Week 2: Respiratory Clinical Case
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
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.
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
Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.
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%
Visit the South University Online Library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, and Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
I PUT IT AT THE END OF THIS POST
Click here to download the care plan template to help you design a holistic patient care plan. The care plan example provided here is meant only as a frame of reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.
Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be 2 pages excluding the title page and references and in 12pt font.
Name your document: SU_NSG6001_W2_A2_LastName_FirstInitial.doc.
Submit your document to the W2 Assignment 2 Dropbox by Tuesday, January 10, 2017.
|Assignment 2 Grading Criteria||Maximum Points|
|Subjective DataThe submission included the patient’s interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.||15|
|Objective DataThe submission included measurements and observations obtained by the nurse practitioner. It included head to toe physical examination as well as laboratory and diagnostic testing results and interpretation (especially those that pertain to the diagnosis).||15|
|AssessmentThe submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.||15|
|Plan of CarePlan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.||20|
|APAUsed APA standards consistently and accurately when citing in the SOAP note and reference page. Utilized proper format with coversheet and header.||10|
SAMPLE (OR TEMPLETE) FOR THE WORK
Title of Plan of Care
South University Online
**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: .
Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe review)
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).