NIKKA T.

DABLIO
BS NURSING 3B
NCM 71

Case Study, Chapter 23, Management of Patients With

Chest and Lower Respiratory Tract Disorders
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; PaO 2 , 55;
PaCO 2, 50; and HCO 3 , 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.
a. What nursing assessment findings support the diagnosis of pneumonia?
In patients with pneumonia, there will be a complaint of fatigue and
difficulty breathing along with the difficulty speaking (inability to complete a short
sentence). Tachycardia, tachypnea, cyanosis, decrease in oxygen saturation,
diaphoresis, and fever will also be observed. Moreover, atelectasis can also be
an indication and an altered mental status can be seen in patients with infection.
b. What diagnostic findings support the diagnosis of pneumonia?
Chest x-ray and CBC results can support the diagnosis of pneumonia. In
chest x-rays, a patient with pneumonia will reveal a presence of apical bullae,
right lower lobe consolidation, and a small pleural effusion. For the CBC, there
will be an increased number of WBC.
c. What nursing diagnoses should the nurse formulate for the patient?
The nursing diagnoses will be impaired gas exchange, deficient fluid
volume, ineffective breathing pattern, and fatigue
d. What goals should the nurse develop for the patient?
The goal should be the elimination of complications; improving the airway
patency, maintenance of proper fluid volume, maintenance of adequate nutrition,
and promoting rest.
e. What overall interventions should the nurse provide?
The interventions should be assessing the rate, rhythm, and depth of
respiration, chest movement, and use of accessory muscles; auscultation of lung
fields to assess for decreased adventitious breath sounds; monitoring of the
patient’s hydration status and maintaining adequate hydration to minimize
thickening of secretions; observe sputum characteristics; monitor ABGs, chest
x-ray and pulse oximetry reading to assess the progress of the patient; Anticipate
the need for supplemental oxygen to correct hypoxemia; elevate head of bed to
promote chest expansion; suctioning to provide patent airway; administering of
medications as ordered; assist with bronchoscopy and thoracentesis; educate and
assist the patient with deep breathing and coughing exercises promote full aeration and
drainage of secretions.
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.
a. What could possibly be going on with the patient and what measures should the
nurse provide immediately?
The patient's signs and symptoms are consistent with Pulmonary
Embolism, which is a common complication after surgery. Tachypnea,
tachycardia, shortness of breath, hypoxia, and hypotension are the signs and
symptoms. Furthermore, she is anxious and complains of a stabbing chest pain
that worsens with inspiration. Interventions includes: encouraging ambulation and
active and passive leg exercises to prevent venous stasis; monitoring
thrombolytic and anticoagulant therapy through INR or PTT; turning patient
frequently and reposition to improve ventilation-perfusion ratio; assessing for
signs of hypoxemia and monitor the pulse oximetry values and encouraging the
patient to talk about any fears or concerns related to this frightening episode.
b. What risk factors does the patient have for a pulmonary embolus?
Surgery, old age, and immobility are the risk factors the patient has for
pulmonary embolus.
c. What measures are appropriate to manage a pulmonary embolism?
The interventions should be: (1) teaching the patient to avoid activities that
contribute to venous thrombosis, such as prolonged sitting and standing; (2)
watching and reporting signs and symptoms of respiratory distress and bleeding
due to anticoagulant therapy. (2) monitoring of ABGs, blood chemistries, chest
x-rays, ECG, and pulmonary angiography; (3) assist in supportive care including
IV fluids, oxygen therapy, ROM exercises, and bed rest; administering
medications as ordered.
d. What measures are appropriate to help the patient in this case study prevent the
reoccurrence of a pulmonary embolism?
For the prevention of recurrence of pulmonary embolism, patient teaching
on adequate oxygenation (e.g. nasal cannula or oxygen mask), proper use of
spirometer and adherence to medication is a must. It should be emphasized that
the spirometer is important to prevent atelectasis and the medications ordered
will help with the perfusion and avoid clots.