Patient Profile T.A., a 45-year-old Caucasian, presented to the emergency department with shortness

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Patient Profile

T.A., a 45-year-old Caucasian, presented to the emergency department with shortness of breath, fever, and a cough that has lasted several days. T.A. is being admitted to the medical unit for treatment of pneumonia. She has a history of hypertension and type 2 diabetes mellitus (T2DM). She has been taking the following medications:

Metformin 500 mg PO BID; last dose last night
Lisinopril 20 mg PO daily; last dose yesterday morning

Subjective Data

Reports that home glucose results have been “higher than normal”
Smokes one pack of cigarettes a day
Has sharp pain in the right lower chest upon inspiration. Rates pain as a 6 on a scale of 1 to 10

Objective Data

Physical Examination

Temperature 101.4°F, pulse 108, respirations 26, blood pressure 150/92
Oxygen saturation 91% on room air
Awake and alert, oriented × 4
Body mass index (BMI) 33 kg/m2 with waist circumference 44 inches
Respirations symmetrical, slightly labored on any exertion, coarse crackles right lower lobes
Cough productive of thick yellow sputum

Diagnostic Studies

Lab values
Glucose 388 mg/dL
Hemoglobin A1C 7.9%
Chest radiography: infiltrates right lower lobe

Interprofessional Care

IV of 5% dextrose in 0.45% sodium chloride at 75 mL/hr
Oxygen at 2 L per nasal cannula
Regular Insulin subcutaneously per sliding scale four times a day
Levofloxacin 750 mg IV daily
Albuterol 2.5 mg nebulizer treatment every 6 hours

Question 1

Describe the factors placing T.A. at an increased risk of infection.

Question 2

What further assessment do you need to perform?

Question 3

What are priority interventions in caring for T.A.?

Question 4

T.A. asks why he is taking insulin here in the hospital when he does not take it at home. How would you respond?

Question 5

As you assess T.A., you note that he has bilateral paresthesia in his lower legs and a 1″ reddened area of skin on the top of his right foot, indicating the presence of neuropathy. Outline what you would teach him regarding proper foot care.

Question 6

Describe additional teaching you should provide T.A. before discharge.

SCIENCE
HEALTH SCIENCE
NURSING
NUR 215

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