Question

• Patient: 84 year old female who is admitted to the hospital after left ankle surgery.

• Initial Assessment: T 39.5 C (103.2 F), BP 102/58, P 88 and regular, R 36 and labored. O2 Sat 88% on RA. She reports her pain level as 2/10 when coughing but otherwise 0/10. She is A&Ox4, PERRLA. Lung sounds reveal bilateral crackles with a nonproductive cough.

• Orders: Admit to medical unit, vital signs q4h with O2 sat; administer and titrate oxygen 2 to 4 L via NC to maintain O2 sat. 90%, sputum specimen, CBC, BMP, Chest x-ray, saline lock, I &O, adult regular diet, up ad lib with use of crutches for non bearing to left lower extremity

Group 1: Case Study

1.What is the pt at risk for and why?

2. Look at the pt vitals – which are abnormal?

3.What do you think the pt will be diagnosed with?

4.What is ordered to help you make this diagnosis?

5.What is an immediate nursing action that needs to be performed for our pt?

6. Are there any nursing interventions that are not ordered that you would like to perform on this pt? Do we need an order for these nursing interventions?

7.What position should you place the pt in?

8.What would you recommend to the HCP to order on this pt?

Answer 1

1.The patient is at risk for respiratory infection because of surgery ,increased age

2.The abnormal vital signs are

• Increased body temperature
• Increased respiratory rate
• Decreased oxygen saturation
• Decreased diastolic blood pressure

3.The patient can be diagnosed with post operative pneumonia .

4.The following test which can be used to diagnose are

• CBC to rule out infection
• Chest X ray to assess for any lung inflammation or inflammatory process
• Auscultation can review altered breath sounds