Student name: 	Paula Ridl				Date of Care:		3/27/12	38/40
History of Present Illness (HPI)
Patient Initials: 	CE	  Pt Age: 71	  Gender:__F___   Date of Admission: 	3/25/12	
Review the last 24 hours of nursing notes and the admitting physician’s history and physical exam to answer the items below, summarize the notes you read in your own words. 

Tell the story of how your patient ended up in the hospital:   (1pt)
71 year old female entered the ED from home with respiratory distress noted as exacerbation of COPD with bronchitis.  She has had recurrent hospitalizations for same.  She is a heavy smoker, and her home environment contains other smokers along with multiple animals including cats.  She entered with BP 128/73, mild tachypnea, O2 nasal cannula, K+ 3.2 and not hearing well.

Medical & Surgical history (list the year of the diagnosis/ surgery)   (1 pt)
Years for medical and surgical history not listed.
Cholecystectomy	CHF			C-section		HOH
COPD			Emphysema		Hysterectomy		Bronchitis
HTN			Anxiety		Arthritis

Social History   (1pt)
Occupation:  Retired
Lives with? Daughter, Son-in-law and granddaughter and great granddaughter and 3 dogs
List family members involved with your patient’s care.  Daughter
Habits (Tobacco/Alcohol/ Drugs)
Heavy Smoker
No Alcohol
No Drugs

Nursing Care:    (1 pt)
Isolation  None
Code Status:  Full or DNR
Pain  0
Fall Risk 3
Hygiene Moderate Asisstance
Activity  Independent
Diet  2000 calorie 
List the equipment that is needed or being used to care for this patient?  (e.g. IV, Foley, Oxygen…)
Indwelling Foley Catheter, Hep Lock, Oxygen – nasal cannula 3.5L
Pathophysiology:

Identify the primary disease(s) that will be explained in this paper.    (1pt)
COPD

Describe the pathology of this disease; include any causative factors/ etiologies that can be identified  
(5 pts).
Chronic obstructive pulmonary disease (COPD) is considered a group of respiratory disorders that are categorized by chronic and recurrent obstruction of the flow of air in the pulmonary airways.  The obstruction is usually advancing gradually, may be supplemented by airway hyper reactivity, and may be partly rescindable.  A history of smoking is the most common cause of COPD.  Other causes can include exposure to dust on the job, chemicals, airway infections, and asthma.  Early diagnosis may prevent or delay the diseases’ advancement, but symptoms are usually not identified until the disease is much advanced.  COPD includes emphysema which is the destruction of lung tissue due to enlargement of alveoli, and these patients are referred to as pink puffers. They are referred to as pink puffers because of the lack of cyanosis, pursed-lip breathing, and the use of breathing accessory muscles.  COPD also includes chronic obstructive bronchitis which is increased mucus, small airway obstruction, and chronic productive cough, and these patients are referred to as blue bloaters.  They are referred to as blue bloaters because of the presence of cyanosis and the fluid retention that is associated with right sided heart failure.   Most patients with COPD have overlapping symptoms of both emphysema and chronic bronchitis. COPD decreases gas exchange in the lungs, decreases ventilation, and perfusion.  Patients present with symptoms such as fatigue, exercise intolerance, cough, sputum production, or shortness of breath.  Late stages of COPD are characterized by recurrent respiratory infections and chronic respiratory failure which can end with death (Porth, 2011).

What laboratory tests and diagnostics are used to diagnose this pathology, identify below which ones your patient has done and relate the results to the pathology. (5pts)
Laboratory Testing
     Hematology Value	Normal	If not, why?  Please relate to the disease process
	WBC	6.3	4.5-11
	RBC	3.7	4.1-5.1		Excess Fluid Volume HTN and edema
	Hgb	11.2L 	12-16		Excess Fluid Volume HTN and edema
	HCT	32.3L	36-46		Excess Fluid Volume HTN and edema
PLT	134 L	150-450	Excess Fluid Volume HTN and edema
INR	
     Chemistry	Value	Normal	If not, why not?  Please relate to the disease process.
	Na	139	135-145
	K	3.3L	3.4-4.5		furosemide for HTN
	Cl	99	98-107
	BUN	28H	6-26		Nephrotoxic drugs - Motrin
	Cr	1.1H	0.5-1.0		Nephrotoxic drugs - Motrin
	Glucose  129H	70-99		Infection – Sputum green and yellow
	Other
    Urinalysis

