Pneumonia Case DAR

D: Patient stated “I can’t breathe because of my cough”. She complained of continuous 8/10 “deep
chest discomfort” when coughing that aggravates with deep breathing and lying flat and gets better
when she is leaning forward or staying quiet. VS as follows 101.5F (oral), HR 106 bpm, RR 20, BP 166/78
(lying, R arm), and O2 saturation 88% on room air. Upon assessment, noted patient to be splinting her
left side with coughing. Skin color is flushed and warm to touch. Capillary refill delayed to 3seconds.
Alert, awake, and oriented x 3. Also noted small amount of thick yellowish expectorate. No use of
accessory muscles or retractions noted. Noted inspiratory crackles to the left lung base during
auscultation. Increased tactile fremitus noted to the LLL. Increased dullness noted to LLL during
percussion.

A: Elevated HOB for comfort and to expand lungs maximally. Administered O2 via nasal cannula at
2L/min. Encouraged the patient to continue with splinting her left side using pillow when coughing to
reduce pain with coughing. Encourage fluids of at least 500mL during shift to liquify secretions. Suction
as needed. Administered Avelox 400 mg by mouth for pneumonia. Continue with Robitussin 10 mL PO
Q4H PRN for cough. Encouraged the use of incentive spirometer with 1000mL as her baseline.

R: Re-assessed VS: 99.9 F (oral), HR 90 bpm, RR 18, BP 142/56 (lying, R arm), and O2 saturation 96% at
2L/min O2 via NC. Pain went down to 2/10 after interventions provided. Patient is sleeping without any
signs and symptoms of discomfort at this time. Continue with the plan of care.

Acute Exacerbation of Asthma DAR

D: Patient stated “my chest feels tight and I’ve been having non-productive cough and SOB”. She also
stated that her “wheezing keeps her awake at night for the past 2 days”. She complained of chest
tightness and rated her discomfort to 4/10 especially when she is exposed to tree pollen or dust mites
and it is usually relieved by her inhalers. Last time she used her Albuterol HFA is “about 4 hours ago”. VS
as follows 98.2 F (oral), HR 124 bpm, RR 32, BP 108/66 (sitting, R arm), and SpO2 84% on room air. Upon
assessment, she appeared pale, tired, and anxious. Lips and mucous membrane dry and pale. Capillary
refill time delayed to 3 seconds. Alert, awake, and oriented x 3. Noted use of accessory muscles of
breathing but without any intercostal retractions. Upon auscultation, noted bilateral coarse expiratory
wheezes throughout lung fields.

A: Maintained high fowler’s position for comfort and ease of breathing. Administered
Methylprednisolone IV and Ranitidine 150 mg PO for acute exacerbation of asthma. Administered
Albuterol via inhalation Q4H PRN for wheezing. Applied O2 at 3L/min via nasal cannula. Educated the
patient on avoiding the triggers to prevent further exacerbation of her asthma and to always carry her
rescue inhaler. Took 240mL of water for hydration.

R: Re-assessed VS: 98.1 F (oral), HR 80 bpm, RR 20, BP 112/69 (lying, R arm), and O2 saturation 96% at
3L/min O2 via NC. Lungs clear to auscultation. Patient stated, “I can breathe much better now”.