Patient Setting:

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.

HPI

Frequent 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.

 

PMH

History 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 History

None

 

Family/Social History

Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF

Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.

 

Medication History

Theophylline SR Capsules 300 mg PO BID

Albuterol inhaler, PRN

Phenytoin SR capsules 300 mg PO QHS

HTCZ 50 mg PO BID

Enalapril 5 mg PO BID

Allergies

NKDA

ROS

Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.

Physical exam

BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”

VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18

Gen: 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 Testing

Na – 134

K – 4.9

Cl – 100

BUN – 21

Cr – 1.2

Glu – 110

ALT – 24

AST – 27

Total Chol – 190

CBC – WNL

Theophylline – 6.2

Phenytoin – 17

Chest Xray – Blunting of the right and left costophrenic angles

Peak Flow – 75/min; after albuterol – 102/min

 

FEV1 – 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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