Case study help!

[bri2012]

i am working on this case study and just wanted to know if i am on the right path! any input would be helpful!

a 65y/o male is admitted to a medical floor altered mental status with sob and a productive cough of thick yellow secretions. the client has a history of smoking for 40 years 1pack/day; htn and takes hctz 25mg daily po. his admitting information: weight 115 lbs and 5' 7", vs: 162/84, 124, 36, 102 f, pulse ox 86% on room air. abgs: ph 7.32, paco2 50, pao2 68, hco3 28. other lab results: sodium 136, potassium 3.5, bun 28, creatinine 1.0. the admitting physician orders are bed rest; regular diet, start o2 at 2l nc and titrate up the o2 to maintain pulse ox > 90%, start iv d5.45 at 50ml/hr, obtain sputum specimen for c&s, and give albuterol 2.5mg via nebulizer every 4 hours and prn; tylenol 2 tabs every 4 hours prn for temp; vancomycin 500mg ivpb every 12hours.

1. what is your interpretation of the client's condition? list the abnormal data and what it means.

htn, bp 162/84

pulse 124 high

resp. rate 36 high

temp 102 high

pulse ox 86% low

2. what is your interpretation of the client's abg results?

ph 7.32 low

paco2 50 high = resp. acidosis

hco3 28 high

pao2 68 low= hypoxemia

3. in which order would the nurse implement the physician (collaborative) orders for this client?

first order:___bed rest_________________________________________

second order___obtain sputm_________________________________________

third order .____start ox at 2l nc________________________________________

fourth order.____start iv d.45 ________________________________________

fifth order: ____give albuterol__________________________________________

4. identify at least 3 nursing diagnoses:

ineffective airway clearance, activity intolerance, and impaired gas exchange

[dmw2489]

remember ABC's as your priority!!! A=Airway... does he have a problem with airway? B=breathing... does he have a problem with breathing? C=circulation... does he have a problem with circulation? I would change the orders around slightly... but look at the ABC's first!! what do his abnormal values mean?? are there any other values that you did not list here that were abnormal like a WBC count or an H&H? BUT FIRST THINK PRIORITY!!

[heavencutstma32]

look at the abnormal data - i would personally list the reasons or nursing dx to why it is low.. like example blood pressure, you listed high - i would list htn.. respiratory rate - instead of high list hyperventilation or tachypnea.. ect.

for nursing dx i would put 2 different ones.. i would use ineffective airway clearance. but look at the VS & think what can raise you BP, Pulse, and Respiratory Rate? Also what can increase your temp? I would put the physican orders in different order. just think about ABC (like the girl above said), what do you need to do first? second? look at the ABCs & think.

[Esme12, ASN, BSN, RN]

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

http://www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

http://www.rncentral.com/nursing-library/careplans

[Esme12, ASN, BSN, RN]

i am working on this case study and just wanted to know if i am on the right path! any input would be helpful!

a 65y/o male is admitted to a medical floor altered mental status with sob and a productive cough of thick yellow secretions. the client has a history of smoking for 40 years 1pack/day; htn and takes hctz 25mg daily po. his admitting information: weight 115 lbs and 5’ 7”, vs: 162/84, 124, 36, 102 f, pulse ox 86% on room air. abgs: ph 7.32, paco2 50, pao2 68, hco3 28. other lab results: sodium 136, potassium 3.5, bun 28, creatinine 1.0. the admitting physician orders are bed rest; regular diet, start o2 at 2l nc and titrate up the o2 to maintain pulse ox > 90%, start iv d5.45 at 50ml/hr, obtain sputum specimen for c&s, and give albuterol 2.5mg via nebulizer every 4 hours and prn; tylenol 2 tabs every 4 hours prn for temp; vancomycin 500mg ivpb every 12hours.

1. what is your interpretation of the client’s condition? list the abnormal data and what it means.

htn, bp 162/84

pulse 124 high

resp. rate 36 high

temp 102 high

pulse ox 86% low

2. what is your interpretation of the client’s abg results?

ph 7.32 low

paco2 50 high = resp. acidosis

hco3 28 high

pao2 68 low= hypoxemia

3. in which order would the nurse implement the physician (collaborative) orders for this client?

first order:___bed rest_________________________________________

second order___obtain sputm_________________________________________

third order .____start ox at 2l nc________________________________________

fourth order.____start iv d.45 ________________________________________

fifth order: ____give albuterol__________________________________________

4. identify at least 3 nursing diagnoses:

ineffective airway clearance, activity intolerance, and impaired gas exchange [/quote

first you patient is hypoxic, tachypneic, tachycardic, and febrile. they don't have enough oxygen so they are breathing faster and they have a temperature probably from pneumonia which will elevate the heart rate. because of the fever, rapid respirations and heart rate they are also dehydrated. they will need fluids and antibiotics for the pneumonia and something for the temp...right? as well as something to help them clear secretions and help breathing by opening the airways.....right?

what is most important here? .....think maslow's hierarchy of needs

what would help them breathe and which could wait like the sputum....although nice if you can get it, not having it won't risk the patients life.:)

[bri2012]

Thank you guys so much! Very helpful!

[Esme12, ASN, BSN, RN]

Thank you guys so much! Very helpful!

You're welcome!! anytime.