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Assessment
150.9 Heart failure, unspecified ( 2017 ICD-10-CM Diagnosis Code I50.9 , 2017). The patient has a CHF exacerbation. The woman may be experiencing it because of the accident that caused some defects that were not initially noticed or because of some situation that caused a sudden overload. It would be advantageous to gather more information to define the main cause of the CHF exacerbation.
J45.901 Unspecified asthma with (acute) exacerbation (2017 ICD-10-CM Diagnosis Code J45.901 , 2017). The patient is diagnosed with asthma, and she receives the required treatment. However, the symptoms remain because she takes other medicines (Phenytoin, HTCZ, and Enalapril) that tend to cause asthma attacks and cough and reduce the effectiveness of other drugs ( Asthma. Medicines that can make it worse , 2014). It may be connected with bronchitis, so it will be advantageous to check that the patient is not experiencing it.
R06.2 Wheezing ( 2017 ICD-10-CM Diagnosis Code R06.2 , 2017). It can be caused by different diseases, but the fact that the patient is diagnosed with asthma presupposes their interconnection. Thus, it can be the main trigger that made the respiratory airways narrow and resulted in a whistling sound during breathing.
Plan of Care
Heart failure, the CHF exacerbation, in particular, should be addressed so that its symptoms become less critical. From the very beginning, the patient should get a combination of oxygen, morphine, diuretics, ultrafiltration, vasodilators, inotropes, and vasopressors (Epocrates, 2017). Assessment for potential precipitating factors is required, and venous thromboembolism prophylaxis should be used. Nitroglycerin and beta-blockers are recommended. Significant improvement is expected after the intake of digoxin, as it reduces the risks of further complications. It is vital to have ECG and CXR tests. The patient should be educated regarding the medication intake and changes required in her lifestyle and diet.
According to Pollart, Compton, and Elward (2011), the management of asthma with exacerbation should start with the assessment of its severity. Then, appropriate medication can be determined. Anyway, beta2 agonist administration is the main intervention that should be maintained. 500 mg hydrocortisone sodium succinate injection or 125 mg methylprednisolone sodium succinate injection should be provided as well as 80 mg or less per day of methylprednisolone [Depo-Medrol] or 400 mg or less per day of hydrocortisone (Pollart, Compton, & Elward, 2011, p. 44). 50-100-mg of prednisone should be taken every day as the patient is discharged. If the medication fails to help and symptoms return, she should consult the ER or a follow-up office.
The patient also suffers from wheezing. However, this issue is caused by asthma, which is already treated. There is a necessity to open the airways, and the medication prescribed for the management of asthma is likely to cope with this problem as well. The client should consult the ER or a follow-up office if expected changes are not observed regardless of the obtained treatment. However, it may be advantageous to continue taking albuterol that was provided during the consultation and had a positive influence on the clients condition.
References
2017 ICD-10-CM Diagnosis Code I50.9. (, 2017).
2017 ICD-10-CM Diagnosis Code J45.901. (, 2017).
2017 ICD-10-CM Diagnosis Code R06.2. (, 2017).
Asthma. Medicines that can make it worse. (, 2014).
Epocrates. (, 2017). Congestive heart failure acute exacerbation. Web.
Pollart, S., Compton, R., & Elward, K. (2011). Management of acute asthma exacerbations. American Family Physician, 84(1), 40-47.
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