Oxygenation, Circulation, and Fluids, Electrolytes, and Acid-Base Balance CASE STUDY

Objective: To apply the concepts of oxygenation, circulation, and fluids, electrolytes, and acid-Base balance and nursing process to a patient experiencing problems in these areas.
Instructions: Go through the case and answer the questions in the order in which they are asked. Formulate each response based only on the information you have available up to that point in the case. Use your own words to formulate responses. Record your typed responses using your own words directly on the ANSWER SHEET. It is due at the start of next week’s class.
Grading: The point values are shown on the ANSWER SHEET. Credit will be reduced for words that are not spelled accurately or for responses that are not in your own words.
Start of the CASE . . . Mr. Edwards is an obese 71 year old who quit smoking 20 years ago. He has a history of hypertension that has been under good control with diet and use of a single antihypertensive drug. Since he retired from fire-fighting over 15 years ago, he maintains a sedentary lifestyle. He is a client in a skilled care rehabilitation unit while he is recuperating from recent knee surgery. He has been making good progress and preparing for discharge, which is planned for today.
You are a student nurse who cared for him last week; at that time you noticed that he was a neatly groomed gentleman (in spite of his recent surgery at that time), remained actively engaged in conversation with you throughout that day, and was known to the nursing staff as being an early riser and taking pride in keeping his room in order. You are assigned to care for him again today.
According to the change-of-shift report at 0645 today, the night nurse stated that he was told that late yesterday afternoon Mr. Edwards had a productive cough and he seemed ‘forgetful’ and slightly ‘confused’. (You recall that last week he was not noticeably forgetful.) The daily vital signs recorded at 0500 today included: respirations of 20/minute, blood pressure of 138/86, pulse of 90, and oral temperature of 99.1°F.
You go to his room, planning to walk with him to breakfast. You first notice he is still in bed, lying on his side in bed with disheveled bed covers. When you ask him how he is, his response is slightly delayed, stating ‘not as good as yesterday’ and ‘been better’. His notable pause between the short phrases made you wonder if he was having difficulty breathing.
1. List 3 things that place Mr. Edwards at increased risk for poor or impaired oxygenation.
2. In order of priority list five things you will do within the next 20 minutes and state a relevant, brief rationale for each.
3. Why is the onset of Mr. Edwards’ forgetfulness or confusion that was noticed yesterday especially relevant for Mr. Edwards? (Limit response to 1 – 2 sentences)
4. Because you noticed that Mr. Edwards was experiencing some shortness of breath while lying in his bed while it was elevated less than 15 degrees, your documentation would include that he was experiencing ______________. (use one word)
CASE goes on . . . . Mr. Edwards decided to stay in his room to eat breakfast. He breathing seems “OK” to you after he sits up and he tells you ‘that’s better’. His wife has arrived and is helping him get his tray ready to eat, so you leave them alone. A little later you return to his room and find him still seated at the side of his bed. His wife has been unsuccessful in her attempts to encourage him to eat more than two bites of food. She tells you that he can’t get up to brush his teeth or eat because it makes him too short of breath.
5. Write the most appropriate oxygenation-related nursing diagnosis related for Mr. Edward’s based only on the information you have at this time. (Carefully consider what you know at this point)
6. List one nursing intervention/activity you would initiate to address this diagnosis and one related, desired outcome.
CASE goes on . . . You decide to go look at the nursing notes to learn more about the “productive cough” you heard about in report, but find nothing documented about it. As you walked back in his room you heard him coughing from the bathroom. You notice there are multiple used tissues in the trash can.
7. In follow-up to what you heard and saw when you came into the room and the ‘productive cough’ you heard about in report, describe 2 specific inquiries you would make at this time.
CASE goes on . . . The client makes his way back to his bed with your assistance. You notice he is having more difficulty breathing and that his skin was noticeably warm. You take his vital signs and obtain a pulse oximetry reading. His respirations are 28 breaths per minute, blood pressure is 146/92, temperature is 102.1 °F, pulse is 104, and SpO2 is 88%. The staff nurse comes in the room, asks you to place Mr. Edwards on 2 L of oxygen per minute, listens to his lungs with you, and assesses the peripheral pulses. There are abnormal lung sounds in upper lungs as well in the left base. The nurse tells you that this is a change from earlier today. Earlier there were a few abnormal sounds in only the upper lobes. Peripheral pulses remain strong and capillary refill is brisk.
8. Write one 3-part nursing diagnosis related to Mr. Edward’s oxygenation problem. Make sure that you base this diagnosis only on the information you have been provided from the case description up to now. Do NOT record the same diagnosis recorded in # 5.
9. List three nursing interventions/activities you would initiate to address this diagnosis and the related, desired outcome(s).
10. What does the new finding of abnormal lung sounds in left base indicate? (Do not over-think this; limit your response to one sentence).
11. Does this finding affect Mr. Edward’s oxygenation, tissue perfusion, or both oxygenation and tissue perfusion? State which and explain how/why.
CASE goes on . . . The nurse contacted the on-call doctor, Dr. Smith, because Mr. Edwards’ regular physician was not on duty today. The nurse shared the changes in vital signs and a summary of all the assessments performed this morning with Dr. Smith, including the fact that Mr. Edwards has a productive cough with thick, yellowish-green sputum. Before Dr. Smith gave any orders, he asked whether Mr. Edwards had a history of emphysema. Then, Dr. Smith ordered several tests including a sputum specimen, chest x-ray, CBC, and serum chemistry and electrolytes. Additionally, orders were given concerning starting several medications, parameters concerning how to administer the oxygen, and cancellation of the earlier plans for today’s discharge.
