Why the client is in the hospital: Medical diagnosis (does not include signs and symptoms) Admitting Diagnosis Information: This paragraph should describe the signs and symptoms that caused the patient to visit the hospital. It should not be what the doctor writes word for word. Paraphrase into your words. You may quote the patient. Definition/Etiology/Pathophysiology: This paragraph is to define and explain the admitting diagnosis/disease.
Fundamentals of Nursing Care Plan
| Client Data: | ||||||
| Initials: P.B. | Age: 80 years | Gender: Female | ||||
| Weight: | Height: | Race/Ethnicity: Caucasian | ||||
| Diet: Heart-healthy diet | Religion: Baptist | Language Spoken: English | ||||
| Allergies:
Latex Aspirin Sulfadiazine Adhesive bandage |
Marital Status: Married | Code Status: Full code | ||||
| Past Surgeries: N/A | Consults:
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Social Habits:
Occasional alcohol intake (once or twice per week) Non-smoker |
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| Vital Signs: | ||||||
| B/P: | P: | R: | T: | SAO2 sat:
|
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| 153/74 | 67 | 18 | 97.4 | 99% | ||
Present History: Admitting Medical Diagnosis:
- Why the client is in the hospital:
Respiratory failure
Admitting Diagnosis Information:
The patient presents with dizziness, difficulty breathing, shortness of breath, and chest tightness.
Definition/Etiology/Pathophysiology:
Respiratory failure occurs when the respiratory system cannot efficiently eliminate carbon dioxide or conduct oxygenation. Respiratory failure is hypercapnic (type Ⅱ) or hypoxemic (type Ⅰ) respiratory failure. Respiratory failure is further described as chronic or acute, depending on the symptoms duration.
Etiology of hypercapnic respiratory failure includes drug overdose, asthma, pulmonary edema, tetanus, cervical cordotomy, poliomyelitis, a chronic obstructive pulmonary disorder, polyneuropathy, porphyria, obesity hypoventilation, acute respiratory distress syndrome, primary muscle disorders, poisonings, myxedema, myasthenia gravis, and primary alveolar hypoventilation. Pneumothorax, bronchiectasis, a chronic obstructive pulmonary disorder, kyphoscoliosis, pneumoconiosis, pneumonia, asthma, pulmonary fibrosis, fat embolism syndrome, obesity, cyanotic congenital heart disease, pulmonary edema, and granulomatous lung disease cause hypoxemic respiratory failure.
Respiratory failure occurs through an abnormality in the central nervous system, alveoli, airways, chest wall, peripheral nervous system, and respiratory muscles. Respiratory failure occurs when there is a malfunction in transporting oxygen to tissues, removing carbon dioxide from the alveoli from blood, and transporting oxygen across the alveoli.
Clinical Manifestations/Signs and Symptoms:
The clinical manifestations of respiratory failure depend on the type of respiratory failure and the underlying disease. Patients diagnosed with respiratory distress present with dyspnea, cyanosis, hypoxemia, tachycardia, hypercapnia, pulmonary hypertension, tachypnea, and neurological manifestations such as anxiety, seizures, and restlessness. Patients with hypercapnic respiratory failure have a PaCO2 of more than 50 mmHg, while those with hypoxemic respiratory failure present with a normal PaCO2 and a PaO2 of less than 60 mmHg. Respiratory failure presents with acute respiratory distress syndrome with sepsis, lung compliance of 40 mL/cm water, pulmonary capillary wedge pressure less than 18 mmHg, and three or 4-quadrant alveolar flooding. Acute respiratory failure presents with several complications. Gastrointestinal complications include g