Question

plese help me to fill it out

Ps.8-100 comun cat the a NU112-Fundamental of Patient Centered Care Student Report for Vital Signs Documentation Client Information Sheet HPI/ PMH: M.C. a 60 year old female widow of Asian-American heritage arrived at the local community hospital emergency department accompanied by her daughter. She is complaining of chills, fever, chest pain and a productive cough for the past 24 hours. The triage nurse did an initial assessment: Presently she has hyperthermia, tachycardia, tachypnea and is normotensive. Past medical history of DM and HTN and COPD. The client also reports smoking 1 pack cigarette per day for 40 years. Record vital signs for this patient based on the information provided. (T,P,R, B/P, and 02 saturation. Include the fifth vital sign.) List 3 nursing interventions you would implement for this tachypnic patient. Document a new set of vital signs four hours after implementing the above nursing interventions. History: Diabetes Mellitus Type 11, Hypertension and COPD. Allergies: Shellfish and Penicillin. Learning Objectives Identify the purpose of accurate patient record keeping Describe factors that cause variations in body temperature, pulse, respirations, blood pressure, and oxygen saturation. Identify ranges of acceptable vital sign values for infant, child, and adult. Identify difference between a patient's normal baseline measurement and present vital signs which may indicate the need for nursing therapies and necessary medical interventions Select appropriate pain assessment tools. Describe social and cultural influences in health, illness, and caring patterns. Describe steps toward developing cultural competence. Dull

Answer 1

Select Diagnosis: Pneumonia.

Her present problems of fever, chills, chest pain and productive cough indicate that she is suffering from pneumonia.

Diagnosis type: Secondary

Pneumonia has occurred secondary to COPD. COPD patients can easily get pneumonia because increased carbon dioxide retention and decreased oxygen results in respiratory failure.

Pathophysiology:

The Causative agent for pneumonia for this patient is an intrinsic factor. The presence of COPD affects the host and spreads into the lung parenchyma. This will irritate the lungs and leads to inflammation. The proliferation of inflammatory response damage to lung tissue and impair lung function.

Therapeutic regimen:

Antibiotics should be administered if the causative agent is bacteria. Antipyretics should be administered to reduce fever. Cough suppressant to relieve cough. Administer oxygen via a high flow mask based on oxygen saturation. Provide a comfortable position and adequate rest.

Current Health problems and related Functional changes:

His current symptoms of hyperthermia, fever, chills limits the mobility of the patient. chronic infection and increased carbon dioxide retention limit her daily activities. His lie style pattern further complicates her condition.