Shortness of Breath WBS
 
 
 
 

Shortness of Breath - WBS

1 years ago by: Naomi Clark
 
 
  • 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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