NURSING CARE PLAN

Mrs. Clarita Santos is a 63-year-old patient that presents to the emergency room with a history of coughing and wheezing for the past 5 days. Originally, she thought she was getting a cold;
however, her symptoms have been getting worse, and she states she has never felt this "sick" from a cold. She presented herself today because she feels like she has become shorter of breath
over the past 24 hours. She tells you that she started feeling sick approximately 5 days ago. It started with a dry cough; however, over the past couple days she has expectorated some clear, and
more recently, thicker rust-colored, mucous or sputum. She said that her sputum doesn’t contain blood but it become rustier in color. She notices some wheezing after episodes of coughing.
This morning, Mrs. Clarita Santos woke up in a "severe coughing" and she said she felt some sharp pain in her chest. She rates the pain a 8/10 when it occurs. She has felt feverish over the past
few days; she sometimes gets the "chills." Her highest temperature was 38.9 degrees Celsius.

Patient Medical History: hypertension, Habits: smoker for 30 years

BP: 110/80, HR: 100, RR: 28, T: 38.8, O2sat: 94%, Physical exam: fatigued appearing, congested cough Wheezing and rhonchi right lower chest with expiration, appears weak, pale and slightly
cyanotic

ASSESSMENT
SUBJECTIVE DATA:
 For the past 5 days the patient
experiences history of coughing
and wheezing that started with
a dry cough and some wheezing
after episodes of coughing
 Client reports shortness of
breath over the past 24 hours
 The client states that over the
past couple days she has
expectorated some clear, and
more recently, thicker rust-
colored, mucous or sputum that
does not contain blood
 Client experienced severe
coughing and sharp chest pain
rated at 8/10, and has felt
 feverish over the past few days,
with a highest recorded
temperature of 38.9 degrees
Celsius
 The client woke up with “severe
coughing” and sometime get
the “chills” as verbalized.
 Patient has history of
hypertension
 The client is a smoker for 30
years

OBJECTIVE DATA
BP: 110/80
HR: 100
RR: 28
T: 38.8
O2sat: 94%

Physical exam:
fatigued appearing, congested
cough wheezing and rhonchi right
lower chest with expiration,
appears weak, pale and slightly
cyanotic