65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing shortness of breath and coughing at least once daily.
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.HPIFrequent asthma attacks for the past 2 months (more than 4 times per week average) serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started no seizure activity since initiation of therapy.PMHHistory of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.Past Surgical HistoryNoneFamily/Social HistoryFamily: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHFSocial: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.Medication HistoryTheophylline SR Capsules 300 mg PO BIDAlbuterol inhaler PRNPhenytoin SR capsules 300 mg PO QHSHTCZ 50 mg PO BIDEnalapril 5 mg PO BIDAllergiesNKDAROSPositive for shortness of breath coughing wheezing and exercise intolerance. Denies headache swelling in the extremities and seizures.Physical examBP 171/94 HR 122 RR 31 T 96.7 F Wt 145 Ht 5 3VS after Albuterol breathing treatment – BP 134/79 HR 80 RR 18Gen: Pale well developed female appearing anxious. HEENT: PERRLA oral cavity without lesions TM without signs of inflammation no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft non-tender non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema on right no bruising normal pulses. NEURO: A&O X3 cranial nerves intact.Laboratory and Diagnostic TestingNa – 134K – 4.9Cl – 100BUN – 21Cr – 1.2Glu 110ALT 24AST – 27Total Chol 190CBC – WNLTheophylline – 6.2Phenytoin – 17Chest Xray Blunting of the right and left costophrenic anglesPeak Flow 75/min; after albuterol 102/minFEV1 1.8 L; FVC 3.0 L FEV1/FVC 60%Create a holistic 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 South University 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 and 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.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.
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