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Pneumonia-COPD case study-2021

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What data from the histories is important and relevant; therefore it has clinical significance to the nurse? Relevant data from present problem Clinical significance  Green phlegm  Chills Fev ... er (102.0)  Difficulty Breathing (no improvement with albuterol)  These vital signs clinically show signs of infection. With the difficulty breathing I would think about possible respiratory infection Relevant data from social history Clinical significance  She was widowed 6 months ago after being married for 64 years, and she feels like it is the beginning of the end for her  This is important because when caring for her we need to keep in mind her age, stressors in her life and any limitations 2. What is the relationship of your patient’s past medical history and current meds? PMH Home meds Pharm class Expected outcome  COPD/asthma  Hypertension  Hyperlipidemia  Cor-pulmonale  Anxiety disorder  1ppd smokerx40 years.Quit10 years ago 1. 1.Fluticasone/salmeterol 1 puff q12hrs 2. Albuterol MDI 2 puffs q4hrs prn 3. Lisinopril 10mg po daily 4. Gemfribrozil 600mg po bid 5. Diazepam 2.5 mg po q6 hrs prn 6. Triamterene-HCTZ 1 tab daily 1. corticosteroid 2.bronchodilator 3. ACE inhibitor 4. cholesterol 5.benzodiazepin e 6. potassium sparing diuretic 1. improve breathing 2. open up airway in the lungs 3. decrease blood pressure and open up blood vessels 4. decrease fatty acids 5. decrease anxiety and calm down 6. help body from not absorbing too much salt and keep potassium level from getting too low [Show More]

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