A 56-year-old African-American was acquainted with the medical staff because of frequent episodes of upper respiratory infections. The woman worked 40 or more hours per week as a file clerk at a local health department and was known as a hard worker. Despite what she described as her “chronic cold”, she rarely missed a day of work, although she frequently needed to request permission to leave work early because of doctor appointments. Fortunately, her immediate supervisor was a compassionate person and understood the woman’s health problem and frequent requests to leave early.
The woman’s hospital chart showed that her respiratory problems began when she was in her early teens. During that period, frequent upper respiratory tract infections and an annoying cough been her only symptoms. The chart also stated she had been a smoker of about one pack of cigarettes per day during her teen years. Over the years, she had quit and restarted smoking many times. For the previous several years, she had treated herself with aerosolized bronchodilators and kept a humidifier running in her room most of the time. She frequently had been given antibiotics in alternating cycles. Her husband often administered chest percussion and postural drainage at home, and she found this treatment helpful for acute flare-ups (cough and increased sputum production).
The woman stated that she had not smoked for 3 months. Over the previous 6 months, however, she stated that she had lost both weight and her generally “good spirits”. She further stated her cough had been almost continuous, with production of copious amounts of foul-smelling, purulent sputum. She denied hemoptysis. She also indicated the her co-workers had become concerned about her condition and recommended that she seek immediate medical attention.
The patient appeared well nourished and and complained of severe, nearly constant shortness of breath; a frequent, strong cough; and purulent sputum production. She appeared cyanotic, and her fingers and toes showed mild clubbing. She performed pursed-lip breathing and used her accessory muscles of inspiration. Cough episodes produced large amounts of foul-smelling yellow-green sputum.
Her vital signs were as follows: bloop pressure 185/90, heart rate 110 bpm, respiratory rate 30/min, and oral temperature 37.9 degrees centigrade (100.2 degrees feihereint). Palpation of the chest and percussion of the lungs revealed no remarkable abnormalites. On auscultation, bilateral rhonchi and persistent crackles over the lung bases were heard.
questions on the above case study are as follows:-
- (a) write 3 nursing diagnosis specific to the patient (b) create SMART GOAL for each nursing diagnosis ( c ) write 3 intervention for each nursing diagnosis
- Using the case study, write a SOAP note
- Using the case study, document using a SBAR