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Competencies in Care: A Comprehensive Evaluation for a Patient with Decline in Lung

Function

Lioudmila A. Maslova

American Sentinel College of Nursing and Health Sciences

N 580-24A: Advanced Practice Nursing I

Dr. Dawn Specht

December 8, 2024
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Competencies in Care: A Comprehensive Evaluation for a Patient with Decline in Lung

Function

Respiratory issues are significant health concerns that can lead to severe complications

without appropriate and timely intervention. The following paper addresses the complex medical

case of a 56-year-old transgender Hispanic man who presents with declining lung function. This

comprehensive analysis will consider additional subjective and objective data, national

guidelines, diagnostic tests, consultations, diagnoses, legal and ethical considerations, a holistic

care plan, Healthy People 2030 objectives, the Circle of Caring, patient education, and billing

recommendations. Each section will demonstrate an understanding of the patient’s multifaceted

needs and the integration of evidence-based guidelines in the care management process, instilling

confidence in the treatment approach.

Assessment

Additional Subjective Data

In this case, the patient's subjective data is of utmost importance. His personal

experiences, such as worsening dyspnea that has progressively affected his daily life and the

specific activities that have become challenging, will provide crucial insights. It is vital to inquire

about the frequency, duration, and severity of his dyspnea, as well as any associated symptoms

such as chest pain or palpitations. Other important questions should include:

Sleep Disturbances: Changes in sleep patterns or quality, primarily related to his ability

to sleep in the recliner versus lying flat.

Smoking History Details: The patient should describe his smoking habits, including

how many cigarettes he smokes daily and his motivation to quit.

Other Symptoms: Inquiry about weight loss, appetite changes, fatigue levels, and the

presence of anxiety or depression specifically related to his health condition, which can affect

energy levels and the ability to engage in self-care, are essential.

Medication Adherence: Understanding whether he has been using his prescribed

albuterol inhaler as directed or if he has missed doses.

Health Literacy and Support Systems: The patient's understanding of his condition and

treatment options and the availability of social support from family or community are crucial

factors in his care. These elements will help us understand the patient's support system and its

potential impact on his health outcomes and treatment adherence.

Furthermore, it is vital to discuss the impact of the patient's transgender identity on his

healthcare experiences and possible barriers to accessing care. This discussion should be

approached with the utmost sensitivity and inclusivity, ensuring the patient feels respected and

understood. Information about these subjective elements will guide the clinical assessment and

management plan.

Additional Objective Data

The additional objective data is a powerful guide for therapeutic interventions,

empowering us to make informed decisions in patient care. Beyond the initial physical

examination, additional objective assessments include vital sign monitoring for changes in blood

pressure, heart rate, and rhythm. A detailed respiratory exam focusing on lung sounds, use of

accessory muscles, and assessment of chest wall movement should be performed. This additional

objective data will help determine the severity of lung function impairment and guide therapeutic

interventions:
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 Pulse Oximetry: Monitoring oxygen saturation levels to assess respiratory function and

the severity of hypoxemia.

 Electrocardiogram (ECG): To rule out any cardiac complications related to tachycardia

or electrolyte imbalances that may result from respiratory acidosis.

 Complete Blood Count (CBC): To determine the presence of infection, anemia, or

hematocrit levels that may impact respiratory function.

 Peak Flow Measurement: This evaluates the patient’s maximum airflow and tracks any

asthmatic components contributing to his symptoms.

 A nutritional assessment: To evaluate the patient’s energy intake and nutritional status,

which may be affected by his reported low energy and possible weight loss.

By systematically gathering this objective data, healthcare providers can effectively tailor

interventions that address the identified respiratory issues (Roos et al., 2023).

National Guidelines and Evidence

Several national guidelines are pertinent in managing this patient’s condition. The Global

Initiative for Chronic Obstructive Lung Disease (GOLD) and the American Thoracic Society

(ATS) are both organizations that offer comprehensive and thorough recommendations for

diagnosing and managing chronic obstructive pulmonary disease (COPD) and related conditions.

