COPD,CHF 케이스
- 최초 등록일
- 2016.07.16
- 최종 저작일
- 2016.04
- 7페이지/
한컴오피스
- 가격 3,000원
![할인쿠폰받기](/images/v4/document/ico_det_coupon.gif)
목차
1. Assessment
2. Nursing diagnosis
3. Planning
4. Opinion
본문내용
Client Background
111... , but recently diagnosed with CHF. He has become increasingly weak and tired, and has ankle swelling. His daughter brought him in when he could do longer get his shoes on.
The patient is alert and oriented x 3. VS: T 99℉, P 95 and regular. R 26, pulse oximetry on 2L 93%, SOB with activity, BP 154/90. Lungs decreased breath sounds at bases, scattered wheezes and crackles, +productive cough with green sputum. HR regular, no extra sounds, monitor NSR +1 pedal pulses, +2 pedal edema, abdomen large and round, +BS, soft, nontender, voiding qs. Weak bilateral handgrip and decreased strength in lower extremities.
<Assessment>
1. Personal information
Name : John
Gender : male
Age : 64
Diagnosis : COPD, CHF
2. Vital Sign
T : 99℉
P : 95 and regular
R : 26
BP : 154/90
Pulse oximetry : 93% (at 2L)
HR : regular, no extra sounds
<중략>
<Planning>
1. Nursing Diagnosis : Ineffective Airway Clearance r/t increasingly weak and tire, increasing bronchus secretion AEB (as evidenced by) decreased breath sound at bases, scattered wheezes and crackles.
참고 자료
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