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Get Homework Help: A Sample Writing Guide

Sample Lab Report Paper on Respiratory Clinic Case Plan of Care

Respiratory Clinic Case Plan of Care

Patient Initials: CF

Subjective Data: CF is a Caucasian female aged 65. She was discharged from the hospital around ten weeks ago, where she had been admitted after being involved in a motor vehicle accident. CF visits the clinic and confirms symptoms, such as shortness of breath, severe wheezing, and coughing, at least once every day. On her visit to the clinic, CF also states that she can hardly speak without breaks to catch her breath. She further confirms having taken albuterol once on the day of her visit to the clinic.

Chief Complaint: CF’s chief complaint is her symptoms, including shortness of breath, severe wheezing, and coughing at least once every day.

History of Present Illness: CF, a Caucasian female, reports having experienced frequent asthma attacks over the past two months. She also reports having experienced other serious health complications, including serious MVA that occurred ten weeks ago and post-traumatic seizure that occurred a week after the accident. CF also reports that she started anticonvulsant phenytoin and confirms no seizure activity since the therapy was initiated.

PMH/Medical/Surgical History: CF reports having a history of asthma attacks since her early 20s. She also states that she was diagnosed with mild congestive heart failure around three years ago. CF adds that she was placed on a sodium restrictive diet and hydrochlorothiazide. She confirms her placement on enalapril last year because of the worsening CHF. However, the symptoms have been under control in the past year.

When it comes to medication, CF has been on Theophylline SR Capsules 300 mg PO BID meant for seizure; Albuterol inhaler, PRN for asthma; Phenytoin SR capsules 300 mg PO QHS for seizure; HTCZ 50 mg PO BID for heart failure; and Enalapril 5 mg PO BID for congestive heart failure.

Significant Family History: CF reports that she lost her father at the age of 59 to kidney failure secondary to hypertension and her mother at the age of 62 to congestive heart failure.

Social History: CF confirms that she is a nonsmoker. She confirms that she does not use alcohol but uses caffeine, which she drinks 4 cups of coffee and four diet colas every day.

Review of Symptoms: CF confirms positivity for shortness of breath, severe coughing, exercise intolerance, and wheezing. However, she denies experiencing headaches, seizures, and swelling in the extremities.

·       General: CF denies experiencing general weakness, fatigue, night sweats, weight loss, fever, and chills.

·       Integumentary: CF denies experiencing itching, non-healing wounds, ulcers, new or changing moles, lumps, discoloration, or rashes.

·       Eyes: CF denies experiencing glaucoma, cataracts, macular degeneration, vision change or vision loss, contacts, redness, pain, or double vision.

·       ENT: CF denies experiencing changes in hearing, discharge, or pain. CF denies experiencing changes in voice, sore throat, congestion in the throat, runny nose, mouth sore, bleeding gums, or swelling.

·       Cardiovascular: CF denies experiences swelling or cramping of the legs, palpitations, chest pain or discomfort, tightness of the chest, difficulty in breathing when lying down, or awakening from sleep during the night.

·       Respiratory: CF reports experiencing shortness of breath, coughing, and wheezing. However, she denies having phlegm, hemoptysis, or experiencing painful breathing.

·       Gastrointestinal: CF denies experiencing problems when swallowing. She also denies experiencing changes in her appetitive, nausea, indigestion, heartburn, constipation, hemorrhoids, diarrhea, or having blood in her stool.

·       Genitourinary: CF denies experiencing pain in the vagina. She also denies experiencing vaginal discharge, urine frequency, incontinence, urgency, or hematuria.

·       Musculoskeletal: CF denies experiencing joint or muscle pain, fracture, stiffness or pain in her back, or redness/swelling of joints.

·       Neurological: CF reports positivity for head injury and seizures. However, she denies experiencing tremors, falls, headaches, or dizziness.

·       Endocrine and Hematologic: CF confirms having a history of anemia and blood transfusions. However, she denies experiencing frequent urination or hunger, excessive sweating, enlarged glands, cancer, or easy bleeding.

·       Psychologic: CF denies having a decreased interest in activities and experiencing nervousness. She also denies having a feeling of hopelessness, anxiety, depression, or stress.

Objective Data:

Vital Signs: A physical examination reveals that CF has BP of 171/94; HR of 122; RR of 31; T of 96.7 F; Wt of 145; height of 5’ 3”; and BMI of 25.7. After Albuterol breathing treatment, the vital signs include a BP of 134/79; HR of 80; and RR of 18.

