The patient presents with an exacerbation of their asthma and significant fatigue
| Name: Smith, Sarah Allergies: Penicillin, Pollen DOB: 17/06/1990 | |
| Medical Record #: | 28-7665 |
| Reason for Seeking Care | Patient presents with an exacerbation of their asthma and significant fatigue. Difficulty breathing and feeling of phlegm in their lungs that isn’t brought up by coughing. Symptoms are unresolved by her inhalers. Patient says they haven’t seen their primary physician in over a year. |
| Client Details: | Sex: Female Age: 31 Height: 5’4 Weight: 140
Vital Signs (upon admission): T: 36.5 C HR: 120 BPM RR: 24 BP: 149/95 SpO2: 92% (room air) Pain Scale: 5
Presented with wheezing upon inspiration bilaterally, fatigue, cough, dyspnea. Patient is anxious about entering the hospital and about finding a way to control her asthma. |
| Past Health: | Asthma diagnoses in 2000. Diagnosed with a seasonal allergy to pollen in 2001. No other health issues or concerns at this time. |
| Current Medications: | Proventil HFA (90mcg Albuterol) Inhaler PRN
Advair Discus (100mcg Fluticasone Propionate / 50mcg Salmeterol) q2d Tylenol 650mg PRN (usually q3 week for headaches)
Patient states she doesn’t use her Advair inhaler because she “doesn’t think it does anything”. When asked about her medications, patient was unable to explain what they were specifically for. When asked to demonstrate using inhalers, patient used incorrect technique. |
| Family History | Patient’s parents are both smokers, but mom quit smoking tobacco 3 years ago and took up vaping. Dad still smokes tobacco every day, he goes through a pack every couple of days.
Patient has 2 siblings both girls and they are both younger than the patient. Patient is single with no children. |
| Occupation | The patient has been working as a receptionist for the last 7 years. |
| Education | Some college. |
| Activity & Mobility | Fully independent. Patient says she used to play soccer on the weekends with a group at her local community center, but since her asthma has gotten worse is unable to play. The only exercise she gets now is walking around the house and office. |
| Sleep and Rest | Reports no issues sleeping. Goes to bed around 2300 each night and wakes up at 0700 for work and 0900 on weekends. Although she gets 8-10 hours of sleep each night, she always feels fatigued. Also reports feeling very tired in the afternoons (1400-1600) and usually has a coffee around this time to keep her awake. |
| Nutrition and Elimination | Patient is lactose intolerant, so she avoids eating milk products unless they are lactose free.
Patient has a coffee every morning and usually skips breakfast, the odd day she will pick something up from Tim Hortons. For lunch she normally has a salad that contain spring mix, kale, spinach, cucumber, tomatoes, peppers, feta with balsamic dressing. Sometimes shell make a sandwich with 3 layers of meat, lettuce, tomatoes, pickles, hot peppers, mayo and Italian dressing. The patient will normally have an apple or granola bar in the afternoon as a snack. The patient eats a large dinner, normally it contains a large portion of veggies, piece of meat and a portion of starch. Sometimes the patient will have a nice big bowl of pasta. When the patient relaxes on the couch before bed, she likes to treat herself by eating some of her favourites, candy, chocolate or chips with a pop. |
| Spirituality / Religion | No religious/spiritual affiliations. |
| Coping & Stress Management | The patient will practice her breathing exercises to help cope with her stress and to reduce the symptoms of an asthma attack. Some other coping strategies the patient uses to prevent asthma attacks is taking her medication on a regular basis, getting her annual flu shot, practicing hand hygiene, and avoiding scented areas. All of these coping strategies help prevent triggering an attack and also help prevent triggering more stress because they more attacks she has, the more permanent damage that can be caused within her airways and this causes a lot of stress to her and her family. |
| Smoking History, Alcohol, Substance Abuse | Patient reports that she does not smoke cigarettes. Patient reports having 2-3 drinks during the week and occasionally drinks in excess on the weekend with friends (1-2 times per month). Patient states that she does not use any recreational drugs. |
hey there according to this patient profile the nursing diagnosis i have is patient is at risk for depression and social isolation due to feeling a negative self-image as evidenced by the patient report of low self-worth and withdrawal from social activities. please I would need help getting
3 goals
3 interventions
3 rationale so for each gaol there would be 3 interventions and 3 rationales.
I also would like a nice explanation of the rationale explaining why and also the website for research for more reading
thank you. 🙂
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