INNA BRUSILOVSKAYA

S.O.A.P. note (RESPIRATORY LAB ASSIGNMENT)

S.

55 yrs. old male, reports cough x 5 days, shortness of breath, & increased sputum production, no fever Past Med. Hx.: Chronic bronchitis, increased shortness of breath over last 2 years No surgeries No known allergies Smokes cigarettes 1 pack a day/ 17 years Has stable & happy marriage Has 1 daughter & 1 son Medications: Theodur - 600 mg 2 x day for 2 years Terbutaline inhaler 4 puffs 3 x day & 1 x night

V.S.: BP- 130/77, HR- 100, RR- 36, TEMP- 37.3 C, Wt.- 175 lbs., Ht- 58 - Increased respiratory rate - Increased pulse - Numerous wheezing, rales and rhonchi (bilaterally) when listening his chest O. - All pulses palpate - When speaks, coughs with yellow sputum

Ineffective airway clearance r/t excessive thickened mucus secretion At risk for impaired gas exchange r/t ventilation-perfusion imbalance At risk for infection r/t chronic disease

A. Patient has chronic Bronchitis --- Smoking is the most likely etiology of it.

P.

Monitor- shortness of breath, sputum production, chest auscultation, pulse, blood pressure, respiration. Check with Doctor, maybe meds or inhaler should be changed/replaced with different one Assess his ability to use his inhaler correctly (& if any problems, correct them). Advise & refer him to stop smoking (give him information on sites & available programs for help) Teach him breathing exercises, & show him these techniques accurately.