RUA Case Study Patient – Option #A
RUA Case Study Patient – Option #A -TC: COPD Exacerbation (Patient Case): T.C. is an 85 yr-old African American female admitted for COPD Exacerbation. Patient presented with worsening dyspnea and wheezing over the last 2 weeks, and productive cough. Patient regularly uses oxygen at home. Patient lives alone in an apartment on the 4th floor (no elevator in the building). Patients’ neighbor brought her into the ED when she noticed patient having trouble getting up the stairs to her apartment after going down to the first floor to do laundry. Patient has not really been able to get out of her house in the past 4 weeks to purchase goods including food, or to renew her prescriptions. Daily weights have been ordered. (Medical/Surgical History): COPD, Emphysema, Smoker x 50 years (still currently smoking ½ pack per day), Hypertension, Hyperlipidemia, Morbid Obesity, and Bilateral Knee Replacement. (Admission Vital Signs): T-38.4 C, Regular rhythm/HR-110, RR-25, SpO2-89% on 4L oxygen with nasal cannula, BP-185/92, weight 113.4 kg/250 lb, height-5’2″ (Physical Assessment): (Neuro) A/O x 4, (Respiratory) Crackles/Rhonchi in lung fields bilaterally with thick green sputum, (Cardiovascular) Irregular, S1 & S2 heard, (Integumentary) Stage II sacral ulcer & +3 pitting edema of lower extremities bilaterally, (GI) Active bowel sounds in all 4 quadrants/diarrhea x 4 days, (GU) new finding of urinary retention/it’s been 4 hours since she urinated, (Musculoskeletal) Generalized weakness/uses cane to ambulate to the toilet with 2- person assistance (Radiology Results): Chest x-ray shows diffuse opacities bilaterally (abnormal) (Lab Results): WBC 14.18, Hgb 8.5, Hct 29, Glucose 287, CO2 10 (Medication Orders): Prednisone 20 mg daily, Montelukast 10 mg daily, Aspirin 81 mg daily, Hydrochlorothiazide 25 mg BID, Symbicort 160 mcg 2 puffs BID, ProAir 1 puff q6hr PRN, Breo Ellipta 200/25 mcg 2 puffs daily GIVE THE FOLLOWING Assessment Highlight key areas of concern General appearance: Vitals: Neuro: HEENT: Cardiac: Respiratory: GI: GU/Elimination: Integumentary: Musculoskeletal: Psychosocial: Labs/Diagnostics: Pathophysiology (include what functional changes are occurring and what processes or issues initiated, lead, and are maintaining the disorder/disease) Pertinent Medical diagnoses/Reason for hospitalization: High priority NANDA diagnosis FOLLOW BY Short term (ST) goal: Long term (LT) goal: 3 ST interventions: 3 LT interventions: Evaluation: NANDA diagnosis FOLLOW BY Short term (ST) goal: Long term (LT) goal: 3 ST interventions: 3 LT interventions: Evaluation: Psychosocial NANDA diagnosis FOLLOW BY Short term (ST) goal: Long term (LT) goal: 3 ST interventions: 3 LT interventions: Evaluation: Give the following: Linkages and Rationale of Diagnosis (Short summary rationale for why these diagnosis were chosen and how they connect to the client’s current situation/condition) Rationale for why goals were selected (Should have a rationale for each short- and long-term goal. Provide references as applicable)
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