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Case 20scenario

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Whitney Cabangan
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16 views

Case 20scenario

Uploaded by

Whitney Cabangan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CASE SCENARIO 1

David, an 80-year-old man is admitted to the hospital with a diagnosis of possible pneumonia.
He states that he is not feeing well and has frequent productive cough, which is worse at night. Vital
signs are Blood pressure 150/90 mm/Hg, pulse rate 92 beats / min, respirations of 22 breaths /min,
pulse oximetry 90 %. His lungs have wheezing and rhonchi in both bases and are otherwise clear. He
states, “my chest hurts when I cough, and the pain radiates into my arms”.

On the nurses’ visit, she noted the following:

 The patient is hooked to an oxygen tank via nasal cannula at 2Lpm


 IVF of DR5LR at 200 ml level

Doctors’ Order Reads:

 Maintain O2 @ 2Lpm
 Start Salbutamol Neb q 4
 CPT every after nebulization
 Start cefuroxime 750 mg q 12⁰ x 4 doses then shift to Ceftriaxone 1 Gm q 12⁰
 Give hydrocortisone 250 mg now then 100 mg q 6 ⁰ thereafter
 For CXR(PA)
 Monitor v/s q 4 hours
 Refer accordingly

1. Carry out the Doctors’ order correctly


2. Compute the dosage of the new medications to be started in your shift; Prepare medication
cards
3. Formulate your nursing care plan (SOAPIE) format
4. Prepare your CHARTING
DOCTOR’S ORDER

DOCTOR’S ORDER

8 AM
 Maintain O2 @ 2Lpm
 Start Salbutamol Neb q 4
 CPT every after nebulization
 Start cefuroxime 750 mg q 12⁰ ANST x 4 doses then shift to
Ceftriaxone 1 Gm q 12⁰ ANST
 Give hydrocortisone 250 mg now then 100 mg q 6 ⁰ thereafter
 For CXR(PA)
 Monitor v/s q 4 hours
 Refer accordingly
Dr. L A
NURSES’ NOTES

NURSES’ NOTES
8-4 Received patient lying on bed with ongoing IVF of D5LR 200 ml – infusing well; with
O2 via nasal cannula at 2Lpm.

S: “ My chest hurts” and pain radiates into his arm


He is not feeling well
Cough gets worse at night

O: Productive cough , wheezing and rhonchi on auscultation


Vital signs:
BP- 150/90 mm/Hg,
PR- 92 beats / min
RR- 22 breaths /min,
Pulse oximetry 90 %.

A: Ineffective Airway clearance r/t retained tracheobronchial secretions as


evidence by productive cough/ excessive secretions and abnormal /adventitious
sounds upon auscultation of the lung

P: Within an hour of providing nursing interventions, the client will maintain a


clear / open airway

I: Positioned the patient in high fowlers


Maintained patency of O2 therapy
Back tapping and postural drainage done every after nebulization
Advised and assisted to deep breathing exercises
Advised and assisted to increase fluid intake as tolerated
Provided comfort measures such as morning care, bathing, change bed linens,
opened windows
Offered diversional activities
Started new meds
CXR(PA) done, to follow up results
Monitored vital signs q 4

E: The patient maintained a patent airway as evidenced by readily cough out


secretions
CPGaliza,
RN
Case Scenario 2:

Patient M.R. is a 68 year old male with no known allergies who presented to
the ED two days ago with intermittent chest pain that had been lasting for 5
hours. M.R. has a history of hypertension and high cholesterol; his father and
paternal grandfather have a history of heart attacks. He was diagnosed with
transient angina after a chest CT, 12-lead ECG, and lab draw. M.R. was
treated in the E.D. according to the chest pain protocol and transferred to the
cardiac intermediate unit. The patient has been complaining of feeling short
of breath over the last 15 minutes after ambulating in the hall. He reports his
pain as a 2/10 in his chest. Most recent vital signs: BP 160/100, HR 90,
Respirations 24, SpO2 on RA 90%. Slight cyanosis noted around lips, breath
sounds clear bilaterally, no extra heart sounds noted, heart rhythm regular, A
& O x 4, all pulses 3+.

DOCTORS’ ORDER
 Repeat ECG
 Start ISDN 5mg SL TID
 Start Nicardipine drip 10mg + 90cc PNSS via soluset x 10ugtts / min then titrate to 5
ugtts to attain systolic BP of 130mmHg
 Monitor v/s q hour and record
 IVF to follow: PNSS 500 ml x KVO
 Hook to O2 @2Lpm via nasal cannula
 CBR without BRP
 Blood chemistry: HDL, LDL, Triglycerides, BUN, Creatinine
 ABG, CKMB, TropI
 Refer accordingly

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