Scenario S.R. is a 69-year-old man who owns his own business. The…
QuestionScenario S.R. is a 69-year-old man who owns his own business. The…Scenario S.R. is a 69-year-old man who owns his own business. The stress of overseeing his employees, meeting deadlines, and carrying out negotiations has led to poor sleep habits. He sleeps 3 to 4 hours a night. He keeps himself going by drinking 2 quarts of coffee and smoking 3 to 4 packs of cigarettes per day. He weighs 280 pounds and does not use alcohol. His wife complains that his snoring has become dif-ficult to live with. CASE STUDY PROGRESS After interviewing S.R., you report the following information to the provider: blood pressure (BP) 164/90, pulse 92 beats/min, respirations 18 breaths/min, SaO2 90% on room air. S.R. is under con-siderable stress, has gained 50 pounds over the past year, and has a history (Hx) of tobacco and caffeine abuse. He complains of (C/O) difficulty staying awake, wakes up with headaches most morn-ings, and has midmorning somnolence. He is depressed and irritable most of the time and reports difficulty concentrating and learning new things. He has been involved in 3 auto accidents in the past year. Your examination is normal except for multiple bruises over the right ribcage. You inquire about the bruises, and S.R. reports that his wife jabs him with her elbow several times every night. In her own defense, the wife states, “Well, he stops breathing and I get worried, so I jab him to make him start breathing again. If I don’t jab him, I find myself listening for his next breath and I can’t go to sleep.” You suspect sleep apnea. CASE STUDY PROGRESS The primary care provider (PCP) examined S.R. and documented a long soft palate, recessed mandible, and medium-sized tonsils. S.R.’s overnight screening oximetry study showed 143 episodes of desatura-tion ranging from 68% to 76%; episodes of apnea were also documented. He was diagnosed with OSA with hypoxemia, and a full sleep study was ordered. CASE STUDY PROGRESS S.R. returns for a follow-up (F/U) visit after being diagnosed with OSA. He reports he has lost 10 pounds, but there has been little improvement in his symptoms. He states he fell asleep while driving to work and wrecked his car. He wants to discuss further treatment options. CASE STUDY PROGRESS S.R. and the PCP decide on the least invasive treatment—continuous positive airway pressure (CPAP). The provider writes a prescription for CPAP. The patient has a choice of which durable medical equip-ment (DME) company he wants to get his equipment from. You help him by giving him the names of 3 reputable companies and advise him to call his insurance company to find out how much they will pay and how much he will be responsible for Background Information Initials:Age:Gender:Allergies:Admitting Medical Diagnosis (es): Pathophysiology (Definition): Signs and symptoms: Treatment (medical/surgical/nursing/ other: Vital signsB/PHRRRTemp Major Secondary Diagnosis (s): Pathophysiology (Definition): Signs and symptoms: Chief Complaint for Hospitalization:History of Present Illness: Patient’s understanding of present health state: Medications Taken at Home: Cultural/Spiritual Assessment LAB WORK and DIAGNOSTIC TESTSDateLab/ Diagnostic TestClient’s ResultsNormal RangesReason for TestNursing Significance Medications: Include Only Current Medications Drug name and class: Include Prescribed Dosage, Route & FrequencyReason prescribed for this clientMethod of action in this client:Evaluation of drug effect:Related nursing care (give at least 2)Drug name and class: Include Prescribed Dosage, Route & FrequencyReason prescribed for this clientMethod of action in this client:Evaluation of drug effect:Related nursing care (give at least 2)Drug name and class: Include Prescribed Dosage, Route & FrequencyReason prescribed for this clientMethod of action in this client:Evaluation of drug effect:Related nursing care (give at least 2)Drug name and class: Include Prescribed Dosage, Route & FrequencyReason prescribed for this clientMethod of action in this client:Evaluation of drug effect:Related nursing care (give at least 3)Drug name and class: Include Prescribed Dosage, Route & FrequencyReason prescribed for this clientMethod of action in this client:Evaluation of drug effect:Related nursing care (give at least 3)Nursing Diagnosis:SUPPORTIVE DATA AssessmentEXPECTED OUTCOMESINTERVENTIONSRATIONALES & REFERENCESEVALUATIONSubjective Data Objective DataShort Term GoalsLong Term Goal Remember to site all of your nursing interventions. Use your nursing care plan book to guide youNursing Progress Notes Narrative NotesPhysical AssessmentNEURO CARDIAC RESP. GI GU INTEG. MUSCULO-SCKELETAL PERIPHERALVASCULAR Time Problem Assessment/Intervention/Outcomes SignatureHealth ScienceScienceNursingMED SURGIC nu2530Share Question
