F.T. is a 70-year-old African American man who comes to the emergency department (ED) complaining of increased shortness of breath. He states that he started using his albuterol inhaler every 4 hours a few days ago, but it does not seem to be helping. He has been having trouble sleeping or doing any activity because of his shortness of breath.
SUBJECTIVE Data:
PMH: COPD, hypertension, and benign prostatic hyperplasia. No history of allergies.
Medications: metoprolol (Lopressor) 50 mg/day PO, furosemide (Lasix) 20 mg PO daily, finasteride (Proscar) 5 mg/day PO, Advair inhaler (fluticasone and salmeterol) 2 puffs bid, and albuterol inhaler 2 puffs q4hr PRN. Does not use O2 at home.
Health Perception–Health Management: F.T. states he usually manages his COPD well with the Advair inhaler and occasional use of albuterol inhaler PRN. He thinks he caught a cold from his granddaughter last week. Increasing difficulty breathing, even with albuterol. Has a history of 30 pack-years of smoking, quitting 5 years ago.
Nutritional-Metabolic Pattern: Not eating, drinking very little over past 2 to 3 days.
Activity-Exercise: At present, cannot walk 100 feet without feeling short of breath, nor walk up one flight of stairs without stopping to catch his breath.
Sleep-Rest: Difficulty sleeping at present. Last night he slept upright in his recliner.
Cognitive-Perceptual: Denies any pain associated with shortness of breath. Feels slightly irritable because of lack of sleep.
Coping–Stress Tolerance: Denies any stress or emotional disturbance.
Discussion Questions
1. What type of assessment would be most appropriate for F.T.: comprehensive, focused, or emergency?
2. From the information provided by F.T., what other information would you ask him about his condition (time permitting)?
3. How will you individualize the assessment based on his current physiologic condition?
4. What considerations will you make based on his age? Ethnic/cultural background?
5. Of the information provided, which subjective assessment findings are of most concern to you?
6. F.T. cannot use his inhaler appropriately while he is talking with you. Is this an appropriate time to teach him about the proper use of his inhaler?
7. What should be included in the physical assessment? What do you think will be the priorities in your physical assessment?