Patient Care Plan
our patient is a 23-year-old female. She presents with coughing and wheezing which she stated started about three weeks ago. She is currently 25 weeks pregnant. Her last prenatal visit was one month ago in another state. She has an appointment with the prenatal care provider next week, however her respiratory symptoms brought her to your office today. History – Chickenpox as a child. Asthma as a child, diagnosed at age 8 for which she used a SABA when needed.
She has not had the need to use an inhaler since she was 19. She takes only her prenatal vitamin. No other acute or chronic problems. She advises you that she is up to date on all immunizations except she has not had a flu shot (it is October). Social – Non-smoker, no drug use. She relocated to your state two weeks ago to get away from an abusive domestic situation. She has no support network in this area and has not yet found employment. She has no medical insurance. HPA – Non-productive cough x 3 weeks. Wheezing audible from across the room.
She states it is like this all day and wakes her from sleep every night. She reports that she is fatigued even in the morning. No other complaints. PE/ROS – Pt appears disheveled but clean. Wheezing in all lung fields. T 98, P 82 regular, R 28 no stridor. FH 130 regular.
The remainder of the exam is WNL. 02 98% and FEV 70% Directions: Construct a narrative document of 4-5 pages (not including cover page or reference page) Diagnose the patient based on the above findings and provide your rationale for how you arrived at the diagnosis.
● An accurate diagnosis with correct staging is provided
● Rationale for arrival at the diagnosis with support from national guidelines is provided Develop a treatment plan specifically for this patient, pharmacologic and non-pharmacologic.
● Correct medications are prescribed to treat the diagnosis
● Rational for medications prescribed adheres to national guidelines
● Five or more non-pharmacologic interventions are provided Describe community resources (using your own community) currently available in your state/city to support this patient.
● Three or more local community resources are provided Provide a communication plan that you will use to ensure the patient is an active participant in the treatment plan. Refer to therapeutic communication concepts.
● A communication plan which includes principles of therapeutic communication is developed Utilize national standards, your pharm(Pharmacotherapeutics for Advanced Practice Nurse Prescribers 5th ED) and/or patho(Porths Pathophysiology Concepts 10th ED) book, and medical or advanced practice professional sources. Do not use patient-facing sources or general nursing texts. Use references to support your concepts. Utilize correct APA formatting (7th edition) and mechanics of professional communication.
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● Professional, peer-reviewed, advanced practice references are used not more than 5 years old
● Grammar and mechanics of writing demonstrate graduate level work
● Adheres to page number requirements