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Medical Surgical Nursing Chief Complaint: Severe productive cough Admitting Diagnosis: COPD History of Present Illness A...

Medical Surgical Nursing

Chief Complaint: Severe productive cough
Admitting Diagnosis: COPD

History of Present Illness
A 56-year-old man with a history of smoking rush to ER with shortness of breathandcough for several days. His symptoms began 3 days ago with runny nose. He reports a chronic morning cough productive of white sputum, which has increased over the past 2 days.

Past Medical History
He has had similar episodes each time of raining season for the past 4 years. Healwaysexperiences fatigue, worsening cough, increased breathlessness and waking up inthemorningwith headache.

Family History
(+) Tuberculosis
(+) Hypertension
(-) Cancer

Personal and Social History
He has smoked 1 to 2 packs of cigarettes per day for 40 years and continues tosmoke. Hedenies hemoptysis, chills, or weight loss and has not received any relief fromover-the-countercough preparations. Admission Order:
NPO temporarily. Start IVF, PNSS 1L x KVO. Hook to O2 therapy via nasal cannulaat 2-3LPM.Nebulization of Salbutamol + Ipratropium now, then every 6 hours. Acetylcysteine(Fluimucil)400mg 1 sachet dissolved 1/2 of H2O every 6 hours, can be started tomorrowmorning. Tazobac(Piperacillin sodium) 4.5 g thru soluset dissolved in PNSS 90 cc x 1hr ODANST( ). For Chestx-ray,CBC, FBS, ECG, Urinalysis and ABG. Please do spirometry and monitor for diseaseprogress. Chest x-ray shows hyperinflation and right lobe pneumonia. ABGresults wasPh7.24,PO2-35 mmHg, PCO2 60mmHg, HCO3 30, O2 sat - 85%. Spirometry with FEVI 35%predictedthat does not change significantly after inhaled bronchodilators. ECG was ordered.

Took vital signs which are: BP: 130/80, T: 37.5 Celsius, PR:89, RR:30.
Examination displayed tachypnea, respiratory distress, use of accessory muscles, and intercostal retraction. Barrel chest is a common observation.

1. Make a nursing care plan (ADPIRE) based on your assessment that needs to prioritize.


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Nightingale answered 1 year ago
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