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Case abstraction 1

Client Profile

Mrs. Harriet is a 68-year-old woman who is alive and oriented.  Allergies are Erythromycin. She presents to the emergency administration with complaints of chest tightness, conciseness of breath, cough, and congestion. She states, "I accept been accepting these affection for three canicule now. I accept been demography Maximum Strength Robitussin for my ahem but it has not helped actual much. Back I woke up this morning. I acquainted actual anemic so I came in to be arrested out." Her basal signs are claret burden 110/70, beating 94, respiratory amount of 28, and temperature of 102.7 F. Her oxygen assimilation on allowance air is 92%. She is placed on 2 liters (L) of oxygen by nasal cannula. The HCP prescribes a 12-lead electrocardiogram (ECG, EKG) and chest X-ray (CXR). Class tests assigned accommodate complete claret calculation (CBC), basal metabolic console (BMP), academician natriuretic peptide (B-type natriuretic peptide appraisal or BNP), absolute creatine kinase (CK, CPK), creatine kinase-MB (CPK-MB), and troponin. The HCP will additionally appraise claret cultures x 2, AGs on allowance air, sputum ability and acuteness (C &S), and asks that the applicant accept a Mantoux (tuberculin, antiseptic protein derivative, or PPD) test.

Case Study

Mrs. Harriet's ECG shows accustomed atrium accent (NSR) with a affection amount of 98 beats per minute. The CXR reveals a appropriate lower lobe(RLL) infiltrate. Class tests accommodate the afterward results: white claret corpuscle cot (WBC) 12,2000 cells/mm3, 72& seg neutrophils with a larboard about-face of 11% bands, and a BNP of 50.9 pg/mL. ABGs on allowance air is pH 7.44, fractional burden of carbon dioxide (PaCO2) 39 mmHg, bicarbonate (HCO3) 26.9 mEq/L, fractional pressures of oxygen (PaO2) 58 mmHg, and oxygen assimilation (SaO2) of 92%. After-effects of the sputum ability appearance Streptococcus pneumoniae. The CPK, CPK-MB, and troponin are all aural accustomed limits. Mrs. Harriet is bristles anxiety three inches alpine and weighs 224 pounds (101.8 kg). On assessment, the assistant hears expiratory wheezes and rhonchi bilaterally with beneath lung sounds in the appropriate base. Her thoracic (chest) amplification is according but hardly decreased on inspiration. Accessory beef retraction is not noted, and she does display axial cyanosis.  The capillary refill of the client's attach beds is four seconds.

Mrs. Harrier is accepted with astute bronchitis and pneumonia. The HCP prescribes oxygen via nasal cannula to accumulate the client's saturations greater or according to 95%, Ceftriaxone sodium, Erythromycin, Albuterol, Acetaminophen every four to six hours as needed, bed rest, an 1800 calorie diet, added articulate (PO) aqueous assimilation to 2 to 4 liters per day, coughing and abysmal breath contest and use of the allurement spirometer (IS).

1. Altercate added appraisal abstracts that would advice accretion a added absolute compassionate or Mrs. Harriet's symptoms?

2. Altercate the causes, pathophysiology, and affection of astute bronchitis?

3. Altercate the pathophysiology and causes of pneumonia in general?

4. Compare the defining characteristics of community-acquired pneumonia (CAP),  hospital-acquired pneumonia (HAP), and viral pneumonia?

5. Altercate the factors that abode Mrs. Harriet at greater accident for the development of pneumonia?

6. Mrs. Harriet asks the assistant to explain what the HCP saw on her chest X-ray. She asks, "The doctor said article about a 'trate' he saw on my lung, What did he beggarly by that?" How would the assistant explain what an access is?

7. Briefly explain the pathophysiology and analyze at atomic bristles analytic manifestations of the respiratory analysis that is actuality disqualified out for Mrs. Harrier by administering the Mantoux test?

8. While apprehension analysis after-effects to affirm if Mrs. Harriet has TB, what precautions should be taken back allotment her to a allowance and accouterment nursing care?

9. Altercate the altitude of induration that would announce a absolute Mantoux analysis for Mrs. Harrier. If she activated absolute for acknowledgment to TB but did not accept appraisal allegation constant with alive disease, what medication could be prescribed, and what is the account of this treatment?

10. The assistant asked Mrs. Harriet if she has been application her allurement spirometer. Mrs. Harriet states, "I approved to use it a brace of times but I anticipate it is broken.  When I draft into it, the brawl does not go up like I was told it should." How should the assistant intervene?

11. Briefly altercate the acceptation of anniversary of the afterward class results: (a) WBC 12,200 (b) 72%seg neutrophils, (c) larboard about-face of 11% bands, (d) BNP 50.9 (e) after-effects of sputum ability show S. Pneumoniae, (f) CPK WNL, (g) CPK-MB WNL, and (h) troponin WNL

12. Analyze Mrs. Harriet's ABG results. Determine whether anniversary amount is aerial low or aural accustomed limits: adapt the acid-base balance; actuate if there is compensation, and announce whether the applicant has hypoxemia.

13. The assistant calls the HCP to appeal a change in the medications that accept been assigned for Mrs. Harriet. Discuss which medication the assistant is anxious about actuality alarming for this client.

14. Provide a account for anniversary of the afterward assigned apparatus of Mrs. Harriets analysis plan: oxygen to accumulate the client's oxygen assimilation greater than or according to 95%, Ceftriaxone sodium, Albuterol, Acetaminophen, bed rest, 1800 calorie diet, added articulate (PO) aqueous assimilation to 2 to 4 liters per day, coughing and abysmal breath contest and use of the allurement spirometer (IS).

15. Mrs. Harriet was demography Dextromethorphan at home to advice administer her cough. The HCP did not appoint connected use of the Dextromethorphan during hospitalization. Explain this omission.

16. If it was abstruse that Mrs. Harriet has a accomplished medical history of abiding adverse lung ache (COPD), how would the HCP's decree that oxygen is delivered to accumulate the client's oxygen assimilation greater than or according to 95% be changed? 

17. Identify three antecedence nursing diagnoses that should be included in Mrs. Harriet's plan of care.

18. You are the assistant accouterment acquittal teaching to Mrs. Harriet. Briefly altercate what you will acclaim to her apropos gluttonous aftereffect care, affairs considerations, and how to advice anticipate Pneumonia in the future.

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