Medications
Albuterol (Proventil) nebulizer 6 times daily
Simvastatin (Zocor) 5 mg PO daily
Methylprednisolone (Solu-Medrol) 125 mg
IV every 6 hours
Student Name:
Lab Values/Diagnostic Test Results
Patient Initials:
Room #:
Admit Date:
R
Age:
72
CODE Status:
BMP
Today's Date:
Full
Gender:
Weight:
Height:
Braden Score:
N
N
N
M
Diet:
N
Activity:
N
Adult regular
Religion:
122
N
N
Allergies:
CBC
Admitting Diagnosis/Chief Complaint
Chronic obstructive pulmonary disease
12.7
N
N
N
N
Assessment Data
Misc Lab Values/Diagnostic Test
Results
IV Sites/Fluids/Rate:
Past Medical/Surgical History
Smoked 2 ppd cigarettes for 40 years and
quit 10 years ago
Hyperlipidemia
Vital signs: T 36.7º C (98º F), P 98 and regular, R 26 & labored, BP
144/73, with a pulse oximetry reading of 90% at rest on 2 L of
oxygen per nasal cannula.
Denies pain but complains of difficulty breathing.
Productive cough with thick secretions.
No hemoptysis is present.
Heart sounds are distant.
Breath sounds are diminished with inspiratory and expiratory
wheezes and a prolonged expiratory phase.
Abdomen is protruding without acute changes.
Ate 25% of his breakfast.
Lipids: total cholesterol 242, HDL 89, LDL
107, triglycerides 107, electrolytes and
kidney function studies within normal
limits.
Arterial blood gases: pH 7.37, PCO 2 57
mm Hg, PO2 65 mm Hg, HCO 3 32 mEq/L.
Treatments
Physical therapy to help with
conservation of energy with activity.
Respiratory therapy for breathing
treatments.
Blood glucose level before meals and at
bedtime.
Titrate oxygen up to 3 L/min to keep
SpO 2 greater than or equal to 92%.
Primary Nursing Diagnosis
Nursing Diagnosis 2
Nursing Diagnosis 3
Supporting Data
Supporting Data
Supporting Data
STG/NOC
STG/NOC
STG/NOC
Interventions/NIC with Rationale
Interventions/NIC with Rationale
Interventions/NIC with Rationale
Rationale Citation/EBP
Rationale Citation/EBP
Rationale Citation/EBP
Evaluation
Evaluation
Additional Information
Evaluation