Case NUR 265:Care Plan #3 What’s the Problem (NUR 265)

Student Name: Clinical section/facility Admitted: Code Status: Full Age: 69 Sex: Female HT: 65” WT: 64..8 kg ALLERGY: bees, ants Chief Complaint: Difficulty breathing and inability to catch her breath at rest. Admitting Diagnosis: COPD Exacerbation Pathophysiology: COPD exacerbations occur when airway inflammation causes increased airway resistance and a decrease in lung functioning (Papi, Luppi, Franco, & Fabbi, 2006). COPD exacerbations result in dyspnea for the patient and a cough that may or may not be productive. The cause may be unknown but can be caused by a bacteria or a virus. PMHx: Bronchospasms, hyperlipidemia, diabetes mellitus, hypertension, CVA, GERD, and constipation. The patient is a smoker and smokes approximately 4 cigarettes per day. Lab/Test Results: RBC 3.75, Hgb 10.3, WBC 7.4, Hct 33, Plt 264, Na 136, K 4.2, BUN 8, Cr 0.4, pCO2 53 (high), pO2 61.4 (low), HCO3 31.2 (high) Pending procedures: none at this time Assessment Findings: Neuro: Patient alert and oriented to person, place, time and purpose. PERRLA. Normal sensory perception. Cardio: Normal sinus rhythm per tele monitor. S1 S2 heard with murmur. No edema observed. Pedal and dorsalis pedis pulses strong and palpable. Cap refill less than 3 seconds. SCD’s in place. Pulm: Diminished lung sounds in all lobes bilaterally, no adventitious breath sounds. Patient reports cough with thick yellow sputum. GI: Continent of bowel, last BM 2/16/19, large soft and brown per patient. Abdomen flat, nondistended, non-tender, bowel sounds present in all 4 quadrants. Cardiac heart healthy in place, mechanically chopped. GU: Continent of bladder, urine clear, pale yellow without sediment. Gentialia not assessed. No c/o difficulty with urination. MS: Grip weak but equal in all extremities. Full ROM intact. Ambulates independently with walker due to unsteady gait and weakness. Skin: Patients skin is dry and intact, no breakdown noted. 20 gauge IV to right forearm, no infiltration noted. IV Site: 20 gauge IV placed in right forearm with no fluids running at this time.