nursing care plan

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CASE STUDY FOR CARE PLAN

Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by paramedics after reporting severe dyspnea and shortness of breath. He has been experiencing cold-like symptoms for the past 2 days. He has a productive cough with thick greenish sputum.

When Mr. W awoke in the nursing home, it was found that he had difficulty breathing even after using his albuterol (Proventil) metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress.

His history includes chronic obstructive pulmonary disease related to smoking 2 packs of cigarettes per day since he was 15 years old. He also has a history of HTN and coronary artery disease. He had bypass surgery 15 years ago. Mr. W is a widower, his wife died 8 years ago. Mr. W has 2 grown children and several grandchildren who visit him weekly. His past occupation was a construction worker.

Initial vital signs:

Blood pressure 154/92 mm Hg

Heart rate . 118 bpm

O2 saturation . 88% on 1 L/min oxygen by nasal cannula

Respiratory rate . 38 breaths per minute

Temperature . 100.9 F (38.3 C)

In the ED, Mr. W undergoes a chest xray and admission labs are obtained including an electrolyte panel, CBC, and arterial blood gas. A sputum sample is sent to the lab for gram stain and culture and sensitivity.

RESULTS:

CBC . WBC 12000 mm3

HGB . 11.6 g/dL

HCT . 35.2 %

Electrolytes

Glucose . 122 mg/dL

Potassium . 4.1 mEq/L

Sodium . 135 mEq/L

ABG

PH 7.32

PaC02 . 55.4 mm Hg

Pa02 51.2 mm Hg

HC03 . 38 mEq/L

Chest Xray – results show abnormal air collections within the lung, lung hyperinflation, and lobular consolidation.

Assessment:

Pt is awake but drowsy. Auscultation of lungs notes bilateral crackles and decreased breath sounds. Pt reports pain of 3 out of 10 when he takes a deep breath.

Medications:

Proventil (Albuterol)

Lasix

Antipyretic

Appropriate antibiotic for probable pneumonia/lung infection

Anti-hypertensive medication

DIRECTIONS:

Students must use the care plan template and it must be submitted to the drop box for grading.

Each section of the care plan must be completed.

There must be 3 Nursing diagnoses (2 physical and 1 psychosocial). Nursing diagnoses must be NANDA approved.

If you have any questions or concerns, please contact an instructor.

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