Nursing 296 Transitions Patient Situation EHR  J.P is a 54-year-old male, 65”, 200 lbs., who appears to be 70.  He has just been readmitted to General Hospital for the fifth time in 3 months.  He is usually admitted f

Nursing 296 Transitions

Patient Situation

EHR

 J.P is a 54-year-old male, 65”, 200 lbs., who appears to be 70.  He has just been readmitted to General Hospital for the fifth time in 3 months.  He is usually admitted for treatment of problems related to his severe COPD.  He has been progressively short of breath.  He has just started with an occasional cough productive of moderate amount of yellow sputum.  His current temperature is 99.8.  His history reveals no known allergies.  He has difficulty voiding in the past with complaints of voiding frequently in small amounts and nocturia.  He was diagnosed last year with Benign Prostatic Hypertrophy and underwent Transurethral Resection of the Prostate.  He has suffered from Rheumatoid Arthritis for the last 5 years. 

        Because of his COPD, which greatly limits his physical exertion; J.P. is considered 100% disabled and has not worked for the past 8 years.  In between hospital stays, he lives in a two-room apartment.  He has a hot plate on which he cooks, but does not have a refrigerator.  He shares a bathroom with ex-Navy buddies.  In the hospital, J.P. is rather well-known and generally liked, because he is so familiar with the environment, he is often in an informal leadership position with new patients.  His major complaint with the hospital is its non-smoking policy, strictly enforced.

        Despite repeated teaching J.P. smokes, a pack and a half of unfiltered cigarettes a day.  The basic physiology of his disease and its relationship have been explained to him repeatedly.  He tells others that smoking is the only source of pleasure left to him.  Whenever he is breathing easy enough, he walks to the sun room and lights a cigarette.  “Live fast, love hard, die young---that’s my motto,” he frequently tells the nursing staff.

        Upon exam J.P. states along with his other recent symptoms, he has not had much of an appetite and has been slightly nauseous.  His doctor felt it was due to his medications.  He has drunk 400 mL in the last 24 hours.  He is alert and oriented x3, pupils are equal and reactive @3mm.  He is HOH and wears glasses for reading.  His color is dusky, skin is warm and dry.  His resp are 26, regular with some use of shoulder and abdominal accessory muscles.  O2 sat 88% RA.  He always in orthopneic position in bed or in the chair.  He is barrel chested and uses pursed lip breathing when he becomes SOB.  Scattered rhonchi and expiratory wheezing are heard throughout both lung field.  He has an occasional cough productive of a moderate amount of thick yellow sputum. His AP is 104 with 4 irregular beats per minute and a fair volume.  BP 160/80.  Bowel sounds are present in all 4 quadrants.  His abdomen is soft and nondistended.  Currently he has been voiding every 4-5h.  His 24-hour urine output was 1000 mL (300 7-3, 400 3-11, and 300 11-7).  His last BM was this AM-mod. soft brown BM.  His lower extremities are pale and slightly cool to touch, Peripheral pulses are palpable bilaterally. Has 2+ pitting bilateral ankle edema.  His hands, writs and feet are often painful and swollen due to arthritis.  His joints are stiff especially in the AM.

Diet, Treatments and Medications

2gm Sodium Restricted Diet

02 @2L/M

CPT (Chest Physiotherapy) with postural drainage every 4 hours

Aerosol Albuterol Sulfate 2.5mg every 6 hours

Theophylline 300 mg every 12 hours PO

Prednisone 40mg PO Daily

Cefuroxime 750mg IV every 8 hours

Ibuprofen 300mg PO 4 times a day

Acetaminophen tabs 650mg PO or supp PRN for temp 101 or above

Ondansetron 4mg IV every 6 hours PRN

MOM 30 mL’s PO PRN

Terbutaline (Brethine) 0.3mg SQ every 3 hours PRN for SOB

Diagnostic Test Results:

CXR: Consistent with emphysematous blebs and cardiomegaly

EKG-Sinus Tachycardia

CBC-RBC  4.02          Hgb  11         Hct 32%

        WBC  18,000

        Segs  76%        Bands 10%    Eos 3%   Basos 3%

        Monos 10%      Lymphs 24% 

Sputum Culture-no growth

Theophylline Level-13.8

Lytes-NA 138 mEq

        K 3.6 mEq

        Cl 100 mEq

        CO2 25mEq

Glucose 110

Cholesterol 200

BUN 20, Creatinine 1.0

Urinalysis

        Appearance-clear                   Sp. Gr. 1.015                 pH 6.2           color-amber

        Protein-neg                         Glucose-neg                Ketones-neg