Conceptual Care Map (CCM) for Infection/Infection Control Phillip is a 70-year male widow, who lives in a nursing home. He used to smoke 1 pack of...

Conceptual Care Map (CCM) for Infection/Infection Control 

Phillip is a 70-year male widow, who lives in a nursing home. He used to smoke 1 pack of cigarettes per day for 40 years. In his younger years, Phillip was quite the drinker. He drank one thirty pack per week.

 The Charge nurse is notified by the CNA that he has been coughing a lot and spitting up yellowish green mucus. He refused his pneumococcal and Influenza vaccination 2 months ago when it was being administered to the other residents in the Nursing home. 

He is sent to the hospital for further examination and the following findings were noted:

Upon assessment from the E.R. nurse, he was noted to be dyspneic while speaking to the nurse and unable to complete full sentences without pausing to breathe. 

Assessment Findings:

Vital Signs: HR 115 bpm, RR 33 (labored), SpO2 83%, Temp 39.2℃ (102.56℉)

General Appearance: Skin appears dusky in color

Ears, Eyes, Nose, Throat (EENT): No bruises, masses, trauma or deformities noted to head. Neck has full Range of Motion (ROM). Mucous membranes moist, but lips cracked and peeling.

Cardiovascular: Tachycardic, pulses are present and regular in all 4 extremities, no extra heart sounds or murmurs. EKG shows Normal sinus rhythm.

Respiratory: Use of accessory muscles, respiratory distress apparent, decreased breath sounds with crackles present, dullness to percussion, increased fremitus, sputum profuse (yellow/green in color), asymmetric chest movements.

GastroIntestinal (GI): Normoactive x 4 quadrants. No abdominal bruits, masses, or organomegaly.

Extremities: ROM intact to all 4 extremities.

Neurological: Slight cognitive impairment evident by forgetfulness of his wife's name, but able to recall after some thought. A&O x3. PERRLA at 3 mm, moves all extremities, gait steady.

Skin: Dusky in color; poor turgor

His Lab Results:

WBC 4,5000 L (5,000- 10,000)

CK 1.6 H (0.8- 1.3)

BUN 42 H (6-20)

Hemoglobin 10.8 L (12-17)

Hematocrit 36.2 L (40-50)

Platelets 115,000 L (150,000- 450,000)

Sputum Culture results are pending