J case Study - Worsening Asthma and Shortness of Breath - Nursing Assignment Help

Assignment Task:

Your patients name is J, she is 61 years old she lives with her husband S in her own home and she has a cat whom she adores.

J has a past medical history of asthma and has smoked for many years.

J was admitted 2 days ago to the respiratory ward with worsening asthma and shortness of breath. 

She presented with an irritating cough and is producing purulent sputum. 

She reports she developed a cold a few days before admission but her usual preventative medications didn’t relieve her symptoms. She is now unable to take more than a few steps before feeling very short of breath, wheezing and having to rest.

VITAL SIGNS

• Temperature of 37.5 deg.

• Blood Pressure is 150/80

• Pulse rate is 86bpm

• Respiratory rate is 22 rpm

• SaO2 is 94%

TESTS:

• Chest Xray

• FBE (full blood examination)

• HB (Haemoglobin) 

• Sputum specimen

• Urine specimen

These test results lead to a diagnosis of infective bronchitis.

Spirometry readings to be done before and after nebulisers 

A high protein, diabetic diet has been ordered 

J is to be encouraged to increase her intake of oral fluids. 

She is to be commenced on a fluid balance chart and diabetic food chart and is to have second daily weighs. 

MEDICATIONS:

• Ipratropium bromide inhaler 2 puffs BD / Spacer (Given for asthma)

•  Salbutamol nebulisers 1ml/1ml NS PRN (Given for asthma)

• Gliclazide 30mg daily (Given for Diabetes)

• Oral Prednisolone 5mg daily (Given for asthma)

• Oral Amoxicillin 1g TDS with meals (oral) (Given for respiratory infection)

• Paracetamol 665mg x 2 tabs TDS (oral) (Given for pain)

• Coloxyl 50mg BD PRN (Given for constipation)

• Pneumococcal and flu vaccines have been ordered to be administered before discharge once her condition has improved. (0.5 ml)

MEDICAL HISTORY:

• Asthma since the age of 32yrs.

• Diabetes Type II

• Osteo-arthritis since the age of 50yrs 

• Anxiety and depression for the past 5 yrs.

• Cholecystectomy in 1994

SOCIAL HISTORY:

J is a retired factory worker who lives with her husband S who is very supportive. 

She has 2 children B 40yrs & M 37yrs who live nearby. 

Both J & S are heavy smokers & have tried to stop smoking on several occasions. 

J has cut down to 10 cigarettes per day but is having difficulty stopping completely.

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