RSPT 2266-2267

CASE STUDY

RSPT 2266-2267Patient Sticker

CASE STUDY

Student ______Date ______

Respiratory Diagnosis ______

A.Description of diagnosis (Describe the diagnosed illness/condition, i.e. etiology, symptoms, treatment, prognosis, etc. Use additional pages, if necessary.):

B.Demographic Data

Age: / Ht: / Wt: / Sex:
Occupation: / Admission date:
Other:

C.Health History

1.Chief complaint:

2.History of present illness:

3.Past medical history:

4.Family history:

D.Patient Assessment

1.Vital Signs:

Normal
Value / Admission / Last 5 days
Date/Time
HR
RR
BP
Temp
SpO2
FiO2
Input
Output

2.Breathing pattern:

3.Sensorium:AlertOrientedLethargicDrowsy

RestlessConfusedDisorientedComatose

4.Chest examination:

a.Auscultation:

1 Clear
2 Diminished
3 Absent
4 Wheezes
5 Rhonchi
6 Rales
7 Pleural rub

b.Size and shape of chest:

c.Excursion:

d.Chest pain and location:

5.Physical observations:

Respiratory
Distress / Cyanosis / Peripheral
Edema / Cough
Quality / Sputum
Amount / Sputum
Consistency / Sputum
Color / Clubbing
None / None / None / Clear / None / Thin / Clear / None
Mild / Nail beds / +1 / Tight / Small / Thick / White / Mild
Mod. / Fingers / +2 / Loose / Mod. / Viscid / Yellow / Mod.
Severe / Lips / +3 / Croupy / Large / Frothy / Green / Severe
Tongue / Harsh / Brown
Toes / Pink
Severe / Bloody

6.Other observations:

E.Diagnostic Imaging (admission)

Date/Procedure / Interpretation

Diagnostic Imaging (last 3 days)

Date/Procedure / Interpretation
Date/Procedure / Interpretation
Date/Procedure / Interpretation

F.Arterial Blood Gas Analysis

Admission / Last 3 ABGs
Date/Time
pH
PaCO2
HCO3-
PaO2
SaO2
FiO2
Vent Settings
Interpretation

G.Laboratory Studies

On admission - Date/Time:

Test / Normal / Patient
Result / Interpretation
Hb
Hct
Na
K
Cl
Ca
WBC
Total protein
Albumin
Glucose
Bilirubin
BUN
Creatinine

Date/Time:

Test / Normal / Patient
Result / Interpretation
Hb
Hct
Na
K
Cl
Ca
WBC
Total protein
Albumin
Glucose
Bilirubin
BUN
Creatinine

Date/Time:

Test / Normal / Patient
Result / Interpretation
Hb
Hct
Na
K
Cl
Ca
WBC
Total protein
Albumin
Glucose
Bilirubin
BUN
Creatinine

Date/Time:

Test / Normal / Patient
Result / Interpretation
Hb
Hct
Na
K
Cl
Ca
WBC
Total protein
Albumin
Glucose
Bilirubin
BUN
Creatinine

H.Bacteriology

Sample / Date / Result (include Abx sensitivity)
Sputum
Blood

I.Pulmonary Function Studies

Date/Test / Normal
Values / Patient Result / Interpretation

J.ECG

Date/Time / Interpretation

K.Other(include date, time

L.Pharmacology

1.List all drugs the patient has received. Describe the action, dosage and frequency of each drug. Also identify possible cardiopulmonary side-effects of each drug.

Drug / Dosage/ Route / Freq / Classification/Action / Cardiopulmonary Side-Effects

M.Assessment

1.From your analysis of the subjective and objective information obtained, list all of the data that supports the respiratory diagnosis of this patient. Be specific and complete.

N.Evaluation

1.List all of the respiratory care procedures ordered for this patient. Describe the indication and the objective for each therapy.

Procedure / Indication / Objective

2.Analyze the respiratory care of this patient. Are the therapies/pharmacologic interventions attaining the intended outcomes? If not, what modifications should be made?

Procedure / Objective being achieved? / Therapy changes

3.Describe this patient’s prognosis. Will this patient require respiratory care following discharge from the hospital? If so, what therapy and where (what type of facility)?

O.Narrative Chronology

1.In a chronological narrative form, describe the course of this patient’s hospitalization. Include all respiratory care orders as well as the patient’s response to them. Do not, however, limit yourself to only respiratory matters. Please discuss the entire hospitalization experience. Use additional pages, if necessary.

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