Pathophysiology of the patient’s medical diagnosis

I need to lean about  Pathophysiology of the patient’s medical diagnosis.

b.      Include 3 clinical manifestations.

c.       Include 3 nursing considerations.

d.      Include 3 teaching needs.

SBAR for COPD Name: MR. Gomez 68 YR OLD, M

Allergies- Ampicillin

Situation: Chief of Complaint: Patient came into the ER with pneumonia and exacerbation of his COPD. Patient was found on the floor at his home. Patient’s daughter stated he was unresponsive. Background: Patient lives alone, lost wife, question of alcohol abuse. Include social worker to offer brief counseling. Hx: Smoking and alcohol (find out how much he is drinking, give pamphlet for alcohol abuse if he feels like he is abusing it) Assessment: Lung sounds diminished in the bases. Occasional rhonchi, with wheezes present in both anterior and posterior upper lobes. Hyperinflation of bilateral lung fields and flattened diaphragm. Crackles present. 5 Liter of O2 given Productive cough- greenish/yellowish tenacious sputum. Neuro: AAO x3 UA- Voided 250- clear- yellow urine upon admission. Gastro- NPO Saline Lock- Left wrist, flushes fine Skin: Pt. states skin is itching and it’s dry. Itching and Pruritis is present on Left arm on left wrist. Assess his airways (to make sure he has a patent airway) and monitor the pts. Breathing pattern for signs of edema and Resp. distress (may indicate an anaphylactic reaction). Breath sounds are more diminished and pt. complains of pleuritic chest pain and increasing SOB.- Nurse must ask for another x-ray order- indicates pleural effusion. Pt. is getting ready for thoracentesis and he possibly needs a chest tube. Deep breathing and cough exercises as incentive spirometer did not work.

Pt. states Pain on left side. Pt. lungs was assessed- oxygen turned up for a bit, there is no movement in the chambers of the water so the pt. lungs must have re-expanded. Resp. Arrest- Code Blue was, Pt. was not breathing. Pt. was intubated. (Maintaining the patency of the drainage system prevents fluid accumulation in the client’s chest cavity- can lead to Resp. distress. Assessment of lung sounds must be assessed. Pt. has a pre-albumin deficiency. Prealbumin is a protein that is made mainly by your liver. Your body uses prealbuminto make other proteins. Prealbumin also carries thyroid hormones in the blood. The prealbumin screen is a blood test that used to be used frequently to see if you are getting enough nutrition in your diet. Tells you how the pt. thinned Pt. injured his arm. Recommendation: Client has an allergy to ampicillin (Unasyn) and now is receiving Rocephin. Itching and pruritis= presence of an allergic response. Should be evaluated promptly.- Abx was stopped and flushed. Pt. should not scratch or rub their chest or arms. Benadryl given for skin irritation.

Abnormal Labs: RBC- 4.8 Hgb-9.3 Hct- 29%. Normal= 40-54% WBC- 13,000 Ph- 5.5 BUN- 22 Normal =7-20 Creatinine- 1.0 Albumin- 3.0 Pre Albumin- 17 Glucose- 180 (Blood sugars ordered because of the steroid)- The body is under stress which raises blood sugars. AST- 45 (liver function levels is high)- continue monitoring Cholesterol- 225 Normal total cholesterol= <200mg/dL, LDL= 100 mg/dL pH- 7.30 PaCO2- 54mm Hg. Normal 35-45 Bicarbonate- 19 Normal 22-28 SAO2- 88%