Patient Initials: Age: 65 Sex: Female

Subjective Data

Client Complaint

The main complaint was a dry cough for two weeks, a low-grade fever, which began two days ago and was high as 101 orally. The patient has a decreased appetite but no vomiting and nausea. The coughs occur at night, and she must sit up on the chair to breathe easily.

History of Present Illness

The patient has been prescribed inhalers during the past even though she does not use them on a daily basis. She has also used antibiotics, and they seem to be helpful when she is acutely ill. Moreover, she has been suffering from shortness of breath in the past two weeks following any activity primarily because of a dry cough. She believes her heart has a problem and complains of a slight sore throat particularly in the morning. Consequently, she feels she may have lung cancer. In the past three months, she visited the emergency room, and she needed to be hospitalized. She refused from being hospitalized but was treated and later released. She claims that she was offered an inhaler and antibiotics before being discharged. She feels that the sickness has become severe and thinks that she has pneumonia. She has come to seek treatment for the prolonged nature of her illness and fever.

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The Past Medical History

Even though she has received treatment of the issues stated above with inhalers and antibiotics, she has not been hospitalized. Equally important, the patient did a chest investigation the last time she had the problem. She claims that she had emphysema. However, when the healthcare professionals asked her to do the pulmonary function test, she refused. She does not take any prescription medicine but self-medicates occasionally with over-the-counter medicine Tylenol for pain. The patient is allergic to sulfa drugs, which cause a rash.

Significant Family History

She has two old sisters who are well and alive, one with breast cancer and the other one suffers from osteoporosis. The 62-year-old sister was diagnosed with breast cancer at sixty, and the 75-year-old was diagnosed with osteoporosis at the age of 55.

Social or Personal History

The patient has been widowed for the past 20 years and receives an annual pension of 40 thousand dollars. Furthermore, she has a high school diploma and owns her house. Additionally, she has a primary care provider who she visits four or three times each year. Her insurance does not cover all the prescription medications, and she relies mostly on samples. More importantly, her two daughters live in a nearby community. She wants her daughters, who are in their forties, to be more involved in her life, but she does not know how to approach them. Moreover, she feels depressed because she rarely goes out, and it is increasing each year. Her daughters provide her with support, but she only sees them once a month. The patient was a hairdresser, but she retired. Moreover, she attends church and occasionally goes to various functions, and her hobby is sewing. The patient is from the US and dwells in a suburban setting. She has a healthy diet, and the dietary intake is adequate. On the other hand, she does not get enough exercise because of the shortness of breath but enjoys visiting the physician. The patient smokes one pack of cigarettes each day, denies the use of alcohol and any street drug abuse.

Description of Clients Support System

The community, family members, resources and self-help movement that exist in the patients community can play an essential role in the recovery process. She will be advised to be more social with the neighbors since they can help in emergency situations and recovery period. She will be motivated to change her lifestyle and exercise more often with the community members. Lastly, the patient must see a primary provider make follow-ups on her health.

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Behavioral or Nonverbal Messages

She rarely has anyone to talk to since she sees her daughters once a month. She does not know how to tell her daughters to visit her more often.

Client Awareness of Abilities, Disease Processes, Health Care Needs

The client should physically train to have a healthy lifestyle. Equally significant, the patient needs to pay for a better insurance cover and avoid self-medication. She should listen to the doctor's advice to cure the ailment effectively. She needs to connect with her daughters to ensure the depression is reduced.

Objective Data

Vital Signs including BMI

BP: 130/72 left hand sitting regular cuff; T: 101 po; R: 20, non-labored; P: 100 and regular; BMI: 21.0; Wt: 130#; Ht: 55.

Physical Assessment Findings

i. HEENT: White substance on the buccal mucosa; does not clean off with a tongue blade. No lymph nodes.

ii. Lungs: Dull to percussion right lower lobe and decreased breath sounds. End-expiratory hiss in the right lower lobe. No rhonchi or rales. Increased posterior-anterior diameter to chest wall.

iii. Heart: RRR with no murmur. Carotids: Absent bruits. Abdomen: Benign

iv. Genital/Pelvic: Not examined

v. Rectum: Not examined

vi. Extremities, counting pulses: no edema, 2+ pulses throughout

vii. Neurologic: Not examined

Lab Tests and Results

i. Pulse oximeter reading: SAO2: 98%

ii. CBC- WBCs 15, 000 with + left shift

iii. Normal sinus rhythm

iv. Radiological Studies

v. EKG

vi. CXR Same as X-ray

Clients Locus of Control and Readiness to Learn

The patient must stop self-medicating and follow the doctors advice of being hospitalized. She should socialize and exercise more often. Moreover, the patient must stop smoking and pay insurance covers that will cover her medication.

ICD-10 Diagnoses/Client Problems

The code is J43.0, unilateral pulmonary emphysema (MacLeod's syndrome) and code J45.991 for a cough variant asthma, and R50.81 for fever because of conditions classified elsewhere.

Advanced Practice Nursing Intervention Plan

Assessment

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The patient reported a dry cough for two weeks that is rarely productive, shortness of breath, slight sore throat, and a low-grade fever. The vital signs are BP: 130/72 left hand sitting regular cuff; T: 101 po; R: 20, non-labored; P: 100 and regular; BMI: 21.0; Wt: 130#; Ht: 55.

Diagnoses

i. Ineffective airways clearance associated with COPD (COPD Working Group, 2012).

ii. Impaired home maintenance associated with activity intolerance.

iii. Impaired gas exchange associated with chronic and acute lung disease.

Expected Outcomes

i. Verbalize the willingness of the neighbors to aid with some of the daily household tasks.

ii. Show better arterial blood gas and oxygen saturation values.

iii. Uphold spontaneous respirations with no excess fatigue (Gupta et al., 2013).

Planning and Implementation

i. Carefully monitor the response to oxygen therapy.

ii. Assess respiratory status and height of consciousness each one to two hours until steady, then, at least, every four hours (Qureshi, Sharafkhaneh, & Hanania, 2014).

Rationale

i. Monitor the effectiveness of medicine offered for emphysema (Taffet, Donohue, & Altman, 2013).

ii. Start talking with her two daughters more often and neighbors to assist in the exercise.

Evaluation

The patients condition will begin to improve slowly. She uses oxygen at night, admitting it is for security. She will continue to use Vanceril and Atrovent inhalers as prescribed. Furthermore, the client promises to stop smoking since it worsens her condition. A nurse can be assigned to the patient to evaluate the progress (Tzanakis, Hillas, Perlikos, & Tsiligianni, 2015).

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