{Author Name [first-name middle-name-initials last-name]}
{Institution Affiliation [name of Author’s institute]}
Care Plan Template
Patient Initials: ABC Age: 65 Sex: Female
Subjective Data:
HPI:
Dry cough for last two weeks
Low-grade fever from last two days, 101 degrees orally
Decreased appetite without nausea
Intense coughing makes uncomfortable during night
Needs to sit up to ease the breath
She had been prescribed inhalers in the past but not a regular user
Had taken antibiotics in the past on acute conditions
Mild activities trigger shortness of breath, due to a dry cough
Condition remained same for the past two weeks with a slight sore throat
Patient doubts that it is a heart problem or she has lung cancer
The patient’s symptoms have been worsening over the past two days.
She faced similar episodes in the past; latest was three months back when she had to visit emergency
Patient was suggested to be hospitalized, but she declined, she got released after several treatments and relief for symptoms
Patient was prescribed antibiotics and an inhaler
The patient claimed it the worst episode, she is worried about her symptoms and thinks that she has developed pneumonia and required hospitalization
Patient seeks medical attention due to fever and extended illness
PMH:
Was prescribed antibiotics and inhalers but not hospitalized in the past
Had chest investigation in the last episode
Patient was sure that she had not pneumonia but emphysema
She had denied for pulmonary function tests
Her X-ray reports showed evidence of emphysema, Hyperinflation of both lungs with increased AP diameter
Patient had asthma in childhood and is a cigarette smoker
Had a hysterectomy 40-45 years back
ROS normal, No other chronic medical problems, No diaphoresis, No palpitations
Shortness of breath but no chest pressure sensation during physical activity
No regular medicines, Occasionally Tylenol 650 mg for pain
Allergic to sulfa drugs that cause a rash
Significant Family History:
Widowed for 20 years, annual pension of $40,000.00 and some savings
A high school diploma, owns a house; finances are essentially stable
Not much aware of community resources
Patient visits her primary care provider for a physical examination three to four times each year
Owns an insurance but not sufficient enough to bear all her prescriptions and bills
Mother of two grown-up daughters staying in a nearby community
Daughters are in their forties, alive and well
Wants her daughters to be more concerned about her but hesitant to approach them
Frequently visit church, her daughters
Social/Personal History:
Takes healthy and adequate diet
No sufficient exercises due to shortness of breath
Chain smoker, one pack per day for 40 years, major cause of her condition (Screaton & Koh, 2014)
No substance or alcohol use
Retired hairdresser and loves sewing
Two older sisters, alive
One 75 years old, diagnosed with osteoporosis at 55
Second sister 72- year-old diagnosed with breast cancer at 60
Description of Client’s Support System:
Daughters and contacts from church
Alone on regular basis, no one to talk
Behavioral or Nonverbal Messages:
Positive health beliefs, ready to learn
Aware of her condition, believes depression responsible for her physical symptoms
Self aware, well oriented
The client’s self-efficacy is decreasing and feeling depressed due to little socialization
Self-oriented and enjoys her session with her physician.
Objective Data:
Vital Signs including BMI:
Vital Signs including BMI:
Vital Signs: BP: 130/72; R: 20, non-labored;
T: 101 po;
P: 100 and regular; Wt: 130#; Ht: 55”
Physical Assessment Findings:
HEENT: White substance on the buccal mucosa, No Lymph Nodes
Lungs: Reduced breath sounds, dull to percussion right lower lobe. End-expiratory wheezing in the right lower lobe
No rales or rhonchi. Increased AP diameter
Heart: RRR without murmur
Carotids: No bruits, Abdomen: Benign
Rectum, Genital/Pelvic, Neurologic: Not examined
Pulses: 2+ pulses throughout, no edema
Lab results/radiological studies/EKG interpretation: Normal
CBC- WBCs 15,000
Pulse oximeter reading: SAO2: 98%
Ready to learn, understands her condition and probable reasons for it
ICD-10 Diagnoses/Client Problems:
Advanced Practice Nursing Intervention Plan
Nursing diagnosis: Ineffective breathing pattern, dry cough, hyperinflation of lungs evidence of Emphysema
Expected Outcomes: Intervention will improve patient’s breathing patterns, Patient will maintain clear airways with relieved breathing during any activity (Ackley & Ladwig, 2013)
Nursing interventions
References
Ackley, B. J., & Ladwig, G. B. (2013). Nursing diagnosis handbook: an evidence-based guide to
planning care. Elsevier Health Sciences.
Emedicine.medscape.com,. (2016). Emphysema Medication: Bronchodilators, Corticosteroids,
Phosphodiesterase-4 Inhibitors, Smoking cessation therapies, Antibiotics. Retrieved 22
Icd10data.com,. (2016). 2016 ICD-10-CM Diagnosis Code J43.9 : Emphysema, unspecified.
Retrieved 22 January 2016, from http://www.icd10data.com/ICD10CM/Codes/J00-
J99/J40-J47/J43-/J43.9
Screaton, N. J., & Koh, T. (2014). Emphysema and smoking-related lung diseases. Imaging.
