Respiratory Clinical Case

Respiratory Clinical Case
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.

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PMH
History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year.
Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler, PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies
NKDA
ROS
Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures.
Physical exam
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18
Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing
Na – 134
K – 4.9
Cl – 100
BUN – 21
Cr – 1.2
Glu – 110
ALT – 24
AST – 27
Total Chol – 190
CBC – WNL
Theophylline – 6.2
Phenytoin – 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the South University Online Library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, and Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

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The care plan example provided here is meant only as a frame of reference for you to build your care plan. You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.
Name: Discussion Rubric

	Excellent 90–100	Good 80–89	Fair 70–79	Poor 0–69
Main Posting: Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.	40 (40%) – 44 (44%) Thoroughly responds to the Discussion question(s). Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. No less than 75% of post has exceptional depth and breadth. Supported by at least three current credible sources.	35 (35%) – 39 (39%) Responds to most of the Discussion question(s). Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. 50% of the post has exceptional depth and breadth. Supported by at least three credible references.	31 (31%) – 34 (34%) Responds to some of the Discussion question(s). One to two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Cited with fewer than two credible references.	0 (0%) – 30 (30%) Does not respond to the Discussion question(s). Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible references.
Main Posting: Writing	6 (6%) – 6 (6%) Written clearly and concisely. Contains no grammatical or spelling errors. Adheres to current APA manual writing rules and style.	5 (5%) – 5 (5%) Written concisely. May contain one to two grammatical or spelling errors. Adheres to current APA manual writing rules and style.	4 (4%) – 4 (4%) Written somewhat concisely. May contain more than two spelling or grammatical errors. Contains some APA formatting errors.	0 (0%) – 3 (3%) Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Posting: Timely and full participation	9 (9%) – 10 (10%) Meets requirements for timely, full, and active participation. Posts main Discussion by due date.	8 (8%) – 8 (8%) Meets requirements for full participation. Posts main Discussion by due date.	7 (7%) – 7 (7%) Posts main Discussion by due date.	0 (0%) – 6 (6%) Does not meet requirements for full participation. Does not post main Discussion by due date.
First Response: Post to colleague’s main post that is reflective and justified with credible sources.	9 (9%) – 9 (9%) Response exhibits critical thinking and application to practice settings. Responds to questions posed by faculty. The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.	8 (8%) – 8 (8%) Response has some depth and may exhibit critical thinking or application to practice setting.	7 (7%) – 7 (7%) Response is on topic and may have some depth.	0 (0%) – 6 (6%) Response may not be on topic and lacks depth.
First Response: Writing	6 (6%) – 6 (6%) is professional and respectful to colleagues. Response to faculty questions are fully answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	5 (5%) – 5 (5%) is mostly professional and respectful to colleagues. Response to faculty questions are mostly answered, if posed. Provides opinions and ideas that are supported by few credible sources. Response is written in standard, edited English.	4 (4%) – 4 (4%) Response posed in the Discussion may lack effective professional communication. Response to faculty questions are somewhat answered, if posed. Few or no credible sources are cited.	0 (0%) – 3 (3%) Responses posted in the Discussion lack effective communication. Response to faculty questions are missing. No credible sources are cited.
First Response: Timely and full participation	5 (5%) – 5 (5%) Meets requirements for timely, full, and active participation. Posts by due date.	4 (4%) – 4 (4%) Meets requirements for full participation. Posts by due date.	3 (3%) – 3 (3%) Posts by due date.	0 (0%) – 2 (2%) Does not meet requirements for full participation. Does not post by due date.
Second Response: Post to colleague’s main post that is reflective and justified with credible sources.	9 (9%) – 9 (9%) Response exhibits critical thinking and application to practice settings. Responds to questions posed by faculty. The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.	8 (8%) – 8 (8%) Response has some depth and may exhibit critical thinking or application to practice setting.	7 (7%) – 7 (7%) Response is on topic and may have some depth.	0 (0%) – 6 (6%) Response may not be on topic and lacks depth.
Second Response: Writing	6 (6%) – 6 (6%) is professional and respectful to colleagues. Response to faculty questions are fully answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	5 (5%) – 5 (5%) is mostly professional and respectful to colleagues. Response to faculty questions are mostly answered, if posed. Provides opinions and ideas that are supported by few credible sources. Response is written in standard, edited English.	4 (4%) – 4 (4%) Response posed in the Discussion may lack effective professional communication. Response to faculty questions are somewhat answered, if posed. Few or no credible sources are cited.	0 (0%) – 3 (3%) Responses posted in the Discussion lack effective communication. Response to faculty questions are missing. No credible sources are cited.
Second Response: Timely and full participation	5 (5%) – 5 (5%) Meets requirements for timely, full, and active participation. Posts by due date.	4 (4%) – 4 (4%) Meets requirements for full participation. Posts by due date.	3 (3%) – 3 (3%) Posts by due date.	0 (0%) – 2 (2%) Does not meet requirements for full participation. Does not post by due date.
Total Points: 100

Name: Discussion Rubric

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Respiratory Clinical Case