Respiratory therapy - Essay Example

Respiratory Therapy This is a soap S is for ive how the patient feels o is observation of the patient an assessment of the patient p planof treatment for the patient This report is about a 79 year old man admitted to the hospital because of the "cough, fever and right lobe infiltrate." He smoked about 2 packs of cigarettes per day since he was 14, and drank alcohol when out of duty. His health at 65 when he retired was good. At 63 he was admitted to the hospital due to a myocardial infarction where he was treated and recovered well.

Nevertheless he continued to drink 4 to 6 bottles of beer a day; he exercised every day by power walking and in his yard S: Before his admission to the hospital, the patient reported "flu like symptoms." He had "chills, a mild fever and the hacking, nonproductive cough. He did not see a doctor although he was advised to. At the point when his fever reached 38.3 C (101F) and he was experiencing shortness of breath he drove himself to the hospital. O: Patient was well-nourished, and in respiratory distress n 2l/min oxygen by nasal cannula.

His blood pressure was 165/90, heart rate of 120 bpm, respiratory rate of 33/min and oral temperature of 39.5 C (105F). "He demonstrated a frequent strong "hacky" and productive cough of white and yellow sputum. His skin appeared pale and damp." At the pronunciation of the 99 phrase the increased tactile and vocal fremitus were observed over the right lower lung along with bronchial sounds in the same region. His oxygen saturation was 87% and his arterial blood gases were as follows: "pH 7.56, PaCO2 24 mmHg, HCO3 -24 mmol/L, PAo2-56mmHg.

His chest X-ray shows a right lobe infiltrated with pneumonia, air bronchograms, and alveolar consolidation. His white blood cell count was 21,000mm^3. S: The therapist performing the rounds, 6 hours later, noticed that the patient complained that his doctor is too "young" and that he feels worse when he came to the hospital, although at this time his vitals were better O: blood pressure 140/70, heart rate 125bpm, and temperature 38.9 C or 102 F, and a better respiratory rate; his cough was more stead and had a smaller amount of sputum;A: his skin appeared cyanotic, he demonstrated increased vocal fremitures over his lobes, and dull percussion notes, and bronchial sounds, and his SPO2 and ABGs had better values.

The next day as it was recorded by the round therapist:S: the patient slept most of the night and was breathing easier, the vitals got even better with his O: high blood pressure at 135/85, hr=90bpm, and resp, rate=19/min; oral temperature was 37.3C or 99F.; he also had strong nonproductive cough; chest ray indicated a partial resolution of the pneumonia, his bronchial breath sounds were audible and his SPO2 and ABGs values improved such as PaO2 163 mm Hg.