Diagnostic Imaging:
a.	In your own words why is this test done- relate it to the pathology
b.	If abnormal, what changes in your nursing care need to be made?
     Chest X-ray: Heart Size is normal, trachea is midline, no active lung disease
     ECG / Telemetry:  sinus tachycardia with 2nd degree AV block with occasional and consecutive premature ventricular complexes; low voltage QRS, ST&T wave abnormality
     CT (Cat Scan) 
     MRI
     Ultra Sound
     Other:

Medications
List all medications your patient has used in the last 24 hours including: 
1.	Medication name (generic) with prescribed dose & frequency, 
2.	The usual dose & frequency, 
3.	Classification & mechanism of action, 
4.	Why this medication is being used for this patient, 
5.	What nursing precautions considerations do you need to know to SAFELY administer / monitor this medications and lastly 
6.	Evaluate the medications effectiveness for this patient (patient response).  (10 pts)

Name (generic) 
prescribed dose 
& frequency, 
usual dose & frequency	Classification/
Mechanism 
of action	Why use this 
medication 
for this 
patient?	Nursing precautions/ 
safety considerations
To administer this medication	Evaluation
Patient response	
Pepcid (famotidine) 40 mg QAM PO/40 mg day at bedtime	Histamine H2 Antagonists/
Competes and inhibits histamine at histamine H2 receptor site, decreasing gastric secretion while pepsin remains at a stable level	GI disorders from NSAID use for arthritis or to counteract increased gastric acid from albuterol	Pregnancy (B), breastfeeding, children < 12 yr, geriatric patients, severe renal/hepatic disease, hypersensitivity/
Seizures, dysrhythmias, thrombocytopenia, aplastic anemia, toxic epidermal necrolysis, Stevens-Johnson syndrome, pneumonia	Patient tolerated drug	
Proventil (albuterol sulfate) 2.5 mg/0.5 ml vial
2.5 mg RT Q4H NEB/2.5 mg TID-QID NEB	Beta Adrenergic Agonists/Causes bronchodilation on B2 pulmonary receptors by increasing levels of cAMP which relaxes smooth muscle, produces bronchodilation, CNS, cardiac stimulation, increased diuresis and gastric acid secretion	COPD, Emphysema, Bronchitis	Pregnancy (C), breastfeeding, cardiac/renal disease, hyperthyroidism, diabetes mellitus, hypertension, prostatic hypertrophy, angle-closure glaucoma, seizures, exercise-induced bronchospasm in children <12 yr, hypoglycemia/Tremors, anxiety restlessness, bronchospasm	Patient tolerated drug
Respirations 16/min after NEB treatment 
Pepcid given to counteract adverse effects of increased gastric acid	
Atrovent INH Soln (iptratropium bromide) 2.5 ml RT Q4H NEB/250-500 mcg given 3-4x/day	Antimuscarinics/
Antispasmodics Anticholinergic Agents/Inhibits interaction of acetylcholine at receptor sites on the bronchial smooth muscle resulting in decreased cGMP and bronchodilation	COPD	Pregnancy (B), hypersensitivity to this product, atropine, bromide, soybean or peanuts products, breastfeeding, children <12 yr., angioedema, heart failure, hepatic disease, hyperkalemia, hypotension, hypovolemia	Patient tolerated drug
Respirations 16/min after NEB treatment	
Sodium chloride
Flush IV line w/3ml As directed PRN INJ 	Replacement Preparations, Irrigating solutions/Source of water and electrolyte	Hep Lock Flush	Pregnancy (C), Hypertonic solution may cause vein damage/Phlebitis, extravasation, disseminated intravascular coagulation	Patient tolerated drug	
