Pharmacology Scenario 2

Pharmacology Scenario 2: Toua Xiong

Documentation Assignments

1. Document assessment data of Toua Xiong, including a focused history, physical examination (including vital signs), focused respiratory assessment, pain level assessment, and assessment of the oral cavity. Note any abnormal findings.

1. Xiong is a 64-year-old male. He has a history of COPD, diagnosed 5 years ago. NKA. Patient is complaining of difficulty swallowing and pain in his throat and mouth, and that it has bothered him when eating or drinking for the last 3 to 4 days. He describes his mouth and throat is being “coated in a white substance, like he just drank milk.”  He has been taking his two inhalers as prescribed.  Vitals- BP: 105/63, Resp Rate: 24 breaths/ min audible wheezes heard externally with equal bilateral chest rise with no visible chest deformities, Pulse: normal and strong 100 bpm, O2: 93%  while on nasal canula 1L/min, Temp: 99 degrees farenheit.  Lung auscultation revealed audible wheezes with inspiration. Heart sounds were normal rate and rhythm, S1 and S2 heard with no murmurs or extra heart sounds.  Patient states pain is a 5/ 10, and worse when he tries to eat or drink.  Nothing makes the pain better and food and drink make it worse.  Patient states he feels miserable.

2. Document the medication(s) that were administered.

1. Ipratopium inhalation 36 mcg/ dose à metered dose inhailor
2. Fluticasone/salmeterol 250/50 mcg/doseà metered dose inhailor
3. 1L/ min oxygen via nasal canula

3. Document the patient education provided to Toua Xiong. Include cause of candidiasis infection and teaching regarding proper administration and care of dry powder and metered-dose inhalers, proper administration of Mycostatin, and oxygen therapy.

1. Patient education provided would be to blow out any residual air in the lungs before inhaling first puff, affix mouth around mouth piece completely and firmly, breathe medication in deep and fast and hold as long as possible, exhale and then rinse your mouth with water and spit it out.
2. Candidiasis infection (or thrush) is a superficial infection of the mouth and tongue. It is an overgrowth of an organism that causes changes in the normal bacteria in your mouth.  It can result of from improper use of your inhaled medication, such as not rinsing your mouth after each use, which leads to a yeast build up due to providing a warm and moist environment for it to thrive in. 
3. Mycostatin administration: measure directed amount for each treatment. Apply after brushing teeth and hold in the mouth for several minutes before swallowing.
4. It is important to alert the fire department of your use of oxygen to treat your COPD in case there is ever a fire or power outage in the area. Oxygen is highly flammable and combustable and it is important to stay clear from anyone who smokes. Your oxygen is prescribed in liters/minute for rest, sleep, and activity, it is important for you to follow for your best possible results.