After hanging up the phone, the nurse tells you, “Dr. Smith ordered that we obtain the most accurate information about Mr. Edwards’ blood oxygen levels. We’ll do that first, and then we need to help Mr. Edwards get rid of these secretions”.
12. Having just read the chapter about oxygenation, you know that the test Dr. Smith ordered to identify Mr. Edward’s blood oxygen levels was: _______________________ (name of test).
13. Why did Dr. Smith want to know whether Mr. Edwards had a history of emphysema? (be brief)
14. List 3 nursing interventions that would be most helpful in removing Mr. Edwards’ pulmonary secretions and briefly describe the rationale for each.
CASE goes on . . . Your shift has finished and you leave. The next week, however, you are assigned Mr. Edwards again. You spend the first part of this clinical day reviewing his records to understand what has occurred in the last week, after you left.
The chest x-ray and sputum specimen confirmed pneumonia with infiltrates in upper lobes and left lower lobe. He was cared for on another unit for a few days while he was acutely ill. During that time, his respirations increased to 48 breaths per minute. He had intermittent high fevers (up to 104 orally) for several days and the antibiotic that was prescribed caused intermittent diarrhea. Although he was thirsty during this time, he was so fatigued that he rarely took ice or water except when physically provided to him. You notice that nursing notes included several assessments that indicated that Mr. Edwards had a fluid imbalance.
15. List 3 physical assessments and related findings that the student nurse may have identified in the record that indicated Mr. Edwards most likely had an imbalance of fluids. (Note, they are not described in the above paragraph).
CASE goes on . . . Next, you noted select laboratory values recorded during that time, including some of the serum electrolytes (sodium = 146, potassium = 4.0; chloride = 96, magnesium = 1.9), components of the CBC (WBC = 21.1, Hgb = 16.9, and Hct = 58%), and urinalysis (no WBC’s, urine pH = 4.9, and urine specific gravity = 1.030).
16. Identify the laboratory value(s) most indicative of this imbalance in fluid and briefly explain how the imbalance causes the change in the value(s).
17. State one nursing diagnosis associated with these laboratory findings discussed in # 16.
18. List four independent nursing interventions/actions that are most appropriate with the nursing diagnosis in # 17.
CASE goes on . . . Also, several sets of arterial blood gases had been performed over these days, including these results: PaO2 = 55 mm Hg, PaCO2 = 65 mm Hg, and pH = 7.3. The SpO2 was 80% at the time these blood gases were drawn.
19. Review the arterial blood gas results. Which values are low, which are high, and what does this ‘picture’ indicate overall?
CASE goes on . . . During the time Mr. Edwards’ had imbalances in fluids, electrolytes, and his acid-base status, you noticed that specific laboratory tests were frequently performed. These included serum electrolytes (sodium, potassium, chloride, and bicarbonate levels), BUN, creatinine, urine osmolality, hematocrit, specific gravity, and arterial blood gases.
20. Explain why it was important to monitor sodium, potassium, calcium, magnesium, and chloride. That is, briefly describe the major functions of these 5 ions using your own words.
Sodium –
Potassium –
Calcium –
Magnesium –
Chloride –
CASE goes on . . . After the day that his respirations briefly soared to 48 breaths per minute, you notice that various nursing assessments indicated his oxygenation status started improving. It has continuously improved since then, but he remains on 2L of oxygen per nasal cannula.
21. List 2 nursing assessments, however, that would have alerted you to a worsening of his oxygenation status?
CASE goes on . . . As you finish looking through his chart, you notice that the serum potassium level that was drawn yesterday was 3.4mEq/L. You discuss this with the staff nurse, who mentions this to Mr. Edwards’ physician during rounds today. The physician responds that this will be treated conservatively through diet.
22. In what way is this value abnormal?
23. List three foods that you will include in his diet to address this issue.
CASE goes on . . . The staff nurses mentions that she is concerned because Mr. Edwards is not as far along in his rehabilitation as he was a week ago and he has been ‘just lying in bed’ for over a week. One of her concerns is his increased risk for development of a deep vein thrombosis (DVT, or sometimes called “blood clot”).
24. List two of the most relevant risk factors that place Mr. Edwards at increased risk for formation of a DVT and explain why.
25. Identify 3 nursing strategies that you would want to use to help prevent Mr. Edwards’ development of a clot. Explain the rationale for use of these strategies in your own words.
CASE goes on . . . Mr. Edwards is being discharged on home oxygen therapy. His discharge plan includes continuation of the rehabilitation program as an outpatient. You are talking with your instructor about what you will include in teaching you provide for your client and wife concerning the plans for home oxygen when Mr. Edwards’ wife interrupts you. She says after this ordeal she is more and more afraid of loosing her husband. She says she knows he has many risk factors for heart diseases and want you to talk to him about this, too, before they leave.
26. List three things that need to be included in teaching related to use of home oxygen.
27. List 3 things you know about Mr. Edwards that may negatively his cardiovascular function.
End of Case . . . At the end of this clinical day, the nursing instructor tells you, “My, you’ve learned a lot about fluid, electrolyte, and acid-base imbalances by caring for this client”. The instructor asks you to share with your peers things that will help prevent fluid and electrolyte imbalances.
28. List 3 strategies that you included in your discussion during post-conference that nurses may use to help prevent fluid and electrolyte imbalances in your clients.

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