Allegra (fexofenadine HCl) 60 mg QAM PO/ 60 mg BID	2nd Generation Antihistamines/Acts on blood vessels, GI, respiratory system by competing with histamine for H1 receptor site; decreases allergic response by blocking pharmacologic effects of histamine, less sedating	Allergies	Pregnancy (C), children, geriatric patients, respiratory disease, closed-angle glaucoma, prostatic hypertrophy, bladder neck obstruction, asthma/
Dysrhythmias, hemolytic anemia, thrombocytopenia, leukopenia, agranulocytosis, pancytopenia, thickening of bronchial secretions	Patient tolerated drug	
Flagyl (metronidazole) 500 mg BID PO/ 	Anti-infectives, Misc, Local Anti-Infectives, Misc/ Direct acting amebicide/trichomonacide binds, disrupts DNA structure inhibiting bacterial nucleic acid synthesis	COPD	Pregnancy (B), 2nd/3rd trimesters, geriatric patients, Candida infections, heart failure, fungal infection, dental disease, bone marrow suppression, hematologic disease/seizures, pseudomembranous colitis, albuminuria, neurotoxicity, leukopenia, bone marrow depress, aplasia	Patient tolerated drug
WBC 6.3	
Tylenol (acetaminophen) 650 mg Q4H PRN PO/325-650 mg Q4-6HR PRN max 4 g/day	Analgesics & Antipyretics, Misc/May block pain impulses peripherally that occur in response to inhibition of prostaglandin synthesis; antipyretic action results from inhibition of prostaglandins in the CNS	Pain or Fever	Pregnancy (B), breastfeeding, geriatric patients, anemia, renal/hepatic disease, chronic alcoholism/
Hepatotoxicity, hepatic seizure, GI bleeding, renal failure, leukopenia, neutropenia, hemolytic anemia, thrombocytopenia, pancytopenia	Drug not given	
Motrin (ibuprofen) 800 mg TID meals PO/300-800 mg TID-QID	NSAID Agent/Inhibits prostaglandin synthesis by decreasing enzyme needed for biosynthesis	Arthritis	Pregnancy (B), 1st and 2nd trimesters, breastfeeding, children, geriatric patients, bleeding disorders, GI disorders, cardiac disorders, hypersensitivity to other anti-inflammatory agents, CHF, CCr<25 ml/min/CV thrombotic events, MI, stroke, hepatitis, GI bleeding, ulceration, necrotizing enterocolitis, GI perforation, nephrotoxicity, blood dyscrasias, necrotizing fasciitis, anaphylaxis, Stevens-Johnson syndrome	Patient tolerated drug/
Pepcid given to counteract adverse effects of GI	
K-Dur (potassium chloride) 10 mEQ BID Meals PO/40-100 mEq in divided doses TID-QID	Replacement Preparations Salt & Sugar Substitutes/ Needed for adequate transmission of nerve impulses and cardiac contraction, renal function, intracellular ion maintenance	Hypokalemia 	Pegnancy (C), cardiac disease, potassium-sparing diuretic therapy, systemic acidosis/cardiac depression, dysrhythmias, arrest, peaking T waves, lowered R and depressed RST, prolonged P-R interval, widened QRS complex	Patient tolerated drug
K+ 3.3	
Advair Diskus 100/50 mcg 14 doses (fluticasone/
salmeterol) 1 inhalation BID INH/100 mcg BID	Beta Adrenergic Agonists Anti-inflammatory Agents/
Decreases inflammation by inhibiting mast cells, macrophages, and leukotrienes; anti-inflammatory and vasoconstrictor properties	COPD	Pregnancy (C), breastfeeding, active infections, glaucoma, diabetes, immunocompromised patients/eosinophilic conditions, angioedema, Churg-Strauss syndrome, bronchospasm	Not administered discontinued	
