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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, PaO2 55, PaCO2 50, HCO3 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. (Learning Objective 3)

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a. What nursing assessment findings support the diagnosis of pneumonia? The assessment findings that support the diagnosis of pneumonia include fever, diaphoresis, complaint of fatigue and shortness of breath, and inability to complete a short sentence before having an increase in respirations above the baseline, which is already tachypneic, and a decrease in the pulse oximetry and development of cyanosis. The tachycardia and presence of atelectasis also support the diagnosis. Altered mental status changes in the elderly patient are seen with patients with an infection. b. What diagnostic findings support the diagnosis of pneumonia? The white blood count is elevated, and the chest x-ray reveals right lower lobe consolidation and small pleural effusion, a complication of pneumonia. The apical bullae and flattened diaphragm are suggestive of the comorbidity of paraseptal emphysema, a type of chronic obstructive pulmonary disease (COPD). The arterial blood gases reveal respiratory acidosis and hypoxemia, which support the patient's clinical presentation. There is a decline in the number of alveoli participating in gas exchange, so the patient has less oxygen and retains CO2 in the limited gas exchange. The body compensates for the retained CO2 by increasing the rate of respirations. The kidneys take 24 hours to increase the sodium bicarbonate that will be used to buffer the serum pH and help to compensate for the respiratory acidosis. c. What nursing diagnoses should the nurse formulate for the patient? • Ineffective airway clearance related to weak, ineffective cough to raise sputum and presence of decreased to absent breath sounds in the right lower lobe. • Ineffective breathing pattern related to pneumonia and COPD manifested by tachypnea, and use of accessory muscles, and complaint of shortness of breath. • Impaired gas exchange related to pneumonia, pleural effusion and COPD as evidenced by hypoxemia and respiratory acidosis, pulse oximetry of 85% on room air.

• Activity intolerance related to impaired respiratory function as evidenced by inability to complete a short sentence before respiratory status declines. • Acute confusion related to hypoxemia manifested by disorientation to place and time. • Risk for deficient fluid volume related to fever, tachypnea, and diaphoresis. • Risk for imbalanced nutrition: less than body requirements related to work of breathing reducing the ability to eat. • Potential complication: respiratory failure. • Potential complication: shock. d. What goals should the nurse develop for the patient? • Improved airway patency • Improved breathing pattern • Improved gas exchange • Rest to conserve energy • Maintenance of adequate nutrition • Maintenance of adequate fluid balance • Absence of complications e. What overall interventions should the nurse provide? • Elevate head of bed to semi-Fowler's to promote oxygenation. • Apply warm, humidified oxygen and titrate as ordered and monitor pulse oximetry and ABGs and respiratory rate and status for response. • Obtain cultures as ordered before beginning antibiotics. The cultures may include blood and sputum cultures. • Report abnormal physical findings, laboratory results, and diagnostic test results to the physician and receive orders. • Provide rest and ask the patient "yes" and "no" questions and encourage the patient to nod his head to conserve energy while respiratory compromise exists. • Use incentive spirometer and directed cough every hour while awake. Assess lungs anterior and posterior afterward to evaluate effectiveness. • Monitor the sputum for amount, color, odor, and consistency. • Provide oral care after meals and at bedtime. • Reposition every hour, rotating side to back to side to promote adequate gas exchange and pulmonary toilet. • Provide 2 L/day of fluids to thin mucus and help mobilize secretions unless contraindicated by another condition. • Monitor intake and output. • Provide linen changes as needed for periods of diaphoresis. • Provide antipyretic/analgesic as ordered for fever. • Provide antibiotics via IV route as ordered within 4 hours of hospitalization and monitor for effectiveness of medication as reflected by improvement in oxygenation, stabilization of vital signs, normal baseline mental status, and decrease in WBC count within 24 to 48 hours. Report adverse side effects immediately. • Consult with dietician for nutritional support tailored to meet the patient's needs. • Monitor nutritional status ongoing, observing caloric intake and value. • Provide patient/family education on ways to decrease risk for pneumonia, which include

proper handwashing, proper nutrition, annual influenza immunization, pneumococcal immunization, and avoiding persons with upper respiratory infections or crowds in the winter months. 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. (Learning Objective 7)

