Formal Care Plan: Pneumonia
Biographical Data The patient is a 78 year old Hispanic female. She was born in Houston, Texas. She is married and has 2 children and is a retired school teacher.
Present Health-Illness Status She was admitted into the hospital from the emergency room with pneumonia. The patient states she drove herself to the emergency room because she was feeling very sick and short of breath. She states she had been feeling like this for the past 3 days. She finally decided to seek care after a coughing spell that left her out of breath. She stated it was a very productive cough with thick yellow mucus. The patient stated she felt very weak and dizzy after the spell. She has noticed her cough is mostly in the mornings and at …show more content…
She stated and appeared to be in a good mood and had a warm smile throughout the assessment. She has an slightly stooped posture and relaxed position. Her body movements were voluntary and coordinated. She was appropriately dressed in a clean hospital gown and well groomed. Her hair was neat and combed back. Her stated age matched with her demeanor and appearance. The patients skin tone was even with no signs of obvious lesions. The Glascow Coma Scale was used to assess her level of consciousness. Her eye-opening response was spontaneous, motor response was intact and was able to follow commands, and her verbal response showed to be oriented x3 after asking her to give me the current year, location of where is at, and her name. Her score was a 15. Her speech was effortless with a moderate pace. She was clear and understandable, occasionally pausing to think. There was not a presence of body or breath odor. She is 5 feet and 3 inches tall and weights 175lbs. Her BMI is 31.0 putting her in the obese category. Fat distribution is mostly around the abdomen area however her arms and legs are well proportioned for the rest of her body. A Snellen Vision chart was unavailable but the patient was wearing glasses and her vision exam was current. She states she needs glasses to see far. Her left radial pulse was 62 with a normal rate and rhythm of 2+ after counting for a full minute. Respirations were 20. Her temperature was taken orally and it was at 99F. Blood pressure was taken bilaterally with right arm at 108/56mmHg and left arm 110/56mmHg. A pain assessment was performed due to patient stating her ribs were hurting. The pain is worse when the patient coughs. It is a dull pain that she feels up and down her rib cage. She says it radiates to the back and rate the pain at a 3 on a 1-10 scale. She is not currently taking anything to relieve the pain and she
Biographical Data The patient is a 78 year old Hispanic female. She was born in Houston, Texas. She is married and has 2 children and is a retired school teacher.
Present Health-Illness Status She was admitted into the hospital from the emergency room with pneumonia. The patient states she drove herself to the emergency room because she was feeling very sick and short of breath. She states she had been feeling like this for the past 3 days. She finally decided to seek care after a coughing spell that left her out of breath. She stated it was a very productive cough with thick yellow mucus. The patient stated she felt very weak and dizzy after the spell. She has noticed her cough is mostly in the mornings and at …show more content…
She stated and appeared to be in a good mood and had a warm smile throughout the assessment. She has an slightly stooped posture and relaxed position. Her body movements were voluntary and coordinated. She was appropriately dressed in a clean hospital gown and well groomed. Her hair was neat and combed back. Her stated age matched with her demeanor and appearance. The patients skin tone was even with no signs of obvious lesions. The Glascow Coma Scale was used to assess her level of consciousness. Her eye-opening response was spontaneous, motor response was intact and was able to follow commands, and her verbal response showed to be oriented x3 after asking her to give me the current year, location of where is at, and her name. Her score was a 15. Her speech was effortless with a moderate pace. She was clear and understandable, occasionally pausing to think. There was not a presence of body or breath odor. She is 5 feet and 3 inches tall and weights 175lbs. Her BMI is 31.0 putting her in the obese category. Fat distribution is mostly around the abdomen area however her arms and legs are well proportioned for the rest of her body. A Snellen Vision chart was unavailable but the patient was wearing glasses and her vision exam was current. She states she needs glasses to see far. Her left radial pulse was 62 with a normal rate and rhythm of 2+ after counting for a full minute. Respirations were 20. Her temperature was taken orally and it was at 99F. Blood pressure was taken bilaterally with right arm at 108/56mmHg and left arm 110/56mmHg. A pain assessment was performed due to patient stating her ribs were hurting. The pain is worse when the patient coughs. It is a dull pain that she feels up and down her rib cage. She says it radiates to the back and rate the pain at a 3 on a 1-10 scale. She is not currently taking anything to relieve the pain and she