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Case Study

 

HPI:

Joan Smith is an 84-year old female who has had a productive cough of green phlegm that started 4 days ago that persists. She was started three days ago azithromycin (Zithromax) 250 mg PO x 5 days by her primary doctor. Though she has had intermittent chills, she has had a fever last night of 102.0F/38.9C. She has had more difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement so she called 9-1-1 and was brought to the emergency department (ED) where you are the nurse who will be responsible for her care.

 

Personal Hx:

Joan was widowed six months ago after 64 years of marriage and resides in assisted living. She is a retired elementary school teacher. She called her pastor before coming to the ED and he has now arrived and came back with the patient. The nurse walked in the room when the pastor asked Joan if she would like to pray. The patient said to the pastor, “Yes please I feel that this might be the beginning of the end for me!”

 

PMH:

COPD/asthma

HTN

Hyperlipidemia

Cor-pulmonale

Anxiety

One pack per day smoker x 40 years; quit 10 years ago

Medications:

Fluticasone/salmeterol 1 puff q 12 hours

Albuterol MDI 2 puffs q 4 hours prn

Lisinopril 10 mg PO daily

Diazepam 2.5mg PO q 6 hours as needed

 

Current VS:

T 103.2F

P 110

R 30 labored

BP 178/96

O2 Sat 86% on 6 Liters per n/c

Pain 3/10 general pain on right side if chest

 

General Assessment:

Appears anxious and in distress; barrel chest present

RESP: Dyspnea with use of accessory muscles; diminished breath sounds nited throughout with scattered exp wheezing

CARDIAC: Pale, hot, dry, no edema; heart sounds regular S1S2, pulses strong 2+ at all landmarks

NEURO: A&O x4: to person, place, time, and location

GI: Abdomen soft/nontender; BS audible in all quadrants

GU: Voiding without difficulty; urine clear/light yellow

SKIN: Skin integrity intact; skin turgor elastic; no tenting present

 

Diagnostics:

CXR pending results

 

Lab:

WBC= 14.5 Prior was 9.2

Hgb= 14. Prior was 12.9

Platelets= 217,000. Prior was 298

Neutrophils= 92 Prior was 44

Sodium= 138

Potassium= 3.9

Glucose= 120

BUN= 32

Creatinine= 1.0

Lactate= 3.2

 

Urinalysis= WNL

 

Questions:

1)    What is the primary problem your patient is experiencing?

2)    What is the underlying cause of this problem?

3)    What are the clinical flags in this case study?

In presentation, VS, labs

4)    What would you expect to see on a CXR?

5)    What are our psychosocial and spiritual concerns for our patient and how can we address those?

6)    Provide a complete SBAR to the provider from what information you have.

SCIENCE
HEALTH SCIENCE
NURSING

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