History Present Problem Assignment Help: How to Answer This Question
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How to Approach This Question
Break the problem into smaller parts and analyze each logically.
Key Explanation
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Original Question
History of Present Problem: Laurie Ross is a 45-yr. old Hispanic woman with hypertension managed with hydrochlorothiazide. She is 63″ (160.2 cm) and weighs 79.3 kg (175 lbs) – BMI 31.0. She felt “crummy” and weaker the last 24 hours and called 911 when she began to have mid-sternal chest pain that increased with coughing and developed a harsh productive cough with green phlegm with difficulty breathing. Initial lab results: WBC 14.5, neutrophils 92%, Hgb 12.9, potassium 3.5, creatinine 1.1, total bili 0.9, ALT 42, chest x-ray revealed RLL infiltrate consistent with pneumonia, blood and sputum cultures collected and pending. Smell of ETOH present on her breath. Blood alcohol level 0.04, urine drug screen negative. She is admitted to the medical unit with a diagnosis of pneumonia. You are the nurse responsible for her care. Personal/Social History: Ms. Ross works in a mid-level management position for a corporate finance company. She describes her job as quite stressful. She drinks 4-5 cups of coffee every day and to least 1-2 alcoholic drinks most days. She states that she shouldn’t smoke and has cut down to about ½ a pack per day. She reports drinking more and sleeping poorly following her father’s death over a year ago. She takes alprazolam as needed for sleep or when she feels more anxious. She is hesitant to be admitted because she has a high deductible insurance plan and doesn’t know how she will be able to afford Describe a situation that required you as the nurse to formulate a correct clinical judgment to either advance the plan of care or to recognize clinical data that represented a change in clinical status in the case study? What can be learned from it What would you do differently? How you can use this knowledge in the future
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