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Asthma Case Studies

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Charles Lewis
INSTRUCTOR: Professor Planillo
Patient initials: M,A
Date of assessment: 12/13/2014
Date submitted: 12/17/2014

Mr. M is a 67 year old Hispanic male, and is 5’7 216 pounds. Mr. M is married and has two grown children . He is a retired warehouse worker after a 30 year career. Mr. was unsure of his family history of disease processes, however, was able to accurately describe his current medical diagnoses. Patient was oriented to place, time, date, and time. Mr. scored an 18 on the Braden sale, The patient showed no signs and symptoms of sensory
Impairment, skin was occasionally moist, client walks occasionally with the assistance of a walker, mobility was slightly limited, nutrition was …show more content…

order and be asymptomatic.
Long term goal: Blood gas analysis results will be within normal limits by discharge. 1). Patient will be placed in bed in semi-fowlers position. (Rationale: Proper body positioning assists with respiratory excursion. 2). Provide oxygen according to patient need as directed by Physician.
(Rationale: Patient oxygen levels will assist with clearing the airways. 3). Assist patient with chest physiotherapy (Hinkle 2014 pg. 493) (Rationale: Chest physiotherapy will assist patient with clearing secretions.
4). Promote therapeutic relaxation imagery. (Rationale: Patient anxiety will lessen with guided imagery and music therapy. Mr. M’s. was taught to find the asthma irritants that exacerbate an asthma episode such as dust mites, animal dander, pollen, mold, and smoke. Mr. M. was also encouraged to cough and deep breath to keep his lungs and airways clear and free of secretions.
Risk for Falls: Short term goal: Patient will verbalize an understanding after being oriented to surroundings and instruction of safety measures. Long term goal: Patient will be injury free during hospital stay. 1). Complete a fall risk assessment (Rational: Fall risk assessment …show more content…

(Rationale: Communication with staff will ensure the patient will not have a fall. 3). Encourage the patient to use a walker or cane. (Rationale: A walker or cane will assist patient with ambulation. (Taylor. 2011 pg. 473-475). 4). Keeping call bell within reach and room free of clutter. (Rationale: Patient will be able to communicate with staff and safely ambulate. Mr. M. was encouraged to use a walker or cane when possible. Keeping a room from clutter, wearing nonskid shoes, and proper lighting will help Mr. M. in staying free from falls. Mr. M’s home should be assessed for safety prior to discharge.

References
Hinkle L. Janice, Cheever H. Kerry, (2014) Brunner & Suddarth’s textbook of Medical Surgical Nursing (13th Edition) Philadelphia: Lippincot, Williams & Wilkins.
Lynn, Pamela, (2011) Taylor’s Clinical Nursing Skills A Nursing Process Approach (3rd Edition) Pennsylvania: Lippincot, Williams & Wilkins.
Dewit, C. Susan, (2010) Medical Surgical Nursing Concepts & Practice, Philadelphia: Evolve Saunders, Elsevier
Buenzil, Wendy MSN, RN, Fauber, PHD, RN, Jones, Jackie, EdD, RN (2008) Nutrition

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