Plan of Care
Assessment
Patient Data
Name: Mr. J.N
Age: 52 years
Gender: male
Occupation: high-school teacher
Subjective Information
Chief complaint: cough, chest pain, difficulty in breathing, loss of consciousness.
History of presenting complaint: the patient J.N, a 52-year-old Caucasian was brought into the emergency department by his wife and son. He was diagnosed with asthma when he was 15 years and has been on follow-up for acute exacerbations. He had lost consciousness when he came in but later regained it. The wife and son reported that he had complained of chest pain, cough, and difficulty breathing moments before he went unconscious. The episodes came after he arrived home late and was exposed to house mites and pollen in the compound. Cough was productive and could barely complete sentences. He often forgets to use his inhaler. This is the third episode of presenting with the same symptoms in one month. He also smokes cigarettes. Does not attend any self-care groups and most of the time he doesn’t know what to do to alleviate his symptoms.
Allergy: he was allergic to house dust which often triggers his asthma attack
Current Medication: Inhaled albuterol 2 puffs when needed.
Past illness:
Review of systems
Constitutional symptoms: he reported fatigue, anxiety, and fever.
Cardiovascular: he reported palpitations, chest pain, cough, and difficulty in breathing.
Gastrointestinal: he denied nausea, vomiting, abdominal pain, diarrhea, or constipation.
Genitourinary: denies dysuria, burning sensation on urination, urgency, increased frequency, or hesitancy.
Skin: he reported itchiness. Denied bruising or bleeding.
Physical Findings.
Vital signs: temperature 99.7 F, respiratory rate 31 breaths/min, pulse rate 112 beats/min, oxygen saturation 85% on room air, pain level 5/10, blood pressure 134/89 mmHg
Mouth: pursed lips breathing and central cyanosis present. Clear and moist oropharynx
Nose: nasal flaring.
Eyes: wears glasses. No conjunctival bleeding. Pupil round, equal, and reactive to light.
Cardiovascular: hyperactive precordium, apex beat at the fifth intercostal space mid-clavicular line. Pulse with a regular rhythm, the rate increased at 112 beats/min, normal volume, and palpable pulses bilaterally. S1 S2 heard. No murmurs.
Respiratory: chest moves with respiration, use of intercostal muscles with intercostal recession. Expiratory wheezes on auscultation. Resonance on percussion.
Abdominal: abdomen moving with respiration, no swelling, tenderness, distention, or palpable masses.
Neurological: oriented and alert.
Skin: warm, intact, and dry.
Summary of the Assessment.
J.N is a 52-year-old male, known asthmatic patient since he was 15, and has been on management using albuterol. He complains of chest pain, cough, difficulty in breathing, and loss of consciousness. On physical examination, he has nasal flaring, tachycardia, tachypnoea, central cyanosis, and pursed-lip breathing, and uses accessory muscles for breathing. There is an evident lack of knowledge about the disease
Nursing Diagnoses
Planning of Care
Nursing goals