CASE STUDY 1,2,3,4,and 5 - Harry Smith, 70 years of age, is a male patient
1. Harry Smith, 70 years of age, is a male patient who is admitted to the medical-surgical unit with acute community-acquired pneumonia. He was diagnosed with paraseptal emphysema 3 years ago. The patient smoked cigarettes one pack per day for 55 years and quit 3 years ago. The patient has a history of hypertension, and diabetes controlled with oral diabetic agents. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. The admission vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 101 bpm, respiratory rate 28 breaths/min, and temperature 101.5°F. The pulse oximeter on room air is 85%. The CBC is as follows: WBC 12,500, platelets 350,000, HCT 30%, and Hgb 10 g/dL. ABGs on room air are pH 7.30, PaO2 55, PaCO2 50, HCO3 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation reveals severely diminished breath sounds in the right lower lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum. (Learning Objective 3)
a. What nursing assessment findings support the diagnosis of pneumonia?
b. What diagnostic findings support the diagnosis of pneumonia?
c. What nursing diagnoses should the nurse formulate for the patient?
d. What goals should the nurse develop for the patient?
e. What overall interventions should the nurse provide?
2. Marie Perez, a 53-year-old patient, is day 1 after a gastric bypass. She complains of shortness of breath; her respiratory rate is 30 breaths/min, heart rate is 110 bpm, pulse oximetry 89% on room air, temperature is 100°F, and her blood pressure is 90/50 mm Hg. She complains of feeling anxious and having stabbing chest pain which gets worse with inspiration. She complains that she feels like she is going to pass out or possibly die. (Learning Objective 7)
a. What could possibly be going on with the patient and what measures should the nurse provide immediately?
b. What risk factors does the patient have for a pulmonary embolus?
c. What measures are appropriate to manage a pulmonary embolism?
d. What measures are appropriate to help the patient in this case study prevent the reoccurrence of a pulmonary embolism?
3. Howard Long is 50 years of age and is a male patient who is diagnosed with bronchiectasis. The patient has smoked 1 pack per day of cigarettes for 35 years. He has a long history of recurrent bronchial infections. He has a chronic productive cough with copious amounts of purulent sputum. The patient complains that he is short of breath even at rest. The patient has clubbing of his fingers. The chest CT scan reveals bronchial dilation.
a. How should the nurse explain to the patient and family the pathophysiology of bronchiectasis as it related to the symptoms the patient is experiencing?
b. How should the nurse explain to the patient and family the goals of medical management that may be used to treat the bronchiectasis?
c. What does the nursing management for bronchiectasis entail?
4. Sallie Thorp, a 21-year-old client presents to the physician’s office with an asthma action plan form she acquired from a literature search on the World Wide Web at http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf . She also brought in the wallet card she found at http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf . She states that she would like to develop the plan with the help of the nurse and physician and review it at each appointment to keep it current. She has had moderate persistent asthma for five years, and she has visited the emergency department several times in the past year with severe asthma attacks. She stated that she forgets to take her medications, because the medications are at times that the hospital provided the inhalers (12 noon and midnight), and she gets confused on which inhalers are the long-acting ones and which inhaler is the short-acting rescue inhaler she is supposed to use when she has an exacerbation. The client stated that if she could, she would like to take the inhalers at 8 AM and again at 8 PM. The client stated that she has a flow meter and a respiratory therapist at the hospital taught her how to use it in the past, and he wrote down her personal best peak flow, which is 400 liters/second. The nurse reviews the client’s medical chart and discovers that the client has been prescribed the following from today’s visit:
• albuerol (Proventil)- 2 to 4 puffs every 20 minutes for up to 1 hour as rescue inhaler. If symptoms improve, then take the inhaler every 4 hours for 1- 2 days. If no improvement after 2 days, call the physician.
• Salmeterol (Serevent)- 50 mcg every 12 hours.
• Fluticasone (Flovent)- 88 mcg or 2 puffs every 12 hours.
• Cromolyn sodium (Nasal Crom) one spray to each nostril once daily and before being exposed to known asthma triggers. You may use the spray up to every 4 hours.
• Measure peak flow meter every morning before using inhalers and record. Use peak flow meter as needed, if you develop symptoms- cough, shortness of breath, wheezing, chest tightness, use of neck and chest muscles to breathe, problems talking or walking because of extreme shortness of breath.
• Follow-up in three months.
• Have the nurse provide education on asthma self-management and fill out the action plan that the client brought with her today and have the physician review it and sign it.
• The nurse also notes that the medications have not changed from the last visit.
a. Explain the medications to the client and practice filling in the asthma action plan.
b. Explain ways to evaluate the client’s mastery of the content?
5. George Brown, 72 years of age, is a male patient who is admitted with the diagnosis of acute pulmonary edema secondary to acute left ventricular heart failure. The patient has a history of coronary artery disease that has been treated medically. The patient is anxious, pale, cold, clammy, and dyspneic. The vital signs are: blood pressure 88/50 mm Hg, heart rate 110 bpm, respiratory rate 32 breaths/min, and temperature 97°F. There are bubbling crackles and wheezing
throughout the lung fields and the patient is raising frothy blood-tinged clear sputum. The patient’s admission weight is 100 kg. (Learning Objective 4)
a. What first actions should the nurse take and what are the rationales for these actions?
b. What are the actions of furosemide that will help the patient?
c. What nursing actions should be implemented when administering a diuretic?
Solution: CASE STUDY 1,2,3,4,and 5 - Harry Smith, 70 years of age, is a male patient