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a. What could possibly be going on with the patient and what measures should the nurse provide immediately? This patient may have a pulmonary embolism o Administer oxygen by nasal cannula o Administer IV fluids to treat hypotension, if ineffective initiate vasopressor therapy as prescribed o Administer small doses of IV morphine or sedatives as prescribed to relieve anxiety and discomfort b. What risk factors does the patient have for a pulmonary embolus?  Postoperative status  Immobility  Age (over 50 years) c. What measures are appropriate to manage a pulmonary embolism?  Perform frequent assessments  Anticoagulation therapy as prescribed  Thrombolytic therapy as prescribed  Administer analgesics as prescribed  Frequently reposition patient  Place patient in semi-fowler’s position for more comfortable breathing  Continuous oxygen therapy  Perform deep breathing and incentive spirometry frequently  Continuously monitor ECG for dysrhythmias and right ventricular failure  Indwelling urinary catheter to monitor output when the patient is Hypotensive  Inferior vena cava filter d. What measures are appropriate to help the patient in this case study prevent the reoccurrence of a pulmonary embolism? 3. Howard Long is 50 years of age and is a male patient who is diagnosed with bronchiectasis. The patient has smoked 1 pack per day of cigarettes for 35 years. He has a long history of recurrent bronchial infections. He has a chronic productive cough with copious amounts of purulent sputum. The patient complains that he is short of breath even at rest. The patient has clubbing of his fingers. The chest CT scan reveals bronchial dilation. a. How should the nurse explain to the patient and family the pathophysiology of bronchiectasis as it related to the symptoms the patient is experiencing? i. This condition is a chronic illness that comes in episodes. The walls of the bronchi become thick and inflamed. The patient is noted having recurrent

bronchial infections, which is a sign of bronchiectasis. Infections will come and go, chronically. Due to the illness being chronic, he has now noted clubbing of fingers b. How should the nurse explain to the patient and family the goals of medical management that may be used to treat the bronchiectasis? i. If the infection is bacterial, antibiotics will be prescribed. Macrolides are a special type of antibiotic that also aids in the treatment of inflammation. The doctor may order a nebulizer or hand-held devices to treat bronchospasm and make breathing easier c. What does the nursing management for bronchiectasis entail? i. Performing good oral hygiene, oxygen therapy, and rest and activity balance. Administer medication as prescribed. Give patient enough time to finish meals, or give small frequent meals for adequate nutrition. Coping mechanisms for the disease.

4. Sallie Thorp, a 21-year-old client presents to the physician’s office with an asthma action plan form she acquired from a literature search on the World Wide Web at http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf . She also brought in the wallet card she found at http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf . She states that she would like to develop the plan with the help of the nurse and physician and review it at each appointment to keep it current. She has had moderate persistent asthma for five years, and she has visited the emergency department several times in the past year with severe asthma attacks. She stated that she forgets to take her medications, because the medications are at times that the hospital provided the inhalers (12 noon and midnight), and she gets confused on which inhalers are the long-acting ones and which inhaler is the short-acting rescue inhaler she is supposed to use when she has an exacerbation. The client stated that if she could, she would like to take the inhalers at 8 AM and again at 8 PM. The client stated that she has a flow meter and a respiratory therapist at the hospital taught her how to use it in the past, and he wrote down her personal best peak flow, which is 400 liters/second. The nurse reviews the client’s medical chart and discovers that the client has been prescribed the following from today’s visit: 

albuerol (Proventil)- 2 to 4 puffs every 20 minutes for up to 1 hour as rescue inhaler. If symptoms improve, then take the inhaler every 4 hours for 1- 2 days. If no improvement after 2 days, call the physician.

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Salmeterol (Serevent)- 50 mcg every 12 hours.

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Fluticasone (Flovent)- 88 mcg or 2 puffs every 12 hours.

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Cromolyn sodium (Nasal Crom) one spray to each nostril once daily and before being exposed to known asthma triggers. You may use the spray up to every 4 hours.

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Measure peak flow meter every morning before using inhalers and record. Use peak flow meter as needed, if you develop symptoms- cough, shortness of breath, wheezing, chest tightness, use of neck and chest muscles to breathe, problems talking or walking because of extreme shortness of breath.

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Follow-up in three months.

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Have the nurse provide education on asthma self-management and fill out the action plan that the client brought with her today and have the physician review it and sign it.

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The nurse also notes that the medications have not changed from the last visit. a. Explain the medications to the client and practice filling in the asthma action plan. 

The Green Zone Section: The best peak flow is 400 liters/sec. and at 80% the peak flow is 320 liters/sec. The nurse reviews with the client that when the client’s peak flow meter measurement each morning before medications is in this range, and the client has no asthma symptoms, then the client’s asthma is under control. The medications used for long-term control include:

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Salmeterol Serevent) 50 mcg every 12 hours; 8AM and 8 PM. The nurse explains this medication is a long-acting beta 2-adrenergic agonist to relax the bronchial smooth muscles for 12 hours. It should not be used for an asthma attack. The nurse could make sure that the inhaler is properly labeled and colorcoded with a green sticker for the green zone drugs.

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Fluticasone (Flovent)- 2 puffs every 12 hours; 8 AM and 8 PM. The nurse explains that this medication is an inhaled corticosteroid used to decrease the inflammation in the airways. Always rinse our mouth with water and gargle in the back of the throat and spit it out after using the inhaler to prevent thrush, a yeast infection that can cause your mouth to be sore and white patches can develop making it painful to swallow. Tell your doctor, if you develop mouth sores or white patches. This is also a green zone med, so I will put a sticker on it to remind you.

