What data from the histories is important and relevant; therefore it has clinical significance to
the nurse?
Relevant data from present problem Clinical significance Green phlegm
Chills Fever (102.0) Difficulty
...
What data from the histories is important and relevant; therefore it has clinical significance to
the nurse?
Relevant data from present problem Clinical significance Green phlegm
Chills Fever (102.0) Difficulty Breathing (no improvement with
albuterol) These vital signs clinically show signs
of infection. With the difficulty
breathing I would think about possible
respiratory infection
Relevant data from social history Clinical significance She was widowed 6 months ago after being
married for 64 years, and she feels like it is
the beginning of the end for her This is important because when caring
for her we need to keep in mind her
age, stressors in her life and any
limitations
2. What is the relationship of your patient’s past medical history and current meds?
PMH Home meds Pharm class Expected outcome
COPD/asthma Hypertension
Hyperlipidemia Cor-pulmonale Anxiety
disorder 1ppd smokerx40
years.Quit10
years ago
1. 1.Fluticasone/salmeterol 1
puff q12hrs
2. Albuterol MDI 2 puffs
q4hrs prn
3. Lisinopril 10mg po daily
4. Gemfribrozil 600mg po bid
5. Diazepam 2.5 mg po q6 hrs
prn
6. Triamterene-HCTZ 1 tab
daily
1. corticosteroid
2.bronchodilator
3. ACE inhibitor
4. cholesterol
5.benzodiazepin
e
6. potassium
sparing diuretic
1. improve breathing
2. open up airway in the
lungs
3. decrease blood pressure
and
open up blood vessels
4. decrease fatty acids
5. decrease anxiety and
calm
down
6. help body from not
absorbing too much salt and
keep potassium level from
getting too low
[Show More]