Week 2: Respiratory Clinical Case Patient Setting: 65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle accident presents to the clinic today. States she is having severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today. HPI Frequent asthma attacks for the past 2 months (more than 4 times per week average), serious MVA 10 weeks ago; post traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy. PMH History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed 3 years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year. Past Surgical History None Family/Social History Family: Father died age 59 of kidney failure secondary to HTN; Mother died age 62 of CHF Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of coffee and 4 diet colas per day. Medication History Theophylline SR Capsules 300 mg PO BID Albuterol inhaler, PRN Phenytoin SR capsules 300 mg PO QHS HTCZ 50 mg PO BID Enalapril 5 mg PO BID Allergies NKDA ROS Positive for shortness of breath, coughing, wheezing and exercise intolerance. Denies headache, swelling in the extremities and seizures. Physical exam BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3” VS after Albuterol breathing treatment - BP 134/79, HR 80, RR 18 Gen: Pale, well developed female appearing anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Cardio: Regular rate and rhythm normal S1 and S2. Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-distended no masses. GU: Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema, on right, no bruising, normal pulses. NEURO: A&O X3, cranial nerves intact. Laboratory and Diagnostic Testing Na - 134 K - 4.9 Cl - 100 BUN - 21 Cr - 1.2 Glu – 110 ALT – 24 AST - 27 Total Chol – 190 CBC - WNL Theophylline - 6.2 Phenytoin - 17 Chest Xray – Blunting of the right and left costophrenic angles Peak Flow – 75/min; after albuterol – 102/min FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% Chamberlain College of Nursing NR361 Course Project Milestone 1 Template Directions: Prior to completing this template, carefully review Course Project Milestone 1 Guidelines. After saving the document to your computer, type your answers directly on this template and save again. This assignment is due by Sunday end of Week 2 by 11:59 p.m. Mountain Time. Name: __________________________ Assignment Criteria NOTE: See Milestone 1 Rubric for details required in each area. Scenario for Milestone Assignment: Scenario is clear and ...

1. Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the
hospital 10 weeks ago after a motor vehicle
accident presents to the clinic today. States she is having severe
wheezing, shortness of breath and
coughing at least once daily. She can barely get her words out
without taking breaks to catch her breath
and states she has taken albuterol once today.
HPI
Frequent asthma attacks for the past 2 months (more than 4
times per week average), serious MVA 10
weeks ago; post traumatic seizure 2 weeks after the accident;
anticonvulsant phenytoin started – no
seizure activity since initiation of therapy.
PMH
History of periodic asthma attacks since early 20s; mild
congestive heart failure diagnosed 3 years ago;
placed on sodium restrictive diet and hydrochlorothiazide; last

2. year placed on enalapril due to
worsening CHF; symptoms well controlled the last year.
Past Surgical History
None
Family/Social History
Family: Father died age 59 of kidney failure secondary to HTN;
Mother died age 62 of CHF
Social: Nonsmoker; no alcohol intake; caffeine use: 4 cups of
coffee and 4 diet colas per day.
Medication History
Theophylline SR Capsules 300 mg PO BID
Albuterol inhaler, PRN
Phenytoin SR capsules 300 mg PO QHS
HTCZ 50 mg PO BID
Enalapril 5 mg PO BID
Allergies
NKDA

3. ROS
Positive for shortness of breath, coughing, wheezing and
exercise intolerance. Denies headache,
swelling in the extremities and seizures.
Physical exam
BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”
VS after Albuterol breathing treatment - BP 134/79, HR 80, RR
18
Gen: Pale, well developed female appearing anxious. HEENT:
PERRLA, oral cavity without lesions, TM
without signs of inflammation, no nystagmus noted. Cardio:
Regular rate and rhythm normal S1 and S2.
Chest: Bilateral expiratory wheezes. Abd: soft, non-tender, non-
distended no masses. GU:
Unremarkable. Rectal: Guaiac negative. EXT: +1 ankle edema,
on right, no bruising, normal pulses.
NEURO: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Testing
Na - 134
K - 4.9
Cl - 100

4. BUN - 21
Cr - 1.2
Glu – 110
ALT – 24
AST - 27
Total Chol – 190
CBC - WNL
Theophylline - 6.2
Phenytoin - 17
Chest Xray – Blunting of the right and left costophrenic angles
Peak Flow – 75/min; after albuterol – 102/min
FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Chamberlain College of Nursing NR361
Course Project Milestone 1 Template
Directions: Prior to completing this template, carefully review
Course Project Milestone 1 Guidelines. After saving the

5. document to your computer, type your answers directly on this
template and save again. This assignment is due by Sunday end
of Week 2 by 11:59 p.m. Mountain Time.
Name: __________________________
Assignment Criteria
NOTE: See Milestone 1 Rubric for details required in each area.
Scenario for Milestone Assignment:
Scenario is clear and concise, including a disease process,
diagnosis, OR identify a patient with a desire to maintain good
health and prevent illness. Include the nurse’s assessment of
learning needs and readiness to learn.
50 points
Education:
Describe in detail content planned for teaching this patient in
the scenario.
40 points
Identify the mHealth application:
Identify a mHealth app that could benefit the patient. Describe
the app including the mHealth app name, purpose, intended
audience, mobile device(s) upon which it will operate, where to
download or obtain it. Include a working link if it is to be
downloaded from a website. Add any other information you
believe would be pertinent to this situation. Make sure to add a
citation for this mHealth app in APA format.
45 points
NR361 Course Project Milestone 1 Template.docx

6. 07/19 JMJ
2
Running head: NAME OF CARE PLAN 1
Title of Plan of Care
Name
South University Online
Faculty Name
NSG 6001
Date

7. NAME PLAN OF CARE 2
**Please delete this statement and anything in italics prior to
submission to shorten the length
of your paper.
Patient Initials ______
Subjective Data: (Information the patient tells you regarding
themselves: Biased Information):
Chief Compliant: (In patient’s exact words)
History of Present Illness: (Analysis of current problems in
chronologic order using symptom
analysis [onset, location, frequency, quality, quantity,
aggravating/alleviating factors, associated
symptoms and treatments tried]).
PMH/Medical/Surgical History: (Includes medications and why
taking, allergies, other major

8. medical problems, immunizations, injuries, hospitalizations,
surgeries, psychiatric history,
obstetric and history sexual history).
Significant Family History: (Includes family members and
specific inheritable diseases).
Social History: (Includes home living situation, marital history,
cultural background, health
habits, lifestyle/recreation, religious practices, educational
background, occupational history,
financial security and family history of violence).
Review of Symptoms: (Review each body system - This section
you should place POSITIVE for…
information in the beginning then state Denies…). - General:;
Integumentary:; Head:; Eyes: ;
ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:;
Genitourinary:; Musculoskeletal:;
Neurological:; Endocrine:; Hematologic:; Psychologic: .
Objective Data:
Vital Signs: BP - ; P ; R ; T ; Wt. ; Ht. ; BMI .
Physical Assessment Findings: (Includes full head to toe
review)
HEENT:

9. Lymph Nodes:
Carotids:
Lungs:
Heart:
Abdomen:
Genital/Pelvic:
Rectum:
Extremities/Pulses:
Neurologic:
Laboratory and Diagnostic Test Results: (Include result and
interpretation.)
Assessment: (Include at least 3 priority diagnosis with ICD-10
codes. Please place in order of
priority.)
Plan of Care: (Addressing each dx with diagnostic and
therapeutic management as well as
education and counseling provided).
NAME PLAN OF CARE 3

10. References