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Cromolyn sodium (Nasal Crom) - one spray to each nostril once daily and before being exposed to known asthma triggers. You may use the spray up to every 4 hours. Nasal Crom stabilizes the mast cell. When a person is introduced to an allergen, it can trigger the mast cell, which leads to inflammation and constriction or tightening of the bronchi. The nurse reviews the second sheet of the action plan that covers various potential triggers for asthma attacks with the client to assess for known triggers. The nurse instructs the client to use the Nasal Crom before being exposed to a known trigger, up to every 4 hours in a 24-hour period of time.

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The Yellow Zone Section: The peak flow range is 200 to 319 liters/sec. for the 50- 79% of the best peak flow. The nurse instructs the client that if the peak flow measurement is in this range or the client has the symptoms listed on the asthma action plan, then in addition to the long-term control meds, the client should take the albuterol (Proventil), a short-acting beta-2 agonist, which rapidly dilates the smooth muscle of the bronchi. The albuterol is the rescue inhaler, so the nurse may add a red and yellow sticker to remind the client what zone of the action plan to use this inhaler. The client should take 2 puffs and if no relief repeat again in 20 minutes with 4 puffs, and if symptoms have not resolved, then repeat again in 20 minutes with 4 puffs. If the peak flow meter measurement is in the green zone after 1 hour, then continue monitoring symptoms to ensure that you stay in the green zone- symptom-free.

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If the symptoms or peak flow measurement does not return to the green zone after 1 hour, then the client should add the albuterol inhaler to her regime with 24 puffs every 4 hours for the next 1-2 days, until the client’s symptoms resolve and the client returns to the green zone.

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If the symptoms do not resolve or the peak flow meter measurement does not return to the green zone after 2 days, then the client should call the physician.

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The Red Zone Section: The peak flow range is less than 50% or 200 liters/sec. The nurse reviews the symptoms the client would experience when in this zone or that the client’s peak flow meter is less than 200 liters/sec.

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The client would immediately take 4 puffs of the albuterol and if no improvement is noted to the yellow or green zone occur within 15 minutes, the client is to call the physician, and if the client is unable to reach the physician, then call “911” and go to the hospital per ambulance.

b. Explain ways to evaluate the client’s mastery of the content? 

Have the client explain the asthma action plan back to the nurse in her own words.

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Have the client demonstrate using the spacer with an inhaler (use a demonstration inhaler that contains compressed air).

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Have the client demonstrate using the peak flow meter and interpreting the measurement.

5. George Brown, 72 years of age, is a male patient who is admitted with the diagnosis of acute pulmonary edema secondary to acute left ventricular heart failure. The patient has a history of coronary artery disease that has been treated medically. The patient is anxious, pale, cold, clammy, and dyspneic. The vital signs are: blood pressure 88/50 mm Hg, heart rate 110 bpm, respiratory rate 32 breaths/min, and temperature 97°F. There are bubbling crackles and wheezing

throughout the lung fields and the patient is raising frothy blood-tinged clear sputum. The patient’s admission weight is 100 kg. (Learning Objective 4) a. What first actions should the nurse take and what are the rationales for these actions? 

First, the nurse should gather the required information regarding current symptoms and pre-medication history. Simultaneously, the nurse should measure various parameters like pulse rate, blood pressure, body temperature, body weight etc. If necessary depending on the severity of the patients’ normal saline, oxygen supply need to be installed. Based on the patient scenario, the patient has diagnosed with acute pulmonary edema and acute left ventricular heart failure. The patient has a history of coronary artery disease that has been treated medically with Digoxin, Lasix and Capoten. Based on the current diagnosis and premedication history, it is necessary to check the lipid profile like total cholesterol, triglycerides, low density lipoprotein (LDL), and very low-density lipoprotein (VLDL) because the patient has premedication history of coronary artery disease (CHD). Apart from lipid profile it is needed to check the sugar level and if possible electrocardiography (ECG) because of the patient diagnosis of acute left ventricular heart failure.

The physician ordered furosemide (Lasix) 40 mg IVP STAT. b. What are the actions of furosemide that will help the patient? 

Lasix is necessary immediately as because the patient was diagnosed with acute pulmonary edema that means there was fluid accumulation or logging within the alveoli or may be in the intra-pleural region. Furosemide acts as loop diuretics to increase the flow and amount of urine. So, it will help the patient with the edema.

c. What nursing actions should be implemented when administering a diuretic? 

When administering a diuretic, it is mandatory to obtain a complete health history including allergies, drug history, and possible drug interactions. The following precautionary measurement should be undertaken.

 Auscultate chest sounds for rales or rhonchi indicative of pulmonary edema  Exhibit a reduction in systolic and diastolic blood pressure.  Maintain normal serum electrolyte levels during drug therapy etc.

6. Carl Edwards is a 75-year-old man with congestive heart failure. Having sustained three myocardial infarctions in the last 10 years, he has decreased left ventricular function. Mr. Edwards takes Digoxin, Capoten, Coreg, and Lasix for management of this disease. Today he presents to the emergency department with fatigue, generalized weakness, and feelings of “skipping” heartbeats. Upon arrival, he is placed on the cardiac monitor, his vital signs are assessed, and an IV is inserted. He currently denies chest pain, but is experiencing some shortness of breath,...