Question Answered step-by-step Completing A Nursing Care PlanYou received the patient at 19:00 on day 2. You receive report and review the EHR. The following information is what you discover. Complete the Concept Map by following the instructions on the document. Scenario:Patient IdentityThe patient is a 54-year-old female, who is a housewife with a BMI of 26. This patient has had asthma for most for his life and it has been controlled with medications and avoiding triggers. She has been using an albuterol rescue inhaler approximately 1 time per month for the past year.Presenting ComplaintsShe was brought into the ED 2 day ago, complaining of shortness of breath (SOB) and a productive cough. History of Presenting ComplaintsThe patient was experiencing SOB for the past 2-3 days and was progressively worsening on the day on admission. It was not associated with chest tightness or pain. She was also having persistent productive cough with white sputum since she was last discharged 12 days ago.Past Medical HistoryShe was diagnosed with diabetes mellitus and hypertension 8 years ago. She was newly diagnosed with bronchial asthma in her last admission two weeks ago.Social HistoryThe patient is a widow for 6 years. She is a factory worker and cares for 3 teenage children. She stays in a factory area and has a cat at home. She is a non-smoker and a non-alcoholic.Family HistoryHer mother and father have no known medical illness, but she has a cousin who suffers from bronchial asthma and is frequently admitted to the hospital.Drug HistoryBronchial Asthma. Pulmicort Flex haler 180 mcg inhaled twice daily.Proventil HFA administer 2 inhalations repeated every 4 to 6 hours, as needed for acute episodes of bronchospasm.Hypertension Fosinopril sodium tablets is 10 mg dailyHydrochlorothiazide tablet 50 mg, dailyType 2 diabetes mellitusMetformin 500mg orally, twice a dayShe has been compliant with her medication and she had no known drug allergy.    Examination DetailsOn examination, the patient was alert and oriented X3. She was pink and appeared to be hydrated. She was also able to speak in full sentences and was not tachypneic. Her blood pressure (BP) was 152/82mmHg, pulse rate (PR) was 109 beats per minute (bpm) and was afebrile. Her oxygen saturation (SpO2) was 96% under 3 liters of oxygen and her blood glucose was 88.Current LabHemoglobin: 13 g/dLHematocrit: 38%Platelet Count: 200,000/mLWhite blood cell: 15,000/mL Medical DiagnosisPatient was initially diagnosed with Acute Exacerbation of Bronchial Asthma secondary to an upper respiratory infection to rule out pneumonia. However, later in the day when the chest X-ray came back, she was diagnosed with pneumonia with right lower lobe effusion.Management PlanThe patient’s current medication was continued and 3 liters of oxygen via a nasal canula was administered. She was also started on an antibiotic after the CXR showed pneumonia with right effusion. Medications Prescribed •            Prednisolone tablets, 30mg daily•            Clarithromycin250-500 mg orally every 12 hours•            Pulmicort Flexhaler 180 mcg inhaled twice daily.•            Proventil HFA administer 2 puffs every 4 to 6 hours, PRN for acute episodes of bronchospasm.•            Fosinopril sodium tablets is 10 mg daily•            Hydrochlorothiazide tablet 50 mg, daily•            Metformin 500mg orally, twice a day      Table 1: Vital Signs from the medical recordDay TimeBPPulseSp)2Blood GlucoseTemperature111.00178/102109100%7097.6oF 14.00152/8210098%   18.40133/7311497% 100oF208.30119/6794100%74  15.20112/8296100% 102.2oF                        This is the format and the elements that Health Science Science Nursing KINE 3398 Share QuestionEmailCopy link Comments (0)

Question Answered step-by-step Completing A Nursing Care PlanYou received the patient at 19:00 on day 2. You receive report and review the EHR. The following information is what you discover. Complete the Concept Map by following the instructions on the document. Scenario:Patient IdentityThe patient is a 54-year-old female, who is a housewife with a BMI of 26. This patient has had asthma for most for his life and it has been controlled with medications and avoiding triggers. She has been using an albuterol rescue inhaler approximately 1 time per month for the past year.Presenting ComplaintsShe was brought into the ED 2 day ago, complaining of shortness of breath (SOB) and a productive cough. History of Presenting ComplaintsThe patient was experiencing SOB for the past 2-3 days and was progressively worsening on the day on admission. It was not associated with chest tightness or pain. She was also having persistent productive cough with white sputum since she was last discharged 12 days ago.Past Medical HistoryShe was diagnosed with diabetes mellitus and hypertension 8 years ago. She was newly diagnosed with bronchial asthma in her last admission two weeks ago.Social HistoryThe patient is a widow for 6 years. She is a factory worker and cares for 3 teenage children. She stays in a factory area and has a cat at home. She is a non-smoker and a non-alcoholic.Family HistoryHer mother and father have no known medical illness, but she has a cousin who suffers from bronchial asthma and is frequently admitted to the hospital.Drug HistoryBronchial Asthma. Pulmicort Flex haler 180 mcg inhaled twice daily.Proventil HFA administer 2 inhalations repeated every 4 to 6 hours, as needed for acute episodes of bronchospasm.Hypertension Fosinopril sodium tablets is 10 mg dailyHydrochlorothiazide tablet 50 mg, dailyType 2 diabetes mellitusMetformin 500mg orally, twice a dayShe has been compliant with her medication and she had no known drug allergy.    Examination DetailsOn examination, the patient was alert and oriented X3. She was pink and appeared to be hydrated. She was also able to speak in full sentences and was not tachypneic. Her blood pressure (BP) was 152/82mmHg, pulse rate (PR) was 109 beats per minute (bpm) and was afebrile. Her oxygen saturation (SpO2) was 96% under 3 liters of oxygen and her blood glucose was 88.Current LabHemoglobin: 13 g/dLHematocrit: 38%Platelet Count: 200,000/mLWhite blood cell: 15,000/mL Medical DiagnosisPatient was initially diagnosed with Acute Exacerbation of Bronchial Asthma secondary to an upper respiratory infection to rule out pneumonia. However, later in the day when the chest X-ray came back, she was diagnosed with pneumonia with right lower lobe effusion.Management PlanThe patient’s current medication was continued and 3 liters of oxygen via a nasal canula was administered. She was also started on an antibiotic after the CXR showed pneumonia with right effusion. Medications Prescribed •            Prednisolone tablets, 30mg daily•            Clarithromycin250-500 mg orally every 12 hours•            Pulmicort Flexhaler 180 mcg inhaled twice daily.•            Proventil HFA administer 2 puffs every 4 to 6 hours, PRN for acute episodes of bronchospasm.•            Fosinopril sodium tablets is 10 mg daily•            Hydrochlorothiazide tablet 50 mg, daily•            Metformin 500mg orally, twice a day      Table 1: Vital Signs from the medical recordDay TimeBPPulseSp)2Blood GlucoseTemperature111.00178/102109100%7097.6oF 14.00152/8210098%   18.40133/7311497% 100oF208.30119/6794100%74  15.20112/8296100% 102.2oF                        This is the format and the elements that Health Science Science Nursing KINE 3398 Share QuestionEmailCopy link Comments (0)