Order Description
Pulmonology Case Study
HPI
A 65-year-old Caucasian female presents with a chief complaint of cough for two weeks. She has been complaining of dry cough since the past two weeks and low grade fever that started two days ago, and was as high as 101 orally. She has had a decreased appetite but no nausea and vomiting. The cough occurs during the night and she needs to sit up in a chair to be able to breathe easier. The cough is mainly dry, rarely productive.
She had been prescribed inhalers in the past; they have been helpful but she does not use them on a routine basis. She has been prescribed antibiotics in the past as well and that seems to help when she is acutely ill. She has been suffering from shortness of breath for the past two weeks following any kind of activity mainly because of the dry cough. She thinks it?s possible that there?s some problem with her ?heart.? She is also complaining of slight sore throat, especially in the morning and feels she may have lung cancer.
The patient?s symptoms have been worsening over the past two days.
She has had similar episodes in the past. The last was three months ago when she had to go to the emergency room and they told her that she needed to be hospitalized. She declined hospitalization at that time and was treated and released. She says they gave her antibiotics and an inhaler before discharging her. She mentioned that though it took some time to feel better, there was gradual improvement in her condition following that treatment. According to her, this is the worst episode that she can remember. She?s very concerned today that she could have pneumonia and might require hospitalization.
She is seeking medical attention today because of the fever and prolonged nature of her illness.
PMH
Though she has been treated for this problem in the past with antibiotics and inhalers, she has not been hospitalized. The patient had a chest investigation the last time she had this problem. She states that she did not have pneumonia but did have ?emphysema.? The healthcare professionals wanted to do pulmonary function tests, but she declined.
X-ray report:
X-ray results: Hyperinflation of both lungs with an increased AP diameter. There is evidence of emphysema. .
She states that she had asthma as a child and is a cigarette smoker. She also had a hysterectomy way back in 1970s. Besides these, she has no known chronic medical problems.
ROS
Shortness of breath with activity. No diaphoresis. She has had a fever. No nausea and vomiting. Denies chest pressure sensation with physical activity. No palpitations.
MEDICATIONS
The patient does not take any prescription medicines. She takes occasional over-the- counter Tylenol for pain.
Tylenol 650 mg, 2 PO as needed.
ALLERGIES/REACTIONS
She is allergic to sulfa drugs that cause a rash.
SOCIAL HISTORY
The patient has been widowed for 20 years. She is receiving an annual pension of
$40,000.00 and has some money that she has saved in the bank. She has a high school diploma and owns her house. Though she has little disposable income, her finances are essentially stable. She has little knowledge of community resources that are at her disposal.
She has a primary care provider, whom she sees three to four times every year for a physical examination. The physician is very busy and does not spend much time with her. She has insurance but it does not cover all her prescription medications. She relies on a lot on samples.
She has two grown-up daughters who live in the nearby community. They are both in their forties and are alive and well. The patient would like her daughters to be more involved in her life, but she is not sure how to approach them about this. The patient?s perception of self-efficacy has been declining over the past ten years. She feels that she could be feeling depressed because she does not get out of the house very often and this depression is only getting worse with each passing year.
The patient has very low level of day-to-day stress. However, she realizes that her depressive symptoms may be causing some of her physical symptoms.
She goes to church and has some contacts there. She sees her daughters once a month. These people are her support system, but she has no one to talk to on a routine basis.
HABITS
? Diet habits
She has a healthy diet and her dietary intake is adequate. The patient has positive health beliefs and knows that she should be doing more to maintain a healthy lifestyle. She does not get adequate exercise because of her shortness of breath. She enjoys visiting her physician.
Smoking: She has smoked one pack per day for 40 years. Alcohol: She denies alcohol use
Substance Use: She denies any street drug use
WORK HABITS
She has always been a hairdresser; is retired now. She goes to church and occasionally attends some of their functions. Her hobbies include sewing. She is from the United States and lives in a suburban setting. Crime rate in her locality is low with easy access
to public transportation. There are a variety of community groups, but she is not aware of these resources.
FAMILY HISTORY
Her two older sisters are alive and well, one with osteoporosis and one with breast cancer. Her 75-year-old sister was diagnosed with osteoporosis at the age of 55. Her 72- year-old sister was diagnosed with breast cancer at 60 years of age.
PHYSICAL EXAMINATION
Vital Signs: BP: 130/72 left arm sitting regular cuff; T: 101 po; P: 100 and regular; R: 20, non-labored; Wt: 130#; Ht: 55?.
HEENT: White material on the buccal mucosa; does not wipe off with tongue blade. Lymph Nodes: None
Lungs: Decreased breath sounds, dull to percussion right lower lobe. End expiratory wheeze in right lower lobe. No rales or rhonchi. Increased anterior-posterior diameter to chest wall.
Heart: RRR without murmur Carotids: No bruits Abdomen: Benign
Rectum: Not examined
Genital/Pelvic: Not examined
Extremities, Including Pulses: 2+ pulses throughout, no edema
Neurologic: Not examined
LAB RESULTS/RADIOLOGICAL STUDIES/EKG INTERPRETATION
CBC- WBCs 15, 000 with + left shift
Pulse oximeter reading: SAO2: 98%
Radiological Studies
CXR ? Same as X-ray
EKG
Normal sinus rhythm
Additional information about the assignment.
Click here to download and analyze the case study for this week. Create a wholistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the 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, 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.
Click here to access the codes.
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.
Format
Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be 2 to 4 pages double-spaced and in 12pt font.
Care plan Template to follow. Needs at least 4 diagnosis and care plans.
Care Plan Template
Patient Initials: ______ Age: _______________ Sex: ___________
Subjective Data:
Client Complaints:
HPI (History of Present Illness):
PMH (Past Medical History?include current medications, any known allergies, any history of surgery or hospitalizations):
Significant Family History:
Social/Personal History (occupation, lifestyle?diet, exercise, substance use)
Description of Client?s Support System:
Behavioral or Nonverbal Messages:
Client Awareness of Abilities, Disease Process, Health Care Needs:
Objective Data:
Vital Signs including BMI:
Physical Assessment Findings:
Lab Tests and Results:
Client?s Support System:
Client?s Locus of Control and Readiness to Learn:
ICD-10 Diagnoses/Client Problems:
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
References
