Patient Initials: __MJ____ Age: _____65 yrs._______ Sex: _____F______
Client Complaints: Mrs. Mary Jane complaints of persistent dry cough for two weeks, fever for two days with highest oral temperature of 101F. She also complaints of poor appetite.
History of Present Illness: Mrs. Jane has had episodes of persistent dry cough with fever in the past. She had persistent dry cough and shortness of breath with any kind of activity for past two weeks. The cough is mainly at night, which interferes with her sleep as she needs to sit up in a chair to breathe easily. Two days ago she had worsening of symptoms and a low grade fever with a maximum oral temperature …show more content…
Physical Assessment Findings: Review of systems (ROS) is as follows:
HEENT – White material on buccal mucosa that does not wipe off with a tongue blade; Lymph nodes – non palpable; Lung Sounds – Decreased breath sounds throughout, end expiratory wheeze in the right lower lobe and dull to percussion, no rales or rhonchi, increased anterior-posterior(AP)diameter to the chest wall noted; Heart – Regular sinus rhythm, no murmur; Carotids – no bruits; Abdomen – benign; Rectum – not examined; Genital/Pelvic – NA; Extremities including pulses – 2+ pulses throughout with no edema; Neurologic – not examined.
Lab Tests and Results: SAO2 – 98%; WBC – 15, 000 with a positive left shift; Chest X-ray – Hyperinflation of both lungs with increased AP diameter and of emphysema; EKG – normal
Client’s Support System: Mrs. Jane has little emotional or social support. Her daughters does not offer her any help. She has no friends or relatives and is not aware of the community …show more content…
Mrs. Jane appears to have acute bronchitis along with the emphysema, which she was diagnosed in the past, is a part of chronic obstructive pulmonary disease (COPD). She has an exacerbation of COPD, which can increase her risks for morbidity and mortality. Mrs. Jane should be educated regarding COPD and progression of the disease. She must stop smoking and so cessation should be discussed. She should be explained the benefits of stopping and benefits in relation to COPD and her health. Positive encouragement that stopping smoking is a really effective and important step that she can take to help herself, together with the reassurance that help will be provided, will be the best approach (Bellamy, & Booker, 2011). This will also aid to reduce a lot of her anxiety. Moreover, pharmacotherapy; self-help material; behavioral support; and referral to stop smoking service should be done. Mrs. Jane shall also be explained the significance of pulmonary function tests to examine the expiratory flow and properly stage her illness (Hattab, Alhassan, Balaan, Lega, & Singh, 2016). Her SAO2 is good, so no supplemental oxygen is needed. She will be advised to go for short walks in her neighborhood to help expand her lungs and improve her exercise tolerance and in long run reduce her weight. It may also provide an opportunity for her to socialize with her neighbors and probably make some friends. She needs a flu and pneumonia vaccine,