plan of care, include the rationales for your priority patient selection, assessments, the nursing diagnosis, related factor, outcomes, and nursing interventions.
Shirley Smith
Age: 52
Race: Caucasian
Gender: Female
Height: 68 inches
Weight: 153 lb. (69.4 kg)
Occupation: Retired
Marital Status: Widowed
Religion: Agnostic
Allergies: None known
Address: Assisted Living facility
Immunizations: Up to date
History
Shirley's husband died unexpectedly 2 months ago, which is the time she entered
an assisted living facility. Shirley states she has become depressed from the loss
of her husband and the inability to physically do activities she desires due to the
COPD.
Shirley presents to the ER with difficulty breathing and shortness of breath at
rest, and increased fatigue. The patient is currently on 2 Liters of oxygen nasal
canula at all times. Shirley smoked cigarettes for 32 years and just recently quit 2
months ago when she was put on full-time oxygen.
Past medical history: hysterectomy at the age of 48, Gastroesophageal reflux
disease (GERD), and Atrial Fibrillation.
Medications
Prednisone (HOLD) 20 mg oral Daily
Pantoprazole 40 mg oral Daily
Warfarin 5 mg oral Daily
Methylprednisolone 125 mg IVP Every 6 hours
Orders
Maintain 2 liters of oxygen via nasal canula at all times to keep
saturation =>92%
• Hold prednisone
• Methylprednisolone 125 mg IVP every 6 hours
• Continue home medications:
• Pantoprazole 40 mg oral daily
• Warfarin 5 mg oral daily
• Continuous pulse oximetry
Notes
Once admitted to the Med/Surg floor, Vital signs are obtained by the nursing
assistant.
• Temperature of 99.9 F
• Pulse 102
• Respirations 32
• B/P 165/87
• Oxygen saturation 84% on 2 liters of oxygen via nasal canula
The patient states she is short of breath, especially with activity. The alarm on the
continuous pulse oximetry went off and created a loud pulsing chirp.
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