Name: PLETE, ANGELINE Date: September 3, 2021

Course & Section: BSN 3-A

F.T. is a 70-yr-old black man who comes to the emergency department (ED) with nausea, fatigue,
and increased shortness of breath, which started 3 days ago. He says that he started using his
albuterol inhaler every 4 hours 2 days ago, and while it worked initially, it is no longer helping. He
can walk only a few feet in his apartment before he becomes short of breath. He sleeps in a
recliner in the living room. He has noticed some swelling to his hands and feet and has been
having trouble urinating.

Other Pertinent Informations:

SUBJECTIVE
 Nausea
 Fatigue
 Increased shortness of breath
 Swelling
 Trouble Urinating

 HEALTH PERCEPTION-HEALTH MANAGEMENT

 States he manages his COPD well with the use of Advair inhaler and albuterol inhaler. He
thinks he caught a cold from his granddaughter last week. Increasing difficulty breathing,
even with albuterol. Has a history of 30 pack-years of smoking, quitting 5 years ago.
 NUTRITIONAL-METABOLIC
 Eating and drinking very little over past 2 to 3 days.
 ELIMINATION
  Voiding small amounts of dark, concentrated urine (mostly at night).
 ACTIVITY-EXERCISE
 At present, cannot walk 100 feet without feeling short of breath. Cannot walk up 1 flight
of stairs (21 steps) to get in or out of his apartment without stopping to catch his breath.
 SLEEP-REST
 Difficulty sleeping. Last night he slept upright in his recliner.
 COGNITIVE-PERCEPTUAL
 Denies any pain associated with shortness of breath. Feels slightly irritable because of
lack of sleep.
 SELF-PERCEPTION-SELF-CONCEPT
 Uses O2 @ 3L/min via nasal cannula at home for the past 10 years.
 COPING-STRESS TOLERANCE
 Does not know how he will manage to get groceries or clean his apartment. His daughter
lives an hour away and has 3 children in school.
 MEDICATION
 Metoprolol (Toprol XL) 50 mg daily PO, furosemide 20 mg PO daily, finasteride (Proscar)
5 mg/day PO, Advair inhaler (fluticasone and salmeterol) 2 puffs twice daily, and
albuterol inhaler 2 puffs every 4hr PRN.
 GENETIC RISK ALERT
 COPD, hypertension, heart failure, benign prostatic hyperplasia. No history of allergies.

Instructions:
1.) Arrange the following Assessment findings and Relevant information, to include 11
functional problems filling out the Subjective Health History Respiratory Assessment of
your Patient

Determining a patient’s needs related to the respiratory system requires an accurate

health history and a thorough physical examination. Perform a respiratory assessment as
part of a comprehensive focused respiratory examination and Health History . Use
judgment in determining whether all or part of the history and physical examination will
be completed, based on your immediate assessment of the patient’s degree of respiratory
distress. If respiratory distress is severe, only obtain pertinent information and defer a
thorough assessment until the patient’s condition stabilizes.