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Shortness of Breath - WBS
- Shortness of Breath
- Psychosocial/Cultural
- Baptist
- Member of church for 20 yrs
- Church members occasionally visit
- Brother
- lives hr away
- diabetic
- hates to bother him
- son
- lives on west coast
- daughter
- lives in florida
- lives alone
- no primary care physician
- goes to quick clinic
- Protective (Integumentary & Immune)
- face flushed
- skin warm and dry
- temperature 100.6
- lips and mucus membranes pink
- wbc 11
- hct 39.0
- hb 14.0
- BUN 10
- K 3.7
- Na 140
- Cl 106
- Sensory/Perceptual & Activity/Mobility & Comfort/Rest (Neuro & Musculoskeletal)
- difficulty sleeping
- wakes up coughing
- frequently tired
- confused at times
- alert & oriented X3
- wbc 11
- hct 39.0
- hb 14.0
- BUN 10
- K 3.7
- Na 140
- Cl 106
- Fluid Gas Transport Respiratory
- history of chronic bronchitis
- chronic cough
- paroxysmal episodes
- respiratory rate 28
- labored
- coughing up thick, yellow secretions
- Xray - infiltrates in lower lobes
- barrel shaped chest
- bilateral wheezes, rales, and rhonchi
- does smoke
- 2 packs day
- 40 yrs
- inhaler 3-4 per day
- over the counter
- lips and mucus membranes pink
- wakes up coughing at night
- uses sternocleidomastorid and abdominal muscles while breathing
- tripod position while breathing
- wbc 11
- hct 39.0
- BUN 10
- K 3.7
- Na 140
- Cl 106
- Fluid Gas Transport Cardiovascular
- BP 156/88
- Pulse 94
- no edema
- peripheral pulses 3+
- Rocephin IV 500 mg IM x T
- hct 39.0
- hb 14.0
- wbc 11
- EKG - nsr
- BUN 10
- K 3.7
- Na 140
- Cl 106
- Nutrition/Metabolism (Nutrition & Endocrine)
- 3 meals a day
- low fat
- includes fiber
- doesn't cook
- 4-5 glasses of water per day
- glass of red wine a day
- lost weight
- 25 lbs in last year and half
- weighs 135
- height 5'5"
- hct 39.0
- BG 234
- hb 14.0
- wbc 11
- BUN 10
- K 3.7
- Na 140
- Cl 106
- Elimination Gastrointestinal
- bowel sounds present
- abdomen soft and non-distended
- occasional constipation
- eats prunes
- wbc 11
- hct 39.0
- hb 14.0
- BUN 10
- K 3.7
- Na 140
- Cl 106
- Elimination Urinary
- BUN 10
- Creatinine - 0.6
- K 3.7
- Na++ 140
- Cl- 106
- wbc 11
- hct 39.0
- hb 14.0
- Growth & Development (Reproductive)
- female
- breast cancer
- 10 yrs ago
- radical mastectomy
- chemotherapy
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