The GOLD guidelines are widely recognized for their thoroughness and relevance to

COPD management. The 2023 GOLD report introduces updated definitions for COPD and

emphasizes the importance of understanding exacerbations and airflow obstruction (Parums,

2023). The guidelines integrate evidence from systematic reviews and highlight the significance

of high-quality studies, particularly randomized controlled trials, which inform clinical practices,

treatment choices, and outcomes for COPD patients (Parums, 2023). Furthermore, they provide a
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framework for managing comorbid conditions and actively involve factors such as air pollution

and COVID-19 impacting COPD management (Parums, 2023).

Like GOLD, the ATS guidelines offer robust recommendations for diagnosing and

managing COPD. They evaluate clinical symptoms, historical exacerbations, and spirometry data

to create tailored patient management plans (Sharma et al., 2024). The ATS also emphasizes a

multidimensional approach, addressing pharmacological therapies and lifestyle modifications

such as smoking cessation and pulmonary rehabilitation (Sharma et al., 2024). Integrating these

elements provides a holistic strategy to improve patients' overall quality of life with COPD.

Evidence from numerous randomized controlled trials strongly supports the

pharmacological management of COPD, as outlined by GOLD and ATS. These studies validate

the effectiveness of various therapies, including bronchodilators and corticosteroids, which are

fundamental in alleviating symptoms and reducing exacerbation frequency (Sharma et al., 2024).

Additionally, smoking cessation interventions are highlighted as critical components of

management, given their profound impact on slowing disease progression (Sharma et al., 2024).

The guidelines encourage tailored pharmacotherapy based on the patient's specific group

classification within the GOLD framework.

Despite the availability of comprehensive guidelines, adherence to GOLD and ATS

recommendations remains suboptimal in clinical practice. Factors contributing to this issue

include variations in clinician awareness of the guidelines, differences in health systems, and the

challenges of implementing guideline recommendations in everyday practice (Albitar & Iyer,

2019). Addressing these barriers is crucial for enhancing the consistency and quality of COPD

management across different healthcare settings.

The U.S. Preventive Services Task Force (USPSTF) places significant emphasis on

smoking cessation interventions for adults, especially those with a prolonged smoking history

(Asiedu et al., 2023). This recommendation is crucial for our patient, underscoring the need for

evidence-based therapy.

Those guidelines are backed by robust evidence, including randomized controlled trials

demonstrating the promising outcomes of smoking cessation and well-managed COPD.

Resources from the National Heart, Lung, and Blood Institute (NHLBI) also offer

tailored strategies for diverse populations, potentially bringing hope and optimism to the

patient’s journey as a transgender individual within a Hispanic community (Li et al., 2023). This

can include culturally relevant health education, access to resources, and developing programs to

improve physical and mental health. The commitment of the NHLBI to improving health

outcomes for diverse populations is ongoing and evolving. Continuous research and

collaboration with community organizations are essential for developing more effective

strategies tailored to the needs of transgender individuals.

Diagnostics

Given the patient’s presentation and smoking history, several diagnostic tests are

appropriate and will provide additional insights into the underlying pathology of his respiratory

decline:

 High-resolution CT (HRCT) Scan of the Chest: To identify possible emphysema,

bronchiectasis, or other structural lung changes that may not be visible on a chest X-ray.

 B-type natriuretic peptide (BNP) levels: To exclude congestive heart failure if the

patient’s cardiac involvement is suspected.

 Sputum Culture: To identify any infectious processes contributing to respiratory

distress.

 Genetic Testing: If indicated and appropriate, to assess for any hereditary lung

conditions.

 Echocardiogram: To evaluate for cor pulmonale that may result from chronic lung

disease.

 Sleep Study (Polysomnography): To consider if sleep apnea is suspected due to the

need to sleep in a recliner.

 A six-minute walk test: To assesses the patient’s exercise tolerance and oxygen

desaturation levels during exertion.

 Complete Pulmonary Function Tests (PFTs) to evaluate various aspects of lung

function, including airflow, lung volume, and gas exchange, providing a comprehensive

view of respiratory health, including a reversibility test after bronchodilator

administration

 Diffusing capacity for carbon monoxide (DLCO) tests to measure how well oxygen

and carbon monoxide can pass from the lungs into the bloodstream, helping to assess the

efficiency of gas exchange in the lungs (Modi et al., 2024).

