Respiratory Nurse Report
I. Patient Information
Patient Name: [Patient's Name]
Date of Birth: January 15, 1975
Medical Record Number: 123456789
Admission Date: June 10, 2050
II. Medical History
A. Respiratory Conditions
Previous diagnosis of chronic obstructive pulmonary disease (COPD).
History of asthma exacerbations.
Family history of respiratory illnesses.
B. Current Medications
Inhalers: Albuterol, Fluticasone
Oral medications: Prednisone
Compliance with prescribed therapy: Yes
III. Assessment Findings
A. Respiratory Assessment
Breath Sounds: Clear bilaterally.
Respiratory Rate: 18 breaths per minute.
Oxygen Saturation: 98% on room air.
B. Physical Examination
IV. Diagnostic Tests
A. Pulmonary Function Tests
B. Imaging
V. Care Plan
A. Goals
B. Interventions
Inhaler education and demonstrations were provided to the patient and their families.
Smoking cessation counseling was initiated.
Regular monitoring is needed for signs of respiratory distress.
VI. Patient Education
Self-Management
Emphasized the importance of medication adherence.
Demonstrated correct inhaler technique.
Instructed on recognizing and reporting exacerbations.
VII. Follow-Up
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