West Coast University Clinical Judgement Plan Concept Map
Description
complete the concept map based on the case study below.
C.J., a 20-year-old female college student, is admitted to the emergency department (ED) with a severe asthma attack after engaging in a tennis match. She is accompanied by her tennis partner, who drove her to the ED. On an initial assessment you see that she is sitting in an upright position, using her accessory muscles to breathe. She appears restless and anxious. Her vital signs are T 98.4° F (36.9° C), HR 128 beats/min, RR 34/min, BP 160/82. C.J. manages to tell you that she has a long history of asthma but that this is the worst attack she has ever experienced. She cannot identify any triggers that she may be sensitive to and has never been tested for allergens. She does not smoke or use alcohol. She had been using a bronchodilator metered-dose inhaler about once a day but has misplaced it.
Lab values
Na: 146
K: 3.8
WBC: 4.5
Cl: 102
Hgb: 10.0
Hct: 34.0
Platelets: 181
Orders received on the unit include: breathing treatment Q6H, CBC, CMP, BNP, PT/PTT/INR in am; chest x-ray; activity as tolerated; pulmonology consult; telemetry monitoring; albuterol 5mg INH Q6H, Methylprednisolone 40mg IV daily, Ativan 0.5mg PO Q12H PRN.
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