Consultation Considerations

Consultations with specialists may be beneficial for comprehensive care. A referral to a

pulmonologist is crucial for managing severe COPD and its potential complications. The

pulmonologist can help interpret complex pulmonary function tests and provide access to

advanced therapies, such as long-term oxygen therapy or pulmonary rehabilitation. If mental

health concerns arise, a psychologist or psychiatrist specializing in LGBTQ+ issues should be

consulted to address the psychological aspects of the patient’s condition. Additionally, referrals

to a smoking cessation program or a registered dietitian may be necessary to address potential

weight loss and nutritional needs.

Medical and Nursing Diagnoses

Given the initial assessment, the following diagnoses could be pertinent:

Medical Diagnoses

1. Chronic Obstructive Pulmonary Disease (COPD) exacerbation.

2. Respiratory acidosis with hypoxemia.

Nursing Diagnoses (Sparks & Taylor, 2008):

1. Impaired Gas Exchange related to COPD as evidenced by dyspnea, diminished breath

sounds, arterial hypoxemia, and hypercarbia (respiratory acidosis).

2. Ineffective Airway Clearance is related to excessive sputum production and fatigue, as

evidenced by cough with clear mucoid sputum and use of accessory muscles during

respiration.

3. Activity Intolerance related to decreased lung function and respiratory distress as

evidenced by inability to lie flat, severe dyspnea, and lack of energy.

4. Risk for Impaired Skin Integrity related to decreased mobility and potential edema from

respiratory compromise.

Legal and Ethical Considerations

Engaging the patient in shared decision-making about his treatment plan while being

sensitive to his unique experiences and potential discrimination within the healthcare system is

paramount. It is essential to consider important legal and ethical aspects, including:

 Informed Consent: Ensuring the patient understands treatment options and implications

within the context of their gender identity.

 Confidentiality: Respecting the patient’s right to privacy regarding their transgender

status and health conditions.

 Cultural Competence: Providing care that respects cultural differences while addressing

biases against LGBTQ+ individuals in healthcare settings.

 Non-Discrimination: Adhering to guidelines that protect patients from discrimination

based on gender identity and ensuring equitable access to healthcare resources (Roos et

al., 2023).

Treatment Plan

A comprehensive plan of care that encompasses medical, nursing, and complementary

therapies is critical to addressing the patient’s needs.

Medical Plan of Care

 Oxygen Therapy: Initiate supplemental oxygen therapy to manage hypoxemia based on

arterial blood gas results and maintain SpO2 ≥ 90%. Due to the hypercapnia risk in

COPD, Oxygen should be titrated carefully.

 Bronchodilator Therapy (Arcangelo et al., 2022):

o Administer short-acting beta-agonists (SABA) such as albuterol via nebulizer for

immediate relief.

o Initiate pharmacotherapy with long-acting bronchodilators (e.g., LABA) to

manage COPD symptoms and a short course of systemic corticosteroids to reduce

airway inflammation.

Advair Discus inhalation powder 100/50 mcg – inhale one puff twice daily
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ProAir HFA Inhaler (Albuterol sulfate 90 mcg) – inhale two puffs every 4-6 hours as

needed for shortness of breath

Prednisone 40 mg tablet – take one tablet by mouth daily for 5 days

 Antibiotics (Arcangelo et al., 2022):

o Given a cough with clear mucoid sputum and acute exacerbation symptoms,

treatment for potential bacterial infection should be considered.

Azithromycin 250 mg tablet – take two tablets by mouth on day one, then one tablet for

four days.

 Expectorants (Storms & Miller, 2018):

o It can help patients with COPD by thinning and loosening mucus in the airways,

making coughing easier, and improving overall breathing.

Mucinex 600 mg tablet – take one tablet by mouth twice daily (Arcangelo et al., 2022)

 Smoking Cessation: Refer to a smoking cessation program with pharmacotherapy

support (e.g., nicotine replacement therapy, varenicline).

Nursing Plan of Care (Sparks & Taylor, 2008)

5. Impaired Gas Exchange

 Goal: The patient will maintain adequate oxygenation and carbon dioxide elimination.

 Interventions:

o Monitor vital signs, including oxygen saturation (SpO2) regularly.

o Administer supplemental oxygen to maintain SpO2 > 90%.

o Position the patient in a high Fowler’s position to enhance lung expansion.

o Administer short-acting beta-agonists (SABA) such as albuterol via nebulizer for

immediate relief.
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o Educate the patient on using bronchodilators and assess the effectiveness of the

albuterol inhaler.

