SOUTHEASTERN COMMUNITY COLLEGE

RESPIRATORY THERAPY PROGRAM

PATIENT CASE STUDY

 

 

 STUDENT NAME: ___________________  FACILITY: ______________    DATE:_________

 

 PATIENT INITIALS: _______  DATE OF BIRTH: _____________  SEX:___________

 

 CODE STATUS: _______  ADMISSION DATE: _________ CHIEF COMPLAINT:___________

 

 Admission diagnosis:        ____________________________________________________________

 

Past medical history: __________________________________________________________________________

 

 

 ASSESSMENT OF PATIENT:

Heart rate: _____    Respiratory Rate:_____   Sao2:_____   Blood Pressure:__________

Breath sounds:_____________________________________________________________

Cough and sputum: __________________________________________________________

Color:________________    Neuro status:______________________________________

Chest inspection:___________________________   Extremities:__________________

Date and result of last chest x-ray________________________________________________

____________________________________________________________________________

How do the patient's physical findings relate to diagnosis?_____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

 

 

LAB VALUES:

Na+________                K+_______   Cl- ________    Hemoglobin & Hematocrit________________

WBC _____________    RBC_____________    Glucose ___________   BUN ___________

Creatinine _________     PT/PTT ____________________   Bilirubin____________

Blood or sputum culture results___________________________________________________

Relate any abnormal finding with patient's condition___________________________________

____________________________________________________________________________

____________________________________________________________________________

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RESPIRATORY CARE:

 

Oxygen device and setting: __________________________________________________________________________

 

Ventilator/IPPB/CPAP/BIPAP setting: __________________________________________________________________________

 

___________________________________________________________________________

 

Arterial blood gas result and interpretation:_________________________________________________________________

 

______________________________________________________________________________

 

Additional respiratory care orders: (Tx 's, CPT, etc)__________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Indications for above therapies: ____________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

What are possible complications of above therapy?_____________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 

What changes in therapy would you suggest and why? __________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 MEDICATIONS:

List patient's current medications: ___________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

 

What are the indications for these medications? ____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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PATIENT COURSE

Summarize the patient's hospital course up to this time: ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

What is the patient's prognosis? Support your conclusion. _____________________________________________________________________________

_____________________________________________________________________________

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