History of Present Illness
A 34-year old female patient sees her primary health care provider for ongoing complaints of headache and dizziness. Additional symptoms reported are dry cough, fatigue, sore throat, nausea, and chills.
Additional measures included:
• Complete blood count
• Complete metabolic panel
• UA
• CXR
• X-ray of face/sinuses
• IV fluids
Past Medical History
Recurrent headaches over the last 2 months. Cycling symptoms of cough, chills, and sore throat.
Patient has utilized the following to control the symptoms:
• over-the-counter acetaminophen and ibuprofen
• Vicks vaporub
• Humidifier
• ChlorTrimeton 4mg over-the-counter twice/day
Laboratory values and Medications
CXR showing consolidation and infiltrates in the left lower lobe and beginning in the right lower lobe
WBC 10,000
Hct 49
Urine specific gravity 1.030
Na+ 148
K+ 5.5
BUN 15.0
Habits and Activities
Patient is a runner, runs early in the morning in her neighborhood
Denies ETOH use
Denies street drug use
Denies tobacco use
Eats 5 small meals/day, does not eat red meat, is lactose intolerant
Does not take any medications other than those listed above, denies use of vitamins, supplements, or herbs
Review of Systems
VS:90/52; 98-24, 90%, 101.0 oral; Ht: 60" Wt: 105# BMI: 20.5
HENNT: pale yellow-green mucus draining through the night and early morning, and intermittently through the day, nasal turbinates swollen and reddened, tenderness palpated over the frontal and maxillary sinuses, throat red, mucous membranes dry and tongue with thick appearance
GI: abdomen flat, no masses, increased constipation
GU:urine concentrated
CV: pulses weak, difficult to palpate distally, no edema, HRRR, no murmur, no palpitations
Resp: chest wall movement symmetrical bilaterally, no use of accessory muscles
Neuro: A&O x3 but lethargic
1. What are three other issues that are hinted at but not addressed for this patient?
2. What are 6 interventions that will address the patient's needs using multi-disciplinary methods towards holistic care?
3. What are 3 top priority nursing diagnoses for this patient?
4. What are 2 nursing considerations for each medication that this patient is taking?
5. List a)ALL applicable risk factors for respiratorydiagnosis and b)respiratory disease complications for this patient.