2. Ineffective Airway Clearance

 Goal: The patient will demonstrate adequate airway clearance and decrease sputum

production.

 Interventions:

o Encourage the patient to perform deep breathing exercises and productive

coughing techniques.

o Administer expectorants as prescribed to help thin secretions.

o Teach the patient pursed-lip breathing to slow respiratory rate and improve

oxygenation.

o Encourage hydration to help thin mucus secretions.

6. Activity Intolerance

 Goal: The patient will demonstrate increased tolerance for physical activity with minimal

dyspnea.

 Interventions:

o Develop an individualized activity plan, starting with rest periods between

activities.

o Encourage the use of assistive devices if necessary for mobility.

o Collaborate with a respiratory therapist for pulmonary rehabilitation assessment

and planning.

o Provide education about pacing activities and conserving energy.

7. Risk for Impaired Skin Integrity

 Goal: The patient will maintain intact skin integrity.

 Interventions:

o Assess the skin regularly for signs of pressure ulcers, especially over bony

prominences.

o Ensure adequate nutrition and hydration to promote skin health.

o Educate the patient about the importance of mobility and preventing skin

breakdown.

Monitoring and Evaluation

 Monitor the patient’s response to interventions and reassess respiratory status frequently

(e.g., lung sounds, SpO2 levels, activity tolerance).

 Adjust the care plan based on ongoing assessments and patient feedback.

 Collaborate with the healthcare team for comprehensive management, including smoking

cessation counseling, nutrition referrals, and cardiopulmonary rehabilitation services.

This plan should be continuously reassessed and tailored to the patient’s specific needs and

responses to treatment.

Complementary Therapies

Offer to the patient to explore the use of complementary therapies such as:

 Pulmonary Rehabilitation: To enhance pulmonary function and overall well-being

through exercise and education.

 Mindfulness and Breathing Exercises: These exercises help manage anxiety related to

dyspnea and enhance coping strategies.

Evaluation
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In the next office visit for this patient, the primary focus will be on evaluating the

progression of his respiratory condition, given the signs of increased severity in his symptoms

and clinical findings. A comprehensive assessment will include repeat pulmonary function tests

(PFTs) to evaluate FEV1 and FEV1/FVC ratios, which should provide objective data on lung

function decline or stability (Zhou et al., 2013). Additionally, a series of arterial blood gases

(ABGs) will be re-checked to monitor oxygenation and acid-base balance changes (Rawashdeh,

2024). It will also be imperative to assess the patient’s inhaler technique and adherence to

prescribed medications, as improper use or non-compliance can significantly impact results. A

review of smoking cessation options, including counseling and pharmacotherapy, will also be

conducted, as continued smoking exacerbates his pulmonary condition.

Based on the repeat PFTs and ABGs, evaluating his clinical status will guide the decision

to continue the current management plan or make necessary adjustments. If tests indicate

worsening respiratory function, consideration for step-up therapy—including third-line treatment

as Long-acting muscarinic antagonists (LAMAs) (e.g., tiotropium, aclidinium) can be introduced

as a third-line option. LAMAs are beneficial for patients with more severe symptoms or those

who experience exacerbations. Tailoring the treatment regimen based on the patient’s needs,

medication response, and co-morbid conditions is essential.

Further imaging, like a high-resolution chest CT, could be warranted if significant

structural lung disease or complications are suspected (Yadav et al., 2023). Conversely, if data

shows no significant change in lung function or symptoms stabilize, there is potential for

improvement. In that case, we may continue with the current management, emphasizing the

importance of lifestyle modifications, smoking cessation, and frequent monitoring of symptoms

to prevent further decline (Moharana et al., 2021). This emphasis on lifestyle modifications

should make the patient and his caregivers feel empowered and in control of the situation.

Healthy People 2030 Goals and Health Promotion

Healthy People 2030, a comprehensive initiative, is committed to improving the health

and well-being of individuals and communities across the United States. It achieves this by

setting science-based, national objectives for health improvement (Santana et al., 2021). The

initiative fosters collaboration among public health partners and employs data-driven methods to

develop long-term strategies for addressing prevalent health disparities and population

challenges. A key goal of Healthy People 2030 is to promote respiratory health, which includes

preventing respiratory diseases, enhancing asthma control, and ensuring access to appropriate

healthcare services for individuals with lung conditions. The initiative underscores the

importance of early detection and proactive management of respiratory diseases, particularly for

vulnerable populations affected by risk factors such as smoking and environmental hazards.

