Establish the pathophysiological triad

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Reference no: EM133847349

CLINICAL SCENARIO: NURSING HEALTH HISTORY

A. Patient's Profile Name: Patients HW Birthday: August 12, 1964 Age: 56 years old Sex: Male Nationality: Filipino Religion: Roman Catholic Marital Status: Married Address: Malanday , Valenzuela City Date of Admission: Time of admission: 8:00AM Chief Complaint: Severe productive cough Admitting Diagnosis: COPD History of Present Illness A 56-year-old man with a history of smoking rush to ER at FUMC with shortness of breath and cough for several days. His symptoms began 3 days ago with runny nose. He reports a chronic morning cough productive of white sputum, which has increased over the past 2 days. Past Medical History He has had similar episodes each time of raining season for the past 4 years. He always experiences fatigue, worsening cough, increased breathlessness and waking up in the morning with headache. Family History (+) Tuberculosis (+) Hypertension (-) Cancer Personal and Social History He has smoked 1 to 2 packs of cigarettes per day for 40 years and continues to smoke. He denies hemoptysis, chills, or weight loss and has not received any relief from over-the-counter cough preparations. Admission Order: NPO temporarily. Start IVF, PNSS 1L x KVO. Hook to O2 therapy via nasal cannula at 2-3LPM. Nebulization of Salbutamol + Ipratropium now, then every 6 hours. Acetylcysteine (Fluimucil) 400mg 1 sachet dissolved 1/2 of H2O every 6 hours, can be started tomorrow morning. Tazobac (Piperacillin sodium) 4.5 g thru soluset dissolved in PNSS 90 cc x 1hr OD ANST( ). For Chest x-ray,CBC, FBS, ECG, Urinalysis and ABG. Please do spirometry and monitor for disease progress. Chest x-ray shows hyperinflation and right lobe pneumonia. ABG results was Ph 7.24, PO2-35 mmHg, PCO2 60mmHg, HCO3 30, O2 sat - 85%. Spirometry with FEVI 35% predicted that does not change significantly after inhaled bronchodilators. ECG was ordered. Physical Examination: Took vital signs which are: BP: 130/80, T: 37.5 Celsius, PR:89, RR:30. Examination displayed tachypnea, respiratory distress, use of accessory muscles, and intercostal retraction. Barrel chest is a common observation. RLE TASK:

1. Conceptualize the pathophysiological alterations distinct to the case.

Establish the pathophysiological triad of Non modifiable risk factors

Patient - Modifiable Risk Factors specific to the case.

Trace the pathophysiological changes and highlight problems that are experienced by the client. Connect the pertinent nursing care and medical

- surgical management to the various signs and symptoms presented by the client.

Reference no: EM133847349

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