FEVER AND PROBLEMS BREATHING

/in /by

 FOR: NIGHTINGALE

Assignment will be chosen related to clinical assignment. Each student will choose a client that you had had your clinical rotation for a case study that you want to investigate. The case study must be approved by your course instructor by the end of your third clinical rotation. The student will research their issue and find current evidence, at least three (3) peer-reviewed nursing research articles related to their condition/issue.

Two weeks prior to the due date of the paper as indicated on the course outline, the student will submit an outline of their paper to their course instructor that includes the student name, case study overview, nursing practice issue, and references in APA format.

The paper must include the following items: 1. Title Page with student’s name2. Client HPI/PMH 3. Client FMH/ROS

  1. Client Medications/Allergies
  2. Client PE that you completed
  3. Client Laboratory/Diagnostic Test results
  4. Nursing Practice Issue related to client situation
  5. How the RN has assigned/delegate/supervised LPN, Certificated Nurse Aide, MedicationAide, and the Unlicensed Personnel
  1. Short summary of the three research articles related to condition/issue
  2. References 

CHIEF COMPLAINT: FEVER AND PROBLEMS BREATHING

HISTORY OF PRESENT ILLNESS

 This is a 67 year old female with history of right MCA territory infarct with resultant left hemiparesis and aphasia, Type 2 diabetes mellitus, hyperlipidemia and anemia, who was sent over from Senet Care Nursing Home  to Global Hospital for a temperature of 100.5 degrees and hypoxia of 85%. 

PAST MEDICAL HISTORY

–RIGHT TERRITORY CVA WITH LEFT HEMIPARESIS AND APHASIS

–HYPERTENSION

–TYPE 2 DIABETES MELLITUS

–HYPERLIPIDEMIA

FAMILY MEDICAL HISTORY

–CABG

–CORONARY ARTERY DISEASE

–CANCER

SOCIAL HISTORY

–no alcohol, drugs or illicit drug use

PATIENT MEDICATIONS AND ALLERGIES

–FAMOTIDINE

–LANTUS SOLUTION

–SPIRONOLACTENE

–GABAPENTIN SOLUTION 250 MG/5ML

–IPRATROPUM-ALBUTEROL SOLUTION

–ASPIRIN TAB

ALLERGIES

PENICILLIN

PATIENT PHYSICAL EXAM

–NONE

PATIENT LABS/DIAGONOSTIC TEST RESULTS

–ABNORNAL RBC

–ABNORMAL HEMOGLOBIN

–ABNORMAL PLATELET COUNT