Lopressor (metoprolol tartrate) 25 mg BID PO/ 50 mg BID	Beta-Adrenergic Blocking Agents/Lowers BP by B blocking effects; reduces elevated renin plasma levels; blocks B2 adrenergic receptors in bronchial, vascular smooth muscle only at high doses, negative chronotropic effect	HTN	Pregnancy (C), breastfeeding, geriatric patients, major surgery, DM, thyroid/renal/hepatic disease, COPD, CAD, nonallergic bronchospasm, CHF, bronchial asthma, CVA, children, depression vasospastic angina, abrupt discontinuation, heart block 2nd, 3rd degree, sinus bradycardia/
Bradycardia, cardiac arrest, AV block, pulmonary/peripheral edema, chest pain, agranulocytosis, eosinophilia, thrombocytopenia, purpura, bronchospasm	Patient had 2nd degree heart block questioned nurse about drug	
Calan-Sr Caplet (verapamil HCl) 120 mg BID PO/ 120-240 mg/day as single dose	Dihydropyridine Calcium channel blocker/Inhibits calcium ion influx across cell membrane during cardia depolarization; produces relaxation of coronary vascular smooth muscle; dilates coronary arteris; decreases Sa/AV node conduction;delates peripheral arteries	HTN	Pregnancy (C), breastfeeding, 2nd 3rd degree heart block, children, geriatric patients, CHF, hypotension, hepatic injury renal disease, concomitant B blocker therapy/CHF, dysrhythmias, Stevens-Johnson syndrome	Patient had 2nd degree heart block questioned nurse about drug	
Mucinex DM (guaifenesin/
Dextromethorphan) 2 tablets TID PO/200-400 mg Q4HR 	Antitussives/Increases the volume and reduces viscosity of secretions in the trachea and bronchi to facilitate secretion removal	COPD
Secretions	Pregnancy (C), breastfeeding, CHF, asthma, emphysema, fever/nausea, vomiting, diarrhea	Patient tolerated drug
Spitting up secretions green and yellow colored	
Theo-Dur (theophylline) 300 mg BID PO/ 10 mg/kg/day in divided doses Q1-8HR max 300 mg/day	Respiratory Smooth Muscle Relaxant/Relaxes smooth muscle of respiratory system by blocking phophodiesterase, which increase cAMP, exact action unknown	COPD, Emphysema	Pregnancy (C), children, geriatric patients, CHF, cor pulmonal, hepatic disease, active peptic ulcer disease, DM, hyperthyroidism, HTN, seizure disorder/seizures, dysrhythmias	Patient tolerated drug	
Solu-Medrol
(methylprednisolone)
Q8H IV/40-80 mg/day	Adrenals/Decreases inflammation by suppression of migration of polymorphonuclear leukocytes, fibroblasts; reversal of increased capillary permeability and lysosomal stabilization	COPD	Pregnancy (C), breastfeeding, DM, glaucoma, osteoporosis, seizure disorders, ulcerative colitis, CHF, myasthenia gravis, renal disease, esophagitis, peptic ulcer, tartrazine, benzyl alcohol, corticosteroid hypersensitivity, viral infection, TB, traumatic brain injury/circulatory collapse, thrombophlebitis, embolism, GI hemorrhage, thrombocytopenia	Patient tolerated drug
K+ 3.3	
Levaquin
(levofloxacin)
250 mg daily at 0600 PO/500 mg Q24HR x 7 days	Quinolones Anti-Infectives, Misc/Interferes with conversion of intermediate DNA fragments into high molecular weight DNA in bacteria	Bronchitis	Pregnancy (C), breastfeeding, children, photosensitivity/
Pseudomembranous colitis, hepatotoxicity, hemolytic anemia, epidermal necrolysis, tendon rupture, anaphylaxis, multisystem organ failure, Stevens-Johnson Syndrome	Patient tolerated drug	
Lasix (furosemide)
40 mg BID/20-80 mg/day 	Loop Diuretic/Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle	HTN & edema	Pregnancy (C), DM, dehydration, severe renal disease, cirrhosis, ascites/circulatory collapse, renal failure, thrombocytopenia, agranulocytosis, leukopenia, neutropenia, anemia, Stevens-Johnson Syndrome	Patient tolerated drug
K+ 3.3	
("Mosby’s," 2011)

