Reference no: EM133928119
Case Study
The client is a 71-year-old female admitted to the emergency department with shortness of breath and chronic cough. She is a retired secretary with 3 grown children who live nearby. Her husband of 44 years died a few months ago. She has never smoked but her husband did smoke constantly. She lives alone in a 2 story home and does not watch her diet. She sees her health care provider (HCP) regularly and they sent her to the ED. The client was recently diagnosed with COPD after being hospitalized for pneumonia and bronchitis for the 3rd time in 1 year.
Admission Vital Signs: Temperature 99.2 F, heart rate 88 bpm, respiratory rate 32, blood pressure 132/80 mmHg, pulse ox 88% on room air
Admission Assessment Findings: Height 5 feet 7 inches, weight 160 pounds, recent unintentional weight loss of over 10 pounds, breath sounds: congested, scattered crackles, diminished in the lower lobes bilaterally, intermittent wheezing. The client reports SOB with no movement and frequent cough.
Medical History: Osteoarthritis, fractured left hip after falling down the stairs in her home with ORIF surgery, frequent bronchitis - every winter for the past 3 years. The client takes OTC ibuprofen for arthritis pain and takes no other routine medications at home. She has completed the course of antibiotics ordered for her las episode of pneumonia.
Laboratory Values: ph 7.28, PC02 56 mmHg, Pa02 58 mmHg, HC03- 28 mEq/L, WBC 9,200, Hematocrit 32.4, Hemoglobin 11.2. No other diagnostic tests have been performed at this time.
Physician Orders: Admit client to Medical-Surgical Unit, monitor vital signs every 2 hours including pulse ox, regular diet, referral to a pulmonologist, respiratory therapy evaluation.
Questions:
1. What assessment and history data should the nurse evaluate that would indicate an alteration in Gas Exchange?
2. What pathology is possibly indicated by those findings? Provide a rationale for your answer and list the client's related risk factors.
3. What diagnostic tests are expected to confirm this diagnosis and evaluate the client's status and response to treatment?
4. What do the ABG results indicate and what pathology do they suggest/confirm?
5. Give at least 3 nursing diagnoses most appropriate for this client. What initial interventions/treatments would you recommend related to those nursing diagnoses? Provide a rationale for your answer.
6. What complications would be of concern to the nurse?
7. What discharge planning and teaching would be indicated?
8. Write a brief SBAR note from the perspective of the nurse calling the HCP related to the scenario following the client's admission to the medical-surgical unit. Situation, Background, Assessment, Recommendation...