Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office

Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office

Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office 150 150 Peter

Patient Details:

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Case Study History

Name:

James, Karen

Age:

57 Years

Gender:

Female

Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.

You are currently working on Phase 1. You have completed Phase 0 of this scenario.

Patient Details:

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Case Study History

Name:

James, Karen

Age:

57 Years

Gender:

Female

Phase

1,

Wednesday

16:00

You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.

Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:

1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?

2). What was the last documented temperature for Karen?

3). Does Ms. James use any sensory aides?

4) What does she rate her pain?

5) What is her MORSE Fall Risk Score?

Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?

[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]

When you are finished with this task, you may click Complete this Phase.

Patient Information

Chief Informant:

Patient

Chief Complaint:

Shortness of breath, productive cough

History of Current Problem:

Patient states she has had 3-week history of influenza. Has now developed a severe cough approximately 3 days ago with shortness of breath. Unable to sleep due to cough, which often causes bronchospasms. Patient also complains of fever, fatigue, and right-sided chest pain. Seen in urgent care 3 days ago and given Z-pack. No improvement in symptoms.

Allergies:

None known

Family History:

Mother died at age of 72 with breast cancer. Father is alive at the age of 79 and has congestive heart failure.

Past Medical History

Previous Illnesses:

Patient has asthma. Also states she gets bronchitis every 1-2 years.

Contagious Diseases:

None

Injuries or Trauma:

None

Surgical History:

Tonsillectomy and adenoidectomy as a child.

Dietary History:

Regular diet. Patient is 5’1″ and 140 pounds. Has recently lost 20 pounds on Weight Watchers diet.

Other:

Social History:

No smoking, no drugs. Uses alcohol in social situations.

Current Medications:

Tylenol 650 mg PO every 4 hours PRN pain or fever
Prozac 20 mg PO every day
Xanax 0.25 mg PO every 8 hours PRN
Xopenex HFA 2 puffs every 6 hours PRN

Review of Systems

Integument:

Denies complaints.

HEENT:

States she had neck soreness related to influenza, with “swollen glands.”

Cardiovascular:

No complaints.

Respiratory:

Complains of shortness of breath, frequent productive cough. States her cough often turns into bronchospasms. Uses inhaler, peppermint tea, lozenges, and Vicks VapoRub.

Gastrointestinal:

Complains of decreased appetite.

Genitourinary:

No complaints.

Musculoskeletal:

Complains of generalized body aches.

Neurologic:

Alert and oriented.

Developmental:

Denies complaints.

Endocrine:

No complaints.

Genitalia:

No complaints.

Lymphatic:

No complaints.

Physical Exam

General:

57-year-old female in mild distress. Appears weak.

Vital Signs:

Temp: 103.2 F, Pulse: 114, Resp: 28, Blood pressure: 154/78 in office this morning

Integument:

Skin clear of rash.

HEENT:

Pupils equal and reactive. Nasal congestion. Neck supple.

Cardiovascular:

S1, S2, no murmur.

Respiratory:

Lungs clear with crepitation in right base.

Gastrointestinal:

Abdomen soft, active bowel sounds.

Genitourinary:

Musculoskeletal:

Moves all extremities well.

Neurologic:

Alert and oriented.

Developmental:

Endocrine:

Genitalia:

Not assessed. Seen by gynecologist recently. Negative pap smear and negative mammogram.

Lymphatic:

No lymph node swelling at this time.

Impressions:

Pneumonia

Plan:

The patient is admitted for IV antibiotics and close observation of respiratory status. Patient will need influenza and pneumonia vaccines.

Provider Signature:

Michael Foster, MD

Day:

Wednesday

Time:

12:45

Chief Complaint:
The patient is a 57-year-old female admitted today for chief complaint of shortness of breath.

Patient’s labs were completed in the primary care provider’s office prior to admission and results include the following:
WBC: 20.2 x 109/L
RBC: 4.51 RBC x 106/ul
Hemoglobin: 14.0 g/dL
Hematocrit: 40.2%
Sodium: 139 mEq/L
Potassium: 4.2 mEq/L
Chloride: 105 mEq/L
CO2: 26 mEq/L
Glucose: 91 mg/dL
BUN: 17 mg/dL
Creatinine: 0.5 mg/dL

She is also febrile at 102.7.
Nursing will initiate IV antibiotics.

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