One of the patients assigned to you is a 54-year-old man who
One of the patients assigned to you is a 54-year-old man who came… One of the patients assigned to you is a 54-year-old man who came to the hospital because of a productive cough and fever for 3 days. He was diagnosed with right lobar pneumonia shown on a chest x-ray taken at the ER. This is his 3rd hospital day, on the telemetry monitor. Past medical history includes Angina, NIDDM, HTN, HLD, left inguinal hernia post-repair at age 4 years old, and Chronic Bronchitis. He has a 30 pack-year history of smoking cigarettes (1 pack per day), but he quit 4 years ago when he was diagnosed with Chronic bronchitis. He still drinks 1 shot of whisky per day. He was diagnosed with recurring non-incarcerated left inguinal hernia 9 months ago. Home medications include. Hydralazine, Dipyridamole, Metformin, Aspirin, and Gemfibrozil. The patient is a new immigrant who arrived in the US 2 months ago and has not established a primary physician. In the ED, other than Chest X-ray, CBC revealed WBC of 19,000 with a predominance of neutrophils, 12 leads ECG with occasional PAC’s, and 1 PVC in the rhythm strip. O2 sat is normal. No history of chest pain prior to the onset of cough and fever. The patient’s medications from home were continued except for Dipyridamole and Atorvastatin was substituted for Gemfibrozil. He was started with Ceftazidime IV. For the last 24 hours, he has been afebrile, WBC count is at 14,000 but continues to have coughing sometimes incessantly. At the beginning of your shift, he complained of mild lower abdominal pain 9/10. You gave oxycodone 5 mg po. The patient was relieved. At around past midnight your patient developed incessant coughing, the nurse administered guaifenesin PO and he had some partial relief but was still coughing occasionally. Two hours later the patient complained of a more severe abdominal pain. 1. With the patient’s current complaint of abdominal pain, how will you focus your assessment to arrive at the patient’s problem? 2. What problem do you suspect for the patient? After identifying the problem, what nursing diagnosis and care plan will you implement. Health Science Science Nursing NURS 221
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