Joan Walker is an 84 year old female who has a productive cough of green phlegm that started four days ago that persists. She

Case Scenario.

Joan Walker is an 84 year old female who has a productive cough of green phlegm that started four days ago that persists. She was started three days ago on prednisone 40mg PO daily and zithromycin 250mg PO x5 dats by her clinic physician. Though she has had intermittent chills, she had a fever last night of 102.0F/38.9 C. 

She has had more difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours wt no improvement. So she called 911 and was brought to the emergency department where you are the nurse who will be responsible for her care. 

Vital signs

Temperature: 103.2F/39.6C oral

Pulse: 110(regular)

Respiratory: 30 (Labored)

Blood Pressure: 178/96

02 saturation: 86% Liters N/C

Nursing Assessment: 

General Appearance:

Appears anxious and distress barrel chest present

Respiratory:

Dyspnea with use of accessory muscles breathe sounds very diminished bilaterally ant/post with scattered expiratory wheezing.

Cardiac:

Pale, hot and dry no edema heart sounds regular S1S pulse strong equal with palpation at radial/pedal/post tibial landmarks

Neuro:

Alert and oriented to person place time and situation x4

GI:

Abdomen soft nontender, bowel sounds audible for auscultation in all four quadrants. 

GU:

Voiding without difficulty urine clear/yellow

Skin:

Skin integrity intact, skin turgor elastic, no tenting present. 

Diagnostic Data

Basic Metabolic Panel

Current                                         Most Recent

Na                       138                                                142

K                          3.9.                                                3.8

Glucose            112                                                 102

Creatinine        1.2                                                   1.0

CBC 

            Current                               Most Recent

WBC                                  14.5                                 8.2

HGB                                  13.3                                  12.8

PLTs                                  217                                   298

%Neuts                            92                                     75

Bands                               5                                        0

Arterial Blood Gas

Current 

Ph-7.25

pC02-68

HCO3-36

02 Sat-84

Radiology

Chest X ray 

Left lower lobe infiltrate 

Hypoventilation present in both lung fields 

Clinical Reasoning Guide Questions 

1. After interpreting relevant clinical data during your nursing health history and assessment what is the primary problem of the patient? state the nursing diagnosis and justify the answer. 

2. What will be the  nursing interventions to address the patient’s primary problem (at least five nursing interventions arranged according to its priority when providing care to the patient then a rationale for each intervention)

3. What psychosocial care priorities need to be addressed for this patient?

4. What health teaching’s priorities need to be addressed in preparation for patient discharge that would promote health and wellness for this patient and or family?