I NEED HELP!

Can you post the case study?

Did your school assign you a case study without telling you how to do a case study?

That's how my whole 4 years was! Here do this...oops did we forget to teach you that? Oh well! It's due in 2 days and it's worth 94% of your final mark. Ok ok maybe I'm exaggerating a little...

Yes, they did!! it's so annoying. i hate it when they do that. It's worth 50%!!! So it's either pass or fail.

Mr Lim, 70 yrs old.

Admitted from A&E.

Provisional diagnosis is pneumonia.

Complaints of breathlessness and productive coughs

Appears to be anxious and tired.

Unable to answer past medical history so wife takes over.

Been coughing for the past week with green colour sputum.

Having fever of 38.5 degrees

BP 140/70MMhG

Pulse 110

Respiration 28

SPO2 90%

Actually, i dont want you guys to think i only want answers.. Could you help me by telling me how do i start off doing it? What is objective and subjective data? What is a nursing care plan?

Yes, they did!! it's so annoying. i hate it when they do that. It's worth 50%!!! So it's either pass or fail.

Mr Lim, 70 yrs old.

Admitted from A&E.

Provisional diagnosis is pneumonia.

Complaints of breathlessness and productive coughs

Appears to be anxious and tired.

Unable to answer past medical history so wife takes over.

Been coughing for the past week with green colour sputum.

Having fever of 38.5 degrees

BP 140/70MMhG

Pulse 110

Respiration 28

SPO2 90%

Actually, i dont want you guys to think i only want answers.. Could you help me by telling me how do i start off doing it? What is objective and subjective data? What is a nursing care plan?

Here's just a running head start, as I'm leaving work in about 2 minutes! :)

Subjective (typically patient complaints):

-Been coughing for the past week with green colour sputum.

-Tired, achy, restless, anxious

Objective (observable and/or measurable data):

-Temp: 38.5 C

-BP 140/70MMhG

-Pulse 110

-Respiration 28

-SPO2 90%

Possible nursing diagnoses:

Impaired gas exchange

Altered tissue perfusion

Risk for fluid volume deficit/overload

Altered though processes

Role strain

Risk for falls

...and the list could go on for days.

Then you might start on some possible interventions:

-Titrate oxygen to maintain O2 sats of 92%

-Bedrest

-Hemodynamic stability

-Ausculation lungs/assess vitals Q4

-Anticipate outcomes and side effects of prescribed meds

-Position in semi-fowlers to increase respiratory sufficiency

-Chest PT

I hope this helps!

opps! looks like i got objective and subjective all mixed up. thanks. that's a lot of help since you'll be leaving for work in 2 mins.

i'm still a bit lost. so what exactly is a nursing care plan? is this considered as a nursing care plan? if i'm asked toderive a nursing care plan for the patient's breathlessness & explain the rationale with chosen interventions, is this the right way?

intervention:

1. explain to patient the need for administration of oxygen and emphasize the safety measures

2. assist patient to a sitting position

3. hold the mask close to the patient’s face for a few seconds before applying

4. constant monitoring of oxygen saturation

5. constant monitoring of equipment

rationale:

1. to prevent fire hazards as oxygen supports combustion

2. to facilitate efficient respiration

3. to allow the patient to feel the flow of oxygen, thereby allaying his anxiety

4. oxygen saturation may decrease which may lead to unconsciousness

5. patient might reduce or increase saturation level which may lead to hypoxia or oxygen toxicity

also, is possible nursing diagnosis the same as potential nursing problems? because two of what you listed, i wrote it under potential nursing problems.

again, thanks a lot for your help. :)

gilagila, are you from England? We may be leading you down a wrong path if you don't know what a care plan is - perhaps that is not what they are requiring from you and even if it is, the process in the UK may be different. What did they say they wanted to see from you when they gave this assignment to you. Do they want a plan of care, or do they want an essay from you analysing what you think might be going on with this patient?

I'm just wondering if it might not makes sense to ask your instructor for input...or do you not have time for feedback before it is due? Some of my teachers have been great about helping me understand what is required and some have been terrible. Either way, it *usually* doesn't hurt to at least ask. Good luck!