Physical Assessment Findings:

HEENT:

·       Head/neck- CF has intact head and neck with no cervical lymphadenopathy; no nodule or thyromegaly. The patient demonstrates full ROM.

·       Eyes- CF has no sclera infections or conjunctiva.

·       Ears- There are no signs of inflammation. CF has a positive light reflex.

·       Nose- CF's nose is pink and moist, and she has no septal deviation.

·       Throat- CF's oral mucosa is intact, and her pharynx does not have erythematous and has no exudate.

Lymph Nodes: CF’s lymph nodes are non-palpable.

Carotids: CF’s does not experience distention.

Lungs: CF experiences labored breathing, coughing, bilateral expiratory wheezing, and dyspnea.

Heart: CF experiences normal sinus rhythm. There are no extra heart sounds or murmurs. Absence of jugular vein distention.

Abdomen: CF experiences bowel sounds in all four quadrants.

Genital/Pelvic: Unremarkable.

Extremities/Pulses: Right ankle edema. Pulse 3+

Neurologic: The patient is alert and oriented. The patient answers questions appropriately.

Laboratory and Diagnostic Test Results: CF lab and diagnostic testing reveals Na- 134; K- 4.9; CI-100; BUN- 21; Cr- 1.2; Glu-100; ALT-24; AST-27; total Cholesterol-190; CBC-WNL; Theophylline-6.2; Phenytoin-17; chest X-ray-blunting of the right and left costophrenic angles; peak flow-75/min and after albuterol-102/min. Moreover, the test results reveal FEV1-1.8 L; FVC 3.0L; FEV1/FVC 60%.

Assessment:

Three priority diagnoses for this patient in order of priority are as follows:

1.     J45.41

Moderate persistent asthma with acute exacerbation

2.     I50.43

Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure.

3.     J44.9

Chronic obstructive pulmonary disease (COPD)

Plan of Care:

1.     J45.41- Moderate persistent asthma with acute exacerbation

·       Education- Educating patients on how to recognize and avoid triggers or factors that can result in tightening of the airway, which can not only be life-threatening but also lead to an asthma attack, respiratory distress, or death (WHO, 2017).

·       Goals- The goal is the identification of risk factors for asthma attacks.

·       Instructions/Interventions- There is a need to avoid stressful situations; avoid pollutants and allergens; use medications as directed; and monitor the heart rate and blood pressure during exercise.

·       Review/Evaluation- There is a need to monitor and record breathing effort both before and after treatment.

2.     I50.43- Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure.

·       Education- Educating the patient on factors that cause heart failure and how to avoid triggers or factors that cause heart failure (Dasgupta et al., 2014).

·       Goals- The goal is to ensure that the patient maintains a healthy diet; is involved in 30 minutes of exercise every day; reduces BMI from 25.7; maintains a blood pressure of less than 130/80mm Hg.

·       Instructions/Interventions- Some interventions include reducing every day's stress; monitoring weight; limiting fluid intake; reducing potassium intake (Dasgupta et al., 2014).

·       Review/Evaluation- There is a need to track heart failure and other symptoms.

3.     J44.9- Chronic obstructive pulmonary disease (COPD) (unspecified)

·       Education- Educate patient on triggers or factors causing COPD.

·       Goals- The goal is to minimize symptoms of COPD and improve lung function, and control cough.

·       Instructions/Interventions- Some interventions include avoiding risk factors, such as air pollutants, cigarette smoking, poor nutrition, and crowded places (Boardman, 2013).

·       Review/Evaluation- There is a need to follow up with pulmonology for a review of the plan of care and evaluation of recordings.

References

Boardman, M. B. (2013). Chronic obstructive pulmonary disease. In Primary care (4th Ed.), pp. 445-454.

Dasgupta, K., Quinn, R. R., Zarnke, K. B., Rabi, D. M., Ravani, P., Daskalopoulou, S. S., ... & Canadian Hypertension Education Program. (2014). The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Canadian Journal of Cardiology30(5), 485-501. https://doi.org/10.1016/j.cjca.2014.02.002

World Health Organization (WHO). (2017). 10 Facts on asthma. Fact file. Retrieved from http://www.who.int/features/factfiles/asthma/asthma_facts/en.html

 

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