Mike is a 69 year old man who presents to the outpatient office with a cough past medial history of hypertension and diabetes mellitus. his cough is productive bring up green phlegm runny nose, sore throat denies fever sore throat pain when swallowing. he has no story of smoking or seasonal allergies. on physical examination , temperature is 98/*f pulse 72 respiration 14 and blood pressure 134/64. lungs ; rhonchi present to bilateral upper lobes sat 98*/. ears TM bulging . nose erythema present with yellow discharge throat erythema present with pustules. he is currently taking metoprolol mg/day and metformin mg twice a day. 1. What are the subjective data in the scenario? 2. What are the objective data in the scenario? 3. What is the most likely medical diagnosis would the nurse expect the ED physician to diagnose the client with? 4. What is the pathophysiology of the disease process. 5. What diagnostic and or laboratory tests would the nurse anticipate the ED physician to order for this patient? 6. What are the reason for ordering or not ordering diagnostic and/or laboratory tests? 7. Provide one or two medications that would anticipate the ED physician to ordered for this client? 8. Identify the classification (s), and indication (s), and side effects of the medications that have anticipated the ED physician would Order. 9. Provide two nursing diagnoses for this client. 10. Provide four nursing intervention for this client. 11. Short term goal for this patient 12. Long term goal for this patient
Subjective data: past hypertension and diabetes. Runny nose, productive cough with green phelgum.
No sore throat, no pain in throat while swallowing.
Objective data: history of hypertension, diabetes, cough, runny nose, temp. 98/*f pulse 72 respiration 14 BP 134/64, ronchi present to bilateral upper lobe, TM bulging of ears, nose erythema with yellow discharge, throat erythema with pustules
Medical diagnosis: the most likely medical diagnosis acc. to symptom is upper respiratory tract infection with pneumonia
Sputum culture test is anticipated In order to rule out the infectious bacteria.
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