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2 pages/β‰ˆ550 words
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APA
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Health, Medicine, Nursing
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Case Study
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English (U.S.)
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Medical Surgical Nursing. Health, Medicine Case Study

Case Study Instructions:

Case study, chapter 23, management of patient with chest and lower respiratory tract disorders.
Harry Smith 70 years of age is a male patient who is admitted to the medical surgical unit with acute acquired community pneumonia. He was diagnosed with paraseptal emphysema 3years ago. The patient smoke 1 pack of cigarette a day for 55years and quit 3 years ago. The patient has a history of diabetes and HTN and is managed with oral diabetic agent. The patient with confusion as to time and place. The family stated that this is new change for the patient. The admission vital signs are as follow BP 90/50 mg/Hg, PR 101 BPM, respiratory rate 28 breaths per min and temp 101.5. The pulse oximeter room air is 85% room air. The CBC is as follows: White blood cells 12, 500, platelets 350,000, HCT 30%, and Hemoglobin 10g/dt. ABGs on room air are PH 7.30, PaO2 55, PaCO2 50, and HCO3 25. Chest X-Ray results reveal lower lobe consolidation, presence of apical bullae, flattened diaphragm and a small pleural effusion in the right lower lobe, Lung auscultation reveal severe diminished breath sounds at the base. The breath sounds in the rest of the lung are slightly decreased. The patient complain of fatigue and cannot finish a short sentence before the respiratory rate increase above the baseline and his lips and nail beds turns bluish tinge and the pulse oximeter decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient cough weakly but does but he does not raise any sputum (learning objectives 3).
1) What nursing assessment findings support the diagnosis of pneumonia?
2) What diagnostic findings support the diagnosis of pneumonia?
3) What nursing diagnosis should the nurse formulate for the patient?
4) What overall intervention should the nurse provide
Marie Perez a 59 years old, is day one after a gastric bypass. She complains of shortness of breath. Her respiratory rate is 30 beats/mins, heart rate 110 per minute and pulse oximeter 89% on room air. Temperature 100C 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 objectives 7).
What could possibly be going on with the patient and what measures should the nurse provide immediately?
Please answer should reflect gained knowledge of the disease process and apply it using critical thinking skills to the specific data in the case study.
Please use Brunner & Suddarth's
Textbook of medical surgical Nursing 13th edition for reference. Thank you

Case Study Sample Content Preview:

Medical Surgical Nursing
                                                              Capscare Academy
Case Study #1
Case study, chapter 23, management of patient with chest and lower respiratory tract disorders.Harry Smith 70 years of age is a male patient who is admitted to the medical surgical unit with acute acquired community pneumonia. He was diagnosed with paraseptal emphysema 3years ago. The patient smoke 1 pack of cigarette a day for 55years and quit 3 years ago. The patient has a history of diabetes and HTN and is managed with oral diabetic agent. The patient with confusion as to time and place. The family stated that this is new change for the patient. The admission vital signs are as follow BP 90/50 mg/Hg, PR 101 BPM, respiratory rate 28 breaths per min and temp 101.5. The pulse oximeter room air is 85% room air. The CBC is as follows: White blood cells 12, 500, platelets 350,000, HCT 30%, and Hemoglobin 10g/dt. ABGs on room air are PH 7.30, PaO2 55, PaCO2 50, and HCO3 25. Chest X-Ray results reveal lower lobe consolidation, presence of apical bullae, flattened diaphragm and a small pleural effusion in the right lower lobe, Lung auscultation reveal severe diminished breath sounds at the base. The breath sounds in the rest of the lung are slightly decreased. The patient complain of fatigue and cannot finish a short sentence before the respiratory rate increase above the baseline and his lips and nail beds turns bluish tinge and the pulse oximeter decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient cough weakly but does but he does not raise any sputum (learning objectives 3).1) What nursing assessment findings support the diagnosis of pneumonia?2) What diagnostic findings support the diagnosis of pneumonia?3) What nursing diagnosis should the nurse formulate for the patient?4) What goal should the nurse develop for the patient?
5) What overall intervention should the nurse provide?
1.    Nursing assessment findings support the diagnosis of pneumonia.
There are several findings from Harry Smith, the 70-year-old that may support the diagnosis of pneumonia. These include complains of fatigue and the inability of the patient to finish a short sentence before the respiratory rate increases above the baseline (Hinkle & Cheever, 2013). Also, the pulse oximeter of the patient has decreased to 82% and the patient recorded coughing. The patient also has a high temperature of 101.5 degrees Fahrenheit and elevated WBC count of 12,500 shows clearly that the patient has an infection. The patient also has respiratory rate of 28 breaths per minute and is also diaphoretic and is using accessory muscles. Also, the patient’s Lung auscu...
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