PATIENT INFORMATION MEDICAL

Initials:H.L. Age: 66 Gender: M Ethnicity: Hispanic Religion: Catholic Code Status: Full Code Medical Diagnosis: COPD
Occupation: Unknown
Pathophysiology
History of this hospitalization:
Social Factor: living at home with his children 66yo Hispanic male admitted due Disease 1: COPD
Spiritual Factor: Praying to COPD exacerbation. Patient has
Physical Factor: Stable
a cough that is prolonged with
Erickson’s Developmental Stage: Ego integrity vs despair, fulfilled *SEE ATTACHED
large amount of whitish sputum,
DOCUMENT*
SOB, and dyspnea. Admin O2
3L/min via nasal cannula.
ASSESSMENT
INTERPROFESSIONAL CARE
Past Medical Medications
History Collaborative Care Discharge Planning
 Albuterol (Proventil HFA) 2.5 mg/3ml) NEB-inhalation, HHN q6hrs
 COPD - Chronic  Ipatropium (Atrovent) 0.5 mg NEB-inhalation, HHN q6hr  Respiratory Therapist will assist  Safe Oxygen use at
Bronchitis  Azithromycin (Zithromax) 500 mg IV qDay with administering NEB- home.
inhalation medications and also  Take medications as
 Budesonide (Pulmicort) 0.5 mg, NEB-inhalation BID
helping patient cough and deep
 Ceftriaxone (Rocephin) 1000mg IV push, INJ q24hrs, dilute with 10 ml prescribed
breathe effectively to clear
sterile water. Give slowly over 3 minutes. airway.  Maintain a healthy diet.
 Enoxaparin (Lovenox) 40 mg SQ INJ qDay  Nutritionist: will provide diet  Follow up with PCP.
 Methylprednisolone (Solu-Medrol) 40 mg IV push INJ q8hrs regulated in sugars, rich in iron,  Abstain for smoking
vitamin C, protein, and enough  Effective airway
calories for patient to have clearance techniques and
Diagnostic Tests enough energy for muscles, to be
Risk Factors positions for better lung
- Na: 137 - ALT: 33 - Bilirubin: 0.5 able to breathe, help with RBC
 Tobacco smoking * (previous smoker) expansion.
- K: 4.0 - AST: 37. - Albumin: 4.0 and WBC production.
 Environmental tobacco smoke  How to conserve energy
- Cl: 101. - ALP: 123 - BUN: 8  Physician, RN, CNA, Pharmacy,
 Occupational exposure - Troponin: <0.01 - Glucose: 128 Laboratory, and Radiology while staying active.
 Alpha-1 antitrypsin deficiency - PTT: 32.7 - RBC: 4.04 -WBC: 11.0
 Age 40 + * - PT: 13.1. - Hemoglobin: 13.4 Safety Considerations Client Education
 Asthma - INR: 1.0. -Hematocrit 40.2 -Platelet: 208
- Microbiology/Serology: Influenza A & B  Keep O2 loose cords  Educate on how
- out of the way to avoid medications need to be
Objective/Subjective Data
falls. taken and why.
-Cough that won’t go away. * -Wheezing* Procedures/Surgical Interventions  Safe Oxygen  Educate on safe use of
-Coughing up a lot of phlegm* -Fatigue  Oxygen 3L/min via nasal cannula (Tx SOB, administration and O2 at home.
-Blue lips or fingernails(pale).* -Frequent colds
Dyspnea and O2 Saturation around 90’s) Safety with Oxygen at  Educate on
-Losing weight without trying. -SOB*
 XR Chest 1 view (r/o Cardiopulmonary home. maintaining a healthy
-Swollen feet, ankles, or legs
Disease)  S/S to look out for when diet and why.
-Having to clear your throat a lot*
going into COPD
-Chest tightness
exacerbation.

Planning/Goals Nursing Interventions Expected Outcomes/Evaluation

Priority NANDA(s)  Short: Pt will demonstrate improved ventilation  Nurse will monitor respiratory rate, depth, and ease  Goal met, patient demonstrated ventilation
- Impaired Gas Exchange r/t and adequate oxygenation as evidenced by O2 of respiration. Watch for use of accessory muscles improvement and adequate O2 saturation from
saturation > 94% parameters for pt. within shift. and nasal flaring and administer O2 as ordered, 90% to 95% with O2 administration.
ventilation prefusion imbalance
NURSING

 Long: Pt will maintain clear lung fields and remain
AEB dyspnea, nasal flaring, cough free of signs of respiratory distress
 Short: Maintain white blood cell count and
and SpO2 in the 90’s. differential within normal limits within 48 hours of
treatment initiation
 Long: Remain free from symptoms of infection
- Risk for infection r/t impaired during contact with health care providers until
discharge.
WBC count.
 Nurse will auscultate breath sounds every 1 to 2
hours.
 Nurse will administer antibiotic as ordered and
note &report laboratory values (e.g., white blood
cell count and differential, serum protein, serum
albumin, and cultures).
 Nurse will observe and report signs of infection
such as redness, warmth, discharge, and increased
body temperature.
 Goal met, patients’ lungs are clear and remains
free of signs of resp. distress.
 Goal met; patients WBC count is within normal
limits within 48 hrs. of treatment initiation with
antibiotic.
 Patient is free from symptoms of infection during
contact with health care providers until discharge.