Docucare Case Studys PDF

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Docucare case study examples with explanations...

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STUDENT NAME: Clinical Case Studies Navigate the Electronic Health Record of each patient in Docucare (accessing past assessment findings and orders) in order to answer the questions associated with each case.

Henry Williams: COPD Exacerbation 69 yo male presents to the ED with an acute exacerbation of COPD. His O2 sats have been at 88%. He is alert, oriented, and appears depressed. His admission history has not been completed due to his current shortness of breath. His neighbor brought him to the ED. CBC, chemistry, and ABG are available. 1. What are the clinical manifestations of chronic obstructive pulmonary disorder (COPD)?  Shortness of breath, wheezing, chest tightness, chronic cough, frequent reperatory infections, weight loss 2. What is the maximum amount of oxygen via nasal cannula that can be administered to a patient with COPD and why?  2L/minute: giving too much oxygen removes the stimulus to breathe and thus reduces the removal of C02 from the lungs 3. What type of lung sounds did Henry exhibit in the most recently documented respiratory assessment?  Decreased lung sounds in right upper lobe, labored and irregular respirations 4. What is Henry’s most recently documented O2 saturation, and how much O2 is he currently on?  Sp02 is 88 while on 2L 02 nasal cannula 5. Explain the significance of a chronically low O2 saturation in the client with COPD.  COPD is a progressive lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing. This leads to hypoxia which occurs when blood does not deliver enough oxygen to the air sacs in the lungs which leads to a low 02 saturation. 6. Based upon his ABG results, what acid-base imbalance is Henry experiencing?  Respiratory acidosis partially compensated 7. What medications are prescribed for Henry that will help his COPD?  Albuterol sulfate, ipratropium bromide, Montelukast sodium, prednisone 8. What assessments should be done before and after administering his albuterol sulfate nebulizer treatment?

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Respiratory status (resp rate, breathing sounds, depth of his breaths) 02 sat, heart rate

9. What teaching should be included regarding the administration and side effects of his fluticasone propionate and salmeterol inhalation powder inhaler?  Max inhalation benefit may not be achieved for 1 to 2 weeks (fluticasone propionate), store in a dry place, use space dividor, wash mouth out after administration 10. What is the purpose of prednisone in patients with COPD?  help to reduce inflammation in your lungs caused by flare ups 11. What are some side effects of prednisone?  Confusion, nausea, vomiting, acne, restlessness, headache, thinning skin 12. What teaching should be included if Henry is discharged on prednisone?  Do not stop drug abruptly/take drug with food/ carry or wear medical identification/report slow healing/ report symptoms of adrenal insufficiency

Case 2 Holly Reynolds: Diabetes Type 2, Hyperglycemia, UTI 72 yo female on a medical floor with confusion, pain on urination for the past 2 days, and high blood glucose levels. She has had type 2 diabetes for 10 years. UA, urine culture, Hemoglobin A1C, CBC, and CMP are available. 1. What are early symptoms of type 2 diabetes?  Polyuria, polydipsia, polyphagia, dry mouth, HA, blurred vision 2. List treatment options for patients with Type II Diabetes.  Blood glucose control, lifestyle modifications including excercise and good diet 3. Explain what a Hemoglobin A1C test is.  A Hemoglobin A1C test tells you your average level of blood sugar over the past 2-3 months. Diabetics need this test regularly to see if their levels are staying within range. It can also tell if you need to adjust your medication. 4. What is Holly’s Hemoglobin A1C result?  9.1% 5. Holly has been a Type 2 Diabetic for 10 years. What are some possible reasons for her Hemoglobin A1C to be elevated?  If she has had a poor diet, especially within the timeframe the test results reflect on, this could cause an elevated result.

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Poor physical activity can also result in an elevated test result It could be a possible indication that Holly may need to make adjustments to her diabetes treatment plan.

6. According to Holly’s CBC, what is her Hemoglobin level?  10gm/dL 7. How can a low hemoglobin affect the Hemoglobin A1C result?  If the hemoglobin is low it could mean the patients red blood cells are “short lived” which can cause falsely low A1C levels. 8. What medication is Holly prescribed to treat her anemia?  Ferrous sulfate 325 mg PO 9. What is Holly’s potassium level?  3.0 mEq/L 10. What is the relationship between insulin administration and potassium levels?  insulin is a potent stimulus for hypokalemia, sparing body potassium from urinary excretion by transporting it into cells 11. What medication prescribed for Holly could be a factor in her low potassium level?  furosemide 12. You check Holly’s blood glucose level at HS and it is 324mg/dL. a. Which insulin is ordered for Holly as sliding scale coverage?  Insulin aspart (rDNA origin) b. How much will you administer to Holly for her blood glucose level?  10 units c. If you administered the sliding scale coverage at 2100, at what time should you go back to evaluate Holly for possible hypoglycemia?  2200-2400 d. What are some symptoms of hypoglycemia?  Shakiness, dizziness, sweating, hunger, HA, irritability, anxiety, nervousness 13. What long-acting insulin is prescribed for Holly and how much does she receive?  Insulin glargine 15 mg SQ q 24 hr

14. How does metformin work to decrease blood glucose levels?  Works by reducting the amount of sugar your liver releases into your blood

15. What won’t metformin be effective in a patient with Type I Diabetes?  Metformin has been found to help reduce glucose production in the liver which is a problem for type 1 diabetes 16. Holly’s U/A shows she has a Urinary Tract Infection (UTI). Review the nursing assessments that are documented and determine what could have contributed to the development of her UTI. 1. The patient is experiencing hyperglycemia which could have caused extra sugar to build in the urine, causing the growth of bacteria which can lead to an infection in the bladder 2. The patient is taking antibiotics which can “kill” good bacteria which can lead to infection. 17. What medication is prescribed for her UTI, and what drug classification is it?  Ciprofloxacin – belongs to the fluoroquinolone class of antibiotics 18. List some side effects of this medication.  Severe stomach pain, diarrhea that is watery or bloody, fluttering in your chest, shortness of breath, sudden dizziness, skin rash...