BSN 440 Discharge Plan

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Name: John Doe	DOB: 08/06/1956
Date of Admission: 6/2/2021	Assessment Date: 6/2/2021
Admitting Diagnosis: Hypercapnic respiratory failure, influenza A	Past Medical History (including surgical history)CAD, COPD, GERD, tobacco abuse, HTN, no past surgical procedure
Subjective history of current hospitalization (what led to current hospitalization?) Mr Doe stated that he has had a headache and sneezing, but when he came to the clinic, he developed a cough and breathing difficulties when standing up.
Family and social history Mr Doe is a widower with a daughter that lives with him. He died from a stroke at 70 years, and his father from lung cancer at 61 years. Mr. Doe actively works on his farm. The patient quit smoking ten years ago.
Summary of physical assessment (complete head-to-toe from hospitalization documentation) Mr. Doe is alert and oriented x3, strength +4 in all extremities, denies numbness or tingling. Pt. has a normal sinus rhythm, blood pressure 130/70, RR 27. Mr. Doe denies dyspnea but experiences breathing difficulties and wheezes noted in posterior bilateral. Pt skin is smooth and intact, no signs of infection were noted. O2 saturations at room air were 90%. Bowel sound active x4 quadrants.
Allergies: Lisinopril

Effects of diagnosis on daily living: Pt currently unable to ambulate and complete ADLs. He depends on his daughter.

References

Allergymontana.com (2021).Pulmonary Function Testing. allergymontana.com https://allergymontana.com/pulmonary-function-testing/

GoodRx. (2021). Stop paying too much for your prescriptions. goodrx.com https://www.goodrx.com/

Healthcarebluebook.com. (2021). Find your fair price. Retrieved from https://healthcarebluebook.com/page_ConsumerFront.aspx

By admin in Essays on January 27, 2023