In modern American society the populous is experiencing both a longevity of life and in turn are faced with more chronic illnesses. In the Ohio-valley region of the United States there is a marked increase of chronic lung and heart issues exacerbated by coal mines, obesity, and tobacco use. Chronic obstructive Pulmonary disease is the third leading cause of death in the United States ("American Lung Association," 2013). B.H. was a 71-year-old male admitted to Hardin Memorial Hospital for shortness of air related to COPD and pulmonary edema. It was my assignment to gather his relevant medical history, assess his signs/symptoms for seeking healthcare, and provide a thorough physical and psychosocial assessment. B.H. stated that he “couldn’t
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The patient was on 2 liters of oxygen via a nasal cannula and also had oxygen therapy at home. B.H. indicated that he did become SOA quickly with minimal exertion and this had become progressively worse in the last few years. The patient was compliant and very interested in learning about all of his medications. His neurological status was alert, awake, and orientated to person, place, time, and situation. B.H. had responses that were appropriate and he appeared to be calm with no visible signs of anxiety. His pupils were equal, round, and reactive to light. There was slight bilateral weakness noted in the lower extremities related to fatigue. The skin was warm, dry and intact with no noted lesions and skin turgor was less than three seconds. Heart sounds were distant and muffled, with S1 and S2 auscultated. No murmurs, pulsations or thrills were observed. His capillary refill time was less than three seconds in both hands and feet. Pulses were palpable in the dorsalis pedis and posterior tibialis with a decreased amplitude that was related to CHF and fluid overload. B.H. had a surgically implanted port in his right upper chest, approximately 3cm below the clavicle. The port terminated in the right atrium. The site was asymptomatic, with an intact and dry transparent dressing. His abdomen was firm, non-tender, and rotund with active bowel sounds in all four quadrants. The focused assessment of his respiratory system revealed coarse, inspiratory & expiratory wheezes and crackles bilaterally on both the anterior & posterior lobes of the lungs in all lobes. Furthermore, his lung sounds were diminished in the lower lobes bilaterally on both the anterior & posterior chest, and his breathing was slightly labored at 18 respirations per minute. B.H. presented with a wet-productive cough with gray-tinged sputum that was sent for culture. The patient presented with 1+
The patient was on 2 liters of oxygen via a nasal cannula and also had oxygen therapy at home. B.H. indicated that he did become SOA quickly with minimal exertion and this had become progressively worse in the last few years. The patient was compliant and very interested in learning about all of his medications. His neurological status was alert, awake, and orientated to person, place, time, and situation. B.H. had responses that were appropriate and he appeared to be calm with no visible signs of anxiety. His pupils were equal, round, and reactive to light. There was slight bilateral weakness noted in the lower extremities related to fatigue. The skin was warm, dry and intact with no noted lesions and skin turgor was less than three seconds. Heart sounds were distant and muffled, with S1 and S2 auscultated. No murmurs, pulsations or thrills were observed. His capillary refill time was less than three seconds in both hands and feet. Pulses were palpable in the dorsalis pedis and posterior tibialis with a decreased amplitude that was related to CHF and fluid overload. B.H. had a surgically implanted port in his right upper chest, approximately 3cm below the clavicle. The port terminated in the right atrium. The site was asymptomatic, with an intact and dry transparent dressing. His abdomen was firm, non-tender, and rotund with active bowel sounds in all four quadrants. The focused assessment of his respiratory system revealed coarse, inspiratory & expiratory wheezes and crackles bilaterally on both the anterior & posterior lobes of the lungs in all lobes. Furthermore, his lung sounds were diminished in the lower lobes bilaterally on both the anterior & posterior chest, and his breathing was slightly labored at 18 respirations per minute. B.H. presented with a wet-productive cough with gray-tinged sputum that was sent for culture. The patient presented with 1+