Description
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65 YO W.F Catholic Full code resides town house in SE Washington
Presented with cough for the past 4 days.
Past med hx: HTN, Systolic heart Failure, Chronic Renal Failure, Pulmonary Embolism, GERD, Breast
Cancer, dilated cardiomyopathy
Past Surgical Hx: Rt Mastectomy
Allergies: Sulfa, Robittusin
Home Meds: Warfarin, Pravachol, Lasix, ECASA, Ferrous sulfate,
Physical Exam:
Neuro: Alert, oriented to person, place, time. Clear speech. Anxious
CVS: heart s1 s2 no murmur, HR 116 regular BP 110/60 cap refill < 2 seconds, no peripheral
Edema. Saline lock line left hand
Resp: lungs scattered rhonchi throughout with crackles bibasilar. Cough productive white,
thick, unlabored resp, RR 22. Pulse oximeter 94% on oxygen 2l/min by nasal cannula
GI: Bowel sounds-normoactive , Abd soft, non-tender. Good oral intake, no BM
GU: Voiding freely
Muscskel: ambulatory, steady gait
Skin: No bruises, rashes. No skin breakdown
Admitting diagnosis: Acute Kidney Injury, Acute Bronchitis,
Hospital Medications: Duoneb, Solumedrol IV, Folic Acid, Ferrous sulfate, ECASA, warfarin,
Zofran, Azithromycin
BMP: Glucose 121, Na 137, Cl 98, K 2.8, HCO3 23, BUN 29, Creat 2.06
BNP: 144
CBC: WBC 15.1, Hgb 15.1, Hct, 30.3, Plat 265 INR – 2.7
Diagnostic Test:
EKG: Right Bundle Branch Block with acute T wave Changes
Chest Xray- No acute disease
Echocardiogram- ejection fraction 26%
Ct scan chest with contrast – mild atelectasis , no infiltrate
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Explanation & Answer
Attached.
Student Name: __________ Clinical Date: ______________
Primary Diagnosis:
Secondary Diagnosis:
Acute Bronchitis
Chronic Renal Failure
Supporting Signs & Symptoms:
Supporting Signs & Symptoms:
•
Lungs scattered
•
Shortness in breath
•
Thick, white cough
•
Reduced amount of urine
•
Unlabored respiration
•
Fatigue
•
Leg pain.
•
Leg pain.
Patient Data:
The patient white
female 69 year old
who resides in town
house S.E
Washington
Problem # :
Risk for infection
Patient goal:
The patient will have
normal laboratory
values.
Nursing Interventions:
Assess the cough
Nursing Interventions:
Assess the urine
Collaborative Interventions:
Obtain cough and urine
care consult, as indicated.
Outcome:
Outcome:
Outcome:
The patient's
laboratory values
have abnormal
limits.
The patient's
laboratory
values have
abnormal limits.
The patient's
laboratory values
have abnormal
limits.
Concept Map Presentation
Author
Institution
Course
April 27, 2020
Introduction
The care plan presentation is of a 65 year old white female living in SE
Washington.
...