“written case study assignment”

 
Mr Hay, is an 82 year old man who has been in your ward for the past week. On admission he was complaining of sharp pain in his chest which is worse on deep inspiration and coughing. His respirations were shallow and he tended to use purse lip breathing with use of accessory muscles.

His temperature was 38 C and he was tachycardic at 106 beats per minute. His family were concerned as he was found on the kitchen floor by a neighbour, and he had been laying there for some time as he had signs consistent with a stage 1 pressure injury to his right hip, ankle and shoulder.

He also had a productive cough, with thick yellow sputum. He mentioned that he had been to his General Practitioner (GP) approximately a week prior to admission and was given antibiotics for the cough.

Medical History:
2010: # NOF and pulmonary embolism
2011 January: Partial thickness burn to left hand No other significant medical history

Social History: Married for 45 years but his wife died mid 2011
Retired from coal mining in 1990 Likes a scotch in the evening Lives by himself and states he copes well. Family lives a few hours away but they visit him regularly

Present Vital signs: Pulse: 98 beats per minute
Temperature: 37.6o C
Blood Pressure 150/95 mmHg
Respirations: 28 breaths per minute at rest and shallow with ongoing
complaint of pleuritic chest pain

Electrolytes:
K+- 5mmol/L
Na+135mmol/L
CL- 92 mmol/L

Arterial Blood Gases:
PaCO2 49mm Hg
PaO2 82mm Hg
HCO3 29mm Hg –
pH: 7.4

Chest X-Ray (AP and Lateral view)
Results:
The lungs are hyperinflated. There are several poorly defined small pleural plaques evident bilaterally which may be consistent with long standing inflammatory change. High resolution CT scanning of the chest may be advisable to further characterise these lesions. The heart shows moderate enlargement and the lung fields are free of any focal abnormality.
Doctors orders:
IV therapy 1000 mL 24 hrly Normal Saline
Titrate O2 to keep SaO2 >94%
Ambulate as tolerated.

Tasks;

identify the patients 3 priority problems from this list.

Activity intolerance
Airway clearance, ineffective
Breathing pattern, ineffective
Hyperthermia
Injury, potential for
Pain
Self care deficit
Tissue integrity impaired
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