication is known.
o Advise patient to inform health care professional of medication regimen
before treatment or surgery.
o Instruct patient to notify health care professional if rash; mouth sores; sore
throat; fever; swelling of hands or feet; irregular heart beat; chest pain; dry
cough; hoarseness; swelling of face, eyes, lips, or tongue; or if difficulty
swallowing or breathing occurs. Persistent dry cough may occur and may

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not subside until medication is discontinued. Consult health care
professional if cough becomes bothersome. Also notify health care
professional if nausea, vomiting, or diarrhea occurs and continues.
o Emphasize the importance of follow-up examinations to evaluate
effectiveness of medication.
Hypertension: Encourage patient to comply with additional interventions for
hypertension (weight reduction, low sodium diet, discontinuation of smoking,
moderation of alcohol consumption, regular exercise, and stress management).
Medication controls but does not cure hypertension.
o Instruct patient and family on correct technique for monitoring BP. Advise
them to check BP at least weekly and to report significant changes to
health care professional.
Adverse reactions/ Side Effects: Dizziness, fatigue, headache, weakness, cough,
hypotension, chest pain, abdominal pain, diarrhea, nausea, vomiting, erectile dysfunction,
impaired renal function, rashes, hyperkalemia, angioedema
Albuterol (Inhaln)- Used as a bronchodilator to control and prevent
reversible airway obstruction caused by asthma or COPD. Inhaln: Used as a quickrelief agent for acute bronchospasm and for prevention of exercise-induced
bronchospasm.
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 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 Instruct patient to prime unit with 4 sprays before using and to discard
cannister after 200 sprays. Actuators should not be changed among
products.
o Instruct patient to notify health care professional of all Rx or OTC
medications, vitamins, or herbal products being taken and to consult health
care professional before taking any OTC medications or alcoholic
beverages concurrently with this therapy. Caution patient also to avoid
smoking and other respiratory irritants.
o Inform patient that albuterol may cause an unusual or bad taste.
Inhaln: Instruct patient in the proper use of the metered-dose inhaler or nebulizer
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.

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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.
Adverse/ Side effects: Nervousness, restlessness, tremor, headache, insomnia,
paradoxical bronchospasm (excessive use of inhalers), chest pain, palpitations, angina,
arrhythmias, hypertension, nausea, vomiting, hyperglycemia, hypokalemia, tremor
Carvedilol-Increases cardiac output, control hypertension
Patient Teaching:
Instruct patient to take medication as directed, at the same time each day, even if
feeling well. Do not skip or double up on missed doses. Take missed doses as
soon as possible up to 4 hr before next dose. Abrupt withdrawal may precipitate
life-threatening arrhythmias, hypertension, or myocardial ischemia.
Advise patient to make sure enough medication is available for weekends,
holidays, and vacations. A written prescription may be kept in wallet in case of
emergency.
Teach patient and family how to check pulse and BP. Instruct them to check pulse
daily and BP biweekly. Advise patient to hold dose and contact health care
professional if pulse is <50 bpm or BP changes significantly.
May cause drowsiness or dizziness. Caution patients to avoid driving or other
activities that require alertness until response to the drug is known.
Advise patient to change positions slowly to minimize orthostatic hypotension,
especially during initiation of therapy or when dose is increased.
Caution patient that this medication may increase sensitivity to cold.
Instruct patient to notify health care professional of all Rx or OTC medications,
vitamins, or herbal products being taken and to consult health care professional
before taking other Rx, OTC, or herbal products, especially cold preparations,
concurrently with this medication.
Patients with diabetes should closely monitor blood glucose, especially if
weakness, malaise, irritability, or fatigue occurs. Medication may mask some
signs of hypoglycemia, but dizziness and sweating may still occur.
Advise patient to notify health care professional if slow pulse, difficulty
breathing, wheezing, cold hands and feet, dizziness, confusion, depression, rash,
fever, sore throat, unusual bleeding, or bruising occurs.
Instruct patient to inform health care professional of medication regimen before
treatment or surgery.
Advise patient to carry identification describing disease process and medication
regimen at all times.
Hypertension: Reinforce the need to continue additional therapies for
hypertension (weight loss, sodium restriction, stress reduction, regular exercise,

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moderation of alcohol consumption, and smoking cessation). Medication controls
but does not cure hypertension.
Adverse/ Side effects: Dizziness, fatigue, weakness, anxiety, depression, drowsiness,
insomnia, memory loss, mental status changes, nervousness, nightmares, blurred vision,
dry eyes, intraoperative floppy iris syndrome, nasal stuffiness, bronchospasm, wheezing,
bradycardia, Heart failure, pulmonary edema, constipation, nausea, erectile dysfunction,
Stevens-Johnson syndrome, toxic epidermal necrolysis, itching, rashes, urticarial,
hypoglycemia, hyperglycemia, arthralgia, back pain, muscle cramps, paresthesia
anaphylaxis, angioedema, drug-induced lupus syndrome
Home Assessment: Patient lives with fianc and father. Patient living situation is safe.
Patient has health insurance and is able to receive needed medications and has fianc to
assist.
Follow Up: Incentive spirometer going home with patient. No other medical devices for
home use. Need to follow up with primary care doctor; appointment had not yet been
made. Pulmonary rehabilitation. Recommendation for motivational interviewing for
smoking cessation. No other team member services are needed at this time.
Summary: The patient has been seen for SOB related to COPD. Patient education on
smoking cessation vital to prevent readmission. Patient education on new medication,
side effects and adverse effects important for the medical well being of patient.
Education on breathing techniques to help with reducing exacerbation of signs and
symptoms of COPD.

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References
Osborn, K. S., Wraa, C. E., & Watson, A. B. (2010). Medical-surgical nursing:
Preparation for practice.

Upper Saddle River, NJ: Pearson Prentice Hall.