RUA Case Study Patient – Option #A -TC: COPD Exacerbation (Patient Case): T.C. is an 85 yr-old African American female admitted for COPD Exacerbation. Patient presented with worsening dyspnea

RUA Case Study Patient – Option #A -TC: COPD
Exacerbation
(Patient Case): T.C. is an 85 yr-old African American female admitted for COPD
Exacerbation. Patient presented with worsening dyspnea and wheezing over the
last 2 weeks, and productive cough. Patient regularly uses oxygen at home. Patient
lives alone in an apartment on the 4th floor (no elevator in the building). Patients’
neighbor brought her into the ED when she noticed patient having trouble getting
up the stairs to her apartment after going down to the first floor to do laundry.
Patient has not really been able to get out of her house in the past 4 weeks to
purchase goods including food, or to renew her prescriptions. Daily weights have
been ordered.
(Medical/Surgical History): COPD, Emphysema, Smoker x 50 years (still
currently smoking ? pack per day), Hypertension, Hyperlipidemia, Morbid
Obesity, and Bilateral Knee Replacement.
(Admission Vital Signs): T-38.4 C, Regular rhythm/HR-110, RR-25, SpO2-89%
on 4L oxygen with nasal cannula, BP-185/92, weight 113.4 kg/250 lb, height-5’2″
(Physical Assessment): (Neuro) A/O x 4, (Respiratory) Crackles/Rhonchi in lung
fields bilaterally with thick green sputum, (Cardiovascular) Irregular, S1 & S2
heard, (Integumentary) Stage II sacral ulcer & +3 pitting edema of lower
extremities bilaterally, (GI) Active bowel sounds in all 4 quadrants/diarrhea x 4
days, (GU) new finding of urinary retention/it’s been 4 hours since she urinated,
(Musculoskeletal) Generalized weakness/uses cane to ambulate to the toilet with 2-
person assistance
(Radiology Results): Chest x-ray shows diffuse opacities bilaterally (abnormal)
(Lab Results): WBC 14.18, Hgb 8.5, Hct 29, Glucose 287, CO2 10
(Medication Orders): Prednisone 20 mg daily, Montelukast 10 mg daily, Aspirin
81 mg daily, Hydrochlorothiazide 25 mg BID, Symbicort 160 mcg 2 puffs BID,
ProAir 1 puff q6hr PRN, Breo Ellipta 200/25 mcg 2 puffs daily
GIVE THE FOLLOWING
Assessment
Highlight key areas of concern
General appearance:
Vitals:
Neuro:
HEENT:
Cardiac:
Respiratory:
GI:
GU/Elimination:
Integumentary:
Musculoskeletal:
Psychosocial:
Labs/Diagnostics:
Pathophysiology (include what functional changes are occurring and what processes or issues initiated, lead, and are maintaining the disorder/disease)
Pertinent Medical diagnoses/Reason for hospitalization:
High priority NANDA diagnosis FOLLOW BY
Short term (ST) goal:
Long term (LT) goal:
3 ST interventions:
3 LT interventions:
Evaluation:

NANDA diagnosis FOLLOW BY
Short term (ST) goal:
Long term (LT) goal:
3 ST interventions:
3 LT interventions:
Evaluation:
Psychosocial NANDA diagnosis FOLLOW BY
Short term (ST) goal:
Long term (LT) goal:
3 ST interventions:
3 LT interventions:
Evaluation:
Give the following:
Linkages and Rationale of Diagnosis
(Short summary rationale for why these diagnosis were chosen and how they connect to the client’s current situation/condition)
Rationale for why goals were selected
(Should have a rationale for each short- and long-term goal. Provide references as applicable)

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