As public health professionals, policymakers, and healthcare providers, our role is crucial

in implementing the goals of Healthy People 2030. In the case of the 56-year-old transgender

Hispanic man presented, his significant smoking history, declining lung function, and current

symptoms of respiratory distress align closely with the initiative’s goals to enhance respiratory

health outcomes. Particularly relevant is reducing the burden of chronic obstructive pulmonary

disease (COPD) and other respiratory conditions (Hasbrouck, 2021). Our health promotion

strategies aimed at individuals like him could involve cessation programs tailored to

acknowledge and address the unique contexts of his life, including sociocultural factors and

barriers to care (Gpmez et al., 2021). Additionally, enhancing access to comprehensive

pulmonary rehabilitation, education about smoking cessation, and proactive management of his
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chronic respiratory condition can significantly contribute to improving his quality of life and

overall health outcomes while also addressing health disparities within his demographic group.

Patient and Family Teaching

Incorporating the Circle of Caring involves engaging the patient’s family members and

support persons to enhance the patient’s care experience. Establishing family meetings to discuss

care goals and preferences can ensure that all voices are heard and a comprehensive management

plan aligned with the patient’s values is developed. Additionally, social workers or community

health workers familiar with LGBTQ+ resources may be included to facilitate access to

comprehensive care and ensure the patient’s voice is central in care planning.

Patient education should encompass a comprehensive approach to lifestyle modifications,

such as smoking cessation strategies, nutritional guidance to improve energy levels, maintaining

physical activity as tolerated, medication use (inhaler techniques), recognizing signs of

exacerbation, and adherence to follow-up appointments and treatments.

Billing Codes

The recommended billing CPT codes encompass a range of services relevant to

pulmonary diagnostics and chronic illness management. Each code corresponds to a specific

procedure or service, facilitating accurate billing practices. The following codes are frequently

suggested for use (Billing Guide for Asthma and COPD Care, 2023):

94060: This code is used for pulmonary diagnostic testing and therapies, which may

include spirometry and other pulmonary function tests designed to assess the patient's respiratory

status.
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94640: This code applies to inhalation treatments, specifically nebulizer therapy, which

helps patients manage respiratory conditions such as asthma or chronic obstructive pulmonary

disease (COPD).

99213: This code is designated for established patient office visits lasting 20 to 29

minutes. It is appropriate for chronic illness management, allowing healthcare providers to

address ongoing patient needs and follow-ups during an office encounter.

99406: This code pertains to counseling visits focused on smoking and tobacco use

cessation. It is considered an intermediate visit for counseling that lasts greater than 3 minutes

but less than 10 minutes, which is crucial for patients seeking to quit smoking.

Follow Up

The patient should return for a follow-up visit in 4 to 6 weeks to reassess his symptoms,

response to the new medications, and any adjustments needed. During this visit, pulmonary

function tests (PFTs) should be repeated to evaluate his response to treatment and monitor his

arterial blood gases (ABGs) to ensure his hypoxemia and respiratory acidosis resolve. He

must understand the importance of seeking immediate medical attention if he experiences

worsening symptoms or acute exacerbations before the scheduled follow-up. This proactive

approach empowers the patient and ensures active involvement in their care. Regular follow-

up visits may need to be scheduled every 3 months afterward to provide ongoing

management and practical treatment adaptations as required.

Conclusion

The management of respiratory distress in this 56-year-old transgender Hispanic man

involves a comprehensive, evidence-based approach that incorporates both medical and

psychosocial elements. Treating respiratory conditions entails continuous assessment and tailored
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interventions guided by national guidelines, underpinned by respect for the patient's identity. A

holistic care plan emphasizes patient and family engagement while addressing health disparities

and ensuring equitable access to resources. Regular follow-ups and adjustments of the

management plan based on the patient's progress are vital in providing adequate care and

supporting the patient’s overall health and wellness. This methodology enhances clinical

outcomes and bolsters patient confidence in their treatment journey (Roos et al., 2023).
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