1. Test Lab Results Date Normal
Student name:
Instructor:
History of Present Illness:
(A brief statement by the Doctor explaining what happened to the patient before they got to the hospital)
Patient is a 85 year old male. He was admitted to USC VHH with COPD exacerbation. Patient presented as alert and oriented. He presents with PMH of COPD/Emphysema with chronic hypoxic respiratory failure on 4L of oxygen and HTN, who presented to the ER with symptoms of worsening shortness of breath. Patient stated that over
Patient Education / Discharge Planning:
(Barriers to education, learning goals, learning outcomes) (Home Vs Facility, services needed after discharge, adaptive equipment needed for home.)
Waiting on acceptance to TCU
Erikson’s Developmental Stage Related to Pt & APA citations
Pathophysiology of Admitting Dx with APA references:
COPD exacerbation
Asthma
HTN
Cultural Considerations: Ethnicity, Occupation, Religion, Family Support, Financial Considerations.
Caucasian
Catholic
Retired
Lives in a single level home with wife
Lives of the retirement that he and his wife get
Patient has an adult son and daughter.
Test
Lab Results
Date
Normal
WBC
15000 (High)
6/24/18
HbG
13.6 (Low)
12-16
CO2
35 mmol/L (High)
BUN
30 mg/dL (High)
Creatinine
0.6 mg/dL (Low)
Sodium
132 mmol/L (Low)
Chief Complaint
Patient Information
Worsening Shortness Breath
Name: H.O.
Age: 85 y.o.
Gender: Male
DPOA: No
Living Will: Yes
Ht: 175 cm
Wt: 69.5 kg
Previous Medical History:
(How does the current diagnosis affect the pre-existing medical conditions)
Admitting/Current Diagnoses:
COPD exacerbation, Asthma
Plan of Care:
Previous Surgical History:

2. Priority Nursing Diagnosis #1 Outcome Goal #1
Objective Signs
Priority Nursing Diagnosis #1
Impaired gas exchange related to chronic lung disease as evidenced by using accessory muscle, low , and CX-R
Neurological
A&O to Time, Place, Person, Purpose. Sensation is normal. Pain 5/10. PERRLA: Brisk. Glasgow Coma Scale: 15. Strength in grasp is Full power. Sensation, Hearing, Smell, Vision and Touch are normal
Cardiovascular
Skin color is pink and warm to touch. Cap. Refill is <3 sec. No peripheral edema. Peripheral pulses are present. Heart sounds RRR
Respiratory
Breath sounds are clear; diminished in RML, RLL and LLL. Breathing pattern is labored (SOB), no secretions are present. Pulse Oximeter is at 96% with N/C at 1 L/min
Priority Nursing Diagnosis #2
Imbalanced nutrition, less than body requirements
Vital Signs
BP: 131/80
HR: 100
RR: 22
O2 Sat: 96%
Temp: C
Nutrition / Hydration
Full liquid diet, feeds himself, at risk for aspiration, no N/V. Moist mucous membranes. No problem with skin turgor. Loss in weight for 32.3 kg. I&O: 2654/2000 GI
Active bowel sounds. Abdomen is round and non-tender. Last BM was on 6/19 (constipation), symmetrical abdomen GU
Clear and straw color urine, no catheter, no odor, no pain. No signs and symptoms of GU symptoms
Rest / Exercise
Barely ambulates, function level is with assistance and walker. Full ROM, steady gait. Sleep patterns are uninterrupted
Outcome Goal #1
(specific, measurable, achievable, realistic, time bound)
By the end of my shift, the patient will have improvement in gas exchange
Outcome / Goal #2
Integumentary
Endocrine
Psychosocial
Musculoskeletal
Interventions #1
Evaluation #1
(start with “goal met” or “goal not met”)
Evaluation #2
Interventions #2 .
“Risk For” Interventions
Keep bed in low position
Position the call light within reach
Position personal belongings within reach
Assistive devices at bedside
Room free of clutter
Non-skid footwear provided
Offer hydration & toileting while awake
Provide education on Fall Prevention (Handout)
Educate patient on risk factors and fall prevention
“Risk For” Evaluation
“Risk For” goal
“Risk for” Diagnosis
(problem r/t cause)

3. Medication Name, Dose, Route, Freq & APA Citation
Why Pt is Taking the Drug and
Method of Action
Side Effects
Nursing Considerations
Prednisone, 40 mg, PO, Daily
Metoprolol, 25 mg, PO, Daily
Theophylline, 160 mg, PO, Q8H
Hydrochlorothiozide, 25 mg, PO, Daily
Lisinopril, 20 mg, PO, Daily
Ceftriaxone, 1 gr, IV, Q24H
Fluticasone, 1 inhale, inhalant, BID
Levalbuterol, 3 ml, HH Neb, Q6H
Ipratropium, 2.5 ml, HH Neb, Q6H
Enoxaparin, 40 mg, SQ, Daily

4. References:
At least 3 references & Standard APA Format