Reference no: EM134012786
Question
Write 3 focus charting (FDAR) on the following scenerio. Lisa is a 74-year-old woman who presents to the ER with shortness of breath and fever. Lisa has a 10-year h of chronic bronchitis and 2 years ago she was also confirmed to have emphysema.
Currently Lisa has a 4 day h of a cold that has progressed to chest congestion and sinusitis. She also complains of a sore throat that makes swallowing difficult. She complains of a constant hacking cough and reports she coughs up a lot of thick, yellow stuff". She states her chest is
"sore all the time and she has a stabbing pain of "8 out of 10" when she takes a deep breath or coughs.
Medical History
Lisa has a hx of frequent (2 to 3 times a year) respiratory infections requiring hospitalization.
Lisa was a 2 pack a day smoker until 2 years ago. She was also recently diagnosed with glaucoma. Lisa also has a hx of HTN and hyperlipidemia. She wears glasses.
Social History
Lisa is married and lives with her husband in a 2-bedroom condo. She retired from her job as librarian 9 years ago.
Initial impressions:
Lisa is diaphoretic and sitting upright leaning over her overbed table. Her breathing is labored and noisy. An IV was inserted in the ER (site - right dorsal hand, gauge - 20). An IV of NS is infusing at 100 mL/hr. The first dose of antibiotics was administered at 0400 in the ER. She has 02 at 6 L by face mask. She is not wearing her glasses. Her husband is pacing in her room and loudly insisting something be done for his wife as it is obvious she is in distress. Lab work has just come back.
Height 150 cm
Weight 61 kg
BP 146/90
HR 102
RR 28
Temp 39 degrees C
02 sats - 90% on 6 L 02 by facemask.