NUR 1022C Assessment & Reasoning
Respiratory System; John Franklin, 35 years
Old-complete case study
Assessment & Reasoning
Respiratory System
John
... [Show More] Franklin, 35 years old
Suggested Respiratory Nursing Assessment Skills to Be Demonstrated:
• Inspection: Inspect thorax for symmetry and configuration- Check to see if he if using accessory muscles or
if breathing is labored.
•
• Palpation: Palpate over anterior and posterior chest for any lump, masses, tenderness & crepitus
•
• Percussion: Percuss over posterior to check for tactile fremitus
•
• Auscultation:
• Auscultate all lung fields
•
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Present Problem:
John Franklin is a 35-year-old African American male who has a history of hypertension and asthma who smokes ½ ppd
since the age of eighteen. He began to feel more short of breath after supper today and began to have a persistent nonproductive cough. He ran out of his albuterol inhaler two months ago and has audible expiratory wheezing when he
comes to the triage window of the emergency department (ED).
John is promptly brought to a room in the ED and you are the nurse responsible for his care.
What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
History of Hypertension and asthma
Smokes ½ ppd since 18
Shortness of breath, persistent nonproductive
cough
Ran out of albuterol inhaler two months ago
Audible expiratory wheezing
Having the history of asthma and because he smokes, this confirm that he
is having an asthma attack that could have flared up.
Having the nonproductive cough is consistent with asthma attacks,
if it were productive, it would be linked to pneumonia.
Client had no way to treat his asthma because he ran out of his medicine.
His wheezing was so loud no stethoscope needed to be used. Means his
condition was bad.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):
Asthma
Hypertension
Albuterol inhaler 2 puffs
every 4 hours PRN
wheezing
Furosemide 20 mg PO daily
adrenergic
bronchodilators
loop diuretics
relaxes smooth muscles it the bronchial
tree and peripheral vasculature by
stimulating adrenergic receptors of the
sympathetic nervous system.
Furosemide is a potent loop diuretic that
acts on the kidneys to ultimately increase
water loss from the body.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 99.1 F-37.3 C (oral) Provoking/Palliative: Denies pain
P: 110 (regular) Quality:
R: 24 (regular) Region/Radiation:
BP: 188/110 Severity:
O2 sat: 91% RA Timing:
What vital signs are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion and Maintenance)
Abnormal VS: Clinical Significance:
BP: 188/10
Oxygen saturation low, client’s airway may be blocked, low amount of oxygen in the blood.
02 sat: 91% RA
Client is taking a lot of breaths
R: 24
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