week 2 mid assignment advance nursingralph28
Week 2: Respiratory Clinical Case Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.
Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.
History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.
Past Surgical History None
Family/Social History Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Medication History Theophylline SR Capsules 300 mg PO BID Albuterol inhaler, PRN Phenytoin SR capsules 300 mg PO QHS HTCZ 50 mg PO BID
Enalapril 5 mg PO BID Allergies NKDA ROS
Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.
Physical exam BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3” VS after Albuterol breathing treatment - BP 134/79, HR 80, RR 18
Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing Na - 134 K - 4.9 Cl - 100
BUN - 21 Cr - 1.2 Glu – 110 ALT – 24 AST - 27 Total Chol – 190 CBC - WNL Theophylline - 6.2 Phenytoin - 17
Chest Xray – Blunting of the right and left costophrenic angles Peak Flow – 75/min; after albuterol – 102/min FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
To access the codes please use this link https://www.cms.gov/medicare-coverage-database/new-search/search.aspx
Please use this templet
Running head: NAME OF CARE PLAN
Title of Plan of Care Name South University Online Faculty Name NSG 6001 Date
NAME PLAN OF CARE 2
**Please delete this statement and anything in italics prior to submission to shorten the length of your paper.
Patient Initials ______ Subjective Data: (Information the patient tells you regarding themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in chronologic order using symptom analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history, obstetric and history sexual history).
Significant Family History: (Includes family members and specific inheritable diseases).
Social History: (Includes home living situation, marital history, cultural background, health habits, lifestyle/recreation, religious practices, educational background, occupational history, financial security and family history of violence).
Review of Symptoms: (Review each body system - This section you should place POSITIVE for... information in the beginning then state Denies...). - General:; Integumentary:; Head:; Eyes: ; ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:; Neurological:; Endocrine:; Hematologic:; Psychologic: .
Objective Data: Vital Signs: BP - ; P ; R ; T ; Wt. ; Ht. ; BMI . Physical Assessment Findings: (Includes full head to toe review) HEENT: Lymph Nodes: Carotids: Lungs: Heart: Abdomen: Genital/Pelvic: Rectum: Extremities/Pulses: Neurologic: Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of priority.)
Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided).
NAME PLAN OF CARE