lOMoARcPSD|3013804
Case studies - Case study
Geriatric Nursing (New York City College of
Technology)
, lOMoARcPSD|3013804
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)
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.
, lOMoARcPSD|3013804
• 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
Case studies - Case study
Geriatric Nursing (New York City College of
Technology)
, lOMoARcPSD|3013804
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)
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.
, lOMoARcPSD|3013804
• 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
