Analysis And Care Plan Creation

Assignment 2: Case Study Analysis and Care Plan Creation

Click here (I COPIED AND PAST IT ON BELOW)  to download and analyze the case study for this week. Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

 

CASE STUDY

 

Week 2: Respiratory Clinical Case

 

Patient Setting:

 

65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily.  She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.

 

HPI

 

Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.

 

 

 

PMH

 

History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.

 

 

 

Past Surgical History

 

None

 

 

 

Family/Social History

 

Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF

 

Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.

 

 

 

Medication History

 

Theophylline SR Capsules 300 mg PO BID

 

Albuterol inhaler, PRN

 

Phenytoin SR capsules 300 mg PO QHS

 

HTCZ 50 mg PO BID

 

Enalapril 5 mg PO BID

 

Allergies

 

NKDA

 

ROS

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