Case Study, Chapter 23, Management of Patients With Chest and Lower Respiratory Tract Disorders PDF

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Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Fourteenth Edition ; Case Study, Chapter 23, Management of Patients With Chest and Lower Respiratory Tract Disorders...

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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; PaO2, 55; PaCO2, 50; and 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)

a. What nursing assessment findings support the diagnosis of pneumonia? Nursing assessment findings that support the diagnosis of pneumonia include:  A temperature of 101.5 (or a rapidly rising fever ranging from 101 to 105 F)  RR of 28 (or tachypnea [25 to 40 breaths/minute])  Confusion (indicative of hypoxia)  Fatigue and SOB  Absence of breath sounds  Inability to finish a short sentence beforenthe RR increases above the baseline  Cyanotic lips and nail beds with a decrease in pulse oximetry reading of 82%

 Hgb of 10 and Hct of 30% (both levels are below normal range for a man and this indicates the lack of oxygen perfusion through the blood)  WBC is 12,500 (elevated WBCs indicate an infection). b. What diagnostic findings support the diagnosis of pneumonia?  Chest X-ray presents with right lower lobe consolidation (consolditation of lung tissue is one of the physical findings)  CBC- Hgb 10, Hct 30%, WBC 12,500  ABGs- show signs of respiratory acidosis; with a marked elevation in PaCO2 and a low pH  Pulse oximetry- 85% c. What nursing diagnoses should the nurse formulate for the patient?  Risk for deficient fluid volume related to fever and a rapid respiratory rate  Fatigue and activity intolerance related to impaired respiratory function d. What goals should the nurse develop for the patient?  The major goals may include:  Improved airway patency  Increased activity  Maintenance of proper fluid volume  Maintenance of adequate nutrition  An understanding of the treatment protocol and preventive measures  Absence of complications. e. What overall interventions should the nurse provide?  Overall interventions the nurse should provide include:  Improving airway patency: through the encouragement of hydration so that it will thin the secretions and make it easier to expectorate  Conserving energy and promoting rest: advise the patient to rest and avoid overexertion, as well as avoid the exacerbation of symptoms via a comfortable position (e.g., semi-Fowler’s position since most patients are orthopneic) and frequent position changes to better secretion clearance and pulmonary ventilation and perfusion  Maintaining nutrition: Administer fluids with electrolytes (such as Gatorade) to help provide fluid, calories, and electrolytes. Oral nutritional supplements may be used to

supplement calories, along with small, frequent meals may also be given. In addition, IV fluids and nutrients may be given if necessary. 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)

a. What could possibly be going on with the patient and what measures should the nurse provide immediately?  The patient is having a pulmonary embolism and the nurse should:  Administer O2 STAT via nasal cannula to relieve hypoxemia and respiratory distress.  IV lines are inserted in case medications and fluids need to be administered  For hypotension that is not relieved by IV fluids, patients are given vasopressors (e.g., dobutamine, norepinephrine, dopamine)  Pulse oximetry and ABGs to monitor and evaluate for hypoxemia  ECG/EKG- to monitor for sudden dysrhythmias and right ventricular failure  Small doses of IV morphine or sedatives are given to relieve patient anxiety, to alleviate chest discomfort, to improve tolerance of the endotracheal tube, and to ease adaptation to the mechanical ventilator, if necessary. b. What risk factors does the patient have for a pulmonary embolus?  Deep vein thrombosis  Surgery (major abdominal surgery)  Being older than 50 years  Afib  Prolonged immobility  Overweight  H/O CVD and HTN

c. What measures are appropriate to manage a pulmonary embolism? Measures that are appropriate to manage a PE include:  Improving respiratory and cardiac status via  O2 tx (to reduce pH; correct hypoxemia and relieve pulmonary vascular constriction)  The use of TED stockings and intermittent pneumatic compression devices (to reduce the risk of venous stasis  Elevating the legs (to increase veous flow). d. What measures are appropriate to help the patient in this case study prevent the reoccurrence of a pulmonary embolism? To prevent the reoccurrence of a PE, we want to:  Encourage the patient to come to follow-up appointments  Encourage the patient to participate in health promotion activities such as immunizations and health screenings  Monitor the patient for residual effects of a PE and their adherence to the the prescribed management plan...