History of Present Illness (HPI), Pathophysiology of Admitting Dx

(Cite References) Medical, Surgical, Social History (1)

History of Present Illness

A.T. is a 56 y/o male admitted to Swift River Hospital unresponsive,

with multiple lacerations on his body. X-ray showed a CT scan

presented signs of blunt trauma to his upper left abdomen, his spleen

appeared to be completely ruptured.

 Patient was brought to the hospital following a motor vehicle accident,

paramedics report he was driving inoxicated and was ejected from his

vehicle upon impact. Pt has a history of chronic obstructive pulmonary

disease and tobacco use, putting him at higher risk of altelectasis post

surgery. He is currently four days post op with a splenectomy,

experiencing shortness of breath, with recent abgs demonstrating falling

PaO2 and an increased CO2 levels.

Pathophysiology

Hypoxemia: Pt AT’s admitting diagnosis is hypoxemia and this is the

reduction of oxygen levels in the blood from lung conditions such as

emphysema causes problems such as headaches and shortness of breath.

Severe cases can have an effect on heart (tachycardia) and brain

function (Copestead, 2019). He is currently experiencing cyanosis in his

extremities, weak peripheral pulses (+1), and shortness of breath.

Chronic Obstructive Pulmonary Disease (COPD): This is the reduction,

of lung function. It is a progressive disease characterized by labored

breathing, wheezing and chronic cough. Because it’s chronic, this

means that the patient has been experiencing these symptoms for over 6

months. This disease is related to A.T.’s history of tobacco use. As this

disease progresses, the patient could be at risk of end-stage respiratory

failiure, impaired function, bronchitis or emphysema.

Medical History

 Patient A.T. has history of hypertension, this is the chronic elevation of

blood pressure. In the US, about 75 million people have this disorder.

Blood pressure is determined by cardiac output against the systemic

vascular resistence. Various physiological mechanisms such as RAAS

and baroreceptors work together to manage vasodialation and

vasoconstriction, also the retention of sodium and water in order to

maintain adequate circulating blood volume. A.T.’s lifestyle contributes

to his consistently high BP, excess alcohol intake and smoking.

Surgical History

 Patient A.T. has surgical history of a splenectomy, ejection from his

vehicle caused blunt trauma to his left abdomen area. CT scan ruled out

it was a completely ruptured spleen. In this the procedure, the spleen,

sitting under the left rib cage near the stomach is removed entirely.

Social History

History of alcohol and tobacco abuse

Cultural considerations, ethnicity, occupation,

religion, family support, insurance. (1) (14)

A.T. is Chinese. Not religious. Has a brother that

consistently visits.

Diagnostic Test/ Lab Results with dates and

Normal Ranges (3)

Test Norms Date Current

Value

WBC 4.0-10.0 04/21/2020 6.7

HBG 14-18 g/dL 04/21/2020 13

HCT 42-52% (men) 04/21/2020 45

Na 135-145 mEq/L 04/21/2020 140

K 3.5-5.0 mEq/L 04/21/2020 4.5

Platelet 140-400 04/21/2020 420

BUN 10-20 mg/dL 04/21/2020 16

Glucose 60-120 mg/dL 04/21/2020 100

Ca 9.0-10.5 mg/dL 04/21/2020 9.9

Mg 4-8 mg/dL 04/21/2020 6

PCO2 35-45 mm Hg 04/21/2020 50

HCO3 22-26 04/21/2020 24

paO2 75-100 04/21/2020 67

CT

Scan

04/21/2020

X-ray 04/21/2020

Explaination of Abnormal Lab Values ex

Decreased PO2 Levels

- Decrease in pO2 levels (<80 mmHg) is indicative of

underlying health problems such as COPD or emphysema,

the patient is not receiving an adequate amount of oxygen

Increase of PCO2 Levels

- Increase of pCO2 is indicative of an absolute decrease in

ventilation/ ineffective ventilation

Patient Information

(1)

Name: A.T.

Age: 56

Gender: Male

Code Status: Full Code

DPOA: n/a

Living Will: n/a

Chief Complaint

Femur pain, Shortness of breath

Admitting Diagnosis

Hypoxemia

Erickson’s Developmental Stage Related to pt. & Cite

References (1)

Generativity vs. Stagnation (40-65 yrs)

-Patient A.T. displays the stage of Stagnation. This stage

in Erikson’s Development is characterized by feelings of

lethargy and lack of enthusiasm. This is indicated by his

continued use of substance and decline in health with

seemingly no motivation for improvement. According to

Erikson, during this stage of life, a person will do their

best to set aside their own thoughts of death, balancing it

with happiness and acceptance. They achieve this by

contributing to the next generation or “making your

mark” (Erikson, 1974).

NURS 121L-A Rev. 2-20

NURS 121L-A Concept Map

Student Name:

Instructor:

Patient Education (In Pt.) & Discharge Planning (home needs)

Goals for patient AT is to teach him proper use of oxygen therapy , and

teaching on woundcare. caregiver proper techniques for wound care,

how to change dressings and cleaning. Also, how to reposition himself to

prevent any skin break down. In addition, we will teach his brother about

wound care and oxygen therapy, requiring a teach back to ensure he can

successfully practice proper hand hygiene and aeseptic technique while

performing these tasks.

Also, because of his history of alcohol and tobacco use, he should be

referred to an AA program.

Intraprofessional Referrals:

- Home Health (LVN): Licensed vocational nurses have the

ability to administer medications and follow up on patient

care. These checks are to make sure the patient’s health is

improving and ensures med are up to date

- Physical Therapist (PT): Help patient restore normal

functional mobility following A.T.’s femur repair

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