CASE STUDY FOR CARE PLAN
Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by paramedics after reporting severe dyspnea and shortness of breath. He has been experiencing cold-like symptoms for the past 2 days. He has a productive cough with thick greenish sputum.
When Mr. W awoke in the nursing home, it was found that he had difficulty breathing even after using his albuterol (Proventil) metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress.
His history includes chronic obstructive pulmonary disease related to smoking 2 packs of cigarettes per day since he was 15 years old. He also has a history of HTN and coronary artery disease. He had bypass surgery 15 years ago. Mr. W is a widower, his wife died 8 years ago. Mr. W has 2 grown children and several grandchildren who visit him weekly. His past occupation was a construction worker.
Initial vital signs:
Blood pressure 154/92 mm Hg
Heart rate . 118 bpm
O2 saturation . 88% on 1 L/min oxygen by nasal cannula
Respiratory rate . 38 breaths per minute
Temperature . 100.9 F (38.3 C)
In the ED, Mr. W undergoes a chest xray and admission labs are obtained including an electrolyte panel, CBC, and arterial blood gas. A sputum sample is sent to the lab for gram stain and culture and sensitivity.
RESULTS:
CBC . WBC 12000 mm3
HGB . 11.6 g/dL
HCT . 35.2 %
Electrolytes
Glucose . 122 mg/dL
Potassium . 4.1 mEq/L
Sodium . 135 mEq/L
ABG
PH 7.32
PaC02 . 55.4 mm Hg
Pa02 51.2 mm Hg
HC03 . 38 mEq/L
Chest Xray – results show abnormal air collections within the lung, lung hyperinflation, and lobular consolidation.
Assessment:
Pt is awake but drowsy. Auscultation of lungs notes bilateral crackles and decreased breath sounds. Pt reports pain of 3 out of 10 when he takes a deep breath.
Medications:
Proventil (Albuterol)
Lasix
Antipyretic
Appropriate antibiotic for probable pneumonia/lung infection
Anti-hypertensive medication
DIRECTIONS:
Students must use the care plan template and it must be submitted to the drop box for grading.
Each section of the care plan must be completed.
There must be 3 Nursing diagnoses (2 physical and 1 psychosocial). Nursing diagnoses must be NANDA approved.
If you have any questions or concerns, please contact an instructor.
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