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (Use Taylor Chapter 25 & N201 materials as resources)  (5 pts)     All subjective 
& objective data is collected and recorded using appropriate terminology. Data not collected or requiring elaboration is explained in the blank spaces.  
Pulse Ox %: 97%
3.5L nasal cannula	BP:  124/70
Right forearm	Pulse:  74
Rate:  74
Rhythm: Irregular	Respirations: 16
Rate: 16
Rhythm: pursed lip breathing?	Temp:  97.1

Route: Oral	Pain:
Rating:     0    /10    Characteristics:          	Ht: ____68”_____
Wt: __130.351 kg___	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Oriented X3
Speech is clear and loud, HOH, glasses

MAE = moves all extremities	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength
ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score_____3_________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	
Complete Bedrest
Full ROM in arms and legs
Grasps equal bilaterally
Moderate Assistance
	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: ____<3 sec_____
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema______legs______________	 
Point of maximal impulse is tapping 7 cm lateral to the midsternal line in the 5th intercostal space
S1, S2 present
Heart Rate is 74    	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	Thorax symmetric with equal expansion
Lungs – Diminished breath sounds with wheezing bronchovesicular

GASTROINTESTINAL:
Diet at home : eats whatever she wants  Current Diet:2000 calorie cardiac diet   
Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________	Abdomen is rounded with active bowel sounds x4
Soft non tender; no masses, no pain
2000 calorie cardiac diet
Last BM 5 days ago
Incision scar on RUQ – cholecystectomy
Incision scar vertical through umbilicus – hysterectomy and c section	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: ____14_____
Drains present:  Y         N       Type_______________	Color consistent with ethnic background, skin warm and moist, #22 LAC
Nails without clubbing or cyanosis
No suspicious nevi
No rash, or petechiae, Echymoses present on both arms
Pallor around lips and around eyes, dark circles around eyes	
EENT: 
Ears:   HOH                  Eyes: Glasses
Nose:                          Teeth:   Dentures        	Hearing Aid and glasses at home
Upper and lower dentures
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type__Indwelling Foley___________	Urine dark yellow, clear, no sediment, no pain

	
PSYCHOSOCIAL/CULTURAL:
Educational level
Developmental level       
Coping methods          
Health Beliefs
Occupation (previous if retired)
Religion & what it means to pt.
Personal/Family Data    (Think about home environment, family structure, and available family support)	
Educational level - 2 years high school

Coping methods - yell and her dogs

Occupation before retirement – Janitor at Danville High School
Religion – Protestant
Family – Daughter, son-in-law, granddaughter, great granddaughter and 3 dogs	
USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

Other: Priority Nursing Diagnosis: (Use NANDA format) (2pts)
Impaired gas exchange related to altered oxygen supply as evidenced by pursed lipped breathing, diminished lung sounds, wheezing, coughing, sputum, O2 nasal cannula, and patient’s position while breathing (leaning forward).
(Swearingen, 2008)

What does the patient/client need to accomplish?
GOALS/OUTCOMES
(2pts)
Measurable patient centered goals are identified, realistic and contain a time element.
	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions
(2pts)
Specific nursing actions can easily be linked to the outcomes.  The interventions are realistic and appropriate to the patient's current status.	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format
(2pts)
Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.  Citation is provided.	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response 
(2pts)
Includes all the following: 
1.Client’s response to the intervention(s),
 2. Status of goals and outcomes, (ie goal met, in progress or revised) 
3. Modifications to the plan of care.	
Patient to have adequate gas exchange after bronchodilator and steroid treatments

	Check vital signs after bronchodialtor treatments

Administer Steroids as prescribed	Brochodilators open airways by relaxing smooth muscles of the airways 
Steroid therapy may decrease airway obstruction, decrease inflammation, and improve dyspnea
(Swearingen, 2008)
	Patient met goal
Respirations 16/min

Reference List for all references used in this document.     Use APA format.          (1 pts)	

References
Skidmore, L. (Ed.). (2011). In Mosby’s nursing drug reference (24th ed.). St. Louis, MO: Elsevier Mosby.
Porth, C. M. (2011). Essentials of pathophysiology (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Swearingen, P. L. (2008). All in one care planning resource (2nd ed.). St. Louis, MO: Mosby Elsevier.